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

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.

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.

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.

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.

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.

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.

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

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.

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.

1. 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.

2. 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.

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.

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.

1. 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.

2. 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.

3. 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.

4. 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.

5. You will be encouraged to feed the baby immediately after the procedur

Sometimes after the procedure, you may see a granuloma at the site of the wound. This may be consistent with the destruction of a small salivary gland or sometimes hypertrophy of the tissues from exercising it too vigorously. If you see such a growth, we recommend that you bring it to our attention. This is a rare occurrence and in our experience, it generally does not need any further treatment. It usually goes away in a couple weeks to months.

Your baby can receive immunizations at any time after the procedure. Additional fussiness may occur; however, it is generally temporary.

Yes, this is normal and something that happens after the procedure. This is usually due to your little one being able to suck stronger. Try giving your child gas drops and gripe water to help decrease gas and reflux, as well as lots of burping during feeds and after feeds, as needed. Also, if you have a carrier, you can use that to help with comfort and decreasing the reflux, as well.

If you haven't already, we would also suggest working with a bodywork specialist. Experts believe bodywork helps babies latch after a frenectomy. They believe this will help with compensations for when the tongue or lip was not functioning properly. This includes a high tone or low tone suck, clenched jaw, biting, feeding better on one side over the other, and other issues like torticollis.

If your child is really uncomfortable, you can give them a nice warm bath, or even get in the bathtub with them and feed that way. We recommend doing this when you have a helper at home so they can help getting in and or if the tub.

If this is happening after a release and does not improve even after 10-14 days after the procedure, please bring this issue up at the follow up appointment. Your child may need an upper lip tie frenectomy also.

Even after the lip tie is released, the muscles might be tight around the mouth and could still be affecting the seal. This may take strengthening of the muscles and the process of learning how to use them. We suggest continuing the exercises and continued follow up with a bodywork specialist.

Agave Pediatrics, under the direction of Dr Agarwal, is one of the leading specialists in the country in 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. This standard of practice of having a consult done by one of our very knowledgeable practitioners to fully assess your child, assess their symptoms related to the tie is necessary to fully assess the function of the tongue and lip, and to discuss the entire procedure and the after care. We want all of our parents to be completely informed of why or why not the procedure is indicated, risks and benefits, and take the time to answer any questions. You then 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.

The upper lip tie procedure is typically done just like the tongue tie. Recovery is typically much less painful than the tongue, because there is more movement of the tongue with oral function than the upper lip. Exercises are also easier because you have to lift and separate the lip from the jaw, and do not have to deal with the jaws.

There are many babies, toddlers, and young children with upper lip ties that experience no issues. This is why we recommend you watch and wait if it is not causing any symptoms at the time of the tongue procedure or until there is a medical issue before having a procedure done. If your child is still experiencing some issues, feel free to schedule a consult.

Unfortunately, cranial helmets/bands have been linked to causing headaches and migraines later in life, even into adulthood. Craniosacral therapy or OMM are excellent treatments for plagiocephaly. This can take a higher frequency of visits than most diagnoses to help.

The procedure itself is very much similar, and local anesthetic (lidocaine) is still used. Majority of babies do better after the lip release because it is a piece of skin that is opened versus muscle tissue. Also, the stretches are a bit easier since you are not opening their mouth, and not messing with muscles.

The clicking itself is not an issue - this just means that the tongue is either still weak, might still have a little restriction, or there is air intake. If everything is going well, the child is eating fine, and isn't overly gassy or having issues with reflux, just be patient and keep up the stretches. The clicking is more of a symptom of the problem than a problem by itself!

If you haven't already, we would recommend working with an IBCLC to help you, and give you specific suck training exercises to try and improve your nipple pain.

If you believe the ties may have reattached, ask an IBCLC to evaluate the milk production and milk transfer. If the ties have slightly reattached, they may need to be opened up. If this is early enough in the process, some extra pressure will open the wound, (it might bleed a little, and that's okay, just breastfeed your baby afterwards), but if you think it is anything more than that, please contact our office. Keep in mind that some reattachment is expected but we want to minimize it as much as we can and get functional improvement.

