Question 1

My child has their consultation tomorrow. Any advice/suggestions before the appointment?

Accepted Answer

From the time you schedule a consultation appointment with a provider to your final follow-up appointment, you and your child will be cared for with the utmost skill and compassion by each of our specialists! Prior to your consult appointment, we recommend writing a list of questions you may have and make sure you get those answered at your visit.
During the consult, we discuss the procedure and the indication in-depth and you will be given a significant amount of information and you can ask all your questions. Sometimes this information can be a lot for the families and hence we suggest that you do as much reading prior to the appointment. There is a lot of ‘misinformation’ on the internet also, and you may want to ask your questions rather than solely relying on opinions expressed on the internet.
Please arrive at least 15 minutes prior to your scheduled appointment time. Consults are done in a holistic manner and include a symptomatic and anatomical diagnosis of tongue tie by one of our certified nurse practitioners or Dr. Agarwal. Your child will be thoroughly examined with additional attention to the structure and function of their oral cavity including the characteristics of the tongue; attachment of the frenulum; muscular tightness; and a complete physical examination including the midline assessment of the baby’s spine and diaper area.
They will also discuss the risks and benefits of the procedure, as well as what the aftercare involves. While you are considering the procedure, we recommend that you begin doing the Pre-Procedure Playful Exercises to help your child get familiar with having your fingers in their mouth several times a day.
Parent education about the procedure is an important component of our program. Your preparation is a necessary and important part of your baby’s treatment process and healing! The ‘Agave Approach’ allows time for parents to absorb information and receive ongoing support as treatment is undertaken. Our aim is to make you comfortable with the procedure and after care, before the procedure day, hence after your consult appointment, we encourage you to watch our videos again and take your time to make your decision. You may come up with more questions, which we will be happy to answer on the day of the procedure.

Question 2

Any tips/tricks on how to get my child's tongue up to stretch the wound?

Accepted Answer

Build on the skills you developed by doing the pre-procedure exercises. If the child has already experienced the exercises before the procedure they are more likely to negatively react to having your fingers in their mouths for exercises.
Remember to start with clean, well-rinsed hands.
Try to make this a playful routine so that you are effectively stretching the tissue and child’s discomfort is kept to a minimum. These exercises do not take a long time to do; however, they should be done consistently to avoid re-attachment.
If your child prefers cold temperatures, you can try freezing teethers or using narrow cylindrical shaped ice cubes wrapped in gauze (like breast milk popsicles).
Try to position your child in a way that’s most comfortable for them and you, while giving you access into their mouth. You can position your baby on a stable surface, such as your lap or a changing table so that you can see into baby’s mouth. If helpful, place a rolled up hand towel or receiving blanket behind their neck to help their head flex back, making it easier to see the inside of their mouth. The goal of these exercises is to keep the wound from reattaching. This can usually be achieved through activities that involve elevating the tongue, protruding it (while the mouth is open, versus only sticking it out while lips are still closed) and moving it from side to side.

Question 3

Consult Process

Accepted Answer

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.

Question 4

When do I start pain medication at home?

Accepted Answer

Each baby metabolizes the numbing medicine (lidocaine) differently so starting pain control before your little one is in a lot of pain is very important. Starting Tylenol (or Ibuprofen or Arnica) within the first few hours of being at home is recommended. Also, keeping on top of dosing will be very beneficial to making sure this transition goes as smoothly as it can. If your baby is at the peak of pain before control medication is started, it can become very difficult to get him / her calmed down enough to eat. So, staying on top of pain is very important.

Question 5

Are speech delays related to tongue tie, or could it be just a developmental thing?"

Accepted Answer

This could be a mixture of both. Does your child try to say the word, but it just doesn’t come out well, or are they just babbling in their own language? Tongue ties usually inhibit the child from making certain sounds since the tongue can’t move appropriately, but it doesn’t delay the actual use of words.
However, if you are concerned, you should definitely see if your PCP can refer you for a formal speech evaluation which can help to assess if the child just has minor language quirks, or if there is an issue that is causing the sounds to not come out correctly.

Question 6

Breastfeeding: Infant Symptoms

Accepted Answer

Because the life-long health of your baby is our utmost concern, breastfeeding is valued as the gold standard of infant nutrition by our providers. Breastfeeding is known to improve a child’s immune system, is a contributor to a higher I.Q., is a protective mechanism that lowers a child’s risk of contracting illnesses and developing allergies, and has been proven to reduce the risk of breast, ovarian, and uterine cancer in mothers.[1-3] Breastfeeding is normal, natural, and a beautiful biological process. It is a skill that commonly takes a bit of time for each mother and infant to master, and is rarely as easy as we assume it will be. ​Breastfeeding can be compromised and become unsustainable when the presence of a tongue tie limits the tongue’s normal range of motion[4-6]. An upper lip tie can limit the ability of the baby’s upper lip to form an adequate seal while breastfeeding.[6-8]
 
● Difficulty latching and/or maintaining a deep latch
● Frequent unlatching and re-latching
● Clicking sounds on the breast
● Leaking/dribbling on the breast
● Gumming the nipple
● Tucked upper/lower lip when on the breast
● Persistent suck blisters
● Spitting up frequently
● Frustration and/or breast refusal
● Poor weight gain
● Fussiness at breast and in between feedings
● Gassiness
● Difficulty bottle-feeding when breastfeeding is being supplemented

Question 7

What is a DO? What is the difference between a DO and an MD?

Accepted Answer

A DO is a Doctor of Osteopathic Medicine. In the United States, there are only two ways to become a fully licensed medical physician: either DO or MD. Both have equal training and universal practice rights. MDs and DOs work side by side in all medical settings. The main difference that sets a DO apart from an MD is the Osteopathic Philosophy.

Question 8

What are common signs and symptoms of tongue tie?

