Tongue tie and breastfeeding

This week, I’m honoured to have a true legend of UK breastfeeding support for you - Sarah Oakley, IBCLC, Registered Nurse and Health Visitor and Tongue-Tie Practitioner.

Sarah and I discuss how and why tongue-ties happen, what you can expect from a tongue-tie division, if it’s right for your child, how to find a practitioner and what after-care is needed. We also dive into the ethics and history of tongue-tie diagnosis, whether divisions are always helpful, and Sarah’s involvement with the Association of Tongue-Tie Practitioners. 

My new book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

Find out more about Sarah on her website www.sarahoakleylactation.co.uk/tongue-tie-assessment-and-division-services

Sarah’s book is called Why Tongue-tie Matters www.pinterandmartin.com/products/why-tongue-tie-matters

Find a practitioner at The Association of Tongue Tie Practitioners www.tongue-tie.org.uk

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

Hi. I'm Emma Pickett, and I'm a lactation consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time, because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end. And I'm big on making sure parents get support at the end to join me for conversations on how breastfeeding is amazing. And also, sometimes really, really hard. We'll look honestly and openly about that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk. 

Emma Pickett  00:46

Thank you very much for joining me for today's episode. I am very excited to be joined by Sarah Oakley, she is, this is not an exaggeration, pretty much the UK is leading voice in the area of lactation and tongue tie. She has a background as a nurse and a health visitor. And she's also a trained breastfeeding counselor, as well as an IBCLC. She is a founding member of the Association of Tongue Tie Practitioners. And she's also the author of a book Why Tongue Tie Matters. And we'll put some of the links to some of that in the in the show notes. She trains health professionals and breastfeeding supporters worldwide. She also likes hens and horses. But I don't think we're going to get to talk about that today, because there's so much to talk about when we're talking about tongue tie and breastfeeding. Thank you very much for joining me today, Sarah.

Sarah Oakley  01:32

Thanks for having me, Emma.

Emma Pickett  01:33

So I just want to start by emphasizing although the title of the episode is about tongue tie, and that's what we're going to be talking about, I want to make sure that we're really clear up front that you are not just a tongue tie practitioner, you are an IBCLC, who supports the whole story of lactation, which I guess every good tongue tie practitioner should be. You're very much looking at the whole picture of someone's breastfeeding journey. And you're helping families to reach their feeding goals, whatever is going on for them. But I'm going to pin you down about tongue tie today if that's okay? 

Sarah Oakley  02:04

Yeah. 

Emma Pickett  02:05

If a family is struggling with a baby who does have a tongue tie, what sort of barriers will they have in their breastfeeding journey? 

Sarah Oakley  02:14

Tongue tie can cause all sorts of havoc with breastfeeding, you know, they might face sore nipples, a baby that won't latch or a baby that will latch but won't sustain the latch. It can cause problems with weight, it can cause reflux issues, it can cause wind and colic type issues. These babies often feed constantly without ever being satisfied, or equally, some of them just do these very short snacky inefficient feeds and then are quite sleepy. And of course, that's quite dangerous in the early days, because parents often think that means they're feeding well, because they're sleeping well. But it can actually be that they're not getting the calories they need. And of course, once parents and healthcare professionals have identified there is an issue with the feeding, then the next problem is actually getting to the bottom of what that issue is what's causing those problems and getting that diagnosis. And it's much better than it wasn't when I started doing tongue tie divisions in 2011. And obviously, I was supporting families with breastfeeding issues a long time before that. I went into Health Visiting in 2002, and breastfeeding counseling in 2004. So I've been supporting people for a long time with temptations propriety division. But when I started doing divisions in 2011, it was really hard for people to get a diagnosis. And actually, in the first year of me doing divisions, only saw about 100 babies in relation to tongue tie. You know, I now see seven to 800 babies a year. And a lot of them don't need divisions, but most of them come to me with a tongue tie query in mind, you know, they come to me thinking there might be a temptation. So the awareness has grown, but still getting that diagnosis and getting it pinned down is hard. You know, parents will often speak to different professionals, different breastfeed supporters, some will say I think there's a tongue tie, some will said don't think there is some will say, well, sometimes don't cause a problem anyway. And some will say, you know, there's a tongue tied there, but we don't think that's your issue. Some will say there's definitely a tongue tie, it needs dividing, and then they come to me and I'm like, actually, no, I don't think it is a tongue tie issue!

Emma Pickett  04:05

Oh, there's so much this was such a mess, isn't there? I mean, take a breath. Sarah, I can see how much there is to talk about this issue. And, you know, I'm obviously not a tongue tie specialist. And I'm I'm an ibclc, you know, in general practice. But, golly, we're in a complicated place with tongue tie in the UK. And that's what we're what we're going to have time to talk about today and unpick today. Now you just refer to something just then you said that people will come with a possible tongue tie diagnosis or an actual tongue tie diagnosis. And they don't necessarily need the division, which I think is really important to highlight. I think people assume that when there's a tongue tie, someone's running out them with a pair of scissors. So just spell out for us. How often is operating operation going to be the solution? And how often do you say to somebody, yes, there's a tongue tie, but that doesn't mean we have to do anything about it?

Sarah Oakley  04:50

Yeah, probably about a third of the, because I've looked at this and it's around about a third, it does vary. You know, I go through phases where I seem to do a lot of divisions, and then I can have a week where I see 20 families, and I might only do four or five divisions in that fat lot. But it runs at about a third of the babies I see that come in where there's an expectation, they may have a tongue tie that needs dividing. And that's not that's not the issue, there may be a restriction in function, but it may relate to muscular and fascial tensions that are better addressed through body work. There may be, you know, no real time restriction there at all. And the lack of weight gain is down to, you know, a supply issue. And that supply issue may be secondary to very poor breastfeeding management in the early days, or it may be some kind of primary issue with things like, you know, memory hyperplasia, or some kind of hormonal problem. I mean, occasionally, I see moms where it's very difficult to pin down why they've had such a problem with with milk production. I mean, the most common causes is poor management in the early days, well, when it comes to low supply, but, you know, there can often be a lot of other things going on with these, these babies. And it isn't all about a tongue tie. And obviously, the ones we see with tongue tie, the tongue tight is often a factor. But there can be other things going on. Often with pain, you know, it's just basic positioning and attachment. And you can often, you know, address that with just him. And actually, even with efficiency, you know, a lot these days, we put them into a leg back position, and suddenly they're feeding much more efficiently than they were in the underarm hold or the cross cradle hold. So it's really complex. And it's really difficult sometimes to tease out, you know, yeah, there's a, there's a mild restriction there. There's a bit you know, there is a tongue tie there. But how much of that is the problem? You know, you it's quite contracting, which is why people don't talk to admins really do need to be really super skilled. In lactation support, we'll be working with somebody with those skills, I'm really worried about the services were that run by surgeons or midwives and officers were minimal breastfeeding training. And they're making decisions about divisions, because I think sometimes those decisions, those decisions are not necessarily appropriate.

Emma Pickett  06:45

Yep. That's why you know, tongue tied division sometimes gets a bad name, because some of the services are being run by people who don't look at the whole story. And then someone cuts the tongue time turns out a huge surprise, it didn't make a big difference. You know, why is anyone shocked? Because there was an underlying issue. Just to unpick something you said a minute ago you talked about, there can be other reasons why a baby might have tension and possibly they might need body work. Tell us what you mean by body work.

