Episode 246: Beyond the Latch: Understanding Lactation and Collaboration with Jeanne Pichoff

Hi and welcome to episode 246 of the Untethered Podcast. Today we have Jeanne Pischoff joining us. John has over 19 years of experience as a pediatric occupational therapist. She's worked in a variety of pediatric settings including the NICU outpatient clinics and the state early intervention system. John owns it, operates a private practice in Louisiana, Flourish Pediatric Therapy and Lactation llc, which is focused on the niche areas of infant feeding, lactation support and early intervention services. After a complicated breastfeeding journey with her second child, she decided that lactation knowledge was critical critical to any therapist providing infant feeding services, and pursued a credential as a lactation counselor before ultimately becoming an International Board Certified Lactation Consultant, IBCLC in 20 in 2020. She's passionate about her clinical work combining lactation support with OT to help families achieve their feeding goals. She loves teaching and has online courses to support these areas covering topics like failure to thrive in breastfeeding infants and impacts of tongue tie on breastfeeding. As well, she also provides online parent education courses in on breastfeeding and transitioning to solids. 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, Holly Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner 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, airway, tethered oral tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019. Thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. John, welcome to the podcast.

Hi, thanks for having me.

I'm excited to chat because you have some really fun maybe expertise as we should call it that I don't have in my repertoire. And so I'm excited to jump in and you know, have you really share with everybody your journey and why, you know, as an OT pursued lactation credentials.

Yeah, so like many people who went into lactation, I was the fire was lit by a personal experience, but not entirely. I mean I've been an OT for almost 20 years now. And probably about a decade ago, you know, I was really niching down to infant feeding, seeing a lot more infants because that is just what I love. It's my passion. Yeah, I was taught on a bottle feeding norm like most therapists out there. And I was, you know, was also learning a lot about tongue tie. About a decade ago, you know, I was getting more infant referrals and a lot of these families were breastfeeding and they had breastfeeding questions and I honestly felt kind of incompetent to help them with that particular part of it. But when you're talking about a feeding referral, that's a really big part of the puzzle if you have no clue about anything related to mom supply or positioning or latch. So I decided that it might be a good idea to pursue some lactation credentials. But I got pregnant around that time and I assumed that I would have this easy peasy breastfeeding experience because my experience with my first child was relatively problem free and we breastfed for 18 months. But you know, life laughs at you when you have these expectations. And we quickly were on the struggle bus after he was born, he, he had a very prominent tongue tie and so I got to experience firsthand excruciating pain, conflicting information from multiple pediatricians and lactation and all the things in our journey. And long story short, we ended up with a partial release of his tongue which didn't do us much good. Ultimately pursued a full release with a dentist. We ended up doing just fine and breastfeeding for a long time. But the experience just made me mad, honestly. And I was like, you know, reflecting on it and I was like, you know, if I did not have the background I had and know the resources around me, we would not have made it, no question. And I just felt like it shouldn't be that difficult for women to find help in their breastfeeding journeys. And so I was like, I'm going to be the change that I want to see. I'm going to pursue lactation credentials and combine these worlds. And at the time that felt a little crazy because I didn't know any other therapist who was in this area there. I mean, social media is a blessing because that's the only way I connected with like minded professionals. But back then that was just a weird thing, you know, or a rare thing. Most of the, most of the lactation professionals around me were nurses and they were mostly, you know, working with moms and not so baby focused, I guess, or don't have the same scope that I do for the baby side of things. So it took many, many years. Of course, I started out as a CLC and decided I wanted to go all the way and pursue IBCLC and finally achieve that in 2020. And I've never regretted it, and it's been wonderful. And I feel like it's a great marriage of skills that works really well for my clientele. And of course, now space, like, more and more therapists, I think, are getting this and understanding how important it is to understand something about lactation if they're working with infants. And so this is not such an unusual thing anymore, but that's kind of how I ended up. It was a combination of, like, ooh, professionally, I don't feel great about my knowledge base in this infant feeding space. Plus, oh, boy, the fire was really lit with this personal experience and having been through it myself. So, you know, yeah, it's amazing how.

Our own children can really light that fire. Right? Yeah.

I mean, that second kid. So we completely changed my career. You know.

That was my first child, and by the time I got to the second, I was like, okay, I feel prepared. But also then she taught me a whole bunch of other things too, that I didn't have to, you know, that I didn't really get thrown. It was a different pathway. Very, you know, similar presentation at birth, but different pathway. So anyways. But do so now with more professionals in our space, like OTs, SLPs, getting lactation credentials. Do you feel like it's almost, I don't say mandatory, but do you feel like it's such a pertinent part of, like, the work that we do? Because you alluded to that. You mentioned that, like, it does seem like an important piece of the puzzle when working with infants, especially.

I do. I think if you're going to be looking at an infant and trying to fix a feeding problem, you, at minimum, should have a baseline understanding of breastfeeding. Or you better have someone that you're collaborating with, like an IBCLC who knows something to help mom, you know, because if your client is breastfeeding and you know nothing about that topic, you're missing a huge, huge piece of that puzzle. How are you going to truly impact that family if you have half the knowledge base? So I really do feel like it's critical. I feel like every medical professional who is intercepting dyads, especially in that newborn period, should, including pediatricians, have a baseline understanding so we can avoid this crazy mess of conflicting information that Families often find themselves wading through in those early days and those early days that birth to four week period is so crucial for family success. And it is so easy for families to get lost in this sea of conflicting information. TikTok social media on top of everything, they're hearing from their doctors and lactation professionals, et cetera. And that's one of the biggest complaints I hear from families is just they don't know who to listen to. And they even get conflicting information from lactation and from therapists and it's like no one agrees with each other. What do we do? And I get it, it's so frustrating, but so much of it is like basic breastfeeding management understanding isn't there. It's just not. Yeah, so we can do better.

