Episode 119: 3 Presentations of Oral Ties with Amey Fields RN, IBCLC

Hi and welcome to episode 119 of the Untethered Podcast. Today we have Amy Fields joining us. Amy is the owner of Arizona Breastfed Babies and she's got a team of four other RNIBCLCs that do virtual and in person consults in the Phoenix, Arizona area. She's a wife and a mother to her husband Steven, who served in the United States coast guard for 30 years. She's got three children, two stepchildren and a three year old granddaughter. Amy worked as a Labor Nurse for 18 years, mostly in the hospital setting, but also assisted in home births and worked a freestanding birth center for two years. She became an IBCLC in 2012 and in 2013 she went to the IATP conference in Florida and that four day conference rocked her world. Quick disclaimer. All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. So Amy, I am so excited to have you join me on the podcast. I think we've been talking about this for maybe a year and a half now, so I'm so glad we coordinated schedules and here you are.

I know, I'm so excited. I did. I went back to our DMs and Instagram. We started chatting in November of 2019 and I love your podcast. I listen to all the episodes and I just think it's a great thing that you're doing.

Yeah, well, and you know, it's so nice to meet people on Instagram who you almost feel like are like instant friends and people who are in the industry that get it, that, you know, advocate and it's really been so much fun to follow you and watch your journey on Instagram and see how you're educating, you know, moms and other therapists and ibclc. So, so thank you for all that you do. Let's jump right on in and let's talk about, you know, I know you're a registered nurse and IBCLC So share your journey with us. You know what? Where did this all begin for you? Have you always been an ibclc? Have you always been in the tot space? You know, I'm curious to know the backstory there.

Yes. So I, about 25 years ago, became an RN, and I started out as an orthopedic nurse first. I did that for about two years, but really wanted to work in labor and delivery. But it's where I got started. Looking back now, I see that the two years as an ortho nurse really did give me some experience and knowledge that I use even now with being ibclc. So that's kind of interesting. But I first got my foot in the door working postpartum at a hospital that was run mostly by midwives. And so the care there was very unique, and it was a great experience, but I still really wanted to do labor and delivery. So I got hired to be a labor and delivery nurse when I was 10 weeks pregnant with my first baby, which was super not fun, but what.

A time to start.

Yeah, I mean, just. I always get. I always had hyperemesis with my kids. I was, like, nauseated, but really wanted this job, and I pushed through it. So I worked labor and delivery at a hospital that was completely opposite than where I had been as a postpartum nurse. So no midwives, very much an assembly line. This was back when we induced everybody at 37 weeks, because why would you stay pregnant any longer than you needed to? There are a lot of interventions, and I knew that I didn't want that for my own birth. And so I had my daughter at a hospital with a midwife and had a great experience. And I didn't even know what an IBCLC was or a lactation consultant. We didn't have one at the hospital that I worked at, but the hospital I gave birth at, this nice lady came in and helped me with positioning and gave me a couple tips and tricks. And so everything was great until right before we were going to be discharged and they came in and said, your baby is jaundiced. To make a long story short, she was, like, almost neurotoxic with her bilirubin. And she. I mean, her level was like 27 at 24 hours of age. And turns out she has a hemolytic disorder. But she was in the nursery for a week under lights, and. And they told me that I could not breastfeed, that I had to stop because formula binds to bilirubin better than breast milk. And this sweet Lactation consultant came into the nursery and handed me a paper that was a journal that basically said bilirubin does not bind better to formula and that breastfeeding is not contraindicated. And that's all I needed. I was like, what? And I knew I was a labor nurse, but didn't know these things. And so I just remember this was 22 and a half years ago. I remember feeling so empowered, like, this is what I need. And we fired the pediatrician that we had and got another one who's amazing. And I wasn't against her being supplemented by any means. She was supplemented. She got formula. My milk wasn't in yet, But I just knew that to completely stop breastfeeding, if it wasn't absolutely needed, not to do it, because babies need that time at the breast. They need to practice. It's a learning curve. There's imprinting that happens with what you put in their mouth. So I was like, if she needs to be supplemented, I want what's best for her in this situation. But I don't want a week to go by where she hasn't been to the breast. Because I just. It didn't make sense to me. And the pediatrician was like, you don't have to stop breastfeeding. You can breastfeed her and then pump, and then we'll give her what you get, and we'll top off with any formula that's needed. And he was so supportive and so breastfeeding friendly. He's from Central America, so I feel like that was part of his, you know, supportive breastfeeding advice was from that. And so went on to breastfeed her for about 18 months. And honestly, other than the first couple of weeks of navigating, supplementation, and then transitioning to just breastfeeding, I'm one of those lactation consultants that I had great breastfeeding journeys with all three of my kids. I really don't feel like I had a lot of struggles. I breastfed her until I was five months pregnant with her sister, and she weaned on her own. My other two children breastfed, and it all went well. It was a really great experience. I had one friend that's a labor and delivery nurse that was breastfeeding her daughter. When I had my first daughter, her daughter was a year older. I called her my best friend. I called her all the time, asked her questions, and she was my support. My mom didn't breastfeed any of the five of us. And she said she remembers that when she had my older brother Someone came in the room and gave her a shot to dry up her milk and she thought that was normal. She didn't know anybody that breastfed except for one of her, one of her sister in laws. That, that was weird. So, so I, you know, again, like had a really great experience with all three of my kids. So as a labor and delivery nurse, I was definitely one of the nurses that if somebody had a birth plan or didn't want to have an epidural or wanted less interventions, they were like, amy, this patient's for you. You take her. Or if someone was having a lot of trouble with breastfeeding, they were like, hey, I can't get this baby to latch. Will you go in there and do that? And I loved that. So around 2009, 2010, my kids were a little older. And you know how you kind of get out of that fog of when you don't have babies anymore and you're like, what, what else can I take on? What can I do?

I feel like I'm finally getting there with a five year old and a three year old, by the way, or almost six year old. It's like finally starting to see a little glimmer of no more brain fog.

