Checklist of signs and symptoms of tongue tie and lip tie

  • Signs of restricted mobility of the muscles of the tongue and the upper lip:

Due to the tie the tongue can only move the front and sides a bit. The tongue cannot go up and back properly, difficulty latching on, drawing in the nipple deep. While very often at the same time the upper lip cannot flange out over the breast, because the tie pulls it inward. So the baby slides off easily. Resulting in small latch, letting go of nipple. Latching on and drinking difficult or only works with a nipple shield or bottle. Falling asleep at the breast or bottle, frustrated, doesn’t seem to want to drink, doesn’t empty the bottle.

  • Signs of compensating due to restricted mobility of the tongue and lip tie:

Tries to hold on to the breast by clenching jaws together. Uses cheek muscles to draw milk. Mother experiencing pain especially at latching on. But not always painful, also just sucking really “hard” or “strong”. Chin quivers from jaw muscles tension. Sucking blisters on lips from friction. This compensating is weary for the baby and especially in compromised growth or premature babies it’s a shame it costs energy. Sometimes babies are called lazy drinkers.

Nipple should come out round, but comes out flattened, with blisters, discoloured and sore. “Raynaud” like symptoms from diminished blood flow to nipple.

  • Signs of compromised ability to get sufficient milk:

Due to the baby’s restricted mobility, only suckles at the nipple and hardly at any breast tissue. There is too little milktransfer as a result. The baby draws in the nipple as if sucking in spaghetti, hangs on nipple like a “cliffhanger”, often pulling and moving the head in an attempt to pull out the milk, sometimes using hands to pull the breast in older baby’s, drinking suddenly painful when teeth come.

Baby doesn’t “empty” the breast (or bottle), drinks often to get enough milk. Plugged ducts, overproduction from drinking often, compromised production in the end.

Baby loses weight more than 7% in the first days, getting back to birth weight takes more than 10 days. Growth stagnates after weeks or months when production decreases. Babies don’t always show; they save energy by sleeping long for example. A sign could be very few poop diapers.

Baby only drinks the “easy” milk, during the milk ejection reflex.  Drinks short or very long. Only making the chin tug and drinking when MER or giving breast compression or supplementing at the breast.

  • Signs of compromised possibility of making a good seal:

Due to the low tongue position, often high palate and the upper lip not flanging out completely over the nipple, bottle or breast, your baby cannot make a good seal and loses suction, you can hear clicking sounds. Also very loud drinking, gulping it down and choking. Complaints of swallowing air.
The swallowed air needs to go somewhere; it goes up or down. Burping, hiccough, spitting, windy, colic.  GER or reflux with or without spitting (hidden reflux). In hidden reflux the baby tries to keep the milk down by swallowing again, sometimes forgetting to breath momentarily. During feeding it can be very uncomfortable for the baby and can become restless.  It’s difficult to put the baby down to sleep. Parents walk with their baby until symptoms subside. The baby can experience pain from the stomach acid in the oesophagus. GERD. Sometimes medication is given which lowers stomach acid.

Thrush is often confused with tongue tie problems. Although you can see it both at the same time. The tongue may have debris in the papilla (from day of birth) due to the fact that the tongue hardly touches the palate so it doesn’t “rub clean”. Pinching and stabbing pain can be from thrush or compensating behaviour from tongue and lip tie. In tongue tie you can see white debris on the posterior part of the tongue behind the tongue tie, the front of the tongue rubs clean against the inside of the upper maxilla. Thrush is a “pearl white” shine or white plaques on the inside of the lips and on the mucous membranes of the inside of the mouth.

*Note that not all symptoms have to be present at the same time.

What does a tongue tie look like

Providers use a classification system to describe the tongue tie. This system only indicates where the tie is attached between the floor of the mouth and tongue. Providers usually use four classifications of Coryllos  or Kotlow, (see pictures below).

Type 1:

The anterior tie is easy to see when the baby cries or tries to lift up the tongue. It can also be felt with your finger under the tongue. It is attached all the way to the tip of the tongue. Very often it makes a heart-shaped tongue when the baby cries or tries to move it.

Type 2:

The anterior tie is a little further from the tip of the tongue. It is also felt like a guitar string or easily seen when the baby cries or tries to lift the tongue. The tongue stays low in the mouth when the baby cries or tries to move the tongue, very often you see a bowl- shaped tongue when crying (only the edges move up).

Type 3:

The posterior tie is further away from the tip and can be made visible by using a special tool, the groove director, or by using your two index fingers that push back the mucous in the direction of the throat and lift up the tongue simultaneously. The tongue stays low in the mouth when the baby cries, tries to move the tongue, or shows indentation or creases, very often you see a bowl shaped tongue when crying (only the edges move up). With your finger you can feel a “speedbump” or guitar string further back.

Type 4:

The posterior tie is not visible, but “hidden” behind the mucous. It can only be shown with the groove director or with two index fingers that back push the mucous in the direction of the throat and lift up the tongue simultaneously. The tongue stays low in the mouth when the baby cries or tries to move the tongue, or shows indentation or creases, very often you see a bowl shaped tongue when crying (only the edges move up). With your finger you can feel a “speedbump” or guitar string further back.

What are those hard white bumps on a baby’s gums?