No, we, we hear and see all the same things. I have a private practice and you know, I hear that and see that frequently say, you know, obviously I teach courses, I have a CEU platform. Like we hear that from therapists all the time. And it's, I think it's one of the biggest frustrating pie. One of the other things you said too was mom versus baby. Right. First, but you know, what you're trained to treat and who you're trained to treat because assess and treat, I should say, because I do feel like there's a diet, I feel like there is a dyad here. Right. And I feel like there is not enough education on both sides. Right. So you've got maybe a lot of SLPs, OTs who take feeding courses and they're really more focused on baby if it's not breastfeeding course. And then you've got the breastfeeding, you know, specialists, whether they're clc, ibclc, what, you know, whatever the credentials are who are maybe more tuned into understanding that there is a dyad at play here. But they're, they may not have the scope depending on their other. They have other credentials or not to actually go into baby's mouth beyond like suck training. Right. So can you speak to that a little bit? Because I feel like you'll have a really good handle on that conversation.

Yeah, I agree 100%. And I know like as a therapist who didn't have any lactation background, I definitely felt like the baby was my domain and especially the mouth. You know, as a more immature therapist, I was much more focused on like oral motor sucking. That's my realm. And now knowing more, I just have an appreciation for, I have to understand what's going on with both parties to be able to prioritize intervention, because, let's be real, postpartum is a fragile, hectic, unbelievable time in every mom's life. And when we're having a feeding problem, that stress is compounding 20 fold. And we simply cannot ask parents to do 8,000 things to fix a feeding problem. We have. If we have a baseline understanding of what's going on with mom, what's going on with baby, we can pick what's top priority for this week. Like, how do we get them in a more secure, stable place to help them move toward their goals? Realistically, it's usually something on both sides. It's rarely ever just baby's issue or just mom's issue sometimes, but often it's just a complicated dynamic. And when we're breastfeeding, it happens in a dyad. We cannot extricate or separate these two parties in this situation. So if you're a therapist who doesn't understand anything about how milk supply works or anything that could be going on with mom that's impacting things, how are you going to help them navigate this? You know? So again, I think those collaborative relationships are super important for therapists who are new into this space and who are just learning so that we ensure that we're prioritizing intervention and not missing something really important in those critical days. Yeah.

You said another key thing when you were. When you were speaking, which was, what, what's mom? Like, what are the goals for that feeding dyad? Not what are our goals for them? Like, what is their goal? And how do we get them into, like, basically a more functional feeding place this week? Like, what can we do today to help kind of move the needle forward and help them feel successful and help baby, you know, help mom nourish baby. Right. In whatever way that's going to be this week. And I love that because I think so often, too, I see a lot of therapists take a course, they've got their treatment plan in place, and we're like, okay, you can't have a treatment plan without a dyad. Like, you. You have to meet them and find out what their goals are and what did. What do they want out of this? And so I think so many have moved away from that. And. And I think a lot of it, too, is fear anxiety. As, like, a medical professional kind of going, like, I want to help, but, like, this is what I was taught, and so this is what I'm going to do. Well, no, like, let's. Okay, that's important. But, like, let's take 10 steps backwards and remember that you're dealing with humans and you know, so yeah, I just, I love that you highlighted that because at the end of the day it's their goals and we are basically here to help them achieve those goals while also trying to gain function like the best we can today. And sometimes that means supplemental aids, compensations like whatever may need to be in place today so that we can be successful right now while we work towards maybe the longer goal that the parent, you know, or the dyad.

And those goals are very dynamic. You know, a lot of families have this goal of we're going to exclusively breastfeed and you know, I'll get them in. And it's like, okay, we're two months old and this is a train wreck of a situation. We're really far from that goal. So let's talk about like, what can we do first? See if this goal is feasible long term. And we're not going to know that yet without digging in deeper. And then as information starts to unfold, as the picture becomes more clear, then sometimes parents have a shift in what they want. And so every single visit with families, I'm always asking, checking in, how are you doing? How does life feel right now? You know, have your goals shifted? What does a perfect feeding situation look like to you? You know, and how are we, how are we coping with everything that's going on?

Yeah, no, I think that's beautiful because like you said, I mean, nothing is set in stone. Right? People change. And I think that it's so interesting whenever we have this conversation because I'm like, like you mentioned, there's just, there's a wide range of what goals look like for families. And so I like that you also highlighted that goals can and do change over time and it is our job to check in. That should be one of the first conversations that we have. You know, like whenever, you know, I'm not treating right now, but when I was treating and I would go in and I was often collaborating with lactation because I didn't have lactation credentials, that was always, how are things going? What's, what are, what feels really good right now? What feels really hard? Like, what is our struggle this week? What are we working towards? Like, what can I help you with today? Right, Because I think when you just ask some of these open ended questions and we don't like project, but we go, we recognize that some things may be going okay, and let's highlight those because that will feel us like warm and fuzzy and good. But also let's also recognize we're still working towards some things. That's why you're here. And really, what can I help you with today? I think that you just get. Sometimes it's like mind blowing, right? Some of the responses and things you never would have even expected to come out of a parent's mouth. You're like, oh, okay, great, yeah, fantastic. But let's do it.

I do feel like so many moms feel or have the fear of being judged. Especially I think there's a perception, you know, that lactation credential, like lactation professionals are like, we're only here for breastfeeding. Right. Like, it's breastfeeding or nothing, and breast is best. And, you know, I think for some, that is the case, but for the vast majority of us, we just want to support families, and breastfeeding does not have to happen just one certain way. Exclusive pumping is breastfeeding. Combination is breastfeeding, you know, and so I think there's this fear of judgment. And so if you just open the conversation up to be like, anything you want to do is okay with me. My job is to give you the tools to get where you want to be, wherever that is, and it's okay if that changes as well. And when you just put that out there, the relief on their face is amazing. Because I've had so many moms who are like, they come back a week later and they're like, you know, I have just anxiety about this original goal, and I feel so much better with what's been happening this week, and I think I want to stick with this. And I'm like, awesome, that's great. You know, it's. I'm completely okay with that. And you should be too, you know?

