Maithilee Menezes, MD, presents on if there is an underlying "excuse" for feedings to be difficult for the infant and is there a need for continuation of care with outpatient feeding clinic?
Good morning, everyone. Welcome back to the early bird rounds. We have a nice presentation to look forward to today. We have two speakers. Our first is doctor M who specializes in pediatric auton. Um And she'll be speaking on tongue ties with her co presenter, Miss ELISA Doherty, who is an occupational therapist and uh she will be speaking on the infant feeding clinic and how tongue ties um are involved as well. So if you have any questions, please feel free to put them in the chat box during the presentation. And um I will put the QR code side up for anyone who did not have time to scan for that as well. So let's give them our full ditching. Good morning everyone. Just as a really brief part, we know that tongue tie is super common and discussed a lot. And we want to take an approach of reviewing what we do, know what the literature is there as well as how we might approach it. And so Miss doty is gonna start us off, especially with the assessment of the newborn and what we might do from that standpoint. And then we'll go from there Good morning and uh hopefully Madison, tell me if I'm wrong, everybody can see my slides. Ok. If I need to change anything, please let me know. Um Thank you for your attention this morning. Um Again, my name is Alisa Doherty. Um I was asked to speak today just on our perspective of infant feeding and its assessment, um little background for me. Um but first disclosures, um I am an employee of BJC Missouri Baptist and I work as an subject matter expert for occupational therapy, as a consultant with Doctor Brown's Medical. I have no financial disclosures today. So my background is um 20 years of expertise in infant feeding. Um I am the clinical coordinator of the infant feeding team here at Missouri Baptist with our mission statement to provide the highest quality of care to all infants and their families that is compassionate, comprehensive and skilled. We educate the feeding team of health professionals and parents by advancing knowledge of newborn science and care as it relates to feeding and advancing knowledge for optimal health of newborns. Our team has extensively grown through the years as population continues to rise. Currently, our feeding clinic is seeing approximately 60 to 75 babies per week from the Saint Louis area, some of the families driving an hour to two hours away, um something that we're very proud of um and continue to give a lot of care and concern to, to make sure that we're providing that evidence based practice. We are occupational therapists. We are also certified lactation consultants. So the categories of assessment will include but not limited to oral motor function, sensory motor skills, neurodevelopment, and state control tone assessment as they relate and contribute to the infants feeding progression. Um So we're not looking at just breastfeeding, we're not looking at just bottle feeding, but we're looking at things from the infant's perspective. We would be ignoring the fact that caregivers parents are important to that piece of the puzzle. So the model of practice that we use is the person, the environment and the occupation as they balance each other. So why we do what we do? Um I I very much believe passionately that all parents, all mothers have a deeper desire to provide to the baby. And sometimes they are going through their own life's challenges that impair that ability. So my role as an occupational therapist and feeding specialists, just to make sure I'm incorporating that parent perspective to drive that feeding goal, whatever it might be. So our job is we need to know the goal, we need to know the attributes that we could control and how we can influence those things. There's also a big component of things that we cannot control and that's relevant. So we need to know if the delivery was complex to the baby, have medical and developmental limitations and how do those things limit the feeding as we're defining? Feeding difficulty, which is oftentimes our diagnostic code. When we're seeing babies in the feeding clinic, we're looking at the pref feeding observations of tone state control, muscle tone movement patterns, their airway status matters. Obviously, the face and mouth and the structure and function matter. The reflex assessment, sucking, nonnutritive suck and the nutritive, all a part of that developmental and pasture perspective. So in our feeding assessment, we need to also contribute the the idea of influence for who is the feeder. What type of f hold are they using? Is it a breastfeeding or a bottle feeding? The latch assessment is important, the quality of suck and how the infant is responding. So for us, the occupation for the baby is is to thrive when we ask parents to put things into a hierarchy of goals, which is important because not everything can be number one, as we all know in our own lives, the job of the infant is to thrive to feed well in adequate volumes, to gain weight and grow matter. We want to make sure that's happening without signs of stress. The role of parent is to protect care, nurture and understand and advocate and on and on. We support that thriving baby when we make sure that we're also supporting the caregivers role. So the development of feeding expectations is really to understand if there's an underlying excuse for the difficulty of the baby's feeding from the sensory motor, oral motor neuro development tone and anatomical perspective. We have to understand medical conditions, impacting the feeding. But we also need to dig deeper and understand if there is a behavioral versus an anatomical issue that's also affecting the infant's feeding and could positive practice help. So we get into the taboo area of tongue tie and I'm pretty sure as practitioners, we all cringe a bit when we hear hear tongue tie with the, according to the ACA Academy of breastfeeding and their