Frequently Asked Questions
My baby is gaining weight, so why should I fix the ties now?
We need your baby to be feeding and not you feeding your babies. Moms will have a hormonal response to the baby that usually lasts 3-5 months. The baby will stimulate the breast and cause a let down of milk. Some babies are just sitting there at the breast and swallowing the milk. We call this "riding the letdown". We need the baby to trigger the supply and demand cycle so the breast empties and fills back up. If this does not happen then the supply will slowly decrease over time and it can be difficult to build back up. We want to fix the ties before this happens. If your baby is not actively using the tongue, then the muscle does not strengthen. This causes weight issues later on because the baby needs to take more volume to gain weight. Sometimes this is when we see Moms constantly moving the baby from one breast to the other to continue to trigger let downs. If the baby is not nursing past the initial let down and moves to the other side, then there is very little hind milk extracted. That is like when we eat simple carbs all day and no protein or fat. It is very unsatisfying and not good for brain and muscle growth.
I'm scared to put my baby in pain; why is this worth it to do so young?
When we fix the ties early, then we get the most movement in the mid face including the jaw and sinuses. Babies do their most growing in the first 6 months of life. When a baby is breastfeeding, but using the jaw to move up and down instead of gliding forward, then the jaw joint is not growing properly. When we change this motion by releasing the tongue so it can make the wave motion and the jaw can glide forward, then more time is spent gliding to stretch out the joint and allow the jaw to move forward with facial growth. We start solids after 6 months and the jaw naturally changes at this age to an up and down motion. Also, the older the baby, the less likely they will change their nursing behavior. Young babies live in the moment and their brains to not have object permanence yet, so they forget and are easily distractible. The older the kids get, the more they are aware of the situation and remember when they see your finger approach their mouth. We still try to keep it fun and don't worry, they are very forgiving. The areas are well healed within two weeks which is a very short time compared to Orthodontics. If the tongue is not up and the palate is not naturally expanded the the jaw and teeth have to be moved. This is where painful Orthodontics including palatal expanders and orthodontic appliances are in the mouth for months to years. Jaw surgery for late teens needs to be done after puberty. The oral surgeon breaks the jaw and resets it forward to allow new bone to form. Yes, it is as awful as it sounds. Remember, when we get the sinus area to develop properly, then there will be fewer ear and sinus infections which means less pain and antibiotics. The list goes on and on...
Why do you prefer the Mam pacifier instead of the Soothie, Bib, or Nuk pacifier?
We have tried all the pacifiers on the market to find the best one for tied babies. We use the pacifier as an exercise to strengthen the tongue muscle and train the tongue to stay up to the palate. It is similar to lifting a light weight with lots of reps while breastfeeding correctly is like lifting a heavy weight with fewer reps. The pacifier is good for tone and coordination while breastfeeding correctly will build strong muscle. The Soothie is very firm and round so it pushes the tongue down. It also has a ridge near the lips and gums which stimulates the baby to bite instead of suck. Any baby can hold a Soothie pacifier in the mouth which is why there are so commonly used in the hospital setting. Dentists also do not like the Soothie or Bib because of the way that they mold the upper jaw into a V shaped when we want a nice oval U shape. The Nuk follows the slant of the tongue when it is tied by allowing the back portion to hump up and the front portion to stay down on the floor of the mouth. We want the tip of the tongue to stay just behind the gumline and the rest of the muscle to be up towards the palate. The Mam pacifier is soft, smooth and in a nice wide, flatter shape to allow this to happen. Using the Mam pacifier 3 times per day or more is what we recommend. Check out the Tug of War exercise under the pre-procedure therapy section.
My baby can take a bottle so why not just pump and bottle feed?
Over time, it is very difficult to continue to keep your milk supply up with just pumping. We praise Moms that want to provide breastmilk for their baby which is certainly better than formula on so many levels. We would never fault Moms that want to do this and offer only praise for the dedication. We just want the opportunity to make a difference if we can fix the nursing experience when there are ties involved. Pumping does get very tedious and old after a while. The newer cordless pumps will allow more frequent pumping sessions but after a while, without the bonding of your babies, the ability to trigger a letdown may dwindle. We are understanding so much more about the importance of direct breastfeeding. The exchange of your baby's saliva onto and into the breast will allow the breastmilk to change composition and alter the kind of good bacteria that are secreted. It also will trigger immune responses which allow antibodies to pass from Mom to baby. Amazing and fascinating. And, of course, the bonding experience between Mom and baby while breastfeeding is like no other.
