July 3, 2024

Oral Restrictions Explained by a Lactation Counselor

Babies, Newborns

In last week’s post, I walked through our tongue and lip tie journey with our youngest daughter. I shared all of the signs that pointed toward her oral restrictions, some of which were clear to us and some that weren’t, and I talked through her frenectomy and what the stretches and healing were like from there.

As a mom and a pediatric sleep consultant, I’m often able to help point out when something seems off, but I don’t always know what it actually is; we need the professionals to help us figure out what’s really going on.

So this week, I’m sharing an interview with one of those professionals. Candy Baract-Donovan, a Certified Lactation Counselor with Like a Sister is giving us an even deeper dive into oral restrictions. She shares her personal experience with tongue and lip ties, as well as her professional experience, including:

  • Signs her own babies had oral restrictions
  • The most common signs that babies have oral restrictions
  • What parents should do if they suspect a lip or tongue tie
  • What it means to have a “mild tie”
  • Symptoms older kids have oral restrictions

And so much more! I learned so much from this conversation and I know you will, too.

Introduce Yourself

My name is Candy Baract-Donovan, I’m a Certified Lactation Counselor (CLC) and co-founder of Like a Sister with my real-life sister, Tiffany. Tiffany is trained as a postpartum doula, so together we help new and expecting parents in a variety of ways.

I had my third baby when she had her first and we really relied on each other a lot. We were talking one day about so many of the tools and resources we wished we had, and decided to totally change our careers and now provide those resources we wish we had!

One resource we couldn’t find was a great feeding class that did anything more than cover the basics of breastfeeding. So we created our feeding basics class to help parents understand all of their feeding options.

We talking about every point of the feeding journey, no matter what path you take (breastfeeding, exclusive pumping, combo feeding, etc.), as well as where things can get off track. Oral restrictions are unfortunately an area that usually gets those committed to nursing off-course.

Yes, sometimes we do have to change how we feed a baby, but for clients who really want to nurse, tongue ties or lip ties shouldn’t be the thing that ends the nursing relationship earlier than planned. All three of my kids had an oral restriction, so our feeding class shares information from personal and professional experience.

Share Your Personal Story of Oral Restrictions with Your Kids

I had my first baby 11 years ago and nursing went well for the first few weeks, but then nursing got incredibly painful. My baby was a happy and chunky baby, growing really well, so when I brought up my concern to the pediatrician, they weren’t concerned because he was doing great (pediatricians are the baby’s doctor, not mine!). It seemed like no one knew how to help me.

I then saw a lactation counselor through the hospital and she introduced me to Dr. Bobby Ghaheri’s work and research, and he’s all about oral restrictions.

I quickly learned that the pain I was experiencing was because my baby wasn’t able to extend his tongue appropriately to pull a lot of breast tissue into his mouth. So he was compressing with his hard palate and gums on my nipple. And as my supply regulated, he was essentially chomping to remove milk and it hurt!

So we finally had his revision done around six weeks old, which was a long time to be in pain. We did a laser frenectomy through a pediatric dentist and then did the wound care and functional exercises to help him heal well.

I had the same pain with my second baby and knew what was going on. So we waited a few weeks and then she had a laser revision, as well. Because I knew what was going on and what the aftercare would be like, it wasn’t as scary.

With our third baby, they noticed her heart-shaped tongue right away. Her tongue tie was so tight it was pulling back the tip of her tongue! This time, we went through an ENT for the frenectomy, and rather than a laser they clipped her frenulum, and she slept through the whole thing!

This taught me to not be afraid of either type of procedure, we made the right choice for each of our babies.

With all three babies, the aftercare was the hardest part, but it’s so important so the tie doesn’t reattach. And I find it’s more unpleasant for the parents than it is for the babies. And now I know more about the pre and post-work you can do to help your baby heal well and have better long-term function.

What are the most common signs that a baby has an oral restriction?

The tongue involves 8 different muscles that are used for eating, posture, sleep, breathing, and more – it’s a complex and lifelong system! When we are talking about oral restrictions, we are talking about tight tissue that restricts normal tongue movement. We all have a string of tissue, called the frenulum, under our tongues, but not everyone has a “tie”.

