The Evidence around Tongue Ties

fourth trimester infant newborn newborn newborn development postpartum tongue ties Sep 25, 2023

Tongue ties are such a vast, controversial, and often misunderstood topic that we brought in pediatric otolaryngologist (ENT) surgeon Dr. Elise Graham to help us wade through the topic. She is also a mom to two boys with a complex breastfeeding journey of her own, which has brought her to shine a postpartum lens onto her field which she admits can gain from providing more support to patients, especially as information about tongue ties can vary greatly and specialized support can be hard to find. In addition to being a pediatric surgeon, Dr. Graham is also a certified lactation consultant (IBCLC) and earning a fellowship through the Academy of Breastfeeding Medicine, which is why we’re very excited to have her guide us through the evidence-based truth about tongue ties.



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[00:00:50] Dr. Sarah Lea: Hey, everyone. Today, I'm chatting with Dr. Elise Graham. She's a physician and board certified pediatric [00:01:00] otolaryngologist. She's also a mom of two young kids, and had her own challenging breastfeeding journey. Elisa and I are diving into the controversial topic of tongue ties. Our goal in this podcast is to share what evidence there is out there, what benefits there is to treating tongue ties and what alternative options might be.

[00:01:19] Dr. Elise Graham: Thank you very much for having me. It's my pleasure.

[00:01:21] Dr. Sarah Lea: I'm so excited. I feel like our conversation has been a long time

[00:01:24] Dr. Elise Graham: coming!

[00:01:26] It took me a little while to get myself feeling like really up-to-date on my research

[00:01:30] Dr. Sarah Lea: Oh yeah. Especially a topic like this, like we talked about before we started recording, which is very controversial and people have really strong opinions on, I think it's really important to come with as much of an evidence-based background as we can.

[00:01:41] Dr. Elise Graham: And I've done a lot of research recently into the, the most recent papers and publications and systematic reviews. And if there is an article, I have probably read it.

[00:01:50] Dr. Sarah Lea: Awesome. Okay. So I thought today we would just get started and you can share a little bit about yourself, your background your training and why you are interested in this topic.

[00:01:59] Dr. Elise Graham: I'm [00:02:00] a pediatric otolaryngologist, head neck surgeon. So I'm a pediatric ENT surgeon for short. I did my medical school and residency training at Dalhousie University in Halifax, and then went to Salt Lake City, Utah for a pediatric ENT fellowship and my interest in breastfeeding medicine and in tongue ties in general came a bit later, actually.

[00:02:21] I am a mom of two little boys and with the first one breastfeeding didn't come easy. And you know, tongue tie wasn't an issue for us, but there was a lot of help that I needed and I became interested in supporting my patients breastfeeding, so complex patients. Parents still want to breastfeed if there's, or may want to breastfeed if there's airway, anomalies or other complex situations with their baby. And I don't always feel like my service does a great job of, my specialty in general, does a great job of supporting patients. I was getting a lot of discussion about tongue ties as well. And I think, again, my specialty is the oral anatomy expert, but I think [00:03:00] some of us get into this trap where we say one metric is fine in the tongue, so everything is fine. And I wanted to provide a better service than that. I'm doing some training in breastfeeding medicine, working towards getting my IBCLC Lactation Consultant designation and working towards a fellowship through The Academy of Breastfeeding Medicine. That's amazing. So I'm excited. I should get my BCLC soon. And then it takes five years for the ABM fellowship. So I'm in progress. Yeah.

[00:03:28] Dr. Sarah Lea: Awesome. Okay. I want to ask you more about the ABM fellowship after, but I thought maybe you could start by just explaining to our listeners a little bit about basic oral anatomy and the function of the tongue and the frenulum, just so we understand the, the basic, where we're going from when we're talking about tongue ties and abnormalities.

[00:03:45] Dr. Elise Graham: So, infant airways are actually designed differently than adult airways. There's a lot of differences and the way that they are is optimized for breastfeeding through evolution, obviously, because that's how we fed babies throughout time. So the [00:04:00] voice box is higher in the neck, and that allows the palate, the soft palate and the epiglottitis, which is the flat that covers the breathing tube when you swallow that allows them to touch. So babies can breathe through their nose at the same time as they nurse. And actually the interesting thing about that is that if a baby is born with complete nasal obstruction, that means it's a surgical emergency because that's something that we have to address immediately. So that's an interesting anatomy fact.

