BackTable / ENT / Podcast / Transcript #8

Podcast Transcript: Treating Tongue-Tie

with Dr. Felicity Lenes-Voit

Dr. Felicity Lenes-Voit from Dallas Children's Health discusses her approach to diagnosis and treatment of Tongue-Tie, or Ankyloglossia, in the infant. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Introduction to Ankyloglossia (Tongue Tie)

(2) Initial Workup and Evaluation of Tongue Tie

(3) Surgical Correction of Ankyloglossia and Effects on Lactation

(4) Functional Physical Examination in Ankyloglossia and Frenectomy Considerations

(5) Risks of Frenectomy Surgery for Ankyloglossia

(6) Operative Techniques and Tips in Frenectomies for Ankyloglossia

(7) Multidisciplinary Approach To Treating Ankyloglossia

(8) Lip Ties and Posterior Ties in Pediatric Patients

(9) Counseling for New Mothers of Ankyloglossia Patients: Breastfeeding and Lactation

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Treating Tongue-Tie with Dr. Felicity Lenes-Voit on the BackTable ENT Podcast)
Ep 8 Treating Tongue-Tie with Dr. Felicity Lenes-Voit
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[Gopi Shah MD]
Welcome back to the BackTable ENT podcast where we talk about all things ENT and more. I'm your host today Gopi Shah. And I have my co-host today, Ashley Agan.

[Ashley Again MD]
Hi there.

[Gopi Shah MD]
We have a very special guest, Felicity Lene-Voit. Felicity was a resident in our program at UT Southwestern and one of our fellows in pediatric otolaryngology, and she's become one of our friends and colleagues. Welcome to the show, Felicity.

[Felicity Lene-Voit MD]
Thank you guys so much for having me.

[Gopi Shah MD]
Thank you for being here. Today we're going to talk about ankyloglossia or tongue-tie, and Felicity really is one of our clinical experts in tongue-tie and lactation and lingual frenectomies. So welcome. First all it'd be just interesting for you to tell us a little about your practice, Felicity, and then your interest in tongue-tie.

(1) Introduction to Ankyloglossia (Tongue Tie)

[Felicity Lene-Voit MD]
Well, I got interested in tongue-tie in a sort of selfish way because I had a baby and was a resident and was trying to figure out how to be a surgical trainee and still breastfeed my baby and pump and all that kind of thing. And so did a lot of reading on the side, joined a support group that's available on social media called Dr. MILK, which was started by a pediatrician and breastfeeding medicine specialists in Arizona, and just kind of started reading more and more and realized that this might be a way that I could help some mommies and babies, because it's really hard when you're having trouble feeding your baby. And so it sort of started as a selfish thing and then a little more altruistic.

[Gopi Shah MD]
I don't think that's selfish. I don't think it's selfish at all. I think it's probably one of the hardest things and nobody really talks about it. And from a personal level, obviously it can be very difficult and it can create a lot of guilt and frustration, and you're a new mom and then you're just trying to feed this baby. On a professional level to be able to understand and understand how we can be helpful I think that is great.

[Felicity Lene-Voit MD]
There are a lot of things about taking care of a dyad that are really attractive to me. I love taking care of kids which is part of the reason that I did a pediatric fellowship, and I'm cultivating a practice taking care of kids. But I also trained for five years as an otolaryngologist and took care of a lot of adults. And so I enjoy the opportunity to sort of have two patients when I'm taking care of a breastfeeding dyad and be thinking about moms factors too, and kind of stretching myself because I'm thinking about thyroid status and I'm thinking about factors related to a mom's delivery experience.

And occasionally even if I'm worried about low supply asking me about birth control, which is definitely not something that I anticipated would be a question that I'd be asking in my clinical practice as an otolaryngologist. But it's good for me to keep thinking about all of that, thinking about the pituitary, thinking about the really complex interplay of mechanical and anatomical factors, which I think about all the time as a surgeon, and the way that that interacts with the hormone pathways and the feedback mechanisms. And then just thinking about how I can be supportive on an emotional level for moms who like Gopi said, it's a hard thing. And most of these things…

[Gopi Shah MD]
Nobody tells you.