Why fix all the ties at once and not one at a time?
It is very difficult for the baby to figure out what to do with the tongue muscle, if we do not take out the ability to use the lips and cheeks to compensate. Also, the lips and cheeks are the easy part of the procedure as far as release, aftercare exercises, pain, and healing. The tongue tie is what takes the skill to release fully and properly and using the type of equipment to cause the least amount of pain, scaring and risk of reattachment. Releasing just the tongue and not the other ties reminds me of serving a healthy salad to eat but keeping the plate of cookies there too. We will still eat the cookies, or at least I would, lol.
Why is my Pediatrician not familiar with ties?
This is a very frustrating issue. Unfortunately, ties are still not being taught in Medical School or Dental School. We are probably years from this. Right now, it is all about Continuing Education. As doctors, we get to decide what we learn for continued education. The doctors that spend the time to learn about ties will be familiar with how to diagnose, understand the different treatment options, and know who to refer to for treatment. Schooling teaches us how to identify disease, not how to make anatomy more functional. This is a specialized field which is why this is all we do at Team Tongue Tie. What we hope is that your Pediatrician will see the red flags of tie issues and refer you to someone who specializes in ties. When the there is a red flag for an eye problem, we refer to an eye specialist. Hopefully ties will go the same direction. We refer you to a Lactation consultant for breastfeeding problems but then your IBCLC cannot make a diagnosis because it is not in their scope of practice. Also, if your IBCLC is not recently educated or continued their education in ties, then they may fall short there too. This is the disconnect. We are trying hard to fix this problem by providing a free dinner lecture monthly for continuing education for all providers. You can let your provider know how to contact us to attend.
Why was this not diagnosed in the hospital?
Especially with submucosal ties, there will not be any initial issues with breastfeeding. After birth, these babies will latch fine. Colostrom is thick and easy to transfer and the baby does not need to get much to be satisfied. Remember that a baby's stomach is the size of a marble at birth then grows as the volume of milk transfer increases. The more the baby exercises the tongue at the breast, the more fatigue sets in, especially when there is a thick restriction underneath the tongue. These Moms often have a delayed onset of milk production which causes jaundice and weight gain issues in the baby. It is very important to pick up these ties in the first 6 weeks of life as milk supply is increasing. If your baby is not removing milk from the breast adequately then pumping the milk out will help to prevent supply issues in the future. If you baby is not strengthening the tongue, even with a release of ties, it may take 6-8 weeks to build the muscle of the tongue to breastfeed efficiently. It is not a magical procedure but a step in the right direction to provide better function for breastfeeding, eating solids, speech, dental issues, sleep posture, and proper airway management.
Why are we seeing and hearing about ties so much more now? Is this a fad?
