Consult

Dr Agarwal examining child's tongue function

Consult Process


A consultation with a Tongue Tie Team provider is the first step. This is done in an appointment separate from the procedure to allow parents adequate time for informed decision-making. While the procedure itself is very quick, it IS a surgical procedure requiring a parental commitment to aftercare in the recovery period. This appointment begins with a thorough assessment of your child’s health, oral restrictions (ties), and related symptoms and challenges with feeding, speech, sleeping, dental, etc. There will also be a discussion of exercises you can start immediately, the procedure, aftercare, risks and benefits. Bring your questions! We have found that the best results happen when parents are fully empowered, informed and prepared for aftercare; and do not feel rushed into a decision. Before the consultation, please watch our video on what to expect as well as our video on the exercises. You can also join our Facebook group for support, and check out our videos on Instagram. Consults can be scheduled at your convenience and are available in each of our 5 locations. (Procedures are, however, done only at the Glendale, Goodyear, and Chandler locations.) To arrange for a consult, please contact us.




Treatment Options


Various treatment options exist for tongue and/or lip ties. These may include the laser release procedure (frenectomy) or just careful watching and follow up. A treatment recommendation appropriate for your child will be made at the consult appointment. Various studies have shown that a tongue tie corrective procedure (frenectomy) is safe and effective; and it usually helps improve breastfeeding, speech, or other difficulties. If both tongue and lip tie co-exist, we generally recommend doing tongue tie procedure first. Most feeding difficulties in a child diagnosed with both tongue tie and a lip tie arise only from the tongue. We have a large number of successful stories but we cannot guarantee that the procedure with be 100% successful. At the consult we will discuss the pros and cons of the procedure and assist you as you make an informed decision for your child. A follow-up appointment is scheduled 2 weeks after the procedure to evaluate the healing process and address any feeding issues that have not improved. If an upper lip tie is present and is affecting feeding, an upper lip tie frenectomy may be performed on this day. Consultation notes will be sent to the referring provider, if requested.