[Felicity Lene-Voit MD]
No. Nobody tells you. You aren't prepared. There's not a lot of availability of lactation consulting. I mean, certainly there are some really wonderful lactation consultants, but it's kind of hard to get plugged in and certainly in a timely fashion. And you can be in a situation where you feel kind of bewildered. And so-

[Gopi Shah MD]
So let's a step back. I would love to hear more about the mother as a patient as well in the sense of tell us just specific concrete things that you... what's part of your H & P in clinic when the baby and mom comes in, let's say it's the two week old baby, just switcher H & P?

(2) Initial Workup and Evaluation of Tongue Tie

[Felicity Lene-Voit MD]
So I have a long, smart phrase in EPIC that I use to kind of evaluate. And of course the first things that I'm looking for are signs that there might be a latch issue because that's directly related to the baby's ability to extract milk, but then there are also reasons why maybe baby is doing fine but mom may not have as good a supply. And of course, it's kind of difficult to tease that out because it could also be related to negative feedback from baby not doing a great job extracting because of a tie or a poor tone or any other reason.

But I asked mom about her thyroid status in pregnancy, which is something that all OBs test for. Of course, I ask about baby's birth weight and how long it took for baby to regain birth weight. I ask her if she's breastfeeding of her, if her breasts feel full before a feed and then empty afterwards. This is more on the baby side, but I ask about the suck, swallow, breathe sequencing to make sure that baby's sucking a few times then swallowing then breathing rather than just suck, suck, suck, suck, suck and not really needing to swallow because that can be an indicator that they're not extracting very much milk.

I've had a couple of moms who make so much milk and they're coming to me because of difficulty eating in it. It turns out not that the baby doesn't have a tongue-tie it's just that mom has so much milk that the baby's almost choking on it because there's either a forceful letdown or there's just so much milk the baby's kind of overwhelmed by it. And usually that's in younger babies. Usually as babies get older they can handle fast flow a little bit better or they come up with mechanisms to deal with it.

So I have one mom who said baby will latch and then she'll just pull off and she'll let milk spray her in the face. And then once it calms down a little bit then she'll latch again. And she thought that was a sign of a tongue-tie. And I was able to help her realize that no, baby is great at getting milk out and you have a great milk supply. So great-

[Gopi Shah MD]
And that happens, yeah.

[Felicity Lene-Voit MD]
... in fact that baby is trying to drink from a fire hose. And then we can talk about strategies to deal with that. I end up sometimes doing almost more counseling during my visits than I do sort of the physical exam sort of procedure stuff, because I would say more than half the time the big issue is probably not a tongue tie. It's something else related to feeding and tongue-tie might be a contributing factor. But it's pretty rare. I think that it's the only consideration for a dyad.

[Gopi Shah MD]
Right. What other things do you take into consideration?

[Felicity Lene-Voit MD]
So some people have different responses to birth control. There's not a lot of great evidence to support that in populations, either estrogen containing birth control or something like the Depo shot or a progesterone implant affects supply. But some moms swear that it does. And so I always ask about it just to have it in the back of my head. If they had a prolonged induction then the baby could have sort of falsely inflated birth weight, and especially in very young infants who haven't regained their birth weight yet it's useful to know that because we might be shooting for a target that's falsely inflated, and we might think there's a problem when there actually isn't.

And so in that case, I'll try to see if we can figure out what the 24 hour wait was because that's more likely to be a little bit closer if the induction took longer than 24 hours and mom got a fair amount of fluids in labor. If mom had a C-section, that's a risk factor for potential delay of lactogenesis 2, so the transition from colostrum to a more mature milk. And particularly if there's any hemorrhage that happens. And so I ask about skin to skin mode of delivery. No one ever has any idea I'm sure. I mean, I don't know how many bags of fluids I got in labor either, but as a general rule if it took a long time, it's probably a little bit higher risk.

Scheduled C-sections are higher risk for delay in lactogenesis than our sections where mom labored for a while and then had a section for failure to progress or some form of fetal distress. But the trade-off is that when we're seeing those moms with really young babies, they're still pretty exhausted from the process of laboring and then having a section. So it can be hard to tease that out.