This is such a loaded question and there are so many factors that may be an issue here. We did not know what we did not know. Sleep medicine is a relatively new field and we are understanding how important the airway anatomy and tongue position affect sleep and behavior. Studies are done on adults and we are trying to extrapolate this data down to children and babies as we routinely do not do studies on this population. Adults also have additional issues related to sleep hygiene including excessive media time, poor diet, alcohol intake, and smoking that can interfere with sleep. Sleep specialists see the rise in sleep apnea is often related to tongue position and airway management. When we fix babies and young children, we see improvement in the anatomy to prevent these issues. We also know that it is not normal for babies or children to snore or be noisy breathers. During sleep, the tongue should be up and the lips sealed. Air should be moving from the nose to the lungs but if this cannot happen then the mouth will open to get the tongue out of the airway. When air is being filtered through the mouth, the tonsils and adenoids get irritated and grow which also pushes the tongue forward. And the cycle continues and progresses. With our patients, we have seen that fixing this positioning and changing the anatomy stops the cycle. It will take time for this clinical evidence to become proven research, especially since doctors frown on prospective studies. There are a few other reasons that we may be seeing more ties. We are looking for them to make a difference and parents are researching and questioning more about their children and themselves. This is where the internet and blogging has been helpful in the recent future. We encourage our families to share their story! We follow our patients and have a great success rate because we make sure the procedure is done right and heals correctly to give our patients the best outcomes. Poor outcomes or repeated revisions often come from incomplete removal of ties or lack of aftercare and follow up which is so important. The body is amazing and can learn to compensate which can be fine for a while but may cause issues later. More parents are being proactive with their children to provide them better health for the future. This is why we are seeing a resurgence of breastfeeding in the first place. Parents want to provide better nutrition for their children and we know Breast is Best. We are coming out of the formula and bottle generation which produced less healthy children and adults with overeating issues, obesity, diabetes and cancers to a new generation which will be healthier with less disease. There are certainly genetic and environmental issues that are in play to further confuse the issue. It will take years to figure out what in our environment (chemicals, preservatives, additives, synthetic vitamins, soil, bacteria, etc.) is turning on the genes to express where the ties form in the mouth. At this point, we have an easy procedure to fix the problem (and possibly prevent future issues) until we can prevent it from happening in the first place.
Is my child going to be in pain during the procedure?
We numb the lip which is more sensitive with a strong topical gel which is a mixture of lidocaine and tetraine anesthetics. The lip tie procedure takes about five seconds, but the topical gel lasts for 30-60 minutes. After the procedure, the numbness often confuses them while breastfeeding because they are used to incorrectly holding the breast with their lip and jaws. They are supposed to hold the breast with their tongue. The posterior portion of the tongue creates negative pressure by moving up and down which allows the milk to be drawn in from the breast. After the procedure, it makes it easier for your baby to nurse by holding and compressing the breast to match the mouth (make a “breast sandwich.” ) The nipple should be free floating back towards the throat and not pinched to the roof of the mouth.
Why not numb the tongue tie for babies?
It takes approximately five seconds to laser the tongue tie with our CO2 laser. There is no nerve in the cord or near the area that is lasered. Because there is usually no bleeding during the laser procedure, it is easy for us to see and not go too far or hurt the surrounding tissue, muscle, or blood vessels. This is not the case with an unskilled hand or with a sharp pair scissors making a blind cut into the tie. The laser depth is about the width of a hair and it takes time to vaporize the tissue so there is no risk of “slipping” and hurting a nearby structure. What babies do not like is that we have to lift the tongue up with a tongue retractor to see. When the tongue releases it feels awkward because they have never felt their tongue elevate freely. The tongue is still attached by the muscle to the floor of the mouth so there is no risk of choking on the tongue or having it fall back in the throat. It is just now free at the center to have it’s full function and range of motion.
What are buccal or cheek ties?
Buccal ties are just like a lip tie but along the side of the upper (or less commonly, the lower) gum line. They attach the cheek to the gumline and allow the baby to use the cheek muscle like a pump or vacuum to suck the milk out of the breast like using a straw. This is not efficient. What we need is a rhythmic wave-like milk removal to fully empty the breast and stimulate production. A fully empty breast makes more milk. Buccal ties are NOT normal ties like an upper lip and tongue tie. They form in utero as compensation for the tongue or shortly after birth if the baby starts using the cheeks and jaw to feed. It takes lactation education to understand how the tongue works, which many providers do not have. All providers at Team Tongue Tie are lactation specialists. Providers that “clip” with scissors do not routinely check for buccal ties because it is not safe to cut them with scissors. Buccal ties can only be released safely with a CO2 laser. Babies use lip ties and buccal ties to compensate for the inability to use the tongue for it’s designed function. In time, the cheek, jaw and lip muscles build strength and then it takes time to unlearn the behavior and allow the muscles to return to their normal size and softness. This is one of the reasons that fixing ties younger is better, so there are fewer bad habits to be changed. This is why we like to fix all ties involved so the baby can use the tongue how it is designed and not use the compensatory areas to feed. The mouth can adapt in time with ties, but it is much more efficient and more comfortable to use the anatomy the way that it was designed.
What kind of pain should we expect after the procedure?
