ļ»æEpisode 68 - Tongue tie with Reena Murray
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Welcome everybody to this week's episode of The Great Birth Rebellion. I'm joined again by Reena Murray, who we spoke to last week on the podcast about osteopathy for babies. And this week we're specifically honing in on the topic of tongue tie. So for those who didn't listen to the first episode, Reena's going to reintroduce herself. But as a backstory, she was one of my very good friends at school. So we've known each other for a long time and she happened to be my maid of honor for my wedding like 22 years ago so we go back a ways but Rena is now a highly qualified health professional and here to talk to us about tongue tie but first Rena can you introduce yourself who are you and why would I invite you on a podcast about tongue tie oh thanks
Reena:
[1:18] Mel for having me back I am feeling old with that introduction.
Mel:
[1:21] I know how old are we I mean I'm turning 40 soon you must already be 40 I just did yes that's right because you're you are slightly older than me um but I love getting older I don't know about you 100%
Reena:
[1:35] I'm super happy with every birthday I get.
Mel:
[1:37] I know I'm really appreciated because I feel like I get permission to get weirder I don't know if you're aiming to get weirder my intention is to every year grow slightly a bit more weird and I feel like as you get older you get more permission to do that because you care less about what other people think of you so anyway I'm enjoying getting older and appreciating the value of all of the wisdom that we're gathering particularly I mean you are gathering wisdom and experience so much in in your area of expertise which I'm so appreciative for uh so where are you what's who's reena who's reena murray well as
Reena:
[2:20] I said last time i am a mom and i feel like that's you know i need to qualify that first because a lot of my journey as a health professional has been guided by my experience as a parent, and I feel like a reluctant practitioner in the area of tongue ties. It's not. Controversy follows it everywhere, and so I'm going to do my best to give a
Reena:
[2:42] balanced response today. But I actually first came across tongue ties maybe 13, 15 years ago with a patient who asked me if I knew about them. And really, I knew a little bit, but had no idea about the world that I was entering into. And that kind of started me down a pathway after I'd done my paediatrics training to become a lactation consultant because I just didn't feel like I had enough answers. And so I was looking for, yeah, I guess more information to help me to support families who were struggling in this space.
Mel:
[3:16] Yeah. So first trained as an osteopath, then got an advanced qualification in paediatric osteopathy and also became a lactation consultant. So it's quite the collection of skills to be sort of feeding into this topic of tongue tie. And yeah, it is a reminder that this is a controversial topic. So if you're feeling triggered or upset by anything that we say, consider that you've just learned something new that doesn't align with what you know about tongue tie. And that's a gift because it's broadened your understanding. And obviously Rena and I might not have all of the information because actually the real true experts in this kind of thing are the parents themselves who have to tiptoe around to lots of different practitioners and websites and speaking
Mel:
[4:08] to other parents and understanding their own babies. So it's quite possible that there's parents out there who know way more than what we're going to talk about but our offering is to tell you what we know and that maybe it will add to your understanding so we're going to go lightly but also realize if you've had a response to this that's upsetting it's time to look inward at why that upset you rather than sending rena and i hate mail thank you very much
Mel:
[4:37] So let's start with the basics and and although people listening to this might not actually be currently experiencing a tongue tie but if you are pregnant or have a baby or plan on being pregnant this could creep up on you and catch you by surprise. And so it's handy to know a little bit about tongue tie. If it doesn't eventuate for you, amazing. You're just extra knowledgeable. Maybe you can help a friend. But if it does creep up on you, it's amazing to have free information about this thing because it's there and it doesn't just go away by itself. So what is tongue tie? What is it?