The other thing is there's so many demands on a new mom's time. Sometimes it's something as simple as how much water are you drinking, and they're not taking care of themselves because they're trying to take care of this baby. And then if they're not hydrating it's hard to give baby hydration if you're dehydrated.

So I don't ask everyone all of those questions, but sort of according to how the history is going, those are some things that I definitely do ask. I ask primip versus multip, "Have you successfully breastfed in a child before?" And I find that the more kids that a mom has had that, and this is born out by the evidence as well, that the quicker milk usually comes in and the more sense they have as far as at least comparatively what the quality of the latches.

[Ashley Again MD]
So the quality of the latch is related to if she's had multiple kids. Is that what you're saying?

[Felicity Lene-Voit MD]
I think she just has more of an experience-based to know what a normal latch is. And especially in the beginning, when you have a small baby with a small mouth, there can be sort of a size mismatch between nipple and mouth and even a very mobile tongue and non-retrognathic chin and a good anatomy baby with a tongue that can be very mobile to extract milk might still have a hard time with latch and there might be painful latch. But something that's a warning sign for me is pain that lasts more than the first couple minutes or so of the feed. There's a lot written by lactation consultants about lipstick shaped nipples. And then cracked her fissured nipples are certainly something that I worry about. I worry about some.

(3) Surgical Correction of Ankyloglossia and Effects on Lactation

[Gopi Shah MD]
So when you're in the room with the patients, I mean, first of all, you're blowing my mind with how much all the history that you're kind of taking in and delving into with the mom and the feeding and all the details there. I mean, I know personally, I definitely I rely heavily on the weight and kind of the charting of the weight to see is the baby gaining weight, because obviously I'm a lot more concerned about a baby who is losing weight or not gaining weight than somebody who's staying on track for growth. And then obviously there's the physical exam. Are there any other big things that you are looking for that help you decide all right, this is a baby who does need a frenulectomy and this is a baby who needs more counseling?

[Felicity Lene-Voit MD]
I definitely agree that the physical exam and the weight are probably the overarching things. And I guess some of the history that I obtain is partly to guide how to counsel, in addition to the... Or some of it is to decide whether or not it's necessary, but some of it is that even if I'm going to do a frenulectomy I still feel like some of the counseling may help if I know about some of those risk factors. And it's also possible that I'm totally gilding the lily and none of this is necessary.

[Gopi Shah MD]
No, I think that's great. I think all of us play a role playing-

[Felicity Lene-Voit MD]
I'm sure they appreciate it too.

[Gopi Shah MD]
... supply is very important. And you can go into this a little bit more, Felicity. You're expert on in terms of especially with the literature in management, that I forget if it was a Cochrane review or one of the new... there's a new tongue-tie clinical practice guidelines, and it talks about how nipple pain, you can say, okay, frenulectomy may help your nipple pain-

[Felicity Lene-Voit MD]
That's absolutely right.

[Gopi Shah MD]
... I'm not sure. So I think the mother's history now makes it very concrete and like, "Hey, this is very important, " I'm like, "Yes." You know what I mean?" It is very important and-

[Felicity Lene-Voit MD]
So one of the things that's really hard for me about this field is that so much of it is based on sort of experience. And of course I'm relatively new in my practice. And so I don't have a huge fund of experience to draw from, but I'm building it and I'm trying to learn all the time. But the reason that's a little bit tough is that there just isn't a lot of high quality evidence. And you are exactly right, Gopi, the only sort of conclusion that was able to be drawn from the most recent Cochrane review on the subject was that doing a frenotomy with an appropriate candidate does improve nipple pain for mom. And they couldn't find an improvement in terms of baby's growth or anything lik that on the baby's side.

And it's hard to know where the data quality issues are in that, but they were able to find that we can make mom feel better. And so then the question is is mom going to be comfortable having us do a procedure on baby for her? And moms are often martyrs and don't want to do that. And so I try to head that off a little bit by reassuring them, obviously, if I think that a frenotomy is appropriate that I don't think it's an overly traumatic experience for the baby.

