An Interview with Dr. Jesse Witkoff

If there is one single issue that had the biggest impact on both my babies’ first year of life, it is tongue tie. And the irony? I wasn’t given any information about the condition until I sought it out myself.

But after struggling through breastfeeding issues, extreme pain, bloody nipples, vasospams, daily weight checks, reflux, infant sleep apnea and airway issues, triple feeding, supply issues, recurring ear infections and many, many nights with uncomfortable, screaming babies, I’ve learned a thing or two.

I have two daughters. Between them, we’ve had 5 oral ties released. My eldest had her tongue tie released twice – once at 4 weeks of age, and once at 5 years of age. My youngest also had two revisions – one on day one, and 4 additional on day 10. She had two of the rarest occurring ties – bucchal ties – and became the subject of presentations on the issue.

Needless to say, it has been a long, and seemingly never-ending journey to find out more information about tethered oral tissues, and the host of problems they can cause. While information has become more readily available in the last 5 years since I first gave birth to a tongue-tied baby, researchers are still discovering more symptoms and striving to fully understand the impact tongue and lip tie have on the mom-baby dyad.

What I remember most from my experience with both babies is a feeling of desperation: feeling like something was off, and like I was failing. I remember the pain – both physical and emotional – as I tried to figure out how to help my babies eat successfully. I remember doubting myself and my instincts when hospital staff and several lactation consultants told me there was no problem. I remember the extreme sense of relief when my pediatrician and the lactation team at the mama’hood Denver rallied behind me and marked our case urgent. And just like that, we were meeting with Dr. Jesse Witkoff, tongue tie specialist, for revision.

I’ve known Dr. Witkoff for years now, and what I’ve learned from him is invaluable. Dr. Jesse has completely changed the course of my parenting journey for the better – with both of my kids – so when I had the chance to interview him about tongue and lip tie, I jumped at the chance.

I hope the information in this interview is enough to help just one mom feel confident, and know she’s not crazy. I hope it helps at least one mom to find relief, and one baby to gain the weight they need. If we’ve done that, we’ve succeeded.

To find a tongue tie specialist near you, visit The Mama Sagas postpartum directory.

Saralyn Ward: Dr. Witkoff, it’s good to talk to you. Thank you so much for doing this.

Jesse Witkoff: Oh, you’re very welcome. It’s my pleasure. It’s become a passion.

SW: First of all, can you explain what tongue tie is, and how moms can recognize it in their kids?

JW: Sure. You have a little attachment of skin under the tongue, the frenum, and it attaches to the floor of the mouth. A tongue tie is when it’s short and it can’t function properly. We usually refer to it now as “tethered oral tissues,” because it’s usually more than just the tongue. You’ll find the lip is often tied as well. There’s might also be some ties on the cheek, which are a little more minor and less common. The lip and the tongue ties commonly occur together, but may also be isolated. A lot more information is starting to come out about all of this.

SW: Yes, I feel like tongue tie is becoming much more recognizable and people are talking about it a lot more, but you don’t hear as much about lip tie. So, you’re saying if one tie is present, we should be concerned with the other?

JW: Absolutely. These ties all occur around the midline of the body, so they can often happen together. Other signs that might indicate tethered oral tissues are the stork bites on the forehead or if that dimple above their their butt, the sacral dimple, is really pronounced, because those are on the midline of the body too. It doesn’t mean the baby would demonstrate all of those signs, but whenever I see other midline defects, I’m more suspicious that there will be a tie.

SW: What about stork bites on the back of the head? Like at the base of the hairline?

JW: Yes, anywhere on the midline.

SW: Interesting. I didn’t know that. Both of my daughters have those stork bites but in different spots.

JW: Yes. When they’re off to the side, they aren’t really as related to tethered oral tissues, but when they’re right in the center, it can be a sign.

SW: Are there other signs and symptoms that are really common with babies that have tongue tie?

JW: Absolutely. Well, first, let me go over how nursing should work. Ideally, to get a good latch, the baby needs to open wide, and that top lip needs to flare. That way they can get the mother’s breast in deep enough to get the lip up onto the breast. If they cannot open wide enough and/or the lip doesn’t flare, then they’re going to get a shallow latch. That’s when they’ll close down on the nipple. And so you’ll see changes in nipple shape, whether they are flattened, lipstick-shaped, creased – even to the point where the nipples are bloody. And also, even if the lip can get on there fully but tongue is tied, then they’ll revert to a shallow latch.

SW: Interesting. And why did they do that?

JW: If the tongue can’t do the up-and-down wave motion that is that it’s supposed to do to pull out the milk, they’ll make their latch smaller and try to compensate, to figure out some way to get food.

For more information on tongue tie and other common new mom concerns, download our FREE ebook: 9 Tips to Get Baby To Sleep Tonight.

SW: Does tongue tie affect weight gain in infants? Are there any hard and fast rule in terms of how much weight a child who has tongue tie is going to be able to gain? Or is every child different?

JW: Every child is different, but they should continue to grow. Now there are some guidelines. By one week to 10 days, they should hopefully be back to their birth weight. After that they should gain about an ounce a day, give or take, or about 5-8 ounces a week.

SW: Will tongue tie stretch on its own over time?

JW: It will not. It’s made of a type of connective tissue, like a tendon, that will not stretch. So that’s a myth. Sometimes, the tongue will continue to grow from where the tie attachment is to the tip. So it looks like it’s stretching, but it’s really tongue growth.

SW: Got it. Okay, so at what point do you treat it?

JW: It’s best to treat it as soon as it’s recognized. The tongue needs to stick out far enough to cover the gum pad. And then guide the mothers breast up to the roof of the mouth, peel off and then drop down creating section like a pump. So some of the things we’ll see if they can’t do that, is they’ll tuck their top lip underneath, they’ll dribble milk out, they’ll demonstrate gagging and choking. They might have excessive gas or burps.

SW: It’s like they can’t control the flow of the milk.

JW: Exactly.

SW: So when diagnosing tongue tie, do you look at the nursing pattern? How do you diagnose tongue tie?

JW: A lot of times we diagnose off the symptoms that the mother reports and the off the physical exam. Everybody has a frenum but not every frenum is tied. The positioning of the child or baby during the exam is critical. They cannot be in the mother’s arms or in the car seat. They have to be flat, and then we’ll lift the lip up. We should be able to lift it up to the nostrils without any strain. And that’s the key: without strain. Soon as you see the lip blanching or curling around, then we know that there’s restriction.

SW: Right, so that’s diagnosis of the lip tie.

JW: Right. And with the tongue, some of the keys to look for are: if they can’t lift the lip, or if they have a high narrow palate- because the tongue is supposed to be up in the roof of the mouth for proper swallowing. If we see that high, narrow palate, then I’m willing to bet there is a tongue tie When I do the exam, I have to have get my fingers underneath the tongue.

This is the hardest part to explain: I think some people look just to see if the baby can stick their tongue out. But that’s only one type of tongue tie, when it’s anterior. You have to feel that tongue and get your fingers underneath at the very base of it, and then lift. If you go to lift, without a tongue tie you’ll feel the floor of the mouth lift up. When there’s a tie, as soon as you get to the end of that tissue. It’s like it’s stuck – it’s basically tied down. It just can’t lift anymore.

SW: I wonder what the history of the diagnosis pattern has been. Because, as you know, both of my daughters were tongue tied. In retrospect my mom swears that I was tongue tied, and that nobody recognized it when she was nursing me. A that point, they just told her to give me formula and go on with life. So it’s kind of interesting. I wonder if there a genetic component and have we seen a change over the years in terms of how many cases are diagnosed?

JW: Absolutely, in both cases. It is genetic. Let’s go back 150 years. What used to happen is a woman couldn’t nurse her baby, so the baby died or maybe there was a wet nurse is in the village. Midwives who assisted the birth usually had one long, little pinky nail. And when they noticed tongue tie at birth they would slice the tie with their their finger. Then, with the advent of bottles, there was a way to store milk. But the biggest thing was when formula was developed. It was marketed as being superior to breastmilk for a couple generations. So if you were having a problem, the message was: what’s the big deal? Go to formula because it’s better anyway. So the ability to recognize lip tie, tongue tie or feeding issues was just basically lost over a couple of generations.

SW: So it’s not necessarily a case of there being more cases of tongue tie now, it’s just being diagnosed more?

JW: Well, there are more because before many of those who had lip tie, and especially tongue tie, they died out. So their genes were not passed on to the next generation. Once we had bottles and formula, then the babies did survive, so now there are more.

SW: Interesting. I always wondered that, because it seemed like tongue tie was like something older generations hadn’t heard of. But both of my kids and so many of my friends’ kids have been diagnosed that it seemed like there was this strange trend towards more babies with tongue tie. But what you’re explaining makes way more sense.

JW: Yeah. So the idea was, you’re supposed to feed your baby, and it doesn’t matter how. But now, what we know is, it’s really more about the baby feeding themselves. Then, it became a status symbol to give your child formula. It was the poor who typically breastfed, those who couldn’t afford bottles or formula. But if you were of means, why would you breastfeed?

SW: Right. So, there were a lot more factors that went into why so many babies were formula fed before, besides just necessity. It was the marketing behind it, and also socioeconomic differences.

JW: Absolutely. And it also used to be that the only way that you got information was from your pediatrician, or maybe a friend or two. But now with the internet and social media, people can do research on their own, and no longer have to depend just on that one source.

SW: Yeah, that’s interesting. But at the same time, it doesn’t seem like there’s a lot of generational knowledge that has been passed down about this, because my generation isn’t hearing about this from our mothers, we’re hearing about it from our midwives or doulas or lactation consultants.

JW: Yes, or from friends who are going through it and may hear something, and they pass it on to their friends.

For more information on tongue tie and other common new mom concerns, download our FREE ebook: 9 Tips to Get Baby To Sleep Tonight.

SW: Right, exactly. So then, down the line, does tongue tie affect things like speech? What else?

JW: Starting from the beginning: liquid. The back of our tongue has to elevate to help us control the amount of liquid coming into the throat. You and I – if we have too much liquid coming in, we throw our tongue to the back and seal off airway so that we can breathe. So babies with tongue tie will gag and choke or come off the breast frequently, or even the bottle, if they can’t protect the airway. The next thing that we see are feeding issues again, once the baby transitions to solids. It’s that back part of the tongue that has to lift and move the bolus of food around. That’s how we control it. So if the baby can’t do that, then they might struggle with gagging, or choking or textures when they start solids. Or they might take a really long time to eat, because they’re trying to get it just right. It’s amazing, the body can compensate tremendously, you know. Babies learn how to use other abilities to compensate.

Then the next issue we encounter is speech, which is definitely affected. Some of the more common issues that you’ll hear are sounds made at the front of the tongue like L’s and R’s. And the sounds at the back of the tongue like S, Sh, Ch sounds. That’s a bit of a simplistic view, rather than going through everything. But those are the more common ones. So they might say, “Ye-whoa” instead of “Yellow” because they can’t make the L sounds, or “Wiver” instead of “River” because they can’t say the Rs.

SW: Can older kids have a tongue tie revision? At what age do you usually do the revision?

JW: There’s no age limit. One of the reasons that I became passionate about this was because I’ve struggled with neck and back pain my whole life from my early teenage years, and snoring. I have seen so many physicians. No one ever looked in my mouth. My speech was fine. I learned to compensate. But as I was studying this, I learned I had tongue tie, and I had mine released year and a half ago. And I would say about 70-80% of my neck and back pain are gone.

SW: Wow, that’s amazing. Well, they do say the tongue is one of the strongest muscles in your body, right?

JW: Absolutely. And when it when it’s tied, and things get pulled back, it impinges on our airway. And we don’t like that. So we sometimes go in a forward head position to open the airway up, that’s what puts strain on the neck muscles. So those who are having serious headaches, TMJ problems, migraines, neck and back pain… tongue tie can be the cause.

SW: Interesting. What about ear infections? Is there any correlation between tongue tie and recurring ear infections?

JW: In bottle fed babies, absolutely.  The mechanics of bottle feeding are totally different than breastfeeding.  They don’t clear their Eustachian tubes, which connect the back of the mouth (oropharynx) to the ear canal.  Milk and formula get clogged in there and that leads to the ear infections.

SW: In terms of lip tie or other oral ties, do those present with problems later in life too?

JW: Not as much. The lip tie is predominantly going to present issues around nursing and then brushing the teeth. We need to be able to get the toothbrush up so that we can get the part of the tooth right by the gum. If we can’t, it can be painful so children may not let the parents brush up there. Also, once teeth come in and babies start transitioning to solids, food can pool up in that area and sit on the teeth and they become more susceptible to getting cavities.

SW: Right. So it’s more dental issues then at that point.

JW: Right, and then beyond that, there are some cosmetic things.

SW: I’ve heard that a lip tie creates a gap in the teeth. Is that true?

JW: Yes. There’s one type of lip tie where the frenum comes down and doesn’t stop on the edge of the gum. It attaches into the bone or even wraps between the teeth- those types of ties can keep the front teeth from coming together.

For more information on tongue tie and other common new mom concerns, download our FREE ebook: 9 Tips to Get Baby To Sleep Tonight.

