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Resources for Feeding, Eating, Drinking, Speech, and Mouth/Airway Function


Hot Topic Blog - Breastfeeding


Lisa Paladino, RN, CNM, IBCLC in New York, New York, USA

November 2018


Babies are born to breastfeed, yet many parents struggle with this natural function. As a Midwife and International Board Certified Lactation Consultant (IBCLC), I have made it my personal mission to support as many parents as possible in reaching their feeding goals.

Lately, this has been accomplished through my specialization in the assessment and treatment of tethered oral tissues (TOTs). These are oral restrictions, also known as lip, tongue, and buccal (cheek) ties. TOTs can have detrimental effects beyond breastfeeding; however, this article will limit the discussion to breastfeeding infants.

The effect of TOTs on breastfeeding was first brought to my attention through a local parent group. Since I learned almost nothing about TOTs in my formal training for any of my credentials, I prioritized educating myself on this topic by reading research articles, texts, as well as by attending conferences and presentations by pioneers in the field. The incidence of TOTs is not something that is easily agreed upon. It is a topic that is new to the forefront of medicine, but not new historically.

Likely due to a few generations of infants in the western world being fed mostly by bottle, there has been little need to learn about the challenges of TOTs related to infant feeding. Bottle-feeding and breastfeeding are completely different processes. Bottle-feeding is a medicalized way of feeding a baby and does not require the sophistication of oral skills used by the properly breastfed baby. This is one reason breastfed babies have significantly better mouth development than bottle-fed babies (Bahr, 2018). As a result, during most of the 20th century, healthcare providers were not taught to recognize or treat oral restrictions. This explains, but does not excuse, the common occurrence of families now struggling with breastfeeding. These families are often denied proper evaluation or told that “everything is fine” when it is actually anything but fine. This leads parents to either give up on breastfeeding or turn to social media for answers.

While I love (and preach) self-empowerment and education, the social media diagnosis of TOTs has me concerned. Parents turning to Facebook to find a solution without guidance from an IBCLC can lead to unnecessary procedures, releases without professional feeding guidance, and failure to achieve results.

For some infants, a simple release by laser or scissor can make a big difference in a breastfeeding relationship. But often that’s not the case. Many infants need body work to adjust to the release of tethers as well as oral exercises/activities to learn to use the tongue, lips, and jaw in new ways. Many parents also need help in adjusting the milk supply to their infant’s need, guidance to heal nipples and soothe painful breasts, as well as emotional support and guidance through the journey.

I worry about parents rushing to a provider for the release of TOTs because what looks like a tongue, lip, or buccal tie in a picture or by exam may not be a functional restriction. In other words, this is often a diagnosis of form over function. For example, we should be diagnosing how the tongue moves during feeding, not what it looks like. A professional evaluation by a provider trained in full functional assessment of parent, infant, and feeding is necessary. An experienced IBCLC will recommend preparation for the procedure and guide parents to have releases of TOTs when the infant is ready. Timing is important for success and improved feeding.

My protocol for assessment and treatment of TOTs in breastfeeding infants involves a team approach to care. The team can vary, depending on the dyad, but often includes a chiropractor, feeding therapist (i.e., usually an occupational or speech therapist trained specifically in feeding), physical therapist, and a dentist in addition to an IBCLC. Different teams are necessary for therapies with older children and adults undergoing TOTs release.

I recommend evaluation by an IBCLC for any nursing dyads experiencing the symptoms described below.

Symptoms of possible TOTs in the infant include:

-Slow or fast weight gain

-Colic or gas

-Reflux (spitting up)

-Explosive poops

-Blisters on lip, especially upper lip

-White coating on the back of the tongue

Symptoms of possible TOTs observed by the parent include:

-Painful breastfeeding (nipple and/or breast pain, with or without visible trauma; cracked or bleeding nipples)

-Misshapen nipples after feeding (either flattened, creased, or “lipstick” shape)

-Frequently clogged milk ducts, engorgement, nipple blebs, or mastitis

-Oversupply or low milk supply

Symptoms of possible TOTs in feeding include:

-Difficulty latching

-Noisy nursing (clicking)

-Bites or chomps on nipple

-Slips on and off the breast

-Falling asleep while nursing

-Nurses for a long time, then wakes up as soon as he/she is put down

-Lots of sucks, fewer swallows

Resources Used for This Article

-Bahr, D. (2018). Feed your baby and toddler right: Early eating and drinking skills encourage the best development. Arlington, TX: Future Horizons.