Sarah Oakley  07:12

And when I talk about body work, I mean things like cranial sacral therapy, cranial osteopathy, chiropractic input, I work mainly with cranial cranial osteopath or osteopath, simply because in my area, we don't actually have a lot of chiropractors treating babies. And I kind of favor the osteopathic approach. And I don't know if that's just because that's what I'm used to. And that's what I've worked with a lot over the years. But I do tend to find we see better results generally from the Osteopath than we perhaps necessary do from chiropractors, but I have had some babies go to chiropractic with great results to cranial sacral therapy as well, I think has a really valuable place. But we in my era don't have a lot of cranial sacral therapists that are working with babies. So the reason why baby may need that and may have these muscular and fascial tensions often stems from either how they were laying in utero, so that position in the womb, or the birth and obviously obviously, if the positioning in the womb was not optimal, then often the birth isn't a smooth process. So babies have had lots of interventions, things like four sets of on twos, emergency C sections, babies that have actually perhaps been stuck in the birth canal for a long time and have actually been born vaginally. But perhaps it was a bit of a struggle in the month of October PCR to make. And the second stage of labor was very long, or legalese babies that come out, you know, with minimal, minimal effort. I actually had somebody yesterday who you know, no second stage of labor that they could just kind of shut out. And those babies often have quite a lot of tensions going on in their neck and their jaw. And obviously, that can then impact the functioning their tongue and the way they latch and all of that. So that's kind of what I'm talking about. I'm talking about bodywork and the kinds of thick babies that might need some help. And actually, the tongue tie itself is part of the fascia that extends across the floor of the mouth. And that fascia extends throughout the body. So the tongue turn itself can cause tensions in that lower jaw and into the neck area that you know that need attention and sometimes divide the tongue tie releases those tensions quite nicely. But sometimes, you know, they remain and they need bodywork to release those.

Emma Pickett  09:08

Yeah, so one of the things that I sometimes see as somebody who's hadn't sort of nerve bruising, I don't know if that's a term that we're allowed to use. So a difficult birth you can see marks from a forceps delivery. And it's not surprising that you know, you need all these nerves to get breastfeeding to work we remember from our lactation consultants exam, and if some of them are compromised, that tongue is just not going to do its job. So yes, it's so important to get this whole story isn't and I can hear you're talking about very much working alongside a team of colleagues, which I think is also crucial. So let's imagine that we've got Baby A who you've done the full assessment of you've watched breastfeed, you know, you've done all this work around looking at the history, and it does look as though they might qualify for doing the different autonomy or the or the procedure. Talk us through what that appointment looks like. What's happening in that division?

Sarah Oakley  09:58

Well, obviously the first thing we do is I'l explain to the parents how the tongue function relates to feeding and why we think there's an indication to divide, I think it's really important parents understand why we're doing it, and also what we're trying to achieve. And then it's looking at the kind of risks and the outcomes around that, because we're the best one in the world, you can do a really successful procedure, but then, you know, there may be ongoing issues. And so it's actually explained to the parents that yes, this tongue ties impacting in this way. But there may be other things we need to address, like the supply issue and all of that. So there might be no need to put in a plan of expressing and, you know, galactic goals and all that to address the supply issue and things. So we go through the risks of the procedure, because it is a surgical procedure has the same risk as any other surgical procedure. So things like bleeding is a risk, infection is a risk, all of these things are very low, it's all very low risk. So the stats on these things are very low, but they do occur, so parents have to know about it, you can damage other structures in the mouth when you cut the tongue tie. Now, some of that is down to the education and skill of the practitioner. But you know, some of these freedoms are the anatomy of them is quite complex. So you know, there are risks around you know, catching saliva glands, you know, nicking the tongue with a scissors, that kind of thing. And there's also the risk of recurrence, which is a bit of a hot potato, because, you know, we've all seen and heard parents talk about how their baby had a division and had to have a second division, the recurrence seems to be largely linked to the anatomy of the friendly limb, the frenum, that's got, you know, the thicker frames have more contain more fascia, it depends is a bit more complicated than how much fashio they contain, it depends on the balance of, or the ratio of type one to type three collagen, we think. So some frames are going to be more prone to scarring and others. And that's quite unpredictable, really. But we have, you know, I counsel my parents on that it's a very thin frame. And that's mainly mucous membrane, I can be fairly confident that's going to heal well and not recur. But then some of the thicker ones, I do cancel them on the fact that maybe a recurrence and what that would mean and what that would look like and that kind of thing. And we talked about how the baby's going to be afterwards, you know, they may have some discomfort, they may struggle with feeding, we may actually make feeling a bit worse before we may get better in some cases. So they need, you know, parents need a lot of information around all that before we even get the scissors out. And then of course, what we then do is wrap the babies up, have have somebody hold the baby's head still, so that can be the parent. But in my clinic, as some of my clinics, I work alone, some of my clinics, I pay an assistant. So if my assistants there, then they hold the baby's head, which the parents usually appreciate. And then we just simply lift the tongue up sizes and snip, snip, snip the frenulum. Underneath the tongue, I use my own fingers to lift the tongue. There are a few practitioners out there that use the Brody directives, which are like the metal spade shaped object with a grooving to lift the tongue up. Not many practitioners in the UK using brush directors, but there are a few. I personally prefer to have my finger in there, because I think it's gentler on the baby's mouth. And you can actually feel what you're doing as well as see what you're doing with a Brody, you're very isolated. You've got one hand on the Brody, one hand on the scissors, there's no direct contact with that baby or that baby's mouth. And I like to have my hand in there. So I can feel what I'm doing as well as see what I'm doing. And that was how I was trained. So and that's how most of us work. And then obviously, afterwards, we feed the babies immediately and then monitor the bleeding. Have a look at the feeding, you know, often there are immediate signs of improvement, which is really encouraging. But again, sometimes they don't brilliant feed with me, and then they go home and the rest of the day, they're not so good with the feeding, because it's feeling a bit sore and a bit strange. And as they start to work that tongue muscle and use it more and use it differently, it will, you know, be quite tired and achy, like any muscle. If you go for a run and you're not used to it, your legs ache if you go down the gym and do the weights, you know, as you're building those muscles, they will protest about it and ache. So we have to prepare the fat families for the fact that you know these babies made go home and be a bit fractious and difficult to feed in those early days. And the feeding, I always say to parents, the first week can be very up and down. And then gradually, you know, things should start to become better and more consistent. But I also canceled on the fact that there's a risk that we'll do the division and it won't make any difference. But it depends on the context of that, that division really and what else is going on? Yeah, I don't offer it if I think there's no chance of it making any, you know, making any difference. Sometimes I have parents coming in where the milk supply, you know, the babies are perhaps you know, 234 months old, there's very little breast milk supply there, you know, the mom has really struggled with all of that is going to be a really difficult fix. And even with lots and lots of expressing things she may not get, you know, slightly they may not get to full milk supply and things. So we talk about all that. And if that bottle feeding, well some parents in that situation will opt to just carry on with a bottle feeding and not do the division you know there is that that balance, I'm not going to put a baby through a procedure on a promise of exclusive breastfeeding or predominant breastfeeding. If you know we're a long way down the road and that perhaps isn't going to be viable for that family. So we have to be honest about it.

