#336 | How Tongue Tie Impacts Vaginal Birth, Breastfeeding & Infant Development

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, I'm Michelle Emanuel. I'm an occupational therapist and also a lactation therapist. My business is located in Cincinnati, Ohio, and my online presence is at tongue tie babies and at tummy time method. And I'm glad to be here. Michelle, we are thrilled to have you back. We did a fantastic Patreon event with you a number of months ago, and we learned so much, and our community learned so much from you in that segment that we are having you back again now officially on the podcast to talk in actually, we're going to talk about something a little bit different than we talked about on Patreon. So if you want sort of a generalized overview of tongue tie, you can get that over on our Patreon episode with you. But today, I think we are going to talk a little bit more about how tongue tie might impact birth and how it sort of begins with the embryo.

Well, one of the things about tongue tie, lip tie, buckle ties, is that they are really embryologic malformations. And this happens when we are very tiny embryo around eight, 910, weeks, when the tongue is forming from two lingual swellings to come together into one and then separate, and that process is interfered with, and that's what we end up calling a tongue tie. Now it affects everybody a little bit differently. And so it affects how we transition as a fetus, which is in the second trimester, and also how we begin sucking and swallowing and breathing and making breathing motions, obviously, because we're in a fluid filled environments, but we're still making breathing motions and practicing sucking and swallowing, and so it ends up developing and shaping our body and influencing our positioning. So a lot of times you'll hear in the history that there was, you know, different with fetal positioning, maybe transverse or breach, or was in one position for a long time, or was super active, or was barely active, there's always just like this, something from the typical, you know, kind of happening. So one of the things that's happening is the baby is actually preparing for birth too that. And there these are reflexes. And so what happens when we have oral dysfunction and restrictions, because it affects all of our reflexes in our what we call our postural control, even at this age, it has an impact on everything we're doing. And so we can get sometimes inhibited reflexes and sometimes exaggerated reflexes. And a lot of times it's inhibited reflexes for birth. And so it's it makes it difficult. And then, you know, we've got the mother's reflexes and the baby's reflexes working together. And when there aren't any barriers that can that works really well. But if the baby isn't able to get into the right position, or is has been in one position for a while, and that's especially with the head and neck position, which is usually turned to one side and tilt it, you end up calling that torticollis.

So are you saying that a baby who is transverse breach, or, probably, more commonly, a baby who is persistently asynchronic, or their head is slightly malposition for birth, which is a very common cause of what you know has always been known as failure to progress, which is, as we know, failure to be patient most of the time, but sometimes these head positions do result in the baby being born by C section. Are you saying that that? I mean, we know the mother's posture and things going on in her body can influence that, but you're saying that a tongue tie might be a major contributor to the baby's position and how they are birthed, absolutely without a doubt. And this comes from listening, asking a lot of questions, and being around a lot of really awesome birthday people who are understanding, you know, what's happening, and also reflecting on all the babies I've seen over the years, because I see very young babies. And, you know, at first, we used to blame the interventions, the fact that the baby needed forceps, or that they were they used a vacuum, or that they did a C section, it's like the interventions were the problem. And it's like, it's actually the interventions sometimes are needed, because there's something going on and it, you know, a lot of times when we say, I keep saying the tongue is the epicenter of development, and so if it's not moving properly, if it doesn't have the proper strength, tone, position and influence, the neck and the head are what compensate first.

Michelle, can you just take a couple of minutes and inform the audience on what the tongue is, because for the vast majority of us, we just think about the thing we can stick out of our mouths, and the tongue is a very major, vast, wide, deep part of the body. And I know that's what you're talking about. So can you just take a step back and explain that first and what you meant when you said that moment? Where it separates. I don't think people will understand that either, without an explanation said about what separates when you said the tongue separates after it forms. So, yeah, well, when we're teeny, tiny embryos, and we're and we're developing our tongue, it forms from two swellings. So you imagine two swellings, and they come together through forces, and they form one lingual swelling, in a sense, and then that lingual swelling, swelling has to separate the the tongue from the floor of the mouth. So that's a process. And what tongue tie is, is that separation doesn't happen. And is the floor of the mouth considered part of the tongue?

