A tongue tie is a condition in which the tongue is tethered to the floor of the mouth by a membrane (frenulum) which restricts mobility of the tongue. It is classified based on the location on the tongue to which the membrane attaches, from Class I to Class IV. According to Dr. Bobby Ghaheri (an ENT specializing in ties), all anterior (Class I or II) ties have a posterior component as well. Lip ties are restricted tissue under the midline of the upper lip and are classified in a similar manner. The class of a tie based on its attachment to the tongue has little bearing on how severely it may impact function. A class IV tie can be just as detrimental to function as a class I, though posterior ties are more likely to be overlooked.
A complete release of a restriction should result in a diamond shaped wound, pictured below:
What are the options for treatment?
Release of tongue and lip ties is always an elective surgery. Families should be educated on their options to make the best decision for them.
- Do nothing
- Oral motor therapy (with OT or ST)
- Pursue revision: best outcomes with OT/ST and lactation support following procedure
The functional impact of the tissue under the lip or tongue is the most important consideration vs. the appearance of the tissue.
Though frenotomy is a low risk procedure, it is important to note that is NOT a “quick fix,” especially for infants and children who have complex issues surrounding feeding and speech development.
What is the role of Occupational Therapy/Speech Therapy in babies/children with ties?
Prior to revision procedure: Families often benefit from getting established with an occupational therapist or speech therapist (OT or ST) prior to a procedure so they can be educated on the necessary active wound management to follow and can get into a routine of oral motor exercise.
Post revision procedure: Occupational therapists and/or speech therapists work on strength, coordination, and active wound management to enable improved function with feeding and/or speech skills. Active wound management refers to the process by which the wound is “stretched” multiple times per day following a procedure to prevent reattachment and to promote vertical healing of the wound, resulting in improved mobility. The wound healing process takes an average of 3-5 weeks for most children. The duration of time in therapy following a procedure varies widely, but is often shorter for young infants. The older a child is, the longer they have had to develop maladaptive compensatory strategies to counteract their restricted range of motion prior to the procedure.
Without revision procedure: OT or ST can provide oral motor therapy to maximize a child’s function with available lip and tongue range of motion; however, the baby or child may hit a “plateau” in progress without revision depending on how much the restriction is impacting function.
In a breastfeeding dyad, the mother’s symptoms are as important as the baby’s symptoms! Weight gain is not the only marker of successful breastfeeding. Some babies with ties may gain weight effectively, particularly if mother has an abundant supply or overactive letdown. Things must be working efficiently for both parties for optimal development and to sustain nursing.
Tongue and lip ties are not the only culprit of breastfeeding issues, but they should be considered if a dyad is having problems that are not resolved with lactation support or therapy support. Tongue and lip ties do not stretch over time; they are comprised of tissue that is not responsive to stretches.
Please see the following recommended parent resources for more information on tongue and lip ties:
- Louisiana Tongue Tie Support Group Page on Facebook
- drghaheri.com A blog by Dr. Bobby Ghaheri, ENT, a widely known expert on tongue and lip ties, which contains multiple articles on the impact of ties on breastfeeding
Articles of particular interest on Dr. Ghaheri’s website include:
- “How Does Tongue Tie Affect Breastfeeding Mechanics” https://static1.squarespace.com/static/52ee7826e4b07fbe8885e2ab/t/53349265e4b08e81fa54f4f4/1395954277229/How_Does_TT_Affect_Breastfeeding.pdf
- “How Does an Upper Lip Tie Affect Breastfeeding”
- “How to Choose Your Provider”
- “The Myths About Painful Breastfeeding”