#295 | Is My Baby Tongue-Tied? with Author Cathy Watson Genna, IBCLC

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Onto the show:

Catherine Watson Genna is a renowned International Board Certified Lactation Consultant in private practice in New York City and author of Supporting Sucking Skills in Breastfeeding Infants. She specializes in teaching professionals around the world how treat to babies with anatomical, genetic and/or neurological issues. Today, she joins us to discuss the controversial topic of tongue tie. The research indicates 5-10% of babies suffer from feeding difficulties that require a surgical procedure known as a frenotomy, however far more than 10% are being diagnosed with tie-tongue and are treated for it. That means a majority of babies with tight frenulum may simply need latch support or muscular-skeletal work to improve their feeding function. 

Other topics we cover today include:

• How to know if it's really tongue-tie
• Torticolllis
• High or arched palates
• Upper lip ties 

...and, most important, we offer advice on how to get the best latch with your baby. 

Cathy Watson Genna

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Transcript

The people that are saying that half of babies are tongue tied, or three quarters of babies of tongue tied, or people that are yanking up on the tongue and feeling the frenulum stiffen, which we know from Dr Mills's research, is normal behavior, I think that there's a whole new crop of pediatricians who've had much more exposure to breastfeeding, and I find that they are a little faster, a lot faster, to refer babies for evaluation, for frenetomy. So I think the pendulum is swinging like it does for pretty much every medical procedure. Think hysterectomy, think tonsillectomy, like everybody had it done and then nobody had it done. And we need to come back to the middle where we're doing it for the people who really need it.

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 Cathy Watson Genna. I'm a board certified lactation consultant in private practice in New York City for the last 32 years, and my special interest is in babies who are ill or have sucking problems. And I'm very, very happy to be on the show today and share some of my team's research and some of the really important information that we've learned about tongue Tai over the last years that I've been in this profession.

Well, we are very, excited to have you on the show. Tongue tie seems to be the sucking problem of the day, and there is a lot of misinformation. It's probably both over diagnosed and under diagnosed. And every mom wonders if their baby is tongue tied. And I would say in my private practice, it feels like 75% of the babies who come in there have some degree of oral restrictions. So this is going to be an enlightening episode for all of us. I know I'm going to learn things I know Cynthia is going to learn things. I know our community is going to be so happy to hear what you have to say. So where should we begin?

Let's begin with the importance of latch. Because if a baby is latched on really deeply to the breast, has a lot of breast in their mouth, then all their muscles can work properly. We We did a research study looking at sucking with ultrasound in Tongue Tied babies and babies with other problems, and we found that half of the families that came to us thinking their babies were Tongue Tied actually just had latch difficulties. And once we fixed the latch, the sucking was normal.

They thought they had tongue tie, and it turned out they didn't. Isn't tongue tie observable? Well, the frenulum is observable, and whether it prevents the tongue from moving enough to breastfeed effectively or not is more subtle.

Oh my gosh. So just imagine all the tongue tie procedures that have been done then in recent decades, where it really was just a latch issue all along. What if a woman had her baby's tongue tie addressed with a procedure and then the latch did improve? Does that ne does that necessarily mean there was, in fact, a tongue tie? Or does it just mean no, the baby could have improved his or her latch without that procedure? In many cases, it just would have taken a little more effort rather than this quick fix --