Accepted Answer

For breastfeeding infants: Most mothers will complain of breastfeeding difficulties including painful feeding sessions, cracked and possibly bleeding nipples, and infants being fussy at the breast. This is because, in many cases, the infant is unable to latch well enough to drain the breasts. This lack of milk transfer is related to the limited ability of the tongue to lift, lateralize, and extend, which are precisely the movements that are necessary to create a proper latch. Infants tend to eat frequently for long periods of time (30-45 minutes), may show poor weight gain, or reflux symptoms, or be overly gassy. Some infants may have swallowing difficulties and/or have associated torticollis.
For older infants: you might see issues with additional problems with feeding. They might have a hard time transitioning to solids, they may gag/choke on pureed foods, puffs, or wafers. They may not want to try new textures of foods. Some infants can still experience reflux, or have a lack of good sleeping habits as evidenced by by waking frequently at night. Some may have difficulty transitioning to sippy cups.
For toddlers: you might notice that all or many of the above symptoms were present when they were growing up, and now that your child is growing they may experience difficulty articulating certain sounds. Toddlers will also continue to be hesitant on trying new textures of foods. Kids at this age can start to show symptoms of hyperactivity or other behavioral problems due to lack of proper sleep cycles. Some toddlers or young children with tongue or lip ties will be very noisy breathers as well.
For additional details check out the signs and symptoms section.

Question 9

Why do we have a consult, procedure, then follow-up?"

Accepted Answer

Agave Pediatrics, under the direction of Dr Agarwal, is one of the leading specialists in the country in the management of tongue and lip ties. We have developed a standard of practice that is now followed by other practitioners too. Tongue/lip tie releases are considered surgical procedures, and while the procedure itself is very quick, there still needs to be a full assessment of your baby or child prior to performing any surgical procedure. The standard practice includes having a consult done by one of our very knowledgeable practitioners to fully assess your child and their symptoms related to the tie. This is necessary to fully assess the function of the tongue and lip, and to discuss the entire procedure and the aftercare.
We want all of our parents to be completely informed of why or why not the procedure is indicated, understand the risks and benefits, and take the time to answer any questions. You have the ability to go home and make sure you are comfortable proceeding with a surgical procedure and your appointment is scheduled. You then come back for a follow up, just like you would any surgical procedure to make sure things have healed well, and to make sure symptoms have improved. While we know it can be a very stressful time having a baby who is struggling to breast feed, or feed in general, we want to make sure we are providing procedures safely and each baby or child is looked at from all angles, not just their tie.
We have done research at Agave pediatrics, which has clearly showed that doing the procedure after a consultation significantly decreases maternal anxiety. Parental anxiety is one of the most common reasons for failure of successful outcomes after the procedure. By decreasing the anxiety by separating the consult and procedure, we have been able to reach success in symptom improvement in a large majority of our patients.
Having said the above, in certain situations we offer same day consult and procedure, because every situation is unique and we try to individualize our care.

Question 10

Speech Problems

Accepted Answer

An undiagnosed or untreated tongue tie may negatively affect speech.[9-11] If your child is struggling with certain sounds and words and has been assessed by a speech therapist, we encourage you look further into the possibility of tongue tie causing issues with speech. Reflect on your child's past feeding habits and possible history of colic and reflux to see if any of those symptoms could point to a tongue tie that has been left undiagnosed. We don't encourage treating a tongue tie to prevent speech issues. We believe that there can be a number of causes for speech problems and tongue tie is just one of the many possible reasons.
While these symptoms may be red flags to evaluate for tongue function, some of them may be caused by other factors like developmental delays, hearing difficulties, etc.
​
Symptoms:
● Difficulty with sounds like L, T, D, N, SH, TH, R, or S once a child is past the age when these sounds are mastered
● Delayed speech milestones
● Prolonged need for speech therapy with slow progress
● Speech that sounds “slushy” or unclear
●  Lisps
● Unclear speech when sentences are longer and conversations are more complex

Question 11

Where did OMM and DOs originate from?

Accepted Answer

Osteopathic medicine is a medical philosophy that was founded by Dr. Andrew Taylor Still, MD, DO. He initially served as a major in the Union Army, and also served as a Civil War era statesman, emancipation activist, and pioneer physician and surgeon. He treated those who were suffering with great compassion and came to understand that medicine at the time was very ineffective. For example, at the time medications prescribed often contained extremely harmful ingredients like mercury.
Dr. Still realized that traditional medicine was failing his patients and those suffering from the Civil War. Sadly, medicine at the time failed his family when he lost three of his children to brain infections. From this loss, Dr. Still was inspired to spend the rest of his life gaining a new understanding of the human body. His goal was to establish a new philosophy called Osteopathy in hopes of changing the course of medicine.

Question 12

Can my child sleep through the night without stretches and pain control or should I wake them up?

Accepted Answer

Preferably the stretches should be done around the clock in spaced out intervals, but we do not want to wake a sleeping baby if we can let them go an extra hour or two. If your baby sleeps 6-7 hours at night, just do a good session prior to sleeping, and as soon as they wake up. It should be noted that many parents have reported to us that the easiest time to do the exercises is when the child is sleeping. Keep in mind that also without waking up for stretches they are not having any pain control at night and might be in a bit more pain when you do the stretches first thing in the morning.
We do not suggest waking the child up for pain meds if they are sleeping comfortably.

Question 13

Can colic, excessive gas, fussiness, or extended feedings improve after a procedure?"

Accepted Answer

Several studies have shown that a frenectomy procedure helps improve feeding difficulties. Some of these difficulties may include: colic-like symptoms, air intake, excessive fussiness, and shorter feeds. Although we cannot guarantee that the procedure will be 100% successful for all infants, in most cases many they feed better immediately after a procedure and continue to improve because their tongue is no longer working against the resistance of a tight lingual frenulum. Breastfeeding infants tend to improve after a short period of time, as the muscles that were restricted must learn to work in a new way.
Former muscle memory fades as the tongue becomes stronger and utilizes its new, full range of motion. Careful attention to the details of good positioning and latch as well as working with an IBCLC and/or bodywork specialists can enhance this process.