position statement from 2021 a tongue tie exists when the tongue is limited in its range of movements and subsequent function. Do the pre presence of restricted suddenly from a tongue tie exists when the infant's anatomy causes decreased movement to the tongue along with an impact of function with again, big pieces of this impact of function. I'm not going to get into the diagnosis in the significance of each given tongue tie. I'm gonna defer on that one because what we're going to really address is the criteria of that function. We can talk about anterior tongue tie, we can talk about posterior tongue tie. But the big thing that I want practitioners to take away is it's about function. Um I do not care if a baby can stick their tongue. I got to the gun line or to the lip line. What I care is about that tongue's ability to compress the nipple, whether it be breast nipple or bottle nipple and to fluently be able to move milk in a negative pressure seal. So oftentimes when we're seeing babies and they're coming in with this potential tongue tie diagnosis. The subjective complaints from mothers who are breastfeeding are often latch difficulties, nipple pain, poor breast emptying, prolonged duration of individual breastfeeding sessions, inadequate initiation when directly feeding at breast, the objective findings are equally as important. We need to look at nipple compression, damaged nipples. Is there milk milk stasis within the breast. Suboptimal infant weight gain due to inefficient milk transfer. But it must include the criteria of in the presence of adequate milk supply. So we have to dig deeper. We can't just say that we have sore nipples or my my baby doesn't empty the breast but then go on to find the mom isn't producing adequate milk supply and is supplementing with formula. Those two don't link together. We must isolate the variables. So as we're again, addressing the person, the environment, the occupation, we must look at subjective and objective measures and do our due diligence to assess each contributing factor related to the feeding with both breast and bottle to calculate risk and benefit for each intervention. Feeding is a dynamic task. I know that's not lost on any of you all. We must suck, we must swallow and breathing is kind of a big deal. Um development matters. We are looking at babies from across the board whether they were born at 28 weeks or they were post term at 41 weeks. It's relevant to understand at a feeding time, who woke, who did we tell the baby it was time to eat despite them being premature. Sure. And then they gave us limited, limited arousal, limited participation and therefore they're not emptying the breast. Is it more an issue of level alertness or is an attention issue that is then related to fatigue issues that could come with a tongue limitation. We need to make sure attention is drawn towards the feeding how an infant swallow is swallows is relevant. Um We, we need to make sure that their tongue is able to move to the roof of the mouth to form a seal with their jaw drops. This creates the vacuum to pull the milk in and while the back of the tongue is rising and following and falling to facilitate a swallow in coordinating with breathing when it and it has an effective swallow. Their lips are passively engaged and not a part of the second section. Mechanic, mechanics of a swallow. When we're talking about lip ties and bugle ties, it's important to understand that when the tongue is functioning properly, lips are passive. The academy of breastfeeding medicine's position statement means the upper labial frenulum is a normal structure with poor evidence for intervention to improve breastfeeding and therefore cannot be recommended. Additional surgery to release A BT should not be performed. So aga again, it doesn't mean that we don't dig deeper and there are instances where we need to talk about the contributing circumstances. But as a baseline, what we're more addressing is the function of the tongue. In summary, a tongue tie is not diagnosed based on the placement of the mouth tension range of motion and function are necessary to consider. Therefore, detailed professional breastfeeding assessment and observation should be conducted before a treatment decision is made. The mechanics of breastfeeding and sucking theory is important to understand which is why our feeding clinic, staff of occupational therapists are all certified in lactation as well. If we don't understand what a mom needs to bring to the table, how can we understand what the baby is supposed to do next? It's comprehensive assessment to make sure that the caregiver knows the ways that they can position the infant with postural support in the ways the baby is working really hard to make this milk transfer. So we focus on the proper vacuum generation, the motor of the latch. I'm not going to bore you with me reading each slide. But the anterior tongue is a part of the oral seal, mid tongue is creating majority of the movement within the oral cavity. So if the tip of the tongue can extend to the gum line and lip line, that's lovely. But that mid tongue is the part that's creating majority of the movement within the oral cavity. So please don't just look underneath the tongue and think that we understand the movement of the tongue, being able to cup a finger, being able to perform that s maintain tongue engagement without losing that engagement, whether it be with a pacifier exam, a finger exam or understanding the maternal anatomy. And it's the way that the pain is addressed during that during that cupping in section is really important to understand, to say, do we need to move forward with an ent consult the milk flow expression? We have to know the flow. So some women have a really strong letdown response. Others have a very, very slow milk ejection reflex. But we have to guide the mother through education on things that she potentially could influence. And I don't say control because a lot of women are working very hard to create a milk supply that is still sub sub optimal for their baby. We need to educate for a mom who's exclusively pumping that. Their gold milk volume is 24 to 30 ounces per day per baby on average. So that just enough milk supply is putting a lot of pressure on a baby to quote unquote, empty the breast in a situation where they are not that good at contributing to the set pattern and emptying that breast latch strategies benefits of a proper latch, making sure that we have that no siple alignment, improved feeding efficiency for the baby is really important to be able to say that we have this work life balance that yes, we need to feed, but we also need rest breaks in between. And how do we do that when we've asked them to triple feed, which is sometimes what we ask them to do as a means to an end. We're going to look at the proper latch that start to nose to nipple. We're going to wait for the infant to demonstrate that wide opening and gape response. And moms should be able to quickly bring baby to rest. When you have a pain response, the normal reaction is to withdraw. Right? Moms are arching back and pulling away or living underneath this theory that their baby is going to crawl up their chest and find the target, which isn't always necessarily material, especially with the babies that we're seeing, they need to be able to find how their puzzle parts fit together. Once the baby is latched, that jaw Ingle should be much greater than 100 degrees with a goal of 100 and 40 degrees. And if it's not, can we believe that tongue engagement to be adequate? Our practice is very strongly results oriented with an evidence based approach. Every single one of our NICU or one of our occupational therapists are also NICU trained. Our comprehensive team will see babies in our NICU. We also see babies within our mother baby unit that have increased risk, risk factors or are noting poor feeding right from the time they were born therapeutic intervention in a clinical setting increases the succe success with feeding. Um What happens is when we understand the parts that we could control and the parts that we can influence. There's this general understanding of how we can accept sometimes how we're going to have to help a baby meet the progressional goal to be that thriving baby and to have adequate weight gain. Our total number of visits in our clinic certainly does vary. Um but most are meeting their long term goals with an average of four visits. I appeal to you for that early referral. Please do not wait for babies to be broken. It is um not just me speaking as an occupational therapist, but as a parent to have that early referral is everything for a mom who is stressed and understanding why they are failing when it really isn't about them. It's about their baby and what their baby is capable of doing. So when infants require longer than 30 minutes to feed or they fall asleep despite a parent trying to re alert when they're struggling to gain weight and they're not back to birth weight by two weeks of age. We need to look deeper to say what else is going on or influencing this baby's response. Infants who show developmental difficulty in feeding or they're choking with feeding, they have limited endurance, poor participation. This is not limited to the premature or late preterm population, but certainly they are one of the most prime examples of babies who have limited endurance, parents need support and babies need the support of the parents. So the best way we get to our out term outcome goals with the long term goal is to make sure that we have that early referral. An interesting fun fact that I just kind of learned from a recent C eu was that babies will learn how to improve on their lab strategy up until the age of 13 months. So what they're doing in the hospital, if they're needing supplementation, whether it's with a little bit of mom's pump breast milk, maybe it's donor milk, maybe it's formula. Maybe we just need to get this baby to eat while mom is working on pumping so that we can be able to bring the two back together again. But they have 13 months to get better. Babies are really cool like that. They keep getting better as long as we give them positive reinforcement of learning. Moms have about 13 days to establish a strong milk supply. Their first hours, their first days, their first weeks of establishing a milk supply are so important for their long term outcomes. So as we educate and enhance the things that they influence, we absolutely can help do better with our babies in their long term feeding goal references are listed and there it is sorry for the fast words here, but tag thank you for your attention. Any questions so far? All right, thank you, ELISA. That was a wonderful review. Thank you so much. I am going to build off of your fantastic work with some background and also, um, let's see. And then I'm just going to ask and confirm everyone can see my presentation. Ok. Yes. Looks good. Fantastic. All right. So, um, as you all know, I'm a pediatric ologist here at children's and I've had the pleasure to interact with most of you on a regular basis. I have no financial disclosures and as we had just gone over and I'll do again, just a little bit of background to help set the stage for what we want to go through. Next. The tongue, the frenulum, as we know is a fold of mucus membrane and extends from the floor of the mouth to the midline of the underside of the tongue. It helps to stabilize the base of the tongue and it does not normally interfere with tongue tip movement. As a partner of mine said, recently, any time you fold a new coat over, you can have a band or a tie. It's like having a pleat in the skirt. We've talked about how it can have challenges from a feeding standpoint. And I also wanted to think about the longer late term later effects that people have often come to and discussed about this including speech and articulation ability to sweep or keep the teeth clean or other challenges this has been recognized as far back as the time of Aristotle from 350 years before the common era techniques regarding tongue Thai released were published as early as the 16 hundreds in textbooks. And reportedly midwives had intentionally overgrown a feet fingernail at one point to help lice those lingual attachments. Thinking a little bit about that embryology. Yay by the first four weeks, that tongue formation begins and it arises from the first, the second, the third and the fourth arches, pharyngeal arches and it starts from the tuberculum empire um to form the anterior tongue, the median swellings then form the posterior tongue and ankyloglossia then results from the failure in the apoptosis or the degeneration of the frame one. But there's a whole lot of stuff that's been talking about tongue tie. And if you think about this from before and now the incidents or the discussion of tongue Thai has gone up tremendously. So, in a systematic review and a meta analysis from 2021 the overall prevalence when they're looking at over 24,000 patients was about 8% though it has been cited anywhere from 0.3 to point to 16% less than 50% though of the patients had had difficulty with breastfeeding at least from the older literature. So as I mentioned, there's been a significant amount of increase in what we know. So tenfold increase from 1997 to 2012 in the reported studies or 866 increase in the treatment recommended over the last two decades, most frequently noted are, um due to maternal symptoms when it first comes up, especially with issues with breastfeeding. And hence, we've had some of that wonderful discussion already. So how should we assess it? Well, I think you've heard a really good overview of how we could have an assessment. Um How about just a grading system? We're discussing that. So several systems have been put forth Klow in 1999 Corallo in 2004, a hat liff assessment, which is a larger assessment of the child rather than just a structural. And then there's also like the latch assessment too to go through a few of them. The Colo system focuses on the free tongue, specifically the distance between the reum and the tip of the tongue and it really only is an an atomic um evaluation. Carlos does look at anatomy. So it incorporates the frenulum attachment point onto the tongue. It grades the firmness and the shape of the lingual attachment. And it recommends that this assessment is being done with a breastfeeding assessment as well. The hat lifts also looks for ankle Glaser with both appearance and function. It has a 12 point assessment in there and it judges that a tongue tie is present if the appearance is less than eight on their grading scale and the function is less than 11 and then the latch system is latch, audible, swallowing, nipple type comfort hold. And I think we're going through a number of that already as we have talked about and identifies difficulty in the breastfeeding process and the breastfeeding competence. So there are a number of different greeting systems. And when we look at this from a socom Moor standpoint, there's not always great correlation, the hat lift system in this review from 2021 looked at it and as I mentioned, there's 12 items in total. It does correlate. Well, when you're looking at it from a breastfeeding assessment tool, and there's a good correlation between function and appearance. The colo system, not quite so much in the corals, there wasn't quite as much of an ability for that um correlation between function and appearance. There are other systems as well and not that we're gonna be extensive and exhaustive with everything. But just to point out that there could be the Bristol Tongue assessment tool, the lingual Frenulum Protocol, the breastfeeding assessment tool, the fre Freno decision tool for breastfeeding diets. And it goes on, you'll see a lot of this if you ever do a deep dive like I did, um you'll see a lot of these different systems and tools being put forth and just so that you're aware of them by no means as I mentioned, this is exhaustive, there are controversies as we have brought up. Is there a posterior tongue tie? Is it only an anterior tongue tie. What is a posterior tongue tie? It's a band of tissue with a perhaps a thick fibrous span that's inserting posterior into the ventral tongue but not extending to the tip of the tongue. As we more classically might see when we look at it from an ent perspective in 2020 with the consensus practice guidelines, experts couldn't come to consensus regarding a post period time, time. Some feel it's not to be a true clinical entity. And there were a lot of challenges with this surrounding the definition, including how do we assess it? The literature is not great in a small sample size and varying methodology. All right, those are different systems. Is there anything else that we might know? Well, let's talk about our assessment. When we first assess a child, at least from the ENT clinic, you can guess we're looking for ABC S, we're looking for any structural problem. The only signs early on might be a poor lad or challenges with feeding. These could be the tip of the iceberg and we may see much more nine months later as you well know when there could be more developmental issues and now we could identify those challenges. So as I'm looking at this kid and I hope you're beginning to identify a few things that are already making me say, um I'm a little bit concerned right here from what I'm seeing, looking at again, as we mentioned, the jaw, the tone, how long is the feeding going on? Length of feeds? Are they tiring? What is the sleep state and the hunger state regulation? What is the latch itself? What is mom assessing? What is mom going through? Is, is she pumping? Is that what's the volume or the rate of the flow? Do they have lactation support? What are their concerns? What are their anxiousness? What is the pain? What is discomfort? So there's a lot going on in here may also be thinking about sounds. Is the child noisy? Is there stir or is there strider? And while I might not have time to do the full assessment, it really makes me think about other members of the team and how can we support this diet? What am I looking for really quickly? And this will be in the slides that'll come out. I'm looking at the head and neck evaluation, the tongue, the mandible, the maxilla, the palate is a relative Glossop tosis and then key. Are there signs and symptoms of relative airway obstruction? What is their tone? Did they have a feeding tube before? Is there neuromuscular disorders? I'm looking at other head neck sources. Is there signs that make me get concerned about nasal obstruction as I mentioned, is there strider. Is there stir or should be thinking about other things like laryngomalacia? Should I be thinking about? What else in the past medical history? Do I need to be thinking about like local fold, immobility. Do I, do I see any craniofacial anomalies coming up? Remember? And you know, this, there are unique features of the neonatal airway. They're an obligate breather until the 1st 6 to 8 weeks of life. There is a superior relative position of the larynx. The epiglottis may be a little bit more acid and collapsible. Remember that the subglottis is the narrowest portion of the airway and it is sensitive to small changes in airway and dimension. In comparison in that upper airway in that newborn, the tongue is larger in proportion. The pharynx is smaller. We talked about the epiglottis. The larynx is more interior and superior and the trachea is narrow and less rigid. So, ok, now we've gone through all of that background. Let's go through some literature. When is it of benefit? So let's first think about breastfeeding going through some of the best articles that I could find and these are the ones that are often cited. And so hopefully, this will be a good resource for you. Later on. Um Dahlberg back in 2006, looked at patients undergoing for anatomy versus sham procedures. They didn't really notice a big difference in latch scores but they did notice an improvement in the pain that mom may feel 2012 Barry and all noted an immediate improvement in maternal pain and perceived feeding. Though the objective observer didn't note any real significant improvement. Edmunds in 2014 did a randomized control trial and I'm sorry about the abbreviations there, but you'll see RCT in the future for these slides. Looking at those assessments, the hatless score did improve after Frey, but the functional scores didn't differ significantly. So a Cochrane review looking at this in 2017 doing a very large analysis said, well as we're looking at this, five of these randomized control trials met inclusion and then they had an n of 302 3 of them did objectively measure breastfeeding. Four of them objectively measured and assessed for maternal pain. Where were the challenges with all of this? There were methodological issues. These were small trials. Most controls in these eventually underwent procedure. None could report increased long term successful breastfeeding. What they did find was that there was a significant improvement for the family though for reduced nipple pain. And unfortunately, there was no consistent positive effect on feeding that sounds like it might be minimizing this a little bit. It's not as we had already said, if there is a significant amount of pain, we need to think about this as a diet. We need to think about what's the system itself? If the family, if mom feels like this is really, really uncomfortable, it's going to affect the whole process and the whole system and it will affect them in terms of their enthusiasm for breastfeeding, their enthusiasm for trying to do this. Um And it will affect how baby interacts as well. So there is some evidence to say that this can be helpful. What about a posterior tongue tie? Should we do a release? So some have tried to do a more rigorous assessment and to be systematic about it. So like a harry in 2017, tried to do an assessment of that from a prospective cohort study. In 2021 they set up a prospective randomized control trial and they had 47 patients and they examined using a bottle feeding system, measuring tongue function. And they also used the breastfeeding self assessment uh survey. So this is what the f mother felt afterwards. And what they noted was that there was some improvement of feeding after the release. There were challenges though that have come up with this including was there concern about how it was set up for the trial as in every child was assessed and they did have a malfunctional and an occupational therapy. Um sorry, speech, assess uh speech feeding assessment. And so all of them did have stretching maneuvers and if this was going through, did that potentially affect the outcome, it depends on how you set up the trial. It is a good trial. It was, well, it was for all of that we have, it was well um set up, but there is also selection bias. All of these were families who were very motivated to come on in and wanted to be able to um have an improvement in breastfeeding and they actively sought the clinic. So, should we just go ahead then and offer a release for it from a breastfeeding standpoint? I think that there's a significant amount of evidence to say that if a family is motivated and they want to try to do more and they're going to be working uh to try to increase flow and increase uh the amount for breastfeeding. I think that there's a lot for yes, especially early in life. Are there any other options? And what is it about in general or for the longer term? Are there any other options? So, this paper was published in 2019 and it came from a quality improvement project at Boston Children's and their goal was to develop a sustainable and reproducible multidisciplinary uh sorry, a reproducible program. They did a multidisciplinary assessment and they developed a therapeutic strategy program. They assessed how often procedures were required both before and then after a comprehensive feeding evaluation. And as I mentioned, all of them were evaluated through a multidisciplinary feeding consultation. So after assessment, they trialed several different interventions. Moms learned different techniques if they were having challenges to stress defeating challenges. Frey was only recommended if their functional impairments appeared to be related to the tongue. In this case, they also included a lip tie of those 115 patients. 72 did not choose to undergo a surgical procedure for tongue tie release. 63% of them essentially did not the rates of freno toy overall. Prior to this quality intervention in the same clinic, about 95% of them were having a release. After going through this, the rates of Frey decreased from 95% to 37% after introducing lactation support. And the ph anatomy was associated with higher maternal worries with feeding and reduced scores on breastfeeding, self efficient efficacy. We often hear I'm gonna change hats a little bit. We often hear about well. But if I have a tongue tie, isn't this gonna cause challenges for my child in the long term? Is it gonna go cause problems for longer term feeding? It's gonna cause problems with speech, right? What about with reflex? And it's gonna cause challenges with sleep apnea. So let's go through some of the literature of what we do have. Does it, is there a benefit for longer term feeding study out of the Netherlands in um 2021 said, yeah, we think that there is going to be some improvement. 60% were still nursing at six months, but this was a very educated group who were all highly motivated and they had time to feed and time to spend with breastfeeding. This is a study done in Netherlands. The family is given a year off to be able to care for the newborn. Not quite what we have in the United States. From San Diego. They did a prospective study with 343 patients and they did a routine follow up at one week and three months, 220 patients were able to do follow up. 56% had mild to moderate improvement in longer term feeding. But at three months, only 20% were exclusively breastfeeding and 17% had stopped completely. At three months, all of these studies have challenges, they're limited in their follow up. All of these are really essentially to infancy. So it's not with the um so not looking at that longer term. After a year, there is no mention of lactation involvement in these two prior studies, nor of other therapies such as speech or occupational therapy assessment or ongoing teaching. And so they did have high loss to follow up what they do come up with though is emphasizing a need for holistic multidisciplinary evaluation, looking at factors involved in breastfeeding before referring on to annoy. What about speech? We hear that a lot 2015 journal of pediatrics, they did a systematic review that tried to be as inclusive as they could because the data wasn't great. So they looked at 1600 studies of which only 15 could be assessed. Two were randomized control trials. Two were cohort studies, 11 were case series one had a poor quality and it compared the surgical techniques but they did not include any untreated control groups. They did note that there was improvement in articulation but not in word sentence or fluent speech. All were challenged with small size, incomplete and poor characterization of the Children. In the cohort studies, there was a risk of ascertainment bias or kids, parents of kids with tongue tie would have higher index of concern for speech issues than those who never had any tongue mobility restriction. The cohort studies, as I mentioned, they compared a control group, no ankle Glaser treated Children with one in with ankle glast untreated. And the outcomes were assessed by parent reported survey only which was non validated. Is there anything else? 2019, a retrospective study, a phone survey looking at kids who had been treated or assessed for tongue tie. These parents did not notice any difference in the speech difficulty or tongue mobility but they did notice potential improvement in tongue tasks. Visconti. So I'm gonna go away. It seems like I'm only looking at ent literature. I'm trying to be as inclusive as I can. So looking at speech pathology, they also did a systematic review. They saw that there was research supported to release decreased nipple pain, but it was inconclusive for speech benefits regarding tongue tie release. And again, setting the same challenges of data and quality of the research. How about from the dental reviews, systematic review, they tried to do as much as they could with a wide inclusion criteria. Cohort studies, case control studies, case series randomized control trials, the self controlled trials or studies I should say showed improvement. The cohort studies with untreated controls didn't show any difference and the randomized control trials compared technique, but they didn't have any controls of any treated versus untreated patients. They all had the same challenges of small sample sizes and varying occurrence rates and outcomes but none could find a connection between tongue tie and speech disorders. So summary general challenges in research, lack of control groups, poor randomization or blinding small sample sizes or variance in sizes between study and control use of non validated assessments, failure to adequately describe or standardized utilization of therapy including even did they get speech therapy or not with patients. So the true incidence of speech difficulties is unknown. There are no clear guidelines except that they strongly evaluate recommend evaluation with the speech therapist before Freno and Frenula Plasty and ongoing care and treatment afterwards. When I have a child who's coming in, I'm gonna be looking for a couple of other things too, but I'm gonna put on my ent hat bias which is uh how well do they hear? Have they had a hearing assessment? What's been going on from that standpoint? What have been their overall developmental milestones? What's going on in their life? So I'm gonna switch hats. What about reflex? Because you may have been beginning to hear, oh, you know, if we do a tongue tie release, it's really gonna help from reflex overall. So let's go through what we could find similar study. 2021 a longitudinal cohort study, 175 diets mom baby diet. They were assessed with the breast um feeding self efficacy form. They also did an ID er Q reflex questionnaire which doesn't really have a formal assessment. We don't know if they did have ongoing therapy or if they had speech or ot or lactation involvement from that standpoint. What did they come up with? These were kids who were followed for 20 days after randomization, they advocated for tongue tie release. After exhausting all non operative interventions. There are concerns though with this study, there was no formal routine assessment. They relied on patient questionnaires and there was a lack of control arm without intervention. I don't think there's a lot that could say one way or the other. Does it help from a reflex standpoint? What about sleep apnea? Because I'm sure you've been hearing this more and more if we do not assess the tongue, if we do not address this, if the tongue goes up into a position where it sits higher in the mouth and it continues to hit the palate, we're gonna have more challenges, we're gonna cause more sleep apnea challenges from this standpoint. So let's talk about it. Looking back at that um large review from 2015, as I mentioned, it has a number of randomized control trials. Their summation on this the data was poor and insufficient and there was no studies including data related to sleep disordered breathing and the non breastfeeding child. Here's a paper that was published in 2019 from a sleep center and that was in an academic medical center. They looked at their Children who had been referred over a 20 month period of time. These Children were 3 to 12 months of age. All of them did have a systematic sleep medicine evaluation, a history and a physical. They also included standardized maneuvers, they did measurements and they did a sleep study. As I mentioned, they tried to use a systematic grading system, combining some of the ones that we talked about before looking at length of the tongue if it was short or abnormal. They also, and they came up with a decision that based on putting all those studies together that an abnormal length was less than 16 millimeters in terms of distance between the tongue tie and the tip of the tongue. After they looked at all of their patients, they said, well, we're going to divide you into two groups. You had a normal frenulum and you had large tonsils and adenoids. We're gonna keep in one group, you had a short frenulum, not big tonsils and adenoids. You did have sleep apnea. So that was about an end of 63. And they looked at the apnea hypopnea indexes to say, what did that mean? In terms of sleep apnea. So they divided them between the two groups. Group A, as I mentioned is the normal friend. They had tons. Um A noun or hypertrophy group B is the short frenulum. Well, we think that there's a difference group A, their I indices were 11.36 plus or minus, confidence in roles of minus 5.39. Group B is 13.06 plus or minus intervals of 4.17. Based on this, there was the short frenulum has a direct association with sleep apnea. When I read this, I have a little bit of a challenge and I should say, I'm sorry that the excluded Children who are obese or they had a chronic medical condition if they had other syndromes associated with this. My challenge is here confidence. The A I indices are 11.36 versus 13.06. Their intervals sure seem really close and I'm having challenges with being able to separate out the two and say that there's not a significant amount of overlap potentially there. But as I mentioned, based on this, they said that the short frenulum has a direct association with sleep apnea. Why do I bring that up? Because these are papers including the ones that we've gone through that are sometimes used to promote or to discount discount. You shouldn't read what's there. Yeah. No, it really causes sleep apnea. Yes, it really causes speech challenges and used to promote. We should do a tongue tie release at best. The data is inconclusive. You should know that there are some more things talking about my functional therapy used in the scope of treatment. I think it'd be hard pressed to say that's something that we would do, especially for our younger Children is tongue tie release all completely easy to do. Sure. It should seem like that. Let's talk about complications cost. This is 500 to $800 depending on where you go. That may be an out of pocket if it is a different child. Meaning if I have a child who's over like four months of 34 months of age, it's not an easy thing to do in clinic. If I have a child who's coming to me at 10 months of age, I'm not gonna do it in clinic which means that there is a cost for sedation. The anesthesia cost could be an extra 500 to $900. The hospital fee might be 500 to $8000. Most complications are thought to be minor, maybe some minor bleeding, maybe there's some pain, maybe they're scarring of the surgical site. There are more challenges than we think in a systematic review looking at what was reported and these are highly, highly under reported. They noted that there was poor feeding, some had hypovolemic shock, there was acute airway obstruction, a prospective study from New Zealand. They noted that a mean complication rate of 13.9 out of 100,000 infants. That complication rate depending on the province could be anywhere from 0 to 85 out of 100,000 Children. Could there be other complications? This is a busy slide but to point out and this is from the breast um International Breastfeeding Journal, surveying members of the Academy of Breastfeeding Medicine. 100 and 30 out of 211 reported a complication or misdiagnosis. 