Sawbones: A Marital Tour of Misguided Medicine - Sawbones: Tongue Ties

Episode Date: February 13, 2024

A tongue tie is not just a turn of phrase, it's a medical condition in which the frenulum under your tongue is too thick and restricts your lingual movement. For a long time, a procedure to cut it has been done as a solution to some breastfeeding woes. But should it be? Dr. Sydnee and Justin talk about the history of this procedure and the medical field's view on it today. Music: "Medicines" by The Taxpayers https://taxpayers.bandcamp.com/

Sawbones is a show about medical history, and nothing the hosts say should be taken as medical advice or opinion. It's for fun. Can't you just have fun for an hour and not try to diagnose your mystery boil? We think you've earned it. Just sit back, relax, and enjoy a moment of distraction from that weird growth. You're worth it. that weird growth. You're worth it. Alright, so I'm here to read some books. One, two, one, two, three, four.

Hello everybody and welcome to Sawbones, a marital tour of misguided medicine. I'm your co-host, Justin McElroy. And I'm Sydney McElroy. I'm so excited to be here. You're kidding me, too, Justin. I don't have any particular reason. It's just nice. You know, it's a regular Sawbone. It's just a nice, no kids in the house.

Can really focus. It's nice. We've had to deal with them lately due to flu and what have you. Get your flu shots, by the way. Our kids got an attenuated version of the flu because they had their flu shots in it. It was not bad at all, it was like a day. There are.

Well, it was like two days, but yes. It was two days for Charlie because she really likes to lap it up. Cooper was ready to party by like 6 p.m. that night. And I will say somehow you and I, I'm knocking on the wooden table here. Somehow we have remained flu-free. Thank you, flu shot, I bet.

Yeah. It's anecdotal, I know, but get it. There you go. No, it is nice to know they are enjoying themselves at school and we are, that was a nice experience. Maybe they are, maybe they aren't. The point is they're not here. They're still young enough that they like school. They enjoy it and we're... I like school. Wouldn't you go back to school if you could?

What grade? Ooh, not middle school. Nope. No, God probably not high school. No. Maybe third. That was really hard, cursive, multiplication. Yeah, man, I'm sitting pretty. No.

I do college. College. College was fun. Yeah. Although I would want to pay to do college again. Is that why there were so many weird 40 year olds lurking around when I was in college? You know, the one guy at the party,

it's like, what are you doing? It's like, it's fun. I'm not having to pay to be here. I'm just enjoying your, your great drugs and your, your Vim and Vigor. Your great drugs. This music. I love this music. What do you kids say this is? Ice spice. Well, I think ice spice is pretty nice from where I'm sitting. That is what you would say. Got any more of those, those great street drugs kids?

That is what you would say. Got any more of those great street drugs, kids? Yeah, but we're not gonna go back and do college again. Nope. No, we're done with that. We're gonna go all the way back to being babies again. Yes, yeah. Thank you, Sarah, for sending in this topic. This was a great suggestion, and Sarah also, hopefully, linked me

to a New York Times article that I read about this. And I was kind of aware of this controversy in our current medical world. And this is an ancient problem that we are still trying to best figure out how to address today. So we're gonna talk about tongue ties. Do you know what a tied tongue, a tongue tie? Anglo glossia.

I have a vague idea. I was, I was distressingly old, I would say before I learned that that was not just a metaphor, uh, figure speech, uh, but it's the, I'm probably going to mangle, but it's from the bottom. It's really hard to point and say, but like the thing that connects the bottom of your tongue to the bottom of your mouth, it's really hard to point into it. But like the thing that connects the bottom of your tongue to the bottom of your mouth, it's like longer than typical,

so the tongue doesn't have as much mobility in the mouth. There you go, there you go. That's the base. And it is, by the way, like the fact that we call it a tongue tie is sort of, like you can find the term tongue tied predating us using it for a medical condition. Really? Like that we adopted the term tongue-tied to mean a literal physical problem in the tongue

after it was already being used like, there are like biblical references to being tongue-tied, meaning like, I cannot speak, but it's not a literal thing. Huh, okay. Do you know what I mean? So it's like- The figurative use came before the literal use. And maybe it's one of those things where the etymology of it is just like was self-evident because we're already using it for this other thing but it's not

really what you mean. It's it already had a derogatory connotation. Yes, yeah tongue-tied did not mean a physical problem at first, and now it does. There. There. There. Putting it... Is that good enough for you, folks? But I do think it's easier to say than ankle-o-glossia. So anyway... But I can say ankle-o-glossia. So anyway. But I can say ankle. Keep working on it. This, the reason this is controversial is because of some, a statement that I'm gonna make

that isn't controversial, which is that breastfeeding is hard. It's hard. If you have a breastfed in your life, then you know that at first you, no matter how much you've read about it, or like myself, I went into it as somebody with a medical degree who had studied it both

as someone who planned on doing it and someone who helped others do it and had looked at like diagrams and talked to lactation consultants ahead of time and all of that stuff. Analysts perhaps most importantly like absolutely like resolute in the decision. Like the will power was there. Yes, and so I went into it from that perspective

