Welcome to the Best of Birthful. Creator and host Adriana Lozada curated and edited each selection in this playlist of the show’s most popular episodes. It’s a tailored introduction to the expansive catalog she amassed over the first five years of Birthful’s 300+ shows.
Michele Emanuel, neonatal/pediatric occupational therapist and founder of the TummyTime!™ Method, demystifies why using their tongues and mouths properly is so important in newborn babies. She links it to overall health and offers easy techniques you can apply at home.
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- Nutrition Assessment: Feeding checklist, from the University of Washington Gaining and Growing program
- Michelle’s Instagram pages (with pictures explaining the different techniques) @tummytimemethod and @tonguetiebabies
- Ankyloglossia Bodyworkers website
- Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More, by Richard Baxter
Related Birthful episodes:
- Suck, Swallow and Breathe, with Alison Hazelbaker
- Tongue and Lip Ties, with Dianne Cassidy
- Flat-Head Syndrome, with Michelle Emanuel
[Best of Birthful] Why Using Their Mouths Correctly Is Vital for Babies
Hey, mighty one. With nearly 300 Birthful episodes in over five years, it may be hard to know where to begin listening to the show. To make it easier, we’ve put together the Best of Birthful series, which showcases some of our favorite or most relevant episodes. This is one of those. If you enjoy what you hear, make sure you subscribe. It’s free, and that way you won’t miss a thing. Enjoy.
Hello, mighty parents and parents to be. So, my talk today is with Michelle Emanuel, and I am so super excited to talk to her about all things related to oral function. Not only for better breastfeeding, but also because it’s a key element in supporting your baby’s development, and even in lessening fussiness, and improving sleep, and lessening reflux even, so there’s a lot there for us to get through, so let’s get to it. Welcome, Michelle. It is great to have you back! I can’t believe it’s taken so much to get you back. I’m so happy.
I’m delighted to be here. Thank you for having me.
Lozada: Why don’t you tell the listeners a bit about yourself?
Emanuel: Okay. Well, I’m an occupational therapist, and for a long time I worked at a children’s hospital and got a lot of experience working with a wide variety of diagnoses, dysfunction, neurodevelopment, in the occupational therapy world, and then three or four years ago I went into full-time private practice. And this is when, like you’re speaking of the changes, and that has been a great move because it’s allowed me to focus on exactly what it is that I want to focus on, which is oral health and function for babies. And as you know, the whole body implications of that with TummyTime!
Lozada: No, I am super excited and I’m super excited to talk to you today, because this is important work. And also, the ramifications, because you think like originally, people got curious about this because of… Come at it from like a tongue tie or lip tie, like this is affecting breastfeeding. But then don’t realize that it’s such a huge spectrum of your baby’s health that has to do with nervous system, and speech further along, and how they even crawl, and then stand up, and it all comes from that tether is kind of signaling an issue, and it’s obviously not just the tether, but the importance of oral function, optimal oral function. Tell us. What do parents need to know about oral function?
Emanuel: Such a great question. So, let’s just start with the very basics, which is that babies, when they’re sleeping, should have their tongue fully elevated to their palate and their lips sealed. That is the optimal oral sleeping rest posture, for the tongue to be up and the lips to be sealed, and that means that the jaw is gently closed. And that itself can have some cascading effects into oral health when we’re awake, because the tongue’s in the right place, the muscle tone is activated, the jaw is in the right position, and the lips are sealed together, which helps create pressures in the body that promote optimal breathing and actually even promote baby to be able to optimally generate suction, the way we efficiently can nurse or even take a bottle.
It’s the neural feedback loops and they reinforce each other, and it’s a back and forth. As they’re sleeping, these neural feedback loops, they feed off of each other and they get reinforcement, and if that’s not happening, it really detracts from optimal oral health, because that reinforcement is not there.
Lozada: And so, and just to make sure I’m understanding right, so the neuro feedback loops, what they’re reinforcing is what?
Emanuel: The nerves are reassured by the contact, and the position, and the touch, and the pressure as you mentioned, against each of the structures. And that’s also what helps to spread the palate. We hear a lot about high bubble palates, that we need the tongue up and the lips sealed to be able to create the kind of pressures in the mouth to be able to expand.