I mean, my youngest was like six, seven at that time. So that was. That's about right. There's hope, there's hope. More lift over the next three years. Okay, I got it. So I became Lamaze certified because I was like, ooh, I'll teach childbirth classes. And then the IBCLC at the hospital I worked at was like, I need help because I'm doing these breastfeeding support group and it's like a triage. Like these moms will come in with bleeding nipples, but then all of the other moms want to socialize and she's trying to run like two different things. And so I went to our director of our labor and delivery unit and I suggested that we start just a postpartum support group so that if they didn't need direct breastfeeding support, they could come. And it was open to all moms breastfed, bottle fed, formula fed babies, and we could have a postpartum support group. So I started that in 2010 and I called it the circle of mothers, and I still run it to this day. Amazing. Yes. I credit that with helping me learn more than anything else because if you just create a space for, for moms to get together and then listen to them, you will learn so much. And I did. It was amazing. And to see the women that got Together in those groups and that they're still friends to this day is like, it's really cool. It's a really amazing thing to watch. So I then thought, oh, I'll become an ibclc. There are other nurses that had the certification and, you know, worked as postpartum or labor and delivery nurses. I didn't really necessarily want to work as the IBCLC on the unit because I saw how hard she worked. But I went ahead and started doing my clinical hours and eventually sat for the boards. So what happened around this time as well is I was running that postpartum support group, and one of the moms brought her doula to the group. I didn't even know what a doula was at that time. I'm like, what? And she befriended me, and she said, I work at this birth center, and they need somebody to teach classes. And I said, that sounds fun. So I went and taught classes at this birth center, and within a couple months, I had quit my job at the hospital, Working full time at a freestanding birth center, immersed in this whole different world after having been in the hospital as a Labor Nurse for 14 years at this point. And I was wearing many hats. Labor nurse, IBCLC teaching classes, like, all of these things. And one of the people that I met during that time was Dr. Agarwal of Agave Pediatrics. And he took care of a lot of our families because his pediatric practice is very supportive and empowering of different decisions that parents have to make. And he told me, amy, I can't do his accent. But he's like, you should go to this conference in Florida. It is coming up. It's four days, and it's on Tongue Ties. And I was like, Dr. Agarwal, what are they going to talk about for four days on tongue Ties? And he's like, just trust me. You need to go. And I was like, I. If you're saying that. And I'm so mind blown. Like, four days on Tongue Ties. Okay, I'm gonna go. So I. In 2013, I went to the International Affiliation of Tongue Tie Professional conference on Tongue Ties. Holy smokes. Blew my mind. It's where I met Michelle Emanuel. I met Jennifer Tao, who is an ibclc. Michelle, you know, Michelle Emanuel is an OT and has the tummy time method, and she's been on your podcast several times. People like Ben Lynch, James Murphy. Interestingly, I remember. I wish I could remember how many people were there. I'm going to say they're like three, three hundred people that were there. It was people all across the different modalities, SLPs, OTs, PTs, dentists. I mean, so many different people. And I remember they had people raise their hands. If you're an ibclc, raise your hand. And like, you know, a bunch of the people there, if you're a dentist, raise your hand. If you're a pediatrician, raise your hand. Two people.

That does not surprise me.

Dr. Agrawell and Dr. James Murphy. And so I was like, well, doesn't this just explain it? And, yeah, as I'm there for the conference and we're learning about how oral ties affect people across the lifespan. In fact, I think that was the title of the conference. And I sat there just completely, like, devastated, thinking of all of these families that I had seen that I didn't help and, you know, very specific families. And I just was so angry that I didn't learn any of this. I mean, as a labor nurse, we learn oral assessments because we do that on every newborn and we put our finger in their mouth to check to make sure their palate is intact and that they have a suck reflex, and that's it. I remember seeing tongue ties over the years and never, ever did anybody ever say anything about it being an issue. I did all of the training and the classes and the clinical hours I was supposed to do and sat for my boards as an ibclc. And I remember there being a couple of photos on the exam that showed a very anterior tongue tie. And it was like, it's a tongue tie. And that was it. And I was like, what I thought a lactation consultant was someone that was going to help a parent pick out, like, which breastfeeding pillow works best for them and help them choose, like, nipple cream jokes on you. It's. I. It really what, like, it was a really difficult, like, thing to wrap my head around. And I did come home from that conference and I did call six families back that I had worked with recently and said, I learned something new and I think this might be what's going on with your baby. And so sent them to Dr. Agarwal.

And sure enough, how amazing you were able to actually reach back out to those families so quickly and make a difference. You know what I mean? Like, I know we've all talked about this a lot, where we take these courses, these MYO courses, these. You know, we take autumn's tots training, and then we come back and we all go, holy cow. And you, like, you start to think about all of these past families, and it can really bring you Down. I mean, you kind of have to move forward from it. If there's nothing you can do to go back and change time, you just can't. Right. But, you know, can we treat now or in the future for other issues that may have snowballed? Sure, a lot of us can do that. But it's. It is so interesting because I had the same exact thing happen. And when I came back, I offered eight evaluations for free to kids who are on my caseload. I said, can I just eval your child? Because I think there's more going on with this new information that I just learned, and I would really love the opportunity to see if there is, if we can tweak our approach and to address the same type of end goal that we're getting to. But maybe this will be more efficient, more effective, more. I just have new tools in my tool belt, and it was phenomenal. I mean, and every parent was like, oh, free assessment. Yeah, totally. Go for it. They weren't upset that I didn't know the information before. They were just happy that I was that clinician going to continue my education and then bring it back and help their children. Which I think is a really cool thing to discuss, because I think, as practitioners, we know, like you and I were talking about this before we hit record, there's always more for us to learn. Like, we even. No matter how long you've been in the field, no matter how many continuing education hours you take per year, you still feel like you don't know everything and you never will. Right. And you can learn a ton from your patients and your courses and all the things out there, but the ability to come back and be real with your patients and be transparent and say, hey, I have something new that I can offer you. I've never had a family be upset about that. I think it's actually a strength, and I think it really puts you up on a pedestal compared to the next person who's not doing the continuing ed and who's keeping kids in therapy for years on end. So, you know, my goal and when I do it is really, how do we get you to that end point in an efficient, effective way? Because we're all tired. We all want to just, you know, get this baby fed or get this child speaking or, you know, whatever our goals are over here. And I think it's so fascinating because I know all of our industries are lacking. I didn't learn any of this in grad school. I went through under four. Four years of undergrad and about I say like two and a half to three years worth of courses dedicated to my major as an undergrad, and then I went through another two and a half years in a graduate master's program. And I don't even think tongue tie was addressed. Pediatric feeding was barely addressed. Okay. It was mostly adult dysphagia, which is completely different. Adult swallowing is nowhere near what happens with an infant swallow. And anatomically, physiologically, it's like very different. So, you know, that's definitely one of my big bandwagons that I always jump on, which I know you've heard me talk about this on the podcast before. A lot of us don't learn it and it becomes our financial responsibility to further our education both time wise and monetarily to get out there and learn this stuff. Because, you know, like, like you said when you were in that group with those moms and you had that opportunity just to be an ear and hear what they're saying, that tells me more than any research article I will ever read. Because these moms are living it. They're living it in the moment. And when you start to listen and you hear the patterns and you start to connect the dots and you start to realize, oh, this is not just a one off scenario. Like, this is pretty common. Why is nobody researching that? Why is nobody talking about this? Why is this? And these moms all think they're alone because nobody's talking about it. Which, you know, thank you. Instagram, we now have, instead of Dr. Google, we have Dr. Instagram these days and everybody is sharing information. Hard to know what to believe and what not to believe, but that's a whole different conversation. But it is, it's so interesting because I think we all have such similar stories with how we, you know, we went, we got into our fields and this is where we started and we never, we never knew. If you'd asked me 10 years ago where I'd be today, I would have laughed in your face. If you told me I'd have a podcast, of course be doing pediatric feeding with like, you know, focus on tots and myo and. Yeah, and that, that never would have come out of my mouth.