Yeah. Well, it's like giving them permission to follow their maternal instinct and do what feels best for them and their child, like, you know, instead of projecting on them. And that's what society thinks, right?

About how, like, so much of parenthood now is, like, working against our own instincts, you know, because we're just dealing with this overwhelming amount of information. So it can be hard to see the forest through the trees, especially when you're listening to multiple medical professionals.

Right, right, exactly. And so on. You know, one of those. Those topics that I feel like is heavily discussed, debated, and not well understood. Let's talk about growth and weight. Because I feel like, you know, in the tongue tie world, right. Weight is not always an indicator of oral dysfunction. Well, it's not indicator, period, but it can be at the same time, so will you talk about, you know, your experience around that topic from an OT and lactation perspective?

Sure. So I'd say poor weight gain is top five reasons that babies are referred to my practice or women are referred. You know, the dyad and tongue tie is also something that, of course, the understanding about it is increasing and it's everywhere on social media. And so I can't tell you how many women come in and they assume that, like, tongue tie is the reason that we're having an issue and we're here to confirm it, essentially.

Right, right, right. You're like, hold on, hold on.

You know, so again, this goes back to, like, understanding the breastfeeding dyad, because part of my intake history, parents have to fill out this huge form with questions about themselves and their medical history because it's a dyad and the baby as well, including the baby's feeding patterns and volumes of feedings. If they're bottle feeding and are they supplementing and are they breast and bottle feeding and what was the last weight and mom's medical history? Has mom had a surgery? Does she have any kind of hormone imbalance? Did she have fertility issues? Because. Because that is important with her ability to produce milk. So before I even meet with them, I have a decent sense of maybe what's going on. But I cannot do this blind without knowing something about mom's medical history and what's going on with her breasts and her ability to lactate and produce milk. And so often we end up with a combination cause of poor weight gain. And I think the maternal factors are something that most many therapists, that they don't have a lactation background, they're in the dark about. And so just to speak to a few of them, some of the reasons that moms may have low supply, which is contributing to poor weight gain in an infant. They may have a thyroid disorder, they may have diabetes, they may have PCOS or polycystic ovarian syndrome. Basically, anything that messes with your hormones function or any endocrine disruptor has the potential to result in low milk milk supply or milk production. If they've had a breast surgery, like a breast reduction or a breast lift, they may or may not have been counseled on how that might impact their ability to produce milk. Many are prepared ahead of time that it's a risk, but many are not. Many are told by their surgeons that it will have no impact. And I have certainly seen women who've had breast surgeries who've successfully breastfed, but I've had others who have been kind of slapped in the face, like, at that time, and just caught completely unprepared because, like, okay, what you're telling me is you had this incision around your areola, and the surgery was relatively recent. All of this doesn't bode well based on what we're seeing currently with your baby's weight gain trend. You know, another cause is if mom had a hemorrhage at any point, say she got into a car accident or she had a hemorrhage during birth. There's something called Sheehan syndrome that damages the pituitary gland, which is very important for producing a hormone, prolactin, that, you know, impacts your ability to make milk. We have retained placental fragments. So if mom gives birth and there's a little bit of placenta left behind that can secrete hormone that ceases or greatly reduces milk production, or we have insufficient glandular tissue. Mom literally doesn't have the anatomy, you know, the glandular tissue in her breast to make enough milk. And so all of these things are possible, you know, and this is within the IBCLC scope to tease this stuff out and figure this stuff out, you know, but it. We need a very thorough history and about a billion questions when mom comes in to figure these things out. And we also have to take into account, is mom taking any kind of medication too? You know, sometimes they're given steroids, you know, and delivery. And that can impact things, too. Birth trauma and the birth experience can impact milk production. If there was an immediate separation of baby from mom for any medical reason, that can impact how much milk she makes long term. So there's a lot of moving parts to figure out why on mom's end, baby might not be gaining weight because of a supply problem. But there are also baby causes, of course, and I think this is where therapists tend to shine. You know, this is the stuff that we're equipped to look at and handle. But again, if we don't have breastfeeding knowledge, we might still be a little bit in the dark about some of these things. But basically, any condition that results in poor transfer of milk from the breast, like a tongue tie, but it's not always just a tongue tie. We could have laryngomalacia, you know, something that's impacting baby's endurance. Maybe we have a cardiac defect that's impacting baby's endurance, or a metabolic issue that's uncovered, you know, as of yet, even though baby's taking enough volume adenoid hypertrophy in some rare Cases. I've had a few babies with really big adenoids, and it took a few months to kind of figure that out after working through some different problems. So. And even just preparation of, like, if baby is bottle feeding, what kind of bottle are they using? Like, hey, Advent bottles that don't work very well. I'm sure some therapists listening to this have had that experience with that new nipple. Yeah, I mean, sometimes it's just the equipment. And so there's a lot to figure out in the diet, in the context of the dyad, what is causing the low weight gain? You know, and typically, the first thing to look at is, is the baby getting enough milk? That's step one. Like, is mom supply okay? And if it is okay, how is the baby getting it out? You know? But those two things right there can be kind of complicated to figure out in itself. But if that seemed. Nothing seems dysfunctional there, then you have to do more detective work and digging. And so for, you know, if we're trying to work on mom issues, that might mean that we have to counsel her on pumping and basic breastfeeding management and feeding frequency. And we may even need to suggest lab work to figure out some underlying endocrine issues and whatnot to rule out all the things that may be impacting her ability to make milk. While we're working on baby side of the spectrum.

I love that you highlighted this very beautiful list because I, you know, we get calls and we're like, we need a tongue tie evaluation. And we're like. I was like, there's no such thing. That's part of a much larger conference. But we say, okay, well, what's. What's the concern? Right? You find out, like, what their main concern is, and then we go. Okay, you know, get you on schedule.