Yeah, yeah, it is. And look at this. So this is the part of the tongue that we can actually see. It's composed of four different muscles. We open it up, you can see that there's different layers and different directions that they go.

We hope everyone's going to we hope everyone's going to watch this on YouTube, so they can see the model that you're holding up right now, and then the other muscles that are kind of coming into the tongue here, and I'm going to show a different one in just a second. You know, these are coming from bones even up here, and they insert on the tongue and move it around. So we can look inside here. Same thing here. Wow. Yeah, so the tongue is really separate from the floor of the mouth. These models don't get it completely right. But this is you can see, see how comprehensive. That's what I call the tongue, the multi muscular midline organ. So there's, we have the right side of our tongue, and we have the left side of our tongue, and that's very true for babies as well. And since a lot of babies have, you know these postural asymmetries, which are 100% indicative of oral dysfunction and restrictions it, you know, it's just very common.

And Michelle, can you also explain how far into the back of the throat the tongue goes and what it ultimately turns into or connects to?

Well, it ultimately, this is what we call the intrinsic part of the tongue, right? And it kind of loops around and inserts on the inside of the mandible on both sides, and then also fans down and inserts on our hyoid

bone, a weapon. Hyoid, hyoid, yeah, right under the chin. Uh huh.

Okay. And you can see, if you look at the airway here, you can see that the front of the airway is the back of the tongue, so that's why it plays such a significant role in swallowing.

Yes, why, when it's short or it's not moving well, or it doesn't have as much strength or not as much function, why the neck has to compensate so much.

So would you say that every baby who's born with any amount of torticollis or head preferential turning would have tongue tie, even if you're not picking up feeding difficulties or physical exam markers that are indicative of tongue tie In the mouth, because this is would be outside the mouth.

Yeah, I am saying that it's impossible to have torticollis without having oral dysfunction and restrictions. And I've been saying this for a very long time. A lot of people are saying it now, and I think it's good, but it's we. We really want to try to understand deeply why, you know, because it's kind of complex, and we're talking about it as simply as we can here, because it can be overwhelming. But at the same time, torticollis is all about a head turning preference, and, you know, people have different understandings of it. And I worked at a large Children's Hospital for many, many years, and they still have the same understanding is when I left there about eight or more years ago, and it's, it's a little discouraging that we haven't taken it further.

And the standard, the standard responses, oh, that will resolve over time. And just do some more tummy time. And, yeah, that's about the Mars it goes right.

And kind of looking at the neck muscles and blaming this one particular muscle, the sternocleidomastoid. I mean, it is a really important muscle, but it's, it's just like such a very, very small part of the whole thing, and it largely ignores the tongue, as you know, as part of the role. And it's just kind of a stretch for everybody to understand in a medical model right now. But hopefully, you know, we'll get more interest in it and do studies, and we'll find out for sure. But I will tell you what that I've been watching this for many, many years, and you know, all kinds of different presentations of torticollis. Now, there are, you know, people who have other things besides torticollis, that will make these cases kind of not the same. But, yeah, it's the net compensating Absolutely. But we as a species are born and we're asymmetrical to begin with. It's our norm. You know, we have the physiological flexion, and we kind of have wonder we're we're just like that. Right? But what happens is that, and as natural as breastfeeding is, we're going from one side to the other, and this is one of the natural things that makes us become more symmetrical. And so we have the first 12 weeks. Part of what the fourth trimester journey is is working out these asymmetries and finding anti gravity movements and learning about head control, and, you know, really coming to terms with gravity. And because in the womb, there's, this is not gravity based movement. This is fluid, and also a lot of compressive forces. And in a sense, and out here, gravitational field is, you know, is a lot different, and the tongue, as we see, is key to the airway, and it makes a difference how we hold our head and space. Is why a lot of babies are tipping their heads back right they extend their neck, why a lot of babies also tip their head forward into head forward posture. There's two ways to be head forward, like this, and then like this kind of chicken neck out front. And both of them are attempts, and we could even count tilters side to side, but all of them are attempts at maintaining airway patency, because the nervous system has wisdom that we understand and completely trust, even if it looks maladaptive, but what we need to do is make sure the tongue is doing what it's supposed to do, so the maladaptive strategies can go away. You know, when something more stable comes and the tongue does more function, everything else can just back off and not have to compensate.