Yeah. I mean, and for people that follow you on Instagram and, and I even do it like an autumn henning, like when you follow some of us, you'll see sometimes we get kind of snarky and I, sometimes I'm like, am I picking on pediatricians too much? Because I had an amazing pediatrician, but some of the pediatricians out there and some of the things that I hear, I'm just like, what the heck are you telling people? And, you know, it's like a form of therapy for us to be able to be snarky and to get that out there. Because there are a lot of medical professionals that are still like, standing in a corner and saying, you know, this is a fad, and all of those things. And so my friend that I was saying, that's my breast friend that helped me a lot with breastfeeding. She's now actually a cnn, so she's actually now a midwife. But our boys are three months apart. So our last children that we had. And so we would be breastfeeding them sitting next to each other. And her son sounded like a little piglet and was so noisy and always had milk all over him. And I remember sitting there, you know, nursing Connor, and I was like, what the. What is going on over there? We just laugh, like. And he was such a chunky baby and we had no idea, you know. And so she nursed him like, she pushed through and nursed him until he was two. But my gosh, he was the so gassy and sounded like a snorty little pig and got milk everywhere and all of these things. And when he was 18 months old, he fell down the stairs and severed. You know, back then we were like that thing. He's that thing right there, that little.

That little thing up there.

And it. And it broke, you know, his. He broke his lip, the frenulum, and it bled everywhere. And we were together. I remember it. And so I'm trying to get a popsicle to get him, you know, to eat it, to like slow the bleeding down a little bit. And. And she was like, I don't. Like, I don't know what that was. But later I remember she told me, like, I don't know, but he breastfeeds so much better. He doesn't leave milk like he did before. And we were like, oh, that's weir. Yeah. And she is. So I have a photo of her I'm going to post in a couple days. She has Tori and a tongue tie. She's so tongue tied. Both of her kids are. Are super tied. And. Yeah. So anyways, he's 17, almost 18 years old, so that's weird that it's a fad.

Right? Right. I know.

It was a thing.

You know what's interesting too is when you look back, it's in like. And I'm Jewish, but it's in the Bible. Okay. Like, it's in old research Old textbooks. Like, it is talked about. This is, you know, and so when people say, oh, this is a fad, I'm like, look, I can get on board with the fact that people are releasing ties without doing functional evals. And we don't know if that tie was actually a tie that needed to be released or not. Like, maybe this was not dealt with appropriately. So we don't actually have a definitive answer. Was it just a frenulum or was it a tight oral restriction? Right. Like, fine, maybe there's over diagnosis, but maybe there's under diagnosis. Maybe they're both occurring. Maybe it depends where you live. Maybe it depends who the practitioners are in your area. Like, there's so many variables that we can't just slap a statement onto it and go, it's a fad. I mean, one. No, it's not a fad. I've talked about this. Like, you know, yeah, probably everybody's sick of me talking about it, but, you know, I just go back to oral. Ties are a real thing. I love Daniel Lopez. I don't know if you've heard him say, you know, you don't have to believe in it. It's not a religion. And I was like, genius. Like, yup. I love that.

It's not Santa Claus or.

Yeah, exactly. But, you know, here's Tooth Fairy. It's like when you have, like, your friend mentioned, your best friend said how much easier it was to breastfeed after that incident. And this is where the pediatricians are like, oh, it's fine. I'll just fall on their face and it'll rip. Well, yeah, that does happen. But one, that. That sounds like really dangerous medical advice to be giving out. We don't really have to go there. I've had a kid on my caseload who I was working with, who was. I worked with him between the ages of, like, three and five. And he. That had happened. Well, he had an extra piece of tissue hanging under his lip because it didn't sever. Well. And it actually caused other complications. And when he went in and finally had. They had to go in and correct that. So it's not even for the kids who do fall and sever. I'm like, nobody's talking about this. Like, it's not. That's not how we deal with medical issues. And I go back to just listening to our moms, listening to our breastfeeding moms, and what are they feeling? What are they experiencing after their child. Their child's tots are released, because that tells me all we need to know really when the symptoms start to improve and mom's symptoms improve. It's not just baby, this is a dyad, which I know I don't have to preach that to you, but people are not, you know, the people running around saying this to me are just highly uneducated, quite frankly.

I agree. In this space, I agree. And I share a lot of the stories on my Instagram of the mothers that are speaking. I always like to listen when I'm doing a console. I ask a lot of questions and I will often say, what do you think is going on? Like, what do you. Mom's intuition is pretty awesome if we tap into it. And listening is so incredibly important. And yeah, we just need to keep sharing these stories. And, you know, now that I've, I've been in IBCLC for almost 10 years, next year will be my 10 year anniversary. And I had, I started a private practice in 2014 and eventually stepped away from being a nurse to do this full time. And I do home visits. I now have a couple of office locations and I now have five subcontractors that work with me, which I don't know how that happened. It wasn't on my agenda. But that's the same thing happened for me too.

I didn't have the plan. It just happened.