and it still feels at first like, how am I going to make this happen? And even when you think, okay, I think that the baby is latching and I think that we're doing it right, it's scary because you don't know for sure. You can do, there are things you can do, like you can weigh your baby right before your breastfeed

and right after your breastfeed to try to see how much they got, like that's really a thing we do. But then you have to check and make sure they don't just have their keys, that's a problem. And so it's really intimidating because then you're just like, well, how do I know if they're getting enough? And everybody tells you like, well,

as long as they're gaining weight and peeing, then they're getting enough. But then there's all these other factors which are like- You want a metric. You wanted to know exactly how many. Well, and this is, and this all plays into this narrative. It is especially difficult if you come from a place and a time where breastfeeding was not necessarily the norm

for the previous generation or the generation before them, which is the situation I found myself in, where we didn't have this sort of like institutional knowledge, so to speak, as a species that had been just passed down because there was a time period, especially in American history, where most people didn't breastfeed.

And so I'm comparing it to the very easy to measure bottle feeding where you can see exactly how much. Right, that's true, yeah. I didn't even thought about that. Not that bottle feeding is, and everything's so easy, and you have no problems if you bottle feed. Obviously there's your own set of challenges, but how much they're getting is, it's scary.

And it feels like something you should know how to do. That's what everybody tells you, like, it's natural. Your body knows how to do it. Like that's, everybody tells you that. And so like, there's all this pressure, like you really should be able to just do it. Right. And there's-

The most natural thing in the world, right? Yes. It should just happen. And you're exhausted already. You're overwhelmed, you're terrified. You're trying to just do this thing that your body's supposed to do for you. And there are all these nowadays,

there's lots more pressure, not only to support you in breastfeeding, but to guilt you if you can't. I think it is fair to say that we went from, hey, breastfeeding is great and you should try it and there's nothing wrong with it, which is good because there was a time period where the message was the opposite,

but we've gone on the way to this is the only way, and if you can't do it, I guess you're not a very good parent. If you're interested in the topic around the time Charlie was born, so that would have been mid-2014, I think, and later we did several in a series, I think, on breastfeeding, several pregnancy related.

Yeah. The mysteries of the boob or something of the breast. What do we call it, something? Yeah, I forgot. We were having a lot of fun about that. Not getting a lot of sleep, but we were having a lot of fun. So it's beyond understandable that if in this sort of scary vulnerable period,

if somebody swoops in who has expertise in this area, and there are lots of people who can claim expertise in this area, when it comes to having a baby, you are surrounded by a variety of different types of medical professionals like doctors, nurses, lactation consultants, dentists, all kinds of various medical specialties who could all weigh in and say, I'm the expert on this.

You also have a lot of the population that has many, many, many, many, many years of lived experience that assures them that they too know the exact thing that you should be doing. And if you were in that moment where you're scared, you're sleep deprived, maybe you really are struggling to keep your baby gaining weight. You know, maybe you've been to the doctor a couple of times

and your baby's doctor has said like, oh, they're not really gaining as much as they should and I'm worried. And so like you're really feeling that pressure. If somebody comes in and says, I know all about this and I can help you fix it. And it's really quick and easy to fix it. And also by the way,

not only will it fix all your breastfeeding problems, but it will prevent any future speech issues that your child might have. It will prevent sleep apnea. It will prevent constipation and scoliosis. I mean, I'm feeling pretty excited. Then you would probably jump on that, right? Yeah.

And that seems to be what's happening now when it comes to the surgeries that we perform to fix what is colloquially known as a tongue tie. I'll just use tongue tie. I think that's an easier way to describe it than ankle oglossia. Yeah. So let's start with what is a tongue tie?

What do like you said- I feel like I did a pretty good job. Yes, but like, how do you, I mean, we don't just, when we diagnose something, we have to have criteria. So already there's controversy in this area because I might tell you one thing and depending on whether or not you think there are more tongue ties than we're diagnosing,

someone else might tell you something different. Like the amount of tongue that is metaphorically tied? Exactly. So what we are taught generally in medical school is that, so there's a band of tissue that connects to your tongue, it's called the frenulum, to the floor of your mouth. And it's actually, I should say, it's like a fold of tissue. It's not just like a string. This is important to know because when you cut it.

Oh man, I just went back to feel it and I really regret it. I hated that. I can feel it. I hated feeling it. Don't feel it. Well, if you feel it, then you know when you cut it, it's not just going to be like a little teeny cut there. Do you understand why?

