Episode 55: Tongue-tie "clipping" (aka frenotomy); are we over-doing it or have we discovered an under-diagnosed problem? with Pediatric ENT Matthew Brigger MD, MPH

On this weeks episode of Ask Dr Jessica, Dr Matthew Brigger joins to discuss frenulotomy, also known as tongue-tie "clipping" or tongue-tie "release".  In the past 20 years, the number of newborns receiving the  tongue-tie releases has doubled at the very least.  The number of babies born with tongue ties has been unchanged, so as a pediatrician, one has to wonder why this procedure has increased so much---  Has the condition been under-diagnosed and now social media has helped bring this issue to light? Or are we  doctors doing too many in the hopes that it will help mothers with breast feeding?  What is the evidence that this procedure is beneficial? Dr Brigger offers much clarity to the  benefits and  draw backs of this procedure.

Dr Brigger has a very impressive resume—he is currently the division chief of pediatric ENT at Rady Children’s hospital in San Diego.  He is also a professor of Surgery at UC San Diego School of Medicine.  He also served as a pediatric ENT in the NAVY, he received his masters in public health at Harvard, and he has authored over 70 peer reviewed studies.  

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children.  Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner. 

Do you have a future topic you'd like Dr Jessica Hochman to discuss?  Email your suggestion to: askdrjessicamd@gmail.com. 

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The information presented in Ask Dr Jessica is for general educational purposes only.  She does not diagnose medical conditions or formulate treatment plans for specific individuals.  If you have a concern about your child's health, be sure to call your child's health care provider.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

Follow her on Instagram: @AskDrJessica
Subscribe to her YouTube channel! Ask Dr Jessica
Subscribe to this podcast: Ask Dr Jessica
Subscribe to her mailing list: www.askdrjessicamd.com

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hey everybody welcome to ask Dr. Jessica the podcast where I interview experts with a goal to help you worry less about parenting. I'm your host and paediatrician Dr. Jessica Hochman. On this week's episode I am joined by paediatric ENT T Dr. Matthew briger. And we will discuss a popular newborn procedure called a friendly a lot of it's also known as a tongue tie release, and this involves cutting that short piece of skin underneath the tongue. In the past 20 years, the number of newborns receiving this procedure has doubled at the very least, as a paediatrician. I know that many newborns are born naturally with tongue ties and they cause no harm. So I often wonder if we are getting the balance right. I want to make sure that we doctors are supporting a mother's breastfeeding efforts, but also that we are not performing unnecessary procedures. Thankfully, we have Dr. briger here today to share his thoughts. Dr. briger has a very impressive resume. He is currently the Division Chief of paediatric ENT T at Rady Children's Hospital in San Diego. He also served as a paediatric EMT in the Navy. He received his master's in public health at Harvard, and He has authored over 70 peer reviewed studies. And as a quick reminder, if you're enjoying this podcast, I would be so appreciative if you would leave a five star review and even better share it with a friend who may benefit from hearing this conversation. Hi, Dr. Berger, welcome to the podcast. That's great to be here. So tell me you're a paediatric aunty. Can you give the audience a general sense of what you do during the week? What does your job entail? Yeah, absolutely. So, so my jobs I'm a paediatric otolaryngologist, which means that after med school and residency, I did a residency in otolaryngology. So e and t and then ultimately went on to go do just a sub specialisation in paediatrics. So then within that world, I actually have another like get a little bit more sub specialise even from there. And so for my practice, what we've sort of built over time is a practice that's primarily focused on breathing, swallowing and feeding. And that's really where my practice is. And as part of that they we built a air digestive programme here down at Rady Children's Hospital, which is the whole programme, the concept there is to have a multidisciplinary approach towards, towards these children who are particularly complex in nature. So as such, you can imagine, I do see a lot of kids with, with tongue tie and how that may play into this whole thing. And I'm happy to be here and talk a little bit more about it. So can you describe so I wanted to talk with you about tongue tie? Or include last year, the metal the fancy medical term for it? Can you describe what it is? Exactly? Because I know a lot of us have it, we've had it our whole lives. And a lot of there's a lot of confusion about when it needs to be addressed with a doctor. And when it can be left alone. So can you just explain what a tongue tie is? Exactly? Oh, absolutely. I think we can even reel this back a little bit in terms of thinking altogether, because really, when it comes down to tongue tie is the focus. And that's sort of the name that has gotten passed around. And there's a history to sort of why it's