I'll give you a. A case example from several case examples. But just last week, I saw this precious family baby is about two and a half months old. And mom emailed me and said, our ENT wants us to see you before we release this tongue. Our pediatrician diagnosed our baby with a posterior tongue tie. And basically, we are struggling with weight gain, and now we have the cause. But our E.N.T. insists we see you first, which. Thank you, E.N.T. you're amazing. But so I see this family, and I'm looking, and this baby has fallen from the 75th percentile on the growth chart to the first in two months. Oh, wow. Yeah, like, off a cliff.

And mine never left the first percentile, so I can appreciate that. Big day.

She started way up there. And the mom commented that like everything was going really well for a while and then it sounds like it was just like the Swiss cheese effect where there were lots of holes in the system and they just fell through the cracks. So they had a pediatrician who was not very breastfeeding savvy who said, this weight loss is fine, you're fine, see you in two months. Which is another thing. Yeah, exactly.

No, no, no.

Some of the doctors around here, I don't know what it's like in your area, but most are great and we have a newbor and then we have a two week wait check in a month and then two months. So there's a lot of good follow ups and check ins as there should be. But there are also some pediatricians who will see babies in that newborn visit and then say, bye, see you in two months. And I can't tell you how many times I've seen absolute disasters from that approach because so much can happen in that timeframe. And if you have a family that's inexperienced, unaware, they have no idea that they're having problems until you get them in and it's like, oh boy, we need to call your pediatrician because this is not good. So anyway, to rewind, that is what happened to this family essentially. Now luckily this family knew enough to be concerned about what they were seeing. And they were like, two months is too long, we're going to find another doctor. But it took them a while and by the time they saw that doctor, this doctor clearly knows a little something about tongue tie, but not how to evaluate the big picture. And so the family walked away thinking that the tongue tie is the reason, you know. Now they also saw another lactation consultant before they saw me. And that person rightfully recommended to the mom, like, your supply has probably really declined at this point because mom was not pumping. Start pumping now to drive your supply up. And so mom started doing that and she had been pumping religiously from the time she met with that lactation consultant to three weeks later when she ended up in my office. But her supply was insufficient. Like she was giving 50, 50 breast milk to formula out of necessity. And the baby was gaining on a stable rate, but needed clearly half of his intake, her intake from formula. So that told me right there, you've been putting in the work, the milk isn't coming, something is going on on your end. Now we need to investigate that. So I recommended lab work. And now we're working through all these things, but I'm looking at this baby's oral function. And I'm like, this isn't bad. It's really not. This lingual frenulum is very el. Sucking is weak. But is it because we've had two months of serious caloric deprivation and this may get better as we start improving weight gain? That's entirely possible. And so here I am with another conflicting piece of information because I'm like, I have to tell you, I don't think tongue tie is the best. I don't think it's to blame for what happened here. I think you guys just ended up in this pickle because you had insufficient production. You didn't know it, you know, and this was a baby that was just very chill. Very chill temperament, you know, Happy never cued them. And those kids are out there and they're really confusing, you know, like, they're the ones that end up like this. They're just falling off the growth curve. And nobody knows because they just don't protest. And so this poor mom, she just. She thought she had the answer in the tongue tie, and that's what all of social media basically was, you know, reinforcing for her. And then I have to give her this information that we may have insufficient glandular tissue at this point. I don't know yet, but we're going to have to work through all of these other things to figure that out. And meanwhile, you know, we're going to work on your baby's body and strength and all of that, so hopefully we can get them to the best possible place where they're transferring. But I don't think a frenotomy is going to fix this for you. So.

Yeah, well, and that's, you know, I think so often it's like, if we can. Yeah, it's like, if we can grasp onto, like, a reason, whatever the reason may be, Right. Someone gives you like, oh, this is the root, this is the cause. And all of your, you know, it's. We kind of run with it because it's like, okay, great, now we know the reason. Like, let's find a solution. And I think it's. It's challenging because we get a lot of families, too, who will call us for this, you know, very similar situations. And we're like, well, let's look at it. Like, why are you looking at, you know, other things? Why are you asking me these questions?

Why are.

Because we also like a very, very thorough intake. And we're not lactation in my practice. We are that SLP OT side of the conversation that we've had so we're doing more. You know, we're definitely asking about birth history and certain things related to mom, but definitely not as deep as what you're. You're doing. But they're always very confused as to like, well, why can't you just fix this? Why can't we just get ready for that procedure? And we're going, well, would you like to maybe prevent a procedure? But we, we may not need this procedure. Like, we figure that out. And I've always been of the let's figure out the best timing and treatment plan for you and your child so that we can look and see. Like, my goal is always to avoid a procedure if we can, if we need it, by all means, you will be prepped and we will collaborate and it will happen. I don't get to make that call. That's out of my scope. However, like, if we can prevent it, that, in my opinion, should always be the main goal. Because like you said, there could be a man, many other things going on. And a lot of these babies are carrying tension sometimes that mimics heathered oral tissues for whatever other reason, you know, body tension that when addressed, it's like.

Oh, wait, things look different.

And no, we didn't stretch the frenulum. It just was mimicking a tie and wasn't actually one.

You know, it's a big soapbox for me is caution hit the brakes, conservative intervention before surgery unless it's slap you in the face obvious that this tie is a problem, you know, and most families are on board with that. But many, many I still get after procedure, and they just, they latched on to this idea that, like, this was the reason for all the issues. And then I have to deliver the somewhat devastating news that this probably wasn't the issue. You know, like, you had your baby, had a food allergy and frenatomy wasn't going to help that. You know, like, yes, they were fussy 247 and had reflux, but it wasn't because they were swallowing air. It was because of this. Sorry. You know, that really stinks. And I hate that situation. And at the same time, I've been there, I've been the mom with the bleeding nipples who just wants relief now. And it seems like an eternity to wait a week or two for an appointment or longer in some cases. So I get why families go straight to the surgeon. I truly do, you know.

Yeah.