[00:04:24] The tongue needs to move in order to, it cups the nipple at the soft and hard palate junction. So it needs to have some movement from down to up to hold the nipple in place there. And it also needs to be able to cup on the sides to hold the nipple in place and throughout the breastfeeding suck, there's no air anywhere in the oral cavity at all. And the tongue is responsible for doing that. So that's the basics of the anatomy. The oral frenulum, the lingual frenulum is a structure below the tongue. It's actually not a discrete structure itself. It's a fold of tissue that is formed because the tongue [00:05:00] elevates. So when the tongue lifts up, there's a fold of the tissues underneath and how thick that tissue is depends on what's pulled into it. So it could just be the tissue on the floor of the mouth called the floor of mouth mucosa, or it could be a little bit of the fascia, which has thicker tissue below it, or even a tiny bit of the muscle. That's right below it called the genioglossus muscle, it's one of the tongue muscles. There's a really beautiful anatomic study that a New Zealand pediatric otolaryngologist did Nicki Mills, Dr. Nicky Mills, that kind of explains that anatomy really nicely, because I think a lot of people think of the lingual frenulum as being a discrete, like a noodle or something. A band under the tongue. It's really just a fold. There's some other frenula that are described in the mouth, one is the upper lip or maxillary frenulum, is a fold or tether between the upper incisors and the lip. And that frenulum has a lot more debate in terms of its role in anything. And most recent data suggests that it is a [00:06:00] normal structure and there's almost no reason that needs to be divided, as long as the upper lip can be pulled out in order to allow brushing the upper teeth, honestly, then it's fine to leave that alone. Again, there's a study that was done looking at the position of the upper lip of babies, because I think that the reason this became popular to think about lip ties is there's this idea that the upper lip has to be totally flipped out fish mode. But this study, although it's small, it was 11 kids and they looked on MRI of the position of the lip. And eight out of 11 kids had their lip in a neutral position. Two of them had them out really flange like that, and these are normal breastfeeding infants. And then when they couldn't tell, so it's the recent, more recent data suggests the upper lip frenulum shouldn't be called the lip tie. It's just a lip frenulum and there's not really any reason to divide.

[00:06:47] Dr. Sarah Lea: Yeah. It's interesting to hear that. Cause there's a lot of information out there, but what I was, my best breastfeeding parents say, I don't care how the lips look. It's how the latch feels.

[00:06:56] Dr. Elise Graham: Yeah. Yeah. Some people, other things that people say about the lip [00:07:00] ties are like, if you have a lip tie, you'll have a tongue tie too, or vice versa. Other studies show that they don't, like more recent studies show, they don't cluster together at all. So I would try and take the lip tie out of the equation. It's not something that I think we have evidence at the present time influences breastfeeding or anything else. Even dividing it doesn't prevent an upper teeth gap necessarily. I've seen that out there. Yeah. There's not evidence to suggest that. And again, if the, if it seems like it's going to interfere with orthodontics in the future, then you know, a kid is older and you can divide it with them awake and consenting to the procedure with some freezing rather than, a painful procedure when they're a baby or something requiring general anesthetic, which is a big deal for kids.

[00:07:41] Dr. Sarah Lea: Yeah, for sure. Yeah. Yeah. So when we're talking about the frenulum impacting breastfeeding, and so tongue tie let's talk about how this has diagnosed and the lack of consensus around diagnosis.

[00:07:53] Dr. Elise Graham: So that's another really interesting everything to do with the tongue tie. There are [00:08:00] tons and tons of papers. If you look on PubMed, which is the usual source we use for finding medical literature, the number of publications has just exploded over the last few years, but the quality of publications, this is one of the problems, it really varies. The, from a breastfeeding perspective, that's the best evidence for tongue ties having a role.

[00:08:21] But in terms of how to even diagnose the tongue tie, which is your question there are multiple tools and there are also a classification schemes that are used, the classification schemes I find to be less helpful because it's just a description of how it looks and that doesn't tell you very much about the function. So examples of this are like, Kotlow and Coryllos kind of thing, and may have heard of those classifications. My favorite tool is called the TABBY Tool or the BTAT, Bristol Tongue Tie Assessment Tool. And these are validated tools that look at the way the tongue moves. So it's not just, where it inserts. So it looks at how the tongue tip looks when the tongue [00:09:00] elevates. Where the frenulum is attached on the lower gumline and how it elevates on the side. So I think I find that to be a useful tool. It gives you a score. It's one score, a score that's lower suggests that there's more likely to be dysfunction, but using that tool, it doesn't say this must be divided. It just gives you some information to communicate with other specialists and document which I find helpful.