tongue tie, because that has sort of been like where it started. But there really there, there's a concern that there are multiple different places that we can have these ties, per se. So let me just throw out there to begin with. And I firmly believe that this is all normal anatomy we're talking about, there's no deformities. Here, there's no structurally abnormal things. The tongue in tongue tie refers to the frenulum, which is basically the connection the fibre span that's put it in from goes from your tongue to the floor of your mouth. We all have it, the dog has it. It's it's just part of who we are. And so what really what it comes down to we start talking about when do we do something about it has to do is it causing sort of pathologic sort of issues. And even that dichotomy of pathologic meaning something that's bad, I'm not sure that it's actually something bad. It's just that it is a spectrum. And I think it's really important here, as we kind of discussed tongue tie, lip tie, whatever it is, we want to talk about as we go through, when it comes to this concept. This is a spectrum. And that's what is one of the things that probably makes this really a difficult topic in general. So I bring this up, because, you know, I'm such a proponent of breastfeeding. And I know that, you know, from my own experience, breastfeeding is is difficult, especially in those beginning couple of weeks. And I think where I struggle is, a lot of moms that I'll meet in the hospital, there'll be having difficulty breastfeeding, and then someone will say to them, it must be a tongue tie, the tongue tie must be the problem. And to be honest, I've heard this so much more in the last, I want to, say, five, seven years. And then when you talk to paediatricians that have been working for 20 3040 years, this was never really brought to so much attention. So I'm just trying to figure out what what's happening here, like, what do you think? What do you think the answer is? Are we really having breastfeeding difficulties? That have we been missing tongue ties for many years, or what's what's happening? So I think that so there's nothing different in the babies, the babies are still being born with the same normal anatomy that exists. It's just variations on that anatomy. I think it's really the increased recognition. And there are a lot of things that are like in medicine and even just within my own world that have sort of analogies to tongue tie. What has been really interesting about this whole tongue tie ankle. glossiest talk is sort of how it is sort of exploded over time. And I can get I'm sort of from a just a standpoint, we look at it any graph, you look at any sort of publication talks about incidents that says ramping up ramping up, but we all feel it. And so back when I was in training way back when we did like, wasn't even a thing, like, I don't think I even learned how to do it when I was a resident. Not that it's like anything particularly difficult, but it's something that we learned over time. But really, I think the place where, when you step back, and, look, it's always been there, there's always been some way of dealing with it. The reality is, is, and I'm sure you've heard the stories about how midwives used to keep one fingernail long, and that fingernail was made for the sweep. And they would do that you're struggling to breathe, like to feed. And it's just kind of a known thing. Now in today's medical legal where you can't just start ripping kids tones, like that's just not going to happen. But that is sort of like the history of like, the first anonomys I knew of were because of the long fingernail of the midwives. Like that's how I came to understand it. And so what we saw is that there was, there's always as the ones that are really tight, well, maybe this may be helping, but really, I think the place reason why we're seeing so much of an explosion. And this is truly I think the first thing at least I experienced in medicine, where social media played such a big role in sort of the changing of it. And I think it's, we as physicians probably sort of missed the boat on this. When Facebook or I think it was my space in my bed, my day, whatever it was called back then as it started sort of rolling out, I sort of looked the other way. And the reality is, is people ran with this. And it really that's how information started to transmit and transmit. And I think it's really a good example, the first sort of medical thing that at least within our world, that has sort of just taken off, it's sort of taking a life of its own. And when you look at it, when you think about time for anonomys, these things, it's actually it's ideal, it is ideal to sort of take off, and whether I don't want to say misinformation, but it just information being in the available that might make it a little rosy, because at the end of the day, we're dealing with an incredibly difficult problem feeding your baby, not only is it a difficult problem, when your baby doesn't feed, you feel it in your heart, you feel it all around, this is so emotionally charged, and to have somebody standing around in a white coat up in some ivory tower, saying you know, you should never do this, that's that doesn't resonate with people. Number two is releasing a tongue doing a tongue tie procedure, it's really it's very low risk. In general, this carries low risk. Honestly, anyone