If breast feeding is a struggle for you or your baby, you have probably heard that clipping a tongue tie, lip tie or buccal (cheek) tie could be the answer to your problem. Procedures to cut these mouth tissues have skyrocketed in number over the past 10 years and are commonly recommended on social media. Of course, mothers who have difficulty with nursing want what is best for their baby, but there are so many questions:
- How can you tell if my baby has a tongue tie, lip tie or buccal tie?
- How does a mother, lactationist or pediatric doctor decide what’s best for any individual baby?
- Who do you talk to when a baby can’t breast feed right?
- What are the most common reasons babies struggle to breast feed well?
- Do all babies who struggle to breast feed have a structural problem with their mouth?
- Can’t procedures that involve blades or lasers in a baby’s mouth be dangerous? What if something goes wrong?
- How do you know if taking the risk of the procedure would help?
- If a procedure is needed, who is the best person to do the procedure? How do I know I can trust them with my baby?
These are all important questions I will address. While support groups and social media comments can provide some ideas to consider, they aren’t a good way to make medical decisions (especially for a baby). You and your baby deserve thoughtful, sensitive and supportive answers backed up with professional knowledge and expertise gained by treating thousands of babies with feeding problems. With over a decade of experience as a pediatric doctor, I am confident you will find the information here accurate and reliable. I am also confident it will pass the test of time. If you find it helpful for you and your baby, feel free to share it with others who are struggling.
Who Do You Talk to When a Baby Can’t Breast Feed Right?
Feeding is one of a newborn’s biggest jobs. Many health problems in babies show up first as feeding problems, so it is best and safest to see a pediatrician first for feeding problems. Pediatricians are experts in every area of a baby’s body and health, so they can check for and care for all the causes of feeding problems. Once more serious problems are ruled out, your pediatrician may refer you to a technical specialist to help your baby in whatever area will be most helpful. That could be a Lactationist, a Speech Pathologist, an Occupational Therapist, or a more specialized doctor like a Neurologist or an Oral Surgeon. Unless a baby has a tooth (yes babies can be born with teeth, we have had multiple such patients) they do not need to be referred to a Pediatric Dentist.
How Do You Tell If a Baby Has a Lip Tie, Tongue Tie, or Buccal Tie?
This question has a trickier answer than you might expect! Babies with restrictive tongue ties reportedly create some specific signs of a problem: pain on their mother’s nipple, and skin break down can happen within a day or two of birth. Babies with lip and buccal ties are reported to have a variety of almost every problem a newborn could have with breast feeding: poor feeding stamina, swallowing air, making clicking noises, spitting up, and difficulty latching.
Because almost all babies have some or all of these symptoms during their first few weeks of life, the presence of these symptoms does not help you find out what is causing a feeding problem. This is especially true because strength and coordination problems are by far the most common causes of breast feeding issues in babies; by comparison structural problems like tongue, lip or buccal ties are rare (and in some cases have no evidence that they cause problems at all, more on that below).
So, How Do Pediatricians Tell If a Baby is Tongue Tied?
First, a pediatrician leans on their anatomy education. There is a very wide difference in the thousands of hours of anatomy and physiology pediatric doctors undergo compared to the hundreds of hours Nurse Practitioners do, and another wide gap again down to the limited amount of low-detailed education a Lactationist receives. This is not a criticism of Lactation Staff; they simply have a different and more focused job that requires only a limited amount of anatomy and physiology. Pediatric Doctors and Nurse Practitioners have a much more in-depth job requiring a much more in-depth education. The deeper the educational background, the more complete and reliable a physical exam is.
Second, a health professional leans on their experience with previous patients. After 4 years of medical school, Pediatricians go through a residency for another 3 years where they examine many thousands of patients. This robust experience helps doctors to refine all the variations of normal that exist in people, while also exposing the doctor to a wide range of abnormal findings. This gives doctors a deep skill level when a normal vs abnormal finding is present. After experience working as a nurse, nurse practitioners go through 3-4 more years of school where they typically examine many hundreds of patients, giving them a strong ability to determine normal findings, but less experience with unusual abnormal findings. Finally, Lactation Specialists are trained through a less formal shadowing process that usually takes 6-12 months. While their job and training are of high value, their training does not allow them enough training or expertise to diagnose problems based on a physical exam.