Some IBCLCs feel comfortable in stretching and opening the wound. You may want to check this with your IBCLC.

If symptoms are still not improving, schedule a visit with one of our nurse practitioners or Dr. Agarwal for further evaluation and treatment options.

Many babies do have a tight lip tie that goes along with their tongue tie, although not all babies will need the upper lip released, so why have an added procedure done if it is not needed. Many of the symptoms that are causing the difficulty feeding can be eliminated by just performing the tongue release. So, allowing one procedure to be done and see how things improve before adding another to the recovery process. Also, some babies are sensitive and do sometimes have a difficult time relearning to eat after the tongue release, adding two painful areas can slightly increase the chances of oral aversion, reattachment, and longer difficulties breast feeding, so if we can avoid that by spacing things out, in most cases this has provided the best feeding success. Although every case is different, and Dr. Agarwal will weigh the risks for each patient and decide with the family the best approach.

Both craniosacral therapy and OMM work very well to alleviate a spasm of neck musculature. Oftentimes we can achieve positive results within one treatment, with some increase in range of motion (ROM) and spontaneous turning of the head to the restricted side.

Keeping in accord with ‘The Agave Approach’, we are conservative and minimalists. We want to give you the highest chances of achieving your goal, with the minimal intervention. If the procedures are done at the same, this will cause more pain for the child, as well as the necessity for more exercises to be done (both tongue tie and upper lip tie require their own post-procedure exercises), which may make keeping up with them more difficult. We have seen in our experience that both procedures do not need to be done at the same time for improvement of symptoms. Hence, we like to perform one procedure at a time, usually starting with the tongue tie. The majority of expected improvement in symptoms can be achieved by performing the tongue tie procedure only.

After the tongue tie procedure, we schedule a two-week follow up appointment. This appointment is to evaluate healing and symptoms improvement as well as determine whether there is a need for additional treatment, which may include a redo of the tongue-tie, or an upper lip tie procedure.

In certain clinical or social situations we do suggest performing both procedures at the same time, especially in older children. Please note that we are NOT opposed to doing both procedures at the same visit. In our vast clinical experience, we simply have not seen the need to do them together as a routine. Roughly 50% of children will end up needing both the procedures, while the other 50% will not need the lip tie to be done. There is no real way for us to predict whether your child is going to need the upper lip tie procedure or not, just yet. We are involved in research to answer this question, but do not have any results just yet.

Proactive pain management is very important. For most babies, the first 24 hours are the hardest. After day 3, the discomfort subsides considerably. Some babies don’t seem bothered much at all, and others can be fussier than usual for the first 5 days or so.

Most infants have a lip tie in addition to their tongue tie. In our experience, not all infants will need the upper lip released. Many of the symptoms that are causing the difficulty with feeding can be eliminated by just performing the tongue release. So, performing one procedure initially and seeing how things improve before adding another, to the recovery process, seems prudent and clinically sound.

Also, some infants are sensitive and can sometimes have a difficult time relearning to eat after the tongue release, adding two painful areas can slightly increase the chances of oral aversion, reattachment, and longer difficulties with breast feeding. Hence per 'The Agave Approach' of “do no harm”, it seems to be the best practice to perform one procedure earlier and then reevaluate. The intent is to ensure success with the symptoms that your child is experiencing. We have been able to achieve this by spacing the procedures, and hence this is our recommendation.

Although every case is different, and Dr. Agarwal will weigh the risks for each patient and decide with the family the best approach.

You will be shown the post-procedure exercises immediately after the procedure is done, and there are explanations of the exercises in the aftercare handout. There are also videos of the exercises in the email you received regarding the procedure.

Stretches should begin 6-8 hours after the procedure, and should repeat every 4 hours (6 times a day) for the first two weeks. At your follow up appointment, you will be told how often to do the stretches for the next two weeks. This part of aftercare can feel overwhelming and challenging for parents, but they are incredibly important.