Michelle, given how much function, how much of our tongue is functioning behind the scenes, and how much tongue there is that's not visible. Can you have a tongue tie that is neither detectable On physical exam or noticeable just by looking like typically tongue ties, defined as an anterior tongue tie or a posterior tongue tie. But Can there be further types of tongue tie that are just not palpable or not visually noticeable, but they're they're further into the tongue structure?

Yeah, and that's a really good point. I'm glad you asked that, because one of the things I didn't say a minute ago when I was connecting torticollis to oral dysfunctional restrictions is that not all ties need to be released. We need to know that many do, but not all of them need to be released. So we That's why we need a very good, astute assessment and treatment plan so they don't all need to be released. But as far as there being different ones, absolutely, because the one human variability, like everybody truly is unique, and tongue tie lands in everybody's lap a little differently, and it's going to depend on a whole lot of things. Yeah, and there, because there are babies who have an anterior tie, and, I mean, to the tip, and they come out and nurse, fine, maybe there's a little bit of compressive forces, and the first couple days, and then it works its way out, and they don't know at all. And then there's another baby with that same classification of Ty, cannot stay on the nipple, cannot open their jaw and get the tongue, you know, stable, cannot swallow promptly enough. So it is. It's a lot. There's a lot of factors to it, and there are some babies that, especially with what we call sub mucosal ties, and those are ones that are behind the tissue. Mucosa is like the skin of our mouth, and so when you lift up the tongue, it's like, I don't kind of see that. Kind of see something. I don't see anything. That's usually the one. When we lift that up, we actually will do what's called the pushback maneuver, where we use our fingers to push it back and reveal it.

These are the ones that the pediatricians never usually pick up on. Oh no, your baby's not tongue tied. They're just fine. And in a way, you're kind of glad they don't, because go sending them for release isn't the answer for a submucosal tie. But where they're not doing is then referring for therapy or lactation to get them in the hands of people that are going to be able to make changes. Because, yeah, it's submucosal. But that doesn't mean it's not impacting growth of the jaw, airway, patency, ability of the tongue to efficiently express milk and get stable under the nipple, or even maintain sexual breathe coordination, all those things that are really complex at the top. You know, for it's it's confusing sometimes to think for pediatricians, because they see how variable it the symptoms are, and it's confusing for them well, and you really have to spend a lot of time observing a baby feeding and watching what happens over time. And then you, of course, have the whole variable of the mother. There's, this is a two part thing, you know, if the mother, you have to take into consideration what's happening with her in her milk supply, and pediatricians are generally not even thinking about that at all. So. Okay, which is why ibclcs and feeding specialists are really the the best people to diagnose these but can we just go back for a second to the embryonic stage, and can you tell us what you know or what you believe to be true about why so many babies are tongue tied? Why? Why are these tongues more commonly not separating the way they should? And why are tongue ties happening at this point? When? What can we do in the embryonic stage? What can we do pre pregnancy, or in early pregnancy, to try to prevent a tongue tie?

Well, I don't know if preventing it is exactly the goal. I think optimizing everything is the answer. One would be, clean up the nutrition. But I don't that's not my piece. But I always tell my clients, like, Let's do nutrition. You know, get someone who knows. Get it with a nutritionist. The GI people. That's almost number one, because sometimes we know that food is our medicine, that type of thing, and people have connected, you know, problems with different foods and allergies and sensitivities, etcetera, to tongue tie, etcetera. Then the other one, I would say, get active. And I mean moving, moving, moving. And find people who can do pelvic floor and can guide you safely, but get moving. Don't get less mobile because you're pregnant. Don't be afraid of movement, but just work with someone who can really guide you and is the benefit of that would be that if your baby is tied that you're optimizing their space and mobility for a good birthing position. That's not going to have any impact on the tie itself, or is it good?

