Tongue Tie Management for Infants to Adults
Dr Shereen Lim is highly experienced in tongue tie and lip tie management for infants to adults.
Functional problems linked to restricted tongue mobility that she helps manage include:
- Infant feeding problems including poor latch and painful breastfeeding
- Poor swallowing, excessive intake of air and reflux-like symptoms
- Difficulties chewing and swallowing food or tablets
- Speech delay or concerns with speech articulation
- Mouth breathing, snoring and teeth grinding
- Poor palate or facial development in children
- Tongue thrust, open bite or poor stability of orthodontic treatment
- Chronic neck and shoulder tension
- Some migraine-like, tension type and other headaches
Tongue Tie Information for Infants
Tongue-ties during infancy can be implicated in infant feeding problems such as poor or painful latch, in-efficient transfer of milk, or excessive swallowing of air and reflux-like symptoms.
Surgical release of tongue-ties can be one piece of the puzzle to improve tongue mobility and help towards resolution of these issues.
Symptoms associated with tongue-ties in infancy may include-
- Shallow or unsustained latch (sliding off the nipple)
- Gumming, chewing or clamping at the nipple
- Poor seal, clicking or smacking sounds
- Gulping of air
- Excess gas, colic, reflux or vomiting
- Short, frequent feeds, or falls asleep at the breast easily
- Poor weight gain and failure to thrive
- Pulling on and off in frustration
- Snoring, congestion or abnormal breathing
- Unable to hold a pacifier
Diagnosis of tongue-tie is based on a combination of birth and feeding history, feeding assessment, oral assessment, and current symptoms.
Book a consult if you would like to discuss your concerns, and have your infant evaluated-
Infant Tongue-Tie FAQs
A tongue-tie refers to when the attachment between the floor of the mouth and the under surface of the tongue is abnormally short or tight and it restricts normal tongue mobility.
This can affect proper sucking and swallowing and can create issues with breastfeeding that affect both the infant and mother. This can include pain, poor latch and inefficient feeding and concerns with weight gain.
The most efficient transfer of milk occurs when the tongue suctions to the palate. As it drops, it creates a vacuum which transfers milk from the breast. Tongue ties can prevent the normal elevation of the tongue required for suction and optimal transfer of milk.
If this does not occur, various compensation patterns may occur. A baby may find it tiring and fall asleep at the breast or have short frequent feeds. They may not drain well, resulting in infant frustration, mastitis, the perception of poor milk supply or poor weight gain.
Other times, babies compensate with overuse or pursing of the lips and cheeks to create the vacuum. Others still will make clicking noises as they lose suction. This is associated with excess intake of air and may result in reflux-like symptoms.
The other problem with some tongue ties is the inability of the lower tongue to extend over the lower gum pad during feeding. This can lead to “gumming” of the nipples, pain, bleeding, bruising, or creased or lip-stick shaped nipples.
Bottle-feeding does not require the same muscular coordination effort or use of the tongue, but bottle-fed babies can still be affected by tongue tie.
They can create abnormal swallowing, leakage and excessive intake of air leading to reflux like symptoms.
When these symptoms arise, and especially if there has been a prior history of difficulties on the breast, then it can make sense to have an assessment for tongue-tie.
Dr Lim will review your medical and functional history forms, ask you to share your challenges and journey and what lead you to see us, and do an oral assessment of your child.
If tongue tie or lip tie is confirmed, we will advise you of potential benefits and limitations and we will address any queries that you have.
If you have had already had appropriate assessment and support with a lactation/feeding consultant and bodyworker, a release may be offered on the day. You will not be rushed into a decision that you are not ready to make.
If you proceed with a procedure, you will be encouraged to feed your infant immediately after. Our team will review what to expect in the next week and all the aftercare instructions once your infant is settled.
A posterior tongue-tie refers to a more hidden tongue tie that does not restrict or attach the tongue all the way to the tip.
It is sometimes mistakenly referred to as a “mild” tongue-tie, and other times completely overlooked because the tongue has not been manually lifted for closer inspection during assessment.
However, these types of restrictions that impact suction of the middle to back portion of the tongue can contribute to significant dysfunction and symptoms equal to the more obvious tongue-ties.
When there are infant feeding issues and maternal symptoms that have not been resolved through other interventions, it is important not to overlook the posterior tongue-tie.
Tongue-tie can lead to improper swallowing and excessive intake of air. This can cause reflux-like symptoms, including:
- Stomach distension or a hard belly
- Unable to sleep lying down for long periods
- Constant pain, crying or irritability
- Prefer to be held upright
- Wake congested in the morning
- Belching, vomiting or excessive gas
Infants with these symptoms may be medicated with adult reflux acid reflux medications that do not address the actual problem.
To avoid misdiagnosis, it is important to address poor latch and symptoms such as clicking, poor seal and leakage at the breast or bottle and gulping or swallowing of air.
In some of these cases, addressing tongue-tie can help improve feeding and reflux-like symptoms, eliminating or reducing the need for reflux medications.
Laser tongue tie release offers the advantage of better bleeding control and cleaner field of view, and the precision to remove tissue layer by layer.