Reena:
[5:20] Yeah. Okay. So I think maybe we'll talk about it in terms of the broader term is oral ties. And because there is not just one oral tie. So as you start to delve into this space, you'll learn that there is a tongue tie, there's a lip tie, and there's also cheek ties. So I suppose the all encompassing term is oral ties or, and then when we're talking about restricted oral ties, we're talking about tethered oral tissues or tops. So you might hear any of those terms if you start looking into this space a little bit. But if we're talking about a tongue tie specifically, when it is pathological or restricted, it's called ankyloglossia. And really it's just a remnant of tissue kind of on the undersurface of the tongue. And it's sort of between the tongue and the floor of the mouth. And it restricts normal movement. And generally, particularly when we're looking at babies, we're looking at three movements in particular. So the ability for them to stick their tongue out so protrusion um the ability for them to move it side to side which is lateralizing and then elevating so
Reena:
[6:21] can they get that tongue up to the roof of their mouth.
Mel:
[6:24] Right which is important for breastfeeding latch to be able to bring their tongue up to the roof of their mouth to actually draw the nipple in 100 yeah and so then the other oral ties the the cheek ones how do you know that that's happening because that's not related to the tongue right is it yeah
Reena:
[6:45] Wow that's even more contentious.
Mel:
[6:48] Than bucket
Reena:
[6:50] Ties we don't uh we're still working on a standardized assessment tool for those and there's a lot of debate about whether they need to be released or not um maybe we'll come back to that.
Mel:
[7:01] Yeah because i'm like whoa i have never thought to check for those yeah we certainly are not taught that in midwifery that that's a possibility and lip ties might so this could again this could be controversial back in the day when I first started training they used to tell us that the lips of the baby had to make this special k kind of shape over the mum's nipple and that's a way to gauge good attachment to the nipple and that if it wasn't doing that you should flick out the lips above or below to make them do that I always thought it was weird because it's so easy to flick the lip out and it's as if it's not involved in the attachment at all and I've since learned that that's true is that what it they're just like curtains it's just window dress thing it it doesn't have a specific function so if the lips are curled in but the latch is great internally we don't actually have a problem and that's why I was curious about lip ties about if they even need any kind of diagnosis or management
Reena:
[8:14] Wow, we're going there.
Mel:
[8:17] The Great Birth Rebellion reach.
Reena:
[8:20] You have to go there. Okay, so I was taught the same thing as you. I think at uni, the Special K, we definitely don't subscribe to that anymore in terms of breastfeeding mechanics. Yes, a neutral posture is fine. The baby does not have to flange the lip up to get a good latch and seal. It's more about the ability for the tongue to be able to elevate and hold that nipple in the mouth and create a vacuum to extract milk out. Now the lips are not probably completely passive in that because the lip, abicularis oris, like the muscle around the lips does sometimes engage to hold on a little bit. But for babies who've got really poor ability to maintain that suction or that elevation of the tongue, say with a tongue tie, you'll often find And the lips are hypertonic. So they're really tight through their lips.
Reena:
[9:09] So in those cases, they're compensating and using it more than what they should.
Mel:
[9:13] So they're using their lips to kind of latch on because of the deficit, an internal deficit.
Reena:
[9:18] Yes.
Mel:
[9:19] Interesting. Okay. All right. So there you go. So don't always necessarily need to release a lip tight in terms of
Reena:
[9:29] Latch yeah correct I think they're often released at the same time because that's the process of the provider whether they always need to be released I don't personally I don't think they always do need to be released it's definitely primarily about tongue function but it's very hard to quantify how much a lip tie release has added to the process maybe it's five or ten percent improvement that was gained by releasing the lip tie and ninety percent came from the tongue we just can't we don't have studies to tell us exactly which way to go with that yet yes.
Mel:
[10:03] And I've and and one thing that I do ask parents as well is one thing is is if either of them have had a gap between the two front teeth it could be that they have had a lip tie and then that could mean their baby has a lip tie anyway that's just a little anecdote
Reena:
[10:21] And if there's a lip tie there's usually a tongue tie so it definitely warrants looking further but I do do a lot of work with dentists and we have this conversation often about you know should you release a lip tie if the tongue's functioning well in a baby because of that diastema or that gap and I think the answer is no it's not releasing the the lip tie or the labioprenulin is not going to change whether that gap is there later on and they need orthodontic work so we we're definitely looking at it's very osteopathic tongue tie assessment because you're looking at structure and function and so when we're assessing a baby we are trying to determine okay what does the structure look like but more importantly how is it working and.