Lozada: And this is something that people can be on the lookout from like hours after birth.
Emanuel: Yes. And it’s very simple to address, and it may not change right away, the baby may not have their mouth closed 100%, but every little bit counts. Just simply take your finger and gently close the mouth so that the lips are sealed and hold it there until the baby seems like they get it. Put them in a good position where it looks like it maintains that.
The other thing I think we can focus on is babies using their facial expressions really big. So, even smiling, and making faces, and raising eyebrows, using the muscles of facial expression, which are also our lips, and our cheeks, and our jaw, and even to an extent our tongue, helps optimize oral function.
Lozada: So, let’s talk more about those signs of things that can be easy to identify by parents of what can be signs of oral dysfunction.
Emanuel: But okay, so signs would be like really big ones. Head turning preference to one side. It doesn’t clear up when you even work on it for… Say you focus on it all day long. Wow, I really notice my baby’s turning their head to the left. And you work on it and it’s still noticeable after the end of the day. That-
Lozada: And people might notice that also with like breast preference when feeding.
Emanuel: Absolutely. Yeah. Asymmetrical latch. Or even baby’s fussier on one side. Maybe they will feed fine, but if they’re just more not settled. So, head turning preferences, and liking one breast, or one being held in one position more than another is a really big one. Some obvious ones are the open mouth posture, just seeing the baby’s mouth open at rest. And drooling is another one, because if your lips are sealed when they’re supposed to be, the baby’s not going to drool. We do make a lot of saliva as a baby and even when we’re teething, but if the mouth is closed when it’s supposed to be at rest, then drooling will be very, very minimal to nothing at all.
Other overt signs would be lip blisters, a tongue that’s protruding out all the time. I call that the three lip look, where the tongue’s kind of peeking out with the lips when it’s not tucked up in the palate, and it’s also not even inside the lips. Sometimes it can be poking out. If the baby still has a little bit of a flat spot or the head is not quite looking as round as you think it should be, there’s some flattening or molding anywhere, that’s another sign that the tongue isn’t working, because the tongue should be the main thing a baby can move well.
So, if they’re moving their tongue well and they’re using their tongue well and it has enough strength, and range of motion, and endurance, then there won’t be many problems with the head and neck. The tongue is really a lot of responsibility for our head control, which is another sign, actually, that parents can see if something’s maybe going on with the tongue, is if the baby doesn’t have adequate head control by when we expect.
Lozada: So, when would you expect it? Because newborns don’t really have much head control.
Emanuel: Well, and that’s an interesting thing to talk about, and let’s do another one about maybe some a little bit common misunderstandings about babies, but actually newborn babies have a lot of reflexes that they respond to when we change their position in space that actually have a lot to do with head-righting and emerging head control. But babies have head control or optimally should be eight weeks.
Emanuel: And that’s a fast period of time, and so it’s a steady gain, though, so like a four-week-old, you would want to see about halfway there. And what head control means is that you can use your whole neck, the front, the back, the sides, together to hold the head up, and it’s a little bit of a bobbly place. But how you could tell that, if you lay your baby down for a diaper change and their head lags back, the chin goes way away from the chest, and the baby doesn’t appear to try to hold the neck and can chin tuck a little bit. Then that would be a good sign to have the baby evaluated a little bit further.
Other signs are like the heart-shaped tongue. Creases on the face right around the mouth when they come off the breast or when you take the bottle out. If there’s red creases around the mouth where the cheeks have… just looks like a lot of pressure. That’s another sign, too. Here’s another one: Baby’s crying and the tongue just lays there. You watch the baby when they’re crying and the tongue just kind of vibrates and just lays there. The tongue, when we’re crying, should sort of lift up and wave around a little bit, almost like a stingray. It kind of goes up and down. And a lot of babies that I see, when they’re crying their tongue either doesn’t do anything or it bowls up really strongly. Looks like the middle of it’s pulled down and the edges are flanged up. That’s another really big sign, actually.