Because get this, smart people who definitely smarter than me, are looking at how the impacts of the pregnancy during the pregnant woman having its impact on the baby and its needs for oxygen, etc, for growth. So it's how the mom's breathing at the same time it's it's activity, but it's also breathing. So you think about when you do activity, usually we do breathe more deeply, get more oxygen, our cardiovascular improves, etcetera. That's going to have a positive impact, versus going the other way is going to have, could have a negative impact. That's what I'm saying. Work with people that have more expertise. But that's good advice, because what we're doing is realizing that, first, the embryo forces are really strong, and you know, we're separating, connecting, we're creating by week eight, nine, all the body systems already. So it's a lot of activity. And then after that, as we transition over to the fetal period, we begin moving our limbs and our muscles and our head and everything. That's a whole lot of what's going on. A lot of times when a baby gets stuck in a position, it's because they didn't move around enough. And if we stay active, that kind of makes it happen.

Okay. So the more the mother is active, the more the baby is going to be active, which is going to help them, help prevent them from getting sort of stuck and kinked in a position in utero. And the more a mother is not active, the potentially less movement her baby is going to have, which could lead to getting a little bit stuck in the uterus. Is that what you're saying?

Yeah, and there's going to be other confounding factors, because it's not a blame and shame game either, about our activity level during our pregnancies. And I know I had all my three pregnancies different activity levels for sure, but yes, there's definitely an impact. And we know that because when we go in for a stress test, or we think we're problem with baby, we try to move them, or get us to drink something, or, you know, blare some music on one side, you know, kind of poke and prod a little bit. But yeah, it's the stimulation for movement is really good, but there's going to be other things. Like the baby has been affected by reduced tongue movement, range of motion, and a lot of times that comes with compromised jaw growth and position too. It's not just the tongue, you know. It can be a little bit more comprehensive in the oral facial area. So and the baby's reflexes, again, as we were starting out talking, are more inhibited, and sometimes it's asymmetrical, like really exaggerated on one side, like you'd say, asynch. And a lot of times we realize that goes down the whole

body, which is why sometimes a baby will be able to latch very well on one side and not so well on the other side. I mean, so often you hear mom say that the baby prefers my left side, or the baby prefers my right side, and if they're having a hard time, kind of flipping over and latching on the other side, sometimes, if you'd keep them in the exact same body position that they were latching on on the right side, and you just shift them over in the exact same body position to the left side, they'll latch beautifully. Okay, and that's because of that asymmetry on one side of the body often, yep.

And another reason to work with a skilled lactation consultant, because position can make a big difference in the early days, to not only protect your supply, but to promote babies skills, to improve.

Do you have a specific position that you think Tongue Tied babies feed best in?

No, I mean, there's so many good ones. I mean, I noticed that football alternating with cross cradle for babies who have a really significant head turning preference to one side can really make the comfort at the nipple. Rio complex for the mom, more it like much more improved. But we gotta clean that up for the baby, because it's compensation. You're going same side, same side for the baby if you do that. But we'll use that for a minute, because it makes the latch better. It's a little bit deeper. But you know, in general, I think we know. What I notice is the position I feel like my client does, they get the baby in naturally, then we'll work with that a little bit. But even if I'm, even if a mom wants to use a pillow at first, I'm like, okay, because I have them here at the office, I'm not even totally against that. And I know, like, you know, traditionally, we're trying to get away from pills and that type of thing, if we can.

Can you explain why? Michelle, I know that women don't understand that controversy.

Yeah, there's a lot of different reasons, actually, and one is that it really does make us rely on non normal biomechanics to get the latch right. Now, I do see a benefit to and this is one thing, like, if you notice a baby like sideline nursing, or they do really well with sideline that's a baby that needs more whole body support. And when they have the whole body support without the gravity having an impact, their latch is better that sometimes the breast friend, you know, it's the firmer one, the one that goes sometimes that can be helpful for a short period of time, because it gives the baby's body a little bit more firm input. These are babies with a little bit lower normal tone and babies with a little bit more subdued sensory processing. Sleepier babies are really even sometimes just babies who are just a little bit more drapey and squishy than other ones. But pillows, actually, we think they help us, but they end up being not so good body mechanics for, you know, the pregnant mom or the nursing mom, when she's a lot of times leaned over and it just interferes with the, you know, getting all the natural connection. Now, part of what being held without the pillow is that it's a little challenging to the baby's postural system. And that's good. So when we persistently use the pillow, it takes that little challenge, which we call a moderate transient stress, or those are things that make our nervous system flower and blossom. That's just how we are. We like these little bitty events that make us rise up, and feeding is one of those. And so if you constantly take that challenge away, then that it's a missed opportunity to build postural control.