It just happened. And I know I muddled through those first years of being an ibclc. I, you know, I love learning, I love going to classes. I feel like I'm never going to stop learning. And I just, I just know that the IBCLC I am now is nowhere close to where I was, you know, nine years ago. And so now what has happened is I have these other lactation consultants that I either know or have reached out to me that want to help moms. And so I realized, like, as much as I have that imposter syndrome and I'm like, who am I to do this? But then I'm like, well, who else is going to do it? And what I've learned now from having the subcontractors that it really is kind of a mentorship type relationship as well, because we don't want to do this by ourselves. It's great to be able to brainstorm with other people is that I am learning from them too. But it's also really making me, like, bring it all up a notch and to figure out, like, why it is that I do what I do and how I can share that with other people. And so that's kind of where like this next part came from because I'm trying to explain to them and, you know, they're going to go take, like, Autumn's class eventually. Hopefully we can get her to come back here to Phoenix. She was just here a couple months ago. Her top class. And I highly recommend for ibclc, the master IBCLC class that Jennifer Tao and Brenna Sampi and Sandra Colson teaches. They're just in. Michelle Emanuel's classes are all wonderful. So as they're, you know, going to work through taking those, we have weekly zoom calls that we go over things. And so this is where this came from because I really needed to be able to explain well, especially when it comes to tots, like, what it is that we're seeing. So I labeled them with three different labels. And of course there's going to be some overlap. But, you know, we have those oral ties that I call the easy peasy, excuse me, easy peasy presentation. And those are the ones that get caught usually pretty quickly. And that's because a lot of times the frenulum there, it's visible and you can see it. And maybe the tongue is attached to the tip or the lip, you know, is attached all the way and goes past the gum line towards the palate and the lip pulls in and under. Like, it's things that people can see and they notice maybe there's a family history. Maybe, you know, another child had it and it was diagnosed later. And the parents, like, want something to happen early on. The symptoms typically are significant and they really need to be addressed right away for breastfeeding to continue. It's like the, I call it the SOS calls that we get, like, something has to be be done. Baby's not gaining weight, there's nipple trauma. And, you know, mom needs help because if something doesn't change, she's not going to keep doing what she's doing. Now, sometimes things can happen. Like somebody can give the mom a nipple shield in the hospital and it hides some of the symptoms, or she starts with pumping along with breastfeeding. And so there's compensations that can happen, but usually the parents know that something isn't right and that something needs to change. So sometimes I'm lucky and I show up to the console and the parents have already done the research or have, like I said, a child before that was tied. And usually they're so relieved that there's a solution to their problems. So these are the babies that sometimes, often I think the restrictions are released and breastfeeding improves right away. So that's What Michelle Chatham calls the tether flow oral ties. So it's released, things feel better, we're all good. And then the next presentation I call the fat farty and fussy oral ties.

I love that.

So this, this is my friend and her son. Sometimes this can be a little harder because baby is gaining weight typically. And for some professionals, they think this is the marker of success. It doesn't matter that mom's nipples are falling off. It doesn't matter that this baby is breastfeeding every hour. Yeah, doesn't matter that they're grunting constantly and the parents aren't sleeping because they have like, you know, my friend's son Jeremy was a snorty little sound, like a little piglet. And so what's happening is babies are just gulping milk from the breast and they're just living on the letdowns and they're breastfeeding frequently. A lot of times the moms have a pretty robust. Not always, but often have a pretty robust milk supply. When I do consults with families that have the fat, farty, fussy presentation, sometimes they're conflicted because they believe what the providers tell them, that their babies are gaining weight. Well, and this is where the moms are like, I feel selfish doing something because I could just pump and just.

Give it in the bottle.

Which babies don't always do better on the bottle, but sometimes. And what I find is that there's a honeymoon period. And not that that means that everything's fun, but the honeymoon period is because the babies can just put their mouth on the breast and gulp the milk that's coming out and they don't have to have an optimal latch. And that's kind of how mother nature has created the situation is we have, you know, the endocrine driven milk supply for that first 12 weeks, so that it switches. We have lactogenesis that happens and switches to more of an autocrine, which is the supply and demand. So in the beginning, our bodies do have the letdowns and the milk flows. Babies don't have to have like the perfect optimal latch right away, but they should be getting there. And when they're just drinking off the fire hose and getting all that air and, you know, it's usually a hot mess. But the honeymoon period typically will end anywhere. I mean, I some with some dyads, I notice a difference even as early as three weeks when the supply starts to downregulate, but definitely between six and 12 weeks. So this I think is where it comes, like where the whole thing where so many women said their milk dried up at three months and just went away because there were so many babies that were just drinking the milk that was flowing, living off the letdowns and, you know, these fat, farty, fussy presentations. Babies typically gulp and choke and they often struggle with the milk flow. They pull back, they cannot. Their tongue doesn't elevate, so they cannot control the flow of the milk. I always tell parents it's like the rudder of the ship. It needs to extend out, it needs to move side to side, it needs to elevate up, it needs to have that undulation. And when they can't control the flow of the milk, they will use their whole body. You see them arching, pulling back. They're trying to squeeze the nipple tight to stop the milk from flowing. And they swallow a lot of air so their abdomen can be distended. So this is why they typically will eat more frequently is because they get on the breast and let's. I'm just going to make up numbers. Let's say they gulp down 2 ounces, but they got so much air, their abdomens distended and they feel like they got three or four. And then by the time they grunt and burp and fart and spit up and do whatever, an hour later they're like, wait a second, I'm hungry, I'm still hungry, I'm hungry. It starts all over again. And they're eating. Usually noisy, they usually hiccup often, you know, and hiccups. Newborns will hiccup like it happens. But when you've got like a six week old that's still hiccuping every single time after they eat. Yeah, that's a red flag. Yeah, they spit up, they have explosive poops, they're like farting and it's like across the room and it's just an explosion. And again, like this is something that an older baby, six weeks, seven weeks, eight weeks, like super explosive stool is not what we need to be happening. That's not normal. And they just seem uncomfortable. You can tell that they're just uncomfortable. Often these babies are diagnosed with reflux. Sometimes they're on medication. And then, you know, these are the ones where moms have like cut out dairy and they put the baby on a probiotic, they're taking a probiotic and everybody is trying to all of these things to try to figure out how to help this poor baby. And yeah, that's the fat, farty, fussy.

I mean, sometimes that's lil. I mean, it's lily to A certain degree, like she was not fat, like she was my 1 percentile baby, but because she was on her own growth curve and she was gaining weight, the pediatrician was not concerned. Right. So that was, you know, oh, she's fine. Written off because we're still on that 1% growth curve. Like all through her first year, we never got over 5th percent, I think, until her second year. And now she's okay. But, I mean, it was incredible because she had. So she wasn't a noisy eater per se, but she had all these other symptoms. And, you know, I refused to put her on reflux meds. I knew something more was going on. They didn't. They didn't want to put her on reflux meds. She wasn't really a kid who seemed to be uncomfortable. Her spit ups, you know, seemed to be happy spitter type of spit ups. And she wasn't spinning up entire feeds, but she was also feeding every hour on the hour because. Or every couple hours because she wasn't getting enough. And I knew that, I knew that something was off, but I was adamant about not giving her formula because of her reaction to it in her first 24 hours of life, or I guess our first 24 hours home. So she was about three days old and she just screamed bloody murder like three hours after having it. And when I called the pediatrician in the morning and said, yeah, that didn't go well. Last night, trying to supplement, like, I will do what I need to do to feed my baby baby. They were like, oh, well, come get. That was Similac. Come get Gerber. Good start. It only has one milk protein. That should be easier. And I'm going, what if she's allergic? Like, what? You're not more concerned that she was literally up screaming bloody murder for three hours, which means I. And she was crying, I was crying. My mom was up with us. And she was like, I don't know what to do with the two of you. And at that point I was. I just made a decision as a mom. I'm like, well, if nobody's going to do anything to help me, because I took her to lactation and that was, you know, oh, it's your fault, your fault. You're positioning her wrong. Okay. It's like taking the car to the shop. She feeds while in the office. You go home, it all falls apart. So basically I was like, I guess I'm just going to pump and feed her and bottle feed her to top off breastfeeds. I know I'm producing enough Milk. But I know she's fatiguing, and I thought maybe this would be easier. It wasn't. She still. When I went back to work a couple of days a week, thankfully, I was only gone for, like, six hours at a time because I was working for myself, so I could control that. My nanny could barely get her to take 2 ounces out of a bottle during six hours. And, you know, I'd come home and I'd breastfeed her right away, and we'd still sit there for 45 minutes to an hour breastfeeding. And then she would fall asleep, be all gassy and fussy, and then we'd do it again an hour and a half later. And here I was thinking this was normal. I thought this was normal. And I was like, well, now I understand why, you know, Europe and these other countries give moms a year off from work. They have to feed their babies, around the corner, walk. And then I learned better.