can do this, like this is not rocket science, it's and when it comes to that, so then like you've got a low risk thing, that you have a low risk procedure for a potentially common problem that carries a lot of weight to it and a lot of emotion. So when that kind of plays through, that's perfect to first sort of run with and terms of social media. So well, my kid had this and got better. And you'll do anything, you know, we will do anything for to get our kids and particularly as Breastfeeding has sort of reestablish itself is the preferred modality is completely ripe. And by the time really science got around to even trying to assess this, the cat out of the bag, and we've been sort of kind of chasing after it for quite some time. That's really interesting. You bring up so many good points. I remember going to a lecture, I paediatric conference on this topic. And the lecturer was saying how all of a sudden there was nothing on Facebook about about tongue ties. And now all of a sudden, there were like 65,000 members discussing tongue ties. And I think you're right social media definitely, you know, was ahead of the curve. But I guess my question is, how do we know when we're doing too many? And how do we know when it's just right. You know, do you have any guidance for parents that are listening? Yeah, absolutely. Look for when, when it is a good time to do this low risk procedure? Yeah. So I think, yeah, we're still trying to find our steady state, I firmly believe we are doing too many, as a, as a population as a community as a whole. And this is a as you, as you well know, this is very regional. So you can be in some parts of the country and nobody gets their tongues, tongue release, you can be in other parts, where everybody does, or seemingly so. And so I think trying to find that balance, I think, as a parent, it's really hard to sort of navigate that. And that's where you have to have sort of the expertise. And that's where I think that it's incumbent upon us to make sure that the children have gone through the adequate evaluation. And we found about adequate and evaluation, it's by having a lactation, lactation consultant, and having that lactation help, that really sort of focuses on feeding and thinks of sort of the surgical procedures as as an adjunct, or perhaps even even one of the not necessarily last resort. But it's kind of it's one of the things that we don't necessarily jump to. And I think far too often. In this day and age, we're looking for sort of the easy fix, and we all share we all want an easy fix. But feeding is hard. Breastfeeding is very difficult. And you know, and I say that as somebody who's never breastfed, but having I bring sort of this different sort of look at it and you want to, and I can do my partner's eyes like as we look at it's like, what do I have to say anything? I know anatomy, I don't know about breastfeeding, and that's what I defer to or lactation consultants, really to understand like if they It's like, in the ER, there's plenty of data out there to show how many kids suffer from poor positioning, where it's a little bit of positioning, and this fixes it. But I do worry that as time goes on, we're training another generation of lactation consultants. Where for anatomy is first and foremost, that's the first thing you do. And so then we have also training paediatricians to say, Hey, first thing, go get the tongue clip, and then we'll work on this, because we do know there some kids, like once you clip it, it just kind of runs with it. And so it's really hard. I think, as a parent, I think you need to have comfort with your lactation consultant, you need to have comfort with your paediatrician and finding that right balance? Well, I think that's just it, I think, because the truth of it is, you know, as you mentioned, when you're when you're a new parent, all you want to do is feed your baby. I mean, that's such a natural instinct, your baby's born and you want to feed your baby. And then I think nature plays this cruel trick where your milk doesn't really come in for 72 hours or so. And, you know, breastfeeding is difficult. It's uncommon, I think, for breastfeeding to be easy from the get go. And tongue tied to me, I think there's definitely value in recognising it. But I also think it can seem like this easy fix for something that is just inherently unfortunately difficult. And so I part of me just wonder is if we were more supportive of new moms and breastfeeding, if we would see, you know, rather than immediately talk about the procedure, if he would talk about ways to help with breastfeeding, talking to lactation, I wonder if we would see fewer of the procedures requested? I think we would. And I think you actually bring up very good point. And I think this is a puzzle, and I use this analogy quite often. Breastfeeding is a puzzle. And the problem is, is everyone's dealt with a different number of pieces. Some puzzles have 1000 pieces, some businesses have four pieces, and breastfeed for anatomy and how the cranium plays into it is one piece of a puzzle, we just don't know how many pieces are to it. And so you bring up a really good point, though, about the education piece. And there's a paper out of New Zealand several years ago, where they basically took their for anatomy rate, which they found in one specific area was like 10%. So that's a very high rate