[00:09:24] Dr. Sarah Lea: Yeah. And I think one thing I found with going through the literature is that there's actually really not a lot of good consensus around, what tools or how to diagnose it.

[00:09:34] Dr. Elise Graham: No that's definitely true. The Academy of Breastfeeding Medicine put out a frenulum or like, you know, ankyloglossia position statement. And they mentioned that there are four tools that they like but that's not exhaustive and those are two of them, but you're right. Every paper you read has different tools used and the inter-rater reliability, you know, how you might rate them versus someone else who rated them later, is very different for these different tools. [00:10:00] So it's it's challenging.

[00:10:01] Dr. Sarah Lea: It's really challenging. And what's interesting, and maybe we can speak to this now, you said before we started recording, is the the number of diagnoses has increased dramatically in the last few years, right?

[00:10:14] Dr. Elise Graham: Yeah. The best data's from the US. And there was a group that published their discharged hospital data. So these are people leaving the hospital after birth, and they found between the years of 97 and 2012, the diagnosis had gone up over 800% for tongue ties. And then they did a follow-up study four years later, 2012 to 2016 and found another 100%. So even steeper slope in diagnosis. And this is just on discharge. So people who have had the diagnosis or the treatment had a clip when they're discharged from hospital, which is not all patients. So I think it's vastly underestimating the rate of diagnosis and in Canada to the increase has been over 200% over a 10 year period in the study.

[00:10:55] It's, some would argue. And I think it's true that there is more awareness [00:11:00] to tongue tie as an entity and an issue. But I also think if we look at this with a critical eye there, it does not seem possible that there are 800% more tongue ties than there were before. The popularity of tongue ties as an entity, popularity in air quotation marks, the awareness has waxed and waned with the popularity or knowledge around breastfeeding. So in the the fifties when formula became really popular and was a bit of a status symbol as well, instead of breast milk, people didn't really talk about tongue ties anymore in the literature or in popular media. But then in the nineties, when it became more known that breastfeeding was so beneficial, that's when the discussion increased a lot.

[00:11:43] Dr. Sarah Lea: That's interesting. Hey, yeah, it's interesting how much I think, popular media and social media these days has really impacts diagnosis and trends, right? You just look at how much information there is out there around tongue ties. And I really struggle because as a physician, [00:12:00] we want to practice evidence-based care and we also want to first do no harm. Maybe you can talk about that next. I don't think that performing frenectomy, is that how we say it? Clipping a tongue tie is it is a minor procedure.

[00:12:14] Dr. Elise Graham: So it, it can be, but it also can be a devastating procedure. First of all, the term terminology, theres frenotomy, frenectomy, and frenuloplasty, these are all the same thing. Frenotomy just means cutting, frenectomy implies removing. So sometimes people will use that term. I think there's, maybe there may be a billing difference, actually, if you write, if you say it's a removal versus a clip, but usually those are interchangeable and then frenuloplasty describes some, there should be some rearrangement of tissue. So like some suturing or something like that. So those are all different terms that kind of achieve the same goal. It's the most common complications are a little bit of bleeding, which has minimal and some pain, but there are case reports, including one, we published here of [00:13:00] people, of babies having bleeding that's bad enough that it leads them to be in shock and need IV fluids, kind of resuscitation, to make them better.

[00:13:07] There are other complications like nerve injury, that's really hard to quant- it's hard to diagnose in a baby there's little, teeny, tiny nerves that control the sensation of the tongue tip. They're very close. And a baby can't tell you if their sensation in the tongue is different. Laser is very popular, but has a risk of thermal injury. The people who like lasers say that it's less likely to bleed, but actually our case was a delayed bleed after laser. It still occurs. The other thing that's not discussed very much is oral aversion. So initially when you cut a tongue tie what I do I use, if I do a tongue tie release, I use sharp scissors. And that I put baby directly to breasts, which is the best pain control off and give a little sugar water first to o, but sometimes they'll, babies will do okay at first, even they may have some numbness from a laser, for example, immediately, but then develop significant pain after the fact. And then you can have breast refusal, oral [00:14:00] aversion, dehydration, that kind of thing. And again, it's hard to know if that's going to happen and it's pretty tough to manage as well.