-Farfel, M., IBCLC. (May, 2017). Treatment of tethered oral tissues by IBCLC. Personal interview.

-Four, R., IBCLC. (May, 2017). Assessment and plan for TOTs. Personal interview.

-Hines, J., DPT. (July, 2018). CST for breastfeeding infants. Personal Interview.

-Kotlow, L., DDS, MALD, FAPD, FABPD. (2017). Breastfeeding should be fun and enjoyable. Retrieved with permission @

-Paladino, L. (2018). Parent’s guide to TOTs.

-Paladino, L. (2017). It shouldn't hurt to nurse your baby. New York, NY: Paladino.

-Quinto, D., OT. (July, 2018). Occupational therapy and body work for breastfeeding infants. Personal Interview.

-Siegel, S., MD, DDS, FACS, FICS, FAAP. (April, 2016). Aerophagia induced reflux in breastfeeding infants with ankyloglossia and shortened maxillary labial frenula. International Journal of Clinical Pediatrics, North America, 5, Available at:

-The International Board of Lactation Consultant Examiners. (May, 2017). History. Retrieved June 03, 2017 from

-The International Lactation Consultant Association. (n.d.). WHAT IS AN IBCLC? Retrieved June 03, 2017, from

-Yasmin, E., IBCLC. (2017). Does My Baby Have a Tongue and Lip Tie [Pamphlet]. Mumbai, India: Yasmin.

About the Author

Lisa is a highly skilled women’s healthcare professional with over 30 years of experience in caring for women. She holds a Bachelor’s Degree in Nursing and a Master’s Degree in Midwifery. Lisa is a Registered Nurse (RN) since 1987, a Certified Nurse Midwife (CNM) since 2008, and an International Board Certified Lactation Consultant (IBCLC) since 2011. She is a recent graduate of Dr. Aviva Romm’s New Medicine for Women Institute Functional & Integrative Medicine Professional Training Program.

Lisa co-founded the Breastfeeding Initiative at Staten Island University Hospital and worked in collaboration with the NYC Department of Health for eight years on efforts toward achieving the Baby Friendly designation. She has been assisting new families to breastfeed since 1990, first at the bedside and in the past 10 years in the outpatient office setting.

Lisa’s unique qualifications as both a nurse practitioner and lactation consultant give her the ability to diagnose and prescribe treatment protocols for breastfeeding management as an independent provider without the need for physician consultation. As a founding member of The International Consortium of Oral Ankylofrenula Professionals (ICAP), she is experienced with assessment, as well as diagnostic and treatment protocols for infants with tethered oral tissues (tongue, lip, and buccal ties). Additionally, she has a network of professionals for collaboration and referral.

Lisa currently moderates a large, local Facebook breastfeeding support group (i.e., the Staten Island Breastfeeding Moms) and a women's health and empowerment group called Roots. She also leads an online Reset and Replenish group, focusing on holistic solutions for thyroid and adrenal health. Her social media goals are to change the culture around infant feeding and wellness, one woman, one family at a time. And, her mission is to support as many parents as possible in reaching their own feeding goals. She is fortunate to work in a collaborative/referral network with a team that includes a laser dentist for frenotomy, body workers, and speech-language pathologists (SLPs). She dedicates her writing/lecturing to the process of developing a team and has lectured at local and international conferences on this topic.

Lisa is the author of the best-selling book, It Shouldn’t Hurt to Nurse Your Baby and the online education program A Parent’s Guide to TOTs which is open for professional collaboration. If you are a professional looking to collaborate on the Parent's Guide to TOTs program, more information can be found here:

Here are some links:

-It Shouldn’t Hurst to Nurse Your Baby:

-A Parents Guide to TOTs:

-Facebook Group (Tongue Tie Experts):

-Lisa’s Facebook Page (Women’s Integrative Wellness):

-Lisa’s email: