Tethered oral tissues (TOTs), which include conditions such as tongue-tie (ankyloglossia) and lip-tie, can significantly impact a child’s ability to feed properly. Whether it’s breastfeeding, bottle feeding, or transitioning to solid foods, these restrictions in oral movement can lead to various feeding challenges. Feeding therapy, often provided by occupational therapists (OTs) and/or speech-language pathologists (SLPs), plays a critical role in helping children with TOTs develop the oral motor skills they need to eat comfortably and efficiently.

We will dive into what TOTs are, how they impact feeding in infants and older children, and why feeding therapy is an essential intervention for children with these conditions. We will also look at the importance of early intervention and how feeding therapy can support long-term health and development.

Understanding Tethered Oral Tissues (TOTs)

Tethered oral tissues (TOTs) refer to abnormal restrictions in the tissues of the mouth, including the frenulum (the tissue connecting the tongue to the floor of the mouth) and the lip. The most common forms of TOTs are:

• Tongue-tie (ankyloglossia): A condition where the lingual frenulum is too short, thick, or tight, restricting the tongue’s movement.
• Lip-tie: A condition where the labial frenulum (the tissue connecting the lip to the gums) restricts the movement of the upper lip, preventing proper latch during breastfeeding or bottle feeding.

TOTs can create a range of feeding difficulties in both infants and older children. Many parents first notice issues during breastfeeding or bottle feeding, but problems may also arise later when the child transitions to solid foods or experiences challenges in chewing and swallowing. For older children, TOTs may affect speech development and even cause dental issues.

Common Symptoms of TOTs in Infants

Parents and caregivers of infants with TOTs may notice:

• Difficulty latching during breastfeeding: Babies with tongue-tie or lip-tie may struggle to form a proper seal, leading to frequent latch breaks.
• Painful breastfeeding for the mother: Inefficient latch due to TOTs can cause pain and even injury to the mother’s nipples.
• Gagging, choking, or coughing while feeding: Restricted oral movement can make it difficult for babies to control milk flow.
• Inadequate weight gain: Babies with TOTs may not be able to feed effectively, leading to poor weight gain or failure to thrive.
• Prolonged feeding times: Babies with TOTs may need significantly longer feeding times due to difficulty extracting milk.

How TOTs Affect Older Children

As children grow, TOTs can continue to impact their ability to eat and speak. Some symptoms in older children include:

• Difficulty transitioning to solid foods: Chewing and swallowing solid foods may become challenging because of restricted tongue movement.
• Gagging or choking on food: Limited oral mobility can increase the risk of food not being managed properly in the mouth.
• Picky eating habits: Children with TOTs may avoid certain textures or types of food that are difficult to chew or swallow.
• Speech delays: Restricted tongue movement can lead to articulation issues, affecting the child’s ability to form certain sounds.

How Feeding Therapy Helps Children with TOTs

For children with TOTs, feeding therapy is crucial to address the various oral motor challenges they face. Feeding therapists, including our OTs at Michigan Pediatric Therapy, are trained to assess the impact of TOTs on feeding and oral development. They create individualized therapy plans to help children improve their feeding skills and overcome difficulties associated with TOTs.

1. Breastfeeding and Bottle Feeding in Infants with TOTs
For infants with TOTs, feeding therapy focuses on improving their ability to latch effectively, extract milk efficiently, and coordinate the suck-swallow-breathe pattern that is critical for feeding.

• Latching support: Feeding therapists can provide guidance on positioning and techniques that help babies achieve a deeper, more effective latch during breastfeeding.
• Oral motor exercises: These exercises help improve tongue and lip movement, allowing the baby to suck more efficiently. Therapists may use gentle tactile stimulation to help strengthen the baby’s muscles and promote better feeding patterns.
• Collaboration with lactation consultants: Feeding therapists often work closely with lactation consultants and IBCLCs to provide a comprehensive approach to breastfeeding support for babies with TOTs.

When breastfeeding is too difficult, some infants may need to switch to bottle feeding temporarily or permanently. In this case, feeding therapy can help by introducing bottle feeding techniques that accommodate the baby’s oral limitations.

2. Feeding Therapy for Solid Foods and Older Children
As children grow and begin to transition to solid foods (typically around 6 months of age), feeding therapy can help them develop the necessary oral motor skills for chewing and swallowing.

• Oral motor skill development: Feeding therapists work with children to strengthen the muscles involved in chewing and swallowing. Exercises may focus on improving tongue mobility, jaw strength, and the ability to move food within the mouth.
• Texture introduction: For children with TOTs who may be sensitive to different food textures, feeding therapists gradually introduce a variety of textures in a controlled and supportive manner.
• Behavioral strategies: In some cases, children with TOTs develop picky eating habits due to their difficulties with feeding. Therapists can help parents implement strategies to encourage children to try new foods and overcome their feeding aversions.

3. Speech Development and TOTs
Since TOTs can impact tongue movement, they can also interfere with speech development in older children. Feeding therapy often overlaps with speech therapy for children who struggle with articulation issues related to tongue-tie or lip-tie. Speech therapists can work on:

• Improving articulation: Helping the child form sounds that require tongue and lip movement, such as “l,” “r,” “th,” and “s.”
• Increasing oral motor control: Strengthening the muscles involved in speech production to improve clarity and fluency.
• Using alternative communication methods: For children who are non-verbal or minimally verbal, feeding therapists may introduce augmentative and alternative communication (AAC) systems to support their ability to communicate effectively.

Occupational therapists (OTs) play a critical role in feeding therapy, particularly for children with TOTs. While speech-language pathologists (SLPs) are often involved in speech and oral motor function, OTs bring a unique perspective to feeding therapy by addressing the child’s overall sensory processing and motor coordination.

OTs assess and treat a variety of factors that may contribute to feeding challenges, such as:

Parents and caregivers often wonder when it’s time to seek feeding therapy for a child with TOTs. While every child’s development is unique, there are some common signs that indicate it may be time to consult with a feeding therapist:

Tethered oral tissues (TOTs) can create significant feeding challenges for children, from infancy through childhood. Whether it’s breastfeeding, bottle feeding, or transitioning to solid foods, children with TOTs often struggle to feed effectively due to restricted tongue or lip movement. Feeding therapy is a critical intervention that helps children develop the oral motor skills they need to eat comfortably, safely, and efficiently.

Feeding therapy not only addresses the physical challenges associated with TOTs, but it also helps children overcome sensory sensitivities and picky eating habits; feeding therapy plays an essential role in supporting children with TOTs on their feeding journey.

If your child is experiencing feeding difficulties related to TOTs, early intervention can make a significant difference in their development. Contact our team of feeding specialists at Michigan Pediatric Therapy in Farmington Hills, MI, to learn more about how feeding therapy can help your child thrive.

Michigan Pediatric Therapy
📍 27655 Middlebelt Rd., Suite 130, Farmington Hills, MI 48334
📞 (248) 939-4030
🌐 mipediatrictherapy.com