But. But at the same time, you know, I just, I feel like we have to, we have to always consider risk to benefit ratios in this equation. And even if the tie is clearly a barrier, the frenatomy is not the best option for every person at every point in time because we have to consider the family's context and the family stress. If the family is moving across state lines or moving from one house to another and they have six other children, or they just cannot commit to the aftercare, or they just don't in their heart feel comfortable with that at that one point in time, who am I to say that's the best thing for them to do? You know, it's just. Because it's not. Sometimes it's just biting their time.

We can cause more harm.

Absolutely. 1,000%. Yeah. So I'm a conservative.

I mean, it's. And that's the whole conversation. Yeah, I mean, the whole conversation around, like, the parents, the dyad are just as important of a piece of this team. Right. As every medical professional who's on the team as well. And that's a conversation we have is, you know, no, you just left today and you had a release and they're told to call us. Like, that's not how we operate. Like, we can try and help you, but I don't really know what this looks like beforehand. And this is going to look very different than probably otherwise versus the ones who call who are like, we're moving out of the country in two weeks and we need to have this done. We were told to call you to prep us. And we're like, okay, well, first of all, like, pump the brakes. Like, let's have a very realistic conversation right now. Because, you know, two weeks is tip. I mean, if you have a newborn, maybe, but like, who's your support team afterwards? Who's going to continue this care? How are you going to manage this while, you know, moving to a new country? And yeah, like you said, there's just so many pieces of the puzzle that I think are not discussed enough that absolutely have to be in place. And we need to have empowered families who feel confident about what they're walking into and how they're going to manage afterwards with a supportive team who is.

Going to be there.

Because even those empowered families who feel ready still are going to require support and need that ongoing intervention following when we now have to teach the baby's mouth how to function with this newly released tongue. It's not just, you know, magic.

And let's talk about, you know, two scenarios. Like, one is the very complicated dyad where mom supply is low and we don't really know why. You know, like, we're going to work to improve it and we're going to see what happens. So often I'll have like, okay, we need to start pumping because your baby is not transferring. Well, that's first step and then we'll see where we get. You know, it should improve over about a week, week and a half. And if it doesn't, then we need to investigate your causes, you know, but if we're working on all these things at one time and they go for a frenatomy, it's like we're doing surgery aftercare, baby's fussy, babies relearning motor movements for sucking and mom's pumping and it's like, it's too many things to address at one time. Some families go for it and they're like, we're fine, we know what we're expecting. Like, we're good. And I'm like, more power to you. But others, I'm, I'm just like, I want to warn you, like, I'm worried you're going to be working on too many things at one time. Here's my recommendation. We take a week, we work on your milk supply, we reevaluate, we see where we are, we reevaluate your goals, and then if you want to go for procedure, do it. You know, and many listen, but some don't. And then the other scenario is in the case of the baby that's not gaining weight, well, the assumption is we fix the tie that goes away. Right? Like, hold your horses, because I personally almost always recommend, let's get to a place, a stable place where we're seeing our growth curve improve in a stable manner before surgery. Because the aftermath of this procedure may result in regression, you know, and we, we need wiggle room. And minimal wiggle room is stable growth and weight gain. Even if we have to do formula to get there or a lot of bottles to get there, I'd much rather everybody feel confident that baby is getting enough and have all the tools they need to survive that aftermath than just to take the risk and be like, well, let's hope the tie release helps, because I've just seen that turn out very badly. Like they plow forward, baby ends up hospitalized, you know, because we just, we don't have a great way to feed that baby, you know, in those couple of days after. And that's the worst case scenario. So we can avoid all that by timing things carefully and not rushing into this.

No. Same conversation that we have is, you know, baby needs to be in a healthy place, not A place where we are like, you know, we may be heading for a tube tomorrow or no, you know, we need to see if we can stabilize baby first because we, like you said, we need that wiggle room. And a good number of babies do regress, and they do. They're fussy, they don't want to feed. You know, there's some babies who are totally fine. We don't know. We don't have a crystal ball. We don't know what that's going to look like afterwards. So I love that you highlighted that because I think, again, so many look at it as the. The quick fix or the solution when it's actually part of a very involved treatment plan that really involves a number of professionals that are going to support you pre, during, and post. And I think that there needs to be more conversation around that. I've also seen it where, you know, sometimes we've had families who come to us and they go, well, we have a tongue tied. I'm like, well, what are the symptoms? And they'll talk about, well, there's mouth breathing, and there is, you know, okay, well, what have we tried so far? Well, we haven't tried anything yet. You know, we were just told to release the tongue tie. That's why we came to you to get ready for that procedure. And I'm always like, well, how's feeding going? Oh, feeding is great. Okay, well, where is your child on, you know, the growth curve? And maybe there's compensatory strategies at play. But my recommendation to families is, yes, how we breathe is important. Let's work on that. However, if feeding is going well right now, that is not a boat we want to rock. Because if you go for a release because you think you're going to fix mouth breathing, when that tie may or may not be related to why the mouth is open and tongue is low. Not sure yet. Let's figure that out. You're probably going to cause a much bigger situation. I've seen that play out, and it breaks my heart because I'm like, these kids, whether they were compensating well or their tongue was functional for feeding purposes, now have feeding issues following a release. And I don't say this to scare people, but I say this because it needs to be. It needs a conversation that needs to be had, and it's a situation that needs to be made aware. And so I tell people, if feeding is going well, yes, intervention is helpful with a therapist, right? With somebody who may know how to address your other concerns. And if feeding down the line becomes a problem, let's address it, then let's then go, okay, let's look at the patterns. The oral, you know, let's look at the oral facial complex. Let's see what oral function looks like and see what happens now. Because, you know, there, there are cases where that automatic swallow reflux integrates and feeding just falls off. You know, it's like all of a sudden we have a lot of kiddos that call us between 3, 4, 5.

Months of age and are like, well, feeding is going really well.

And now we don't know what happened. And I'm like, this is that age range, come on in. You know, like, let's see what's going on. But to your point, there could also be so many other things going on too. So it's that, that detective hat we put on that allows us to really tease out what is the root cause here. And that's going to also influence, right, what we recommend and what we work towards.

