In older babies, children and adults with a tongue tie, compensatory oral habits may be present. During pregnancy, a baby swallows amniotic fluid with a tongue tie, which means that hiccups may already be present. An older child and adults have exhibited compensatory behaviors for years as surrounding muscles and tissues compensate for the limited functional movement of the tongue. Think of moving food in the mouth from side to side, swallowing well without choking, wiping your teeth after eating and talking. Often the patient swallows with his tongue forward instead up and back, which is called a tongue thrust. This can affect the position of the teeth, jaws and the overall body posture.

The preparation for a treatment is therefore twofold:

1. Compensatory movements in the head and neck region can be quite “stuck” and therefore better checked and treated by a special therapist before a tongue tie release. We hear from patients that they have this done by a physiotherapist, manual therapist, orofacial therapist, chiropractor or osteopath for complaints such as incorrect posture, stiff neck, jaw clenching, grinding and headaches. Treating a tongue tie alone is not sufficient if the surrounding muscles keep the compensating behaviour and restrict functional movements.

2. Treatment also improves if the patient goes to a specialized speech therapist in OMT (oromyofunctional therapy) before and after the treatment. This can help to analyze incorrect oral habits and swallowing and train or unlearn these. If an OMT speech therapist is not available, the Kieferfreund app is an option to train and practice (see www.kieferfreund.com and https://www.tonguetieclinic.com/tongue-tie-therapy/https://www.tonguetieclinic.com/tongue-tie-therapy/)

After the release, you may notice things that may last a little longer, such as lip swelling, drooling, gagging, or other discomfort or peculiarities.

* Granulation tissue; This is a small lump of extra scar tissue that can form on the wound. If you suspect you see this, send a photo, it is not serious and if it is a hindrance to drinking it can still be removed.

* Drooling; Because the swallow has to be learned again after tongue tie release, it is possible to notice drooling for a while in a child or baby.

* Reattachment; After the treatment, the wound simply wants to heal with scar tissue.  With doing aftercare you hope the wound does not close too quickly or too tightly. If too much reattachment occurs, the tongue or lip mobility can be limited again. When you live abroad it is the adviceble to check the healing with somebody knowledgable in a week, that can also be done at our clinic if you can stay a few days, but has to be arranged with making the appointment for treatment. In The Netherlands you can call the Tongue Tie Clinic for an appointment.

* Muscle pain; After the treatment the adults and older children notice (muscle) pain or discomfort in the jaws, tongue and throat sometimes as well. See the FAQ about pain relief.

* Baby spits more; Because the baby drinks more effectively, it may be that the stomach is not used to the amounts and it spits back up, but it may also be that the baby is still drinking air for a while.

* Smelly breath / mouth; We sometimes hear this from parents and can last from a few days to a week, it’s ussualy no problem whatsoever.

* Swollen upper lip; This can last for up to 5 days after lipband treatment.

*  Quivering jaws remain visible longer; Because the tongue, after it has come loose, many of the muscles still need to be trained, it may be that the compensation continues with the jaw muscles, but compensation behavior may also need a chiropractor or manual therapist to remedy it. See the FAQ about compensation behavior and videos explaining this.

* You have to help lips flange out; The baby is not used to flanging the lip, this may be helped.

* Suction blisters still present; They can be present for longer, especially on the upper lip.

* Crying doing aftercare; What we hear from parents and notice at the aftercare consultation that the baby cries with the aftercare exercises, but stops as soon as you stop or start feeding or changing diaper and such.

* White plaques/debris on tongue still visible; Because the palate is often high and the tongue is not well trained to stay up, even at rest, the white plaques/ debris on the taste buds remains.

* Bottleteat; We notice that the teats with a broad base cannot go deeper into the mouth, so a teat that can go deeper and gives more mouthfilling, such as the smaller, narrower types, is often better.

* Baby stays upset longer than 48 hours, crying, drinking worse. In the older baby who has had to compensate for a long time with a tongue tie. Before the treatment, often these babies were fussy and drinking poorly and found there own “technique”. Treatment of compensation behavior is often necessary. See FAQ compensation behavior. People often give painkillers for longer. But one also has to take into account a normal virus infection occurs at the same time. You can go to the doctor with a fever, see the FAQ about fever.

* Gagging may still be present after the release.

* A baby cannot swallow the tongue after the release.

* Apnea are also observed in babies . It is not directly related to the release. Tongue tie can be related, read the research.

Providers use a classification system to describe the tongue tie. This system only indicates where the tie is attached between the floor of the mouth and tongue. Providers usually use four classifications of Coryllos  or Kotlow, (see pictures below).

Type 1:

The anterior tie is easy to see when the baby cries or tries to lift up the tongue. It can also be felt with your finger under the tongue. It is attached all the way to the tip of the tongue. Very often it makes a heart-shaped tongue when the baby cries or tries to move it.