It does not hurt to touch the areas. The issue is that the muscle of the tongue is now sore because it has not developed properly and is now being used differently. This is a new workout for the tongue. It would be as if you were doing a series of twenty minutes of squats or lunges and then rest for a few hours and repeat the series over and over again. The affected muscles would become sore and by the third time or so, you would be fatigued. It would then feel better to move around and stretch, however, the affected muscles would still be sore. After a few days doing this series of new exercises, relief would come. This is the same idea post procedure. Tylenol (for babies under 6 months) and ibuprofen (over 6 months old) will help during the healing. Patients tend to do better as far as pain and feeding if they stay ahead of it. When parents are proactive and give the medication regularly for the first 2-3 days, we find better feeding and happier families. Infant massage, Bodywork, skin to skin, baths, singing will all help your baby heal. The goal with the aftercare is to get in quickly and stretch the areas; to get them moving and to help them to heal, while keeping the sites as open as possible.
Why is aftercare is so important?
You may read elsewhere that stretches have not been taught or recommended or that they should be done differently. Each patient’s ties open differently and will want to close differently, so we will tailor the stretches as those areas heal. If the muscles in the tongue were strong enough and could coordinate perfectly after release of the ties, then stretches may not be needed, but that is rarely the case. The tongue muscles are often underdeveloped. It takes time for the jaw and lip muscles, that have been working too hard trying to compensate, to weaken as the tongue learns to lift, get stronger, and function independently. Just like any new workout, it takes about six to eight weeks to build new muscle.
Why do you need to recheck patients in the office and not just from a picture? How do I take a picture or video for you to review?
It is very challenging to get a good picture of the released areas. You can lift and pull in different directions and the area may look reattached, when it is not. It is very important for us to feel the area so we can tell whether there is an early reattachment or just muscular tension that is lifting the area. This tension can get worked on by your chiropractor and/or a trained physical therapist. We are always happy to look at videos or pictures to see how the stretches are going. The best way to see tongue movement with babies is with crying. Film a 15-30 second section of crying with a diaper change or film as you do the stretches so we can see the sites. To take a picture of the upper lip, lift with both hands on either side of the site and flip the lip up to the nose. while another person takes the picture. As far as the tongue, put your index fingers on either side of the diamond and lift up to the roof of the mouth while someone takes the picture. You can also get a picture of the diamond while sleeping as the tongue should be up on the palate and you may just pull the lower jaw down and take the picture.
Why is bodywork so important and recommended?
Bodywork includes therapy done by chiropractors, osteopaths, physical therapists, myofunctional therapists, speech therapists, and craniosacral therapists (CST). We tell parents that we have the easiest part of this equation because fixing ties with a skilled hand and using an amazing C02 laser is what we do. We cannot release the muscular tension that exists under the ties or the molding of the head; the tension in the neck and spine caused by a long or difficult labor; or a low, tight or uncomfortable position in the womb. It is often helpful for hands on treatment to reset the nervous system after the release. Chiropractors that work on babies use gentle pressure similar to checking if a a piece of fruit is ripe. Children and adults can hold muscular tension from having ties for long periods. This type of therapy helps with releasing the tension from using the wrong muscles to compensate for inadequate tongue function.
Why is there so much saliva after the procedure?
The tongue tie is often holding down the salivary glands and when we release the tie, the salivary glands are free and tend to be overactive. It takes 7-10 days for this to better regulate. You also are pushing right along the duct with your stretches. This action stimulates and releases more saliva which does help the area heal. This is actually therapeutic and should not be worrisome. If your baby is two to eight months old, teething is also possible and makes babies drool as well.
Why is my baby spitting up more since the procedure?
This is often caused by overeating. Your baby is more efficient at the breast and is now getting more milk faster. Their brain has not caught up with their stomach knowing it is full already. As long as the spit up or vomit is milk or digested milk and not bright green, projectile or painful, then spitting up is normal. Be prepared to do more laundry until your breasts regulate some. Try to substitute the Mam orthodontic pacifier towards the end of a feeding when your baby slows, starts to fall asleep and is doing a faster, twitchy suck without many swallows.
The sites started bleeding with the stretch, what does that mean?