for anonomys being done for the for these children. And what they did was they did a concerted educational programme to paediatricians to parents who lactations, like, where they brought this conservative programme, and they drop it down to somewhere around like 2%, or something like that. And they made a significant change, because of the education. And I think you're absolutely right. And I think, unfortunately, some of the pressures of how we practice medicine today, don't allow us to have that time and those constraints that I would say, it's our challenge as, as providers to be able to kind of push back and say, No, this is this is the right thing for our patients. That's a great point. Can you explain what a for anatomy is? Exactly? Can you describe to the listener what what that procedure is like? Absolutely. And so there's a variety of different ways to go about it. But essentially, at the end of the day, what we do is we place a little groove director, so basically what this is, it's like a retractor it looks like almost like a set of Mickey Mouse ears. And what does it lifts up the tongue and it basically allows a little groove for the finial to go in between. And by lifting up the tongue that exposes gives us a nice beautiful view, things that we have to keep in mind from an anatomic standpoint. And this is me putting on my paediatric otolaryngologist surgeon of the mouth sort of approach is there are some important structures there which are very rarely injured, but can be devastatingly, when they get injured becomes a very difficult problem to manage. That includes where the salivary ducts come through. And then also if you were to get and as those come through, if you get scarring down over those that can lead to sort of a lifetime of having to deal with salivary gland issues. So basically, what we do is we lift up the tongue, then we clamp the tongue, and we typically at that point will cut it so me, I'm a surgeon, that's what I do. I spend my entire day using scissors using knives like so. So it's very natural for me to use scissors to make that incision. Some people have to use a laser. Now I do use a laser my practice all the time I use it for places that's difficult to get to. And there's a movement amongst some to use these lasers in this area, which I don't know that it provides a whole lot of benefit. And unfortunately, we've given where I live in the system and sort of a tertiary quaternary care sort of area I get to see or I guess I have the privilege to see through when things go awry, including lasers that have caused severe burns had children have to have be intubated I've actually seen the children actually receive a tracheostomy from having undergone a basically a tongue type procedure that went awry. And so lasers tend to be like while they tend to be a are safe in general, they do add an add degree of wrist I just in my hands don't feel that as necessary, because I don't have to introduce any collateral sort of damage per se, which was what the laser does that heats up the area around regardless of whether it's a cold laser, Baby Friendly laser, whatever sort of names you have for it. At the end of the day, it's still using heat and heating area around where the friend so you're more in favour of just clipping, just clipping. Okay, okay. Have you ever seen a patient bleed from clipping you know uncontrolled? Probably Absolutely. Once again, as a surgeon, all bleeding stops, we've laid all bleeding south, well, one way or another. And so we certainly have seen kids who have had to be transferred to us who they could not stop in and outside office. Now we're sort of the armamentarium that I have, I have other things at my disposal. And so I'm able to go down at this clip the vessel, I'm not sure that using a co2 laser or using any type of laser is going to prevent that as much as good technique, sort of as you proceed. Each of the ones I've seen that were bled, there were just basically they went too far. And I think that's always the hard part is knowing when to stop. So if you find an experienced provider, it sounds like it should be a very low risk procedure be a low risk procedure. Okay. Okay. I don't want to anyone who's opting to get the procedure? I don't want to scare them too much. Yeah, no, not at all. Like, like I say, I live in the scenario where I see I see it all. Now the reality is I, the vast majority of kids who have for knives, I never see them, and they do wonderfully. And so think of it as being it just, you want to make sure that when you're thinking this through that you remember, there are these sort of outliers. But in general, it's a super safe procedure, and it provides great benefit for a lot of children. It's just trying to be thoughtful. And that's really I think the biggest thing was, is being thoughtful about how we approach it. I agree with that. Art medicine. Absolutely. Is not everything. So black and white, only A, B, C or D. Right, right. That's right, right. Babies aren't reading our books, I can tell you that. That's, that's that's a very good way of saying it. Now, what about the upper lip ties. So that's also been gaining popularity, in addition to clipping, you know, underneath the tongue, above the tongue sort of above the top teeth. That layer of skin has also been known to be encouraged to be cut by Sam. So what are your thoughts on that? Yeah, so