[Gopi Shah MD]
When do you decide to go ahead and do the frenotomy versus you know what, maybe you want me me to see a lactation consultant or have a speech evaluation.

(4) Functional Physical Examination in Ankyloglossia and Frenectomy Considerations

[Felicity Lene-Voit MD]
When I do the physical exam, I look visually to see if there's a tie. But to me, what matters a lot more is the functional exam. And tell me how you all do this, but I use a gloved finger and I stick it on in there and kind of tickle the palate to try and stimulate the suckle response. And then I feel the tongue move and I try to see how good of a hole baby has on my finger as kind of a surrogate for how much suction they're able to generate. But then also there's that what's as important as the suction is actually the massaging movement from posteriorly to anteriorly of the tongue, sort of coaxing milk out of those duct tools. And so if I don't feel that tongue kind of undulating in a coordinated fashion from posterior to anterior, I don't know that I think that cutting the frenulum is going to help a ton.

Of course, I look to see if they can stick their tongue out of their mouth past their gums, but that hasn't been shown to be a totally helpful parameter in all cases. And so I honestly don't know how much weight to put to that. I always document it, but I feel like the sort of functional assessment is a little more reassuring for me if I'm going to recommend the procedure. There are some situations where baby seems to have torticollis, their jaw seems really stiff, or they're having other symptoms that might need worrying about swallowing or make me worried they have a laryngeal cleft or something like that. And if I'm getting any sort of antenna signals that they had tone issues or mom says anything that makes me think, "Oh, maybe they have sleep apnea," I really am very reluctant especially the first time I meet them to do a procedure.

I know that the clinical consensus statement wasn't all that worried about cutting a tongue-tie being an issue for OSA, except for a baby who we're going to be worried about their airway anyway. But I like a little bit more data in that situation. So if they seem, if something just seems a little off, then I feel a whole lot better about having Speech look at them first. And at children's where we're working towards... We haven't quite gotten there yet, but we're working towards getting sort of a more integrated clinic that will eventually involve an outpatient lactation consultant and a speech therapist so that we can evaluate people together and have sort of almost like a multidisciplinary clinic that's a one-stop shop.

And of course, it's going to start small and until we sort of prove we need it's going to be really hard to get a lactation consultant because they're expensive. But I think that ultimately, if we can get that set up it'll be really helpful for patients, particularly if we can get people in, if we can have enough clinic sessions a month that we can get people in within the first few weeks of life and maybe keep them from setting up supply issues because baby isn't latching right, and milk isn't being emptied and so mom's supply goes down because it's a supply demand issue.

And so I think those are the things that kind of make me wait, although overall, I think it's a pretty low risk procedure. And particularly if a pediatrician who has referred me patients before and who I trust and know has sent me a patient. My threshold to do it is a little bit lower because I think that the potential for harm is pretty low.

[Ashley Again MD]
Yeah. I agree.

[Felicity Lene-Voit MD]
At the same time, it's very controversial to do frenotomy to sort of prevent future potential speech impairments and articulate.

[Gopi Shah MD]
Yeah. What do you tell the families, they come in because tongue-tie was on the physical exam at the two month checkup but they're not having feeding issues, and yet they were told that, "Well, we just don't want them to have speech issues later on."

(5) Risks of Frenectomy Surgery for Ankyloglossia

[Felicity Lene-Voit MD]
I find that a really difficult topic because people... I appreciate our colleagues so much and they're doing 40 well-child checks a day. And I want us to be operating as a team. And my reading of the literature is that there's no evidence that is going to be a factor. And so I have been telling families that my strong recommendation is that we wait and see, because we could potentially avoid a procedure for their child. And that of course is assuming that there aren't any other issues, no feeding issues.

I think that, especially after their three months when it gets a little bit trickier to do in clinic and would require an OR anesthesia and general anesthesia event to do that I just don't think it's worth it unless they're having something else done. If the kid meets criteria for tubes then I do still have a fairly low threshold, I think, to do a frenotomy concurrent with some other planned procedure because it doesn't add a lot of time or a lot of risk. But I'm really reluctant to put someone to sleep-

[Gopi Shah MD]
I agree.