Mel:
[11:03] So if it looks like a tongue tie but everything else is amazing latch is good there's no nipple discomfort or damage and the baby's able to transfer milk then that's part of the decision making process of like well yeah there's a tongue tie but actually everything's functioning as it should My question as well is about language development later, because this is something that gets peddled. It's like, yeah, you might be feeding well, but if you don't correct it, there could be issues with mouth development and language later in life.
Mel:
[11:37] Do you know anything about that?
Reena:
[11:39] Yeah. I mean, I'm not a speech pathologist, so I want to be careful. And I would say we need to seek out people who are experts in that space. And I think before we go any further, it's probably worth acknowledging that none of us as health professionals are trained in oral ties in our undergraduate training. You said yourself, you weren't. I wasn't as a lactation consultant, definitely not as an osteo. And that's true for dentists, for pediatricians, for GPs, for nurses. It is just where we are, I think, in the field of medicine at this point in time that no one incorporates it into their undergraduate training. So when you have seen multiple health professionals and no one's been able to help you, it's not that they don't want to help you. It genuinely is perhaps like me. They haven't had a patient who's introduced them to the concept and then gone and explored and educated themselves. And so it really requires parents to just be educated and informed because they're going to need to drive the conversation with those health professionals as much as we are trying to do that as well.
Mel:
[12:43] Yeah, well, and that's true. even as a midwife I work with babies this was not something that we learned at university I didn't even learn it in my time at the hospital and then the only reason I know really anything about it and helping with some kind of assessment is that my good my good friend and work wife is a lactation consultant and she taught me a bit of a crash course in a basic assessment and if this then refer or basically was the education i got not really any health professional has been given the good proper information about diagnosing tongue ties at the very very least so it's just i think each health care provider takes initiative to learn and understand it because like you said somebody arrives with it and and you know for me as a midwife when women are saying what's going know with my baby's latch why are my nipples so damaged what you know this baby's not transferring milk you're forced to get an understanding of what tongue tie is because I'm often the first point of call and need to refer people on to the next step so what are the signs and symptoms that your baby might have an oral tie
Reena:
[13:59] Okay. I'll run through a bunch of them, but it is quite complex. And I would say just because your baby might have a couple of these doesn't mean that they have an oral tie. So just, you know, take it for what it is.
Mel:
[14:11] I think in infants particularly,
Reena:
[14:13] We see a poor or shallow latch. So like feeding on the end of the nipple. Frequently they'll slide off the nipple. So they won't be able to maintain that latch. Or they'll gum or kind of chew on the end. And then we see things like nipple trauma as a result. Frequent gagging or choking. So sometimes it's letdown related, but other times it's actually they're not able to lift that tongue up like we talked about and actually stop or compress that flow of milk. And as a result, they kind of get flooded and then a gagging and choking, which then can also lead to increased vomiting because if they've taken air in during that process, they're then going to vomit that up. Increased colic or fussiness or wind generally, again, because of that process of air-induced reflux, which we touched on in the last episode. Really long nursing periods beyond what's kind of normal or acceptable for that age. Frequently falling asleep is another big one. So obviously we expect a baby to fall asleep in that really early postpartum period. But if that persists, then often it's a baby that's really fatigued, working very hard and not able to effectively transfer milk. And so they just fall asleep.
Reena:
[15:27] You then often see short sleep episodes as a result because they've snacked, they've fallen asleep, and then they're awake because they haven't been satisfied. So that kind of pattern can occur. Babies are often not able to hold a pacifier or dummy in their mouth. Again, it cannot elevate the tongue enough to kind of maintain that suction. Sometimes you'll see green stools. That one is a little bit controversial. It can be other things as well. So again, a good breastfeeding assessment is needed to work that out. Often they can pull off the breast. So again, it's part of that regulation. Either they're fussy because they're not able to extract the milk as effectively as they'd like or they're getting too much and they can't slow the flow. Congested breathing and snoring, again, linked a little bit to that reflux, vomiting kind of coming up.
Mel:
[16:21] Do they have a habit of mouth breathing more so?
Reena:
[16:25] Yeah, mouth posture, mouth breathing. Yep. What else do we see? Sometimes in older kind of, if we're looking at say transition to solids around six months, they can be very messy eaters, dribble, do a lot of persistent tongue thrusting, and they can be very noisy feeders as well. Yeah. So it's a whole range of things that lots of babies present with. Not every baby who presents with these symptoms is going to have restricted oral ties, but certainly if they're there, we want to do an assessment and rule it out that's the baby then the mom will also usually present with things like cracked bleeding nipples, or that real lipstick shape nipple when they come off because it's being compressed up onto the palette just behind the gum yeah.
Mel:
[17:13] There and it looks looks like it's being pinched
Reena:
[17:15] Correct it literally looks like the head of a lipstick when it comes out after a feed yeah yeah blanched nipples sometimes so you know white nipples after a feed painful feeding obviously that would probably be the main symptom that mums present with. Often, by the time they've come to see us, they're on nipple shields. So they've come out of hospital and they're on nipple shields. And then if we see them a little bit later on, often they've got a history of recurrent astitis or blocked ducts or just poor drainage. Yeah.
Mel:
[17:48] Yeah. And then sometimes, I don't know if this is a usual thing, but the babies who I've found have ties, sometimes they don't gain as much weight each week and that's just to do with their ability to transfer the amount of milk. And yeah.
Reena:
[18:04] Yeah. And I think that's true. It is a journey and it's different for every mum and baby. I think you classically do see low weight and low milk supply, but equally I have babies who are thriving because mum's got a really abundant supply, but they're terribly ineffective at transferring milk. And those babies, we will often see between three and four months of age as kind of that milk supply transitions and from being more maternally hormonally driven to baby driven, their inability to pull that milk out will often see that drop in supply and a drop in weight at that point. So if people take nothing else away from this, know that just because your baby is gaining weight doesn't mean that there isn't restriction in the oral function.
Mel:
[18:48] Yes obviously I think in hospitals they don't really diagnose babies with tongue ties it's the journey that parents go on after they leave hospital after they've given birth or if you are fortunate enough to have a private midwife who's with you for six weeks after you you've had your baby which is where my work is then women are just left on their own and as you said not many health professionals actually really fully understand tongue tie or are trained to identify it and so I don't think a GP is a great stop leave the local community services you might land on a really great practitioner who's done the work who's done the thinking about this but I do think parents are left to find out this stuff on their own and they go on a wild goose chase to find the right information. So I want to take this actual opportunity now to direct people to Rina's, Rina's got a tongue tie educational course or program. It's, it's, I think it's a place to start. If you're not sure if this is what's happening for your baby, it'll cost you less than going out to seeing a practitioner to actually purchase this course. Where can they find it, Rina?
Reena:
[20:03] At DrRenaMurray.com.
Mel:
[20:05] DrRenaMurray.com. I'll put that in the show notes. But if this is what you suspect might be happening for your baby, then start there. You can do it at home. You'll find out probably more than most healthcare professionals know anyway, and it might give you a really clear direction for where to go next. Because this is even a challenge for me as a midwife is where do I send this person now?
Mel:
[20:29] I think this baby's got a tongue tie. But who else could parents go to if they suspect their baby has a tongue tie? Who should they see?
Reena:
[20:41] Yeah, that is a great question. As we talked about, because it's not standard practice to be trained in it in any discipline, and certainly it wasn't when I did my lactation training, you're not guaranteed that every even lactation consultant you go and see is able to do a comprehensive oral assessment as well as a breastfeeding assessment. I think the best thing to do is ask, are you trained in oral assessments for tongue tie? And if they say yes, they know what they're talking about very likely. And if they don't, then hopefully they'll be able to refer you on.
Reena:
[21:12] The point of me developing that course was to try to help more parents kind of cut through the confusion. It's really hard. We get asked the same questions over and over. And if I had one goal, it would be that oral assessments would just be done as part of the newborn check in hospital, because then we would not have all of these mums coming out who really want to breastfeed, but you know, in terrible pain and distress because perhaps there is an oral tie or maybe there isn't, but either way, we just need to, you know assess it rule it in rule it out and then move on so yeah I think it depends where you are geographically you might have a great lactation consultant you might have an osteo who's trained who can help you you might have a chiro you might have a really great dentist who is able to do it I know in Sydney we've got we've got pediatric dentists we've got general dentists we've got pediatric surgeons we've got ENTs like it's a really and speech pathologists it's a really diverse mix of people who are able to work in this space and you really need to see I suppose someone who is trained appropriately but also is at the right age for your baby so obviously you know breastfeeding family are going to need to see a lactation consultant and do the the breastfeeding assessment because a primary health care practitioner can diagnose a lactation consultant can assess but cannot technically diagnose the tie so you need to then go and see a GP, pediatrician or dentist.
Reena:
[22:41] As an osteo, we are primary healthcare providers. And so I sit in a in-between space because I hold those two qualifications, but it's really about who is in your area that is going to be most able to help you. And some of the forums online are good for directing people to experienced providers in their area. Yeah.
Mel:
[23:02] Yeah. Other parents who've been through it you know they can save you a lot of time and drama trying to find the right person There is, and this is my other bugbear, it should be as part of a normal newborn assessment. I mean, we're checking every baby's heart, for example, and they have, you know, there's a tiniest chance that there's going to be something wrong with that, but we're not checking every baby's mouth as a routine thing. What I'm hearing, though, is that there's a spattering of skills and there's massive variation across professions of who can and who can't. Diagnose or even identify a tongue tie so if for health professionals listening what are we looking for if we suspect a baby has a tongue or oral ties what can we do at a basic level to assess if that's what's actually happening I
Reena:
[24:01] Mean I think you could really quite easily learn one of the standardized assessment tools, which is the ATLIF. We might put it in the link at the end. And you can get pretty good. You can assess every baby according to that criteria. There are a few standardized assessment tools. And every baby you see, you'd pretty quickly learn what you're looking for. But it's a balance of how is it working? So doing a suck assessment as well as looking at what does it look like? And when we combine those two things together, we get a score that indicates whether we should do a frenectomy or not. So I think that's quite simple for any health professional to start with.
Mel:
[24:36] So we'll put that that tool if you are on the mailing list for this podcast you get access to a resource folder every every week we send out an email and if you get access to a resource folder so we will put that assessment tool in the resource folder for any health care provider who wants to have an understanding of a way that you can get good at And you made a really great point. First, learning what normal looks like. If you assess every single baby and you go, right, all of them could do this, that's great. The minute one of them can't do that, you're hyper-attuned to that issue. Yeah. What's that tool called again?
Reena:
[25:19] ATLAS, Assessment of Lingual Frenulum Function.
Mel:
[25:23] Assessment of Lingual Frenulum Function. ATLAS. We'll put it in the resource folder. So that is the direction you can go in as a healthcare provider. That's your starting point. And so if then you go, okay, that's not normal, where do you refer to?
Reena:
[25:42] Again, it depends on what health provider you are and who is available in your area. I think you made a really valid point. There's some really amazing health professionals across all disciplines working in this space, and some are in hospital and some are outside of hospital. And so it really, you know, you've got pediatricians who are doing really great scissor releases or scalpel releases because that's their skill and their tool of choice. You've got ENTs who are doing it operatively, and then you've got dentists who are using laser. And I think the argument around the tool is less helpful for parents. It's really about who is in your area, who has undergone further training and is highly skilled that we could, you know, send you to. And that'll look different depending on where you are in Australia or, you know, globally. It's not a helpful argument to say the type of provider. It's really just about the network in your area.
Mel:
[26:33] But it could be a dentist, could be a pediatrician. could
Reena:
[26:37] Be a GP could be in Australia they're probably the main ones or an ENT yeah in other countries other health professionals have got rights to perform the release that we don't necessarily have in Australia.
Mel:
[26:49] And there are some tongue tie clinics like there are some dentists for example you know I've got a particular service that's where I refer everybody to that's where one of the lactation consultants in our area did their training on tongue tie and sort of down on the grapevine said this is a really good clinic because one of my concerns is if you send a baby to be diagnosed at a clinic that does the releases, you know, does just every baby get a release or is there some, you know, do they go to these clinics and go, oh no, your baby doesn't need a release? That's my concern is that when you're taking them to the place that does the releases to get the diagnosis, that I think maybe they could get an unnecessary release.
Reena:
[27:37] Yeah, I think that's a common concern and there's probably definitely, weight to that. I think in how I would approach an assessment, I want to make sure that I've done a breastfeeding assessment and an oral assessment before I send them anywhere. Now, I'm not affiliated with anyone in particular, so I send people based on the outcome of those results and then wherever geographically it works for them that I am confident in a provider in their area. And I think if you can cover all of that, you've got a really comprehensive assessment and diagnosis and that gives parents a bit more confidence in actually having it done as opposed to, yes, seeing someone who hasn't actually covered, say in this context, the breastfeeding side of things. But equally, when we mentioned speech, you want to be going to see a speech pathologist who is trained in that space to actually determine whether the function at that point is normal or pathological.
Mel:
[28:29] And for parents playing at home, I think it's very possible that you'll jump through a few practitioners before you get the full picture and actually come to the point of having it corrected. It might not be a one-stop shop option, unfortunately.
Reena:
[28:49] Yes, that's very common and confusing and really challenging for parents. And I think there's no simple answer for how we fix that. Again, it comes back to if we all had a standardized tool for assessment and we were all doing the same thing, then we'd probably get more consistent results and less conflicting information. But that's not where we sit at the moment, I don't think.
Mel:
[29:12] Can you do you know much about the procedure to have it corrected this is something that parents often ask me like well how would they do it and I'm like oh there's I mean there's a few options that you already talked about the different tools but can you describe what a correction of a ton tie might be like for parents listening yeah
Reena:
[29:34] Okay well it's really they're releasing the fascia or the connective.
Mel:
[29:38] Tissue at
Reena:
[29:39] The floor of the mouth to allow the genie of or the muscle to actually, I suppose, be free and be able to move in the ranges of motion that it needs to for normal function. So they can do it with, as I said, scissors, scalpel, or laser are the common tools of choice. And it really does come down to the particular provider. I think you can, if you listen to a lot of the global experts and they're all in different fields, most of them would say it's about their skill as a provider in terms of executing a complete release as opposed to yeah whether it's done with scissors or not.
Mel:
[30:17] And they don't numb the area because it's their mouth, right? That's my understanding.
Reena:
[30:23] I think it depends on who you see and what protocol they follow. Yeah. And the age of the baby, the whole range of things.
Mel:
[30:31] Totally. And I've had clients who found the procedure to be an absolute non-issue. They went in, had it done, the baby fed. There was virtually no tears. Like it was so straightforward. And then others who were like, oh, my gosh, it was terrible. There was crying. There was blood. There was like, you know, and had very dramatically different experiences.
Reena:
[30:58] Yeah. I think that can happen within the same, like with the same provider. I certainly have experienced that spectrum with patients. Some babies you wouldn't even know it was done. And I think also some of the variability comes in in terms of whether they had like a class for or it depends which way you want to describe it basically but a severe tongue tie all the way to the end very obvious and whether that was released and just that portion released so the baby got some improved function but maybe the the deeper fibers or the submucosal portion wasn't released and so generally providers who are going to release all of that and do the submucosa it's a bit more involved and often those ones you might see yeah a little bit more of a difficult response Potentially, yeah.
Mel:
[31:44] Reena, is there, after the procedure's done, is there ongoing work that the parents need to do with the baby or is that just the end of it?