SW: So if a mom is reading this and she has a six year old with a tongue tie, who has gone this long without a revision, is it something that she should definitely do now?

JW: At that age, there aren’t as many issues. If it’s not affecting speech, airway or head and neck pain, it’s more just the risk of trauma in tearing it. Usually they’ll tear the tongue tie incompletely.

SW: So it can tear on its own?

JW: Yes. In fact, that’s what some healthcare providers advise: that you don’t need to treat it. Even as a baby with nursing problems. They’ll say tongue tie doesn’t have anything to do with nursing issues and the procedure is voluntary.

SW: Ouch!

JW: Yep.

SW: And so if it tears, is the kid bleeding from the mouth? And they don’t do anything to treat it?

JW: Typically nothing needs to really be done. Occasionally, you know, if the tear is big enough it it may need to have sutures placed. Sometimes it can tear the gum off the teeth, and then you have a bigger issue, and have to get them sewn back on in an emergency visit.

SW: What is involved in tongue tie revision?

JW: We use a cold, non-touch laser to release the tie. Unlike procedures that are performed with a scalpel or “hot” laser, cold lasers seal blood vessels during treatment so the patient experiences little to no bleeding. No sutures are needed afterward, and the laser sterilizes the wound so the risk of infection is very minimal.

SW: And what is recovery like afterwards?

JW: Usually the patient is a little sore for 24-48 hours afterwards, but recovers quickly. These tissues tend to heal fast. That’s why keeping up with post-surgery exercises (what we call Active Wound Care or AWC) is one of the most important things, though. These exercises are required for approximately four weeks after treatment, and they are done so that the released tissue doesn’t reattach during the rapid healing process. Reattachment can cause new limitations in mobility and the return of tongue or lip tie symptoms.

SW: So then the reason a mom would get consider a revision is really for breastfeeding, making sure that they’re able to feed the baby, and that the baby gets what it needs, but also speech and dental issues early on in life?

JW: Yes. But also airway restriction, and that is a big thing at really any age.

SW: Yeah, our second daughter had tongue tie, lip tie, two bucchal ties AND laryngomalacia, all at the same time. It was a dicey first few months. But I always wonder – with a baby like that, you know, years ago, what would have happened? Because I feel like we’re probably very lucky that she’s alive right now, that we live in the time that we live in, and that people are able to treat those issues.

JW: Oh wow. Yes, I mean, once we had the advent of bottles and formula, the ties wouldn’t have been as much of an issue, but the laryngomalacia – that’s something that can make a difference on whether they live or not. Laryngomalacia is pretty rare, while tongue ties are very common.

SW: Is tongue tie a dominant gene? I thought I heard that at one point.

JW: I would think so, because it’s passed on very commonly.

SW: If a mom thinks that her baby may be tongue tied, where should she seek help? Here in Denver, we’ve got your clinic, which is amazing. But if someone is in, you know, the middle of Iowa, what does she do if she thinks her baby is tongue tied?

JW: You have to seek out people who are experienced, which will largely mean doing internet search. And pay attention to symptoms. Start documenting them. Some of the symptoms that should make them a little suspicious are: if they have a difficult latch or if the baby has hard time staying on the latch.

SW: If they’re sputtering?

JW: Yes, and with excessive gas, that can lead to reflux. Sometimes it’s air and not acid. And so they’re treated with acid reflux medicines that don’t work. There was a great article that came out, finally proving that in 2015. I’ll see that a lot. Then, you know, if the baby is frustrated at the breast, if they arch their back, and are in discomfort at feeding times. Or, cluster feeding: It’s like lifting weights. You can do it for so long, but then you fatigue. So a tongue tied baby will work, work and work and then they just fall asleep. They’re tired, they wake up, they’re hungry. And so they don’t go that two to three hours between feedings. They’re just constantly feeding – like a full time job. Lip calluses are another symptom. The lip should be flared. If you’re getting a callous it means there is friction that shouldn’t happen.

SW: Huh, both of my daughters had lip callouses and I didn’t know that.

JW: It’s amazing how symptoms just get missed or blown over due to the lack of education. Another symptom to pay attention to is if they are chomping or gumming or tucking the lip. Another symptom is if they have an easy gag reflex. Or if they’re lazy eaters.

SW: Like falling asleep every time they try to eat?