Okay. This is important. It's going to feel really super bad. Well, I don't know. Most people have it done when they're too little to remember, although there are adult procedures. But anyway, so the lingulofrenulum,

this little band of tissue, if it's too short or thick or fibrous or whatever, the point is your tongue can't stick out of your mouth more than like one or two millimeters past your lower teeth. Okay. So you might like stick your tongue out. They can go pretty far,

but imagine it could just barely edge over your lower teeth. Okay. And is that the metric? So that's the metric we're using. So what we were, that was what I was taught is that, and you can look then, you look under the tongue, and if that band of tissue is connected almost all the way to the tip,

it doesn't have to be to the very tip of the tongue, but like basically almost to the tip, then you have concern for a tongue tie. Now, you wouldn't even be considering this if you weren't having problems with latching and breastfeeding more than likely. At least this is how I was taught. Like you're not gonna go looking for tongue ties.

If what you're hearing is the baby can't latch, there seems to be some problem. Like they keep trying to and they get worn out and they're hungry and they're crying and it hurts really bad every time we try. Then you might start entertaining like, well, maybe there's a tongue tie. Okay. So all of that though is controversial that I just told you because there are lots of different assessment tools now that people use and different areas of medical professions prefer one assessment tool over another.

And each tool is associated with either a higher or a lower rate of diagnosing tongue tie. A little sketchy, guys. Right. And sometimes people will say it's because the band's too thick, too short, too wide, too long, like nobody ever has decided exactly what that means. And then to add to all that controversy, in 2004, there was an article that introduced the concept of a posterior tongue tie

Okay, what would that be anterior meaning that the band of tissue is too close to the tip of your tongue and you're like the front And a posterior meaning that it ties too tightly somewhere along the back So there's somewhere along the back Tongues all the way back and it's supposed to be the strongest muscle and No, I've heard that. Well. That your tongue is the strongest muscle. Give me a look like you don't know if that's true or not. I don't know.

I'm gonna keep talking about posterior tongue tie. But the problem is not everybody even agrees that this is a thing that can happen, a posterior tongue tie. That I mean, because what it sounds like is that you look at the tongue, okay, somebody's having problems with breastfeeding, you look at the tongue, well, okay, there's no tongue tie, the tongue extends easily from the mouth and the, you know, the phrenulum is in attached close to the tip and like, all that's okay. And then you come up with another reason like, well, but it's still a problem with the tongue

tie and here's why. Um, so there's a lot of controversy as to whether that is even a thing. Uh, your strongest muscle in your body is, uh, the masseter, the ones you use for chewing right here. These are the strongest in terms of being able to exert force. Your tongue isn't just one muscle. So that's a popular misconception that I just was propagating. So I wanna go in and tell you this.

Thank you for debunking that. You're welcome, folks. This is what you come to me for, debunking science stuff. It's funny because it feels like something that I should know as a doctor, but I will tell you, we do not spend a lot of time in medical school

like comparing the relative strength of a single of like a muscle or muscle. Well, that's only because you're not going to create an imaginary tier list where muscles have to do battle against each other in some sort of Mortal combat. So There's also by the way to add some more Confusion to this whole picture. There's a concept of lip ties. Okay. Which if you, so if you reach underneath your upper lip, you feel the little band of tissue that connects your upper lip to your gum.

Yeah. There are some people who will tell you that those lip ties could interfere with breastfeeding and need to be cut as well. This is a very controversial area and there are a lot of your nose and throat specialists who say, no, no, no, no. That is not a thing.

I was gonna say, Sid, this is all seeming a bit more contentious than I kind of expected it. It's a very contentious area. This is, we'll get emails about this. This is a very contentious area. Well, I think part of it comes from It feels really weird to do surgery on a baby

Because it kind of feels like we're trying to and obviously it's necessary sometimes This is not a surprise to anyone, but there is something I think biologically about it where you feel like we are there is something, I think, biologically about it, where you feel like we are sidestepping evolution, in a sense, or we are somehow outside of the natural order of how we are supposed to develop. We're doing guesswork about the evolutionary model that maybe we are not well enough equipped to do. Well, I mean, I think the thing is,

if you look at, and we're gonna get into this. I'm not saying that's logically found it, I'm saying that is my emotional response. Like, I don't know, that might, like the pancreas, right? Yeah, but this is it. Or willem de Feau and poor things, like finding out that you need certain organs. But there is, I mean, you can see, and there have always been very rare cases of a tongue that is almost completely attached to the floor of the mouth. Like that does happen. And in those cases, the tongue is almost it, like it almost can't move. Yes. And you can imagine why that would be a problem.

Obviously, I think we can all agree on that one. Yes, breastfeeding, but also for all of life. Yeah. So in those cases, trying to fix it, it doesn't, I mean, there's nothing that feels wrong about that to me because, you know, this is necessary. This is just basically an embryology when everything's developing,

sometimes stuff doesn't finish. And that can manifest. That can manifest in catastrophic ways. And that can manifest in minor inconveniences that maybe we can fix pretty easily, to allow you to eat normally and speak normally, right? So I think that's all, that is where this falls into. The question is, since it is a little bit subjective, all of the criteria we use to diagnose it,

where does your line fall? It turns out that the line is radically different. Anyway, the way we fix it, which we've already kind of alluded to, is you snip that band of tissue. I mean, that's, it's, frenectomy or frenotomy. Automy would indicate that you're cutting a hole in something, whereas frenectomy or frenotomy. Automy would indicate that you're cutting a hole in something, whereas frenectomy is removing,

like ectomy is removing it, automy is making a hole in it. I think that you hear them used interchangeably because it's either way, it's the same thing. It's both. You're just cutting it. And the way that they do that in modern days is they, so you can either use your fingers,

like to go on either side of the band, lift the tongue straight up, and a pair of scissors and snip, or there's a laser specifically for this. There's also a little tool, if you don't wanna use your fingers, you can use this little kind of like fork shaped tool and lift the tongue up that way and snip.