[00:14:06] Dr. Sarah Lea: Yeah. Yeah, absolutely. I think the only ones I've ever done clearly, cause I am a family physician, not an ENT, or that just the super obvious, like thin but significant, just that clear avascular that we just clip it and put baby on the breast. But yeah, the more invasive the laser procedures, I just worry about those. Because the research I've done has shown that I don't know if there's actually truly a really significant benefit when it comes to breastfeeding and potential long-term outcomes.

[00:14:33] Dr. Elise Graham: So the best evidence there is for tongue tie release is for breastfeeding. And it's actually, there was a systematic review, I think it was in 2015 that, so that's a collection of data from a bunch of different papers that they look at the quality of the paper and they use that when they're deciding on reporting their results and look at a larger number, pooling together all the different patients, and that found that there was, they could show, a significant improvement in maternal pain. That was short term. That was the only thing they could [00:15:00] definitively say. A tongue tie release provided in terms of benefit. I think the literature is still lacking and we have work to do, but I think in a significant tongue tie there is an improvement in latch and transfer in babies, though the, it doesn't really come out in the systematic reviews. In terms of technique, laser versus scissor. All we can say about that based on that current literature is that there's not a benefit to laser. So it's, that the literature does not suggest there's a benefit and my personal feeling and perhaps bias is that I feel that scissor is superior because I can control much more and there's no surrounding injury related to the heat. But again, I think that there's a lot of debate about that, especially from people who use a laser, they feel that superior and that's the reason they use it. Yeah.

[00:15:45] Dr. Sarah Lea: Okay. So I'm just going to summarize what you said to make sure that my understanding people understand is that in terms of, oh, so in terms of diagnosis, there's not any really clear consensus. There's a few tools that we can use, but there's problems with inter-rater reliability. Meaning that I might diagnose one grade, you might diagnose a [00:16:00] different grade based on our assessment of the same baby. Is that correct?

[00:16:04] Dr. Elise Graham: It is. I think that's more true of the classification schemes than the tools. I find the tools to be more useful because they have very nice pictures. The TABBY, I think is lovely. But yes, that is, that's a concern for sure.

[00:16:16] Dr. Sarah Lea: And then when it comes to evidence around doing a release, the best evidence that we have is for maternal pain, improvement in pain of the breastfeeding or chest feeding individual and potentially improvement in latch and maltransfer, but that's just not yet represented in the literature. Is that right?

[00:16:31] Dr. Elise Graham: I think that's pretty accurate. And I think most people who provide the procedure feel that there is a benefit, but we haven't been able to show it really well. Yes. Yeah. Okay.

[00:16:39] Dr. Sarah Lea: And can you differentiate by what people mean when we mean anterior versus posterior tongue tie?

[00:16:46] Dr. Elise Graham: So that's another huge debate. And I don't know what a posterior tongue tie is. And I am a pediatric, I'm a pediatric most like I am a mouth expert. And if you look at the papers by professional [00:17:00] bodies, that's the same for them. So The Academy, again, The Academy of Breastfeeding Medicine put out a consensus or a position statement and they did not mention the word posterior tongue tie once in it. And that's why, I went to the presentation on that at the conference. And that was intentional because there's so much debate about what a posterior tongue tie is. Same with The American Academy of Otolaryngology. There's a recent position statement or consensus statement. And in that they could not come to any agreement on what a posterior tongue tie represented. Even when they said something, as some, as simple as some people feel that a posterior tongue tie is a tongue tie that is not at the tip and restricts movement. That's, we couldn't even get through to agreement on that. So I think that that's a term that I don't use either. I feel that I'm just not sure that there's a consistent definition of it. And for me what's important is is there a structure that is restricting or is there, is there tissue that is restricting tongue mobility and that's, what's important and that's what I'm going to deal [00:18:00] with. Not, anterior versus posterior.

[00:18:02] Dr. Sarah Lea: I agree. I think a tongue tie is a tongue tie.

[00:18:06] Dr. Elise Graham: Yes. And it has, it has to do with function and it doesn't have to, yeah. I think it's irrelevant kind of the position. Yeah. Yeah.