Question 14

Breastfeeding: Maternal Symptoms

Accepted Answer

● Nipple “flattening”/whitish compression stripes post-breastfeeding
● Bleeding, cracked, scabbed, or blanched nipples
● Vasospasms
● Severe nipple pain while breastfeeding
● Plugged milk ducts
● Low milk supply
● Mastitis
● Thrush
● Frustration and anxiety associated with breastfeeding
● Difficulty bonding with infant

Question 15

Is Tylenol safe to give if I suspect my child has the MTHFR genetic mutation?

Accepted Answer

Many parents are now suspecting this genetic mutation in their babies and concern is starting to spread with the wide variety of social media information. If you have concerns, please address them with your provider and also your pediatrician prior to this appointment.

Question 16

Treatment Options

Accepted Answer

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.

Question 17

After 6 weeks of exercises, should I keep doing them?"

Accepted Answer

In the human body, healing tissue changes in appearance over a long time. In our experience we have seen that there is a decrease in incidence of reattachment when the exercises are done for 6 weeks.
However there is a finite chance that there will still be reorganization of the wound and this attachment may happen. We often see wounds that look like they have reattachment, but over the next several months improve considerable and the movement of the tongue improves. This can go in the opposite direction as well. Wound healing is not a static process, it is dynamic.

Question 18

What is the Osteopathic Philosophy?

Accepted Answer

DOs have 4 tenets:
1. The human person is a UNIT, including the body, mind, and spirit. All three need to be considered by the physician when seeking health.
2. The body is able to SELF-HEAL. For example, even when a person suffers an injury such as a cut, while stiches may need to be placed, it is the body that must ultimately heal the wound.
3. STRUCTURE is closely related to FUNCTION. As a result, dysfunctions within the structure can affect function. If we are able to improve the structure, we can restore function.
4. OMM is based on careful application of the above three principles.

Question 19

Bottlefeeding Infant's Symptoms

Accepted Answer

At Agave, we believe that bottle feeding is a healthy way to provide nutrition to your baby. We want to help you whether you are providing formula, breastmilk, or both. While these symptoms may be red flags to evaluate for tongue and/or lip function, some of these may be caused by other factors like a fast flow rate, swallowing difficulties (dysphagia), gastro-esophageal reflux, etc.
​
Symptoms:
● Difficulty latching to the bottle
● Needing to trial SEVERAL bottle systems to find one the child will take
● Gagging when bottle nipple is presented
● Chewing/gumming the bottle nipple
● Clicking sounds while sucking
● Collapsing the nipple
● Pulling away from the bottle frequently
● Dribbling while feeding
● Coughing during feeds
● Prolonged feeding times (over 30 minutes to complete age-appropriate volumes)
● Falling asleep/fatigue during bottle feeds
● Gassiness, air intake, frequent spit ups
● Upper lip curling inwards when sealed on the bottle
● Bottom lip moving back and forth, on and off the nipple when feeding

Question 20

Pre-Procedure Exercises

Accepted Answer

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 aSpeech 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
 
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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.

Question 21

My child was diagnosed with a tongue/lip tie at our consultation; however, we were told to obtain an official speech evaluation prior to having the procedure done. Can issues with muffled words and tongue tie improve through speech therapy?"

Accepted Answer

Obtaining an formal speech evaluation allows you to see whether or not the child’s speech is delayed, or physically restricted by the tie.
Also speech evaluation and therapy is very important because the procedure itself is only one part of the picture. Being able to use the tongue properly depends on retraining the tongue and oral muscles to make correct sounds. Hence, helping the tongue move and participating in speech therapy, can enhance the success of the procedure. Furthermore, working with a speech therapist can help if there are sensory issues, and also with post procedure exercises.

Question 22

What should I expect on the procedure day? Should I bring anything?

Accepted Answer

On procedure day, please remember that your child can eat up to 30 minutes before your scheduled procedure (this includes: breastfeeding and bottle feeding for infants, and any food or drink for older patients). After that, please refrain from breastfeeding/bottle feeding and any food or drink.
For infants 12 months or younger, you may also bring a receiving blanket for your baby to be wrapped in for the procedure. The familiarity of their own blanket can be comforting. Please understand that most babies do cry because they don’t like being held still. This is temporary, and your baby will be returned quickly to your waiting arms! For older children a blanket, their favorite toy or something that comforts the child is also helpful.
Dr. Agarwal will review and answer any questions you have BEFORE the procedure. The procedure will be completed by Dr. Agarwal. He and/or our staff IBCLC will also demonstrate the post-frenectomy exercises for you.
The use of a Class IV CO2 Laser instrument by a skilled, trained provider results in a safe treatment. As a medical office, we are governed by OSHA safety standards; and we have safety protocols in place to reduce or eliminate the risk of injury due to accidents. In keeping with our safety protocols, parents are not allowed in the procedure room.

Question 23

What is that white patch of skin under the tongue/lip and do I try and scrape it off?

Accepted Answer

a.   The white area is the mouth’s way of putting a scab on the wound. Do the stretches by rubbing the wound vertically and horizontally.

b. The wound usually developed around days 2-3 and last until about day 10-14.

Question 24

Do high palates cause similar difficulties in feeding? How long does it take high palates to flatten out?

Accepted Answer

High palates are commonly associated with tongue ties because of embryonic developmental processes. Having a high palate may contribute to poor suction and ineffective coordination between the tongue and lips. Athough there are no studies that have evaluated how long it may take for palates to flatten out, clinically we have seen that a good percentage of them flatten out over time. We also, very commonly, see that children with tongue ties need orthodontic work and palate expanders.

Question 25

What is the best age to get the procedure done?

Accepted Answer

The ideal age for the procedure is when you start seeing problems associated with limitations in tongue movement. In breastfeeding babies, if there are issues associated with breastfeeding, research done at Agave (and corroborated with other studies) have shown that a procedure done within the first couple of weeks is most effective in improving the symptoms.
Having said this, it is extremely important that there is a clear functional impairment established by your provider, before the procedure. For the breastfeeding dyad it is also important that the baby have a lactation consultant, and body worker before the procedure because often enough, these interventions may mitigate the need for this procedure. We are particular about establishing a need for the procedure by doing a thorough evaluation as this increases the chances for improvement after the procedure. It is important to make sure that children who benefit from the procedure get it done at the right time.
At Agave, we do not suggest getting elective procedures.

