At Agave Pediatrics, we have seen that tongue and lip ties can impede breastfeeding, cause extreme pain for breastfeeding mothers, effect speech and solid feeding. Our team specializes in diagnosis and treatment of children with tongue ties and lip ties throughout the state.
Your first visit to Agave will be with one of our Nurse Practitioners who specialize in evaluation and care of tongue and lip ties.
During your first visit your child will be assessed and appropriate recommendations will be given based on your child's needs.
If a procedure is recommended you will meet with Dr. Agarwal at your next office visit for the procedure.
Dr. Agarwal has performed thousands of corrective procedures successfully which have facilitated healthy breastfeeding for babies and mothers as well as improved speech and dental health for older children.
Day of Procedure
Dr. Agarwal at Agave Pediatrics has performed thousands of tie release procedures for tongue ( lingual frenectomy) and lip (labial frenectomy) over the years. On the day of the procedure, Dr Agarwal will assess the child once again and discuss the procedure and its 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 Chandler or Glendale location).
The baby is given a local anesthetic injection to numb the site.
A cool 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 & appropriate range of motion such as lift & 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 baby and you are as comfortable as possible for your trip home.
After the Procedure
Immediately after the procedure:
After the procedure, our staff IBCLC will guide you to a Lactation Room and assist you in latching your baby.
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 mom and baby 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 baby’s tongue in the first 24 hours after the procedure.
Checking for Re-Attachment:
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 size: it should not get smaller or disappear
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 re-attachment is expected, but minimizing it is important for over-all improvement.
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 baby will also help bleeding to stop. If bleeding does not stop child needs to be evaluated immediately.
Follow-Up Care During the Healing Process:
We are here for you during the healing process. We have a variety of ways to provide this support, and we encourage you to take advantage of the support methods that will work best for you.
• Bring your baby for in-person guidance, support and discussion with our IBCLC
• Please continue to work with your personal IBCLC. Our Support Clinic is designed to be an additional resource.
Proactive pain management is very important. For most babies, 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.
Please refer to the Tylenol Dosing Chart given to you for the appropriate dose for your child.
Please call if your child is using Tylenol frequently past 3 days.
Arnica 30 C (Homeopathic Treatment)
Crush 10 pellets into a powder and dissolve in 1 to 2 tablespoons of breast milk or water.
Please in refrigerator for up to 24 hours
Give Arnica solution as needed every 30 minutes by a dropper -10 drops at a time
Arnica can be give for fussiness or inflammation every 30 minutes in between doses of Tylenol, until child is calmed
Ibuprofen (over 6 months of age)
Please refer to the Ibuprofen dosing chart given to you for the appropriate dose for your child.
Please call if your child is using Ibuprofen frequently past 3 day
Pain Management Tips
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.
Many times just “clipping” a tongue tie is not enough. Babies usually begin sucking inside the womb, so even a baby who has their ties released as a newborn may need therapy to relearn normal tongue movement patterns. Children with a restrictive tie will over use their jaw, lips and/or cheek muscles to compensate for decreased tongue function. 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) and/or Speech Language Pathologist (SLP), because they can assess your baby’s suck and show you exercises specific to your Child.
Doing playful exercises with your baby while you are considering the procedure helps them become familiar with having objects, in or near their mouth.
Your playful interactions will build your baby’s trust as well as your own confidence and expertise with the exercises.
Playful Exercise Tips
Start when your baby is in a quiet alert state or early active alert state.
Talk in a pleasant voice, smile, sing, laugh, and make eye contact with your baby so this is playful and reassuring for them.
Stroke the baby’s upper lip to encourage them to open their mouth. It is a respectful way of “asking permission” to do the exercises.
Try to do the exercises 3-5 times a day before a procedure.
Be sure to start with clean, well-rinsed hands!
If your baby fails to respond or looks away, baby is telling you he or she wants to be done and this should be respected. If your baby becomes distressed or upset, please respect their cues and stop the exercises.
Make sure to provide comfort and console them.
This can help decrease sensitivity or defensiveness and can also help increase awareness of the face muscles.
Cheek massage: Place your thumb inside the lower corner of the mouth with the thumb pad in contact with the inner cheek. Place the pad of the index finger on the outer cheek. Gently follow a “c-shaped” movement pattern to stretch this area. If you feel resistance, pause for a few secs and you may feel the tension release. ** If your baby resists having one finger inside their mouth, you can start with drawing a “c-shaped” line from their nostril to lower jaw bone (chin). You can also draw lines from their nostril towards their ear – similar to drawing whiskers.Use slow and long movements with firm pressure. Fast movement with very light touch can sometimes create more aversion.