[Felicity Lene-Voit MD]
... for a problem that may or may not materialize. And the evidence that's available, granted not high quality evidence, suggests that that's not really going to probably be the most likely factor.

[Ashley Again MD]
Yeah. Yeah. I agree. I think there's a big difference between doing it in clinic and having to go to the operating room and use general anesthesia and that sort of thing. Just-

[Felicity Lene-Voit MD]
And I think that it's a low risk to anesthesia, but there's still a risk.

[Ashley Again MD]
Yeah. I find myself kind of yielding to parents who really want it done when their child is young enough to have it done in clinic, because it does feel like a minor procedure. It feels like almost like, I don't know, you're getting ears pierced or something maybe slightly more invasive than that. But have you seen, to kind of expand on that, what kind of complications do you see or have you seen any?

[Felicity Lene-Voit MD]
So I like to cut all the way back. If I'm doing it I like to get all the way posterior and get that diamond of tissue in the floor of mouth. And so I have had, I think, more bleeding from that than sometimes may happen if you don't do that. But it has always stopped with pressure. I haven't had any issues. I have read case reports of babies getting cardiac toxicity from topical lidocaine because it's just so hard to dose in a little bitty infant, and sublingual absorption is first pass and it's kind of unpredictable and very efficient. And then reports of methemoglobinemia if you use, what is it, an ester based topical anesthetic. There's a case report of a baby getting staph floor of mouth wound infection.

[Gopi Shah MD]
It sounds awful.

[Felicity Lene-Voit MD]
I know. I've only seen one, but when I read it I was like, "Okay. Well, keep that in the back of your mind for if a mom calls and says babies got stinky breath." We might have to look at it. And-

[Ashley Again MD]
Do you use Afrin, Felicity? Yeah, what is your technique? Tell us more.

(6) Operative Techniques and Tips in Frenectomies for Ankyloglossia

[Felicity Lene-Voit MD]
I don't know if the Afrin is necessary. I use Afrin because I'm an ENT and we love the stuff, but I honestly don't know if it's necessary. I think pressure is probably fine. So one more weird complication, sorry to backtrack, is that I have read, and this was attributed to use of a laser, so a hot method, I have read about getting floor of mouth sialoceles or sort of ductoceles in the lingual gland outflow tracks from basically a kneeling off the egress points of the ducts when getting too close when cutting the tie.

[Ashley Again MD]
Do you use silver nitrate? Do you use a hemostat?

[Felicity Lene-Voit MD]
I don't use either of those unless I have to. I don't think there's evidence about the hemostat, but I see how it's appealing sometimes because you sort of clamped off the vessel already a little bit. But honestly I use a groove director. I lift up the tongue. I have the baby swaddled and have a nurse helping me. I use a headlight and then I snap anteriorly. And then honestly for the posterior dissection I usually mostly do a blunt dissection with my finger to make sure that I released the entire posterior extent because I feel like that way I have more feedback as to when I've actually gotten to muscle and I don't cut into muscle.

And there's been a few things written. Of course, it's impossible to get great data on this in infants, but certainly on anatomical studies some of the sensory nerves are very close to the muscle and right under the mucosa when you get sort of the junction of the tongue and the floor of mouth. And I don't want to cut those accidentally. So I have leaned more towards doing blunt dissection at the end, and then I hold pressure. I look to make sure that I got that diamond shape release in the floor of the mouth. And then I give the baby a sweetie as a pacifier. Actually I've switched Since the clinical consensus statement came out, which recommended giving sweeties before also, I've switched, and I give them sweeties sort while we're getting set up to sort of prime those happy neuro-transmitters and-

[Ashley Again MD]
Can you tell us what sweeties are for those listeners who may not be aware?

