Frequently Asked Baby Questions
Why should I do this?
I'm scared to put my baby in pain. Is it worth doing a procedure 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 growth in the first 6 months of life. When a baby is sucking and is 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 a restricted tongue, then the baby can make the wave-like motion and the jaw can glide forward. When more time is spent gliding, then the baby will stretch out the joint and allow the jaw to move forward with facial growth. If there is a tongue tie connected to the jaw, then it is holding the jaw back and this prevents normal growth of the jaw. Babies 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 feeding and nursing behaviors. Young babies live in the moment and their brains do not have object permanence yet, so they forget and are easily distractible. The older the baby gets, 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, babies are very forgiving. The areas are well healed within two weeks, which is a very short time compared to the need for years of Orthodontics. If the tongue is not resting up on the palate or roof of the mouth then the palate is not getting expanded naturally and the jaw and teeth will have to be moved later. 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 fewer antibiotics. The list goes on and on...
My baby is gaining weight, so why should I fix the ties now?
We need your baby to be feeding themselves 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 letdown 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. This is sometimes when we see Moms constantly moving the baby from one breast to the other to continue to trigger letdowns. If the baby is not nursing past the initial letdown and moves to the other side, then there is very little hindmilk extracted. This compares to when we eat simple carbs all day and no protein or fat. It is very unsatisfying and not conducive to healthy brain and muscle growth.
Why choose a CO2 laser to repair the ties instead of just a pair of scissors or a simple diode laser?
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 a release, aftercare exercises, pain, and healing. The tongue tie is what takes skill to release fully and properly while using the type of equipment that causes the least amount of pain, scarring, 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.
Is my child going to be in pain during the procedure?
We numb the lip, which is more sensitive with a strong topical gel, with a mixture of lidocaine and tetracaine 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 3-5 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 of scissors that makes 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 its full function and range of motion.
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 that we can make sure that 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. 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.
Why is aftercare is so important?
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 a hands-on treatment to reset the nervous system after the release. Chiropractors and cranial osteopaths that work on babies use gentle pressure similar to checking if a piece of fruit is ripe. This type of therapy helps with releasing the tension from using the wrong muscles to compensate for inadequate tongue function.
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 of 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 the pain instead of trying to catch up from behind. 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, and 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.
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 pull the lower jaw down and take the picture.
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 saliva is therapeutic and should not be worrisome. If your baby is two to eight months old, teething is also possible and this makes babies drool as well.
The sites started bleeding with the stretch, what does that mean?
In 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 are 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.
Is it normal for the lip to be swollen after a lip tie release?
Yes! When the lip is very tight from the tie, often there is some swelling in the evening after the procedure. That is why we use our cold laser first as it prevents pain and swelling. It would be much worse without that treatment. Our older kids and adults say that it is not uncomfortable, but that it just looks puffy. It is usually better within 1-2 days. Sometimes, we see the same thing with the buccal (cheek) tie release if they were very tight.
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 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.
Why do the sites look so big and open?
The deeper or tighter the fibers of the ties, the bigger the diamond opening tends to be. This goes for upper and lower lip ties as well. We are only removing the thick collagenous fibers. We do not touch the muscles. This is what stretching, massage, and bodywork are for. We want full function of the area without restrictive fibers. The areas will contract in some and get covered with new soft tissue, which is why you are rubbing over the areas to keep them smooth, soft, and flat.
Is bad breath normal after the procedure?
Yes! It is from the odor of the healing tissue and the fact that the mouth is open more because the tongue is tired. It gets better about a week after the procedure. Try running a cool mist humidifier at night to help with congestion and with keeping the healing tissue moist.
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 whom 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 there is a red flag for an eye problem, we refer to an eye specialist. Hopefully, ties will go in 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 is not continuing their education in ties, then they may fall short there too. This is the disconnect. We are trying hard to fix this problem by educating providers and we hope you will too after you have learned from your experience with us.
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. Colostrum 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 the 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 your 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 a 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?
What do I look for in my kids that were not released to know if they need the procedure now?
We base our need for an initial assessment on symptoms. If you or your children are symptomatic, we are always happy to check their mouths in the office for ties. Most of the kids that we fix have speech issues, excessive drooling, eating issues, sleeping issues, dental/orthodontic issues, and/or chronic neck pain/headaches. Most adults that we release have sleep issues including apnea or snoring, chronic headaches/jaw/neck pain, speech issues, dental/orthodontic, and/or mouth fatigue after talking all day. Bottom line, the most important sign would be airway compromise. Children and adults should be sleeping with their mouths closed and breathing through the nose. If the mouth is closed then pull down the jaw and make sure the tongue stays suctioned up to the palate. If you do not see this, then we need to check your anatomy in the office. The tongue needs to stay up to the palate so it is out of the airway. We do not want even a partial obstruction affecting sleep, breathing, and oxygenation of the body. The pressure of the tongue on the palate will widen the hard palate making room for the teeth and allowing aeration of the sinuses, keep the soft palate firm and elevated, and prevent the tonsils from enlarging and moving forward over time.
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 that 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 speaking 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 that 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, the insurance coverage will change. Insurance plans are never comprehensive for all conditions.
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.
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 original 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.
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 by 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 the 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.