Lozada: And I know you’ve mentioned before also face tension. I think that relates to what you’re speaking now. And even that dimples shouldn’t be a thing. It’s like, “Wait, what?”
Emanuel: Yeah. Well, and there’s some of those things that we think are really super cute about babies that are signs, like dimples, and they are adorable, but they’re a sign of abnormal oral tension, too. Because part of our face shouldn’t pucker in. There’s something pulling that in. And then the other one is like this super double chin. And yes, chubby babies are absolutely adorable, but when the baby has a very obvious double chin, a lot of times, and there’s a lot of material or tissue underneath the chin, a lot of times that’s because the tongue is actually lower in the jaw than it needs to be. The tongue needs to be elevating up and kind of residing inside the jaw, and then the rest of the tongue is up in the palate. But if the tongue is not up in the palate and it’s pulled down in the jaw, a lot of times you’ll see more of a double chin than is really super cute.
And then the other thing that is cute about babies is when they cry and the squeak, that… Or laugh. When they do that. And that’s a sign too that there’s a little bit of airway, and that’s gonna be dictated by the tongue, too. There’s not actually literally anything wrong with the airway. Unless there is, and that would be already identified. But if it’s just making the squeak sounds, that’s a sign of decreased strength. So, there’s a lot of human variability, and that’s what makes it a little bit not clear in the tongue tie world, in the oral dysfunction world sometimes, is just a lot of human variability. And the way a tongue tie would affect me is gonna be different than it’s gonna affect someone else.
And that’s true for every baby, so that’s why we really need to focus on having an individualized approach and things that are specific to each baby that is struggling and that needs some help. And I know that can be discouraging sometimes, but it’s really important to see what the real problems are and not just throwing the kitchen sink at babies. You know, doing absolutely everything, hoping something lands.
Lozada: Well, yeah, and that can be overwhelming for the parents, too. If you’ve got a two-week-old and you’re going left and right to all these appointments, that’s like, “Ah!” It’s too much. Right? So, who would be a good first line, first point person to help identify these things in terms of professional?
Emanuel: The first person is especially with a nursing baby needs to be a knowledgeable IBCLC, International Board Certified Lactation Consultant. Those are usually first responders and they’re people who are helping the breastfeeding relationship and there’s a lot to that. And then additionally would be a pediatric occupational therapist, or a speech pathologist, or even sometimes a physical therapist. In certain areas, there are physical therapists who really work with oral function. Most of the time an oral motor professional is gonna be an OT or a speech, though. And these are people who have knowledge, because it’s also not just about the tie. It’s about because we’re working with babies, it’s about the developmental process that they’re at, and where they’re going, and for those of us who work with babies a lot, we know that these issues… When we even work with them and resolve them to a certain point in infancy, still need to be addressed at certain periods along the way in the developmental continuum.
And this is another reason why having a multidisciplinary approach is really important, so that we don’t have gaps, and that we don’t get too micro-focused on just releasing a tie and having things be better just today. This is ongoing. Reach out to different professionals who may have something to offer as it relates to the whole body. Chiropractors, other body workers, craniosacral therapy, myofascial release.
Lozada: And I really love the visual that you mention often, I see it a lot on your Instagram, of how a baby is going from being curled up in utero to unfurling in different ways until they got upright to walking.
Lozada: And all the steps that need to happen in that unfurling of the frontal body, right?
Lozada: Yeah. Can you speak more about that? Yeah.
Emanuel: Yeah, so in the womb we’re developing a lot of that curled up position, can also be called physiological flexion. Flexion means to be bent up. And that helps us develop a lot of bend in our joints, and the muscle tension, but also babies in the womb, they do straighten out and extend. That’s what the mom feels with movement and kicking. But these just really brief periods of time of straightening and then they go back to this really curled position, so that when the baby’s born, their shoulders, and their elbows, and their hips, and their knees are bent, and they stay bent. And then over about three or four weeks, gravity has an effect, and you start to see the baby lengthen out, and they’re not as bent.
And then we go from being all curled up to being straight, and then even bent backwards a little bit into extension, and that’s what lets us get upright and walk on two feet really easily.