[Felicity Lene-Voit MD]
It's sugar, water. It's nothing. It's like a simple syrup for babies. They get a cocktail without any alcohol in it. And so we dip their Passy in it, or if they didn't bring a Passy, we don't always have them in the Pyxis, then I just dip my clean gloved finger in it and let them kind of suck on it. And then do the procedure, give them back the Passy and the sweeties, hold pressure. I love it when they come with the pacifiers that you can put your finger on the inside because I can hold extra directed pressure in the little hole in the center of the pacifier. And then once I think we have acceptable hemostasis, I have mom feed them. That has a lot of benefits. I feel like it helps with hemostasis additionally and kind of gives them time to stabilize any clot that may be forming.

It gives them all the good oxytocin from nursing. It helps mom feel sort of comforted because she gets to snuggle with them and help them through their pain. And, like I said, I don't think that it's too bad for the kids. Knock on wood, I haven't had kids who go on a nursing strike or won't eat or something like that as a result of the procedure. Now there's time and anything can happen. But I think it's relatively well tolerated. Again, it's so hard to test and a little infant. I mean, what are we going to... We can't even show them an assemblage of smiley faces. So-

[Ashley Again MD]
But I think you hit the nail on the head earlier where you just don't want to miss other reasons for poor PO.

[Felicity Lene-Voit MD]
Exactly.

[Ashley Again MD]
Like you said tone, reflux, well, maybe they're falling off the latch because they're uncomfortable with reflux or-

[Felicity Lene-Voit MD]
Maybe they're choking because they have a cleft-

[Ashley Again MD]
Exactly.

[Felicity Lene-Voit MD]
... or a laryngomalacia.

[Ashley Again MD]
Laryngomalacia. Yeah.

(7) Multidisciplinary Approach To Treating Ankyloglossia

[Felicity Lene-Voit MD]
And in that way, I actually think that we can really bring a lot to the table as ENTs because those are things that we're thinking about all the time, and why I have really appreciated working with pediatricians as well because they have a different perspective on it and the things they're looking for are different than the things I'm looking for. And so I think it's nice to load the boat, circle the wagons, have a wide sort of broad viewpoint on, hey, what's going on with this baby.

[Ashley Again MD]
Yeah. Yeah. More multidisciplinary approach for sure.

[Gopi Shah MD]
But I do think it is hard to do that. I mean, I agree. I think that multi-disciplinary having all the hands are great. And I think as a new mom, it'd be really nice to have what the lactation consultant thinks, what does the speech pathologist think. But sometimes these clinic visits are within two weeks of birth. They kind of want to come in right away.

[Felicity Lene-Voit MD]
I always get behind because I spend too much time on them compared to what we're scheduled.

[Gopi Shah MD]
Do you ever see patients that have had... Do you think that these things scar again in terms of revision?

[Felicity Lene-Voit MD]
I think they could. It's again frustrating. There's no evidence about what to do post procedure in terms of doing stretching exercises. There are people who swear by specific mobility exercises. And I don't know. I'm not able to be guided by a randomized controlled trial on this. So I'm curious to know what you guys do. I tell mom for two weeks every time, either before or after, or both baby feed starting the day after the procedure because I don't want the same day of the procedure I don't want them to disrupt any clot if there's clot there, but I tell them to just finger sweep back and forth five or six times and try and break down any potential scar tissue. And that's not much to do. And it's probably not doing anything. And maybe over time I'll change my practice and get more enthusiastic about more exercises.

Certainly there are people within the academy of otolaryngology who have been doing ankyloglossia work for a lot longer than I do who strongly believe that they're necessary, but I just haven't been able to find published evidence of a particular protocol that's any better than any other protocol. And so I'm sort of hesitant about adding more to the burden of being a new mom.

[Ashley Again MD]
Yeah. I do the same thing and I must say I do not see a lot of patients requiring revision.

[Gopi Shah MD]
Yeah. I have them just do a little finger sweep under the tongue twice a day for like seven days. You know what I mean? But I agree. I don't have anything too extensive. And in terms of revision, I think I've only seen it in six, seven years maybe twice.

[Felicity Lene-Voit MD]
That's good.

[Gopi Shah MD]
Now that being said, they're not all my own per se. You know what I mean? So I don't think it's that common. And then if they are coming back, like you said, I think you have to think of other reasons for poor feeding because once people see something structural, like you said, there might be other functional things going on.