The goal of these exercises is to keep the healing tissue open and separate, in order to prevent reattachment, and to encourage the movement of the tongue. These exercises do not need to be forceful: they should be gentle but firm. You do not need to touch the wound during the exercises, as all the stretching is done by lifting around the wound, NOT directly on the wound. However, if you do touch the wound, it is fine, and does not increase the chances of infection.

Talk to your child, make funny sounds and faces. You can do the exercises randomly so your child doesn’t negatively anticipate them. They can be done before or after a feeding, nap, diaper change, etc.

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. You can do these exercises facing the baby, or from above the baby’s head, with their feet pointing away from you. Sometimes when the baby is crying and their tongue is raised, a quick set of exercises can be done. Some babies will sleep through the stretches.

Tongue tie can cause restriction of movement of the tongue which can cause various problems throughout a human’s lifespan. In infants it can cause problems with breastfeeding and/or bottle feeding because the tongue is restricted in its natural movement of sucking and transferring of milk from the breast or the bottle. With breastfeeding it can often cause nipple pain, latch problems, and poor weight gain amongst many other symptoms. Different problems may also occur later in life, such as speech problems, dental complications and breathing problems. For more information, please see the references section.

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.

This is an excellent and frequently asked question. Over the years, we have discovered that there is no absolute way of knowing whether a child is going to need only a tongue tie release, or both the lip and tongue tie release. In our office, we usually suggest doing the tongue first, especially with breastfeeding, because it addresses 80% of symptoms in most babies. Afterwards, 50% of families will go ahead with the upper lip procedure while others have complete resolution of their symptoms and do not need it. Clinically, there is no way to predict if symptoms will be improved with either of the procedures.

We have done scientific research on this and the results are inconclusive as to if they should be done together or if the tongue tie procedure should be done first. We also take many other considerations which include risk vs benefit, particular clinical or social situations, etc. This situation is best addressed at the time of the consult. We do not suggest automatically performing both procedures at the same time.

OMM can be used to help treat the sacrum, as an example. The parasympathetic nerves at the sacrum are responsible for controlling the colon. The sacrum (tailbone) is cocooned within a giant network of suspensory ligaments and an intricate concentration of fascia. A strain within this biomechanical region, for both adults and children, can impact stools. Rebalancing the pelvis and treating the sacrum can help a patient have softer, more regular stools.

For most babies, the first 24-48 hours are the hardest. Staying on top of pain management is very important. We suggest that you may start giving pain medication 2 to 2.5 hours after the procedure. If you have traveled a distance of a couple of hours, please consider bringing Tylenol or Ibuprofen (depending on what is appropriate for your child) so that you can give a first dose before traveling home.

Thre are a number of signs and symptoms which can be relieved or significantly improved by clipping of the tongue tie (also called frenotomy or frenectomy). This is a safe and effective treatment for tongue ties and several studies have shown that it usually helps improve breast feeding in babies. The procedure can also help with issues related to speech, breathing/sleeping, and/or dental complications.

The recovery after a lip tie procedure is usually easier compared to the tongue tie procedure. This is because by the time the child has had the lip tie procedure done, they have already had the tongue tie release done. Because of this, they might have some kind of comfort/familiarity with the exercises that were previously used. Also, the movement of the upper lip is less compared to the movement of the lip, hence there is less pain.

The pain management remains the same, as pain lasts on average for 3-4 days. Very rarely, some parents have reported more discomfort after the lip tie as opposed to having more pain after the tongue tie.

Frenectomy (also referred to as the "procedure" for tongue tie), is done at the bedside in our office and entails the following steps and possible risks.

For Infants: The infant is restrained in a papoose board and then given local anesthesia prior to the procedure to numb the site. The tongue tie tissue (frenum) under the tongue of the infant’s mouth is then cauterized using a laser. The procedure itself is very brief and the infant can go straight onto the breast afterwards (or bottle as the case may be). Many mothers feel less nipple pain and a better latch almost immediately. After the procedure, no special care (other than exercises) is needed, though most infants may feel pain for 1-3 days, which is resolved with Tylenol and/or Arnica (a homeopathic treatment).