The tissue under the middle of the tongue, lips and on the back of the cheeks are present to some degree in every baby (except those with more significant findings like a cleft palate etc), even in babies with no problems breast feeding. That means doctors and nurse practitioners must determine if the tissue is restrictive. If tissue stops a body part from moving well, cutting it may help the baby. If it is not restrictive, cutting it will not help the baby and may cause harm (and unnecessary cost). To help determine which ties could be problems (restrictive) and which are normal, 2 different grading methods were established for lip ties, Kotlow and Stanford. While commonly used by Lactationists and Dentists, both the Kotlow and Stanford methods have been shown to be unreliable, even when the same provider rates the same patient’s mouth repeatedly. (Shah et al, Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia, 2021; Santa Maria et al, The Superior Labial Frenulum in Newborns: What Is Normal?). Grading tongue ties has a similar lack of good standards, and there is no standard at all for buccal ties.
Without a reliable standard to use, there is no way for a provider to know if a baby has a lip or a buccal tie, because all babies have these parts in their mouth. Making the uncertainty worse, almost all babies have the common and varied symptoms reported to be caused by lip and buccal ties (fussiness, gassiness, spitting up, clicking during eating, etc). This is part of the reason that Pediatricians, Ear Nose and Throat Surgeons, and Oral Surgeons never recommend lip and buccal tie procedures for babies.
Tongue ties are different, because the tongue is different from the lips and cheeks. The tongue, unlike the lip and cheek, has a much larger range of motion to go through to do its job of nursing at the breast. If a mother-baby pair has restrictive tongue tie symptoms, they should see a Pediatrician for a simple exam with clear findings to determine if a procedure may be helpful. With mouth open, a normal baby can lift the tip of their tongue to the roof of their mouth and stick their tongue out far enough to reach the outside of their lower lip. If a baby can’t do these 2 things, and other more common reasons such as muscle strength and coordination problems are ruled on by additional medical exams, your baby may benefit from a procedure to cut the tissue and allow normal mobility of the tongue. Many babies with a band of tissue that looks close to the tip of the tongue still have normal tongue mobility, meaning they will not benefit from a release procedure. Unlike lip and buccal ties, tongue ties cause more specific problems and have clear and simple exam findings to help you and your provider tell if there is a structural problem. Similar to lip and buccal ties, every baby has a band of tissue under their tongue, and it is rare that it is the cause of breast feeding problems.
What Are the Most Common Reasons Babies Struggle to Breast Feed Well?
If all babies have webs of tissue inside their lips, on the back of their cheeks and under their tongue, and these tissues rarely cause problems with feeding, what are the most common reasons? See the following top 3 list:
1. Poor Coordination
By far, the most common cause of difficulty feeding at the breast is poor coordination. Sucking and swallowing while still breathing, all while laying down, is a little bit complicated! Careful coordination and timing are needed, and new babies are don’t specialize in careful coordination and timing. Babies come out with good reflexes and instincts to breathe, suck and swallow, but most newborns need to practice a few hundred times before things get reliably smooth. Breast Feeding is a lot like learning to read: almost everyone can do it with enough time and practice, some learn fast and others are slower, but with patience and support, almost everyone will master the skill. In our decades of combined experience, we see that almost every baby struggles to feed the first week of life, but by 4-5 weeks of age most have figured it out and very few struggle.
2. Size or Flow Mismatch
If a baby has a small mouth, even a normal sized nipple and areola can be difficult to hold onto for a full feeding. The same is true of milk flow: many mother’s let down faster than a newborn baby can handle, especially during the first 2 weeks after birth. These problems usually resolve quickly as babies grow, and are rarely a problem beyond 4-6 weeks of age.
3. A Naturally Short Tongue
Like having small ears or short fingers, some babies have very short tongues with a flat tip. This causes feeding difficulties that look very similar to babies with a tongue-tie: pain and skin breakdown near at the nipple with a shallow latch. However, these babies don’t have a tongue tie, and cutting the frenum under the tongue does not help these babies feed better. This is another problem solved with time and growth, and is rarely a problem after 6-8 weeks of age.
All of these problems are FAR more common than restrictive ties. Thankfully, they are all things that Doctors and Nurse Practitioners regularly identify in our patients. When present, we recommend the help of a Lactation Specialist as opposed to a more painful, invasive and potentially harmful procedure.
Are All Babies Who Struggle to Breast Feed Tongue Tied?
Thankfully most problems with breast feeding are not structural. As explained above, all the most common problems that challenge babies as they nurse do not need a procedure. Only a small percentage of babies have a restrictive frenum in their mouth. There is some evidence that a restrictive tongue tie release is helpful for babies, while there is no evidence whatsoever that cutting lip or cheek (buccal) tissue helps babies more than giving them time and Lactation Specialist support (as of 2025 at time of writing).
Can Tied Tongue Surgeries to Cut Tongue, Lip, and Buccal Ties Hurt My Baby?