[Felicity Lene-Voit MD]
Right. And I also think that there might be a placebo benefit to the procedure. I've had a couple patients where they feel immediately the minute we finished the tie that everything is fixed and better, but I just don't know. I mean, because there's going to be some swelling and I feel like the baby often sort of has to relearn how to use their tongue. So I tend to tell mom that I think it's going to be a little while, days to a week or two, before things are sort of optimized. And I do tell her to be very perfectionist about the latch in that time just because I don't think that it's a magic bullet. Cutting the tie doesn't all of a sudden make the baby know how to use the tongue if the baby was having a hard time using the tongue before.

[Gopi Shah MD]
Right. Absolutely.

(8) Lip Ties and Posterior Ties in Pediatric Patients

[Ashley Again MD]
So what about lip ties? Oh, man. Is that going to take us an hour to dive into?

[Felicity Lene-Voit MD]
Yeah. The short answer is that there's not a lot of evidence for lip ties. I have cut very few, and it's when I... I'll watch mom nurse the baby. And if baby just cannot flange their upper lip over the breasts to get a seal then I will do it at the same time as the tie. But I just haven't been able to find a great reason to do it. My sister's a pediatric dentist. So I've talked to her about this too, because moms will sometimes ask, "Well, is there going to be a gap in their teeth?" And the teaching and the evidence available in the dental literature is that that problem is going to fix itself. And so I think it's kind of a similar argument to the speech articulation error one where maybe we don't need to borrow trouble.

[Ashley Again MD]
Yeah.

[Gopi Shah MD]
What are your thoughts on posterior tie? It's going to be another 30 minutes…

[Felicity Lene-Voit MD]
Yeah. I think it suffers from a PR problem because I think when an ENT hears posterior tie, we're like, "Well, do people not understand that the tongue is attached to the mouth posteriorly?" Of course, it needs to be attached back there. And so I think it's like a language issue, and my interpretation is that it actually is more of a mobility issue where behind the sort of more visible portion of the frenulum there might be a little more attachment of the mucosal layer and maybe even the muscular layer to the floor of the mouth. And that's why I said, I tend to go all the way back and even if there's only an anterior tie I tend to do that blunt dissection to try and make sure we get all the way back so that if there is some posterior sort of a kneeling I address that.

I have not done a lot of frenotomies for just posterior thickening. I don't think that I'm philosophically totally opposed to it so much as I just have found other reasons in those kids for them to have issues. And so I've sort of wanted to take care of those first. And there is a higher risk of bleeding. And potentially what I'm doing by going all the way back is high-risk for pain too. We are closer to those nerves like I was saying, the sensory nerves on the ventral tongue posteriorly. But it's just been a little harder to justify in the cases I've had because those kids have had small posterior chins, have had crummy latches, and I've mostly sent them to lactation to see if we can optimize that first, just because it is a little bit more controversial.

Again, I'm not totally opposed to it. I do think that there can be mobility restriction posteriorly, but I don't know that it's the panacea that people on internet message boards sometimes think that it might be.

[Gopi Shah MD]
Yeah. No, I agree with you. I think that's where I'll definitely take the glove finger and just feel I think the whole posterior thing. It's hard to really know, but it is kind of maybe more of a thicker mucosa that covers it. I guess that's what we're thinking about, but again, it's like you said, it's the mother baby, what's happening, what's going on history that if making that little release may help, we'll see. But I agree with you, it, it may or may not always tell the... Anytime I'm in counseling, this, it may or may not change… this may not be the home run.

[Felicity Lene-Voit MD]
Exactly.

(9) Counseling for New Mothers of Ankyloglossia Patients: Breastfeeding and Lactation

[Gopi Shah MD]
Yeah. And like you said, with stuff that new moms not just like a first time mom but just having a new baby, it's a very exhausting time. You're very vulnerable. There's a lot of information out on different mom groups, different Facebook, different just sources. And so I think having a patient being able to come to see you and you have some evidence or something to help them, evidence-based decision making to help them in this time is probably the best we can do, right? Because cutting the tongue-tie isn't necessarily... But it's who and how to counsel.

