ORAL RESTRICTIONS & TONGUE/LIP FUNCTION EVALUATION

As a Speech Language Pathologist (SLP) and Certified Lactation Consultant, I am usually not the first stop on a breastfeeding journey. By the time a client finally finds me, they are usually frustrated and ready to give up. I am usually the “last stop” after many dead ends and false reassurances. 

Most of the time, the families who are finally referred to me have already been dismissed by their Pediatrician who has told them “everything is fine” without even performing an intra-oral functional exam. Many families have seen several other Lactation Consultants who have also completely missed the underlying issue. Lactation Consultants are skilled in basic lactation education and support, however most do NOT receive the additional intensive training required to properly identify significant oral dysfunction. Pediatricians (like most general medical practitioners) certainly do NOT receive specialized oral motor/function training, except for rarely some Pediatric Dentists or Pediatric Otolaryngologists who choose to specialize in Oral Restrictions. 

Untreated oral restrictions can present like “normal” benign infant issues such as:

🚩Reflux

🚩Gassiness

🚩Nipple soreness

🚩Low Milk Supply 

🚩Breast Refusal

🚩Inability to Latch

🚩Colic

🚩Neck muscle tightness/Torticollis 

🚩Sleep disruptions 

🚩Slow Weight Gain 

🚩Mastitis/Plugged Milk Ducts

🚩Suck Blisters

🚩Milk leaking from Breast or Bottle

🚩Biting on nipples

🚩Recessed Mandible/Jaw Tension

In isolation, many of these complaints can easily be dismissed as just “normal breastfeeding issues”, when they are actually symptoms of oral dysfunction. Many professionals will try to address each issue individually which will lead to many dead ends without addressing the underlying issue. Without finding the RIGHT feeding specialist who is skilled and knowledgeable in assessment and identification of Oral Restrictions, many women are forced to give up breastfeeding altogether. Had this mom not found me when she did, she and baby would not have been able to sustain a successful breastfeeding relationship. 

Other warning signs for older children include:

• food still left on the spoon (upper lip is unable to clear the spoon due to restricted labial range of motion)
• gagging
• coughing
• choking
• not attempting to self feed
• continued used of suckle pattern
• unable to use a straw or open cup
• dental problems such as cavities
• food left between the teeth and cheek
• grazing
• one side chewing 
• poor weight gain.

⚠️If the ties continue to remain untreated, children may have difficulty with speech since the tongue and lips cannot form the proper positions to create certain sounds. Sounds like K, G, NG, SH, CH, TH, T, D, N, L, R, S and Z will most likely be affected.

⚠️And lastly, in children and adults, some common problems include TMJ disorders, frequent headaches, migraines, braces, palate expansion, chronic dental issues, and chronic neck pain. 

Oral assessments can be broken down into 3 parts:
Functional | Visual | Structural

The Functional Assessment

The functional component of the oral assessment is, in my opinion, the most valuable and needs to be done first! The functional assessment involves assessing what your baby physically can and cannot do with their oral anatomy. Functional assessments are carried out in one of two ways, In-Person or Virtual:

1. With an in-person visit: I’m going to pop on a glove and feel around in your baby's mouth. I have a series of short exercises I do to check your baby’s range of motion and reflexes to see if there are any issues with function and to check their oral reflexes.
2. With a virtual session: I have you complete these exercises yourself (don’t worry, I give you instructions that are easy to follow) and answer questions to gather this data. Typically, I prefer to do this before the session so that we have time to do the exercises while your baby is nice and happy to get the best information possible.

The Visual Assessment

The visual component of the assessment involves looking at your baby’s oral anatomy and watching how they are using their oral anatomy to meet their needs. Babies are fantastic at finding ways to work around their challenges which are called compensations. Visualizing their oral anatomy and watching how they feed and compensate at the breast and bottle are absolutely necessary to shape a care plan, but without the functional component, the visual assessment alone often fails to provide lasting solutions. It is also possible to misattribute something you see visually as a problem when the functional assessment may show that, regardless of how it looks, it’s not actually an issue. During the visual component of the assessment, we often trial different positions and techniques to see if we can alleviate the challenges with these strategies.

1. With an in-person visit: This is accomplished by watching you feed your baby at the breast and the bottle. I also visualize your baby’s oral anatomy during the hands on exam to make sure I have seen how the anatomy is structured.
2. With a virtual session: We use videos of your baby crying, videos of you doing an oral assessment maneuver so I can see the frenulums (again, I give you easy to follow instructions), and videos of feeding at the breast and bottle. Some of this we may repeat on a live video call, but I prefer to get video beforehand so that I know we see what we need to see, and we can spend our time together finding solutions since we gathered the data (and likely the answers) beforehand.

The Structural Assessment

The structural component is where we look at the baby’s full anatomy from head to toe. Baby’s are full body eaters, and what’s happening in their bodies is often manifested in their mouths and vice versa. So, we are looking from head-to-toe to see what is going on with your baby’s posture, tension, muscle tone, and reflexes. We are checking for obvious concerns with tone, or issues such a plagiocephally, or tortocollis, as well as the less obvious concerns that can be easily missed by the untrained eye. We check infant reflexes to make sure they are presenting in an age-appropriate fashion.

1. With an in-person visit: This may be accomplished by assessing the baby in live time, or by photos and videos submitted ahead of time. With my practice, I prefer to do all of the same paperwork ahead of time with pictures to review so that I can focus my assessment. The more focused the assessment, the quicker we can get you the answers you are hoping for. It also allows me to assess your baby’s anatomy over several different positions to check for consistent, atypical positioning.
2. With a virtual session: We do the photos beforehand so that we can make sure I have been able to see everything before the session in case baby is not tolerating the camera well, or the connection is unstable. Oftentimes, I am looking for very subtle misalignments and asymmetries, so relying on a video consultation to achieve this isn’t a good plan in my experience.

CONSEQUENCES OF UNTREATED TONGUE TIE:   

Taken from; Tongue Tie – from Confusion to Clarity by Carmen Fernando

For Infants:

• Impact upon milk supply
• Termination of breastfeeding
• The baby failing to thrive
• Poor bonding between baby and mother
• Sleep deprivation
• Problems with introducing solids

Maternal Experience:

• Pain
• Nipple damage, bleeding, blanching, or distortion of the nipples
• Mastitis, nipple thrush or blocked ducts
• Severe pain with latch or loosing latch
• Sleep deprivation from baby being unsettled
• Depression or a sense of failure

For Children:

• Inability to chew age appropriate solid foods
• Gagging, choking or vomiting foods
• Persistent food fads
• Difficulties related to dental hygiene
• Delayed development of speech
• Dental problems starting to appear
• Strong incorrect habits of compensation being acquired
• CHECK OUT OUR TINY MYO PROGRAM - which focuses on Early Intervention for Speech, Feeding and Myofunctional Therapy for children ages 2-4

For Adults:

• Inability to speak clearly
• Clicky jaws
• Pain in jaws
• Migraines
• Receding jaw
• Effects on social situations, eating out, kissing, relationships
• Dental health, a tendency to have inflamed gums, increased need for fillings and extractions
• Difficulty keeping dentures in place

If you have any concerns that your baby or child has an Oral Restriction (Tongue Tie), please schedule an assessment.