Yes, 100%. And I have that conversation almost daily because families are, they get to a good functional place with feeding, but they're worried because people are talking to them about the potential long term impacts of ties. And I was like, I can talk to you at length about what you may see or may not see, but here's the deal, like to do a procedure to try to prevent something that may or may not happen. It's not great medicine. It's a risk. Why would you rock the boat in this situation? I don't feel the benefits outweigh the risks for you because risks are, it's a low risk procedure, but it's not no risk. Risk risk is pain aversion, reattachment, no change or worsening of your situation. So more power to. You can do whatever you want to do and you will find a provider who will release this for you. But just know that everything that might happen in the future might still happen even if you release this tongue. And I've certainly seen plenty of babies. You know, I love. One of the things I love about my practice is that I see people fairly short term, but they often call back because they have, you know, concerns or questions about moving to solid. So I get to see these kids longer term, you know, six months, a year, even beyond sometimes. And I've come to appreciate that the tongue tie release does not mean the tongue is going to fly up to the palate and they're going to automatically breathe through their mouth flawlessly. And we're not going to have any issues moving Forward with solids and closed mouth breathing on the regular. That's just not the way it works. It's just more complicated than that. But that is the perception that people have. And, you know, they have this perception that if they release this tongue, their kid is not going to have speech issues down the line, etc. Like, that's just really complicated. There's a lot of reasons kids have speech issues, you know, so.

Yeah, yeah, yeah, yeah. My daughter has a fully functioning tongue, and she's still. You know, you don't hear the tongue thrust, but her tongue comes forward when she says. When she goes, the tongue's coming through like inter or through her teeth. And I'm like, still. And I'm like, we got to address this again. But she had additional expansion. So, you know, and any time you make changes and growth is occurring in the orificial complex, you may have to go back and redo or touch up or, you know, go back into therapy for things that you maybe worked on previously. Because if it worked for the compensations in place and then we change the structures, it may no longer work with the new structures. Sometimes it does, sometimes it doesn't. So that's that whole conversation where there's a lot of people, and I won't say a lot, but there's some maybe prominent names in the industry who are like, we address it as soon as we see it and this, that, and the other. And I'm going, well, okay, I can appreciate this conversation. But at the same time, daily life and function needs to come first. Function, yes, we look at structure, but function, how are they functioning right now?

I agree.

And if function is not impaired, don't touch it. But. And then to your point, you said, you know, people come back to you. The same thing happens in our practice where, you know, we need to educate. We need to say, hey, if you start to see X, Y and Z, or if this transition to solids is a struggle or you notice certain things about speech, just give us a call. We'll have a conversation with you. We'll figure out if we need to address something, you know, because we're not. There's no crystal ball. Right? There's no magic way to prevent all the things down the line. Yeah, I mean, that's a whole other conversation. Like I know you and I could talk about for hours on end. As far as I know expansion goes once you're a little older and all.

That, but especially in the myo space. I mean, I'm not a myofunctional therapist. I Only see infants, you know, But I. I'm in the myo world. I mean, I'm all. I see you guys on social media, and I have plenty of friends. And I do feel like there's been this, like, shift from, like, 10 years ago. Nobody knew about ties or, like, it was just like, on the horizon, you know, and now every therapist knows about ties. And it's kind of like you have a tie and you have a tie and you have a tie and fix all the ties. Like, it's just. We get a little bit myopic as a community about the role of tongue tie and, like, seeing it as this panacea of oral function and feeding. And I'm just like, no, slow your roll. It's a little more complicated than that. And I do feel like. I do feel like sometimes if that is, like, suggested on social media, there are people that are really quick to, like, hammer down, like, compensations aren't normal and optimal. And. But it's like. But it's functional. And maybe the family wasn't in a great place to address this. And maybe, you know, like, maybe you shouldn't consider, like, a drastic surgical intervention if everything's going okay. Just saying so.

Yeah, yeah, yeah. No. And, you know, I think some of those polarizing views, because I know I've put some of those out there, too. I think it's educational in aspect, but it comes back to, like you said, the patients sitting in front of you and, you know, the things that kind of kill me these days is there's a lot of these mini MYO programs by non therapists coming out and where a lot of the education is kind of riling up parents. Because, yes, it's important to educate on nasal breathing. Yes, it's important to educate and correct oral rest posture. But this also falls under the realm of what we do as therapists. This is what, this is what we do in feeding. Like, this is feeding therapy ultimately. Because, hi, if you can't breathe, you're going to struggle, struggle to eat high. If your tongue is not in the right position, you know, your feeding postures are not correct like that. That's what we're addressing. If your mouth is not closed at rest and you're not nasal breathing, we're going to go, maybe this has something to do with my feeding is a struggle right now. Maybe we need, you know, like you said, there were some rare cases where they did have those hypertrophic, not tonsils, adenoids, you know, and so who knows, right? And we get kids with laryngomalasia like you said, we get kids with all different kinds of presentations. Heart issues, gastro issues, you know, and this is like, I even teach this in one of my courses or someone else teaches it in my course. But, you know, it's something where I think when people's eyes are open to it, it's like, hey, yeah, there is, there's a place where tongue ties are real and they absolutely can wreak havoc. And sometimes that is the main cause. But there's also a whole laundry list of other things that could be going on too. So let's not just, you know, throw that all out and pretend like that doesn't exist. Which is what I think this conversation unfortunately has shifted towards. With, you know, it's, oh, it's just jaw position, it's just tongue tie, it's just nasal breathing issues.

Correct.

Or rest posture. And, you know, I'm like, okay, that's a part of the puzzle. But like, also, it's so much more.

Yeah. And I think, I think the longer you're in something and you, you, it's, it's in growing immaturity, I think, as a practitioner. Right. And we've all been through this process where you start out feeling like you know a lot. Right. And then the more you learn, you're like, you feel like you know nothing.

The Dunning Kruger, right?

