Supporting Babies with Oral Restrictions: Next Steps After a TOTS Identification
- Virtual Breastfeeding Inc.
- 1 day ago
- 3 min read
If you’ve read our previous blog on tethered oral tissues (TOTS), you already understand how oral restrictions can affect breastfeeding and why they are sometimes missed. Once TOTS are identified or strongly suspected, many parents ask the same question: What are the next steps?
This blog focuses on how TOTS are typically addressed after identification, outlining a stepwise approach that prioritizes assessment, functional support, and addressing compensation first—before considering frenotomy when progress remains limited. We’ll also discuss why collaboration with a lactation consultant and other specialists before, during, and after frenotomy is so important for long-term feeding success.
Step 1: Start With a Comprehensive Feeding Assessment
Once TOTS are suspected, the first and most important step is a thorough functional feeding assessment, not a rush toward intervention.
An International Board Certified Lactation Consultant (IBCLC) evaluates how the baby feeds in real time, focusing on:
Oral movement and coordination during feeding
Latch depth, comfort, and stability
Milk transfer and feeding efficiency
Parent comfort and breast symptoms
Head, neck, and body positioning during feeds
This assessment helps determine the extent to which the restriction is affecting function and guides the rest of the care plan.
Step 2: Address Compensation and Support Oral Function
Because babies adapt to oral restrictions, many develop compensatory movement patterns that allow feeding to continue, even if it is inefficient or uncomfortable. These patterns do not resolve automatically and often need targeted support.
At this stage, care focuses on:
Supporting more functional oral movement
Reducing compensatory tension patterns
Improving coordination and endurance for feeding
The Role of Oral Function Exercises
Oral function exercises are gentle, purposeful activities designed to support awareness, mobility, strength, and coordination of the tongue, lips, and cheeks. When guided by trained professionals, these exercises can help babies use their oral structures more effectively during feeding.
Exercises are typically brief, individualized, and incorporated into daily routines. They are not meant to be aggressive or forceful, but rather to encourage more efficient movement and reduce reliance on compensatory strategies.
In many cases, addressing compensation and supporting oral function leads to meaningful improvements in feeding without the need for further intervention.
Step 3: When Frenotomy Is Considered
If progress remains limited despite appropriate assessment, lactation support, and functional interventions, frenotomy may be discussed as part of the care plan.
A frenotomy is considered based on function, not appearance alone. It is not a first step, but one possible tool when oral restrictions continue to interfere with feeding efficiency or comfort despite conservative measures.
Families need to understand that a frenotomy is not a standalone solution. Babies must learn how to use their increased range of motion, and existing compensatory patterns may still be present without ongoing support.
Why Team-Based Care Matters Before, During, and After Frenotomy
Because feeding is a whole-body activity, families often benefit from working with a collaborative care team—especially when frenotomy is part of the plan.
This team may include:
IBCLCs, to support feeding mechanics, milk transfer, and parent comfort
Pediatric physical or occupational therapists, to address body tension, alignment, and motor patterns
Speech pathologists, to support oral motor coordination and functional feeding skills
Myofascial therapists and chiropractors to help release tension, improve alignment, and support overall mobility
Gentle body-based therapists, such as craniosacral providers, to support regulation and mobility
Medical providers trained in frenotomy, when a release is indicated
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