Yes and no. So it's easier for a baby with a more mobile tongue to get a bigger mouthful of breast. One of the problems with tongue ties, it tends to result in either a shallow latch, or the baby can't maintain the latch, because when if this is the nipple and the breast, and this is the baby's tongue. When the baby goes to suck, the front of the tongue is pulled off the breast, and then the nipple slips to the front of the baby's mouth, and the baby kind of has to start from scratch, and we think that that's what's responsible for that clicking sound that many Tongue Tied babies make when they're sucking, and that's from a study by Dr Allen. I think,
I think it's important for everybody to know that every baby has a frenulum, and that the presence of a frenulum does not mean that your baby is tongue tied. Your baby should have a frenulum. And then, of course, there are some. Very, very obvious cases where the frenulum is extremely anterior and holding the tip of the tongue down, and those are always the ones that I feel like we just kind of just have to take care of right away. In fact, I my my son, my third child, was born with a tongue tie like that, and I actually snipped it myself while he was sleeping, when his tongue was resting up on the roof of his mouth, and his mouth was wide open and he didn't even budge. He had no idea that happened and done. Never had to worry about it again. That's not the majority of the challenging tongue tie cases, though. So it really comes down to functionality. And I think one of the biggest problems is that the people who are often diagnosing or not diagnosing tongue tie are not the people who are assessing the breastfeeding issue, it's the pediatrician. Many people are getting the getting their babies assessed by a pediatrician who really doesn't know very much about the functionality of breastfeeding. Would you agree that used to be quite true, but I think that there's a whole new crop of pediatricians who've had much more exposure to breastfeeding, and I find that they are a little faster, a lot faster, to refer babies for evaluation for phrenatomy. So I think the pendulum is swinging like it does for pretty much every medical procedure. Think hysterectomy, think tonsillectomy, like everybody had it done, and then nobody had it done. And we need to come back to the middle where we're doing it for the people who really need it. So yeah, pediatricians used to get be very poorly trained in breastfeeding, but our newer ones tend to have more breastfeeding knowledge and and are more savvy about tongue tie. The problem is there are so many confounders. There are conditions like having a tight neck muscle, a torticollis that can make the tongue tighter by pulling on all the muscles that attach to the hyoid that attached to the tongue, and pull the tongue, you know, keep the tongue restricted, but don't respond well to phrenotomy. So that's just one of the things we learned in our research. And I'm sure that there are more that we don't know about because we don't fund research. Our research was self funded. So it was my expensive volunteer work for six years.

Wow, self funded. And this is like one infant feeding is what is more important than infant feeding? And how is it that it has to be self funded to solve an infant feeding problem? Yep. Is there any way a parent, or is there any way a mother, after giving birth can evaluate or assess whether her baby has tongue tie?

One, one issue is if, if we get a really good latch to the breast, if the baby has a big mouth full of breast and is still biting mom, then the baby may be tongue tied, or again, baby may have muscle tension holding the tongue back. So it's really important to get a really good evaluation. So have a lactation consultant check the latch and the baby's behaviors, and then have the you know, if that doesn't make a difference, then it's possible that there's a tongue tie.

Can you tell us what some of the very strong indicators are for you when evaluating a baby, that a baby does actually have tongue tie, other than, you know, a mother a shallow latch, or an inefficient latch, or a painful latch, right? One of the big the big clues is when the baby cries their tongue tip goes down behind the gums, and maybe the sides will come up. So the tip behind the gums is called a low tongue posture, and only the sides going up is another sign that the tongue is held down in the middle. So that's a really big clue. Now, babies with torticollis will have a restriction in their tongue elevation, but it'll be uneven, so the tongue will go up more on one side than the other. So that's one of our big clues, that baby's got tight muscles holding the tongue down on one side versus the baby has a true tongue tie, but that's one of the more accurate things to look for. Another important clue is that the baby can't keep their tongue over their gums when they're sucking, they try to but they can't, so they're biting the tongue over the lower gum. Is what prevents the baby from biting us when they're when they're nursing this way, when their teeth come in, they're not biting the breast, and because their head is tilted back, when the top teeth come in, they're at an angle to. The breast, they're not pointing straight down where they can bite, so nature protects the breast from getting bitten. But a baby who's tongue tied and can't keep their tongue over their gums, they're just going to chew, because when your gums are stimulated that way, that's what you do. It's a reflex for babies.

And a baby who's doing that, the mother will often experience nipple compression or pain, chronic soreness, or even a feeling sometimes that's described like a flicking or running, yeah, that flicking open the tongue using an unusual movement to try to hold on.

What about just a ibclc or a pediatrician feeling under the tongue? How much does that play a role?