Emma Pickett  14:41

You mentioned bottle feeding I know that the nice guidance doesn't really talk about doing the division to support bottle feeding and and there seem to be some practitioners in the UK that don't feel anyone should have a tongue tie division to help bottle feeding. What are your thoughts on that?

Sarah Oakley  14:55

I think it definitely does benefit both bottlefed babies. Actually ATP recently did an audit on bottle fed babies where they asked practitioners to feed in data on the bottle fed babies they were treating. Unfortunately, the sample wasn't very big. We didn't get as much data in on that as we would have liked, which is often the case when we do these audits. But it very much showed that the bottle fed babies do benefit from it. And we, that's an ongoing audit. We've made interim ongoing things so that practitioners can keep feeding that data and their outcomes on both their babies. So we build up a bigger sample of bottle fed babies, and we can demonstrate there is a benefit. There are some studies interesting, one of the RCTs that they did in Southampton, back in the early 2000s actually did what did include some bottle fed babies. And when they wrote the nice guidance, Mervyn Griffis was part of the panel and he very much one of the nice guidance in 2005 to include bottle fed babies. But because the data was limited on it nice basically said, we publish breastfed babies or we don't publish it at all. But we're not including bottle fed babies, which was a shame. But there are more papers out there. Now looking at both their babies, there was one published fairly recently in Australia by somebody called Philip hand, where he looked at reflux in bottle fed babies and found that, you know, divisions really helped those babies. And certainly, that's probably the main reason why I do it in both babies is reflux. And these babies are often on allergy formulas. And that result Gaviscon care about the whole thing. Some of them come in on all of those things, and actually do the division and we can wean them off all of those things. A lot of them are diagnosed with allergy, actually not an allergy issue. And it seems crazy really because drugs like a map Rizal and allergy formulas are hellishly expensive for the NHS. And it begs the question why the NHS not looking at this little bit more closely and go? Well, let's rule out tongue tie. And let's perhaps treat that first. Because that's very cheap, compared to all these other things, you know, the 1000s of pounds that have been spent on medications and allergy formulas, which could be saved by a procedure that you know costs very little. 

Emma Pickett  16:47

Yeah, yeah, I'm glad you mentioned before about how tongue tie doesn't work for some people, but also even the ones that does going it is going to work for some time division doesn't necessarily work for some people. But the division isn't going to be a quick fix, it's very rarely going to be that magic one. I'm gonna have sometimes work with moms who've said, Oh, my goodness, I can't believe it. This feels completely different. And it really is like a magic wand. But for some mums, it does seem to take kind of a week or a couple of weeks. If somebody hasn't seen a difference after a week, is there still time to see a difference, do you think?

Sarah Oakley  17:18

Yeah, definitely I say I tell all my families expected to take two to two to four weeks to see significant improvement. A lot of them go show significant improvement for that two week mark. But I want people to be realistic. And again, I think if you're if the only issue is sore nipples, you know, and I do see babies in the early days, you know that they're under a month old. And really the only issue is sore nipples are transferring well, they're gaining weight, Mom's got good supply, those favors often are where you get the more instant fix. And literally straightaway or within a few days, everything's going to be fine, that so many have got other issues going on, they haven't been transferring milk, well, they've got weight issues, they've they're needing top ups, the supplies as good as it could be. And it takes you know, it can take a few weeks to wean those babies off. Most babies will wean them off the top ups, if the you know, things go well, within three or four weeks, but I have had babies I've worked with for three months. And it's taken us three months to get them off all the top ups and get them to full breastfeeding. And I've had reflux see babies where it's taken longer, you know, with things like reflux, it often takes a good while a few weeks for it to really settle down completely. And obviously, some of those babies will still spit up a bit of milk because there's other things contributing to the reflux situation. But two to four weeks, I think is a realistic expectation. And I will say to parents will be those babies that take longer, and obviously the babies that need lots of bodywork, you're working alongside that it might take three or four sessions with an osteo to resolve all those issues. So the latch might not be completely perfect or completely adequate until you know they've gone through that process as well. So they do need ongoing support these families. And I think that's another issue. You know, some people go and pay for a division, or go through an NHS clinic, they get the division, and then they're thrown out into the community with no ongoing support. And that is, you know, it's not gonna be successful if they're not getting support with building up the supply, weaning off the top ups, getting the body work and all of that. So, yeah, it's an ongoing process. And parents should expect if they come to a practitioner and pay for a division that they will be the need for ongoing support, they should be asking about what that ongoing support involves and what it's going to look like. And, you know, with the best one in the world, we all want to do lots of work for free, but that's not a viable thing. And in fact, for my CQC registration, I had to prove my business was financially viable. So I do you know, I do give a certain amount of free follow up support, but there is a point where, you know, parents do need to expect to perhaps have to pay for things like bodywork, and to come back for further help and support if things are problematic and can usually be a difficulty. So it's not just about paying 200 pounds for a division, you know, that's going to be the fix. 

Emma Pickett  19:44

Yeah, yeah. You mentioned using scissors, which does seem to be what most people do in the UK, but you do sometimes hear of sort of anti surgeons obviously we'll be using a scalpel. And there are sometimes laser practitioners being talked about, is there a difference in someone's experience if different tools are being used? 

Sarah Oakley  20:00

There is Yeah, I actually did a survey a couple of years ago, I was asked to a lecture for breastfeeding conferences in Australia, you know, Barbie Claire's organization. And I collected, I put a survey out, I only left it out there for a week, I wish I'd left it out there for longer. I put it out via social media channels for a week and I got over 1600 responses, I got a bit scared about that. So I closed it down. Because I thought 1600, that's a lot of data. 1611. Anyway, I've got somebody to data crunch it for me. And we've whittled it down to 16 108 responses. And those responses came in from all over the place. They weren't just from the UK, predominantly, scissors was the most commonly used tool. But there was quite a few that were using a scalpel, and obviously some using laser. But because it was predominantly UK based, we didn't get as many laser responses as we did scissors, that when we crunched the data, what it showed was was that generally, you know, laser does tend to cause more disruption to feeding. So I asked parents about the behavior of their babies over the first three days after division, how long they cried for after the procedure, how long they were unsettled for after the procedure, how much analgesia they had to use in those first three days, how the feeding looked in those first three days how much disruption was to feeding. And it felt that survey very clearly showed that, you know, babies were more likely to be unsettled, more likely to need pain relief, more likely to struggle with feeding, if they'd had laser, as opposed to scissors and scalpel, that actually the scalpel experience was very similar to the scissor experience. So there is definitely a difference there. And I think that's because with laser, there is a tendency for them to go deeper and wider than we go with scissors because they don't have to worry about the bleeding because you know, the laser cauterizes as it goes so that there isn't a bleed, there's so much bleeding risk. So I think, you know, we're more cautious with scissors because we're worried about bleeding. And also obviously, laser uses thermal energy, which creates like a burn really. So although you've got the wound from the laser, you've also got further damage surrounding that wound from the from the thermal energy. And we all know bounce quite, quite uncomfortable. So I think that's why now the laser providers will say there's less pain. But then they often use local anesthetics at the time of the procedure, which we don't need to use for scissor division. And also, they often send the parents out with a whole regime of pain relief, you know, they'll put them on regular analgesia for several days after, whereas we don't tend to see the need for that or or do that. And actually, again, when I looked at the the levels of analgesia use, definitely the parents who had laser divisions were having to use more outdoorsy with their babies than the parents who've gone down the the scissor or scalpel route. So I think there is definitely a difference. There's lots of claims that you know, there's less bleeding with lasers, yes, there is at the time of the division. But there have been reported cases of significant bleeds once the babies have got home because they do have larger wounds. And often the laser providers recommend things like disruptive room massage, and because if the parents are going in there rubbing the wound that often triggers bleeding. So then we get and obviously that increases the pain as well for these babies. So I think there's also that that we need to from that survey, there's a lot of questions that we need to look at more closely. And, you know, is it the laser that's causing more pain? Or is it the aftercare? You know, that these parents are being asked more frequently to do aftercare with with laser than they are with scissors? But I honestly don't think that we can say that, you know, laser is better or superior or less disruptive to these babies, because it doesn't appear to be

