- A congenital condition characterized by abnormally short, thickened, or tight frenulum, or an anterior attachment, that restricts mobility of the tongue and/or lip.
- Variably causes reduced tongue mobility and has been associated with functional limitations in breastfeeding, swallowing, and speech.
- Orthodontic problems including malocclusion, open bite, and separation of lower incisors,
- Mechanical problems related to oral clearance and psychological problems.
- It is also implicated with Aerophagia Induced Reflux.
- AKA – Ankyloglossia/Tongue-Tie. Buccal-Tie. Lip-Tie.
- The restriction is a functional Visual degree not considered severity.
- In the competition between muscle and bone, muscle always wins.
- Present in 15-25% of newborns.
- TOT accounts for 25-60% of all breastfeeding problems in newborns. (REF?)
- Attached from the very tip of the tongue to 4-5 mm from the tip with a sail
- Attached 4-5 to 10 mm from the tongue tip with a sail; but can be submucosal without a sail.
- Attached 4-5 to 10 mm from the tongue tip without any visible membrane above the mouth floor
- Attached >10 mm from the tongue tip with no visible membrane above the mouth floor. It is all Submucosal.
Breastfeeding: Success / Postures / Pain
- Difficulty/inability to achieve a deep latch
- Latch pain &/or burning (50% tongue tie have pain. 50% don’t.)
- Difficulty swallowing fast flowing milk (rapid letdown or bottle held upright). Pulls away.
- Frequently falling off the breast, +/- a click
- Tires while feeding (falling asleep briefly & feeding all the time or crying in frustration)
- Milk supply does not increase in volume at the expected time (or ever)
- Milk is not removed leading to engorgement, plugged ducts, mastitis, or abscess
- Lip Stick Deformity – typical of anterior tongue-tie (MC deformity)
Other Hx Indicators
- Struggles with weight gain
- Urine and stool output are poor; stool remains a dark green >5 days; risk of jaundice
- Choking, grunting or crying when lying on the back (diaper changes, sleep)
- Frequent emesis or “apparent” GERD (in part due to AIR)
- Extreme Anxiety needing bouncing every waking moment, especially during nursing
- Inability to use a pacifier successfully due to the poor seal – often forcefully ejected
PHYSICAL EXAM FOR TOT
- Recognize At-Risk Oral Anatomy
- Perform a Simple Suck Assessment
The Oral Exam
- Every newborn should be examined for:
- Ability to open the mouth widely
- Tongue rising above mid-mouth (when crying)
- Tongue able to extern past the lower lip (1cm)
- Symmetrical seating of the mandible
- Intact hard and soft palates (note shape, pockets, symmetry)
- Upper and lower lips intact and evert easily
- Finger sweep under the tongue
- (Especially a single upper tip blister.)
- Visible midline membranes & tongue shape
The Organized Suck Pattern
- With your 5th finger upside down in the infant’s mouth you should feel:
- Good seal & suction (no air leak & pulling finger back moves the infant’s head)
- A strong rolling undulation wave from the front of the infant’s tongue to the back
- Peristaltic movement of tongue initiates that throughout whole GI tract.
- No snap-back.
WHAT THE HECK IS A FAUX TONGUE TIE?
- Look like tongue tie but respond to alternative Tx. Sx same (functional impairment) but no actual TOT. Usually due to birth strain.
- Birth Trauma– Cranial deformity from in-utero pressures indicate body muscular and/or fascial tightness that make it difficult for the newborn to turn/rotate the head in all directions needed for effortless breastfeeding. This mimics many of the features of a true tongue tie though the tongue function may be entirely normal. [Faux Tongue Tie]
- Actual & Faux Tongue Tie– After a complete release of all restrictive elements and demonstration of perfect tongue function, the infant may not improve at all when put to the breast. When a highly skilled lactation specialist cannot latch an infant who has had a complete tongue tie released, muscle/fascial restriction is almost always cause.
GERD VS AEROPHAGIA INDUCED REFLUX (AIR)
- Over 50% of infants with GERD resolve after TOT revision
- Swallowed air distends the stomach making emesis more likely
- A poor seal at the breast may be due to tongue tie, upper lip tie, or both
- Aerophagia is reduced substantially by a deeper latch and by “fish lips”
- Avoiding Rx
Reduced acidity in infant GI árisk of infection & âcritical nutrient absorption.
Clove Essential Oil 1d/10mL coconut oil on Q tip to wound for 10 sec before EX
Article on Aerophagia and ULT: Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie) by Scott A. Siegel
DECIDING FACTOR: FEEDING
- Visual degree not considered severity. Impact on feeding & function determines Tx.
- Rule #1: Feed the baby!
- Surgical: No difference between lazer and blade in literature
- Likely depends primarily on practitioner expertise
- True RCT not possible.
- Cohort and case series studies look very positive in terms of breastfeeding success and long-term tongue ROM.
- Difficult to assess speech.
- Impact on nipple pain consistently higher if revised in 1stweek of life
- Wound care. (See Drghaheri.com – videos on wound care)
- Oral aversion tends to occur more if paranoid about it
- Minor bleeding is MC reported
- Vitamin K shot at birth? Von Willebrand Disease unDx at that time
- 1 of Dr S’s patients had excessive bleeding after blade revision by Dr B.
- Fixed vs. Dynamic Notch - Fixed notch doesn’t go away right away
- Immediate Improvement vs Retraining Time (3-8 weeks)
WHY FOLLOW UP WITH MANUAL CARE IS RECOMMENDED
- Connectedness of fascial and connective tissue structures
- Immediate change in superficial ST after surgery
- Complete the adaptive release of tethered tissues
- Support healing with full and functional ROM
- Treatment of “Faux Tongue Tie”
MANUAL CARE FOR TOT
- THERE ARE THE BONES OF THE CRANIUM THAT PRIMARILY EFFECT SUCK:
- Frontal: Shifts so one side is slightly prominent after feeding.
- Occipital: Major impact on CN due to foramina
- Parietal: Often rigid. Consider sagittal suture restriction. (midline tether)
- Temporal: TMJ implications
- Sphenoid: Rocks sella turcia to stimulates pituitary to release GH during BF
- Palate: Impacts suck response and latch directly
- CRANIAL NERVES THAT EFFECT SUCK
- Hypoglossal nerve (XII) - Hypoglossal Canal (occiput)
- Controls tongue movement (motor only)
- Patterns necessary for latch and suck
- Travels through the hypoglossal canal
- Disruption of the occipital segments can lead to nerve entrapment causing ineffective, mis-patterned, loose muscle control in tongue.
- Glossopharyngeal (IX) - Jugular Foramen (occiput/temporal)
- Sensory fiber post palate and tongue
- Travels through the jugular foramen
- Gag reflex!
- Vagus (X) - Jugular Foramen (occiput/temporal) & C1
- Sensory fibers control the larynx, heart, lungs, trachea, liver, and GI tract, and external ear
- Motor fibers control the larynx, heart, lungs, trachea, liver, and GI tract
- Poor suck with a high-pitched squeal during feeding
- CAUSES OF CRANIAL MISALIGNMENT THAT MAY AFFECT SUCK
- Fetal position in utero
- Birth process - too fast, too much pressure, malposition
- Birth Interventions
- Forceps – Direct & forceful cranial compression. Consider TMJ.
- Vacuum – Hematoma. Usually less harmful than forceps. Depends on technique.
- CS – Statistically less likely to BF. Consider cranial stimulus during passage, potential in-utero malposition, & excess forces/distress.
- TOT – Soft tissue tether points impacting cranial symmetry and restriction patterns.
- Hypoglossal nerve (XII) - Hypoglossal Canal (occiput)
INDICATORS THAT CST AND CHIRO CAN HELP WITH BF
- Asymmetry of cranium
- Gag response
- Favours a breast.
- Looks toward 1 side
- Takes a long time to nurse. Exhausting. Never satisfied.
- Always hungry
- TOT – tethered oral tissue
- Excessive gas
- Arching in frustration. (Dural tension & ANS)
- Always starts a full assessment. Treatment with intention requires understanding.
CMT: RULE OUT AND TREAT
- Torticollis or lateral flexion restrictions (ST & JT)
- Rotation restriction or malposition (C1!!)
- Severe TMJD
- Feeding Rhythm: Breath, suck, swallow.
- Temporalis mm should be engaged.
- Should not be furrowed/angry.
- Distract jaw and lift frontal bone while feeding and see if it helps.
- Internal & external STT
- CMT: manual (SH/HVLA), AM, DROP
- Sacral malposition
CST: TREAT WHAT YOU FIND
- Address global tension pattern in dural system first.
- Requires correction at C1/OCC first. Foundation.
- Palate symmetry
- Especially sagittal. Cf Midline defect.
- TOT stretches
- Palate pressure
- TMJ support (external only)
- Tummy time (hate tummy time = red flag
- 1 mo 15 min total a day
- 2 mo 30 min
- 3 mo 1 hr
- Corrective care (torticollis, rotation restrictions, etc.)
- Support for Milk Supply. (See blog)
- Perinatal mood disorders (Stress, sleep, support)
- CST together (So great!)
- BF training or retraining (for mom & babe)
- Nipple healing (see photos in slides
- Consider lazer treatment (Rutland Physio)