Type 2:

The anterior tie is a little further from the tip of the tongue. It is also felt like a guitar string or easily seen when the baby cries or tries to lift the tongue. The tongue stays low in the mouth when the baby cries or tries to move the tongue, very often you see a bowl- shaped tongue when crying (only the edges move up).

Type 3:

The posterior tie is further away from the tip and can be made visible by using a special tool, the groove director, or by using your two index fingers that push back the mucous in the direction of the throat and lift up the tongue simultaneously. The tongue stays low in the mouth when the baby cries, tries to move the tongue, or shows indentation or creases, very often you see a bowl shaped tongue when crying (only the edges move up). With your finger you can feel a “speedbump” or guitar string further back.

Type 4:

The posterior tie is not visible, but “hidden” behind the mucous. It can only be shown with the groove director or with two index fingers that back push the mucous in the direction of the throat and lift up the tongue simultaneously. The tongue stays low in the mouth when the baby cries or tries to move the tongue, or shows indentation or creases, very often you see a bowl shaped tongue when crying (only the edges move up). With your finger you can feel a “speedbump” or guitar string further back.

Depending on the size and spread over the jaws, there are two options:

Pearl of Epstein:

These are small thickened inclusion cysts on the palate, but can also occur on the gums or palate. Usually seen as multiple, white, rice grain large elevations in the vestibular (lying against the cheek) mucous membrane of the upper jaw (alveolaris processus). They are small cavities filled with fluid, (cystic nodule) covered by a thin epithelium (layer of skin) and filled with keratin (a type of protein).

The Epstein pearls are completely harmless, do not hurt, do not need to be treated and disappear spontaneously. Treatment is therefore not necessary.

“Bohn’s” nodules (hard bumps):

These are white-like bumps spread over the entire upper and / or lower jaw (see photos). The exact aetiology is unknown, but it is suspected that they arise as a remnant of the dental lamina or of heterotrophic salivary glands. They can be present over the entire lower or upper jaw or on the palate (palate). These hard bumps are benign and disappear over time. Treatment is therefore not necessary.

Sometimes other normal anatomical structures are being noticed. It often concerns bulges or ridge on the floor of the mouth and they have nothing to do with the tongue tie.

There is a lot of discussion about determine and treating the types of tongue tie and / or lip ties. Sometimes there is no clear membrane visible under the tongue and parents are sent home by the doctor without treatment, while a “hidden” tongue tie is the cause of feeding problems. Therefore, the classification does not determine the severity of the feeding problem, it only determines the degree of attachment.

The classification that is generally used is Kotlow his classification of the lip tie (1 to 4) and Coryllos her classification of the tongue tie (1 to 4) (see frequently asked questions what does a liptie or a tongue tie look like).

Tongue tie:

• Heart-shaped tongue;
• Indetation in the middle
• During crying a low tongue position with sometimes a dent or a bowl shape;
• White debris from halfway the tongue to the back

Liptie:

• Suction blister upper lip in babies;
• Bloodless and red/ white line under nose when drinking babies; (see photo)
• Blanching attachment of tie on the edge of the upper jaw (see photo);
• A diastema when teeth come through

• Signs of restricted mobility of the muscles of the tongue and the upper lip:

Due to the tie the tongue can only move the front and sides a bit. The tongue cannot go up and back properly, difficulty latching on, drawing in the nipple deep. While very often at the same time the upper lip cannot flange out over the breast, because the tie pulls it inward. So the baby slides off easily. Resulting in small latch, letting go of nipple. Latching on and drinking difficult or only works with a nipple shield or bottle. Falling asleep at the breast or bottle, frustrated, doesn’t seem to want to drink, doesn’t empty the bottle.

• Signs of compensating due to restricted mobility of the tongue and lip tie:

Tries to hold on to the breast by clenching jaws together. Uses cheek muscles to draw milk. Mother experiencing pain especially at latching on. But not always painful, also just sucking really “hard” or “strong”. Chin quivers from jaw muscles tension. Sucking blisters on lips from friction. This compensating is weary for the baby and especially in compromised growth or premature babies it’s a shame it costs energy. Sometimes babies are called lazy drinkers.

Nipple should come out round, but comes out flattened, with blisters, discoloured and sore. “Raynaud” like symptoms from diminished blood flow to nipple.

• Signs of compromised ability to get sufficient milk:

Due to the baby’s restricted mobility, only suckles at the nipple and hardly at any breast tissue. There is too little milktransfer as a result. The baby draws in the nipple as if sucking in spaghetti, hangs on nipple like a “cliffhanger”, often pulling and moving the head in an attempt to pull out the milk, sometimes using hands to pull the breast in older baby’s, drinking suddenly painful when teeth come.

Baby doesn’t “empty” the breast (or bottle), drinks often to get enough milk. Plugged ducts, overproduction from drinking often, compromised production in the end.

Baby loses weight more than 7% in the first days, getting back to birth weight takes more than 10 days. Growth stagnates after weeks or months when production decreases. Babies don’t always show; they save energy by sleeping long for example. A sign could be very few poop diapers.

