TOTS: Tethered Oral Tissues — What Are They, Should They Be Released, and What Does Recovery Look Like?
If your baby is struggling to latch, making clicking sounds while nursing, or you're experiencing nipple pain that won't resolve, tethered oral tissues — commonly known as TOTS — may be the reason. At Lactation Loop, our board-certified IBCLCs are specialists in identifying and managing TOTS, and we're here to help you understand what this means for your breastfeeding journey.
What Are Tethered Oral Tissues (TOTS)?
Tethered oral tissues is an umbrella term that refers to restrictions in the soft tissues of the mouth that limit normal movement. The most common types are:
Tongue Tie (Ankyloglossia) — A tongue tie occurs when the frenulum, the small band of tissue connecting the underside of the tongue to the floor of the mouth, is too short, thick, or tight. This restricts the tongue's range of motion, making it difficult for a baby to effectively remove milk from the breast.
Lip Tie — A lip tie occurs when the frenulum connecting the upper lip to the gum is too tight, preventing the lip from flanging outward properly during nursing. Lip ties often occur alongside tongue ties.
Buccal Ties — Less commonly discussed, buccal ties involve restrictions in the cheek tissue that can also affect feeding and oral function.
How Do TOTS Affect Breastfeeding?
TOTS can cause a wide range of breastfeeding challenges for both mom and baby, including:
Poor latch or shallow latch
Clicking or smacking sounds during feeding
Frequent falling off the breast
Excessive gas, colic, or reflux symptoms
Slow weight gain or difficulty maintaining weight
Extended feeding sessions with baby never seeming satisfied
Nipple pain, compression, or damage for mom
Low milk supply due to inefficient milk transfer
Breast engorgement or mastitis
Many families struggle for weeks or months before a TOTS diagnosis is made. If you are experiencing any of these symptoms, we strongly encourage you to reach out to a certified IBCLC for a thorough feeding assessment.
Should Tethered Oral Tissues Be Released?
This is one of the most common questions we hear from families, and the honest answer is: it depends. Not every tongue tie or lip tie requires release. The decision should always be based on a thorough functional assessment — not just the appearance of the frenulum.
At Lactation Loop, we take a conservative, evidence-based approach. We recommend considering release when:
Breastfeeding is significantly impaired despite proper positioning and latch work
The baby is not gaining weight adequately
Mom is experiencing persistent nipple pain or damage
The restriction is causing compensatory oral patterns that are affecting feeding function
Conservative measures like bodywork and feeding therapy have been attempted without sufficient improvement
We always recommend a full evaluation by an IBCLC before and after any procedure. We work collaboratively with trusted pediatric dentists and ENTs who specialize in frenectomy procedures to ensure your family receives comprehensive, coordinated care.
What Does the Release Procedure Look Like?
A frenectomy — the procedure used to release a tongue or lip tie — is typically a quick outpatient procedure. There are two common methods:
Laser Frenectomy — Uses a laser to precisely release the restricted tissue. This is currently the most common method used by pediatric dentists and is known for minimal bleeding and high precision.
Scissor Release — Performed by some ENTs and pediatricians using sterile scissors. Quick and effective, particularly for anterior tongue ties.
The procedure itself usually takes only a few minutes. Most babies cry briefly and then calm quickly, often nursing immediately after to soothe.
What Does Recovery Look Like?
Recovery after a frenectomy is an important and often underestimated part of the process. Here is what to expect:
The first 24-48 hours — Some babies are fussier than usual as the wound heals. Others feed better almost immediately. It varies from baby to baby.
Wound healing — The release site will form a white or yellow diamond-shaped wound as it heals. This is normal and not a sign of infection.
Stretching exercises — Most providers will recommend wound stretching exercises to prevent reattachment. Your IBCLC will guide you through these in detail so you feel confident performing them at home.
Bodywork — We strongly recommend craniosacral therapy, chiropractic care, or pediatric occupational therapy before and after release to address any compensatory muscle tension that has developed. This is a critical part of successful outcomes.
Feeding therapy — Working with your IBCLC after release is essential. It takes time for a baby to learn new oral movement patterns. Your IBCLC will help you support your baby through this transition and optimize breastfeeding success.
Full improvement — Most families begin to notice meaningful improvement within 2-4 weeks post-release, though some babies need more time and support.
How Lactation Loop Can Help
At Lactation Loop, our IBCLCs are trained in the assessment and management of tethered oral tissues. We provide pre-release feeding assessments, post-release feeding support, and ongoing care to help your family reach your breastfeeding goals.
We serve families in Michigan, Florida, Texas, New York, North Carolina, and Indiana with in-home, in-office, and virtual visits available. Most major insurance plans are accepted including Aetna, Cigna, UnitedHealthcare, UMR, Meritain, and Wildflower.
If you suspect your baby may have a tongue tie or lip tie, don't wait. Early intervention leads to the best outcomes. Book an appointment today at lactationloop.com or call us at 941-254-2502. We're available Monday through Sunday, 9am–8pm.