[00:18:12] Dr. Sarah Lea: So I think we talked about this, but I want to come back to it and talking about the potential consequences or adverse outcomes associated with, we talked about the risk of bleeding infection, nerve injury. And in the short term that could lead to well bleeding, obviously could lead to like need for hospitalization, resuscitation, blood transfusion, even more worrisome outcomes we don't need to talk about. And oral aversion. Is there any potential for more delayed like food aversions or impact in speech? And we'll talk about the benefits, or not of speech later, but just in terms of the adverse outcomes related to a frenonomy or frenectomy.

[00:18:48] Dr. Elise Graham: I don't think that there's evidence that there would be a delayed onset of those things though. There we did see in our case that we published a patient came in seven days following their tongue tie release and had bleeding [00:19:00] then. So that was a surprise. That's actually how we, when tonsils plead after tonsil surgery, it's usually a week after. So we propose maybe that's a similar mechanism, but typically it's a, an immediate thing that we see. And we don't I'm not aware of evidence that suggests that you have a delayed onset of complications in speech or swallowing related to tongue tie release, not in the literature that I've seen. I will say that the vast majority of tongue tie releases are uncomplicated. So I don't want people terrified. But I just think sometimes it it's presented as, well let's just do this as it's risk-free and if it works great, if it doesn't, whatever, but I think that we should think about the procedures we're doing and make sure that they're indicated even if they're in quotes "minor". Cause it can have complications.

[00:19:40] Dr. Sarah Lea: Yeah, absolutely. One of the other indications we briefly touched on was an argument for releasing a tongue tie for speech. And can you speak to the evidence around that a little bit.

[00:19:51] Dr. Elise Graham: Sure. The current consensus is that this tongue tie should not be divided prophylactically for speech. So just in case. The data surrounding speech outcomes and [00:20:00] tongue ties is also poor. So again, I use systematic reviews because they're a pooling of multiple studies and you can get a study that is poor quality published. So just because something is in the literature doesn't mean that it's good evidence. And that's something that I think is really important to think about. So the systematic reviews, there are four related to speech and all of them show that there's insufficient evidence to perform frenotomy for speech indications. That said, there are selected patients, like some people have gone through speech therapy, and I think that's the first step always, lots of speech therapy. They have a significant tongue tie and they have a speech issue related to that particular, certain sounds like the th sound and so on, do require a little bit more tongue mobility. In those cases, I would have a discussion with families about division with a strong caveat that it may make no difference. So it has to be a, an informed discussion and the speech language pathologist I work with agree. Typically things can be worked past, it's not necessary to divide [00:21:00] for that reason. Very rarely I will. Yeah.

[00:21:04] Dr. Sarah Lea: Yeah. It's interesting. There's, I feel like a topic like this is, we're never going to get clear consensus and it's always an informed consent discussion.

[00:21:12] Dr. Elise Graham: Yes, absolutely.

[00:21:14] Dr. Sarah Lea: And so in general, okay. I'm going to summarize our conversation. Let's see if this works. So in general it is, it's not a small procedure. It does have potential adverse risks, which depending on like the level of the level, I'm just trying to, I'm trying to explain, when you can see just that little thin band...

[00:21:30] Dr. Elise Graham: Okay. So the thickness of the tie does make a difference. I think if someone's dividing, they should have the ability to manage the complications. So if someone's, if someone is cutting it, they should be able to manage it if it bleeds. That's another thing to think about when you're doing it. Yeah. So it is, it can be a minor procedure, but we shouldn't assume that it will be, we need to do it because it's necessary. Not because we may as well.

[00:21:52] Dr. Sarah Lea: Yes. Yes. And it can help latch but probably, maternal pain definitely, probably milk transfer. And then in, I would [00:22:00] argue in breastfeeding the same as in speech pathology, you might want to try some other techniques before you do an invasive procedure. Working on latch, re-establishing, trying some other tools and techniques before you jump to clipping a tongue tie

[00:22:14] Dr. Elise Graham: A hundred percent. You should always be assessed by a, an experienced professional who has expertise in lactation. Things like, correcting the latch. All those things are really important and that's the way that we do all surgery. We don't jump to surgery for anything, unless we make sure that medicine doesn't work or like medical therapy doesn't work and it should be the same. Agreed. Yeah.