There's a little there's a little difficulty with stretching the tongue and then pressing on the frenulum. The frenulum is job is to guide tongue movements, allow the tongue to move, but as it tries to move too much to stiffen up and prevent excessive tongue movements. So it act it, it allows some freedom of movement, but also some stability by preventing out of range movements. And so if we yank the tongue up and press on the frenulum, it's going to be stiff. And I think this is one mistake a lot of professionals make. So what's really important is to look at the baby's own tongue mobility, and we've learned a lot of this from Dr Nikki Mills from New Zealand. She's an ENT doc, and she's done some beautiful work on the anatomy of the floor of the mouth.

How about palette shape? What do you think about a baby's palate being high, flat, bubbled? How much of an indicator are these of tongue tie and why?

Well, this, having an unusually shaped palette definitely gives you a clue that there's something off about tongue strength or tongue mobility, but it can be from various reasons. So some babies, their head is compressed a lot in utero, and those babies are going to have a long head and a high palate, because the tongue just can't get up there. Normally, the palate forms from two shelves that come up and meet like a little Gothic arch, and then the tongue will spread that and make it into a rounded Roman arch. So, but I love that analogy. That's a great analogy, a gothic arch to a Roman arch. Yeah, that was, that's brilliant. Okay, yeah, I can't take credit for that one great doctor, Betty curlis, pediatric surgeon extraordinaire, and no longer with us, and I'm part time architect, amazing woman, just brilliant. So when we see a palette that is not that beautiful gothic arch and nice and wide Roman Roman arch, sorry, thank you. When we see a palette that's not that nice, round Roman arch. Then we know that something kept the tongue from getting up there so it the baby could have low muscle tone because their nervous system isn't mature yet, or the baby could have had a tongue tie, or the baby could have some torticollis and the whole jaw is off center, like the upper Jaws usually like this, and the lower jaw may be tilted a little bit or a lot, and that prevents the tongue from being able to really spread the palate. Well, I've seen some babies with torticollis where they've got a flattening on the side where their tongue actually touches on the edge of their palate, and then it's narrower on the other side. So can you talk to us a little bit about the challenges with having a higher or bubbled palette versus a nice Roman palette?

Right? So when the the tongue holds the breast like this. The front of the tongue makes this nice U shaped trough to hold on to the breast and the cheek fat pads support that you and the edges of the tongue should touch the edges of the palate. If the palate is very high and narrow, it makes it harder for the for the breast, for the tongue, to hold on nicely, and that may destabilize the suck in itself. This is something we have very little research on, and need it. And would you also say that it could decrease the sucking pressure? Me? Meaning that the baby has a harder like a lower vacuum and less ability to remove milk, especially when the breasts get a little softer. We think so there's only so much the tongue can move and still hold on to the breast. So the front of the tongue is grooved around the breast, and it just goes up and down with the jaw. Okay, the back of the tongue follows the front of the tongues movement in a nice wave from front to back. And this is Doctor David allads research. He showed this beautifully on a very complicated ultrasound study that tracked the tongue at 28 places. Well, yeah, going all the way down that. You mean the full anatomy of the tongue, going all the way down into the body, right from between the mouth, right behind the jaw bone, because ultrasound can't see past the jaw bone, oh, to the base of the tongue. Mm, hmm. So all along here, they were able to track where the tongue is on each frame of sucking, on each of these little coordinates, and show that the front of the tongue holds on to the breast and the back of the tongue continues the movement of the front of the tongue, and that's how sucking and swallowing work.

I mean, 28 points, that's just evidence of how sort of complex and powerful the tongue is, and how important it is that it is functioning in the right way. Because that's, that's so many points of activity that are necessary to be functioning well.

And that was just, you know, just to be able to see how the tongue was moving, you know, it's, it's a continuous wave along that muscle, that complicated muscle. I have so many questions, trying to think of of where to go next before we move on from tongue tie. At the beginning of the episode, Trisha said around 75% of babies are getting diagnosed with that now. And I believe it, and I definitely it just doesn't sit right with common sense that from an evolutionary perspective, this would be going on. So we know very scary number.

Yeah, yeah. So if, if you had to guess, and you were to evaluate, say, 500 American babies from well nourished moms who had good prenatal care. And you just looked at a random sample of 500 babies and studied them, the mouth anatomy, how they breastfeed and latch had support with latch from an appropriately trained ibclc. What percent would you think you would agree actually need the intervention of a tongue tie procedure? 25, to 50

that many still well, the the research shows us that between five and 10% of babies seem to be Tongue Tied researchers who do a really good job, and then only about half of those babies really need for an automy. You don't have to be perfect to be a human being. You just have to be good enough to work.

But you said 25 to 50, which is even higher than that number 525 would Oh, you meant 25 to 50 babies, yes, yes, yes. I was thinking in terms of the 75% Oh, percent, no, no, 25 to 50 babies. Five to 10%

Yeah, okay, oh, I'm glad you cleared this. Yes, yes, yes, yes. Five to 10% the people that are saying that half of babies are tongue tied, or three quarters of babies of tongue tied, or people that are yanking up on the tongue and feeling the frenulum stiffen, which we know from Dr Mills's research, is normal behavior.

And they're not necessarily looking at all the other complexities of latch and the issues you know in a dyad, like every mom and baby, is a unique dyad, meaning that you can't just apply a tight frenulum to mean a need for phenomy, and that's going to fix every mother's breastfeeding challenges. There's just so many other variables in every situation, one of which is most commonly what you said in the beginning is just latch. Mothers aren't getting their babies latched on deeply enough. So I do still have a lot of questions on tongue tied, but maybe we should talk for a second about latch and why it's challenging to get the correct latch, and what absolutely, absolutely part of it is the way that we've all been trained. You know, we were trained grab the brush, shove the baby in. And that actually isn't the best way to help the baby grab a good mouthful. The way our brain works is if we are taking a part. Our body and making the muscles anticipate a movement we need to we need to start that movement ourselves. So if the baby opens their mouth and mom shoves them in, the baby can't get that nice mouthful. So what we've learned is that babies, if they can face plant in the breast. Chin really in. Then the nipple touches their philtrum, the little target here that that causes the baby to open their mouth and tilt their head back. When a healthy baby opens their mouth, their tongue should come down, so the latch looks like this big, open tongue down, grab the breast, up and over the nipple, and the baby lunges in.

They lunge in. That's familiar, cause, yeah, because moms have seen so many, you know the old method, sit up straight, grab your breast, squish it, shove the baby in, which is a lot more work than leaning back, cuddling your baby and letting your baby do it. And then we have ways to help if babies don't get it, yeah, one of the biggest issues I see is mothers trying to actually put the nipple in the baby's mouth. Just bottles Exactly. They target right to the center of the baby's mouth. And of course, they're going to get a shallow off, shallow centered latch, which is going to be painful, yeah, so in that that nose to nipple lineup is so important, yeah?

And I do that with bottle feeding too. If I have a baby who needs to take some bottles, we just we put the nipple across their lip and let the baby open and start to lunge, and then I tilt it so the baby can get to it. So I that works. I actually put the nipple right on the side of the baby's face, on the cheek, to try to trigger that rooting reflex so they turn and open their mouth wide, and then the bottle. But what you definitely either one of those work, what you definitely don't want to do is stick the nibble in the baby's mouth.

And I want to explain to everyone why, because I think you two have so much knowledge I can I can better relate to those who don't. I'm understanding from your your descriptions here, that the reason you want them to not have the nipple put right in their mouth, and they need to do that lunge uses, because in doing so, they will get more breast in their mouth in that process, yes, that right? Yes.

And they will have their lower jaw further down on the breast tissue and away from the nipple, because the nipple is not where the milk is, the milk is in the breast. And if the baby's compressing the nipple one, it hurts, and that's why it hurts, because your body is telling you this is wrong. Yeah. You say.

Wait a minute. Let's try that a different way.

Yes. And then you move and you adjust, and you say, Oh, this doesn't hurt. And then the baby gets so much more milk. When it doesn't

hurt, it's meant to be win, win. Yes, exactly. The mom is comfortable. The baby gets maximal milk.

So what we want moms to hear in this conversation is your baby has a role in the latch and let your baby, you know, help you latch on. And two, do not tolerate that pain, because pain is your body's way of saying, no, no, no, this is not right. Something needs to be corrected.

Absolutely. And we're socialized to accept any kind of pain, especially in childbearing. You know, yes, labor hurts because it's a close fit for that baby's head and the passage on the way out, as you you to very well know, yes, but other than other, other than labor, you know, our body should not hurt with something we do dozen times or more a day. Well, women are self sacrificing. We endure period pain. We think that that's normal. We endure labor pain, we think that that's normal. Labor is intense, there's no doubt. But it does not have to be extreme pain, and breastfeeding certainly should not be. I always tell mothers that mild to moderate discomfort in the first week or two is acceptable, since your nipple is getting a little bit used to this off, on, wet, dry, wet, dry kind of thing. But pain is never normal, yeah, I think especially the first couple of days with your first baby, colostrum is like honey. It's training wheels for learning to coordinate swallowing and breathing. Baby was swallowing amniotic fluid, but didn't have to close their airway the same way, because everything was full of fluid, and now he has to keep the food out of the airway and the air out of the food way, and that thick, sticky colostrum gives him that ability to do that. So those first few days, baby has to suck harder to get that colostrum out, and so tender nipples are common, especially with the first baby, those first couple of days, but it should never cause injury.

Yes, exactly agree.

Why this didn't ever happen to me. Through my breastfeeding years. But why do some women, or so many women, have chapped or cracked nipples? I can't make sense of why that happens. The stress on the nipple from a baby latched or sucking abnormally. So if, if the baby is shallow, that front of the tongue is putting a lot of stress on on the nipple. So it can be mechanical this way. We've also seen baby, a baby on ultrasound, who tilted the mom's nipple like 30 degrees, and that was like invisible. We didn't see any signs when the baby wasn't latched on. We could only see it on the ultrasound. Other things we've seen are babies who they're holding on for dear life. And sometimes this happens in babies with mild tongue ties. They hold on really, really hard, and the nipple doesn't get enough blood, so the nerves in the nipple start screaming, and then we get that white, bright, bright white nipple tip when the baby lets go, and that tends to trigger those vasospasms we may see and mom gets stinging nipples as soon as the baby comes off. So yeah, we see a number of things that babies do that that can cause this excessive forces on the tip of the nipple that then cause it the skin to rupture. It's like you want your airplane to be very well maintained, because microscopic cracks on the wing can eventually result in catastrophic, sudden failure. Same thing happens to your nipple skin. So it's getting a little damaged, a little damaged, a little damaged, and then it just goes. That's it.

And a warning sign of that is when mothers are feeling sensitivity to touch fabric, shower water, they can't wrap a towel around their body. When they get out of the shower, they're hiding their nipples from everything. Then you sort of know you're on that path with the micro abrasions that eventually are going to erupt into a crack --

Exactly.

I'd love to go back to Tongue Tied for a minute, because I think that there's just so much more that we need to discuss. If, if 10 to 15% of babies is that what we said are

actually 10% of babies are actually, truly tied in, in the sense that they need a frenatomy. What are your recommendations for those mildly tied babies, or just, I call them just, you know, tight, tight, mild babies, relaxation, not necessarily cutting. What do you recommend for those babies?

Right? For some of the babies, what they need is a little physical therapy or a little bit of speech therapy exercises to soften up some of those muscles, and some lactation consultants can do some of this gentle mouth exercises to get the tongue doing what it should do. We can also give the baby a little bit of gentle support. So it's gentle, steady traction underneath their chin, the soft muscle. And we're just taking that hyoid bone and those muscles under the hyoid bone that are involved in sucking, and we're giving them just a little bit of gentle, steady forward pull while the baby sucks. If this is the right thing, you'll see the baby will suddenly go from Chompy sucking to slow, deep drawing I'm getting I'm getting milk sucking, and that's something the mom can do herself.

Absolutely, absolutely, I recommend that she just do it with her thumb and rest her fingers on her baby's head. He won't care once he's latched on.

And what are your thoughts on body work, cranial sacral for babies. Infant, chiropractic, myofascial work. Do you have a preference? It all depends on what. It all depends on what is the issue. So if we've got musculoskeletal issues, then you know, physical therapy, speech therapy. Infant, chiropractic, cranial cranial sacral therapy is a sub specialty of osteopathy, dos, or full physicians in the US. So they can do, they can do the hands on, plus the diagnosis of whatever else is going on. So there's a wide variety of practitioners that can be really good in this area. We have the most research for speech therapists and physical therapists.