Any medical intervention involving blades or lasers can have complications. But lip tie repairs have higher risks than tongue tie repairs. This is because there are important branches of muscles and nerves in the tissue under the middle of the lips, while in the tissue under the tongue there is no muscle and no important nerves. At Redwood we have unfortunately seen quite a few babies injured by Dentists who do lip tie repairs. These babies had many months to several years of difficulty feeding and gaining weight due to nerve and muscle damage done when the laser used to cut the lip tie severed important nerves and muscle fibers in the lip frenum. Thankfully, we have never seen a baby injured from having a tongue tie repair.
Should I See a Dentist for My tongue Tied Baby with Feeding Problems? What If Something Goes Wrong?
The answer here is simple. If your baby doesn’t have teeth, they do not have a reason to see a Pediatric Dentist. Pediatricians and Nurse Practitioners have substantially more training and experience in diagnosing and treating problems with feeding. If your baby has a rarer problem like a tongue tie, your medical provider can do the repair at Redwood. The procedure is quick and simple, and there is no difference in outcomes if done by a laser or a set of curved scissors designed for the specific procedure. There is also the cost: Dentists usually charge far more than Pediatricians for the exact same procedure. Finally, Dentists in the Kansas City area have unfortunately begun to charge cash and do a lot of lip and buccal tie procedures in the past 7 to 8 years.
Because there is no evidence to support doing these procedures, and Pediatric Dentists charge for each mouth part separately, many families pay over $1000 out of pocket for procedures that have no evidence of helping a patient but sometimes cause real nerve and muscle injuries that last years. When these injuries occur, Dentists do not have the training or expertise to help their patients- they send the injured patients back to Pediatricians to manage the patient’s growth, feeding problems, and muscle/nerve damage recovery. Recovery from these injuries usually lasts months to years, and sometimes is assisted by an Occupational Therapist. So, in a nutshell, Dentists (doctors who specialize in teeth) have started doing more and more lip and buccal tie procedures (no teeth involved), and they charge cash.
Lip and Buccal tie procedures are not medically recommended in infants by any type of Physicians- Pediatricians, Ear Nose and Throat Surgeons, or Oral Surgeons. This is because there is no evidence that these procedures help babies, and the chances of harm are greater than the chances of help. Finally, when babies are harmed by these procedures, the Dentist sends the patient back to the Pediatrician for management of the nerve and muscle injuries (and the feeding and growth problems that follow), as Dentists are unable to manage such problems.
How Do I Know If Taking the Risk of a Tied Tongue Surgery Would Actually Help My Baby?
This is a very important question. Any procedure has risks. By doing studies that compare patients who have a procedure to patients who do not have a procedure, we can tell if a procedure truly helps patients and find out how common the risks are. Without studies to prove benefits and tell us what the risks are, professional ethics are clear that procedures should not be done. Lip ties and Buccal ties are a good example of procedures in this category. There are no comparative studies available to show effectiveness and provide information on risk, so these procedures should not be performed on babies.
Sometimes, several small studies are done separately on a procedure, but don’t show the same results for effectiveness. They can help show how risky a procedure is though. This is the current situation with tongue ties. There are some studies that show a tied tongue surgery is helpful, and others that don’t show help. But all of the studies show a low level of risk. This combination of low risk and undetermined helpfulness means Doctors may recommend a procedure, but not in every situation, and with a clear explanation to parents of what to expect, “maybe helpful, maybe not, but safe to perform”. These are the reasons why doctors sometimes recommend tongue tie repairs and do not recommend lip and buccal tie repairs.
If a Procedure Is Needed, Who Is the Best Person To Do It? How Do I Know I Can Trust Them With My Baby?
When a baby needs a procedure, you don’t want just anyone to do it. Consider the following things when making this decision:
- You want someone with the best training and the most experience doing the procedure
- You want someone trained and experienced to manage any and all complications that could occur after the procedure, someone who will take full responsibility for your baby’s outcome from start to finish
- You want someone you know and trust
- You want someone who knows your baby
- You want someone you can easily communicate in the days and weeks after the procedure
- You want someone who will not overcharge you for the procedure
At Redwood, our Pediatricians and Nurse Practitioners are committed to supporting you and giving the best care to your baby. We have the professional training and experience to make the right diagnosis, so you can be sure you aren’t putting your newborn through an unnecessary procedure. We do this procedure frequently, so our technical skills stay on point. We are available 24/7/365 should anything come up after the procedure and need to be discussed. Finally, we care about our long-term financial relationship with you, we want to do the right thing by you. We wont overcharge you or your insurance company for the procedure.
Call us today to schedule your next appointment and get help with breast feeding, tongue ties, or anything else!