Question 26

My child won't suck on a pacifier or on my finger. How do I do the suck training?

Accepted Answer

Many babies do not perform “non-nutritive sucking”, and won't suck on something they do not find comforting. However, some babies won't function without a pacifier in their mouths. If you can try a drop of breast milk on your finger and see if they will suck that way, and then try a little tug here and there, it will be beneficial.
If your baby won’t suck or just gives up when you start to tug, just keep trying.

Question 27

My child has thrush, clicks when feeding, and I have severe nipple pain - could it be related to tongue tie?"

Accepted Answer

"My PCP informed me that they did not find any significant impairment of my child’s tongue and did not recommend the procedure. However, my older children had tongue ties which improved after the procedures in the past. Hence, I am unsure if my current issues with breastfeeding my little one are due to the tie or thrush. Any advice?"
 
Clicking in itself is not a problem, but it can be a sign of a problem. The presence of thrush may be resposible for some of these issues. We recommend visiting your PCP to check for a possible thrush. If your child is being treated for thrush, we recommend either dropping the medication in his/her mouth or rubbing it with a towel and/or cotton swab.
If child’s tongue has good range of motion, it may be their latch is a bit off and on top of the thrush, they are not doing a great job at sucking. So, this can definitely be a contributing factor.
Often milk residue seen on the tongue, because of a tongue tie and high palate can be falsely diagnosed as thrush and will not respond to any treatment, as it truly is not thrush. It would be a good idea to get in touch with an IBCLC to work on latching and continuing the treatment as suggested by your PCP. We will be happy to evaluate the problem and guide you. If we see the presence of milk residue due to high palate and tongue tie, appearing as thrush, we can recommend appropriate treatment steps for it.

Question 28

What is OMM/OMT?

Accepted Answer

OMM stands for Osteopathic Manual Medicine/Osteopathic Manipulative Medicine. It can be also be abbreviated as OMT, which stands for Osteopathic Manipulative Treatment (OMT). This is a medical procedure completed by a DO (Doctor of Osteopathic Medicine). While OMM is widely recognized for treating musculoskeletal concerns, any body system can benefit.
OMM is able to treat the soft connective tissues, the nervous system, the digestive system, the lymphatic system, the musculoskeletal system, and more simultaneously. As a fully trained physician, Dr. Neuer is able to understand in completion how these systems all correspond to one another and how if one system has a dysfunction, this can manifest as a disease in another area of the body.

Question 29

Frenectomy Procedure

Accepted Answer

Dr. Agarwal at Agave Pediatrics has performed thousands of tie release procedures for tongue (lingual frenectomy) and lip (labial frenectomy) ties over the years. On the day of the procedure, Dr. Agarwal will assess your child once again and discuss the procedure and any possible complications with you. The procedure involves little to no pain for the child and has improved feeding and speech for many children.
 
●  Tie release is a brief and minor procedure done in a treatment room in our office (at either the Chandler, Goodyear, or Phoenix location).
●  The child is given a local anesthetic injection to numb the site. 
●  A laser is used to release and cauterize the tissue under the tongue or lip. As the tissue is being released, it is continually checked for any bleeding, as well as for appropriate range of motion such as lift and extension.
●  After the procedure Dr. Agarwal will show you the results. 
●  Exercises and wound care will be reviewed with you 
●  Pain management will be reviewed with you.
● If you are breastfeeding or bottle feeding, we will encourage you to complete a full feeding cycle while in the office so that both infant and you are as comfortable as possible for your trip home.

Question 30

Eating Solids

Accepted Answer

We understand that there are many choices for solids available, and at times the process can be difficult and frustrating. We want to help you whether you are just starting the transition to solids, already on your way to stage 3 foods, or more. 
While these symptoms may be red flags to evaluate for tongue function, some of them may be caused by other factors like low muscle tone, sensory processing difficulties, gastro-esophageal reflux, etc.
​
Symptoms:
● Gagging with purees/spoon feeding
● Tongue thrusting when foods are presented
● Excessive spillage of food from the mouth
● Pocketing of foods in cheeks and/or the roof of the mouth
● Difficulty managing mixed textures (chunks of meat in sauce, pieces of pasta in soup, etc.)
● Avoiding certain foods
● Difficulty with textured foods (chunky/thicker purees, oatmeal, etc.)
● Difficulty with complex solids that require more efficient chewing patterns (meats, breads, raw vegetables, etc.)
● Prolonged mealtimes and frequent reminders to chew, to take another bite, to not pocket foods, etc.
● Extremely small bites of food, and prolonged times to clear them
● Needing to drink between bites to clear food
● Dipping food excessively to moisten it

Question 31

What is the white stuff on the tongue and is it thrush?

Accepted Answer

This is a normal layer that develops in babies with tongue ties. However, babies who do not have ties are able to rub their tongue up against the roof of the mouth which wipes that layer off. Babies with a tongue tie and high palate are unable to do so, so the white layer is normal and will eventually be scraped off as the tongue movement improves.

Question 32

What is OMM actually doing?

Accepted Answer

OMM is essentially applied physiology. Our understanding of the body's anatomy allows us to use our hands to help treat affected body tissues.
Example: a patient has an ankle sprain and associated swelling. Our goal would be to reduce swelling, improve healing time, reduce pain, and allow anti-inflammatory medications to better reach the tissues. To do so, the OMM treatment would focus on:
-Treating the pelvis to alleviate lymphatic congestion
-Addressing the adductor muscles to alleviate any strain in the adductor canal (where the lymphatic vessels run)
-Treating the hamstring insertion point at the popliteal fossa (also where the lymphatic vessels run)

Question 33

When should I see a Lactation Consultant (IBCLC)?