I mean, there's definitely some overlap. And, you know, I don't know if she has, like, food sensitivities or anything. And so maybe, like, the absorption of the milk she was getting or her tummy just hurt, and so she wanted. She wanted smaller amounts. But, you know, there are babies in any of these that, like, especially with this fat, farty, fussy one, like, they may have true re. Like acid reflux, too. Like, it could be the air. The air aphasia, and that's part of it. And it's like, also acid reflux. So, yes, I mean, there can be babies that kind of fit in a little bit of all of these. But, I mean, a lot of times I find that I'm like, oh, that's this one. Or. And it helps me as an IBCLC to know, like, which questions to ask and how to help these parents. And, you know, for the parents that maybe don't want to go right for the release or they need a little bit more time to think about it so that, you know how you can help them and also what you can tell them to watch for. Yeah.

So, yeah, the other thing I'll add to is we get a lot of parents calling around, like, three, four months of age because, you know. Yes, that's usually the time the mom is going back to. To work if she is after her maternity leave. But also we know that the. The reflex integrates, the automatic reflex, you know, where they're just kind of living off that feeding reflex, a swallow reflex. And then all of a sudden, it's supposed to integrate to a certain degree, and it's volitional. They get to choose whether or not they eat at this point. And so when that starts to happen, you know, around four, five months, we get these phone calls and moms are like, my child, you know, it wasn't great, but at least they were eating. And now they've just stopped. And we're like, well, that's, that's problematic. So, you know, there's so much that changes during the first year of life. There's so much growth or so much, you know, reflex integration and just all these different variables and skills developing and, you know, just.

It.

There's a lot going on. And feeding can be such a challenge if a couple, couple little things are off. And I posted this image on Instagram recently with like 10 buckets. I call them like the 10 bucket analogy or metaphor or whatever you want to call it. And, you know, I try to explain this to parents. If you've. If your child is swallowing air, there goes one of the 10 buckets. And your child is, you know, maybe they do have real. They have actual acid reflux, there goes another bucket. Your child is, you know, and you can just keep going on down the list, but every single symptom takes away energy from them being able to successfully feed. And when we start to look at the capacity that our infants are working with to try and feed, you know, let alone mom is on her own, like low level of buckets to just being a new mother, being in that, that postpartum phase, it's. It starts to really make people realize, like, these are not just little babies whose jobs are just to eat and sleep and, you know, exist. They're. They have some hard work to do. And if they are not functioning at full capacity, we really need to step in and we need to act quickly. We need to intervene fast. We don't want to put them on a wait list. We don't want to say, oh, you know what, this is fine, let's reconvene in a couple of weeks. If they're struggling, we need to get in there now. So again, another conversation for another day, but just made me think of that, that whole topic.

Yes. So, Jennifer Tao, that's an ibclc does the master IBCLC class recently just did a online class on older baby breastfeeding difficulties. And she talked about exactly that. That when you have a new baby, you know, if they have food sensitivities or their latch isn't optimal, they're swallowing a lot of air and they're uncomfortable, they'll still go back to the breast because they want to eat and they want to be close to the, to the parent, to the mother. And as they get older, a lot of things become volitional and they will start to realize like, my stomach hurts after I eat or it's too hard. And you know, not that taking a pacifier or taking a bottle is a milestone. It's not something that like, oh, we need to make sure every baby could do it or there's something wrong. But when I have a parent come in and they say that they can't get their baby to take, like I like a three week old baby to take a pacifier, that's red flag. Or yes. Or we're like, you know, we tell parents to introduce a bottle. If they want their baby to take a bottle, at some point they should introduce one because of that sucking reflux. Around three to four weeks postpartum, even if it's just like a snack feed, a half an ounce doesn't even have to be a full feed. But to do that regularly and if they're struggling with that, that early on, that's a red flag too because sometimes babies with ties can breastfeed but can't bottle feed and vice versa. So it's, there's so many things to watch for and. Yeah, yeah, definitely. And I also tell parents, you know, when we first start nursing a brand new baby, we do sometimes do have the breastfeeding pillows and we have to sit in a certain area, we position the baby. It's like learning how to drive a car. When you first learn how to drive a car, you're white knuckling the wheel and you have your hands at 10 o' clock and 2 o' clock and you're remembering every single thing you learned in driver's ed and you don't want to have to change lanes, like if you have to merge, oh my gosh. And breastfeeding is a lot like that. You're like, okay, I gotta get the baby latch. But eventually, like you should be able to not even look down, like you just pick up the baby, put them to the breast, eat a burger or whatever, like answer the front door, play with your toddler. And for most women now, there are some that if their breasts are like very large or something, they might need a little bit more of a prop or something. But for most dyads, breastfeeding should get easier. Breastfeeding, a carrier, all of those things. And so when you have a three and four month old and that mom is still Having to use the My Breast Friend pillow and can only breastfeed in one position. Like, that's not. That's not okay for that mom or that baby. Like, that's. It's. To make it that hard. And I think that's part of what my passion is, because I want moms to get to that point when they're breastfeeding, when they're like, oh, this is why people do this. Like, I enjoy this child.

Yeah, that's why that was me. And I was like, oh, oh, oh, okay, I get it now.

This is what it's supposed to be.

Like, yeah, okay, now I get it.

Wow.

Wow. What I went through with Lily that I thought was normal at the time. So far from normal. And why did nobody tell me that?