And do you recommend a certain number of sessions for a mom and baby, or is it just completely dependent on their level of difficulty.

Yeah, it depends on what's going on. If we have the baby with torticollis, physical therapy has the most positive research, and we want to start it early. If we have a baby who's asymmetrical, and we see that this, you know that things just aren't lined up, you can start. Start with physical therapy, or you can start with the osteopathy, chiropractic craniosacral. And if in a couple of sessions you don't see a big difference, then it may be time to shift gears.

And how important do you feel it is in your experience for babies to have bodywork prior to having a phrenatomy.

Yeah, this is a real issue, isn't it? Firstly, body work is poorly covered by medical insurance. Secondly, we would really like moms to be home and nursing their babies those first few weeks. Babies nurse really often in the first two weeks, so that they build the milk supply, and the more the parents have to go running around, the less that's going to happen and we can have an impact on milk production. So I want to be absolutely sure that this is something that's going to work for this family. So if I don't see any any kind of asymmetry, musculoskeletal tightness on one side, or something not working properly, then, you know, I don't think that that's the greatest intervention. I think we need to say, ha, okay, we've got a baby whose tongue doesn't work the way we want it to work. The frenulum looks decent. Let's find out whose expertise This is.

I'm actually really happy to hear you say that, because I have had some phenomena providers who won't even see a baby until they've had two sessions of body work. And I'm saying, Well, you know, I know unicorns with those. I know type ones. Yeah, I know this. Those babies get fixed right away, yeah. And it's a, it's a deterrent for some mom's body workers are not inexpensive. They they might be spending hundreds of dollars depending on the area that they live in. Or, you know, recently, I was working with a mom who lived in rural Wyoming who was gonna have to drive four hours to see a body worker. It's, yeah, no, frustrating, always and never are bad words. In healthcare, there's so much individuality. And it's, I talk a lot with Dr Tina smiley, and she's like, I wish lactation consultants knew differential diagnosis, because it would make it would make a lot of these problems go away.

So I explained that better for our for our listeners. So differential diagnosis is when you see a cluster of symptoms and you think of all the different things that could cause it, not just the most common or the one that comes to your brain first. And there are many. There are many exactly, and there are probably things we don't even know of. There was a survey that was done by breastfeeding medicine doctors. So these are MDS or DOS, who are also ibclcs, who, who treat fornatomies themselves do pherotomies themselves treat tongue ties? And it was a survey of the things they missed. So the biggest issue were musculoskeletal things when muscles aren't doing the right thing, because something's out of place, or because the baby was in a weird position and and something didn't get to grow properly. There were cardiac things, neurological things. So, you know, there's a whole list of things that it could be, but we don't know enough to tell the difference. So this is why I think we need to upskill ourselves as ibclcs, so that we understand this process and that we're not just jumping on every baby's tongue tied and it's an easy mistake to make. We want to do good fornatomy is fairly simple. And you know, we really want to help moms and babies. I think one other thing that I think is really, really important, Trisha. I want to ask you, when a mom is having trouble watching, does she get it after one session? No, right? See, I think this is exactly I think this is one big piece of the puzzle. Moms say, Well, I saw lactation consultants. I had one consult, but they don't remember what we told them. They're postpartum, they're exhausted, they're sleep deprived, they're anxious. Their nipples hurt, their bottom hurts. It's like, Alright, come on. So when I see moms for latch issues, I offer them a free online follow up, like the next day, you know, just a few minutes. We just practice again. If they're having trouble, I have them send me a video, okay, so I can see what's wrong. And it's that the latch. It takes practice. It takes a lot of practice. Dr, smiley, as you may know, was my mentor. She. Me, and I feel extremely fortunate for that, but she always described it like putting, like, you know, two strangers on the dance floor, and they're going to step on each other's toes. It's not like you just put them out there and flip the music on and they have their rhythm. It takes time. It takes getting to know each other. It takes these little tweaks of you, and then your baby, and then you move like this, and then your baby moves like that. And eventually you find your flow. But it does not happen overnight, and it does not happen in one session. In one session with an IV CLC, who in four hands on, sometimes you can get it just right. A lot of times you can get it just right. That doesn't mean that they're going to be able to recreate that at home,

right? Which frustrates us, because we wish we could just wave our magic wand and everything would be perfect. But, you know, it takes multiple visits very often.