Lozada: I love the different steps or moments that babies have when then they suddenly can… You see them doing tummy time and then they’re starting to do more yoga poses, like cobra, or having that extension, and then they do the sort of the airplane, like they lift both hands and legs and they’re all just on tummy, curled up, right? Curled like a little bow. And then how that’s gonna then help them create strength, upper body strength to get up on those… up to hands and knees position for then crawling, and eventually get up.
Emanuel: Hey, and I wanted to mention that Superman that you mentioned actually is a really special reflex that babies have, and it comes on around three months, where they lift up their arms, their legs, their head, everything from the surface, and it looks like they’re flying. That is really hard to do for babies that have had oral dysfunction and or tethered oral tissues. So, this can make… Some babies’ moms will say, “Oh, he hates tummy time,” around this time. Because there’s such a strong impulse and a desire to get into that extended position, into that Superman flying position, but they’re inhibited. It feels really challenging. It feels too daunting, so they get upset.
Lozada: When we talked last time, I remember one of the key takeaways for me was that tummy time can be a few seconds, like 15 seconds, and then… Because it can be very stimulating. And you know, roll out of that, and then roll back in, and I find sometimes people go, “Oh, baby hates tummy time.” But because they’re trying to do it for 15 minutes.
Emanuel: Exactly. And that’s why I love the TummyTime! Method. I love problem solving. You know, why? And sometimes it is because it’s just too long. I like to say take your eye off the clock and put your eye on the baby, and any amount of tummy time is good, because we can always build the quantity if we get the quality and the baby feels like, “Hey, this is good for me.” And it has to have that little bit of the feeling.
Here’s the thing about development, is it’s kind of set up around a little bit of challenge and stress helps you a lot. You know, not being able to reach that toy is what motivates a baby to emerging with their crawling skills. They want to be able to pull themselves forward and reach the toy. There’s a motivation to it. There has to be something… It’s that next tangible thing. We want this easy balance of challenge in the baby’s life and them to be able to problem solve and get in and out, so I say yeah, roll the baby out as soon as they need to take a break. Pick them up and calm them down. And you can roll them back into tummy time if you want to do a little bit more time.
But just these little bits of exposure, short, frequent sessions, it’s just more palatable. It’s easier to do and you can develop a routine around it. I always say do it every diaper change, and little by little it builds. The endurance, and the strength, and even just their own sense of, “I can do this.” And that’s something I want to talk about, too. If we’re gonna get into what’s tummy time good for, and a lot of times it’s for preparing a baby to have a tongue tie release.
Lozada: So, let’s talk about that. Yeah.
Emanuel: Identification of tethered oral tissues is an important piece of information about oral health and functions for babies. It is true that if there’s a structural limitation limiting the tongue that that needs to be taken care of, but because of what we were talking about earlier, the reduced tongue function has had an effect on the body, and sometimes those effects are extreme enough to be interfering with moving forward with the tongue tie release. Like if the baby’s tongue is not moving at all, cutting the connective tissue is not going to communicate with the nervous system or the muscles how to move differently. It definitely eliminates the barrier, but if the baby hasn’t been practicing a little bit of the movement, it’s not necessarily going to happen.
And because the procedure itself is a procedure and we need to hand it to the babies, they’ve had a procedure done. There’s a recovery period that needs to happen. And when we go into recovery, that’s often not the time when we’re trying new oral motor patterns. It’s often the time we kind of hunker down and go into a kind of protection and healing mode, so there’s certain things that we do to help that, the healing happen optimally, and it’s dependent upon where you’re at, and what provider you’re using, what tool they’re using, so there’s no standard for that, either.
But where I’m at, we do wound care exercises, and the parents do this three to four times a day. We go in and lift the tongue up and make sure that the wound is not healing back down on itself. But being prepared for release means that you have had some practice with the wound care, that you have made some progress at making the muscles be a little bit more balanced of the shoulders, the neck, and the jaw. And it depends on how many body-wide effects there are from the tongue tie at how long that takes, but there is for each baby an optimal timing of release that we want to try to figure out. It is not usually that we identify and we go straight to release. Want to equip and empower the families with what they’re gonna be doing afterwards and making sure they’re showing confidence that they can provide that, and also helping the babies actually function better a little bit before the release.