Exactly. I mean, I just think that every. Every mom deserves to have that experience. And so, you know, then there's the sneaky oral ties. And these are hard for me even, because I was listening to your podcast the other day with Sephora, and you guys were talking about the gray area, and I feel like, you know, the babies that fall in this. It's hard because, you know, first you want to be. Have a therapeutic presence and listen to what has been going on, and you want to meet the parents where they're at. And you kind of mentioned it, too. Like, sometimes there can. Sometimes there can be oral restrictions, but no significant breastfeeding issues. Like, I have had that. I've had parents that are like, I'm okay with nursing my baby frequently, and they're not super gassy, and I'm going to bed, share with them, so I'm going to nurse them all night long, and that's going to help drive my supply. And they're breastfeeding through maybe some compensations, but they make it work and it doesn't feel hard to them. Maybe the struggles will show up later. Maybe they'll come be knocking on your door because they're having difficulties with chewing stuff, solids or speech issues and snoring and airway issues and sleep apnea and dental issues and orthodontic issues. Maybe they'll have to get a palate expander when they're older. Like, these are the things that. Like, my crystal ball doesn't work. I can't say for sure. And I think these are the situations where we just have to tread lightly and be careful because it is what is giving this whole thing a bad reputation, because sometimes these are the. The tetherburg babies that get released, and there's so many other issues going on, but now we have a train wreck. And, you know, sometimes if breastfeeding is going well and they're breastfeeding well and we release ties, and then it can become horrible.

I don't want to be the one who rocks that boat.

No, I don't either. So I'm, I'm always like, you try to give the parents all of the information and help them maneuver through that, and hopefully they're open to body work. But I think this is something that isn't talked about enough. I've heard you talk about it on your podcast. What about those babies that may be doing okay? And we know that that might not be the situation when they're older, but we don't.

How do we don't have a crystal ball. And I think that's. It's a conversation I really enjoy having because I know a lot of people are uncomfortable in the gray and people are uncomfortable with the unknown. And I think for me, it becomes more exciting because I'm like, ooh, this is like a discover. Like, I get to be a detective. And really what I'm looking at when I look at these, these patients is function and functional impact and optimal function. So if baby is functioning and functioning well and they're. And they're really at this point in time, there are no feeding concerns and there are no airway concerns and mom is functioning fine. I do not want to rock that world, but I will absolutely arm that parent with information and educate them so that they can come back to me if something changes. Like, hey, if this starts to happen or you start to see this, or when you introduce solids, you know, you start to see this happening. Like we call me, we're going to have a con, like, we may want to bring you back in or, and. Or for a parent who's a little bit more nervous or anxious, we might say something like, come back in three weeks, come back in a month, come back in six weeks, depending on how old their baby is. Let's just do a check in, right? Because we don't want to wait and see. I believe more in the watch and see approach. Like, let's keep our eyes on this baby, but let's not intervene just because down the road we know this child probably will struggle with this, that or the other. None of us know that. And anybody who tells you that is there are practitioners out there who will say, oh, nope, if there is a tie, you 100% need to release it. And I'm over here going, no, no, no, no, no, no, no, no, no, because it's not a tie if there's no functional impact. It. It's just a frenulum. It might be a tight frenulum, but it's only a tie when function is impaired. And of course, I just saw a speech pathologist actually post.

A.

What was it? Article that was. It was from Shaw. It was a research article from Shaw 20 et al. 2020. And, you know, they claim that. I want to go back. I have it right here. But the limitation of this study. Okay, I'm going to tell you the limitation, then I'm going to tell you the title. The limitation is that they did not specifically look at the function of the structures, but rather. Rather they just looked at the anatomical. You know, they looked at the anatomy. Okay, now this, I'm pulling it up on Instagram right now, if I can find it, because someone DM'd it to me, so I know I can pull it up quickly. Here we go. And what they. What the article was, the title of the article is Upper Lip Tie Anatomy Effect on Breastfeeding and Correlation with Ankle Glassia. It was in the laryngoscope. Okay, so that is a very misleading title because here you're telling me that this is about upper lip tie. We're talking about anatomy effect on breastfeeding. Hello, Function and correlation with ankleoglossia. But the one limitation of the study is that they didn't look at the function, the structures. They just looked at the anatomy. Well, that doesn't tell me anything. So here they're trying to basically say that lip ties are unrelated to breastfeeding and that we don't actually have to flange as wide as we thought we had to flange for a proper latch. And, you know, and this is dangerous territory because this is being posted by a pediatric SLP who does feeding. Right? And I responded and I said, diagnosing a tie versus a frenula must involve function. That single limitation makes us a study about simple anatomy, not clinical application. And that's where we really need to dive into things like this, because we're not talking about function at all. We're looking at anatomy. And it's not about the anatomy. I mean, yes, it is, but it's.

It.

Function drives everything.

Everything. Yeah, that's why we can't diagnose from a photo, even though there are people out there that are trying to do that. And, you know, there are providers that firmly believe that all ties have to be released at the first couple weeks of life to have best outcome. And so a lot of times what happens is I get the babies on my list in my appointments that were released really early on, and things didn't get better because it wasn't the right time to be released. The prep work wasn't done, and maybe the baby didn't need to be released at all. I don't know. I didn't see them before. And so, I mean, I get families that saw other IBCLCs with a first baby and went through the whole release process. And then afterwards when they thought about it, they were like, did that really need to be done? So that's the other thing is, like, making sure that the parents have all the information they need. And honestly, sometimes it is waiting to see what's going to happen with the function. So they have to know 100% that that release that was done needed to be done. And so that's been a challenge to, like, be able to walk parents through that. And I do, I do love it too. Like, I love walking them through that and giving them the information and helping them make the best decision. But then you run into situations where, you know, their doula or their midwife or they're like, just go hat. Like, everybody now thinks that they can diagnose a tongue tie and that a tongue tie needs to be released right away. And, you know, it's. It's hard because I feel like sometimes we're doing all the cleanup for that, and I just don't think that's being talked about enough. And that's, that's like the big struggle for me right now.

Yeah, I completely agree with that and I apologize for any background noise for our listeners. My, my yard is currently being mowed.

Well, I live by the Air Force base, so the jets were flying over earlier, and I was like, oh, she'll say something if it's no, I didn't even hear it.