Reena:
[31:56] Great question. So yes, again, the literature is still not forthcoming, I don't think, in terms of the right way to do the aftercare. You will find a lot of providers will say, yes, we want you to stretch that wound for about three to four weeks post frenectomy to try to encourage wound healing in such a way that you get elongation of those fibers in kind of the vertical plane. So we're not getting a nice web of connective tissue that kind of takes the baby back to square one. But that isn't easy. We've worked with, I would say thousands of families through that and it's really challenging. And I think I always approach tongue ties in the same way that I would do the rest of musculoskeletal medicine and that's conservative first. And then, you know, failing that, we would refer for surgical if necessary. And so I think we're definitely not going to send every baby that comes through our door and we're definitely going to look at the family dynamics, as you mentioned, Bea, about, I suppose, yeah, how that's going to work for the whole family and whether that's the right decision or not and for lots of families it isn't appropriate and knowing that I think is really important because just because you see something doesn't mean that we need to intervene we really do need to understand what's right for that whole family it can be looked at later if it's a problem and I would say just because it's present doesn't mean that it's going to be a problem later on we certainly do not have enough data to suggest that so.
Reena:
[33:19] Yeah being really careful about who we refer and when is important because if we're asking them to do the aftercare and they need to stretch that sort of every six hours that that's a lot and and some families don't cope with it but I would also say to those families and I do say to them it's okay like we will support you through this and so sometimes it is that body work afterward is not appropriate because that baby doesn't need anyone else in their mouth they just need time on the breast and so we're going to support that family in one way and then another family we might be able to do some body work and we might be able to get those stretches done and it really I think is important just to work with the families on what's right for them at that time. It's not a black and white aftercare process yet. We do not have enough studies to say one way or the other definitively do nothing or do all of the stretches.
Mel:
[34:05] Yeah, right. And I guess, and we should say, I don't think we said it, that not every tongue tie needs to be corrected.
Reena:
[34:12] No.
Mel:
[34:13] Is there a criteria that helps clinicians know which ones to correct and which ones not to?
Reena:
[34:21] Well, yes, like there's a visual criteria, but then you need to come back to that functional assessment as well because just looking at structure means a lot of oral ties will be released just based on what they look like. But if there's no compromised function, then why would you intervene? So it's that really comprehensive assessment that's necessary, I think.
Mel:
[34:40] So it's more about that if the function is impacted, that is more meaningful than if it looks like something dramatic. Yeah. Yeah, and there's different grades, you said, too. That would be all part of having it diagnosed.
Reena:
[34:55] Yeah.
Mel:
[34:56] Yeah. I was curious about what causes tongue ties, and I know this can be quite the controversial topic.
Mel:
[35:04] Do we know anything about how and why they develop?
Reena:
[35:08] Definitively, no. We definitely know that they're on the rise. Why they're on the rise, though, is a bit ā€“ I think there's a lot of reasons, and no definitive answer on that either. I think genetics definitely we know that they're more common in boys and that's just what the data is starting to show us we know that they develop in utero and that there's a hereditary a possible hereditary link but really the causes there's lots of theories they're being documented back even as far as the 1600 so it's not a new concept it's just that I think probably the increase in scientific study as well as I think social awareness and then genetics is probably seeing that increase as well as breastfeeding rates have increased you know so we went through that period of in the 1800s and not a lot of people breastfeeding formula was introduced and so we found a way around feeding difficulties but as breastfeeding rates have increased it probably has a part to play in terms of why we're seeing more but it's lots of reasons but yeah the exact cause, no. Folic acid, iodine, evolution, they're all being researched, but nothing is definitive yet.
Mel:
[36:18] Yeah. So parents can't, you can't blame yourself basically. You're like, oh my God, because I know a lot of my clients talk about the connection between folic acid supplementation and the MTHFR gene and that somehow that there's some interplay, but you're saying there's not definitive research on that.
Reena:
[36:36] No. And also a tongue tie, Now, the cadaver studies are showing that it's not a midline defect like a spina bifida or a neural tube defect. It is just a restriction in the fascial tissue or the connective tissue of the floor of the mouth, which then kind of leads a little bit away from that folic acid theory.