Emma Pickett  23:12

Okay. You mentioned aftercare, and that is another area where things are very confusing for parents and people are told very different things. I mean, you go on social media, and you know, look at forums where parents are talking about their time to experience and the differences in what parents are being told is absolutely extraordinary. The idea of wound disruption is something I will be honest, I'm uncomfortable about and when I, when I when I read the research, I'm confused about why it's still happening. So I'd be interested to know a bit more about that. What do you normally say when you're asked about kind of post procedure care?

Sarah Oakley  23:45

My post procedure is obviously lots and lots of feeding, so lots of breastfeeding, or if that formula fed baby, lots of lots of feeding, because the feeding is really good rehab because obviously babies using their tongues and they're getting used to using it and it's building up the muscle and the tone and all of that. So feeding is really good. And obviously breast milk contains endorphins. So breast milk is really good after division because it helps to keep the babies comfy and calm and, and all of that. Lots of skin to skin and that kind of thing to serve them. But in terms of kind of aftercare, I don't recommend doing anything with the womb, no rubbing of the womb, massage in the mood, anything like that. I do recommend some gentle exercises like tongue poking games, finger sucking, I use quite a bit of finger feeding with some of these babies because especially the babies have got very low tone or very poor function. Because they find that's really good for them. It's really good physical physiotherapy for them. And we do the lateralization exercise where you run the finger around the bottom calm. And also the the exercise I often recommend they do the exercise where the when the baby is in a deep sleep where you pull the chin down, and the tongue is up in the roof of the mouth and you hold the chin down while the baby can't have it while it's asleep. It does this kind of peristaltic motion that helps to strengthen the base of the tongue up so we recommend that because it's a nice gentle thing that they can do that the babies are unaware of because they're asleep while they're doing that finger sucking and stuff. Babies find really comforting and things so Again, ATP looked at what practitioners when their membership are recommending, and most people recommend those kind of gentle exercises which are on the ATP aftercare leaflet. Some people recommending tongue lifts very occasionally I'll suggest people do tongue lifts, were on worried about a very thick frenulum. Or where it's a second division, I might recommend that the theory been if you gently lift the tongue a few times a day, you're kind of stretching that wound slightly to allow that that scar to kind of stretch and not tighten up too much. We haven't got any evidence for any of this, though. And the very few people within the ITP recommended disruptive way massage. And there was the study done at the everlean. Er in London. In 2022. I think it was published. Yeah, 2022 that actually looked at disruptive remasters, and they had 599 babies, and half of them, they just left to do you know, standard kind of stuff. The other half were asked to do a regime of massaging the wound. And what they found was that most of the babies, I think it was only 43% for parents in that group actually did the massage because they found it too upsetting and too distressing for their babies, and actually didn't find anything, any difference in outcomes in terms of healing or breastfeeding. So that kind of demonstrated that is not particularly acceptable for two parents, which we always said, you know, we always found that a lot of parents reported giving up on it after a day or two. And that actually, it didn't in that sample, it didn't appear to make any difference to outcomes. And if you look at the research around wound healing, you know, if you disrupt other wounds, you cause more scarring. 

Emma Pickett  26:29

Yes, I think I'm so glad you said that. I'm so confused there, I'm no, I'm not a nurse or a health professional the way that you are, but surely, if you fiddle around with a wound, the wound is gonna go and make more scar tissue I don't understand 

Sarah Oakley  26:41

As a nurse, you know, we were told to do minimal dressing changes, don't keep changing the dressing, because you're disrupting the healing. And I've never been asked as a nurse to go in with my finger and rub a wound or break down the healing tissue never ever, you know, it was, you know, you did everything not to disturb that natural healing process. And in terms of introducing infection, you know, apart from the fact you might make it bleed and cause the baby a lot of pain. And now I've got colleagues, you know, who around London, London area who, you know, have been exposed to this, because it tends to be London based practitioners that are more likely to recommend disruptive room massage. You know, they've reported cases of seeing babies post division, where the parents have done the disruptive way massage, and then those babies have developed an aversion and won't take the breast or the bottle and end up with an NG tube. The risk of harm from it, I think, was always what held us all back. It was like, we've got no evidence this is beneficial. And actually, there's quite a few concerns about harm here. So why we you know, why are people suggesting it? Interesting kings in London that were the big advocates for it have had a big change recently. And since January, they've stopped doing disruptive rumors. Okay. Oh, good. So King's College no longer recommend disruptive room as much, which is, which is progress, I think. 

Emma Pickett  27:48

Yeah, definitely. Definitely. So I had a mum that I've been supporting recently, who went back for a second division. And I'm afraid she was told by the practitioner, that it was her fault that there was a second division because I don't know if I don't think this was an ATP member, by the way, because she hadn't done the exercises. Right. And that's why the baby had had reattachment. I mean, if someone tells you they've been told that what would you say? 

Sarah Oakley  28:15

I would say there's no evidence for any of it. So and what is the right regime? I mean, that was the other issue with the disruptive room massage thing. I mean, kings were the big advocates for it, but they kept changing their regime. I mean, you know, I know I can think of, you know, there were at least two changes in their rating, they were recommending, no one actually knows, even if this stuff works. And even if it was acceptable. Every practitioner recommending disruptive room massage is recommending something different. And in terms of exercises, you know, most of us do tongue poking games lateralization is finger sucking and stuff. There are other exercises I sometimes recommend in specific situations, but there's no evidence for it. And there's no, you know, we don't know how often how long for or anything. So we're using kind of guesswork if you like, you know, we're using our experience and our judgment to say, Well, we think this might help. So let's try this for a week and see how you get on with it. But there's no, you know, you can't determine the spectral parent, you didn't do it correctly, you didn't do it often enough, you know, and it's your fault, because we don't know, we know, there's no research on it. We don't know what, what the optimum regime after a division is. And we don't know if we actually need to do any of this at all, you know, the anatomy studies by Nicky Mills, you know, actually have thrown up quite a lot of explanations as to why some friends bleed more when they're cut, why some scar up more. And it does seem to the anatomy of the frame is is a big dictator in whether it recurs or not well, we're not God, we can't change that, you know, and nor can the parents so to blame the parents for recurrence, I think is really unethical. Yeah. You know, we just don't have that magic answer to prevent this. And we're in the lap of the gods with the anatomy really? I think so. Yeah, that's grossly unfair to blame parents. They should never be blamed for a recurrence. 