But, you know, I live next to Walter Reed, and we get, we get the helicopters back and forth to Walter Reed National Medical center, like, all day long, direct flight path over my house. So I'm. It probably. I wouldn't even hear it, honestly, at this point, because it's like ingrained in my brain. But, you know, I think that we bring up some really great points. And I think the other thing to highlight is even as these kids get older, and I know we're really focused on the breastfeeding diet, which can go until an older age, I know in the US we're not used to that. That's not the norm here. But yes, people do feed their Babies like well beyond four years of age by breast, you know, in other cultures and countries. But when we look at some of these kids, I actually saw a post today in a Facebook group where a, an RDH had said, you know, well, this kid went and got released. We only did a couple pre op sessions. The parents basically, you know, we have situations where sometimes parents don't listen and release providers will go ahead and do it. And they did suture this child up. They couldn't get the child to elevate the tongue, remove the tongue at all pre op. Well, guess what? It's not going to change post op. It's not. Because it's not. Yes, it's related to the tethered tissue and the tongue being used to be down there. But what if the child has CP undiagnosed? What if this child has a apraxia that's undiagnosed. What if this child has a motor coordination disorder and they physically do not have the motor brain connection. And I'm saying it like this, like you know, that neuro connection in place to physically follow a direction and elevate their tongue and move it all around. Well, now we have a situation because now we've changed the anatomy and this child is left to basically fend for themselves. They were compensating with what they had before. They're going to continue to compensate. And that's why this whole discussion of like when is it the best time to release is so individual. We can't just, you know, do I see really great results if we get in there pretty quickly with little ones? Yes, if you're trying to avoid pre op and we know there's a functional feeding issue at play or an airway issue and we're getting in there and we're dealing with this in the first couple weeks of life. Can we get away without like tons of pre op and maybe just a little bit of body work and. Yes, absolutely. Okay, I'm not going to. I've said that plenty of times in the past and you know, people have their different guidelines for, for this. Some I've heard people say the first four weeks, the first five weeks, the first six weeks and I'm like, whatever. Okay. We're in that range. Beyond that, these children need to be prepped, otherwise you are doing a major disservice to their ability to function. And we have two goals in life that keep two things to do that keep us alive. Right. Breathing and eating. And we are messing with both of those when we release a tongue that is not ready to be released. And that is why, honestly I feel like that's why we have so many practitioners, medical practitioners out there, who are basically calling it a fad or saying that this is over, this is being overdone and everybody has a tongue tie now. And because there are practitioners out there who are carelessly releasing babies, tongues and older, you know, children and adults too, when they are not ready for it yet. So I really think that this is, this is the big conversation that everybody needs to be addressing. We need to be clear, collaborating, we need to be working together, we need to be having some kind of. I had Rashida Jaju, who's a local pediatric dentist in the Virginia area, on the podcast recently and she's actually going to present for the MYO membership in July. And she has this beautiful stoplight system. And I won't give the whole thing away because that's her thing. But the practitioners working with the child have to sign off on it with her. Not and say like green light, this child is ready. I can tell you those patients who are ready for release have the best outcomes following release. The parents are prepped, the child is prepped. It's so the anxiety is there. The anxiety is not as high. These children and parents are not in this fight or flight post op like these parents where they're not prepared. We are doing a major disservice. And I'm just waiting, I am waiting for the lawsuit from a parent who decides they're pissed off about medical malpractice, their child getting a release and not being given all informed consent and this, that and the other. That's going to totally disrupt this, this whole process because it's going to happen with the amount of people getting into the tots release space and not properly prepping patients. And I just, you know, I'm not a pt, but I've heard people compare it to knee surgery. Okay, yes, you have to prep for knee surgery. There's thing called pre op for knee surgery, you know, and then there's also post op and it's quite a bit post op. Why do we think we can release a tongue again tied to like our two most important jobs in life, breathing and eating without surrounding preparatory activity and post op, you know, treatment that.

This is where my orthos. Yeah, this is where my ortho stuff like comes back and I'm like, oh my gosh. We would, they would meet with a dietitian, they would meet with pt. They would be addressing those things beforehand if it was an elective knee replacement or hip replacement. I talk about that with my families a lot. Then when it's the dyad, you're talking about mom's nutrition and just where they are. Are you going to be able to do the exercises and are you going to be able to do the body work? Are you ready for all of that yet? You just pushed a baby out or had a c section 5 days ago. Can we give it a week before we do this? And I do have some clients that the baby is three, four days old. And I'm like, yeah, you can go today and have that released, because you could just tell that this tongue is. Just wants to be released and it's going to move. And yeah, definitely. Being prepared is so incredibly important. And, man, I thought I again, I thought I was just gonna help him pick out nipple cream, right? Breastfeeding pillow. And now I'm like, you know, having to talk about oral rehabilitation and, you know, motor skills and just all that stuff. With babies. With babies. It's just. I love it. Obviously, I love it, and I will take all of the classes and do all of the things because I just think it's so incredibly important. I'm in the middle of learning about cranial sacral therapy through Carol Gray, and it totally got interrupted because of COVID I actually was there last March 2020, when it all went down and had to fly home early. So it really stinks. But I don't know that I'll be a cranial sacral therapist and hang a shingle for that necessarily. But, man, it has helped me learn how to really assess and read a baby's body from the tip, you know, to the top of their head to the tip of their toes. And allopathic medicine likes to compartmentalize everything. And so. So that's why people think the tongue is the tongue, and it's just there and not realizing that the tongue is also connected to the tip of your toes and all everything in between. And, okay, we just got a bad review, like, not too long ago.

I love that you're smiling and laughing about it.

I feel bad. And I did reach out, you know, to the parents and tried to work through it. But here's the thing, is that part of what was said. It was one of my subcontractors that saw the. The dyad, and one of the things that was said was they felt like the lactation consultant was asking questions about things that had nothing to do with breastfeeding, and they just thought that that, like, that she was judging them or that that was. What was the purpose. And the thing is that we do. And you do this too, because I've heard you say it. We ask about everything. How does your baby sleep? Where does your baby sleep? What are you eating? Do you wear your baby. What kind of orthodontia did you have growing up? We're asking all of these questions because it all paints a picture to tell us where we're at at this moment. What kind of medication specifically? Maybe antibiotic exposure? Have you had. Were you a child that had strep a lot and had a lot of antibiotics? Did you get antibiotics during pregnancy or labor? Like, all of these things make a difference. So I think that for some families, it's really important to be able to explain why we're asking so many different questions. What happens with this baby throughout the day and night of. Affects breastfeeding. Yeah.