Depending on the size and spread over the jaws, there are two options:

Pearl of Epstein:

These are small thickened inclusion cysts on the palate, but can also occur on the gums or palate. Usually seen as multiple, white, rice grain large elevations in the vestibular (lying against the cheek) mucous membrane of the upper jaw (alveolaris processus). They are small cavities filled with fluid, (cystic nodule) covered by a thin epithelium (layer of skin) and filled with keratin (a type of protein).

The Epstein pearls are completely harmless, do not hurt, do not need to be treated and disappear spontaneously. Treatment is therefore not necessary.

“Bohn’s” nodules (hard bumps):

These are white-like bumps spread over the entire upper and / or lower jaw (see photos). The exact aetiology is unknown, but it is suspected that they arise as a remnant of the dental lamina or of heterotrophic salivary glands. They can be present over the entire lower or upper jaw or on the palate (palate). These hard bumps are benign and disappear over time. Treatment is therefore not necessary.

How do I know if my baby has a tongue tie or a lip tie?

The midwife, lactation consultant, maternity care nurse or speech therapist, may have told you about the possible functional problems in babies and children due to a tongue tie or a lip tie. The knowledge is also shared among parents through the internet.

A tongue tie is not always easy to see, especially if it is deeper under the tongue. Not every doctor, midwife, lactation consultant IBCLC or maternity care nurse has enough experience to assess this properly. It is wise to find a practitioner with experience in this area. A lactation consultant IBCLC who has experience in assessing the tongue tie and lip tie may be able to assess it.  After doing an oral examination she may even find the tie “hidden” behind the oral mucosa. When in doubt, make an appointment with a lactation consultant or a practitioner with experience. Sending a photo is possible for review, but can never provide a definite answer.

Pediatrician Dr. James Murphy (link) came up with the following method. When the finger slides under the tongue, it should be easy and smooth. If it is difficult to move from left to right under the tongue over the floor of the mouth and a “string”, “speed bump” or “fence” is felt, this may indicate a tongue tie.

When the baby is crying, and the tongue stays down, it could be caused by a tongue tie actually pulling the tongue down. Sometimes only the sides of the tongue rise so that the tongue makes a bowl shape.

The upper lip should be able to flange relatively easily. If the lip is lifted and gently pulled, and the upper jaw turns bloodless where the lip tie is attached, that may be an indication of a lip tie. This test is also called “blanching” or anaemia test (see photo).

Which different types of tongue ties and lip ties exist?

There is a lot of discussion about determine and treating the types of tongue tie and / or lip ties. Sometimes there is no clear membrane visible under the tongue and parents are sent home by the doctor without treatment, while a “hidden” tongue tie is the cause of feeding problems. Therefore, the classification does not determine the severity of the feeding problem, it only determines the degree of attachment.

The classification that is generally used is Kotlow his classification of the lip tie (1 to 4) and Coryllos her classification of the tongue tie (1 to 4) (see frequently asked questions what does a liptie or a tongue tie look like).

How can I recognize a tongue tie or lip tie?

Tongue tie:

  • Heart-shaped tongue;
  • Indetation in the middle
  • During crying a low tongue position with sometimes a dent or a bowl shape;
  • White debris from halfway the tongue to the back


  • Suction blister upper lip in babies;
  • Bloodless and red/ white line under nose when drinking babies; (see photo)
  • Blanching attachment of tie on the edge of the upper jaw (see photo);
  • A diastema when teeth come through

Wat zijn mogelijke klachten bij een strakke tongriem of lipband?



  • Pijn bij moeder (niet altijd), kapotte tepels, kloven, tepel komt er afgeplat uit na drinken of is wit weggetrokken (soms denkt men aan Raynaud);
  • Gebruik van tepelhoed, aanleggen lukt soms helemaal niet;
  •  Baby kan de borst niet goed leeg drinken waardoor verstopte melkklieren of borstontsteking (mastitis) ontstaan;
  • Naast borstvoeding mogelijk kunstvoeding bijgeven en/of extra kolven om productie op gang te krijgen en houden.


  • Klakkend geluid (vacuüm loslaten);
  • Baby maakt een kleine hap, zuigt de tepel naar binnen;
  • Baby drinkt heel “krachtig”, bijt soms, of klemt met de kaak;
  • Drinkt onrustig/ongeduldig aan de borst of is juist snel vermoeid;
  • Drinkt kort, laat veel los, of “hangt” juist “de hele dag” aan de borst;
  • Veel lucht mee drinken, refluxklachten, koliek, spugen, boeren, bol buikje, windjes;
  • Matige groei van de baby;
  • Doordat de tong niet naar het gehemelte omhoog kan bewegen blijft  het gehemelte soms hoog. Dit geeft mogelijk minder ruimte in de neus, waardoor de baby verkouden lijkt en door de mond blijft ademen;
  • Doordat de baby moeite heeft de tong volledig te gebruiken, blijft er een witte aanslag achter op de tong. Dit is dan geen spruw, maar smaakpapillen met aanslag (zie foto);
  • Baby’s met een strakke lipband waarbij de voortanden doorkomen rond een jaar krijgen soms opnieuw problemen met voeding en gaan bijten.


  • Kinderen die slecht vacuüm kunnen creëren hebben mogelijk eerder last van een middenoorontsteking.


Er zijn wereldwijd verschillende borstvoedingswebsites (borstvoeding.com) waar veel foto’s (link) en beschrijvingen van de problemen te vinden zijn. In Engels www.drghaheri.com.