Lozada: And yeah, no, and I think that’s a huge… It’s really important for people to hear this, because we kind of get into this mindset of, “Oh, the tie will do it.” And then the tie didn’t fix all the problems. And it’s because there’s only so much the release… There’s only so much the release can do. And also, if it’s a really tight tether, and you release it, and baby was used to moving in a certain way, now it’s like, “Whoa! I gotta learn how to move with this new range of motion, range of possibilities.”
Emanuel: And that can be actually scary for a baby when you’re using your tongue for stabilization and support. And also, we want to really look at movement, not just the restriction of the tongue, because every baby that I’ve worked with that has even a tongue tie can get a little bit better before release. Because like I said, when we’re doing the release, that’s just cutting the connected tissue, and while that’s a very important, integrated, surrounding all the tissues of our body, cutting connective tissue doesn’t change movement. It allows it to happen. You still have to move differently and moving is part of our nervous system, and that’s been held down.
The movement has not been just restricted since birth. It’s been restricted since gestation.
Lozada: For months. For months, right? Yeah. Months.
Emanuel: Yeah, it’s solidified in the brain. That is how the brain is developed around that, so we have to create new brain pathways, new ways of moving.
Lozada: Well, and that’s part of the idea that, you know, why it’s so important to have a knowledgeable provider assess your child. And sometimes just because they’re an IBCLC or just because it… That doesn’t mean necessarily that they are knowledgeable, and I don’t want to make generalizations, but sometimes I see IBCLCs in the hospital who are so busy, and don’t have… They have a short amount of time to spend with each dyad, that they’ll go in and see that… You know, the latch looks good. Everything seems good. But that the birthing person is saying, “I’m feeling pain.” And they’re like, “But this looks good. It looks okay.” And then they walk away and it’s like the mom, the birthing person is saying, “No, but there’s something that feels off.” And nobody’s listening to that.
And I’m like if it feels off, there’s gotta be something more there or a way we can make it less… more comfortable for you, and baby, and probably… Because it’s not about just that feeding, that moment, that day. It’s about your breastfeeding relationship over the long haul and your baby’s development over the long haul, and also saving your nipples.
Emanuel: Right. Well, that’s the thing, and I echo that so much, which is why I’m always supporting private practice IBCLCs, women who are supporting in the communities in private practice. They have a little bit more, or I should say a lot more, autonomy. Because sometimes the lactation experts in the hospital are limited even what they can say, or they’re allowed to say, and so even if they could or want to, sometimes they can’t. And they have to give as general advice as possible. And here’s what I have to say, is like get home as fast as you can and get to a knowledgeable IBCLC, so that they can help you over the long haul. This is someone who can help you not just for the days and hours in the hospital but can potentially support you for weeks and months to come in your breastfeeding relationship.
Lozada: Yeah, and trust your gut. And the sooner you can see this knowledgeable person, because things can snowball, and “bad habits” or compensating habits can form that then it will take more time and more work. Could you tell me about therapeutic sucking in a little bit short time, and then anything else you wanted to get to before we close up?
Emanuel: Well, therapeutic sucking or suck training is what we can do with babies to help promote optimal oral function. I am a big proponent of doing this in tummy time. I feel like babies are less gaggy, they’re more accepting, and their nervous system is just more regulated. Actually too, we can use gravity in the position to help support that, so I’ll usually roll them into tummy time, and I like to do my pinky, pad side up. And I start shallow in the mouth and as the baby begins a non-nutritive sucking pattern, which is usually a fast sucking pattern, about two per second, I’ll slowly allow my finger to go back a little bit further, because what we’re trying to do is encourage the baby to cup the tongue around your finger.