Okay. And then, but like I said, there are also very expensive fancy lasers that some people buy, and they use these very expensive fancy lasers for this as well. We have been doing this, not with lasers. I mean, probably since forever, we have like wood carvings

that demonstrate doctors doing this from the 1600s. It's mentioned in ancient literature. We have like accounts of how they fixed it starting in probably like the 1600s. It's mentioned in ancient literature. We have like accounts of how they fixed it, starting in probably like the 1600s and moving forward. And the opinion through most of history has been that this is a very rare condition. A lot of people talked about that, even though they had heard of cases,

like that there are lots of writings from early physicians Saying that they'd never actually seen one Really? Yes, one of the really bad ones like the real legitimate ones But well what I mean at the time it was a I think that the diagnostic criteria was a little less controversial The doctors are saying no, I've never seen an issue with a tongue being so attached to the bottom of the floor that it would cause a problem. Wow, that's weird. But even back then you see writings from nurses

who disagree, no, it is more common than you know. Not that it is incredibly common, but I think what we're talking about is this a so rare that you might as like a person like myself I might go my entire medical career and never encounter it or is it rare in the sense that I'll only see it a handful of times or is it something that I should be diagnosing on a yearly basis? That's what we're talking about, sort of that range. And I mean part of the problem too is who was delivering the babies? We're kind of in the 1700s for a lot of when these writings were done.

Who was delivering the baby? Who was actually caring for the baby early on? And when would a doctor have any interaction with the baby? And how much time would the doctor check back in to see how things are going and everything? So you have in most cases midwives who are actually doing the deliveries and midwives would be the ones who would do the procedure were it necessary. So the doctor might not even know.

The doctor might not ever see the baby until after this has been done, breastfeeding is well established. You'd have no reason to ask about it, unless either one, the baby still isn't breastfeeding well, or two, there was some sort of complication that arose. But in either case, there's an argument to be made, like were doctors not diagnosing it

because it wasn't that common, or were doctors not seeing it? Now there are writings from a midwife, a German midwife at the time, Justine Siegmunden, who said that the frequency like was one in a thousand. So someone who would know, who would have that first contact and would say that that's about how common

they would estimate it to be. It's weird that that is not as meaningful. Like it feels like a number we should be able to zoom in on and just know, right? But it's the criteria is so squishy. It's weird that that is not as meaningful. Like it feels like a number we should be able to zoom in on and just know, right? But it's the criteria is so squishy. It's so squishy, cause that's why, like, you look at pediatric textbooks from the 1800s and one, it says that it's one in a hundred

and in another, it says that it's one in 10. So nobody knew. There are writings, and there was another physician who wrote that it was one in every three children. Wow, well then that certainly seems wrong to me. And again, we're talking about a time in medicine where we're still, oh my gosh, all time, where we're still trying to figure it out, right?

Like, and also before the internet, things like a medical textbook or a really influential sort of treatise could be published in a vacuum. So you're publishing this thing based on your own expertise and experience and you're not necessarily seeing what's happening somewhere else.

And so you might get a very skewed and if it hits just right at just the right moment, it might have huge impact on kind of our, our understanding of something medically, but only represent a tiny slice of the truth. You would think now we would be closer to understanding absolute truths because we can know what's happening everywhere all at once. But I think you could make the argument that that is almost somehow made it worse. So this puts the prevalence anywhere from 0.02% to 10.7%. Okay, great. So yeah, so we don't know. So what do we do about it? What should we do about it?

Why is there controversy now? I'm going to tell you after we go to the billing department. Let's go. The medicines, the medicines, that I still need my card for the mouth. My name's Doug Dugay and I'm here to talk about my podcast in the middle of the one you're listening to. It's called Valley Heat and it's about my neighborhood, the Burbank Rancho Equestrian District, the center of the world when it comes to foosball, frisbee golf, and high speed freeway roller skating. And there's been a Jaguar parked outside on my curb for 10 months. I have no idea who owns it. I have a feeling it's related to the drug drop that was happening in my garbage can a little over a year ago.

And if this has been a boring commercial, imagine 45 minutes of it. a little over a year ago. And if this has been a boring commercial, imagine 45 minutes of it. Okay, Valley Heat, it's on every month on MaximumFun.org or wherever you get podcasts. Check it out, but honestly, skip it. Hello, sleepyheads. Sleeping with celebrities is your podcast pillow pal. We talked to remarkable people about unremarkable topics all to help you slow down your brain and drift off to sleep. For instance, we have the remarkable Neil Gaiman.