Emma Pickett  29:55

Yeah, that's the sort of message I gave for so I'm glad I was on your page as well. Yeah. Um, so, I mean, you mentioned ethics. I think ethics is a big word when we're talking about this whole area of, you know, feeling support and tongue tie support. You know, it's 2024. We've got nice guidance supporting doing tongue tie division in some cases. But we still hear of health professionals who say that they don't believe in tongue tie that it's almost some kind of faith based thing. And it's so frustrating and distressing for families. Do you think things are better than they were when you first started? What's the what's happening do you think with that?

Sarah Oakley  30:30

I think definitely, things are a lot better. I mean, when I first started in my area, that our local families had to be referred to as county to get a division they had to go to Bedfordshire, from Cambridgeshire. There was a service in Norwich, where they were quite on board with the whole tongue tie thing. And there was the Bedford service. That was really it for the NHS. And then I came along, started doing them privately. And, you know, there was lots of, I mean, I had I had GPS threatening to report me, they're gonna report me to nice, which was really interesting, because nice isn't a regulator. So you know, that's nothing to report me to them. Nice wrote the guidance on this. So maybe they're not the best people to go to. But yeah, I mean, I had, there was a lot of hostility to what I was doing. And I was called barbaric and cruel and all kinds of stuff. Yeah. And threatened to beat. They never did it. But you know, are we gonna report it won't go ahead, then. Mervyn Griffis actually stepped in and calm the local GPs down and said, you know, get a grip. So luckily, I started moving around at the time, and he kind of backed me up, but he said, I have a little chat with them. And that kind of dampened all of that down. But it was a lot of hostility to it a huge amount of hostility, there isn't that hostility anymore now, because there's a lot of NHS services now that, you know, so many more NHS services now than there was then. So if the NHS are doing it, that kind of then makes it okay, but there are still a few pediatricians, GPs, even midwives and health visitors out there. That will say, it makes no difference. It's a fad. You know, it's cruel, you know, it's, you know, barbaric. And I still get the odd person coming in saying they spoke to their health visitor or their GP about it. And they said, oh, there's no evidence for it, don't do it. You know, it'll just cause you baby pain in distress, and it won't make any difference. You still get that, but it that's very rare now, whereas that was very common 1012 years ago, okay. Things have changed, there is more acceptance of it. And I think it's because there are a lot more NHS services now. So that's increased the acceptance of it. Because now it's kind of like, well, the local hospitals are doing it. So if you're a GP, in your local hospital offering this thing is a bit difficult to then tell parents that it's a waste of time. But you know, there are still people out there that and there are people I mean, I had a GP say to a mum, this is a few years ago, I told them, tongue tie didn't exist until Sarah Oakley came along, like I invented it.

Emma Pickett  32:40

There's a statement!

Sarah Oakley  32:41

You know, 100, you know, we know that we were dividing 

Emma Pickett  32:43

Yeah, you were quoting in your book, all these ancient documents from like the 1700s. 

Sarah Oakley  32:47

1700s, 1800s, there are texts that refer to dividing tongue ties in, in babies to help with feeding and it was routine practice until the 1950s. And the only reason it stopped them was because you know, the promotion of formula feeding at that stage. And it was, instead of addressing the breastfeeding issues, moms were given free samples a formula and sent on their line told that bottle feed was better for them and better for their babies and all of that. So that was why we then had that kind of 40 year period between the 50s 1930s and the 1990s, where it was largely ignored as an issue because breastfeeding was ignored it wasn't it, you know, there wasn't a real breastfeeding support. And then we got a little bit more educated and, and from the 1990s, started realizing that breastfeeding had a real value and should be supported and, and then Tongue Tied division, that kind of thing again, but, you know, it's not like it wasn't something that you know, something that's a recent fad, or a recent invention. You know, babies probably had tongue ties, you know, since the beginning, really, yeah. But certainly for a number of years we've been doing this procedure, it's not a new thing.

Emma Pickett  33:46

A little advert just to say that you can buy my four books online. You've Got It In You, a positive guide to breastfeeding is 99p as an e book, and that's aimed at expectant and new parents. The Breast Book published by Pinter Martin is a guide for nine to 14 year olds, and it's a puberty book that puts the emphasis on breasts, which I think is very much needed. And my last two books are about supporting breastfeeding beyond six months and supporting the transition from breastfeeding. For a 10% discount on the last two, go to Jessica Kingsley Press. That's uk.jkp.com and use the code MMPE10, Makes Milk Pickett Emma 10. Thanks. 

Emma Pickett  34:33

One of the sort of thing areas where it's still I said sometimes hear a bit more of a moan is the idea of a posterior tongue tie. So yeah, really, quite recently, someone was saying to me, Oh, our own NHS clinic only do anterior tongue ties. Yeah, they don't do posterior tongue ties. And there seems to be lots of different terms used to describe different kinds of tongue ties. So you get percentages and types and how do you define the different types? What's the kind of criteria that you like to use? Is it useful to talk about different types?

Sarah Oakley  35:03

No, I don't think so. I mean, if you look at Nikki Mills as work on anatomy, a tongue ties, a tongue tie, really, I think the anterior posterior thing is really difficult because some people, you know, for some people, a posterior tongue ties, anything that's not attached right at the very tip of the tongue. For some people, a posterior tongue tie is, is only what we used to talk when we talk about submucosal tongue tone, and that's a whole nother hot potato. That basically if you look in the literature on tongue tight, if you look at the research, when they talk in the studies about the types of tongue tie, they were dividing, the anterior tongue ties are generally the ones that are attached to the front half of the tongue. So anything that's right at the tip going back half way, but anything that's attached halfway or further back, they refer to as posterior. But within that section of posterior tongue ties, that kind of group of posterior tongue ties, we had the concept of the submucosal tongue tie. Now a lot of people said submucosal, tongue ties with the true posterior, and everything else was anterior. Now, the submucosal concept was born in America, Katherine Watson, Janet and Betty Corollas came up with that in 2004. And they came up with a classification system of type one, type two, type three, type four, so your type ones and type twos, were the ones that were in the front half of the talk. So the type one was at the tip, the type two, they said was two to four millimeters back, type three was halfway back. And then you had this type four, which was a submucosal. tongue tie. Now, what they theorized was that there was this cohort of babies that they were seeing that weren't moving their tongues correctly, and had deficits in tongue function and feeding problems. But they didn't have an obvious frenulum. So they kind of came up with a hypothesis that these babies had a friendly lamb, but it was buried at the base of the tongue in the genius glasses muscle. We now know from Natick studies, that was completely wrong, you know, because the tongue tie is actually a folding the fascia that comes out for the for the mouth, attaches to the underside of the tongue. But back then I was taught when I cut tongue ties that we were cut in a discreet band of tissue. So that was what Betty and Catherine were working on that basis that it was this band or strand of tissue. And then it could somehow be buried at the base of the tongue and needed to be kind of pushed out by putting pressure at the base of the tongue, bringing that that banded tissue up and then snipping it. What we actually think we were snipping was actually the center of the genius closers, muscle, not friendly them at all. So the whole concept of submucosal tongue tie has been debunked. So if you define a posterior tongue ties, or somebody COVID onto it, then posterior tongue ties don't exist anymore. And they're all just tongue ties. But it's really complicated. And I don't know if I've actually explained it very well.

