1. Introduction / Plain Theory

Oral restrictions refer primarily to ankyloglossia — commonly known as tongue-tie — a condition where the thin membrane (lingual frenulum) under the tongue is unusually short, thick, or tight, restricting normal tongue movement.
Similar tethering can occur with the upper lip (labial frenulum) or cheek attachments (buccal ties), sometimes affecting how the baby latches, sucks, and swallows during feeding.

The reported prevalence of tongue-tie varies widely, from 4% to 10% of newborns, due to differences in diagnostic criteria. In most cases, mild restrictions are harmless; however, when significant, they can contribute to feeding difficulties, maternal nipple pain, and inefficient milk transfer.

Tongue function plays a crucial role in feeding, swallowing, breathing, and early oral development — and restrictions may influence these functions both mechanically and neurologically.

2. Typical Symptoms and Functional Impact

In the baby:

• Difficulty latching or staying latched during breastfeeding.

• Clicking sounds or excessive air intake while feeding.

• Prolonged or inefficient feeding, poor weight gain, or reflux-like symptoms.

• Excessive dribbling or gagging.

• Restless feeding behaviour and crying due to frustration or fatigue.

In the mother:

• Nipple pain, cracking, or bleeding.

• Incomplete breast drainage leading to engorgement or mastitis.

Functional impact:
Feeding challenges may lead to stress, anxiety, and early cessation of breastfeeding, affecting bonding and parental confidence.

Red flags:
Persistent feeding refusal, choking, respiratory issues, or failure to thrive should prompt medical assessment.

3. Contributing Factors / Underlying Causes

Feeding dysfunction in infants is multifactorial, and while oral restriction may play a role, it is rarely the sole cause. Contributing factors include:

• Anatomical tethering: a tight frenulum restricting elevation, extension, or lateral movement of the tongue.

• Birth strain and cranial tension: affecting tongue base mobility and cranial nerve function.

• Cervical or mandibular restriction: limiting jaw excursion or head positioning during feeding.

• Neurodevelopmental immaturity: poor coordination of sucking, swallowing, and breathing.

• Maternal factors: nipple anatomy, milk flow, or positioning during breastfeeding.

Understanding whether an oral restriction is functionally significant (affecting movement and feeding) is more important than its visual appearance alone.

4. Osteopathic Approach

Osteopathic care aims to support the mechanical and functional components of feeding, especially when oral restrictions coexist with tension in the head, neck, or diaphragm.

An osteopathic assessment may include:

• Evaluation of cranial, cervical, and orofacial mobility — including tongue base, jaw, and hyoid relationships.

• Gentle manual techniques to release myofascial tension that may influence tongue and jaw movement.

• Support for coordinated sucking, swallowing, and breathing through balancing the upper body and diaphragm.

• Collaboration with lactation consultants, midwives, and pediatricians to ensure a comprehensive approach.

When indicated, osteopathic treatment may complement a frenotomy (surgical release of the frenulum) by improving pre- and post-procedure mobility, comfort, and coordination.

The goal is not to “treat the tie” but to improve the baby’s ability to feed, settle, and develop functional oral movement patterns in a gentle, individualized manner.

5. Scientific Evidence & References

Current evidence on oral restrictions and manual therapy is evolving, with growing recognition of the mechanical and neuromotor interactions involved in infant feeding.
While surgical release (frenotomy) can improve feeding in some cases, outcomes are enhanced when combined with functional and manual therapies addressing associated tension patterns.
Osteopathic and gentle manual interventions are generally reported as safe and well-tolerated in infants when performed by trained professionals.

References

1. O’Shea JE, Foster JP, O’Donnell CP, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev. 2017;(3):CD011065. Link

2. Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and lingual frenotomy: national trends in inpatient diagnosis and management in the United States, 1997–2012. Otolaryngol Head Neck Surg. 2017;156(4):735–740. Link

3. Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): use in a lactation consultant private practice. Clin Lactation. 2010;1(3):25–31. Link

4. Martinelli RLC, Marchesan IQ, Berretin-Felix G. Lingual frenulum protocol with scores for infants: an early diagnosis tool. J Appl Oral Sci. 2012;20(4):397–402. Link

5. Douglas PS, Geddes DT. Practice-based interpretation of recent tongue-tie research: a critical review. J Hum Lact. 2018;34(4):765–775. Link

6. Cerritelli F, Pizzolorusso G, Accorsi A, et al. Osteopathic treatment in infants with breastfeeding difficulties and oral tension: a prospective observational study. Int J Osteopath Med. 2020;35:1–9. Link

7. Miller JE, Newham J, Reid SA. Treatment of unsettled and excessively crying infants: a systematic review and meta-analysis of manual therapies. BMJ Open. 2018;8(1):e019040. Link

8. Castejón-Castejón S, de-la-Cueva-Reguera M, et al. Effectiveness and safety of osteopathic manipulative treatment in infants with oral motor dysfunction: randomized controlled trial. Int J Osteopath Med. 2023;48:12–20. Link