I'd always had a vague interest in life, culture, food preparation, sleeping with celebrities, hosted by me, John Moe, on MaximumFun.org or wherever you get your podcasts. Night night. Okay, Sid, the modern era of tongue-tie. Okay. So the treatment, and I mean, again, has always been fairly similar. So you find writings from Celsus and Galen, and they describe an ancient-

Well, Paracelsus, Paracelsus get up in there? No, well, I mean, I didn't quote him, probably, probably. But Celsus and Galen both said basically the same thing. You just lift up the tongue. If the, if the baby, if the tongue is really attached and the baby can't talk. So we're waiting until the baby can talk, I guess. The, you just grab the tip of the tongue and you cut underneath it and try not to bleed too much.

And that was pretty much it. And use a sharp instrument is basically what is insinuated. So whatever your sharp instrument is, something you use to cut things. I think that seems preferable to whatever rusty old nail file you have laying around. Well, and this would be if the procedure is being done by a physician. Because midwives were not supposed to use any sort of instruments. That was kind of part of the deal. Like you can deliver the babies, but if you need to do something that a surgical instrument

would be involved, you need to call a doctor. That was kind of the, that's a crude way of dividing the labor, I guess, literally. And metaphorically, other than a catheter, I believe a catheter was literally, and metaphorically. Other than a catheter, I believe a catheter was allowed, but nothing else. So when a midwife delivered a baby and the frenulum needed to be cut, they could not use a tool.

Oh, aw. So it was common practice, and this is about 1700s to use a fingernail. Amen. Yes. Amen. And there are writings that reflect this. The tongue is sometimes so closely tied

to the lower part of the mouth by the means of the brindle that is obligated to be cut. This is usually done by nurses and midwives with their nail. So nurses or midwives who delivered the baby would have a sharp nail to use, yes. And I mean, again. If it just says nail though, maybe it's a special,

maybe it's not a fingernail. No, it's a fingernail. Maybe it's a special nail. It's definitely a fingernail. They use for just this purpose. There are lots of writings that talk about the use of a sharp fingernail or even just like, well, and moving forward, even just like your finger to tear tissue.

But yes, a sharp nail was very common. And again, we're not in an era where we understand like infection. So the idea that our fingernails are dirty, because all of our fingernails are, no, all of us. That's just the nature of your fingernails. You touch things with your hands and you get germs under there.

The idea that that would not be sanitary. Now, to be fair, I don't have a ton of stories to tell you about like, okay, to compare this to some so I think that this is a good comparison. When we talked about teething, we did a whole episode on teething, and if you wanna learn more about it, I will just warn you, it's- It's a bracing, it's a much more bracing listen

than you think that you're going to be participating in. We thought teething was a problem at one point that we needed to help along. And so it was not uncommon to cut gums to help the teeth break through. And there are definitely accounts we talk about of infections that arose, fatal infections that could arise from that.

I don't have a whole list of fatal infections to tell you arose from this practice. I'm not saying it didn't. I mean, certainly it must have at some point, right? Aren't your antibody, like, I'm gonna make myself sound stupid, but at that age, aren't you like just ripping it with antibodies and stuff, like healing agents

and stuff like that? Like you're just like juiced full of stuff from mom, like. If you're breastfeeding, if you're breastfeeding, yes. And then also the mouth has natural like protective, like that there are elements within your mouth specifically and your gut to protect you against infections. And also the mouth is already, it's not like it's a sterile environment to begin with.

It's dirty actually. Yeah, Harvard tons of bacteria. So I don't know, but either way, you didn't have to use your fingernail. You see other accounts of things you can use. And a lot of this, and I think this is where you get into some of the early controversy about it. A lot of this kind of goes into like folk medicine writings, like, because you could

use a fingernail or you could use like a sharp coin. Yes, like a piece of money. Sometimes you would find like surgeons using specific tools like other than scissors or lancets, they could use things like silver nitrate or iron sulfate, which are both like caustic substances that will cauterize, sort of burn and damage the tissue that way. So you find some accounts of that

or like ligature, meaning they would like try to cut it or I mean, try to tie it so that it would die. The wound, again, I think it's important to know there is a wound left behind, because it's actually like, if you imagine once you cut that, it's gonna be like a diamond shape. It's not just a little snip. I think a lot of people assume it's just a,

it's like a string. It's not a string. It's a folded band of fascia of this tissue that has formed. And so when you cut it, there's a little hole there. And they used to recommend things like barley water or honey to treat the wound, or they would just say like the breast milk will treat it. You know, it goes right to where we need it to go.

Even throughout all these years, most physicians would still argue that you probably don't need to do this. And they would say the only indication is, you know, if the kid is showing signs of a lack of nutrition, they're not gaining weight, you know, they're clearly suffering from that. There were some certain things you could look for,

like when they feed a clicking sound that might indicate the tongue was trying and like a click as it was trying to. You have to imagine that how involved, especially with breastfeeding, the tongue is with like molding around the nipple and force helping to force the milk out of the nipple. Yeah.

And so as the, there would be like a clicking sound as the tongue wasn't able to, I don't know, to perform this, that they would wear out. And again, there were some pretty obvious descriptions of like the tip of the tongue being attached to the floor of the mouth. But while this was going on, most physicians were saying, but this is so uncommon.

And we don't trust the midwives who are diagnosing this this frequently and who are doing this procedure all the time. Now, how much of that was because it was being overdiagnosed and how much of that was because there's always been conflict. And when we've talked about it on the show in multiple different episodes,

the history of midwifery and Physicians who deliver babies and the interaction between those two groups. It's always been contentious. Yeah it's always been sort of a turf battle and so You know, were they just dismissing these concerns from the midwives because of sexism and arrogance or were they dismissing the concerns because they weren't valid? Yeah. Probably some of both, right? Right. So anyway, you kind of have this debate that rages on,

and I mean, we're all throughout the 1800s where there are a lot of doctors saying this is kind of like a folk medicine thing. You don't need to listen to this, but then there are nurses and midwives who are saying, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, nowives who are saying, no, no, no, no, it's much more common than you think.

And all of this, at least on the US end, kind of quieted down in the 1900s. Why? Why? Why did we not have this raging battle? Once we get into like more standardized practices of medicine where we're starting to like really rely on evidence-based medicine, we're using tools to diagnose things, when we're moving into that era of medicine, this should have been solved, right?

We should have figured out what the truth was. That was the right time to take something like this that's controversial, drill down on the science, look at the studies, look at the outcomes and decide who's tongue tied and who isn't, who needs treatment and how do we do it? Because breastfeeding fell out of fashion. It didn't become that prominent of an issue for a while because especially with the wide release of standardized formula that you could purchase.

And we've done a whole episode on formulas so you can hear about all of the weird stuff we tried to feed babies before we had formula, thank goodness. But once formula became something that you could purchase that we knew was like perfectly made to meet a baby's nutritional needs, a lot of people stopped breastfeeding. And again, we've done a whole episode on this,

but a lot of the kind of social view of breastfeeding in this country was that it was what you did if you couldn't afford formula. And so formula was seen as like the better, this is what you did if you were more affluent, if you had means, if you wanted to give your baby the best, you bought formula, and if you absolutely couldn't afford any of that, I guess you could breastfeed, but it was looked down upon.

And so it certainly wasn't something you were going to talk about or seek a lot of support for, or any of that, because it was almost seen as shameful. So for a while, there's no real arguing about tongue ties. Right, because we aren't, because, oh, okay. Yeah, does that make sense? Yeah. Okay, well, as what happens with all things,

breastfeeding came back. So you start to see in the 70s arise in the interest of breastfeeding again. I know that seems, that's such a long time ago. Like to say this, it started in the 70s. Why are we just now having this huge debate about tongue ties and breastfeeding in the year 2024? Well, because kind of like I already mentioned, for a lot of people starting to try to breastfeed, they didn't have that sort of cultural knowledge base to turn to.

They didn't have a parental figure or another older person in the family who they necessarily could look to for that sort of support. Their friends were kind of in the same boat. We talked about several times, it's really hard. These things change really slowly because for every bit of new science there are, you've got a bunch of people who are like, listen, all I know is I made it through doing it this way.

So like this is how I was brought up and it's that cyclical thing of perpetuating it too. And you really, it takes a while to sort of turn that tide. Like I feel like I am at a point now where if I had a younger person in my life who was looking to me like, hey, I'm trying to breastfeed, can you help me? I could start to offer that support,

but I feel like that's just a generational tide that has turned here recently. Anyway, so as you start to see a resurgence of breastfeeding, the controversy kind of returns. So in the 90s, we see some like actual tools created to diagnose a tongue tie. And one that is used a lot is the Hazel Baker assessment tool that which was made by Allison Hazel Baker,

an international board certified lactation consultant. And you'll see that IBCLC, that's somebody who can provide evidence-based knowledgeable support in breastfeeding. And they are especially early on having one of those in your hospital like we did, who could help me help me troubleshoot, counsel me, was just amazing. Are they different from Lululecia League?

Lululecia League is its own thing. Like the IBCLC, people who have that designation have actually gone and become certified lactation special. It's like the certification board. Okay, got it. So you could certainly work with Lil' H.A. and be, I mean, probably most of them are IBCLCs, but they're different, you know what I mean?

Yeah. Like they're different, yeah. Complimentary, different organizations. So anyway, she created this tool that, and you can look it up, it's free for you to check out. And it has like different criteria, like how does the tongue look when it's lifted? Because when you lift up your tongue, if it's really attached to the bottom of your mouth, it will look heart-shaped.