100 out of 211 reported in a separate way misdiagnosis and the most common was a neuromuscular dysfunction that had not been adequately assessed. Let's also put into here that we are seeing that there was inadequate breastfeeding support and nonrecognition of abnormal or official anatomy. Should note that there was only one ent in this group. Most were pediatrics, neonatology, dentistry and these were all people with expertise in breastfeeding and clinical practices. So if I was gonna give a summary, I'd say our take home points position and airway will always influence the examination. We need to think about. If there's multiple lesions that can be present, we need to think about other factors that are play when we're thinking about the long term, including hearing and the environment. We ask try to be consistent use a standardized form. Is there a perfect system? No, but you can look at that and say, what do I says every single time, critically appraise the literature the studies that I pointed out are the ones that are often used to be talking about um tongue tie. And if it's potential complications in long term, look at the methodology, you are very smart, educated people, take the time to look at that. I took a lot of time to look at this. And I have to admit, I was surprised at what was being used to cite for support. There is significant variability in the measurement, the length of the follow up. Many use, varying outcomes and measures and varying grading systems. The most important find your village pediatrics, lactation, make sure that they're certified. Someone like Miss doty is IBLCC certified. A lot of questions come up from dentistry. Do you have a pediatric dentist of somebody that you might trust? Well, think about the people who will be able to help you along the way, occupational therapy, speech therapy, especially for the older patient. If we had a goal, our goal would be at one point, could we have a shared previsit? Could we do comprehensive visits and multispecialty evaluations? This is my dream. It doesn't mean that it's there yet. And then importantly, coordinate decision making and communication with parents and providers and that we, if we are going to advocate for this, we are also committed to our outcomes and assessments and these are my references and you are more than welcome to all of this. Um And this is by no means exhaustive as I said. Um ok, wonderful. That was great. Thank you so much. Um If anyone has any questions you can uh put them in the chat box, I will pull up the QR code for you all to scan for credit. Anyone is also welcome to unmute if they can't find the chat box if you have any questions. Um I do wanna remind everyone what we have for next week. Um Doctor Blake Montgomery from pediatric orthopedics will be speaking on common spine pathology, work up when to refer and how urgently. And then I also wanted to remind everyone of our speaker series program that's coming up this Tuesday, October 24th at 6 p.m. We have Doctor Merrill Perlman um from pediatric gastroenterology and she'll be presenting on updates in IBD. So we'll look forward to both of those. I see two things in the chat. What are the wait times for the clinic? So Lisa, I will defer to you for um for your clinic for ent clinic. We try to get Children in same week. We know that our wait times right now are ridiculous. But we have very specifically a policy to try to get Children in as quickly as they can if they're in the newborn feeding for assessment for a tongue tie. If they are an older child, meaning they're like 10 months, 12 months, three years, then they'll go in the regular um assessment um and then does little flower family practice still do Fre Frenulectomy. The answer is yes, it's out of pocket. The last time I heard it was anywhere from 600 to $900 depending on how much is done. Um I did not put it in mine and I'll put this really quickly. Um If you go online and you type in tongue tie and tongue tie release, you'll see lots, lots of things online about how they do it. And people will promote different techniques really quickly. I will say looking at all of that, there is no benefit of one technique over the other. Um laser is not more effective than a cold steel. Um And someone who does all of that, I do not do laser and clinic and I do a cold steel technique. Uh Lisa wait times for you. So, so we take great pride in getting babies in as quickly as possible. Sometimes it's as soon as same day, depending upon their level of need. Um In other cases, we do look at within 48 hours, there are times where we have to extend more than oh, I think I've got somebody else in there. Um More than more than 2 to 3 days, but we also keep a wait list when we are busy because sometimes we do have families that will call with a last minute cancellation and are able to get a baby in. So the short answer is sometimes same day, but generally speaking, no longer than 48 hours to get babies in scene. We do really recognize that once the referral is being made, a lot of times families are coming from this place if I needed the help yesterday. Um So it's a big ask for, for some moms to seek support. Um And when they are seeking that support and that referral is made, we often find they are desperate for that intervention to get some answers to talk about next steps to making feeding just more efficient, more productive on those steps towards a thriving baby. And I do want to say, I, I really hope that it didn't come across that I'm putting on anyone. I think that um, all providers that are trying to help for that mom baby diet and to be able to help, to do that. That's great. I just want us to also think about it in a holistic way that if I'm trying to do something and I really want to, we, we do need to think about cost. It's a lot to ask a family to pay $1000 perhaps out of pocket. And I do get kids who are refer to me because their insurance will pay if they come and see me, but not necessarily a different practice. Well, that seems like that might be all our questions. Um Thank you for, for those questions and we really appreciate the time that you guys took out of your morning to present this topic. Um, so we hope to see you back sometime soon and have a great weekend and, um, let me know if anyone needs help with the slides or that you're seeing me credit. Thank you very much. Everybody have a great day. Thank you. Thank you all. Appreciate it.