So the actual data that's out there on that, if you think that the data for anklet glossy for the tongue is is shaky, you get to the data lip, and it's even more shaky as to what it actually means. And I can tell you from experience over time, I, there was a time in my life when I was not so sure, and I did not release a whole lot, there are certainly kids who can absolutely benefit from it, no question about it, at least tend to be the kids who you're going to reproducibly See, you cannot get their lip to flare. And that's typically, and I do rely on the lactation consultant to help us sort of direct that. I would say the vast majority of kids do not need that clip. But it is something that we always kind of keep is, I think it is in the realm of candidate benefit. Absolutely. But once again, it requires sort of that good thought process. And I always try to impart upon you whoever is that I may be training that. Whenever we're doing surgeries, whenever we're doing procedures, we need to know what it is we're trying to fix. And so in for these things is what are we trying to do? Is it so it's not just well, we can't breastfeed isn't why why can't they breastfeed? What are we trying to do? Are we trying to get a deeper latch? We're trying to get a more efficient latch? How where are we losing it? Right? Is milk transferring? Well, I usually feel like even if you want one sign that I look for, is the baby able to transfer milk well, so can the can the baby, you know latch on? And do we see that there may be gains weight after after nursing? Do we hear good second swallow. And those are all really good signs that despite saying a tongue tie, the baby should be okay. I always use the sort of analogy that how many people we've seen how many people I've seen as it backward, yo as I was training in the adult end world where they have these horrible tongue ties, and they do just fine. And they are public speakers. And I was in the military where as there's one particular person I remember, this guy was one of the most like prominent public speakers and he had severe tongue tied, but people can work around it. And I think it's the same thing all the way down to the breastfeeding. There are some some kids who can figure it out. And some kids just can't. Yes, yes. I think if I may sound a little cynical here. My concern with the upper lip tie because from my experience when the upper lip is phalange, or when it's when it's brought up for breastfeeding, I worry that actually the upper lip will rub on the breast world caused pain for the baby because you now have an open sore where it you know where it's touching the breast so I have a hard time understanding how that one anatomically is helpful to clip so the cynical part of me and so forgive me for saying this. You know, I think it's an easy part of me wonders if it's an easy procedure to bill for right so if you're in there and you clip the lower lip and you can make a good amount of money for that and then you can quickly do the upper lip for not much at a time and you make I don't know double there's a piece of me that wonders if we brought reimbursements down for that procedure would as many be recommended or done. I don't know if you have any thoughts on that. I think that I love that can of worms because that is a great can of worms because it I can tell you as your from our standpoint where we kind of see this, like, within our within our region, there are numerous things over the over the years, numerous clinics that have popped up specifically doing this and you'd like to be able to think that yo, there's but yet that everyone's doing this for the babies that best interest. But unfortunately, much of medicine has sort of has, has built in this way that is fee for service, which is a, which is has competing competing objectives, you might say, and I think in your athletes do to kind of like, plug into that, where that could be a concern. And I think, you know, we also see some places where they actually I mean, to the point where I've even seen places that offer discounts based on how many you have done, which to me, like, that hurts my heart even just to see it. And so for me, I believe exists in a system that doesn't necessarily favour sort of one over the other like, which is, which works out a little bit better, I think for us, but there are certainly places where the financial incentive is outweighs the additional procedures. It's mal aligned. Absolutely, yes, no, I, I think and I'll tell parents before, a lot of times, I'll talk to parents, and I know they have the meeting with you know, whoever it is like the EMT or whoever is going to perform the procedure for the tongue tie. And I'll tell them ahead of time, just so you know, if we're going to do the lower lower lip, try not to do the upper lip, because the evidence really isn't there that it needs to be done. And so they'll they'll say, okay, and they'll listen to me. And then when they get to the doctor's office, and then I see them later, they'll say, Oh, we ended up doing both. They said we were too embarrassed when the doctor recommended it, we didn't feel we felt embarrassed to go against his recommendation. Yeah, you know, and I think that's, that's a represents a real struggle. So I'll tell you personally, like I, I pretty much always recommend doing the tongue without the lower lip, I'd say it's a