Oh, that would also be the same reason that over swaddling, or even maybe any swaddling your baby is not helpful, and typically these babies who are more tense and tight and probably tied, are needing to be swaddled more because they are tense and tight and the swaddling seems to help them regulate their nervous system, but the opposite is actually What they need to be unswaddled and to be making those movements and building those connections. Is that correct?

Here's, but here's the kicker. Okay, here's, here's where it gets a little bit wild is that we are in a back to sleep culture. So if your baby is back sleeping, we're putting parents in a situation where they are working with a non natural sleeping position, and they have to do some things to compensate for that. So that's what swaddling does, because it provides boundaries and proprioceptive input, which is the squeezing input, so that we know that we're being held, that we because we are ventral feeders, we're ventral feelers, and when we're on our back, we don't feel the ventral stuff. And so those and ventral sleepers, I would say, would you say and ventral sleepers? Yeah, oh yeah, yes, my favorite topic, actually. So when we're asking parents like to do something that very difficult and against the grain, you know, so swaddling has its place, but I really am against, you know, necessarily swaddling all the time, but using sleep sacks that can help, because it's a nice way to give some boundaries, but not restrict movement. So there is that. There's been some good ones made, but, you know, I feel sorry for parents because they're, they're left in the lurch. Which kind of, in a way, because these we gotta sleep like that's the only torture we can even have to anyone truly, is to not let them sleep, because our brains get really, really, really compromised when we haven't slept. And it, it shows up in many different ways, and it can, it can really change people. But I hear what you're saying. And so the other thing is, we want to do therapeutic doses of tummy time during the day, you know, that's, you know, we could come back and do a whole thing about tummy time. That would be great. But the the swaddling is it as needed early on, you know? And then during the day, supervised tummy time naps on a firm flat surface during the day, parent, awake, safe surface, direct supervision and that. And I think, well, can we hold them? Yes, absolutely, that counts. And being held contact nap. But if we're working with oral dysfunction and restrictions, we want to go we have to do a little bit more therapeutic dosing. Let's do it on a firm flat surface. And if you want to be super close. You can lay right next to them, on them, you know, be right there with them. But we want to utilize gravity again, which is part of what is happening. You know, they're reckoning with gravity, especially in the first 12 weeks, and weight bearing on the face and the jaw and letting the tongue come forward and alternating the side.

Michelle, do you believe deep down that there is any risk, actual risk, to a baby sleeping on their stomach, on a firm, flat surface with their head turned to the side that has sort of normal neurological development that's breastfeeding in a safe home, at least during the day. I mean, do you feel worried about this? Do you feel concerned about Sid? Not cases, maybe not at all. Not at all, that would even say at night. I'm going to tell you why. Now we have to say there's no smoking in the home too, because the risk factors are smoking formula, you know, in the surface not being controlled for which none of the SIDs literature controlled for the surface. Okay, and we have a great product, and I don't get any kickbacks. This is something I believe, the Newton mattress, the breathability, which is made of 90% air. So we also, and it's made, you know, same size as a crib and everything. So we have a surface we know that's unsufficable, because the problem is that we didn't really separate out SIDS and suffocation. So if we pull those truly apart, I think we're going to get a lot different situation. But we're, you're on an unsufficable surface. You don't even need to turn your head, you know, to so that's not going to stop SIDS, because SIDS is something deeper than suffocation. It's where, I think it's the vagus nerve and all the cranial nerves, they just, it's something terrible and heartbreaking happens there.

Yeah, right. It's like an like a sleep apnea that a baby doesn't come out of, which isn't because they're sleeping on their stomach. It has nothing to do with the sleep surface.