We go over this in-depth in our feeding basics class, but as a quick lesson…

When a baby nurses, they should have a lot of breast tissue in their mouth – not just the nipple and areola. The goal is for the baby to open wide, latch on up and over the breast so the tissue can expand fully in their mouth, and the nipple should be far back. And a good latch looks like a rocking motion as baby is feeding. This is why you can nurse a baby with teeth!

When a baby has an oral restriction, however, it’s as if they’re trying to drink a milkshake by chomping down on the straw. And it’s not supposed to work that way!

Common signs your baby might have an oral restriction include:

  • Pain for the nursing mom
  • Weight loss concerns
  • A recessed chin
  • A heart-shaped tongue
  • Neck creases/red folds in the neck
  • Lip blisters
  • Sleeping with the mouth open
  • Baby is unable to stay awake while feeding or hold the nipple in their mouth (a “lazy eater”) – transferring milk is a lot of work and some babies can exhaust themselves and burn more calories than they’re getting
  • Lipstick-shaped nipple after nursing- this shows that the baby is using more of a chomping motion than a rocking motion
  • Reflux, gassiness, or “colic”
  • Clicking noise while eating
  • Baby favors one side over the other (even during tummy time!)

It’s important to note that an oral restriction is not something you can simply see, it’s an anatomical issue. These symptoms could point to an oral restriction or they could simply point to a poor latch! So it really takes a village of providers working together to figure out what’s going on!

It’s also important to note that oral ties are not simply a breastfeeding issue; oral restrictions still impact bottle feeding, too! It’s actually easier to see restrictions on bottles because it’s harder to hold the nipple in and there’s not as deep of a latch.

Finally, I’m a firm believer that there’s no such thing as “nipple confusion,” just flow confusion. This is why I encourage parents to introduce the bottle early, and I am okay with using pacifiers. There is a right way to introduce those things and it shouldn’t disturb the nursing relationship with the baby.

If a parent suspects their baby has an oral restriction, what should they do?

There is a whole team of providers that can help when you suspect your baby has an oral restriction, and that team includes:

  • Lactation counselors
  • ENTs or pediatric dentists
  • Bodyworkers (chiropractic and/or craniosacral therapists)
  • Pediatricians
  • Occupational therapists
  • Speech and language pathologists
  • Physical therapists

We always want to see if there are non-surgical options first. A lactation provider can’t diagnose a tongue or lip tie, but they can tell you when something is going on and they’ll help point you in the right direction.

Even if they suspect a tongue or lip tie, it’s important that you don’t feel pressured to get a release right away. A good provider will recommend you try other things first, like craniosacral therapy.

Dr. Ghaheri talks about the importance of looking at risk versus reward. Are the symptoms now worse than they’d be after the release? If your baby isn’t symptomatic, he doesn’t recommend releasing simply due to the possibility it could cause speech or sleep issues down the road.

When seeking a provider, it’s also important to find someone who does not simply talk about wound care but also about function. A frenectomy is not a “quick fix,” because the tongue doesn’t know how to properly function. Some people say their baby had a frenectomy done but it “didn’t work,” and it makes me wonder if it wasn’t fully revised or if other work needed to be done beyond just the physical release.

What’s the difference between CLCs and IBCLCs and which do you recommend for oral restrictions?

CLCs are Certified Lactation Counselors and IBCLCs are International Board Certified Lactation Consultants. IBCLCs usually have clinical backgrounds.

Generally speaking, it’s not so much about the basic training or the title – those are just the tip of the iceberg. To really serve patients well, we have to not only get the continuing education that’s required, but pursue more because we want to keep learning. It’s important to me that a lactation provider is up-to-date with research and evidence-based care, and can speak with a lot of knowledge. They should also be willing to share areas in which they don’t know as much information.

Many people go into the lactation field because they believe breastfeeding is the best option; they see it as their job to promote breastfeeding. There are other lactation providers, however, who are there to treat the dyad, or the parent and baby pair; if something is off for one then it’s off for both. We help families function by helping them figure out what the right feeding choice is for them so everyone is healthy and happy and feeling supported.