For older children: The child is restrained in a papoose board or made to lie on a table (depending on their age) and given a local anesthesia prior to the procedure to numb the site. The tongue tie tissue (frenum) under the tongue is, then, cauterized using a laser. The procedure itself is very brief and the child is taken straight back to the parents. After the procedure, no special care (other than exercises) is needed, though most children may feel pain for 1-3 days, which is resolved with Ibuprofen (Motrin or Advil) for children older than 6 months of age, Acetaminophen (Tylenol) and/or Arnica (a homeopathic treatment).

Risks: Although it is a minor procedure, as with any surgical intervention, it does have some risks, including but not limited to, infection, bleeding, pain, allergic reactions, temporary numbness, injury to the mouth, or reattachment.

Arnica 30 C is a homeopathic treatment that can be used for pain relief. There are several formulations of Arnica on the market, but we highly suggest purchasing Arnica 30 C (aka: Arnica ‘Montana’ 30 C). You can purchase this medication at Sprouts, Whole Foods, or Amazon.

To use Arnica: Take 10 pellets and dissolve it in 1 to 2 tablespoons of water or breast milk. You may have to manually disintegrate the pills if they do not dissolve. Once made, the solution is good for 24 hours.

Once you are able to get the Arnica to dissolve: Give 10 drops of that liquid as needed. For fussiness or inflammation, it can be given every 30 minutes to 1 hour until child is calmed. For preventative use, give once every 3-4 hours or at the time the Tylenol is given. No dosage and effectiveness correlation has been established, and hence the use of Arnica depends on how the child is responding. Arnica can be given every 30 min for up to 5 times, and these can be repeated 2-3 times/ day.

Though we have found Arnica to be very useful in taking the edge off the pain, Tylenol/ Ibuprofen provide much better pain relief and Arnica should be used only as an adjunctive medication. Many parents have been able to use just Arnica for good pain control, but that is rare.

OMM can help treat the thoracic spine, where the stomach and gastrointestinal visceral nerves are located. Additionally, aiming treatment at the parasympathetics within the upper cervical spine can help reduce reflux.

Research has shown that issues can arise from an upper lip tie in regards to poor seal on the breast and/or bottle, dental hygiene, and spacing of teeth. If you are still breast or bottle feeding your child, take notice to whether or not your child has difficulty with flanging their upper lip, where it seems that they suck the upper lip in while feeding. Symptoms may include: popping on and off breast or bottle, parent needs to adjust child’s latch frequently during feeds, etc.

If your child has had their tongue-tie released, and is still showing symptoms of a shallow latch, they may benefit from an upper lip tie procedure. As your child’s teeth begin to come in, some with an upper lip tie present may show a significant spacing in between their upper two front teeth. Although, a gap can close as the mouth grows and more teeth come in which push the teeth together. With older children, some might begin experiencing pain with brushing their teeth secondary to an upper lip tie. This could eventually lead the child to not want to brush their teeth and develop dental caries or deposition. If your child has this spacing in between their teeth and/or starts/continues with pain with brushing of teeth, they may benefit from the procedure.

At this time we do not recommend any other natural pain relief options, but feel free to consult with a naturopath for more information.

Here at Agave, we release tongue and lip ties up to age 18.

After a tongue and/or lip tie revision, we do not recommend using an Orajel for pain relief as that formulation has been taken off the market for the potential complication of causing methemoglobinemia. Instead of Orajel, we suggest the use of Tylenol or Ibuprofen (for children > 6 months old) and the dosage is based on your child’s age and weight. Additionally Arnica 30 C, (a homeopathic remedy) can be helpful.

We have collected some articles in the references section. There are many informative articles, abstracts, and reviews in scientific literature about tongue ties. To find more material such as this, try searching Google Scholar (or other academic search engines) for keywords such as “lingual frenectomy”, “ankyloglossia”, or “tight lingual frenulum”.