Well, yeah, early on, they looked and they said, Oh, babies don't have the arousal pathways to do it. And then they redid the study, like, 10 or 12 years later, like, oh, they do have the arousal pathways. But still, we recommend, you know, you do this, I want to jump in and just make a comment about SIDS. I know we're not. The purpose of this isn't a comprehensive conversation about SIDS, but I just do feel that we need to get on the record that there is evidence pointing to toxicity being linked to SIDS, and it's a very controversial topic, but I personally don't believe people just up and die. I've never believed babies just up and die. There are links to certain vaccinations and babies not surviving the next 24 hours. That's in the VAERS database. There are, there was a New Zealand mattress wrapping study that indicates that the fire retardants in the United States are linked to SIDS. So there's not a question in my mind, and I think there's enough research to support this that toxicity also plays a very big factor. So my own advice to clients, right off the bat is use an organic mattress, and worst case scenario, an old hand me down mattress that off gassed already the toxins that we put on our baby products in this country that are banned in other countries. And again, the New Zealand mattress wrapping study was a fascinating demonstration of how they reduced, basically eliminated SIDS by removing toxins. So definitely worth factoring into anyone's consideration about why SIDS happens.

Yeah, that's a, that's a super, great point. Yeah, I don't, I don't have any, and I think there's enough. I think there's enough damage in a way that we do by eliminating these prolonged periods of ventral surface weight bearing, which is when the baby's on their stomach, is what we call that ventral surface weight bearing, because, you know, that's where the nervous system and autonomic nervous system, so when you're asleep, it really does receive a lot of benefit, and it just it. It does change postural development. It changes how we develop, you know, as humans, and we're okay, I guess you know to be, you know, sometimes everybody's like, it's okay if we're not crawling, it's okay if we're not talking so much, it's so it's okay we're just coming more and more okay with doing less and less. And I think I was just getting very reverent for what we were talking about and everything and just everything that babies are kind of come against, because they're expected to get all of their tummy time needs met in just a few minutes a day, when, prior to, you know, the mid 90s, they were spending almost half their life there.

But, and you're right about optimization, there is definitely a movement we've encountered, and we've seen where there's a large push in the past 20 years to say it's all good. If you have a non verbal baby, it's fine. And if a baby isn't functioning, quote, unquote, normally, it's fine. And it's it's misguiding the conversation. To indicate those of us who want what's best for a baby, what's optimal for a baby is not a judgment. Nobody should want a baby that isn't developing normally. Nobody should accept that and be told by doctors, this is fine. There's there's enough divergence where some people just don't talk. It's like, no, that's not what a society should accept. We should figure out why this is happening and do everything to optimize that baby to have a full and fulfilling, healthy, complete life. And it's preposterous to me that this has become controversial and that there's even an indication that this is about judgment or trying to be better than someone else. It's such love for your fellow person when you want what's best for them, and it's so uncomfortable that the conversation, it's this, this distracting conversation sometimes comes into it, of course, optimization, like, that's the one thing everyone should agree on. It should only be a question of how I am just Yes, we're singing the same songs, and I'm so glad, because it feels lonely sometimes out here, because you just meet so many people that are like that, and pediatricians, you know, I love working with pediatricians, and I'm not, you know, I can't be judgmental. They have to follow, you know, the whole organization's, you know, way. They can't really deviate from a lot of the recommendations when it comes to being in a big practice, etc. But I really wish they would want to understand a little bit about the connection with with all of these things, tongue tie and even torticollis and the need for lactation support, therapy, support, and if they would just refer, they don't have to even understand it, they would just refer instead of saying, No, I don't see it, you know, doesn't work for me.