very small percentage. And generally, it's a very directed sort of thing. And I'll tell you, quite honestly, just from the standpoint of the procedure, while they're both fairly easy, the tongue of the upper lip is the one that take can bleed a little bit more. And so it can just be more of a just kind of bog things down, as you might say, but I think that you, really, when you can imagine, like, from a standpoint of a parent, I think it's really hard for them to speak when they go to see the specialist who knows all this, and it's gonna make these recommendations. It's very hard when the incentives are not aligned like that. So I agree. And I would encourage, once again, I think that any time a parent like a parent should be able to feel like they can ask the questions, what it is we're doing and why we're doing it. And any provider is not willing to be able to give that description and be able to say it in a coherent manner, then I would have my reservations about letting that person operate on my child. That sounds about right. I agree with that. It's so much as who you trust, right? Building trust with providers? Absolutely. Are there any key signs that you look for? Any, any position of the tie or any? Any phrases that parents will say to you that makes you more inclined to want to clip the tongue tie? Yeah, so I think, when I'm looking at it like that, generally for, for me, they tried to understand like, is I take the objective data first. So I'm always kind of looking at sort of, are they gaining weight? And is it more just as more than than just say, Oh, we're just not getting weight, or it's really hard. I do also look at sort of like the time like, how long does it take you to feed? Like, is this just consuming your entire day? Because, you know, by the time you get through a feed, so those are things that I'm always sort of like very cognizant of, and then he is, the problem is you get into, like, all these sounds, and once again, as somebody who has never breastfeed, I don't know, they all seem to click, you know, I think there's some of this sort of kind of goes through, which I think people like, well, you hear the click, you hear the click hear the click, and I'm not sure that that really makes a whole lot of sort of sort of sense, as we kind of kind of think it through. And so really, I tried to make it bring into sort of the shared decision making as we go together. You can imagine Sometimes, though, it's like, as you know, as in T searches, we kind of get in this position where by the time they arrive, you know, the boat has sailed, like they're getting their tongue clip, like no matter what we say, we're not talking to anybody out of it. And so we've actually been experimenting and exploring, actually having a lactation consultants in our office and be able to do sort of a doing this together. And we are fortunate that we have a couple of speech pathologists who work with us very closely, who do dysphasia. So it's true swallowing abnormalities, and they who are actually also lactation consultants, which brings an additive sort of benefit to it. This is so helpful, and it sounds like you're really balanced, a balanced position. I try to be I love that term shared decision making because I completely agree with that, you know, so many things are, I think best for the family is if you present information, and we're not as physician so hard headed about our decision, we work with the family and share in that decision. So yeah, and I say to them all the time, I'm a surgeon, I make decisions. I do it that's I make a decision. I have to live with it every day, like that's what I do all day every day. Yes, I don't have a hard time making decisions. But the reality is is like my decision is based on just what I see. And so if we can bring this all together because it's once again it's at your heartstrings. This is such an emotional subject that has no clear right answer. If there was one clear right answer, we all do the same thing every time. I think that's exactly right. I, you know, I work with my dad, my dad is a paediatrician, and we've worked together for the last, you know, over a decade. And he's been in it been a paediatrician now for over 40 years. And this tongue tie procedure boggles his mind, because he said, You know, I've been practising medicine for 30 something years, and all of a sudden, it was never an issue before. And now all of a sudden, everybody's getting their tongue tie clipped. And as you say, it's it's a minor low risk procedure. But, you know, one just has to wonder, yeah, did did we miss the boat? Are we overdoing it? Maybe somewhere in between? or, or? Or do moms just need more breastfeeding support? Yeah, so I think that I think your your dad's totally out of this. And it's the Darwinian Yeah, exactly. I think we are clearly like, like, there are definitely kids who it absolutely helps. But I mean, there's certainly times when we see Fernando, and he's being done, because it's like, well, I don't know. And in fact, one of our, one of our lactation consultants, actually refers to the HMF. There they so that the Hail Mary for anatomy, like, we got that correct. Let's try it, they were gonna lose breastfeeding. So it's time for the HMF. So, which is kind of like, it's a little bit sad. I think, in some ways, it's like, that's truly like, we don't know what we're really treating. And