[00:22:36] Dr. Sarah Lea: Yeah. It's interesting. We approach it so differently, but you're right. And I think it's funny cause I've done like, family medicine, obstetrics, breastfeeding stuff for a number of years now, but not until I did my extra training where I was like, oh my gosh, like small position changes for both mom and baby can make such a huge impact for latch. And I think it's absolutely right. If someone says you have a tongue tie, I would say, okay, go to see a provider. Get some [00:23:00] support with maternal and infant positioning. See if you can improve the latch and improve the milk transfer. And if you can't, then you could consider further intervention. But exactly if you have osteoarthritis, mild osteoarthritis of your knee, you're not going to jump to a knee replacement. You're going to say, okay.

[00:23:14] Dr. Elise Graham: Yeah. Let's get some physio. Yeah, exactly. Yeah. And I think again, it's probably, there's probably a few different reasons that we seem to jump to a surgical procedure for this. And one is it's felt to be so minor that I think people are like, oh, let's just get this off the table. When it just may not be necessary. And we may put kids at risk for, oral aversion, bleeding, et cetera. The other thing is. I'll name the elephant in the room. There is some financial incentive to divide tongue ties. So that's something to consider just when you look around. There are some places that have made a business out of tongue tie release, and you just have to be aware of that. If it seems like everybody who goes through the door gets a tongue tie release, then maybe that's not where you want to go. You want to be sure that you're getting appropriate support before you go down that road. And certainly not every [00:24:00] place is like that. I think most people have patients' best interests in mind. But it is, it can be pretty financially lucrative. Yeah, which is crazy because it's not lucrative for you. No, it's it's. It is a procedure that is covered by OHIP. So if it's done by a physician, if your family doctor does it, when you leave the hospital or whatever it would be covered, but if, you can find it private pay and it's very expensive to patients.

[00:24:22] Dr. Sarah Lea: Same here in BC, like we can do it and bill for it, but to go to a private clinic, it's like 5, 6, 7, $800.

[00:24:30] Dr. Elise Graham: That's it. That's the same here. Yeah. And again, I don't think everybody's out for the wrong reasons, but I just have to do your, they always say, do your research and that's the same for your, your provider. You want to be sure that you're getting the support you need and not a procedure just for the procedure sake.

[00:24:45] Dr. Sarah Lea: Okay. Yeah. So do you have any favorite resources that we might recommend to people who are like, oh my gosh, I had no idea there was such controversy and that the evidence isn't there. Where might you direct people for like easily, easy digestible information?

[00:24:59] Dr. Elise Graham: That's, that is [00:25:00] a great question. I think it is challenging to find good information. Tongue tie on social media, you get greater, just the word, hashtag tongue tie, no modification to it. You get over a hundred thousand posts. I think it is very challenging to find evidence-based information. Most of the best evidence-based things are at physician level, I would say. So The Academy of Breastfeeding Medicine has free protocols that you can look on, it's, and they have a, frenotomy protocol. So that describes all the evidence around frenotomies, and I'm a part of the team that's rewriting or revising it. Yeah. JAMA also puts out patient pages and I think there will be one about for frenotomy soon. Yeah. So that's one thing to look for. JAMA is a great resource for evidence-based information. It's challenging to find it at parent level. I try to do a little bit on my own social media, but again it's such a charged topic that one has to be careful how one approaches it.

[00:25:57] Some of the things that I think are important to know about tongue ties, [00:26:00] there are many other things that are that they're reported to be associated with, which, for which the evidence is really poor. So an example is sleep apnea. People say that sleep apnea. So our consensus statement, the ENT consensus statement says all it says about that: tongue ties do not cause sleep apnea, full agreement kind of thing. So it's just not, it's not a thing. They, if anything, there's certain patients that I take care of who have really small chins it's called Pierre Robin sequence. So they get airway obstruction because the tongue falls back and actually having a tongue tie is protective in that sort of situation. Having your tongue held forward. So it's just, doesn't make physiologic sense that there would be improvement in sleep if your tongue was less tethered forward. The second argument

[00:26:43] Dr. Sarah Lea: It's like the opposite.