JW: Right. I’ve never seen a true lazy eater. You know, babies are hungry. They want to eat. So those are the signs we see from the baby. For the mother: painful latch, shallow latch, the change in nipple shape, plugged ducts, mastitis, feelings of failure, and loss of milk supply. The maternal hormones drive the milk supply for those first three months. Then after that, the baby that has to remove the milk from the breast in order to stimulate more production. If they can’t effectively remove milk, that’s when all of a sudden supply drops off. Everything may have went well, mother had a good supply, then all of a sudden between three and six months supply drops off.

SW: I had no idea that was part of it, too. That’s right in line with what I experienced as well.

JW: Yeah, once all these pieces come together, it’s like, “Oh, now I know.”

For more information on tongue tie and other common new mom concerns, download our FREE ebook: 9 Tips to Get Baby To Sleep Tonight.

SW: And 3-6 months is right when a lot of women are exhausted with breastfeeding as it is, because a lot of them are going back to work at that point. So they also might think, “Maybe my supply is dropping because I’m going back to work and I don’t have time to pump and I’m more stressed,” and whatever else… so I can see how tongue tie would be completely missed and undiagnosed at that point, too.

JW: Exactly. Another thing to look for is if your baby is congested a lot, or the baby can’t lay their baby flat to sleep and has to be propped up. A lot of times that’s caused by the reflux coming back up. And as far as the airway restriction, I’m now having a lot of orthodontists starting to recognize this problem and refer patients over. The tongue has to get up in the palette, helping the palette spread, which opens up the airway. And if it doesn’t, because the roof of the mouth is the floor of the nose, then the nose and sinuses are too narrow, and they can struggle with with breathing and sleep apnea.

SW: Got it. So if a child is snoring a lot, is that a sign that there could be tongue tie as well?

JW: Yes. And in children that are a little bit older, if they’re just tossing and turning at night, tearing the sheets up, bedwetting that goes beyond, say four years old….

SW: How is that related?

JW: The body shuts down those systems while we’re sleeping. But if you stop breathing because of that tight airway then your body’s trying to wake you up. So that’s why kids will toss and turn, they’ll sleep light, and sometimes have bedwetting.

SW: Huh. I had no idea… my mind is kind of blown. I knew from working with you with both of my daughters, that you had a lot of information to share. But there’s so much more I learned today. I can’t believe that we don’t have this information out there readily.

JW: I agree. I mean, there’s a lot of resistance.

SW: And why is that? Because I can imagine parents might go to some pediatricians and say, I feel like my daughter or my son might be tongue tied, and ask if this is something they could look into, but they would be dismissed. And I’m not sure why that is or what the response should be.

JW: I’ve heard various things, like there’s no education in their medical school programs. I know there certainly wasn’t for us in dental, with a pediatric specialty, but I’ve heard that from some physicians- that there was no training. The pediatricians get something like nine hours of lactation and that’s it. And things get passed on from other physicians and they assume, “If you have a situation with tongue tie, shouldn’t everybody have the same symptoms?” But it’s not like that. It’s a dyad. The baby’s anatomy and physiology combined with the mother’s anatomy and physiology is unique. There can be compensation. So I think lack of knowledge is one of the biggest things. There was a TED talk that I saw that stated it takes 20 years to bring about a change in medicine. Right now, many physicians don’t believe in the interior tongue tie. So a lot of times, what will happen is, they’ll go in and they’ll do a scissor cut. But that’s like the sail on the boat: they cut the sail, but they didn’t get the mast. So the tongue still doesn’t have full movement. So I often see that they just release the front part but the baby still doesn’t have the full lift of the tongue.

SW: Right. Well, that’s exactly what happened with my oldest. When she was a baby, we had her tongue tie clipped at four weeks out. They did a scissor cut. And now, at five years old, you just released the rest on her tie with the laser, because she was having difficulty with speech.

JW: Right. In cutting that little front part, there’s no nerves or blood vessels. So you can go in there and cut that easy. Now, some will get relief with nursing from that. But it doesn’t mean you fully fix the problem. Still, some providers will say, “Look, they had a frenectomy and it didn’t work, so it’s unnecessary.”

SW: I feel very lucky to have a pediatrician who recommended we see you! But, like with everything, I suppose the moral of the story is to do some research, be your own advocate, and have a conversation with your medical provider.

JW: Exactly.

SW: Dr. Witkoff, I am very grateful for your time and for your insight. Thank you.

JW: Oh, you’re very welcome.

For more information on tongue tie and other common new mom concerns, download our FREE ebook: 9 Tips to Get Baby To Sleep Tonight.