The first 2 days, there is often bleeding along the edges of the areas because they try to close in so fast. Just keep using firm pressure to stretch. You cannot push too hard or make the areas bigger. Remember, we had to open these with a laser. Often your last stretch was not hard enough and then if you get a good stretch, you are just opening what had closed in the past 4 hours. Make sure your stretches are frequent and with consistent firm pressure. When the tongue is still resting on the floor of the mouth and there is still lip and cheek muscles that have formed and are tense, reattachment is more likely. The more the areas are functioning correctly and the more you are guiding the healing then the better the outcome and function will be.
Why do I still have to flip the lip at the breast if the tie is gone?
Your baby or child has built up muscle just under the nose which helped to engage the lip to hold onto the breast, bottle or cup. It takes 3-6 weeks of not using the muscle (like when we cast a broken bone) for the muscle to weaken and get smaller. It is often hard to keep the lip flipped over the muscle that is there, especially if they continue to use it as the tongue fatigues. Continue to rub the outside of the lip like a mustache, pull the lip up to the nose, and rub the lip in various directions to try to relax the muscle. Continue to watch your baby at the breast or bottle and flip the lip out when you see it curled. In time, the muscle will get smaller and the bad habit will break.
Is the yellow color of the healing areas a sign of infection?
When the lasered areas heal, the tissue may look white, gray or yellowish. The yellow color is very common in babies less than 6 weeks old because of residual jaundice that naturally goes away. The last area for the jaundice to resolve is in the mouth. As long as your baby is pooping yellow or green and not white, then this is not worrisome. It is just part of physiologic and breastmilk jaundice. The younger the baby, the more yellow the color. Babies under a week will look neon yellow or orange. There has never been a reported infection after frenectomy. In thousands of these, I have never seen one either. But if the tongue is hot, red and swollen or your baby has a fever then please reach out to us. You can always send a picture for us to look at.
What is a superbill and what do I do with it? How do I submit a claim to my insurance?
We take full payment for services at the time of the procedure which includes your follow up visits. We provide you with a superbill, or paper invoice, for you to submit to your insurance for reimbursement for services. These superbills are available on your patient portal after the procedure and 2 week follow up visit. There will be an address on the back of your insurance card stating where to submit your claim. Your insurance company will have a form for you to fill out that you can find on their website or by calling their member services. Everything that they need to process the claim is documented on our superbills. We will provide 2 sets of superbills as we split up procedure coding from office visit coding for reimbursement. The amount of medical or dental reimbursement depends on the type of plan that you or your employer purchases so each plan will reimburse differently. There are hundreds of different plans out there which is why we cannot provide a reimbursement estimate for you. We find it does help, especially when making a medical appeal after an administrative denial, to write a personal letter explaining why the procedure was necessary for you or your child and include the before and after pictures we have taken that are available on your patient portal. You can use the information on our website to help create the letter as well. Were you going to stop breastfeeding which you know was best for your baby? Is your baby having breathing or sleeping problems from the ties? Speech or feeding issues? Tell your story from the heart! Make sure to check the boxes correctly when you fill out the claim forms and sign the appropriate areas so that they send the reimbursement check to you and not to Team Tongue Tie.
Do you take insurance? Are you part of my insurance network? Do I need a referral to see you? What about Medi-cal?
We are not in any insurance network. We are not a preferred provider for any insurance. We are not a Medi-cal provider. This all means that we do not take your insurance card for payment or bill your insurance and you do not need a referral to be seen in our office. We take a payment upfront in the form of a credit card, HSA card that works like a credit card, Care Credit card, or cash. We provide you with a superbill (or invoice) to submit to your insurance to get reimbursement for services provided. It is always best to contact your medical and dental insurance company first to find out their process of reimbursement after seeing an out of network provider. We recommend to speak to more than one person if what they are telling you does not seem correct. Medi-cal does not provide reimbursement to you for these services. We have looked into joining local insurance plans like Blue Shield, Aetna, and others, but it would mean that Dr. Sacker would have to be affiliated with local hospitals and take care of sick patients as well. We are not seeing regular pediatric patients in the office so we can focus on our specialty and we also want to provide a safe environment for our patients.
Don’t I pay less if I go to a provider that takes insurance?