In terms of lasers, there are differences in lasers. For example, the most widely available lasers used in dentistry are diode lasers, which are technically not lasers.
They do not cut with light energy but use heat. This is associated with more thermal injury to adjacent tissues.
Dr Lim uses the LightScalpel CO2 laser which uses light energy to vaporise the tissues and avoiding collateral thermal injury. It offers efficiency, precision (minimal collateral damage) and good bleeding control. In contrast to the Waterlase, previously used by Dr Lim, it is used without water spray. Dr Lim perceives this offers a better experience for both infants, and older patients.
It is generally recognised that the choice of operator will be a much more important factor in outcome than the type of laser, or the choice of tool.
Choose someone who has experience working with infants and is highly recommended by other parents and health care professionals, and who will reinforce a team approach to resolving the issue with lactation and feeding support and bodywork.
An upper lip tie refers to when the attachment between the upper lip and the upper jaw or gum restricts the normal mobility of the upper lip.
When the upper lip is tight and cannot elevate properly, it can lead to poor seal and shallow latch. In these instances, a lip tie release can be considered.
Otherwise, it is normal for infants to have some flesh in this area, and upper lip tie release should not be considered for the sole purpose of avoiding a gap between the front teeth in the future.
This is quite variable for each baby and the level of dysfunction that they have had.
Tongue-tie release can be considered like removing a cast on the arm that has been there even before birth. It is not expected that the tongue would automatically know what to do and that everything would move and function immediately after.
The aim of tongue-tie release is to improve mobility and it is only the first step to improving function.
Babies with tongue tie have adopted compensations with sucking and swallowing in utero, and in the earliest days of life, so it may take time to learn how to use and strengthen the tongue.
Dr Lim and her team encourages a team approach and support by lactation consultants, feeding therapists, and other professionals, to help restore normal mobility and functional patterns.
It is not uncommon for things to go backwards and forwards in the first week after a tongue tie release. It is most usual with good support that parents report some improvements at the one-week review.
Bodywork refers to light manual therapy to address areas of very gently release tightness and strain in the head, neck, and body.
Compressions and other strains may have occurred from the in-utero position, their passage through the birth canal, or interventions such as c-sections, vacuums, forceps, and other more complicated deliveries.
These can impinge nerves involved in sucking, swallowing, and breathing, and movement of the tongue.
They can also contribute to restricted movement in the neck, and this can affect an infant’s comfort during feeding.
Having these restrictions and impingements addressed prior to surgery can help set an infant up for more comfortable movement and an easier transition following tongue tie release.
It can also help some babies be calmer and more relaxed in the mouth, which makes it easier to access their mouth during the procedure, and for parents to manage after.
Post-release, bodywork helps improve functional mobility in the same way a doctor would want to gently release stiffness around the arm after removing a cast to encourage further movement.
Our welcome email offers a list of cranial osteopaths and chiropractors that have offered this gentle therapy to our patients, and we have received consistently good feedback about.
A lot of unusual things can happen when tongue-ties are released in relation to postural changes throughout the whole body and release of tension.
It’s not unusual to hear parents report that their babies are less tense and can cope better with car rides or tummy time.
Whilst having a very unsettled baby on car rides is very stressful, it is not recommended that you pursue tongue-tie release for this as a primary reason.
Our team is focused on caring for your infant and ensuring that the procedure can go smoothly and efficiently.
We can do this by eliminating all variables including parents in the room.
We work in a team of three, with one team member solely focused on swaddling, comforting, and talking your child through the procedure.
We completely understand this may not suit some families, and we want you to be fully aware of this up front to offer you the option to explore alternative release providers.
Since making a shift to the use of the LightScalpel CO2 laser, Dr Lim has introduced the use of topical anaesthetic for infant tongue-tie releases. We specially order a low concentration topical paste consisting of 3% lidocaine with 3% tetracaine. This will ensure babies do not feel heat or pain during the few seconds of the procedure. This paste will last up to 15-20 minutes after the procedure.
There is a lack of attention and training on tongue-ties and tongue function for most health care professionals.
Even a dentist, or so called “physician of the mouth”, Dr Lim received no training in this area or the role of the tongue in sucking, breathing and palate development.
There is no one profession that is better suited for tongue-tie diagnosis.
It is more important to seek an opinion from a health care professional that has sought professional development in this area and is involved in the team management of tongue-ties on a regular basis.
The field of tongue-tie research is relatively new, and there has been an explosion of published research and new knowledge on tongue-ties and their impact in the last decade.
We are understanding that posterior or more hidden tongue ties may be implicated in poor suction during feeding, and the development of breathing disturbances during sleep in childhood when they are not addressed in infancy.
Despite this information coming to light, there remains a lag in its dissemination into educational institutions and clinical practices.
Tongue-tie diagnosis is not a fad. There is a growing need for more professional attention and education to reflect the growing knowledge available.
Dr Lim has been invited to present on this topic to various professional groups locally, and in the Phillipines, Malaysia and US to help fill this void.