And that cupping will… It’s like a central groove of the tongue, it’s the sides of the tongue, and this is supposed to be all the way almost to the back, lap up around your finger. This is what allows the baby to develop the strength and the stability to support holding the breast or the nipple. That strength and support is what allows the middle to back part of the tongue to wave in that peristaltic wipe motion. That’s what generates negative pressure or suction, those are the same thing, in the mouth. That’s what makes efficient flow of milk, transfer of milk from the breast, or the nipple. And I like to do it before a feeding even a little bit for just even a few minutes. Get them on their tummy, let them get some sucking, and then you should see a better latch after that, because the first stage of it is just the baby relaxing with the sucking. And that can be hard depending upon how sensitive the intraoral cavity is.
So, if babies are more gaggy than a normal say experience, then it’s gonna be a little bit more challenging. You’re gonna work with the sensation first, maybe really stay really shallow in the mouth. But the more practice they have with non-nutritive sucking, that can help them process the sensory better and get stronger.
Lozada: Yeah, and I think that’s important to know that it’s not just relating to somebody who has a tethered oral tie, but also just because we talked at the beginning about like lip blisters being something that is identifying. And you get babies that in utero got into patterns of comfort sucking that some babies find their mouth, and so… Their hand, sorry. And that’s great, but some of them suck on their tongue, or suck on their lips, and they come out freshly squeezed and you see these lip blisters and you’re like, “You were sucking on your lips when you were in there. Now we’ve got a habit that we have to just pay attention to.”
Emanuel: And a lot of times if babies are overusing their lips like that, it means they’re not using their tongue enough. Because lips, the top lip is helping to form the seal, but the bottom lip should be really relaxed, and the tongue and the top lip are actually what form the seal. But if the tongue can’t, it forces the bottom lip to have to really clinch on. These are the babies that have a really tight chin, or that really deep crease in the chin. Yeah, so if they’re… The lips should be nicely, easily relaxed for the most part, and not rubbing and getting friction blisters, and that’s a huge sign that the tongue’s not working itself, and so therapeutic sucking or suck training is great for all those babies.
I like to do exercises with babies and certain things can really help. What we really want to do is evoke the natural feeding instincts and reflexes and chutzpahf of the individual baby. We want to tap into that and get that going rather than exercise it out, or doing exercises, or activities. I mean, those are short-term things to evoke these natural processes that happen with development, neurodevelopment.
Lozada: Yeah. It’s a supportive process rather than a… Yeah. So good. This has been such a fun talk. I mean, I always learn so much from you and I’m sure the listeners probably have lots of questions, so we’re gonna direct them to your Instagram of TongueTieBabies, and TummyTime! Method. Thank you so very much for all you do and for talking with me today.
Lozada: You’ve been listening to a Best of Birthful episode. To listen to the original, longer version of this episode, click on the link in the show notes. And there are many more where this came from. Look for episodes with the words Best of Birthful in the title to continue your deep dive to inform your intuition. You can find the in-depth show notes for this episode at Birthful.com. You can also connect with us directly on Instagram. We’re @BirthfulPodcast.
Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Alie Kilts contributed to the production of the Best of Birthful series. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Come back every week for more ways to inform your intuition.
Lozada, Adriana, host. “Best of Birthful: Why Using Their Mouths Correctly Is Vital for Babies.” Birthful, Lantigua Williams & Co., August 4, 2021. Birthful.com.
About Michelle Emanuel
Michelle is a neonatal/pediatric occupational therapist, national board certified reflexologist, certified craniosacral therapist, certified infant massage instructor, and a registered yoga teacher specializing in the pre-crawling infant. For 17 years, she worked at Cincinnati Children’s Hospital Medical Center, in both inpatient/NICU and outpatient/development realms. During this time, Michelle developed the TummyTime!™ Method (TTM) to help parents and babies overcome challenges and love tummy time. She also educates, certifies, and mentors professionals to become certified in TTM. For the past few years, Michelle has been in full-time private practice, evaluating and treating babies with cranial nerve dysfunction (CND), tethered oral tissues (TOTs) and pre-crawling baby oral motor/developmental concerns. She also travels extensively teaching her curriculum, collaborates and co-teaches with other TOTs professionals, and is on the teaching staff of the Academy of Orofacial Myofunctional Therapy.
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