Emma Pickett  37:34

I think you have, I mean, it's complicated. There's a lot of anatomy knowledge required, I think you gave us a good picture

Sarah Oakley  37:41

A tongue tie is a tongue tie. So it doesn't really matter where it's attached on the under surface at the target can cause the same problems. And the procedure is the same submucosal tantrums we shouldn't be talking about anymore, because that concept of has been bumped by the anatomy studies, it doesn't really know now, it doesn't anatomically exist. So we need to walk away from that and actually come from what's in general said, we need to walk away from that and look at other things like bodywork and stuff to address those babies that have got a deficit in tongue function, but don't have an obvious frenulum. The whole thing is, yeah, has become a bit of a problem. But yeah, in my area, I've got NHS services where the surgeons will only snip the ones that are right at the tip of the tongue. And then they'll often be snipped the front bit, because they don't believe that back that is actually going to cause a problem. But of course it does. And often, if they snip the front bit and think about it in, it has no impact on the feeding and actually sometimes makes it a bit worse. Because that baby has kind of learned to compensate to some extent with the title you've got, and then you change it. And this is a restriction and it's slightly different. And then some of those babies really then struggle. So I do see a few babies that come to me where I think yeah, that perhaps is difficult if you've not witnessed the procedure to know whether it was fully divided or not. No one can tell a few days down the line. But you know, I There are surgeons that admit, you know, that say for parents, we only sit at the front back, we leave the back bit in because we don't believe that causes a problem. And then they pitch up at my clinic a week later saying, you know, we're still really struggling with the feeding here. Can you have a look? 

Emma Pickett  38:59

Yeah, they might sometimes we're the ones called reattachment, but it wasn't a reattachment.

Sarah Oakley  39:04

Yeah. If the surgeon is admitting they don't actually divide right to the base that time they just they just snip the front bit out, well, then, you know, you know that, that that that might be a problem and that it may not have been a full, a full division. But what is a full division? That's controversial as well. You know, do you need to achieve a diamond and expose the genius closers muscle or not, you know, or do you just need to cut far enough back to release that tongue to allow the baby to use it sufficiently for feeding, there's a whole load of controversy around that. And if you cut too deep, you know, you're gonna get more bleeding. If you cut too deep, potentially you're gonna get more scarring. So the whole kind of, you know, there's a lot of controversy around what is a full division. And I think the success and success of the procedure has to be measured in the breastfeeding outcome or the battlefield outcome. If you get a good outcome that was a successful procedure in terms of you know, the feeding outcome is good. But as I say, you can sometimes do a really good division and you know, you think you have done a really good job there that was released that time the babies you move in that tumble, but it doesn't translate into a better seating outcome. So it's a really complicated area. And I think the whole issue around what is the full division is quite a controversial area. 

Emma Pickett  40:10

Yeah, I think I think one thing that I'd like to talk about which is kind of difficult to work out how exactly how to discuss this, we all know the NHS is under a lot of pressure. We know that community midwives are having to see tons of families who have come home after a traumatic birth experience or traumatic postnatal experience, you know, we are in a mess. So we could have a whole nother hour talking about what's happening in the UK with our health services. And one thing that worries me and I know I'm not entirely alone about this is that sometimes when someone is under pressure, they don't have time to see a full feed, they don't have time to look at positioning attachment. They go into a home, they do an assessment, they appear to see a tongue tie. And that baby's then thrown into tongue tie services goes down the route of having a division without having had that whole picture. So you have I guess you could call that overdiagnosis. But you could also say at the same time in the UK, we've got under diagnosis, can you have over diagnosis and under diagnosis at the same time? 

Sarah Oakley  41:07

Yeah, I think you can have tongue ties that are myths that should have been divided that weren't or divided late, because they were missed in the early weeks. And then that can have a catastrophic effect on the breastfeeding outcome. You can you can have babies that yeah, are getting divisions unnecessarily. I think that I think we've got both problems. Actually. I see both, you know, and I have parents coming to me that Yeah, exactly. That a midwife has gone in at day five babies not gaining weight. Yeah, I think babies got tanked. I'll refer you into the service got seen a couple of weeks later had a division done. And then they come to me, it hasn't really helped, you know, and you question whether Yeah, did that baby actually need that procedure doing or not? Or was there something else going on? Very often, I've had that situation actually with with mammary hyperplasia. You know, I've had parents that have been sent down the division route, because I beg is not gaining weight. And actually, when I've seen them, the mum has got clear evidence of memory hyperplasia. And you know, when you talk about did you milk come in? How much have you been able to express? You know, there's a, there's a supply issue on that side, that's been completely overlooked. And it's all been about, oh, this baby's probably got a tummy tuck. The problem is 99% of babies have a lingual frenulum. So 99%, babies could have a friend, your friend your tummy, because you know, 99% of them, I've got something we can cut. But we know that only a small percentage actually need have a restriction that impacts feeding and needed revision. So there is a huge scope for over diagnosis. And there's a lot of concern about that. I don't think we've got any stats on it in the UK, but in places like America, Australia and New Zealand, there has been concerns raised about the, you know, explosion in tongue tie division, and whether, you know, there's a lot of unnecessary procedures going on.

Emma Pickett  42:43

And that's what will happen if we don't have proper lactation support, you know, and, you know, the if the NHS funds, a tongue tie clinic, but the same hospital doesn't have a lactation support clinic, and there's no lactation specialist out that's, that's what you're gonna get. I mean, I've had, you know, several times a mums come to one of my groups where I volunteer, post division, things aren't better. And the positioning attachment is a car crash. And when I wouldn't use that phrase talking to the mum, but you know, the baby's like half a meter away and no chin contact, complete disaster. Obviously, no one's ever watched that mum feed before, and that mum had a division on her baby before she had any support repositioning attachment, it's, you know, and it's really hard because I don't want to blame individual health professionals, you know, that that community midwife who did that referral, you know, we have to have empathy for how difficult it must be to be in that situation. So not, you know, baby's asleep, you've got 10 more people to see that day, you haven't got time to see all those feeds. But it's just bananas that there are so many local authorities that have done tie services and no lactation specialist services. 

Sarah Oakley  43:45

Yeah, it's quite bizarre, and there's no proper assessment, you know, they're not using assessment tools or anything. And I go around the country do a lot of work for NHS Trust, training health is as midwives are using things like the tabular bristle tool, because that's a really easy tool to learn. But, you know, I know in my in my local area, they don't use any kind of assessment tool at all. So there's no assessment, formal kind of assessment of tongue function. And there often isn't a proper feeding assessment done before they actually go into the service. And then when they get to the service, they see a surgeon for 20 minutes, who doesn't, you know, the parents say to me, they don't didn't even really ask me what was going on with the feeding, they just basically I'm the baby's mouth and said, Oh, yeah, we'll cut that or no, we won't cut that. and off you go. And that's it. You know, there's no real because a lot of parents come to me having sometimes taken baby number one through the NHS system, and they come to me with baby number two. And they're actually quite shocked by the difference. Because they say, well, at the last night, they didn't ask us about the feeding, they didn't watch the feed. They didn't give us any information about risks or anything. And you think that's, I mean, that's terrible. You know, that is really terrible. And some I've had some parents on the second division when I've gone through the risks with them. They've been like, oh, I don't know if we want to do it now. And I'm like, but you did it with your first baby. Yeah, but they didn't tell us all that the first time around. And you're like, Oh, God, this is really this is really worrying. You know? Yeah, and it's not just NHS so so private services like this as well, there are surgeons and dentists out there offering private services that are much different. And there are private services offered by midwives and things who don't have specialists lactation qualifications. And I pick some of those up sometimes, you know, they've paid a private midwife to go in and do a tongue tie division for them. But then they come to me because they haven't had any follow up help or support. And then there are things that I think needed addressing, you know, at the time of that division that haven't been like the supply and all of that, and that's really frustrating. And the parents end up there kind of paying twice, because they're paying these people similar fees to what they would pay somebody like me, but they're not getting that lactations. But sometimes they're paying more if I see surgeons, dentists, they're often paying an awful lot more. But all they're getting is a friendly lottery, they're not getting anything else. That really is no good. 