The most important movement for good feeding is tongue suction. If there are problems with feeding, it is most important to check if tongue elevation is
Tongue elevation is also important for speech development, articulation and proper swallowing. Proper suction is critical for palate development and tongue tone to optimise breathing.
No, tongue-tie release does not cure a person of these very multifactorial issues.
It is best not to proceed with the mindset that tongue tie release will prevent problems down the track for your child.
The primary aim is to improve tongue mobility and allow the tongue to function more normally.
If better breastfeeding can be achieved, that is a worthwhile immediate goal. Breastfeeding offers the best work out of the tongue and jaw muscles. This helps prepare babies for speech and chewing. For this reason, it can help minimise the trajectory of problems.
We also want to focus on whether the procedure can help with immediate problems, including excessive swallowing of air and reflux like symptoms.
It would be reasonable to expect that further intervention will be required in future to help optimise both the structure and function of the mouth and muscles.
High arch palate refers to an upper jaw that is high and narrow.
This is an issue because it is associated with a narrow nasal floor. This is linked to increased resistance to nasal airflow. It is a known risk factor for the development of snoring and obstructive sleep apnoea later in life.
High arch palates in infancy are usually a reflection of suboptimal sucking and swallowing in utero. They may be more common in children born with tongue-ties, premature infants who have less sucking and swallowing practice in utero, or neuromuscular conditions.
When the tongue is unable to properly suction to the roof of the mouth, it does not offer the functional stimulus required for the palate width to develop. There is nothing to counteract the inward forces of the lips and cheeks. At this time, the palate is very moldable and is distorted by this muscle imbalance.
The more severe the high palate, the more severe the dysfunction and less likely we can expect post release suction to be perfect.
However, tongue-tie release with excellent lactation or feeding support may be helpful to offer greater stimulation of the muscles to minimise the trajectory of problems.
It would be normal to expect that there will be some degree of structural and functional deficit that will have to be addressed as a child grows.
In the past, this high palate has not been that well recognised and often the first sign was dental overcrowding and addressing that with braces, sometimes pulling out teeth in the process.
The great news is that early recognition opens more opportunities for earlier intervention and optimisation of both structure and function earlier in subsequent years.
Reattachment refers to the tendency of wound edges to join back together in the absence of interference when healing. This occurs particularly quickly inside the mouth. Dr Lim perceives this to be the most significant risk of this procedure.
Post release, it is normal to expect that feeding will not all of a sudden optimise with tongue-tie release. There may be time for the muscles to develop tone and coordination. This is when the wound is healing most rapidly.
Dr Lim endorses stretches, or the application of light tension across the wounds by parents on a regular basis during the healing period.
This will help counteract the normal reattachment and wound contraction process, and preserve as much of the new potential range of mobility of the tongue as possible.
In addition, early optimisation of function with lactation or feeding support, bodywork and avoiding or at least minimising the use of dummies which hold the tongue down also plays an important role in minimising reattachment.
We will contact you within the next business day, and strongly encourage families to return for a one-week review at no fee to check wound management.
Following this, we are happy for you to reach out to us with any persistent concerns after you have sought lactation/feeding support and bodywork. Please feel free to
send us any other questions any time.
Dr Lim also encourages reassessment with our practice from age 4 years to flag other opportunities to optimise structure and function in the future.
Tongue Tie Information for Children and Adults
When tongue tie is not addressed during infancy, babies may adapt (for instance with a switch to bottle feeding or the use of a nipple shield) or compensate with overuse of other muscles and tongue ties remain hidden.
The oral dysfunction leads to poor resting posture, co-ordination and of the tongue, and may present as other functional concerns later in life.
Poor tongue tone and function ultimately plays out during sleep. When all the muscles are relaxed, the tongue is unable to properly perform one of its most important functions, to keep the upper airway or throat open.
Untreated tongue ties have now been linked to the development of mouth breathing, snoring and obstructive sleep apnoea in children and adults. These breathing difficulties lead to fragmented and unrestorative sleep, and in some cases oxygen deprivation. They have been linked to a whole host of physical, mental and emotional problems as well as increased risk of behavioural and learning difficulties in children.
What’s more, there may be overuse of the muscles of the neck or jaw to move the tongue. This may result in chronic neck tension, jaw pain or headaches.
What’s the solution?
A tongue tie release to improve mobility of the tongue may be one small piece of the puzzle to resolve breathing, speaking or sleeping issues in children and adults.
The treatment plan for tongue tie management begins with a review of concerns, a functional history and oral assessment.
Older children and adults will require a more comprehensive plan of action to prepare for best functional outcomes, and release will not be done on the day.
Futher Treatment Options
Myofunctional therapy refers to exercises aimed to improve the rest posture, strength and co-ordination of the tongue and other upper airway or throat muscles.
This therapy in conjunction with tongue tie release is particularly suited for patients from age five and upwards to help retrain normal muscle patterns and encourage full range of mobility of the tongue.
When this therapy is done pre and post tongue tie release, it offers the best functional outcomes and minimises scarring or reattachment of the tongue.
Myofunctional therapy has been proven as an effective adjunct to other treatments to reduce mouth breathing, snoring and obstructive sleep apnoea and myofascial pain.