Often NOT! We are just taking a payment upfront and the other offices are taking your insurance copay or nothing upfront and then you pay the balance of the payment after insurance reimbursement. So in the end, it ends up the same cost to you either way. We are not a preferred or in-network provider on any insurance so make sure you know what your medical and dental insurance covers for your particular plan. Unfortunately, many medical and dental plans do not cover this procedure. Hopefully, in time, and with parent letters explaining why this is important and how this has helped, insurance coverage will change. Insurance plans are never comprehensive for all conditions. We do offer Care Credit. This company pays us your charge (minus a percentage) instead of you upfront. Then you will have 6 months interest free, no payment required. This can give you time to get your insurance reimbursement before you need to pay the company. Apply by clicking the button below and bring your Care Credit card in for the consultation and procedure.
Why choose a CO2 laser to repair the ties instead of just a pair of scissors or a simple diode laser?
Dr. Sacker has used all 3 so she knows first hand! Scissors are sharp and make an even cut that can more likely reattach. It is also very common to not cut enough or not be able to cut enough because of the tie depth, location or extent of restriction. One can only cut what one can see and what is safe to cut. Since you cannot see what is under the area clipping you have to stop short. It is very common for providers to cut the anterior or front portion of the tongue tie in anterior to the salivary glands and leave the posterior portion intact. The problem with this is that it is the posterior portion is what controls the middle and back portion of the tongue which is the area that is needed for breastfeeding and swallowing. It is also very difficult to cut into a submucosal tie that is more of a sheath attached to the surface of the tongue. It will bleed and one is not able to open it fully because of the bleeding and safety issues. Buccal ties cannot be cut with scissors because of their location and size. Upper lip ties can be partially cut by skimming the gumline with the sharp instrument. The upper lip tie is covered by a sheath of sensitive tissue so it always hurts and bleeds with a scissors. One is unable to cut it completely into the groove between where the teeth form which leaves the remainder of the cord attached to the bony area and upper gumline. The clip with scissors does help elevate the lip for breastfeeding, but it often regrows and will affect teeth location and make teeth brushing difficult or painful. Lasers can repair an incompletely released lip tie at a later date, but the area is more sensitive and has scarring from the previous clip so more laser energy is required which makes the procedure itself and the healing more challenging.
The CO2 laser is the most gentle soft tissue laser on the market right now. Most of the time, there is no bleeding. Using this laser can be faster than scissors! It is definitely safer because it is working above the tissue, cauterizing at the same time as vaporizing the tissue in a bloodless field which allows clear view for vessels and nerves. The diode laser works with heat, requires more energy to release the tissue, and causes a bit more scarring, especially with submucosal ties. It is very hot and unsafe to use on buccal ties. Just like our iPhones and other similar technology, we have better ways to do things now; we just need the medical community and insurance companies to catch up so our families can get the best care possible!
What kind of support is included during the procedure and aftercare?
We work 1:1 with you and your family immediately after the procedure to help with the initial latch while breastfeeding. We will show you how to do the aftercare stretches and then you will practice so we can make sure you are doing them firmly enough and correctly. We will see you back in 2-4 days for an initial recheck to check the sites and as often as needed, until the next scheduled recheck at 2 weeks post procedure. Anytime you feel that the sites are healing incorrectly, you may text us a picture or email us a video of talking, crying, or just lifting and moving the tongue around. You can get a good picture of the lip by holding it up with 2 hands on either side of the site and have someone else take the picture. You can get a good picture of the tongue while sleeping by pulling the jaw down, as the tongue should be up on the palate, so the whole diamond will be visible. If awake, use 1 finger on each side of the diamond and lift up to the palate while someone else takes a picture towards the floor of the mouth. We are happy to provide lactation support by email or text during the healing period. We encourage you to see your own private IBCLC within a week post procedure, then weekly until breastfeeding is going well. Some babies with weak tongue muscles will take 6-8 weeks to improve and we recommend an office visit with your IBCLC for a weighted feed once a week. For those babies and children with continued muscle tension in the posterior tongue and neck, it is important to start bodywork with a pediatric chiropractor early, and continue 1-2 times per week until muscle tension resolves which may take 6-8 weeks.