Absolutely. Yes. And it's like it just kind of keeps piling on. And it's like, I mean, you just develop this appreciation for how nothing is simple. Just nothing is simple. I mean, I, I, I reflect all the time about the breastfeeding quote unquote advice that I used to give to people. And I see every day on social media, I have this firm scroll by and ignore policy when I see breastfeeding questions proposed on mom groups because it kills my soul to read the responses. But I was once that person giving the seemingly well intentioned but ultimately ridiculous advice, you know, but now that I know better and know more, I'm just like, I'm so sorry past moms that, that I led astray unwillingly, you know, because I didn't know anything. I mean, it's, it's a thing. It's. Yeah, that's a whole conversation too. I echo that.

Yeah. I mirror that situation where it was like, okay, I'm gonna, I'm that warrior. I'm gonna pop into these Facebook groups. I'm gonna educate. And now I'm like, I have removed myself from those Facebook scroll by. I'm like, I just, yeah, I'm like, I gotta focus on my patients. I gotta focus on. Yes, it is. You know, and that's where I try to tell people. I'm like, you're not gonna win the Internet today. So just like, maybe instead put your energy and time into creating education that does speak to like, that's gonna get a wider reach. Right. Because that's gonna have more of an impact than one post. You're gonna comment, people are come at you and that's lost on the Internet.

Nobody on those platforms is there to have a productive conversation and to learn more things. They just want to argue their point. It's so toxic too. And I, like, I see both sides, like on therapy groups and on like lactation groups. It is wild. So I have just kind of like stepped back from some of that like banter because I can't. It's very triggering. Yeah. I'm like, I just, I can't keep the peace. Keep the peace. Right. I'm just going to educate my patients and the medical professionals around me who are willing to listen to me and collaborate on patient care. But like, but I would love to have a conversation about some of the well intentioned but ultimately harmful advice that I see given to patients regarding weight gain struggles. Okay, yeah, let's talk about that. Okay. So I had a patient I've seen a few times at this point, like probably seven times, very complicated case. I saw him at six days old. He was losing weight still, which is bad at six days old. And it was one of those things where we had to unfold and try some things. But mom had a thyroid issue, insulin resistance, all of that spells bad things for milk production. She had severe nipple pain, nipple trauma. Baby had an obvious tongue tie, like anterior almost to the tip. So I had her walk away pumping. We had to start supplementing to ensure he was gaining well. He ended up having a tongue tie release. Mom is now able to breastfeed without pain, but long term formula supplementation is on the table because we just have not been able to get to sufficient levels. And so we discussed lab work at one point because she used to be treated for her insulin resistance and she's not currently. And I said, well, why don't you talk to your physician about drawing some labs. Let's kind of see where you are now and maybe resuming your treatment would be in order. You did this before you were pregnant, it may help you now. And her doctor said, I mean, have you just tried breastfeeding on demand because that will improve milk supply? Has she tried breastfeeding on demand, lady, we've been through, like, that's all she's doing. Like, she's pumping eight times a day and she was nursing every hour and a half. If it was gonna work, by now, it would work. And the baby's not gaining weight without formula. Clearly we need the formula. But thank you for your input. Can you please order the lab work that we requested? You know, so I think there's like, there's this, I guess arrogance is the best word, although I don't like that word, I guess. But you know, there's the assumption that you know more about breastfeeding than you do. And I think it's worse when you're in like a position of like power medically. And then parents often take that and run with it because they assume the doctor knows a lot, but they often don't. Yeah, right. Especially about breastfeeding. The other thing, one of the other things I see is the Haaka use, oh my gosh, like, you know, people, people here, like even their doctors or people will recommend that they use the Haaka to boost their milk supply. But I've seen this result in weight gain difficulties with babies, because essentially we're taking the easy milk out of one of the breasts if mom puts it on one side while she's nursing the other. And so that's a soapbox of mine. Like, it's on my intake form. Are you using a Haaka? If you are, how much, how many times a day and what are you getting out of it? That's very telling. And I added it only recently because I was seeing so much of this. I'm like, I need to put this on my intake officially so it doesn't like come out of the woodwork two visits down the line because I forgot to ask about it. The other thing I'll see a lot from pediatricians. Baby will go in, they're like, ooh, the weight gains of concern. The good ones will be like, we're going to refer you to lactation. But meanwhile, maybe your baby's not getting enough hindmilk. Keep them on one breast so that they get all the hindmilk. Like, no, don't do that. That's such bad advice. It's well intentioned, but it's bad advice. Because in lactation land, we know that the whole four milk hindmilk conversation, it's not a non issue, but it's a non issue for the majority of the population. The one subset of the population that genuinely should be worried about this are the moms. Who have a copious massive oversupply. Like the moms who can pump 20 ounces in a session. 4 milk, high milk imbalance, baby not getting enough fat. That might genuinely be an issue in those scenarios. But if you're a just enough for mom or a low supply mom, the worst thing you can do is isolate your baby to one one breast per feeding. It's going to lower your milk supply over time and decrease the amount of milk your baby's taking per side. So. But I see that advice given all the time and again, it's just well intentioned because the pediatrician learned something about this and they want to pass on this nugget and they think it's going to be helpful to this family. But it's just, it's well intentioned but it's ends in disaster, especially if that family isn't seen quickly, you know, after this advice is given. Because that can quickly downregulate a supply if we're not careful. The other thing is timing feedings. I see that recommendation made all the time and that may or may not be good advice. It's very individual. So I'll often hear the pediatrician telling patients like only limit the baby to 10 minutes per side or 15 minutes per side, which in theory should work well. But what if mom has really asymmetrical production and she makes 3 ounces on her right breast but only half an ounce on her left? You know, it's not going to work so well in that situation. Or if they be sleeping the entire time and they're genuinely not drinking, why are we even spending 30 minutes doing this? Like let's spend our time doing something better like pumped, get things going. And the last thing I want to speak to is the avoidance of pacifiers and bottles if you're breastfeeding. Because if you use these tools it's going to doom you. Right? No, I mean in lactation land they preach these, these concepts to families and I feel like they put the fear of God in them and the hospital, hospital that if they use the pacifier or use a bottle, their efforts to breastfeed are forever doomed. And I'm just, I feel like I spent all day reassuring parents that this is not the case. Rarely is it the case. And if we bottle feed carefully and if we choose our tools carefully and you go into this knowing what, you know, like an educated approach, it's not going to end badly for you more than likely. And it may even help tremendously. I love pacifiers as a tool for helping sucking function. It's so simple to use and it's one of the easiest things that families can use rather than giving them rote exercises. I've gotten so far away from doing that because it just, it's not practical for families. And the paci works well if we pick it well. And bottles are absolutely necessary for some families in the event of poor weight gain because yes, I know they're at breast supplementary systems and other means and cup feeding and ways of getting milk into infants if they're just not taking it by the breast. But practically many families don't want to do that or they can't do it for long term or it doesn't work well for them and the bottle just feels easier to them. So I've seen so many families who are like syringe feeding for weeks and then when they come in, I'm like, how's that going for you? Does it feel stressful? Do you want to do that? And they're like, I mean, it's horrible, but if we give them a bottle, we're never going to meet our breastfeeding goals. And I'm like, hold the phone. I don't think that's the case. Try it. You know, and they're like, oh, thank God. It's, it's okay. It's not bad. So, you know, like, I just, I.