Accepted Answer

It varies. Some parents see a Lactation Consultant (LC) on the day of the procedure even though your baby may be in pain or very sleepy after the procedure. The 3-5 days after  the procedure can be some of the roughest days for your little one, so trying new positioning and new feeding techniques might be overwhelming. Discussing this with a LC on the day of your visit and / or with your provider would be the optimal way to identify the best time to see a LC  for a follow up and for trying new feeding techniques.

Question 34

Same Day Consult/Procedure

Accepted Answer

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.

Question 35

I have been told by an IBCLC that if I do not get an immediate frenectomy/procedure, my breastfeeding will not take off. Is this true?"

Accepted Answer

This is a major difference of opinion in practice between Agave and other offices. We strongly believe in a thorough evaluation which may take a couple of days for appointment rather than an immediate frenectomy without a thorough evaluation or established need for frenectomy. We do not suggest that frenectomy be performed until the milk supply has been established and we know that the tongue tie is causing impairment in transfer of milk. We have done research at Agave which shows that the appearance of the tongue is not a measure of the severity of the tongue tie or the need to do the procedure as soon as possible.
We do suggest the procedure be done quickly once the diagnosis has been established by demonstration of impairment of function. One of the biggest determinants of breast feeding success after frenectomy is the presence of improved maternal milk production. Doing the procedure right away often increases maternal anxiety to an extent that it can reduce milk production. We strongly believe that early on, measures should be taken to decrease maternal anxiety, and increase maternal comfort/milk production by making sure the family is fully informed. Utilization of breast pumping is also very important early on, so that the mother continues to produce breast milk and has good success when the baby is ready to transfer the milk post-procedure. We have shown that a consult/procedure will answers all questions and this decreases anxiety and thus increases milk production which makes the procedure more successful.
Having said this, there are definitely exceptions to the rule where we have suggested very early frenectomies, especially for families who have been through this before and have a level of comfort for the procedure. Every family and child is different and deserves an individual evaluation for their particular spectrum of clinical symptoms.

Question 36

What tips are there for doing exercises with my toddler?

Accepted Answer

The best behavioral technique that works for toddlers is that they are easily distractible. A lot of parents are able to play with the child and get them distracted while performing the exercises. Also make sure that the child has adequate pain control on board, because if they exercises are hurting a lot it will be more difficult for parents to distract the child. The exercises can be done is a very playful manner in which the child can be asked to imitate the parents when moving the tongue around. Another game to play to see if the child can lick (peanut butter, jelly, etc. by moving their tongue from side-to-side.
For pain management, you can try giving your child colder foods like ice cream or a popsicle. This may incentivize them to cooperate and provide pain relief at the same time.

Question 37

Why does my baby need to be 1 month old or have had a Vitamin K shot before the procedure?

Accepted Answer

We require the Vitamin K shot to be administered prior to a frenectomy procedure to avoid preventable bleeding. At birth, many newborns do not have adequate levels of Vitamin K in their body. Vitamin K is a hormone which is required for blood clotting. As the baby grows, the bacteria in the baby’s gut produces Vitamin K. Over time it is absorbed and normal levels are established in the body. As a frenectomy is a surgical procedure, there is a possibility of bleeding associated with it. Bleeding associated with tongue tie may happen because of anomalous veins, which uncommonly occur in the area; or from the deficiency of Vitamin K. As previously stated, we are typically able to prevent this bleeding with the Vitamin K injection given to all babies at least 12 hours before the procedure. Thus, we can ensure that any bleeding which occurs is not from Vitamin K deficiency.
Many of our families prefer to do oral Vitamin K as opposed to injectable Vitamin K. However, it is well established in the scientific community that injectable Vitamin K prevents the often debilitating intracerebral late onset hemorrhagic disease of the newborn. Studies over the years have not established the bioavailability of oral Vitamin K; therefore, we require our babies to have received this injection prior to the procedure because we are also concerned about the overall health of the child.
There is only scant evidence which is able to identify when Vitamin K levels in the body are normalized; but, the evidence suggests that it normalizes by 2 weeks to 2 months of age. At Agave Pediatrics, we have chosen the median time for this to be about a month.

Question 38

When and how often do we do the exercises / stretches, and how do I know I am doing them correctly?"

Accepted Answer

The stretches post procedure are extremely important as this is what is allowing the wound to heal in an open position versus in a closed position that can lead to “reattaching”. The process of getting the tip of the tongue up and back and then going across the wound will help to detach the fibers that are trying to close the wound, and that is not what we want. Getting the tongue to move side to side is helping the tight oral muscles to  stretch and to move in the natural way the tongue should move. The stretching exercises are shown in this video
The recommended amount of times per day is about 6. Try them at all different times of the day. If your baby is under 2 months, some babies might sleep through them. If you can only do them with one finger, that is ok as long as you are getting the movements done.

Question 39

How can I tell if there is reattachment?

Accepted Answer

a.    Reattachment is a scary word and the thought that a baby may  need to go through another release procedure can be very stressful. Reattachment is a risk after the surgery but it is a minimal one. All wounds heal, and we just ask that you do your best when it comes to stretches to hopefully prevent the healing process from doing its job. If your baby has improved in feeding, and symptoms have decreased, and you have been doing the stretches, the risk of reattachment is very minimal.
b.     If you start to feel a bump in the area, the wound has significantly  closed before day 7 post procedure, or you feel a tightening of the tongue movement during stretches please call the office for a follow up to check for re-attachment. 
c.    Also, if you were told that your baby had a very tight tongue tie, sometimes what may happen is that the deeper muscles may have come forward after  the more surface ones were released. It is not the same as reattachment and can be a potential problem but a very minimal one.

Question 40

What body tissues can OMM treat?

Accepted Answer

Virtually all tissue can be treated using OMM, including:
-Fascia (the saran-wrap like substance that is integrated throughout the body)
-Bones
-Joints
-Ligaments
-Muscles
-Tendons
-Nerves
-Spinal cord and spinal nerves (example: using techniques to help alleviate pressure on a stenotic central canal or stenotic neuroforamen)
-Brain, dura (like helping alleviate tension on the dura from the sacrum)
-Viscera (like helping move stool through the colon)
-Lymphatic fluid (helping reduce swelling)

Question 41

After the Procedure

Accepted Answer

Immediately after the procedure, our staff IBCLC will guide you to a lactation room and assist you in latching your infant. If you are working with a lactation consultant, you will be referred back to your IBCLC for follow-up approximately 3 to 5 days post-procedure.
​
You will be encouraged to complete a full feeding while in the office so that both mother and infant are as comfortable as possible for the trip home.