Pre-Procedure Exercises


When the tongue tie is released, the muscles of the mouth may need retraining and strengthening. It is best to work with an International Board Certified Lactation Consultant (IBCLC), Osteopathic Manual Medicine (OMM) provider, and/or a Speech Language Pathologist (SLP), because they can assess your infant’s suck and show you exercises specific to your infant or older child. Exercises will be reviewed on consult day and on the day of the of procedure. After the procedure, it is of utmost important that you do the tongue/lip stretching exercises at regular intervals. Here are the tongue exercises for infants, which you can start before the procedure in order to get your baby used to them: 1. BEEP, BOP, BOOP Game (Desensitizing the Palate and Gag Reflex): Some babies resist a deep latch because they have a very sensitive gag reflex. Systematically desensitizing it can be helpful. Begin with touching baby’s chin saying “BEEP” - Touch baby’s nose; saying “BOP” - Touch baby’s upper lip; saying “BOOP” (touching the upper lip will tell baby to open mouth) - Press down on the center of baby’s tongue saying “BEEP”. If baby does not open mouth when upper lip is touched, tickling the lower lip may help. (Catherine Watson Genna: Supporting Sucking Skills in Breastfeeding Infants)
2. Cheek Stretches: Gently hold the inside and outside of your child’s cheek and gently stretch outward while gliding/moving your fingers up and down. Gently follow a c-shaped movement pattern to stretch this area. If you feel resistance, pause for a few seconds and you may feel the tension release. If your baby resists having a finger inside their mouth, you can start with drawing a c-shaped line from their nostril to chin, and lines from their
nostril towards their ear as if you were drawing whiskers. Please use slow and slightly firm movements.
3. Follow the Finger (Lateralization/side to side Exercise): Slide pinky or index finger along baby’s lower gums, massaging from one side to the other, encouraging baby’s tongue to follow your finger from side to side with the tongue. Repeat 3-4 times. As you do this, use your thumb to support your hand and the baby’s jaw to increase stability.
4. Lifting the Tongue: After the procedure, this exercise elevates the tongue toward the roof of the mouth to stretch the frenectomy site vertically to keep the diamond open and tall, lessening the risk of re-attachment. Place the pads of your pointer or pinky fingers on the left and right edges of the diamond shape. Sweep your fingers up and down swiftly and firmly for 4 or 5 strokes. (This takes about 5 seconds.) This can also be done using just one finger/one side at a time. If child becomes upset, return to “Follow the Finger” game or allow the baby to suck on your finger. When child is calm, proceed to the next exercise. For tight or reattaching tongues, it may be helpful to push your finger deeper/firmer on the sides of the tongue for the lift. Avoid pushing too deep and causing gagging or choking.
5. Push Back the Tongue: This exercise stretches the tongue toward the roof of the mouth, further improving its ability to lift by stretching along the midline. Place the pad of your pointer or small finger on the underside of the tongue. Firmly push back on the tongue 3-4 times.
6. Tug-o-War (Strengthening exercise): Touch baby's upper lip to encourage them to open wide, then slide your finger in their mouth, pad up, on top of their tongue and allow them to suck. While your baby sucks and you press down on their tongue slightly, gently play tug-o-war, pulling your finger out slightly and letting them suck your finger back in. This may sooth baby after the other exercises. It can be especially helpful just before baby breastfeeds since it helps baby learn proper tongue movement for breast and bottle feeding.
7. Tummy Time: You may have heard about tummy time helping with motor development and head control. Tummy time is also the BEST position for a baby to engage in strengthening tongue and oral skills for optimal latch and feeding. Many babies do better with suck training and pre/post exercises when in tummy time vs. on their back. More info can be found at www.tummytimemethod.com --- Here are the tongue exercises for older children (2 years and older): For children at least 2 years old, in addition to doing #4 and 5 from the above exercise, below are fun ways to increase tongue movement, especially if your child is older and therefore potentially more resistant to the manual lifting and pushing-back tongue exercises.
1. Put a small dab of nut butter or something with a similar texture (please be mindful of any food allergies) on the alveolar ridge (gum line immediately behind the teeth) and try sweeping it off with the tongue. You can help increase tongue elevation by helping to hold the jaw stable while the child’s mouth is open and their tongue is sweeping peanut butter.
2. Put a dab of nut butter on their upper lip, and have them extend and lift their tongue to lick it off. Make sure that their mouth is wide open and the tongue is coming out independently to do this.
3. Put a piece of cheerio or meltable puff on the tip of the tongue. Have the child elevate the tongue to make contact with the palate/roof of the mouth. Hold the piece of cheerio in place or mash it to dissolve. Please be mindful of your child’s age and skill while using this exercise, to avoid choking risks.
4. On a plate, or in a small shallow cup, like a 1/4 c measuring cup, spread easy cheese/whipped cream/jelly etc., and have your child lick it off. Make sure that their mouth is wide open and the tongue is coming out independently to do this.
5. Place cheerios, puffs, popcorn (if age appropriate) on a plate, and have your child pick them up with just their tongue, by sticking their tongue out.
6. Have your child stand in front of the mirror with you and have them mimic your tongue movements (stick your tongue out, curl your tongue, tongue to top teeth, tongue to molars).
7. Use a vibrating toothbrush or Z-vibe to stimulate the roof of the mouth and have the tongue follow the vibration.
8. Reward cooperation with stickers, small toys, reading a favorite book, etc. We have videos of these exercises here. --- Here are the lip exercises: 1. The Mustache: Place pad of index finger along philtrum (space between nose and lip) and follow the boundaries of the lip towards the chin. It will look like you are drawing a mustache on your baby’s face and can become a fun activity. Please use slow and long movements with firm pressure. Again, fast movement can sometimes increase the chances of aversion.
2. Fish Lip: Also referred to as the grandma squeeze, gently pinch on either side of the upper lip frenulum (tie), to raise the center of the lip up and away from the gums. If your older child is able to pucker and round their lips themselves, have them do that instead.
3. Flip the Lip: This is really exactly what it sounds like. Take two fingers and place between the upper gum and the upper lip on either side of the released tissue (below right photo), and flip the upper lip up toward the nose. Hold for 5 seconds. This stretches the upper lip, and makes the wound visible to check the progress of healing.




Same Day Consult/Procedure


There are families who prefer a briefer consultation and a procedure done on the same day. These are often experienced parents, who recognize the symptoms in a new baby, or first-time parents who’ve had another health professional recommend an appointment. Many parents study the information on our website and determine that this amount of information is adequate for them to have a solid base of working knowledge toward a fully informed decision.