[00:26:44] Dr. Elise Graham: Exactly. Yeah. The second argument that people make about it, as they say it's long-term. So when the tongue is tethered, it can't sit properly in the pallet. So the pallet becomes more high arch so you develop a breathing posture. And again, the evidence for that, there are papers about it, but the evidence is so [00:27:00] poor. That we just can't make that conclusion at the present time. Maybe, if we find that there's a really great paper that suggests that's true, I'll change my tune. But at the present time, there's no evidence that's the case. But other things are reflux. People say tongue ties cause reflux because you get swallowing of air, aerophagia. The discussion is I've asked my GI colleagues and they thought I was crazy. This is not something that causes reflex in the GI. That's not something they look for as a cause. There's no evidence. The paper that describes this that's quoted on social media is from 2014. It is, a single individuals tongue tie, practice looking, if they're continuing to use reflux medications, so it's not a causative thing. And then they decide at the end that it's called reflux aerophagia. Like they many people stopped using their reflux meds after their tongue tie released, therefore it is reflux aerophagia that caused their reflux. It's not a good quality study at all. And it's very widely quoted all over social media. That's another [00:28:00] thing I'm trying to think of what I - they cause everything according to social media. Tension, again, that's a huge one, tension. There's not evidence for that. What people will say is that I've seen posts that are like the tongue isn't it, fascia of the tongue is attached to the fascia of the spine and therefore tension here leads to downstream muscle tightness. There's just, no, there's just no evidence that's the case. I don't know what the relevance of tension is exactly, like torticollis. This, none of this is related to tongue tie. The fascia in your body is all interconnected and it all ultimately is likely connected to your spine in some way. So again, it sounds good, but it doesn't make sense. It's just the tongue ties cause everything according to popular media and the evidence does not. It doesn't fit with that. Maybe there'll be more evidence, maybe people will do more studies and do a better job of proving this, but I have to go with what we have now and it just, there's no evidence.

[00:28:55] Dr. Sarah Lea: Yeah. Okay. That's really helpful. And I think people who are listening, it's important to understand that like we are [00:29:00] coming from a medical evidence-based lens and this is breastfeeding and tongue ties. People are so passionate about it. And I always say, evidence and statistics are great for population, but when it comes to you and your individual experience, like we're not discounting your experience.

[00:29:16] Dr. Elise Graham: Absolutely. No.

[00:29:16] Dr. Sarah Lea: We're just showing, saying what the evidence shows so that we can properly counsel our patients. And I think ultimately, like you said, it comes down to the risks and the benefits of any intervention in any procedure are never zero, right?

[00:29:29] Dr. Elise Graham: Yeah, absolutely. And I think another problem with my specialty and I can say this cause it's my specialty, is sometimes we are a bit dismissive of people's concerns about it. Maybe we don't have the time, not all of us have the time or the training. So if you come in and you're really, if a parent comes in, I'm a parent too. If you come in and you're really worried about something and someone says, no, that's not it. Look, he can stick out his tongue over his gum. He's got no problems, but you're having terrible pain and you're not being supported, obviously you're going to find someone else to help you. And I feel if I've got the tongue, I've got the time or I make the time for [00:30:00] this. And we talked through the evidence and lip ties. I get a lot of referrals for lip ties, for example, I think some people say no, this is not a thing. And then that's. But if you go to someone else, who's got the time to talk to you. Maybe their interpretation of the literature is different and you end up with a lip tie release, which doesn't have much evidence. I should. Speaking of things with no evidence, have you heard of cheek ties? Is this something that's come up in your life?

[00:30:19] Dr. Sarah Lea: Not yet. Not yet. Maybe, but I probably have chosen to ignore it.

[00:30:23] Dr. Elise Graham: Yeah. That's smart. Buccal ties are the latest trend. There's a band of tissue. Yeah. That if you lift up your cheek, you will see a band of tissue that goes from your gum, to your cheek. There is no evidence that this should be divided and this is the latest thing that's getting divided right now in an outpatient setting. If anything, again, it's, counter-intuitive stabilizing the buccal fat pads, the cheek fat - so if you were to try this, it would decrease. But yeah. So it's it it's very common to have these divided, but the evidence is not there. So again, the consensus statement from us is buccal ties do not exist. So it's just [00:31:00] not a thing.

[00:31:01] Dr. Sarah Lea: Okay. Very interesting. Wow. What an insightful podcast. Thank you so much Elise for taking the time.

[00:31:08] Dr. Elise Graham: I'm really happy to be here. And this is a topic that I'm really passionate about. And I. I think a lot of the problem is a lack of support. And I agree. Yeah. People are, breastfeeding is not easy. It is a struggle. There are some, for some people it's beautiful and natural and so on, but that's, I feel like that's less of a common experience than having some issues. And I think in some cases, the tongue tie is such a low hanging fruit. That it is the first thing, if there's any problem. And it's not always, it's not always the problem.

