All about oral restrictions

by | May 26, 2020

Oral restrictions can make breastfeeding your baby very difficult. Lactation consultant Samantha Crompton explains what they are, and what you can do about them.

Your little one’s tongue plays an important role in their dental health. Even before birth, the tongue helps to develop straight healthy teeth – unless your baby is born with an oral restriction or tongue-tie symptoms, which can be identified in the first moments after birth.

What are oral restrictions?
There are three common types of oral restrictions that we see in babies: tongue ties (ankyloglossia), lip tie and buccal ties.

Tongue-tie, by definition is the embryological remnant of tissue in the midline between the lower surface of the tongue and the floor of the mouth, that restricts movement of the tongue. Everyone has a frenulum – a small fold of tissue that secures or restricts the motion of a mobile organ in the body – under their tongue, and normally this is made up of mucous membrane. If there is a tongue tie, however, the frenulum can be made up largely of collagen, which stretches very little (max 3%).

Lip tie ‒ which is less common ‒ is attachment of the upper lip to the gum tissue, and buccal ties are the least well known, and most uncommon. These are tethers extending from the cheeks to the gums.

Normal oral functions in babies
Normally, when a baby’s mouth is open, he should be able to elevate his tongue and maintain this elevation, move the tongue side to side (lateralise the tongue), cup and spread the tongue.

During feeding, the baby opens his mouth wide, and his lips create a seal to help create a vacuum. The tongue then curls around and cups the breast, creating a seal. The baby then lifts and drops his tongue to create a vacuum to remove the milk from the breast.

The tongue also grooves to help control the bolus of milk. Cheeks, jaw and facial muscles help stabilise the breast and help the tongue to drop and draw out the milk. The palate plays an important role in creating the vacuum, also closing off the nasopharynx [the juncture of the back of the nose and the throat] for swallowing.

If there are restrictions or problems with any of these areas, it can affect how effectively the baby is able to remove the milk from the breast and affect the breastfeeding relationship.

Symptoms of oral restrictions
In babies, symptoms of oral restrictions can be varied, but include irritability or colic, coughing, choking and gulping during feeds, being tired and falling asleep at the breast most feeds, difficulty latching, being gassy or having excessive wind, sliding off the breast and continuing to have to relatch, gumming, chewing and clamping down on the breast, clicking noises or poor suction noises, poor weight gain or weight loss, and reflux.

These symptoms can be masked at times if the mother has an oversupply of breastmilk or if the baby is being topped up with expressed breast milk or artificial milk.

Mothers also have symptoms if their babies have oral restrictions, and these are as important as the baby’s symptoms and must be assessed. These can be cracked, blistered, bleeding and painful nipples. The nipples also look pinched, creased, bruised, or they have abrasions after the feed. A white stripe on the end of the nipple, discomfort or pain while breastfeeding, low milk supply, and plugged ducts, mastitis, and thrush are further symptoms. Often mothers feel general frustration with feeding and dread the baby waking up to breastfeed.

Many of these symptoms have a variety of causes, which is why it is important that they are thoroughly assessed by a certified lactation consultant.

Treating oral restrictions
A simple surgical procedure called a frenotomy can be done, with or without anaesthestic, in the hospital nursery or doctor’s office. The doctor examines the frenulum under the tongue and then uses sterile scissors or, if trained can use a laser, to snip the frenulum free.

The procedure is very quick and discomfort is minimal since there are few nerve endings or blood vessels in the lingual frenulum. Babies generally don’t like being held down or restrained, which can cause some agitation. If any bleeding occurs, it’s likely to be only a drop or two of blood.

After the procedure, a baby can breastfeed almost immediately, and complications are rare ‒ but could include bleeding or infection, or damage to the tongue or salivary glands, usually when done by an untrained practitioner. It is also possible for the frenulum to reattach to the base of the tongue.

The upper lip tie is a little different, as the upper lip frenulum has extensive blood supply and many pain receptors. This procedure needs to be done under anaesthetic.
It is suggested that the tongue tie be addressed first. Once tongue position and function are corrected, the upper lip frenulum can be reassessed and treated only if the upper lip is being prevented from being everted [turned inside out].

While deciding on treatment
It is important that while deciding on treatment, you feed the baby.

Work with your lactation consultant to find ways to get that baby to latch and drink as effectively as possible using various techniques.

Protect your milk supply. If baby is not adequately removing the milk, discuss ways to increase and maintain your supply through expression or other methods to keep the milk flowing adequately with your lactation consultant.

Treat other issues in the meantime. If the mother has developed cracked painful nipples, or thrush, make sure to work with the lactation consultant and healthcare provider to treat these issues, so when you have made your decision you are starting from the best possible place.

Educate yourself on the short and long-term consequences of treating or not treating the oral restriction. This is the best way to make an informed, evidence-based decision. Ultimately it is the parents’ decision whether or not to treat, or wait and see.

If you have decided to do the frenotomy, it is important that you:

  • Breastfeed immediately. After the feed the practitioner will check that bleeding has stopped.
  • Learn and do the functional exercises to improve mobility and suck strength. This baby might have been sucking incorrectly from birth, so it’s important that you teach baby how to suck correctly.
  • Pain relief is rarely needed, but paracetamol can be given if necessary.
  • Contact your healthcare provider if bleeding reoccurs.

If you are having feeding problems and suspect that it might be oral restriction, contact a qualified lactation consultant in your area. It’s important that a full feeding assessment is done, including maternal and infant history, examination and feeding observation. And importantly, in all of this, you must protect your supply.