[Felicity Lene-Voit MD]
And I think everyone's just trying to do the best thing for their baby, and they worry that if they don't get the tongue-tie cut they're going to completely torpedo their breastfeeding relationship. And if that's important to them that's a source of a lot of emotions. I mean, it can be a real privilege to kind of walk with them through that. And also it can be difficult because if I really don't think the tongue-tie is going to help them I feel a lot of empathy for them and I want to help solve the problem, but it's not always a solvable problem.

[Gopi Shah MD]
Right. Right.

[Ashley Again MD]
Well, I think that that is super helpful and super informative. And Felicity, what are we missing? Are we missing anything else in terms of evaluation, workup, counseling?

[Felicity Lene-Voit MD]
If they're having poor milk transfer whether it's because of the tongue-tie or because of any other of the reasons, we've talked about tone or baby being little or anything, then they have to be pumping because they will lose their supply if there's not effective milk extraction. And so if they want to continue to provide breast milk then they have to be emptying their breasts. And for most women, it does vary, but for many women it's 8 to 10 to 12 times a day that that has to happen. And so it's a big commitment. But that's counseling that if I'm sensing that this is really important to them I want to make sure that they've heard that because I don't want us to have baby grow into their latch but then there's no milk there because mom didn't keep it up, because that'd be really heartbreaking.

[Ashley Again MD]
Right.

[Gopi Shah MD]
And as for me the non-professional advice from a personal standpoint, the nipple creams after every feed was always helpful, massage, definitely intermittent pumping was always helpful, a ton of water like you mentioned in the beginning, trying to relax as much as you can. They say try to relax.

[Felicity Lene-Voit MD]
It's so easy to do that.

[Gopi Shah MD]
Yeah. Exactly, exactly. How can people find you?

[Felicity Lene-Voit MD]
Well, they can come to Children's Dallas and I am more than happy to see them. I also see patients on Fridays up in Frisco at the UT Southwestern THR facility there. We're building that practice, have a wonderful team up there, great facilities, and not much weight at all. I always have a ton of availability. So I'm happy, happy, happy to see people. And I'm really happy too if there're any pediatricians listening if you want to reach out and have a discussion about any of your patients, I am always delighted to do that.

[Ashley Again MD]
Awesome. Thank you so much for being here, Felicity. I admire your passion for the topic and have learned so much and will be applying that to my practice as well. So thanks for taking the time.

[Gopi Shah MD]
I have a whole new set of questions to ask. I ignored the other half of the whole dyad here for many years. Awesome. Well, thank you to all of our listeners for tuning in.

[Ashley Again MD]
You can find us on the socials. So we are on Twitter @_backtableENT. We are on Instagram. Our handle is _backtableENT. So keeping that consistent and you can find us anywhere where you find your podcasts, iTunes, Spotify, Stitcher, and more. Please subscribe to our podcast and rate us. Send us your comments and your feedback. Send us suggestions for topics that you would like to hear about, and reach out if you want to come on the show.

[Ashley Again MD]
We'd love to talk to you.

Podcast Contributors

Dr. Felicity Lenes-Voit discusses Treating Tongue-Tie on the BackTable 8 Podcast

Dr. Felicity Lenes-Voit

Dr. Felicity Lenes-Voit is a practicing ENT and an Assistant Professor in the Department of Otolaryngology at UT Southwestern Medical Center in Dallas ,TX.

Dr. Gopi Shah discusses Treating Tongue-Tie on the BackTable 8 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan discusses Treating Tongue-Tie on the BackTable 8 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2020, October 20). Ep. 8 – Treating Tongue-Tie [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Articles

Frenotomy procedure for a baby with tongue-tie

Frenotomy Procedure for Tongue Tie Treatment

Baby with tongue-tie being evaulated for mother-baby dyad

Treating Tongue Tie: Evaluation of the Mother-Baby Dyad

Topics

Frenotomy Procedure Prep
Tongue-Tie Condition Overview