If the pediatrician or lactation counselor said there’s no oral restriction but parents still suspect something, what should they do next?

I would wonder what type of exam was done and if someone physically looked at the baby and watched them eat, or if they only saw a picture. Did they feel around in the baby’s mouth? Did they say the tie was “mild?”

This is when we really need a bigger and more holistic picture of what’s going on. What are the symptoms? Why are the parents concerned? Is it pain for the parent, symptoms for the baby, or both?

As a general rule of thumb, I tell my clients that if they get an answer and don’t feel like they can adequately repeat back the “why” from the provider (when telling their husband or LC, for example), then I recommend talking to someone else.

I also want to make sure you find someone who you respect as a professional and who respects you as your baby’s parent.

This is likely one of the parents’ first opportunities to learn to be their child’s advocate and that only continues with time. If the parent is confident with their provider and feels like they have a path and plan forward, I’m not going to dissuade them. But if they’re coming back because something isn’t comfortable or baby still has symptoms, then we’re going to look at getting another opinion.

The next path I suggest is bodywork by a reputable chiropractor and/or craniosacral therapist – it can only help! If we see an improvement after tension is released from that bodywork, then something like a frenectomy might not be necessary.

What does it mean to have a “mild” tie?

Being restricted is all about function. What do they mean by a “mild” tie? Does the baby have a full range of motion or not? Are they mildly restricted in how they can use their tongue? Can they remove milk effectively? Can they rest their tongue on the roof of their mouth? Can they close their mouth when sleeping?

Saying a tie is “mild” just doesn’t give us a lot of specificity, so grading a tie isn’t super useful moving forward.

If the baby has great function but some sort of tie, there are stretches and exercises that they’ll likely do well with. Similarly, if there are symptoms of a tie but the baby is gaining weight appropriately and feeding is going well, functional exercises could be a great place to start.

If, however, symptoms aren’t resolving or you’ve hit a “plateau” of progress after functional exercises and bodywork, it’s time to look into a revision to get over that hump.

What are the symptoms of a toddler or older child with a tongue tie?

Some common symptoms of older kids having tongue ties include:

  • Picky eating
  • Poor dental health (the tongue’s job is to clear food!)
  • Sleep issues, such as snoring, open-mouth breathing, and apnea

Dentists who are informed on airway issues, as well as ENTs, are providers to look into if you’re concerned about your older child having an oral restriction.

Orthodontic appliances are often a helpful tool for older kids, however similar to getting a frenectomy, it’s not simply about the revision. A child might need a palate expander so their tongue can properly sit on the palate, but they will also need exercises to teach their tongue how to function well.

Myofunctional therapists are providers who often help with different tools and exercises to reteach the tongue and palate to work well together.

Is there anything else you’d like to share?

One thing that keeps people paralyzed when it comes to oral restrictions is that it’s scary to think your baby may have a surgical procedure done. The whole experience can be upsetting, and sometimes you see an immediate difference, but it can also take time.

I recommend you work with people who understand this fear and who don’t brush you off. Anything having to do with keeping your baby fed and nourished is so visceral, so we all need an empathetic care team who will listen and understand.

How can people connect with you and find your resources?

Check out our website and follow us on social media! Tiffany and I love to educate, so we have lots of resources on social media and our DMs are always open.

Our typical clients are really into research and planning and they are goal-oriented. We have a Postpartum Planning Toolkit that is an E-Book and workbook for customized postpartum plans. We also offer an on-demand new parent prep class as well as a feeding basics class.

We also now have a membership that parents can join for three months at a time. With this membership, you can meet other parents, join our monthly live Zoom calls, have access to all of our resources, access to us, and more.

Our one-on-one consulting also helps you once you bring your baby home. We have weekly check-ins, provide ongoing feeding support, and help you find other resources as necessary.

Our goal is to be like a sister to every client. We are judgment-free and evidence-based, and we’re not trying to sell a specific method, but helping you parent in your own way.