Upper lip stretches: Place pad of index finger along philtrum 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. Fast movement with very light touch can sometimes create more aversion.
Follow the Finger (Functional Lateralization 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 or 4 times. As you do this, use your thumb to support your hand and the baby’s jaw to increase stability.
Desensitizing the Palate
Some babies with a high or bubble palate resist a deep latch because they have a hyper-sensitive gag reflex that is provoked much closer to the front of the palate than usual gag reflexes. Systematically desensitizing can be helpful.
After stroking baby’s upper lip and they open their mouth, the index finger is gently slid back along the hard palate (roof of the mouth). Start by massaging the child’s palate near the gum line (immediately behind where their teeth would erupt). Progressively massage deeper but avoid gagging the baby. Repeat the exercise until baby will allow a finger to touch the palate while sucking on a finger. It may take several days of short exercise sessions to be effective.
Tug-o-War (Strengthening Exercise)
Touch baby’s philtrum or upper lip to encourage them to open wide. When baby does, slide your index finger in their mouth, pad up, gently stroke palate, then flip over and apply gentle pressure while stroking from the back of the tongue to the front of the tongue. While your baby sucks and you press down on their tongue slightly, gently play tug-o-war, pulling your finger out slightly. Baby’s response should be to suck harder on your finger and pull it back in. This can be especially helpful just before child feeds since it helps baby learn proper tongue movement for breastfeeding.
You can also do this with a narrow, cylindrical shaped pacifier like the Soothie brand. Cylindrical shaped pacifiers help the tongue. Gently pull it back out – just until you feel resistance as the baby sucks harder, trying to hold on. You may need to support their jaw a little as they learn to use their tongue more effectively.
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.
Post-Frenectomy: Wound Care Exercises
Caretakers are a necessary and important part of your baby’s treatment process and healing! Initially, post-procedure exercises can be the hardest on parents and infants; however, they are necessary and helpful in the long term. We are here to teach you firmbut gentle (not forceful) methods so that your child may tolerate them as well as possible. We are here to support you as you learn to do them well.
The goal of the exercises is to keep the healing tissue open and separate. This area needs to heal without the released tissue re-attaching back together. Within 24 hours or so of the procedure, a white diamond shape will be seen at the wound site.
PLEASE do the exercises consistently, 6 times/day until your two-week follow-up appointment.
After that appointment, exercises may continue for up to another 4 weeks to decrease the chance of re-attachment and continue to help muscles of the mouth
If you are working with an IBCLC or Speech Pathologist, they can guide you through the specific and unique needs of your baby’s oral-motor patterns.
Please start these exercises 6-8 hours after revision, unless given different instructions by Dr. Agarwal.
Doing the Wound Care Exercises
Build on the skills you developed by doing the pre-procedure exercises. Remember to start with clean, well-rinsed hands. If you are doing these while baby is awake, try to make this a playful routine so that YOU are effectively stretching the tissue and baby’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.
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 start with the gentle facial massages and stimulating their philtrum to open their mouth. Once you are allowed inside their mouth start with “Follow the Finger”. Doing these first helps baby become familiar with your fingers in their mouth (again) and exercises lateralization of the tongue (moving it from left to right).
“Lifting the Tongue” This exercise elevates the tongue toward the roof of the mouth to stretch the frenectomy site which keeps the wound open as it is healing and lessens the risk of re-attachment.
Place the pads of your pointer or small fingers on each side of the wound. Use the left and rights points of the diamond shape as a guide.
Using a motion that lifts the tongue upward toward the roof of the mouth, sweep your fingers up and down swiftly and firmly for 4 or 5 strokes. (This takes about 5 seconds.)
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.
“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 up above the top point of the wound on the underside of the tongue.
Firmly push back on the tongue 3 or 4 times.
It is recommended that you do the exercises consistently 6 times/day and randomly so that they don’t become a predictable activity toyour baby. Exercises can be done before a feeding; sometimes, afterward. Sometimes just before a nap, sometimes just as baby is waking up. When baby is crying and their tongue is raised, a quick set of exercises can be done. Finally, many babies do surprisingly well when the exercises are done during their deep sleep cycle, either during a nap or in the middle of the night – if you happen to be up!
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If you have any other questions, please feel free to contact us by phone or email.