A book that we recommend is “Tongue Tied,” by Richard Baxter, DMD. Dr. Agarwal has written the foreword for this book.

Many families, rather than reading scientific articles or authoritative texts like the book above, gather information on tongue ties from Facebook support groups and friends. There is value discussing issues like tongue ties in these “mommy communities”. However, such conversations lack the scientific rigor associated with clinical investigation and experience. In fact, many of these Facebook groups are hijacked by a few very vocal responders who advertise their biased viewpoints as the truth. These opinions are often not clinically sound. We strongly recommend that you seek the opinion of professionals who are well-versed and have experience in the diagnosis and management of issues related to tongue ties.

Initially, your child’s mouth will be numb at the site of the procedure. This will last for approximately 2- 4 hours. Please prepare to ease your child’s discomfort by having pain medication on hand. Stay ahead of pain for the first day, using Tylenol and/or Arnica (and Ibuprofen for children older than 6 months of age) as needed.

We recommend having at least 2 of the 3 medications on hand so that you are already prepared on procedure day!

If you have traveled a distance of a couple of hours, please consider bringing Tylenol or Ibuprofen (depending on what is appropriate for your child) so that you can give a first dose before traveling home.

You can time the medications so they will be at peak effect for the therapy sessions. Also make sure to not skip the stretches after the procedure has been done, as these are essential to prevent reattachment of the tie(s).

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

MTHFR is an enzyme. In instances when mutations in MTHFR cause the enzyme activity to be severely impaired, it can lead to elevated level of an amino acid called homocysteine. Buildup of this amino acid may increase the risk of blood clotting and heart disease. With what we know about the MTHFR gene mutations, acetaminophen metabolism is not affected by this enzyme. At Agave, we have a minimalistic approach and prefer not to use any medications, if we do not have to. We do not recommend routine use of pain killers. However if you still have concerns, please discuss them with your health care provider.

You may start these exercises 6-8 hours after the revision, unless given different instructions by Dr. Agarwal. If there is any bleeding after the procedure, Dr. Agarwal may have to use silver nitrate locally to control it and you will be instructed to not do exercises for at least the next 24 hours.

Of course! You may feed your baby directly after the procedure and give them a pacifier if needed. If you are bottle feeding, have your bottle ready post-procedure. After the procedure, our staff IBCLC will guide you to a lactation room. Our Staff IBCLC can also demonstrate the exercises if needed. Pain management and wound care will be reviewed with you, as well. You will be encouraged to feed while onsite so that baby is as comfortable as possible for the trip home.

Older children can be given their regular diets after the procedure. Cold foods and beverages, ice creams and popsicles are particularly comforting to children as they temporarily numb the area.

Tongue tie (TT) is a small band of mucous membrane (a frenulum) and/or a fibrous tissue that connects the middle part of the tongue to the bottom part of the mouth. Some children are born with fusion (either partially or completely) of the tongue to the bottom of the mouth. People often refer to this abnormality as being "tongue tied." The technical name for tongue tie is ankyloglossia.

Right after the procedure, the wound is going to look slightly reddish and may have a very small amount of bleeding which can be seen as pink saliva. Very often, you cannot even see the wound because there is no bleeding and the red color associated with the procedure is minimal. However, starting the next day or so, you will start seeing the wound covered with a whitish or yellowish membrane. If your child is significantly jaundiced, this film may appear almost look fluorescent yellow or even sometimes slightly greenish. This is the healing tissue of the body which you would see covering any kind of oral ulcer. This area usually looks like a diamond and serves as a good landmark for where to stretch the wound.

Sometimes during the stretching exercises, there may be minimal bleeding, but other than this, bleeding almost never seen. You don't need to go over the wound to remove the white tissue. If you happen to go over it, either by accident or during exercises, the whitish film may slough off and you will see a clean looking wound below it with a whitish base. Do not panic - this is normal.