Okay, so what is your opinion on upper lip ties and cheek ties?

Cheek ties, I know absolutely nothing about there's a lot of work being done on fascia, which is what frenula are made of mucosa andor fascia. Whenever we have a muscle, it's covered with layers of fascia. It's connective tissue. It's like the white membrane that you peel off your chicken and, you know, the transparent membrane that's connected to those little white tendons. Okay, so, and then the meat is actually muscle. So that's the same arrangement we have in our body. When there's inflammation around the muscle or in the fascia, then the fascia tightens up and the muscle can't relax. And there's a lot of work being done in Italy by Dr Antonio and Carla steco, their husband, wife, team and brilliant. And when a muscle is tight, it's going to pull on the fascia next to it. So possibly some of these very tight frenula could be for muscle tightness that's pulling on that structure, because it's what connects, connects your cheek to your to your jaw. So, so in theory, the body, the body work, could help relax that rather than going in there and cutting, yeah, and when, when the latch is shallow, baby overuses their lips and cheeks to compensate Exactly, exactly, and then those cheek muscles, especially the inner one that's attached to the closest to the to the frenulum, the buccal frenulum there, that is going to tighten up the Most, because the buccinators are the ones that are working hardest when you're lacked shallowly, instead of the masseter, which works harder when you're latched well. So these changes in muscle activity may be trans transmitted as tension to the fascia and the friendula. So this is something that I think we really need to fund research into for breastfeeding. As far as the upper lip goes juicy, relatively low lying, labial, friendly are normal. So as long as there's a tiny bit of bone underneath that lip frenulum, it's going to move up as the child grows. There are many studies, some of them are done in India and Pakistan and other parts of the world. But humans are humans, and if there's that tiny little piece of bone there that frenulum will move up, and by 14 or 15, any gap will have closed. Now there are lots of reasons for gap between the front teeth, so just cutting the labial friendly doesn't take care of all of them. Very occasionally, when the labial friendly wraps around the gum rather than going, you know, just getting inserted into it, those are called papilla penetrating frenula. They may prevent the lip from having enough mobility to hold on to the breast, and then it can be a problem, but then what we see is calluses all down the lip. When we lift the baby's lip, it should touch the touch the nostrils.

If a baby's lip is unable to touch the nostrils and they are having some difficulties, nipple pain, things like that, you might then recommend and

yeah, and the tissues blanch when we Okay, yeah. So those are, those are the signs from the dental literature, from that that. Lip needs to be treated. In our research team, we did one ultrasound of the baby who only had the upper lip treated, and they were able to get a much better latch. Because this is a baby who was really, really tight and really, you know, really needed it to maintain the latch. We try to allow best tracks. I think this is way less common than tongue tie. Is

I agree? Yeah, I agree with you. In wrapping, if there were one piece of advice that you could give to every breastfeeding mother out there, it's not easy to pick. But what would it be?

Trust your baby is competent. A lot of the ways we treat babies are left over from the 1940s and 50s, when mothers were told their babies can only see shadows and they can't feel pain. We know that those things are absolutely not true. Babies can hear, they can see, they're nearsighted, but that's so that they can watch our face when they're on the breast, so know your baby's competent, and don't get your baby's way, like keep the mittens off.

Your baby tell you, Oh yes, I'm hungry, mom. You know this is a polite request for dinner. Yes, babies. Know they are crazy smart, and we just have to trust them. Tatiana, kondra from Russia, she's an idclc there. She says, hug your baby. And that is the best setup for lash get comfortable, hug your baby, let your baby hug your breast.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

One of the biggest challenges I have is is getting mothers to let go of the apps and recording everything their baby does down to the second that they start feeding. And it's just so left brained. And breastfeeding is so not left brained.

Thank you. Dr. Smiley, yes, showed us how very right brained it is. Yeah.