Emma Pickett  45:44

Yeah, that's that's a little bit of what I see as well. And, yeah, difficult, we've got the work to still be done. And even though there's so much that has been achieved. So just just a little bit of a footnote, you've talked about memory hyperplasia, if someone's not familiar with that term, sometimes it's called insufficient glandular tissue, which is not a great phrase to use. But essentially, we're talking about a man with a primary barrier to milk supply being fully developed. So if that's the situation, having the tongue tied procedure done, it's not going to magically make that mum develop a full milk supply. I met a Brazilian mum the other day, who said that in Brazil, you hot you pretty much don't get out of the delivery suite. And without the tongue tie procedure being done. It's it's super fast. It's it happens within the first 24 hours, it's part of the immediate check that you have done on the baby. Is that an ideal? Is that a good thing to have these procedures done super quick? Should that be I know some people say, I've seen petitions flying around about how get the tongue tie on the postnatal check and or are we just setting ourselves up for more divisions? Because people aren't being properly trained in lactation? And just seeing a friend, you know, a friend Nealon? What do you think about these really early divisions?

Sarah Oakley  46:50

I don't think we should routinely early do any divisions, I think there is an argument for putting into the Nyepi. And having these babies checked at birth. Tell me what an IPS check. So the newborn check that all the babies have when they look at their eyes, their hearts and why you know, your baby, within the first 24 hours of being born, we'll have had to have that done. They usually do it before they discharged from hospital. So there is an argument because obviously on that check, they check for cleft palate. So why don't they check for tongue tie, I think you'd have to really upskill those people doing those checks, so that they could actually do a proper thorough assessment of the tongue function. But I think an assessment at that point can be misleading in terms of function. Because these babies are often a bit tight, they just move born. And I've seen babies, you know, day one, day two, day three, where they're not poking their tongues out very well. And they're not, you know, perhaps lifting the tongues as much as I'd like. But they are very tight. So I've just been born, I've been curled up inside that when they've come through the birth canal or been pulled out with a C section. And you know, they are quite tight in their little necks and jaws. And that tension, you know, loosens up in those first few days, I think you can get a bit of a misleading assessment at that point. So certainly with the tongue ties that are attached further back, and perhaps a bit longer and stretch here, you could go and cut those. But actually, if you just waited a few days, things would loosen up and the thing would improve without any intervention. And I think there is also a concern, that if you if the baby is feeding Well, in those first 2448 hours, if you then jump in there with the scissors, you know, that could actually disrupt that feeding. And I do interesting, I find, you know, occasionally we'll get babies that have a nursing strike after division and will not latch at all. And they tend to be the babies in my experience that are less than 10 days old. Because they're not really established on the breast as well, you know, if they're 234 weeks old, are much more established on the breast. But my experience is where I get mums ringing me and saying, you know, we can't see you today, the baby fed obviously with you. But since we've got home, we're really struggling to get any milk that getting to latch, they are often those very young babies. So that's a consideration. Obviously, if, if it's a five day old baby, and they've lost 20%, that body weight and that moms nipples are shredded to pieces, you're going to intervene to do that division. But sometimes I get them brought to me in that first week. And actually, yeah, there are signs, you know, they've got a restriction, there are signs that things aren't as good as they could be because mom gets a bit of nipple pain for the first 10 seconds when the baby latches on. And, you know, maybe that baby isn't, you know, feeding quite as efficient as you'd like. But the weight is okay, you know, they've lost a bit of weight at day three, but they're starting to pick up with that they're doing the wet and dirty nappies as you expect. You know, some of those I'll do a bit of a watch and wait with and we'll have a discussion around that. Because I am worried that you know, things going relatively well at the moment, are we going Am I gonna turn this bag into a non lecture and I have had babies where I've divided in those first few days where they've struggled with latch and refuse to latch for a few hours after the but I've had a few that have done that for a few days. So that's a bit of a worry if you're doing a fordell baby, and then they decide they're not gonna latch for five days, that mums then got to get on the pumps and do the expressing and actually, maybe if you'd have waited a bit longer, you could have manage that feeding in the interim. And maybe then when you did the division, it wouldn't be so it's really difficult. It's a real judgment call and comes with experience. And but I do have few, a few that were all have a conversation with the parents about the fact that the fee is not too bad, shall we just watch and wait a little bit here and I'm happy to see again a couple of weeks and review where we're at. And then we mark them we've made, some of them are quite anti retirement, you know, long term, we're gonna cause a big problem as the baby needs bigger feeds and stuff. But you know, if things are going okay, in that first week or two are you better just hang off hold off a little bit rather than causing another problem. So I have a bit of a concern about jumping straight in there. And I think what we really need is better support service, you know, we need better assessment of the feeding. If this feeling is assessed properly in those first few days, you can pull out the ones that definitely needs revision immediately. And I do get a lot of non latching babies coming to me at day two, we sit at the front and they start to latch on feed. Brilliant. That's what we want. And they definitely need a division very early on. But I think yeah, it's that we need to be really good at feeding assessment and the tongue tie, there needs to be part of that feeding Assessment and Support process, not a kind of separate assessment and a separate thing.

Emma Pickett  51:04

Yep. Yep, that makes a lot of sense to me. I know you're a modest person, Sarah, but I will say, you know, I've been doing this, this job throughout the sort of history of the watching the ATP setup and, and watching, you know, the work you've been doing. And I just want to say an enormous thank you to you on behalf of the mums that I support and breastfeeding supporters as well. You have made such a difference the experience of breastfeeding families in the UK, I'm talking to you, and also all the tongue tie practitioners that are part of the ATP. 

Sarah Oakley  51:31

Yeah, I mean, there's a huge amount of work that goes on in that organization, I actually don't do as much for them. Now, as I used to, I've kind of stepped back I the first seven years I was full on. And then I've stepped back. But I mean, I still am involved and do quite a bit of stuff for them. But I don't do anything like I used to let other people do that now. I 

Emma Pickett  51:48

I think seven years sounds like a lot Sarah, you're allowed to step back a little bit. And you're still training, I know, you're still doing a ton of stuff. You know, the NHS support is patchy. And I know that ATP practitioners are so saving breastfeeding experiences every day. We've talked a little bit about this already. If someone is wanting to choose a private practitioner, if that's the choice they're making, we can signpost to the ATP listings, I normally would suggest that they look for someone with breastfeeding, qualified qualifications. So you know, an ibclc as an easy way to check for that. What other questions would you normally expect a parent to ask if they're your follow up? What kind of follow up with expect a reasonable question? 