Over the next 4-5 days, the white diamond tissue will start getting smaller. If it starts looking like a straight horizontal line you will know there is some reattachment happening, You should do more stretching to keep the diamond shape.

By about the 7th or 8th day, the film usually sloughs off and you will start seeing light, pink area below the tongue. What we want to see is a diamond shape, though lesser in size. You still need to do exercises after the wound is not seen and takes the color of the normal mucosa. This can happen anywhere between 10 days to 3 weeks.

In the first 3-4 days after the procedure the baby may show signs of pain and discomfort. We suggest aggressive pain management with appropriate medications and other modalities including skin to skin contact, soothing activities like baths, breast feeding, singing and cooing, gentle touch, and light swaddling. This seems to work very well for the majority of the babies.

Many families do not want to use any medications for pain and that is an option. However, we suggest that if the child seems to be in pain, medication should be administered so that we minimize the chances of breast aversion or later feeding difficulties. Pain associated with the procedure is a normal phenomenon and does not mean that there is a complication or infection. Once the pain associated with the procedure subsides, babies usually get much happier as they are able to feed better.

Every child is different and some do not need any medications, while some need around the clock medications for the first 3-4 days. There is no way to see beforehand which category the baby will fall into. Pain after the 5th day is unusual. If they seem to be in significant discomfort after the 5th day we suggest you call the frenectomy provider and get the child evaluated.

We have often seen that when parents change feeding patterns from exclusive bottlefeeding to exclusive breastfeeding, if the babies do not adapt well, the frustration the baby expresses may be perceived as pain.

The baby will continue to have some discomfort with the exercises for the remaining 6 weeks, but should not be in frank pain and shouldn’t need any medications unless the wound has been reopened for any reason.

It is very important that parents be emotionally ready to handle the baby’s pain as we have often seen that parents react negatively to the perceived pain in the baby and in turn, will stop doing exercises. This results in increased chances of reattachment. It is extremely important that parents are aware of and comfortable with the pain management strategies after the procedure.

It is very interesting that in a large percentage of cases babies who were perceived as fussy and clicky pre-procedure over the long run become very happy and amiable afterwards. This is a frequently noted observation in our practice.

Yes, this can still happen because the nerve endings are still irritated. For most children, the first 24- 48 hours are the hardest, however after day 3, the discomfort usually begins to subside as the inflammation starts decreasing.

Staying on top of pain management is very important. Call if you are still having to use Acetaminophen or Ibuprofen 4 times/day, past 3 days, as we may need to change the after-care instructions.

After the first 3 days, we still suggest giving medication for the pain, (Tylenol, Arnica, Ibuprofen), but only as needed.

Advocacy is a very important part of our tongue tie program. The connection between a mother and the maternal community is extremely strong and invaluable. We suggest that you reach out to other mothers through social media mom groups, friends, and family and share your experience. This does not mean judging your pediatrician (as they have not been trained for handling tongue ties). Sharing the information is vital, in this day and age you can become an agent of change and help many other mothers to breast feed or help children to improve their speech. You can also talk to your pediatrician and share your story with them.

We have been very fortunate already from moms sharing their stories with the community. In the past years, some of the fiercest critics of Agave have become some of our strongest supporters. We often ask mothers for testimonials, attendance to summits/lectures because they are able to share their personal experience with the audience. If you would like to help out with this, please reach out and let us know. It can be very important for other providers and mothers to hear your story.

After a tongue and/or lip tie revision, we do not recommend using coconut oil because this may cause faster healing of the tissue and the tongue tie might re-attach. In addition, the application of coconut oil requires you to go onto the wound, but we want you to go AROUND the wound when dealing with the tongue tie site.

In the past we were suggesting the use of coconut oil on the wound and one of our older videos on exercises still has it there, but since we have not found this practice to be useful and do not suggest that anymore.