Please take note of what the incision looks like immediately after the procedure. Take a photo of the white diamond shaped wound that becomes visible under the tongue in the first 24 hours after the procedure. The white diamond should remain the same size; it should not get smaller or disappear.
 
The aftercare handout can be found here.
 
With every set of exercises, check for re-attachment by noting the size and shape of the white diamond. The white diamond should remain the same shape with distinct, straight edges. It should be even from side to side: the edges should not look muddled or “tucked in.” You should not see tissue protruding from the base.
​
If you detect re-attachment, please call the office for further instruction. Some reattachment is expected, but minimizing it is important for over-all improvement.
​
Possible Bleeding:
At times, the exercise sessions can cause a small amount of bleeding. If this occurs apply firm pressure to the wound with a clean cloth or cotton ball. Breastfeeding your infant will also help bleeding to stop. If bleeding does not stop, the child needs to be evaluated immediately.
​
If you have questions, check out our FAQs, contact us, or visit the tongue tie support clinic.*
*The in-person tongue tie support clinic is currently on hold due to COVID-19 precautions, but we offer support via text, email, or phone. With a lactation consultation, you can bring your infant for in-person guidance, support, and discussion with our IBCLCs.

Question 42

Sleep/Breathing Problems

Accepted Answer

An undiagnosed or untreated oral tie may lead to an increased risk for physiologic alterations resulting in poor breathing and sleep quality, and evidence suggests that normal development of the cranial, facial, and neck structures is positively impacted by long-term breastfeeding.[11-13] The natural jaw movements and suck motions that take place during breastfeeding assist in creating optimal shape and function of the head, neck, mouth, and sinus cavities. Having a free-moving, high-lifting tongue helps to promote optimal feeding (breast and bottle), swallowing, breathing, and sleeping. In short, we need to feed, breathe, and sleep WELL to function WELL.
​
Symptoms:
● Gagging, coughing, or choking during feeding, sleeping, or when swallowing oral secretions
● Breathing through the mouth instead of the nose during feeding, play, or rest
● Dry, cracked lips
● Excessive drooling
● Persistent nasal congestion and sinus symptoms
● Snoring
● Waking frequently at night
● Frequent sore throat
● Obstructive or apneic periods during sleep (Obstructive Sleep Apnea)
● Daytime fatigue
● Behavior and concentration changes

Question 43

Is lip swelling after the procedure normal?

Accepted Answer

This is completely normal because the lip is a soft tissue with limited space, hence injection of local anaesthetic may cause swelling, and as the tissue heals there may be further swelling. Most lip swelling goes down in 2-3 days.

Question 44

Dental Problems

Accepted Answer

There are many dental problems that can arise with undiagnosed or untreated tongue/lip ties.[13-15] Some dental symptoms are due to the inability to clear food adequately, while others are due to the physical restriction of tight oral tissues.
​
Symptoms:
● Gap/diastema between two front teeth
● Tongue getting stuck between front teeth
● Gum disease
● Gum recession
● High palate
● Cavities/dental caries
● Overbite
● Open bite
● Crooked teeth

Question 45

What will I experience on the day of the procedure?

Accepted Answer

On the day of the appointment, please arrive at your designated time. You can feed your baby up to 30 minutes (or earlier) prior to your appointment, but please do not in the office. You can feed the baby immediately after the procedure.
Dr. Agarwal will come in and see you and the baby, the medical staff that assists with the procedures will take the baby into the treatment room and get the baby swaddled. Dr. Agarwal will inject a small amount of numbing medicine (lidocaine) into the area being treated for release by laser. The laser is used for ~10-20 seconds and then the same medical staff brings your baby right back to you. Dr. Agarwal will come back to see you and answer any questions. He will show you how the tongue moves and let you know how the procedure went. You will be encouraged to feed the baby immediately after the procedure.
They will also discuss the risks and benefits of the procedure, as well as what the aftercare involves. While you are considering the procedure, we recommend that you begin doing the pre-procedure exercises to help your child get familiar with having your fingers in their mouth several times a day.
Parent education about the procedure is an important component of our program. Your preparation is a necessary and important part of your baby’s treatment process and healing! The ‘Agave Approach’ allows time for parents to absorb information and receive ongoing support as treatment is undertaken. Our aim is to make you comfortable with the procedure and after care, before the procedure day, hence after your consult appointment, we encourage you to watch our videos again and take your time to make your decision. You may come up with more questions, which we will be happy to answer on the day of the procedure.

Question 46

Pain Management

Accepted Answer

Proactive pain management is very important. For most children, the first 72 hours are the hardest. The use of Tylenol or Ibuprofen based on your child’s age and weight and Arnica 30 C, (a homeopathic remedy) will be helpful.
Dosage information is included in the packet you received at your consult, as well as in the email that was sent to you, and is also available on the aftercare handout.
​
● Initially, your child’s mouth will be numb at the site of the procedure. This will last for approximately 2 hours.
● Please prepare to ease your child’s discomfort by having pain medication on hand before procedure day.
● If you have traveled a distance of a couple of hours, please bring Tylenol or Ibuprofen so that you can give a first dose before traveling home.
● If your child is uncomfortable with the exercises, be sure that their pain is being managed.

Question 47

What do you mean you can work on structures like nerves?

Accepted Answer

Many disease states represent an imbalance within the autonomic nervous system.[6,7]
-Sympathetics: These are responsible for "fight or flight," including heart rate, respiratory rate, etc. The sympathetic nervous system can be directly treated along the rib heads of T1-T12, and at specific ganglia within the cervical spine.
-Parasympathetics: These are responsible for "rest and relaxation," including digestion, stools, etc. The parasympathetic nervous system can be directly influenced within the upper cervical spine and within the sacral region.
Gently treating these regions can help bring the two systems back into harmony with each other, and reduce symptoms of a specific condition. This has a cascade-like effect on hormones, brain functioning, heart, and lung functioning as well.