So, but anyway, the elasticity of the phrenulum, how the function stuff, like how far can you lift it and how far past your lower lip can you stick it out. So anyway, there's a whole, you score the baby on all these different things. And then at the end, they tell you like either, no, your perfect score, your tongue works fine, or well, it's acceptable, but there might still be some issues

or there's definitely some impaired function. And then if you have impaired function, then you can be referred to have that frenectomy or frenotomy, you know, performed now as people were starting to become aware of this and and treating it and I was trained on how to do I've never done one I've never actually done a tongue-tie release But I was trained on how to do it in med school

You just take your nail and get You just take a sharp nail. There was an article published, and I referenced it earlier in the American Academy of Pediatrics in 2004 that really sort of, again, sometimes an article just hits at this moment. And it was not a study that was done.

It was not based on like, I have all these numbers and we compared these two groups. It was not that kind of article. It was more based on like I have all these numbers and we compared these two groups. It was not that kind of article. It was more based on a person's experience as a pediatric surgeon who did these procedures and kind of making the case that based on my personal anecdotal experience,

I believe there are a lot more tongue ties than we're diagnosing and I believe we should be doing this procedure a lot more frequently. And it really had a huge impact on the world of infant care and tongue tie release. In the ensuing years, there would be all this new debate and controversy among pediatric surgeons and dentists and lactation specialists culminating in the year 2020 when there was a panel of ear, nose, and throat specialists

who released their sort of consensus guidelines on it and said, basically, we are over diagnosing tongue ties. We're doing these procedures way too frequently. And the idea of like the cheek or lip tie, all of that sort of thing, we shouldn't be doing period. But despite that, and despite the fact that by the way, there are no high grade studies that say a tongue tie release does something beneficial.

There are lots of testimonials. There is lots of anecdotal evidence. But as far as the kind of studies that we use to guide medical decision making, there are none that tell us. Babies are notoriously tough for this kind of research, though, right? Because no parent wants to be like,

my little Dakota will be the control, like nobody wants to do that. It's really hard. I mean, and especially like if things are going well, you're never gonna complain. If things aren't going well, it could be due to a variety of issues, but if there's one that is a quick fix.

And the other thing too is that breastfeeding, for most people, you tend to struggle at first, and then it gets easier as you go. And so it's kind of like the cure for hiccups or warts. There's gonna be something that you do right before it goes away and then you're gonna credit it with that. There are probably some children getting tongue tie releases

who breastfeeding would have improved with time anyway. It had nothing to do with that. They just also had that done. And in addition to all this, there are risks. They're rare. Most of the time this procedure, they don't do it. By the way, we usually don't use any kind of anesthesia other than maybe some topical,

like put something numbing on that area and then just do it. That's it. That's the extent of the anesthesia. It's not a surgery that we put you to sleep for or anything like that. It's done very quickly in an office or like in the hospital setting, in the nursery.

I mean, it's not something that you would go under generally anesthesia for, okay? But there are some complications that we've seen and that New York Times article, which is a really nice sort of like summary of all the controversy around it. If you're interested in why there is such a kind of debate, it's called Inside the Booming Business

of Cutting Babies Tongues. It was published this past December, but they detail some cases where things went terribly wrong. And they're, because of the pain after the procedure, some babies have aversion to all foods and all like bottles and breastfeeding because now they've associated their mouth with pain. Okay, but what are you supposed to do?

You know, like as a parent, what are you supposed to do if the doctor comes in and is like, we got a, we got a snip here. Like, I mean, how do you know the difference between somebody who really needs it as he doesn't? That's, I mean, I think what you're asking is, is the problem that a lot of parents are up against right now and you, you will hear it.

Like there are parents who say you need to get this done because I did it and it saved my breastfeeding relationship with my child. And then there are parents out there who are saying, I had this done and my child still can't eat solid food at one year and had to eat through a feeding tube for a while. I think that one thing you need to look for

is the person assessing for a tongue tie. First of all, they should be doing it in person. If there is someone who works through the internet and tells you based on pictures or descriptions that your baby needs a tongue tie release, I would not trust that person. Go somewhere else. I'm not, I don't know if your baby has a tongue tie or not,

but you cannot diagnose it through a blog. And there are people out there. And that's the thing too. People maintaining blogs? Bloggers? You know what I mean. You can't diagnose it based on. You can't use a blog to treat something.

I think what is happening. Kids are my space to. You have scared groups of new parents on the internet and like Facebook groups and things like that who are saying, what do I do? I can't breastfeed because of blah, blah, blah, blah, and I'm scared and help." And then you have bad actors who go into that group

and say, your baby's tongue tied. I don't even need to see. I can just based on what you're saying, and you can come to this office where I'm affiliated and they will do this procedure for you. It takes 30 seconds. It does cost $7,800, $900. Your insurance does not cover it,

but it will fix all of your problems. And that is the problem is we have a space where there are people who are making pseudo scientific claims about who has it and what the potential benefits of it are. Because that's the other thing. They're also touting that if you have this done, it will prevent your baby from developing sleep apnea

in the future and also make sure that they don't get scoliosis, which why would it have anything to do with either of those things? So there are all these pseudoscientific claims and I think the other thing too is, I believe our culture has accepted that not all of us physicians can be trusted.