Feel like, yeah, no, the hospital, my.

Job is like, like unveiling myths and helping reassuring families be like, this is, it's gonna be okay. Promise or I can't promise. Yeah, almost promise. Yeah.

The mother baby like friendly hospital that I deliver both my girls in had that whole, you know, position of no, you know, and they weren't anti bottle. They were very much so like you feed your child how you want to feed them, but they were very anti pacifier for the first, like two to three weeks because of exactly what you said. And you know, and I also, now that I know better and especially by the time I had my second, I was like, well, this is a really great tool that maybe we should be using to help, like you said, establish suck training and to be able to do some of these things that are going to help baby to function when there isn't also a milk flow involved that they're trying to manage that they're not managing well, like where we need to build some skills. And so sometimes not having the bottle present with the milk flowing out and just, you know, escaping out the corners of their mouth while they're trying to learn how to suck, I'm like, we that is a skill we need to address. And so I love pacifiers as a tool and it's one of the things that I think parents also feel very comfortable using.

And I totally understand the recommendation as a lactation consultant. Yes. If we keep sticking a paci in a baby's mouth and we didn't, we deny baby the opportunity at the breast milk production will decrease. It will, it will mess up the calibration of milk production. But that's not what I see the majority of the time. Most of the time, mom is bringing baby to breast over and over and over and over and it's not going well for some reason. So realistically, that might provide a skill building opportunity while giving her some much needed relief. And if we're protecting the milk supply with pumping, we have nothing to lose here. Nothing. So I always ask, you know, like, it's, it's on my intake questionnaire, do you use a pacifier? How often? What kind? And you know, when I talk about that in the session, I'm like. And they say, no. I'm like, do you want to be using one? Like, why aren't you using one? And some are adamant, like they never want their baby to have one. And I'm like, cool, we don't have to have one. It's not an absolute necessity. But I don't want you to fear using one.

Yeah.

And here's what I'd recommend based on your baby's sucking patterns, here's what would help us move toward your goal. If you're open. So.

Yeah, yeah, no, I love that. I love all the myth busting and the education and you know, we find the same things with pediatricians who mean well, but are, you know, we like to remind our families they are not typically trained in feeding of any sort. So while they may have taken a course or they may have come into some knowledge, there, there are many layers to the onion that they're just unfortunately not trained in. And so, you know, again, we love our pediatricians, but let's.

The specialists, I love them and they can't know all the things. And I feel grateful to be in the community I am in because we have fabulous pediatricians around here. We really do. Like, the vast majority of the referrals that I get come from pediatricians who know like, they see a family in front of them who wants to breastfeed or they're having trouble with bottle feeding and they're like, I'm going to send you to a resource. Here you go. Like to, to dig into this Problem further. You know, meanwhile, start supplementing or do whatever, you know, you gotta do. But ultimately they refer. And that's really all we want as therapists is like, yes, please.

Collaboration referrals. Yes. Like, let's put them at the center and make sure everybody's getting the care they need and not speaking out of turn when it's not our expertise. It should be that simple.

Right? It goes the same for us. Like, I mean, I deal with a lot of poor weight gain patients and, you know, I'm often picking up the phone or sending faxes with my notes and being like, hey, pediatrician, or hey, nurse practitioner, your patient has lost weight. Here's our plan. If you want a different course of action or you have questions, please reach out. You know, and they really appreciate that. And I mean, we've collaborated well, like on mutual patients as a result. But sometimes I'm sending kids for medical evaluation. Like, I saw a baby last week who had meconium stool at day nine and yellow eyes. And mom was like, everything's going really well. And then we, you know, we did the wait. And I'm like, I don't think it is. I'm sorry. And I was like, in fact, I'm going to text your pediatrician right now because she may want you to go in for another jaundice level. And she's like, oh, goodness me, yes, please send them over and everything's fine. But, like, the sweet mom just had no idea, you know, that things were going off the rails because she had a really chill but very sleepy baby who was overly jaundiced because he wasn't getting enough volume, you know, and so that was a situation where medical intervention was, you know, needed and I needed the pediatrician, so I sent them on. Yeah.

And that's what we're here for. Well, this has been amazing. Thank you so, so much for joining me. Where can everybody find you?

I am on Instagram Flourish at Flourishpediatric Therapy, I think. Yes, Flourish Pediatric Therapy. I have a Facebook page for my practice and I teach several courses on the lactation OT platform.

Thank you so much.

You're welcome. Thanks.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, airway and feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halibalkin.com or pop over to Holly Balkan on Instagram to get all the latest updates.