Mel:
[36:53] Yes. Yeah. And the other, yeah, because that's what, I've noticed is when I first started, it was very rare that, you know, you'd vaguely hear about tongue tie, but now it feels like so many babies have tongue tie and everyone's got a tongue tie story, you know, in their friendship group. So it's really charged. But yeah, I think that's some of the context of what's happening with tongue ties. It's kind of snowballing and practitioners aren't keeping up with them.
Reena:
[37:27] Yeah, I would agree with that. I think it's hard, past experience. And given that we are seeing a hereditary link, some families have already had two or three boys who've had it. And so their natural response is, I just want to get on top of this and out in front so that I don't end up three months down the track and dealing with this. But I would say it's not a quick fix and it's not an easy solution. It rarely is a quick fix. It takes time. It works well when there is significant restriction in function and we're trying to maintain breastfeeding in the diet, but it's not always the answer that people are looking for. And sometimes the trauma for the family is greater than the perceived benefit.
Mel:
[38:08] I think we've kind of covered all the questions I had in a roundabout way. I did think while you were talking about thought of a question, actually, because we talked about the possibility of having it treated surgically. But are there other treatment options
Reena:
[38:23] Yeah definitely yeah certainly depends again what their age is but as an osteo we will treat them first and we will try to improve you know cranial nerve function to the jaw to the oral structures you can't stretch the freedom itself but you can definitely improve function to the muscles and so that would be how we would approach it as an osteo. But I think it depends on the age. I'm sure there are chiropractors out there working in this space and physios who probably would have a similar approach in terms of musculoskeletal. But then you've got speech pathologists who are working on improving, you know, feeding strategies to improve oral tone, but then also just, you know, how do we get around that? Can we get that baby feeding? And very often quite successfully. And then they're also working in the speech space, obviously a bit later on yeah yeah awesome I was just gonna say I think we touched on that in the last episode I think it's really important you're exactly right there are lots of reasons why a baby can have difficulty sucking and it's not just to do with a tongue tie and so to release that without actually addressing all of the other problems
Reena:
[39:34] and potential cranial nerve deficits does that baby a disservice so yeah and.
Mel:
[39:39] For women who are having feeding difficulties breastfeeding difficulties
Mel:
[39:45] The people who are experts in helping with breastfeeding difficulties are lactation consultants. And then this follow-up work can be done with osteopaths if it's not a tongue tie.
Mel:
[39:57] But keeping the dyad together, the mother and the baby, and seeing how their symptoms coincide and how they interact with each other is the important part here. Which I think is where maybe some of the other practitioners might be lacking. So if you just see a pediatrician who's solely focused on your baby or a dentist who's solely focused on your baby or an ENT or whoever, it's important that both are considered. And so lactation consultant can be an excellent first step for any breastfeeding issue. And then they can be sort of the gateway to exploring what that issue could be. So if you're having trouble breastfeeding, like everyone has said, it's not necessarily because there's a tongue tie there's a there's a whole muscle like the mouth is a massive muscular structure and it could be an issue with any of that so yes I think immediately jumping to tongue tie could could send you spiraling into that journey and yeah I guess what I'm offering is that if you've got breastfeeding issues potentially next steps could be a lactation consultant before considering surgery and all these things yeah
Reena:
[41:16] And remember that the mum is involved in that process so we need to look at
Reena:
[41:20] you know what's going on with the mum and her milk supply it's not just all about baby.
Mel:
[41:24] 100 awesome all right that has been this week's episode of the great birth rebellion we talked about tongue tie rena's course is available at drrenamurray.com I'm going to put all the details for that in the show notes below we're also going to pack the resource folder full of information on tongue tie that Rena's got actually the resources from that course we're going to jump into the into the resource folder along with information about that assessment tool for health professionals who are listening and wondering what that tool was so thanks for being here guys tongue ties controversial if you've got heaps more information we'd love constructive advice and info and we will see you in the next week's episode of the great birth rebellion to get access to the resources for each podcast episode join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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