And I like to tell parents that. I like to say, look, we're going to ask you questions. And I am sure that you saw, like, the slew of questions on the intake that you were probably like, how is this relevant? It's all related. It is all related. And we don't. You know, and the one thing I've heard other people say that I love is that we don't. Our body doesn't operate in silos. Everything affects everything else. And our entire full body health starts in the mouth. I love that there are these holistic dentists that talk. Talk about how every ailment throughout the body begins in your mouth. And when you start to look at it that way, and then you look at that picture of fascia that, you know, circulates Instagram. I always forget who the originator of that photo is. It's out of a textbook, but they show you how you're quite literally tied from the tip of your tongue. Not tied, but fascia is connected from the tip of the tongue down to the tip of your toes. And when you realize how interconnected fascia is throughout the body, you start to go like, oh, so if I have tight tissue here and it pulls my hyoid bone maybe up and forward, and then that can, you know, that changes the position of my esophagus. And then, oh, okay, well, now this all starts to make more sense. Like, nothing's really sitting where it should and everything's kind of off. And if we can release some tissue and do some body work and get things back in alignment and get things functioning properly again, you know, it seems like just such a little procedure, but what you're doing is you're actually disrupting the entire body by having a procedure you're not ready for. And that can send a child into fight or flight. The other thing I like to tell parents too is even when you are prepared that not every child comes out of this feeding like a pro. Right? It takes time. We have to continue therapy, like, and I want everybody going in expecting they're going to have to continue therapy afterwards. We need to continue body work. There's a healing period. Here's, you know, I want them to have all the education that way. And look, do some of those kids like you described with your easy peasy oral ties, like, that was mia. She was released. And I was like, I quite literally didn't have to do anything surrounding feeding. Now she did need bodywork and she was in PT throughout her first year of life. And then I took her to CST and an osteopath. And you know, she was never delayed, but was always teetering on that borderline of being a late crawler, being a late, you know, and she dragged her right leg behind her when she crawled and when she went up the stairs. And you know, it was very interesting to watch how it impacted her differently. But she, she had, she was kind of like that torticollis like presentation. Both my kids had tight necks. And so while for her feeding became pretty easy, it impacted her in other ways. And you know, and that's another thing that we need to, to consider. And that's why people say, well, is this bodywork stuff? Like, you know, I don't even understand what they're doing. Is this really worth it? Yes. The answer is yes. If you are somebody who knows what they're doing, yes, 100%. Even though they may appear to barely put their hands on your child, if they're doing craniosacral work or osteopathic work, they are making sure that systems are working, things are flowing, your child is, you know, healthy and it's, it's very cool to sit down with these individuals and to hear them explain what they do because it's, it's both fascinating. But I've also been the patient now, and now I understand the difference between how I was functioning before that treatment and how I was functioning after that treatment. So yes, it's absolutely worth it.

It's so, so worth it. And with babies, we are also asking, like, what position was your baby in utero? Did they prefer one side or the other? Like, what happened during the birth process? All of those things. Because some of what went on with Mia might have been, like, her position in utero that. Yeah. Cause those tension patterns. And when I worked in the hospital, we had this pediatrician that was a do. And when he would come do rounds, he would do osteopathic manipulations with the babies. And so sometimes we were like, you know, go do this baby. For sure. It was a vacuum extraction or whatever. And he would go in there and just chat with the. You know, was his. His patients. And he would chat with them and talk to them and do, you know, just five minutes of some adjustments. And often the breastfeeding would go so much better. And I'm like, oh, that would be so great if they had an osteopath that could just go around or someone that did craniosacral and just go into all the hospital rooms and do that with the parents. So I'm a huge believer. I think every baby and every mother should get adjusted or have bodywork or whatever modality it is that you're comfortable with. Yeah, it would. It's such an amazing benefit. So. And you were talking about, like, you know, sometimes the release is done. I have families that sometimes the release is done, and then they're like, the baby's clicking now, and I'm like, yes, okay. It's something different, like, and that probably means that the tongue is moving differently, and we're gonna. We're gonna optimize that like, that sometimes the clicking gets worse before it gets better. And sometimes the tongue couldn't move at all, and there was no clicking, and we release it, and it's trying. It's trying. And it gets pulled back, and we're like, okay. So I think, yeah. Oh, my gosh. I know. Probably talk about this for all day about this, because we have to. This is what I love about the last couple of years and social media is I don't feel as crazy anymore because I'm like, oh, Hallie sees that too. And, you know, Autumn like, sees and just all of these different people, and I'm like, okay, okay. This is not. I'm not crazy.

Yeah. Yeah. Well, and I think one other thing that you had mentioned, too, that, you know, sometimes we get these families who maybe are not ready to release or who don't want to. To do a surgical procedure. And we have to also realize that we may know what we know as clinicians, and we may feel like we know what's best, but ultimately, at the end of the day, it's up to that family. Right? So we sit here and we preach this stuff and you know, we're very pro tots, release when it's necessary and all that fun stuff. But I also think that we have to reel it in a little bit and not never make a family feel guilty, never make a family feel, feel like they're failing their child. Never make a family feel like, well, if I was you, I would do this. So I don't understand why you're not doing. I mean, because ultimately, at the end of the day, it's the same thing in all medical procedures, informed consent and the patient gets to decide what they choose and what they don't choose, and that's on them. And you know, and that as a, as a parent, you know, there are certain things I've decided for or against for my own children too. And you know, that's, that is your right as a parent. So we can still support and work with families, you know, to the extent possible given, you know, a lack of tongue tie release, even though we feel like one might be necessary. But you know, we also know that they're going to compensate in those situations. They may compensate well or they may not compensate well. And then that sometimes, you know, I always like to be gentle because I've had families who are like, nope, nope, we're not doing this. And then teachers, two weeks later they call back and you're like, okay, we're ready. What's the next step? You know, and so I always like to leave that door open and try to do the best that I can do for that family and that child because you never know, you know, they might change their mind or they might not. And again, you know, I'm, I respect that parent's decision and just, I try to do my best and if we hit a wall, I'll be the first one to tell you, look, this is the best that we can do right now with the anatomy in play at play. So, you know, I respect your decision, but I think this is, you know, this is what we're looking at. So anyways, I felt like we could, you know, start to wrap up on that note. I know, like, we, like you said, like when you went to the IACP conference for four, you're like, what can they talk about for four days? Like, I don't know, I have 115 episodes now.

So I know I, I was, I definitely, I remember telling Dr. Agarwal like, well, now I have to, to go because I can't even imagine what they're going to talk about. So there's obviously a lot I don't know.

Yeah, it's so interesting. But how cool of you to be like, so open to it. And, you know, and, and that's where I feel like the best practitioners are, those who are open to being told, you know what, what you used to think is actually wrong, or things have changed or we have new information, you know, consider this. Have you taken this into account? You know, and it's kind of like when you remain open to that. Like, and it's funny too, because my family will tell you I'm the number one person who could never be wrong as a child. So for me to be vulnerable enough as a practitioner to be like, prove me wrong, tell me something new, change my path, change my mindset on this, you know, it's kind of like come full circle. So it's a funny topic in that one. But yeah, the best practitioners are really those who are continuing to be. Hone their craft, you know, and listen. They're listening to their families, they're listening to the patients and really trying to figure out how can we best treat them. So thank you. Thank you for your work.

Thank you. I appreciate. This was really fun. It was.

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