Question 48

When I do stretches my baby pulls his tongue down and back and I can’t get under there.

Accepted Answer

a.    There are wonderful videos of how to do the stretches. Although these babies are very cooperative, your baby will probably not be as cooperative and that is very normal. All we can ask if that you do your best, finding times when your baby is the most relaxed is the best. Some it’s right before diaper changes, some its right after a feeding, some it’s while sleeping. You decide what time you feel is right but try and switch it up. Before feedings is not always recommended because it can cause discomfort which might not be the best for feedings. 
b.    If your baby is clamping down on your fingers, try this technique. Lay your little one down, use one hand and place your palm on the side of their face and put your thumb in between their gums so they bite down on your thumb, then use your pinky finger on the other hand to do the stretches, then switch sides. Sometimes this can be helpful.

Question 49

What is all the talk about Chiropractic therapy or CST and do I need to do it?

Accepted Answer

When a baby develops in utero with tongue and /  or lip ties, it’s not just those areas that are tight, the muscles of the head, neck, face, and back can also be  tight. Releasing the tongue tie  addresses just one of the muscle structures that is loosened. But many other muscular areas are still very tight, even after the tongue release,  and chiropractic therapy performed by someone who specializes in children using Cranial Sacral Therapy (CST) may be  what would be needed  if you chose to explore this option.

Question 50

Am I allowed in the procedure room with my child?

Accepted Answer

It is a very short procedure and the baby is only away from the parents for 5-10 minutes. Your child will never be alone, as there are always at least 2 people with them the entire time.
We do our level best to comfort the baby by swaddling them as needed, giving them a pacifier (if that’s what the baby wants), singing to the baby, and ensuring they are as comfortable as possible.
In the past, we have allowed parents to be in the room for the procedure. However, at this time we do not allow parents to be there. In the past, parents have stated that it is very emotionally trying for them to see the procedure. Some moms have even worried that they might lose their milk supply because they were so stressed out. We have also had parents who have said that they have felt dizzy. We then had to take care of them before we could perform the procedure. This unnecessarily delayed the procedure and caused extra stress on the baby and the parents.
For older children, we have consistently noted that children are more compliant with our instruction when parents are not present for the procedure. We ask that they keep their mouth open for 45-60 seconds. This period of time is open much longer when parents are present because the children are distracted and unable to follow instructions.

Question 51

What symptoms are related to a tongue tie?

Accepted Answer

1.    For babies:  most moms will complain of difficulty in breast feeding. These difficulties include painful feeding sessions, cracked and possibly bleeding nipples, baby being fussy at the breast, baby is unable to drain the breast due to a lack of transferring milk, baby eats frequently for long periods of time (30-45minutes), lack of weight gain, reflux symptoms, overly gassy and uncomfortable from gas, swallowing difficulties and possible torticollis.
2.   For older infants: you might see issues with developmental milestones regarding feeding. Babies might have a hard time transitioning to solids, they may gag on pureed foods, gag and choke on puffs or wafers, and a lack of wanting to try new textures of foods. Some babies can still experience reflux, lack of good sleeping habits by waking frequently at night, and difficulty transitioning to sippy cups.
3.    For toddlers:  you might start to notice that all the above symptoms were present, and now your child is experiencing difficulty articulating certain sounds. Toddlers will also continue to be hesitant on trying new textures of foods. Kids at this age can start to show symptoms of hyperactivity due to lack of proper sleep cycles. Some toddlers or young kids will be very noisy breathers as well
4. For additional details check out the signs & symptoms page

Question 52

What does the term "somatic dysfunction" mean?"

Accepted Answer

Somatic dysfunction (SD) refers to a change or dysfunction that is palpated by a DO within the body. This is also what we diagnose and then directly treat with OMM. This does not mean that something is "out of alignment," rather, that part of the body (like a vertebra) may be held by a sustained muscular contraction within its normal range of motion.[7]
Additionally, we can treat an area of restricted range of motion, tissue texture change (swollen/boggy tissue), asymmetry, sensitivity, or tenderness that is found within the body (the soma, hence the term "somatic").
For example: after long days of working on the computer, a sustained contraction of the paraspinal musculature at the junction between the neck (cervical spine) and the thoracic spine can occur, often palpated at the T1 level. This can result in a minor change of rotation, sidebending, and flexion or extension at that vertebral level. We would address this with OMM.

Question 53

My baby wont suck on a pacifier or my finger, how do I do the suck training?"

Accepted Answer

Many babies do not perform “nonnutritive sucking”. A baby wont suck on something they do not find comforting. While some babies wont function without a pacifier in their mouths. If you can try a drop of breast milk on your finger and see if they will suck that way and then try a little tug here and there, it will be beneficial. If your baby wont suck or just gives up when you start to tug, that is ok, just keep trying.

Question 54

What grade is my baby’s tongue tie and when is it bad enough to be released?

Accepted Answer

The degree or grade of a tongue tie is not the deciding factor in whether a procedure is indicated. If you are experiencing symptoms related to the ties, that is when a procedure is warranted. Doing a procedure when symptoms or complications are not present only to prevent potential issues later, is not a cause for a procedure at this time.

Question 55

I suspect my child is developing breastfeeding aversion. What should I do?

Accepted Answer

Breast aversion is a rare occurrence after frenectomy. With the present protocol of the exercises at Agave Pediatrics we have not seen many cases of breast aversion. However it is seen in babies who are already at risk for breast aversion. Such babies may have been poor feeders, or had failure to thrive, or other sensory issues. It can also be sometimes seen secondary to extremely vigorous exercises or poor pain control.
If you do believe that your child is facing breast aversion, the first thing you should do is to see an IBCLC who can help you truly diagnose it. If breast aversion is clinically disgnosed, we suggest you decrease the exercises to a minimum, increase pain control, and increase non-nutritive nurturing activities with your baby, such as skin to skin contact.
It is very important that the nutrition of the baby is given due importance as this may sometime require bottle feeding, syringe feeding, and in extreme cases, tube feedings.

