Breastfeeding Issues: Understanding Tethered Oral Tissues (TOTS) and What Parents Can Do
- Virtual Breastfeeding Inc.
- 6 days ago
- 5 min read
If breastfeeding is painful, inefficient, or consistently difficult, tethered oral tissues (TOTS) may be a factor. TOTS are oral restrictions that limit the movement of the tongue, lips, or cheeks, which can interfere with latch, suction, and milk transfer even when feeds seem frequent.
Because feeding is a full-body activity, babies with TOTS often compensate by using other muscles, which can cause tension in the jaw, face, neck, or body and make breastfeeding more tiring or uncomfortable.
In this blog, we will explore this often-overlooked challenge, including tongue tie, lip tie, and buccal ties, how TOTS can affect feeding, why they may be missed, and what parents can do to get support.
What Are Tethered Oral Tissues (TOTS)?
TOTS is an umbrella term for oral restrictions that limit mobility and function within the mouth. These may include:
Tongue tie (ankyloglossia)
Lip tie (upper or lower)
Buccal ties (restrictions in the cheek tissues)
These tissues may be tight, thick, short, or positioned in a way that restricts normal movement. While each type affects feeding differently, they often occur together and influence how the mouth works as a unit.
Tongue ties can limit the tongue’s ability to lift, extend, cup, or move side to side, which is essential for effective milk removal. Babies may compensate by using more jaw pressure or head and neck movement.
Lip ties can restrict the lips from flanging outward comfortably. This may make it harder for babies to maintain a seal at the breast, sometimes causing air intake, latch instability, or nipple discomfort.
Buccal ties involve restrictions in the cheek tissues. Limited cheek mobility can reduce suction, contribute to clicking sounds, milk leakage, or fatigue during feeds.
Even when a tie affects only one area, the whole-body impact can be significant. Babies often adapt to restricted oral movement, which can create tension patterns throughout the face, jaw, neck, and body, affecting comfort and endurance during breastfeeding.
How Tethered Oral Tissues Can Affect Breastfeeding
Breastfeeding relies on coordinated movement of the tongue, lips, cheeks, jaw, and body. When Breastfeeding relies on coordinated movement of the tongue, lips, cheeks, jaw, and body. Restrictions in any of these areas can make it difficult for a baby to latch deeply, maintain suction, or transfer milk efficiently.
Babies with TOTS often use compensatory strategies such as increased jaw pressure, lip tension, or altered head and neck positioning. While these adaptations allow feeding to continue, they are often inefficient and can lead to fatigue, discomfort, and ongoing feeding challenges for both baby and parent.
Signs of TOTS in Babies and Parents
Because TOTS affect function rather than just appearance, signs may vary widely and can change over time.
Common signs in babies may include:
Difficulty maintaining a latch or staying latched
Clicking or smacking sounds during feeding
Milk leaking from the corners of the mouth
Gassiness, reflux-like symptoms, or frequent spit-up
Long or frequent feeds with little satisfaction
Fussiness during or after feeds
Slow or inconsistent weight gain
Preference for turning the head to one side or difficulty opening the mouth wide
Signs of tension in the face, neck, or body during feeding
Parents may experience:
Nipple pain, compression, or damage
Shallow or uncomfortable latch
Recurrent plugged ducts or mastitis
Feeling that feeds are constant or ineffective
Concern about milk supply despite frequent feeding
Even subtle or intermittent signs can be meaningful when viewed together.
Why TOTS Are Often Missed
Tethered oral tissues are frequently overlooked because they may be less visible or only apparent during feeding. Babies may latch initially, but limited mobility and ongoing compensatory patterns can make milk transfer inefficient.
Standard newborn checks often focus on appearance rather than function, so restrictions can go undetected.
A thorough feeding evaluation considers:
How oral structures move during feeding
The baby’s ability to coordinate sucking, swallowing, and breathing
Head, neck, and body positioning
Signs of tension or compensation in both the baby and the parent
How TOTS Can Affect Milk Supply
Milk supply is driven by effective and consistent milk removal. When oral restrictions limit a baby’s ability to transfer milk well, the breast may not receive adequate stimulation, even if feeds are frequent.
This can lead families to believe they have a “low milk supply,” when in reality milk is present but difficult for the baby to access. Over time, inefficient removal may contribute to a true decrease in supply if not addressed.
What Parents Can Do
Early, informed support can make a significant difference.
Seek a Comprehensive Lactation Evaluation
An IBCLC can assess latch, milk transfer, oral function, feeding mechanics, and maternal symptoms to determine whether tethered oral tissues may be contributing to challenges.
Optimize Positioning and Feeding Techniques
Adjustments such as deeper latch strategies, improved alignment, and positions like laid-back or side-lying feeding can help reduce compensation and improve comfort.
Incorporate Oral Function Exercises
Targeted oral function exercises help improve awareness, strength, coordination, and range of motion of the tongue, lips, and cheeks. These exercises are often used before and after feeds or as part of a broader care plan and should be guided by a trained professional.
Examples may include:
Gentle tongue elevation or lateralization activities
Lip stretching or flange support exercises
Cheek activation to support suction and endurance
Suck training to improve rhythm and coordination
Address the Body as a Whole
Because TOTS often involve tension and compensation, some families benefit from gentle body-based therapies (such as pediatric physical therapy, occupational therapy, or craniosacral therapy) in conjunction with lactation care.
Support Milk Supply as Needed
Temporary strategies such as hand expression or pumping may help maintain milk production while underlying feeding challenges are being addressed.
Explore Further Interventions When Appropriate
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