And at the same time, they're telling mothers how important it is to breastfeed, which is a wonderful shift away from telling them that it's fine to formula feed, although there are still many saying that too. But there's this big push to help mothers breastfeed, and then we're and then we're also, on top of that, giving them all these rules that they're supposed to follow with their baby that are completely interfering with the baby being able to breastfeed, like scheduled tummy time, because your baby has to be on their back all the time when they're sleeping, when they could be sleeping on their stomach, or they could be sleeping on you, and getting natural tummy time, which was just how it was always done, because mothers were holding their babies and carrying their babies and putting them down on their stomach. On their stomachs, and then wake windows. Oh, your baby should stay awake. Let me know when they're two weeks of age. They should stay awake for seven minutes before they fall asleep naturally by themselves, making just making mothers like, what are they supposed to do? You know, they're trying to make this work with breastfeeding, and then they have all these ridiculous non natural, non biological rules that they feel pressured to follow that completely derail the system. And then, if the baby's tongue tied on top of that, they're not doing the things that are going to help undo the tongue tie naturally, without going to get the release immediately. So then they're just going to get a release immediately and woof. Like, Wow, no wonder we have a lot of breastfeeding problems.

Another reason why the whole tongue tie community needs to step it up and really do what I call optimal timing of release, which is knowing which ties need to be released when they need to do it. Not every baby is identify and go right away.

What's the harm in a release that never needed to take place?

Well, you know, at the very least we've put a baby through a procedure and then uncomfortable wound care for three to four weeks, like that's the least of it. And the risk benefit ratio for that happening for a baby who really needed the range of motion, and it really worked for is high on the benefit and low on the risk. But when you look at a baby who doesn't really benefit from it, and it really you couldn't even get to the tissue, and it made absolutely no difference, that's all risk. And so what happens to that baby? It's going to depend on a lot of things, like the babies. Temperament, and there can genetic inherent protective factors, you know, veracity, resiliency, regulation, things like that. Would we just look at things? Sometimes we're only with development checking off motor things and physical things. But what I look at as an OT is the sensory processing and how the Perry and oral sensory processing is so crucial to nervous system regulation and development and the biological imperatives of how feeding develops and how impactful chewing is and proper feeding is to our cranial facial development. What were you going to say?

Tell us also what the risk is in doing a release too soon. If you know they need to remain sort of the same. One would be like you weren't able to get everything you would be able to get had we worked on it a little bit more. Because the muscles and the tissues differentiate from the fascia with a little bit of work, neuromuscular work. Another one is that you've already put them into a certain healing stage when developmentally, it's not matching, okay, you did it before they were ready, and so you're not going to get as mature of a response. And a lot of times, for some babies, it's just about how they're regulated and get puts them into fight or flight. And for some babies, it sends them into what we call dissociated state, which is more like tuned out, kind of like staring off. And that baby gets ignored a little bit because they're not so loud, but that there's that the two faces of dysregulation, the one which is crying and upset, or, you know, just fussy and needing a lot, you know, the high needs baby that type of thing, or the baby who's just kind of flat and blank and staring off a lot. You know, both of those are are dysregulated states.

And the preparation for getting these babies ready for a release is mostly in doing body work and working on the nervous system and the reflexes and practicing feeding.

I mean, for me, because I focus on newborn to pre crawling infants, body work is a good thing, but it's too much of an umbrella term for babies. We need to do specific neurodevelopmental therapeutic measures, because they are developing their head and postural control. People who are have already developed that and we've integrated our reflexes. That's a whole totally different type of human than the babies that we're working with, because they're in reflex elicitation and utilization and integration towards the end of this this crawling period. So it's unique to the pre crawling infant, the the input that they need from sensory etc. So most of the time, we need to do a lot of sensory approaches, which is a lot of vestibular moving in different planes, and obviously big postural movements that's going to include the tummy time developmental continuum, but also, you know, babies on their backs do things. They're reaching up, and they're getting their feet, and they're, you know, even working on rolling. So all those things, because you see babies later, like, let's see, they strolled through infancy, and they even crawled a little bit, and now they're walking like I saw a baby this morning, 16 months old, and has a very distended abdomen, and has lordosis. He's walking, but that lordosis means that you have a sway back, right, and then, you know, his head is forward, so really, very posturally comp, you know, compromised, and he had a tongue tie release when he was six weeks old. I didn't work with him. This was actually my first time. My first time seeing him, and they they did a little bit of body work, but it's not enough for that infant at that age, because it permanently affects their posture if you don't get in there and really do therapy, so you gotta do that too, and making sure that we're approaching it from a sensory perspective too, and then making sure we're getting lactation care, because we need to change the mouth. We can't just go along doing the same patterns, whether it's position changes or getting a bigger Gabe or, you know, just exercising the lips, tongues, cheek or jaw. We've got to do that intentionally and mindfully. It does not spontaneously get better optimally?