We see a lot of anxiety associated with 'reattachment'. When any tissue heals, there is fibrous tissue laid in between the two sides of the wound which bridges the gap, and it later remodels itself. This happens after tongue tie surgery also. After the procedure, the increase in the movement of the tongue (after cutting the thick tie tissue) causes improvement in the symptoms. We expect this improvement to continue, hoping that it heals with new fibrous tissue which is not as tight. In the meantime the muscles also get initiated. Hence we recommend start working with bodyworkers even before the procedure is performed and definitely after the procedure. This forms the basis of initial and continued improvement after the tongue tie procedure.

As the wound heals, if the symptoms have improved, there is NO need to consider it to be a 'reattachment' even though it may look like the frenulum has grown back. Very simply stated, the diagnosis of tongue tie in the first place is dependent on the symptom complex and movement of the tongue, and the diagnosis of reattachment is also dependent on the same. The appearance of the frenulum is only a secondary issue. Anatomical 'reattachment' is acceptable to an extent, as long as there is functional improvement. In this circumstance the procedure DEFINITELY does not need to be repeated. If the symptoms have improved, let us not consider reattachment to be a bad word. Hopefully, we have been able to alleviate some concerns.

Pictorial representation is only a fair representation to diagnose tongue ties or reattachment after the procedure. Per our ‘Agave Approach’ we refrain from making judgements or evaluating just by looking at pictures, as this can be completely misleading and may make you believe that the baby may need another procedure (when they do not), or missing reattachment and the necessity of performing an additional procedure. Pictures may speak a thousand words, but they do not take the place of an in-person evaluation. We are also not offering evaluations by Skype/remotely.

Within 24 hours or so of the procedure, a white diamond shape will be seen at the wound site. This is normal healing tissue, not a sign of infection. You may want to take a picture of this for size reference. (If your child is crying and their tongue is raised, it is fairly quick to get a picture before comforting them!)

It is important that you try to maintain the diamond shape with the exercises, until it is completely healed. The edges of the white diamond should stay sharp. If the diamond is shrunken or not even from one side compared to the other, there may be reattachment happening. You will likely be able to release it yourself with your fingers. You may want to give your baby some medication for discomfort if you need to do a firmer exercise to open it up. Some re-attachment is expected, but minimizing it is important for overall improvement. Only do this if you feel reattachment! We want to avoid irritating the wound if possible.

Early on there should not be any tissue stopping your finger like a “speed bump” in the fold area. Later in the healing process a small ‘speed bump’ is normal, however it should be much smaller than what your child had before the procedure.

Reattachment occurs due to the babies’ normal healing process. We can decrease the rate of reattachment by proper exercise. It should be known that it is not possible to prevent all reattachment with exercises as we have seen it occur with or without exercises. However, the incidence is significantly decreased with proper exercise. Hence we strongly recommend them. If your baby has reattachment, it is not an indication that your technique was faulty or you are “not a good parent”.

Please make sure that you learn the technique well and do it as prescribed. There are many ways of exercising the wound. The most important and fundamental things which decrease chance of reattachment are stretching the wound and making the tongue move. Please see our videos for further explanation.

There are cases in which a tongue which looks to have reattached completely but functions much better than it was before the procedure. In this instance it is not called reattachment.

The heart tongue can be developmental because that is how the tongue developed in utero. After the procedure, over time, almost all tongues will improve in appearance. However, in severe cases you may still be able to see a small notch at the tip of the tongue, which is to be expected.

If after the procedure, the tongue loses its heart shape, but in the next couple of weeks starts looking like how it looked before the procedure, it may be a sign of reattachment. Having said this, the most important sign of reattachment is a regression of symptom improvement.

The need for a revision after procedure is solely dependent on the function. If you have noticed that the symptoms associated with the tongue have at first improved and then regressed, which may indicate a need for a revision.

In our clinical experience we have noticed that there is a decrease in reattachment with proper exercises, evaluation, and treatment by a bodyworker and IBCLC.

We also receive many patients who have had a procedure elsewhere with not much improvement in symptoms. For these patients, we do our evaluations and determine the need for another procedure, after which the symptoms are often improved. It is impossible to determine whether this was due to a partially-done procedure or reattachment.