that's not how I like to practice that, how I like to think about it as we go through. And so the reality is, like, my practice does focus on a lot of more complex children that have a lot of other sort of issues. And so I just want to get sort of like some of those overflows, where as it comes through, but I think as we step back, we have to wonder, do we really need to be doing this to all these babies, and, like, I have the perspective of having seen some, some bad outcomes. But the reality is, the vast majority do not, which is once again, why it's easy for people to say, Oh, just go get your tongue tie clip. And to be able to set up sort of these different places that might be a little bit more, I love pushing the word but very incentivized to move forward with. I think you're right, though, at the Hail Mary term. I like that, because I do notice, you know, if, if mom has pain with, you know, severe nipple pain, or the baby's not gaining weight, and you know, the baby's falling asleep at the breast, and we just really have nothing left and we can't figure it out. It is sort of a hail, Mary. suggestion, maybe this will work. Who knows? And sometimes it does, sometimes. Exactly. And there's, I've never done a Hail Mary for anatomy that mom did know that that's what it's called. shared decision making. And then one last question about evidence for this procedure. Some people also ask about speech. They wonder if getting the procedure done will help with speech articulation in the future? Is there evidence to support this? So the problem is, is that that is a little bit of a very hard to study, but it's a crystal ball sort of question. I think in as much as I have looked all around for crystal balls, I still haven't found one. And when we go to it's very hard to study, there's no good because nobody's going to randomise to and then two sets of patients that are somewhat similar, and then, hey, we're not going to do it. We're not going to do it, then see where they end up. So are there plenty of stories of kids who, you know, who get their tongue tied procedure released? For speech? Yes. Now, is it anywhere near the number like it released for breast video? Absolutely. Not like? Absolutely not. And so I think that you clearly there's a there's a dichotomy there. I don't think that I think there are some kids who may it may potentially benefited. However, like I said, I have known so many adults who have what would you we would consider to be type one, like the Paytas tongue pay you imagine, who are completely eloquent. And so that is something where I think that decision, it gets made with a speech therapist when they're older. And the way that I always kind of present this to families is to actually do a much different procedure, like the procedure I do to release for speech issues, is actually a little bit more involved and involves kind of just recreating the tongue fold through there. It does involve sutures, I do do that. And I think that is one of the things that does tend to do when, when they're a little bit older, you have a little bit more leeway. And you can do a little bit, I think, a better procedure. Thank you so much. Any Is there anything else that you want to add? Any? I think we've covered a lot of ground, you answered so many wonderful questions. My parting sort of just as we sort of think about it as sort of like bringing it all home is that is to realise, you know, kind of goes back to that thing that we all know is you know, nothing in life is free. Nothing in life is easy. And you're in you. It's a thought that you put through it and it's not a free ticket to anything and I think it's what I would say is that this can be very helpful. And really, I think of it as like improving efficiency. And these and sometimes even talking about like it's kind of like you know, we're trying to just do a little bit of surgery to kind of move things along as long as we can kind of all except that whether or not you'll get your for anatomy is not the end of the world and it's not going to change anything new the law Long Term regardless of sort of how, how we're working through, but if it's a way that we can be able to maintain breastfeeding. Great. And I think that, you know, is a parental decision that I think should be made. And just with sort of thinking about it all and not blindly just getting tongues clip. That's really a nice summary that, right if if parents are looking for something that might be helpful, and it's very low risk, we should support them, but also, providing proper education, I think is really important. The reason why so many people do it is because it can be such a useful adjunct. But it's just it's an adjunct. And that's what it is. It's just just a piece of that big puzzle. Yes. And in addition to this puzzle, I think when it's all over, I like to stress to families, moms will still need support with breastfeeding, we should still recognise that they can ask for help reach out to lactation their paediatrician family members experience friends. Absolutely. Absolutely. Thank you so much for the invitation. Thanks for letting me join you. Oh, it's really fun. You're great. Thank you so much for tuning into this week's episode of Ask Dr. Jessica. If you're enjoying this podcast, I would be so grateful if you would take the time to leave a five star review. We'll see you next Monday.