Baby only drinks the “easy” milk, during the milk ejection reflex.  Drinks short or very long. Only making the chin tug and drinking when MER or giving breast compression or supplementing at the breast.

• Signs of compromised possibility of making a good seal:

Due to the low tongue position, often high palate and the upper lip not flanging out completely over the nipple, bottle or breast, your baby cannot make a good seal and loses suction, you can hear clicking sounds. Also very loud drinking, gulping it down and choking. Complaints of swallowing air.
The swallowed air needs to go somewhere; it goes up or down. Burping, hiccough, spitting, windy, colic.  GER or reflux with or without spitting (hidden reflux). In hidden reflux the baby tries to keep the milk down by swallowing again, sometimes forgetting to breath momentarily. During feeding it can be very uncomfortable for the baby and can become restless.  It’s difficult to put the baby down to sleep. Parents walk with their baby until symptoms subside. The baby can experience pain from the stomach acid in the oesophagus. GERD. Sometimes medication is given which lowers stomach acid.

Thrush is often confused with tongue tie problems. Although you can see it both at the same time. The tongue may have debris in the papilla (from day of birth) due to the fact that the tongue hardly touches the palate so it doesn’t “rub clean”. Pinching and stabbing pain can be from thrush or compensating behaviour from tongue and lip tie. In tongue tie you can see white debris on the posterior part of the tongue behind the tongue tie, the front of the tongue rubs clean against the inside of the upper maxilla. Thrush is a “pearl white” shine or white plaques on the inside of the lips and on the mucous membranes of the inside of the mouth.

*Note that not all symptoms have to be present at the same time.

The midwife, lactation consultant, maternity care nurse or speech therapist, may have told you about the possible functional problems in babies and children due to a tongue tie or a lip tie. The knowledge is also shared among parents through the internet.

A tongue tie is not always easy to see, especially if it is deeper under the tongue. Not every doctor, midwife, lactation consultant IBCLC or maternity care nurse has enough experience to assess this properly. It is wise to find a practitioner with experience in this area. A lactation consultant IBCLC who has experience in assessing the tongue tie and lip tie may be able to assess it.  After doing an oral examination she may even find the tie “hidden” behind the oral mucosa. When in doubt, make an appointment with a lactation consultant or a practitioner with experience. Sending a photo is possible for review, but can never provide a definite answer.

Pediatrician Dr. James Murphy (link) came up with the following method. When the finger slides under the tongue, it should be easy and smooth. If it is difficult to move from left to right under the tongue over the floor of the mouth and a “string”, “speed bump” or “fence” is felt, this may indicate a tongue tie.

When the baby is crying, and the tongue stays down, it could be caused by a tongue tie actually pulling the tongue down. Sometimes only the sides of the tongue rise so that the tongue makes a bowl shape.

The upper lip should be able to flange relatively easily. If the lip is lifted and gently pulled, and the upper jaw turns bloodless where the lip tie is attached, that may be an indication of a lip tie. This test is also called “blanching” or anaemia test (see photo).

We also have this comprehensive checklist.

Mother:

• Pain latching on (not always), damaged nipples, nipple gets flattened after drinking or is discouloured (sometimes Raynaud) ;
• The use of a nipple shield, otherwise latching on not always possible;
• Baby cannot drink the breast well, causing clogged mammary glands or inflammation of the breast (mastitis);
• In addition to breastfeeding, formula feeding is required or the mother needs to pump to get production going.

Babies:

• Clicking sound (releasing vacuum);
• Baby cannot open mouth wide, sucks only the nipple in;
• Baby drinks very “forcefully”, sometimes bites, or clamps with the jaw;
• Drinks restlessly / impatiently at the breast or is quickly tired; Drinks briefly, releases a lot, or drinks “all day” on the breast;
• Drinking a lot of air, reflux symptoms, colic, spitting, burping, distended belly, wind;
• Moderate growth of the baby;
• Because the tongue does not reach the palate can up moving the palate sometimes remains high. This may give less space in the nose, making the baby appear to have a cold and continue to breathe through the mouth.
• Because the baby has difficulty fully using the tongue, a white deposit remains on the tongue. This is not a thrush, but taste buds with plaque (see photo);
• Babies with a tight lip tie where the front teeth come through around a year,  sometimes get problems with feeding again and “bite”.

Children:

• Problems with the pronunciation of letters where the tongue has to be raised to the palate. Unclear speech. Eating solid food gives problems when the bolus of food cannot be moved well in the mouth from left to right and from front to back and is difficult to swallow. The child pushes his fingers, or leaves the food in the cheeks or chokes. Some little ones refuse certain textures or “pieces.”
• It is difficult to lick the rear molars, which can cause cavities. Brushing teeth is difficult, especially if a lip tie is present.
• Or have middle ear infection, because they do not properly empty the Eustachian tube when swallowing.

More good information on www.drghaheri.com.