Tongue tie diagnosis is frequently associated with other musculoskeletal issues like torticollis. Because of these issues, we believe it is very important to work with a bodyworker (depending on your child’s age and symptoms). Bodyworkers are physicians with experience in osteopathic manipulative medicine, myofunctional therapists, physical therapists, occupational therapists, feeding therapists, and chiropractors with experience in working with children.

Pediatric chiropractors and other body workers do not work by adjusting the baby’s joints, they work on the muscles and their attachments. These interventions are extremely important for successful improvement in function after the frenectomy. Often, just working with a bodyworker may improve symptoms to an extent that a frenectomy may be either delayed or may not need to happen. It is very important to seek service from bodyworkers who are specifically trained in oral tie issues in children as opposed to a bodyworker who only works with adults.

It is important to keep in mind that some bodyworkers have differences in opinions with your regular medical providers on certain health related issues. We highly recommend getting a medical evaluation and treatment for issues within the purview of general pediatrics from a pediatrician.

We recommend bodywork for children with oral ties as we have seen improvements associated with a holistic approach. Our recommendation is narrowly focused on this issue and the management of oral ties. Please check with your regular primary care providers about continued follow ups with the bodyworkers.

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 or lip tie addresses just one of the muscle/fascial structures - many other muscular areas are still very tight, even after the tongue/lip release.

Osteopathic manipulative medicine, myofunctional therapy, feeding therapy, craniosacral therapy, and chiropractic therapy address these issues. Many practitioners perform a combination of these therapies and are highly effective in improvement of function.

It varies. Some parents see a Lactation Consultant (IBCLC) 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 lactation consultant on the day of your visit and/or with your provider would be the optimal way to identify the best time to see a lactation consultant for a follow up and for trying new feeding techniques.

Post-procedure, our own IBCLCs at Agave will meet with you to review our aftercare protocol, assist with latching the baby if desired, and review basic, age-appropriate, lactation management. Complicated lactation situations will be referred to your own IBCLC.

If you have a relationship with an IBCLC, it is best that you follow with them, as we tremendously value relationships between families and their caregivers. If you do not have an IBCLC that you are working with already, we will refer you to IBCLCs that share our evidence-based philosophy, our safety protocols, and our proven model of care.

Experts believe that myofunctional/craniosacral/chiropractic work helps babies latch before and after a frenectomy procedure. They believe this will help with compensations for when the tongue or lip was not functioning properly. This includes a high tone or low tone suck, clenched jaw, biting, feeding better on one side over the other, and other issues like torticollis.

At Agave, we have worked with many professionals. Please make sure that your bodyworker is certified in the discipline that they are practicing.

We have Ramya Kumar, SLP, IBCLC at our Glendale location who specializes in myofunctional therapy and craniosacral therapy. At our Glendale and Chandler locations we have Dr. Katie Neuer, DO who specialises in osteopathic manipulative medicine.

Others include: Dara Salzano Dacunha D.C. (Scottsdale), Chrissy Stamm-Christian, D.C. (Phoenix), Thrive Chiropractic--Dr. Shana Gorman-Dunn, D.C. (Phoenix), Integrated Therapies, LLC -- Allison Kennelly, MS. CCC-SLP (Phoenix). There are other professionals in the valley who we also recommend and a list may be obtained from our office or your IBCLC.

Some include:

The Milk Spot - Central Phoenix

Arizona Breastfeeding Center - Tempe

North Star Wellness - Gilbert

Mommy Help Center - at home visits in Phoenix

Modern Milk - Scottsdale and Gilbert

Southwest Perinatal Education Services - at home visits in the East Valley

Breastfeeding Counseling - Northern Arizona

Breastfeeding USA - multiple Phoenix locations

Banner Desert Support Group - meets every Thursday 1-2:30 p.m

La Leche League of Arizona - multiple Phoenix and Tucson locations

Mama's Latte - Northwest Tucson

All About Breastfeeding - Tucson (Northwest Hospital meets every Wednesday at 1PM or 6PM at the Women’s Center classroom)