Question 56

Why is silver nitrate sometimes used during the procedure? Does this change the recovery time?

Accepted Answer

The lingual and labial frenulum areas where we work usually do not have any veins. Hence, these procedures are almost always blood-less (except for very mild ooze). However, your child may have an anomalous vein in the area and that can bleed during the procedure.
Bleeding is very rare during the procedure, for any reason if this does happen, we have been using silver nitrate sticks to cause local cauterization to help bleeding. This has helped in almost 100% of the cases. After the procedure if silver nitrate has been used, you will see a black and grey area at the site. This should be of no cause for concern. The black area will slough off in the next couple of days.
If there has been bleeding and silver nitrate has been used, we advise parents to defer from exercises for the next 24 hours. After that you can start regular exercises. We have not seen any increased incidents of bleeding with the exercises after silver nitrate has been used. Silver nitrate itself does not cause any pain, and though we always recommend good pain control, in our clinical experience we have not known children to need extra pain management after it is used.

Question 57

Can my baby sleep through the night without stretches or should I wake him / her up?

Accepted Answer

Preferably the stretches should be done around the clock in spaced out intervals, but we do not want to wake a sleeping baby if we can let them go an extra hour or two. If your baby sleeps 6-7 hours at night, just do a good session prior to sleeping, and as soon as they wake up. Keep in mind that also without waking up for stretches they are not having any pain control at night and might be in a bit more pain when you do the stretches first thing in the morning.

Question 58

What kind of manual techniques will a DO use?

Accepted Answer

Techniques are utilized based on the type of problem that is present as well as the patient and their body. There are numerous techniques, the common ones are listed below:
-If a range of motion issue is present, we often use a technique called "muscle energy"
-Strain/counterstrain is used for muscle spasms 
-High-velocity, low-amplitude (hv/la), a still technique, articulatory, used for joint capsules
-Soft tissue, myofascial release both direct and indirect are used for fascia, muscles, and fluid buildup

Question 59

Does OMM have any negative side effects?

Accepted Answer

After an OMM treatment:
-Infants can sometimes experience a deep sleep the day of treatment; a mild temperature increase (this would not cross the fever threshold); some babies can have a mild temporary increase in spitting up.
-Older children/teenagers can also experience a deep sleep the day of treatment; they can also feel sore for a couple of days after treatment, similar to how a work-out would feel due to release of lactic acid.

Question 60

My child has been drooling a lot since the procedure. Is that normal?

Accepted Answer

Any injury inside the mouth increases saliva production. This is because saliva has healing and anti-inflammatory properties. This is a normal response and should not cause any concern.
Interestingly, in many older children who have problems with excessive drooling (due to the inability of the tongue to direct the saliva for swallowing) it is remarkably reduced after the procedure.

Question 61

How do I know if my baby needs a lip tie release?

Accepted Answer

Lip releases are not always needed. Signs that a baby still needs a lip release include continued reflux symptoms, excessive gas and baby is uncomfortable from gas, continued clicking, gulping, baby popping on and off the breast, fussy at the breast, slides off the breast easily, frequent spit ups or vomiting. A lip tie causes the mouth to be tight and therefore unable to properly create a seal around the breast or bottle and therefore air is swallowed with each feeding.
On a side note, babies can have worsening of these symptoms after the tongue release because as their suck gets better they end up swallowing even more air.

Question 62

What tips are there for doing exercises with an older child?

Accepted Answer

If you have not had the procedure done yet, try to do the exercises 3-5 times a day before the procedure, to allow the child to get used to the exercises and having your hands in their mouth.
Start when your child is quiet and non-agitated. Talk them through the exercises. You can have them do the exercises on you for fun and to build more trust and familiarity with them. Using a mirror may provide a visual cue for some children and create an additional element of fun as well. We advise to try doing the stretches while your child is sitting up, like in a bouncer, swing or car seat. This can help make getting the tongue up easier.
If your child becomes distressed or upset, please respect their cues and stop the exercises. Make sure to provide comfort and console them. Building trust with your child is very important to avoid oral aversion before or after the procedure! We understand that toddlers and older children can make this process more challenging. Just do your best!
For pain management, you can try giving your child colder foods like ice cream or a popsicle. This may help relieve pain near the tongue/lip tie site.

Question 63

What is the worst case scenario if I don't get the procedure done?

Accepted Answer

The diagnosis of tongue tie is dependent on functional deficit. As this entity is relatively newly described and has not been treated in the recent past, there are many adults (and their family members) who have tongue ties. Over the years, these individuals have learned to compensate for the dysfunction (limitation of tongue movement) associated with tongue-ties. In other words, people often grow out of the symptoms that their tongue ties cause.
With the body of evidence and experience that we have now, we suggest that the release be taken care of at the time of diagnosis. In the same way, do not recommend that a tongue tie be electively released in the absence of symptoms. Human bodies are amazing machines and compensate for many major issues, including limitation of the tongue movement. Many children with tongue ties may have manifestations associated with tongue ties appear at different stages of development from children to adulthood. Literature is still coming in about the effect of tongue ties in adults which include speech, dental, and feeding issues.

Question 64

What will I experience on the day of the appointment of the procedure?

Accepted Answer

On the day of the appointment, please arrive at your designated time. You can feed your baby upto 30 minutes (or earlier) prior to your appointment, but please do not in the office. You can feed the baby immediately after the procedure.
Dr. Agarwal will come in and see you and the baby, the medical staff that assists with the procedures will take the baby into the treatment room and get the baby swaddled.
Dr. Agarwal will inject a small amount of numbing medicine (lidocaine) into the area being treated for release by laser. The laser is used  for ~10-20 seconds and then the same medical staff brings your baby right back to you.
Dr. Agarwal will come back to see you and answer any questions. He will show you how the tongue moves and let you know how the procedure went.
You will be encouraged to feed the baby immediately after the procedur

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