Is there an age that you believe is always too young for a baby to have a release? Is there a threshold?

No, because even some babies do great right at birth. You just, you know, if you have a really qualified, you know, provider who has the assessment tools, I'm not big on lasers in the first seven days of life, because I love thinking about the baby as the biological human, and what impact that could do in the mouth. And so I would rather scissors, you know, before that. But tell us. Tell us a little bit more about that. Though, what do you mean the impact of lasers in the mouth, like the potential for scar tissue? Or just deeper damage, yeah, and just how, you know how soft and sinewy that the tissues of the newborn are, and they kind of firm up the first week, you know, after, if you feel the difference between that newborn or two or three day baby, like those tissues are so soft and still real squishy, you gotta be really careful. I mean, one time we were even lifting up doing an assessment, and, you know, a newborn, and it popped off the little piece of the front of me even popped off of the gum line. It was really, really high just by gently lifting it. But the tissues firm up a little bit. And just a different type of procedure, and it takes a little bit longer. And I think, you know, sometimes we're looking at, you know, laser versus scissors based on how it heals. And I'm talking more specifically just about how the newborn skin is. You know, any tie that is identified at birth is usually releasable by a good by the scissors. Now that may, you know, need reassessment and that type thing down the way. But I think any age that you go and I also don't think that anybody's too old for a release, but the your everybody's not qualified for release unless they've done therapy. I would say that that's every age from newborn therapy. Well, a lot of times now we're calling it myofunctional therapy. It's actually kind of like its own little thing. It's not credentialed, so you're you know, but you practice myofunctional therapy. It's been around a long time. There's a bunch of research coming up saying how amazing it is for obstructive sleep apnea. And there's already been connections made between tongue tie, the phenotype of tongue tie, and obstructive sleep apnea. So that is a very adjacent research. And I developed a program called Baby mile, which is the myofunctional therapy application to babies, and because it traditionally was for ages four and five and up. But there's tons of applications for babies and toddlers and preschoolers So, but it is all about this oral, facial area, and so it's very specific intensive, but we can't just stay in this area for babies, especially, but everybody, they need the whole body, all the way to the toes, because of the fascial connection, tongue to toes, facial connection, and also because babies move in whole body synergies and reflexes and feeding is actually a postural activity. You know, I can look at a baby's feet and imagine what their latch looks like, because feet are compensating and holding themselves in different ways. And there's certain things you know, a lot of women naturally will support babies feet because they understand it has an impact on the latch. A lot of lactation consultants will, you know, prompt for that, and it makes it a lot better as well.

Michelle, what do you, in all honesty, what do you wish were different about your industry that would make things so much better?

Do you mean in my profession of OT or the tongue tie community or baby development? Well, I guess what I mean is this, your expertise is very high, and you have a lot of insight, and, you know, there's a lot of bad information out there, you know, there's a lack lack of knowledge. What would you change?

I would say I would add a bigger communication pathway. Because, like, if I have a complaint about something such as, you know, nobody wanting to talk about deeper with torticollis, I don't have a lot of avenues for that. So if there are a pathway of communication from providers who are advanced thinking and or, you know, thinking about actual things that are going on with the current babies and families, I would, I would add that, I would add that pediatricians would want to listen a little bit more and make make make bigger pathways, and also refer prolifically. You know, the worst thing can happen if you refer to someone is they can say, oh, no, you don't need me, you know, but it's very rare that if you know someone needs help, they're and they're talking to you about at your pediatrician's office, that they don't need expertise. I would say, open up lines of communication and refer. What do you wish parents knew? What do you want them to know that there's people out

here like us that want to hear and want to help and want to refer and want to add and contribute to your baby and your health and how your family is going. There really are and to reach out and to keep asking questions and know that there are a lot of people out here that want to help you.

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