And I think they've taken that to an extreme, I would argue, right? Like I don't think making the statement that there are some doctors that are bad actors is not a, well, that's not controversial. I mean- It's practically the thesis statement of Solomon. Right.

I think what's tougher- We live in the gray area between trusting medicine fully and distressing medicine for doctors fully. What's tougher is that in this article, they detail an international board certified lactation consultant who seems to similarly be dabbling into pseudoscience and therefore is a bad actor in this space

because they're recommending this procedure without going through any sort of proper assessment and making claims as to what it can do that are not true or based in any science. And I don't think we're as used to that. I mean, usually I think the public kind of sees like doctors were the villains,

but usually like people like nurses or lactation consultants, sort of like the other healthcare professionals are usually always the good guys. And this is a case where I think you've got bad actors in multiple areas. Yes, of course, I'm not letting doctors off the hook. Please don't get angry at me.

But you've got bad actors in all the various healthcare realms, including dentists who are getting in on this. There's a whole conference that they talk about, tequila and tongue ties, where they let a bunch of people come and look at the cool new lasers and buy these new lasers. And they told them like, if you buy these lasers, then you could do one procedure a day

and make your money back within the first couple of weeks. And then it's just profit, profit, profit. If you get these fancy $80,000 biolace lasers. Just be wary of anybody offering new parents certainty get these fancy $80,000 biolace lasers. Just be wary of anybody offering new parents certainty or control because I feel like that is the thing that you crave most is any sort of certainty and anybody who's saying this will fix it, whatever your problem is for sure,

you instantly distrust them. Yes, and if there is someone who would diagnose you without actually assessing you, that's a problem. I mean, cause there are assessment tools like I referenced, but it requires you to actually examine the patient and talk to the parent and like, even like watch the breastfeeding issue, watch the latching issues, like to observe it directly to see and then make sure there's nothing else going on that might need

help with or troubleshoot or whatever. Like if there's somebody who isn't going through that process, I would find that a very untrustworthy provider and I would go seek counsel somewhere else. Because again, that doesn't mean that tongue ties don't exist. They do and some of them do need to be treated, but there are probably a lot of tongue ties being done, a tongue tie release is being done unnecessarily right now. There it is folks. So, and if you, by the way, I feel like because this has

become, I mean, we're talking about like an 800% increase in these procedures being done. I mean, like in recent years. So, I mean, the number of, and again, most of the time, this will be a complication-free procedure. So most of the time, whether it helped or not, nothing happens bad, most of the time. When it does go wrong, it can go really wrong

and that matters. If you're someone out there who's listening to this and thinking like, oh my gosh, I got my kid, you know, a frenectomy and now I'm questioning and I'm doubting, please don't. I was very worried about talking about this that just statistically there might be somebody out there who's starting to feel some guilt.

We didn't have this done, but I definitely during our breastfeeding journey, I engaged in lots of pseudo-scientific sort of thinking about some of the like supplements that I bought. I made you make me those cookies constantly when I didn't really think those cookies were helping me make milk. They just liked the cookies.

I went and bought the pink- A completely legitimate reason to ask you to make your cookies, by the way. I'll just make you cookies if you wanna eat cookies. But I engaged in a lot of pseudo scientific thinking because I was so desperate and scared and I was willing at that point to think, oh my gosh, maybe I don't know.

Maybe I shouldn't trust my scientific mind anymore. Maybe I should just... Rely on my husband. Yes, that's right. Well, rely on like this, what might be considered sort of like a, I don't know, this knowledge passed down through the ages.

That I'm going to, yeah. I feel the ancient wisdom you mean, yeah. I mean, I know I fell victim to that because I was desperate to do whatever I could, you know, and we all are, you know, that's a very normal thing. If you're a parent or guardian to look at your child and say, I will do whatever I can.

So please don't beat yourself up. It is easy to get taken in. And this is an area where I think in another 10, 20 years, we're gonna go, oh my gosh, what are we doing? Yeah. Thank you so much for listening to to go, oh my gosh. Yeah. What were we doing? Yeah. Thank you so much for listening to our podcast, Saw Bones. We hope you enjoyed your time with us here today.

Thanks to the taxpayers for these, their song, Medicines is the intro and outro of our program. We got a fun episode for you. It is a crossover episode with our friends, the Glockham Fleckens. They do a podcast called Knock Knock High. You may have seen Dr. Glockham Fleckens. What? I keep nailing it every time I don't know why I'm getting so tickled. Glockham Fleckens, yeah. The TikToks. We're a guest on their show, Knock Knock High, and they're guests on our show. It's a really fun conversation. It's a weird like us like meeting the basically like parallel universe version Justin and Sydney, but uh, keep it out for that is going to do it for us.

Until next time, my name is Justin McRoy. I'm Sydney McRoy. And as always, don't drill a hole in your head. Alright! Yeah! Maximum Fun. A work-grown network of artist-owned shows. Supported directly by you.