[00:31:37] I think we just need to keep an open mind and look for other problems. There can be serious medical issues that are misdiagnosed as tongue tie. I've heard of kids, getting a tongue tie release for noisy breathing, which was laryngomalacia, which has a floppy airway problem. And it's very different, it's just. Not everything is a nail. And we just need to look into the whole child and the whole dyad, the mother and the baby together and their fit [00:32:00] and find out what the real problem is and then address it.

[00:32:02] Dr. Sarah Lea: Oh, I couldn't agree more. And it's so funny. Because I think like the, you said lack of support, and in Victoria in which I don't know how many hundreds of thousand people live here, but we have one breastfeeding medicine physician and I'm slowly making my way there. Full-time, there's another one that's doing it. Part-time and when I told my husband, who's also a family physician, I was getting into breastfeeding medicine. And then I said, maybe I'll just do that, like exclusively. And he's like "just breastfeeding". And I was like, just breastfeeding! Remember how hard it was for me with my first.

[00:32:32] Dr. Elise Graham: It is so hard and yeah. Yeah. I was very lucky that I had a physician who was really literate and helped me, but it can go. It can go the opposite way. And I think that we shouldn't minimize, you don't want to say the evidence is just for maternal pain. That is so important. We need to make it comfortable so that people can keep breastfeeding because breastfeeding is, though it's not for everyone, it is the optimal nutrition source for babies it's designed for this. I don't know. It's, I agree. I'm really passionate about breastfeeding medicine. The way that I'm going to use it in my practice is not [00:33:00] lactation consultation, but to support complex babies who come see me and their parents want to continue breastfeeding or chestfeeding, or the patients that have questions about things like oral ties and so on, I can support them. It's a really important field and there's there's a lot to do. And a whole lot of research that still needs to be done to-

[00:33:19] Dr. Sarah Lea: And I think so many, like how great would it be for us to have an ENT like you here! Because people always ask me who else can I go to? And I'm like, I don't know, cause most of our ENTs don't have a an interest in this and don't know the literature haven't done the training and what, they would, patients would probably feel dismissed because as you said, the evidence is very minimal until they just say, oh no, it's not a thing, but that doesn't help when you're desperate for solutions to improve your breastfeeding experience.

[00:33:44] Dr. Elise Graham: And, I don't, I actually don't know the people in BC very well. So it may be that there's someone that is developing interest I'm, I've been trying to do, take opportunities to do talks for my colleagues or otolaryngologist elsewhere as well. Just to talk about this topic, I think it comes up [00:34:00] in community ENT a lot more than people expect that it will from their training. I, should I divide it? What about sleep apnea? What about speech, et cetera? And, we only know what we are taught to. To some degree, To do some reading, but yeah, it's it comes up a lot, and I think people are getting more interest. Yeah, perhaps they'll look me up. I'll happily do a talk out there.

[00:34:19] Dr. Sarah Lea: Yeah. Oh, that would be great. I'll keep that in mind.

[00:34:22] Dr. Elise Graham: Yeah, absolutely.

[00:34:23] Dr. Sarah Lea: So where can our listeners find you on social media to learn a bit more about what you share? And I love that you also share about your life and being a mother in medicine because it's fricking hard.

[00:34:33] Dr. Elise Graham: I try my best to be pretty real about it. I'm @EliseGMD, E L I S E G M D. Sometimes I'm better than others. We have a lot of seasons in our lives and sometimes it's too busy in my regular life to post, but I do posting facts and quizzes and evidence-based things in addition to stuff about my own family and life and research. Some of it is about breastfeeding medicine. Some of it is about ENT topics in general. And I like interacting with people and hearing [00:35:00] about their experiences. I can never give personalized medical advice and I never would, but it's nice to hear, what people are experiencing in their lives. Yeah.

[00:35:06] Dr. Sarah Lea: Awesome. We'll put that we'll put your tag in the show notes below and I'll share some of those resources for people.

[00:35:12] Dr. Elise Graham: Great. Thanks. It's been my pleasure to chat with you about this. There's just so much more to know about it.

[00:35:17] Dr. Sarah Lea: I know, I feel like we could, there's many other topics we could cover. Thanks so much for taking time from your busy schedule.

[00:35:24] Dr. Elise Graham: No problem again. It's my pleasure. Thanks for having me. Thank you.


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