Sarah Oakley  52:29

Alrighty, so they need to ask about Yeah, what follow up is provided? And what does that look like? You know, what the cost attached to that? Is there any kind of free, you know, free follow up or anything available, or you know, what's included in the package that they're buying kind of thing? And I think they need to look at the experience of the person as well, definitely on the ATP, it does say what you know, it does have people's qualification, so you can pick out on that listing who's an ibclc and who isn't. So that we might know, we've made that quite easy for people to sort that out. But it goes a little bit beyond that. Because you know, you can have somebody that perhaps has been a midwife for two or three years, done their ibclc done a tongue tie training very quickly, they're not necessarily going to have as much experience perhaps as somebody who's been doing it as long as I have. So I think you do have to look experience and reputation as well. So asking other local families, have you used this person? How did you find them? You know, were they okay? Did you were you happy with the service you've got? Because it's really difficult, we do need to make sure the ATP if they list people have already checked that they've got the NMC registration that they've got on Thai training, that they've got CQC. But really, parents ought to be checking that kind of thing out as well. You know, I'm CQC registered and I've been inspected. So my inspection report is on my website, you can click the button and read my inspection report. And I think sometimes there's some value in doing that. I don't think parents check people out enough and look at people's websites, what do they say about themselves on their website? You know, a lot of families come to me and they're clearly not read my website, I've got no clue who I am. And then I have a copy of my books out on the shelf in my clinic. And they'll go, oh, did you write that? That? Is that your book? You know? And and, you know, they're kind of, and they asked me questions, and they're kind of like, we don't know, if we can ask you it's been our baby's got a bit of a nappy rash. Can you ever look at? Well, yeah, you know, I'm a nurse and a heartbeat. So I'm quite happy to look at a nappy rash. You know, but they haven't really clocked that, you know, they've just booked me because I was the first one that came up on the listing when they went into the directory. And I don't think that's necessary, you know, the directory is your starting point. But I think it's worth doing a bit of research and actually ask those people, you know, you know, you know, ask them about their CQC registration and ask them about their experience and qualifications and, and all of that and look at them. You know, I think people do more research on it by card sometimes than they do when they look at some type practitioner

Emma Pickett  54:38

or a pram.

Sarah Oakley  54:40

Or, yeah, or, you know, and I think, you know, you don't just go for the first person you come to maybe just have a little look around and just ask locally what people's experiences are. Because, you know, it's not the same across the board. And there are some really excellent practitioners out there who spend hours and hours of their lives. You know, supporting families and there are others who do the division and then a very difficult to get hold on I do get parents coming to me saying I, I had a division done two weeks ago with so and so. And I've been emailing her furnaces and can't get hold of her. And I am a bit of a bit of a bit of a one for that, because I will go right, I'll try and get hold of it. And I have done that I have actually gone to myself and said, Look, this man was trying to get hold of you need to follow them up. Because I don't want you to come to me and pay again, you know, and some of them are very happy to come about getting some of them say, Well, I'd rather see you anyway, because I've since heard you know that you're really good. So I'd rather we're gonna see it. But you know, I will try and get those practitioners to do the follow up because it's not fair, you know, they should be able to access them again, and not have to pay a full fee to come and see a new practitioner and start from square one again. 

Emma Pickett  55:41

Yeah, thank you, Sarah. Thank you for doing that. That's definitely something you're you're not paid to do. So that is massively appreciated. Okay, slightly off out of field question here. We've talked about there being more tongue tie divisions being done. And that's almost certainly about breastfeeding rates, improving more awareness, you know, social media conversations, more trained practitioners, the nice guidance coming out. Could it also be that there are more tongue ties? Is that a thing?

Sarah Oakley  56:06

I mean, people you get all this stuff online about folic acid and genetic mutations? And is it possible that there are more tongue ties now than there were historically it might it might be, there's some kind of environmental factor going on. I mean, with regards to folic acid, there's, I only know of two studies that have looked at that one found absolutely no link at all between folic acid and tongue tied. And the other study found an association with mothers who took folic acid pre conception. So they took it pre conception, there seemed to be an association with the baby then having a tongue tied, but the sample of that study was only 200 dyads. So it was way too small to say that there was any kind of causative link there. So it may just been, you know, something within that sample. So as it stands, there isn't really any evidence for folic acid triggering tongue ties, and certainly you don't want mothers not to take folic acid because spider 50 was a far bigger problem. And so we mustn't, you know, go down that road. Interestingly, there was an article written in 1959 in the BMJ by adoptee research, the history of tongue tie division, and, you know, tract it back a few 100 years and all of that. And at that point, they were talking about one in four babies having a tongue tied division now, that was in the 1950s, when it started to die out as a practice, but one in four is quite a lot. More recently, we've talked about one in 10. But that came from a study done in Southampton in 2002, when they were doing the RCTs there, and I actually think if they reran that study, now, they'd come up with a bigger number than one in 10. Because they were really only looking at the very obvious tongue ties that have close to the tip of the tongue at that point. There was a study done in Spain recently, within the last three years, I think, was published in 2021, where they came up with a figure 46%, which seems huge. 

Emma Pickett  57:44

Oh, golly. Okay, 

Sarah Oakley  57:45

so that was one in two babies in that sample, and it was 1372 babies. So it's quite a decent size. 

Emma Pickett  57:50

Okay, gosh, that's a load, isn't it? But obviously, it goes without saying what we were saying before, that doesn't mean all those babies needed to fit. They did. That's not the same thing

Sarah Oakley  57:58

Yeah, 46% had a tongue tie, I think was 32 or 33% had a division. So you know, it was one in three babies.

Emma Pickett  58:06

That's so high, what's its high, let's go and study the water in Spain. I mean, that is incredibly high.

Sarah Oakley  58:13

And there are other studies that have come up with a, you know, an incidence of 2% In some countries, you know, I mean, it runs in families is genetic in origin. So it would make sense that some countries might have a higher incidence, and others depend on the gene pool. But the fact is, we don't really know there may be environment, God, you know, goodness me, you know, there's so much going on in the world isn't so much pollution, you know, we've been exposed to so many things, whether there is some environmental factors that are triggering more or not, that's a possibility. But my feeling is that it has always been quite a common thing. And that the rise is around greater awareness. But that rise may be over and above what it should be, because there may be some overdiagnosis going on, and some over treatment going on. I mean, this is this is a lucrative thing. And this is, you know, doing doing tongue tight division, there's, you know, if you're doing it privately, obviously, you that you can make money out of it. So I think there are some people out there that, you know, are more inclined to divide that, I'd like to think people wouldn't be like that, and professionals wouldn't be like that. But I certainly think there's concerns about that in a lot of countries where it's a private healthcare system in places like America and Australia and stuff, that there are some people that are using this as an income generator, but actually, NHS hospitals use it as an income generator as well, because, you know, it can help them pay off that deficit, if they're getting lots of referrals coming in from out of county, you know, there are hospitals local to me that take a lot of out of county referrals because it brings in a lot of money to that hospital. So then is there that, you know, that drive to find tongue ties to divide. So, because we've got a mark, you know, free market system within the NHS. So, you know, the more babies they see, the more divisions they do, the more money they make. So that's a bit of a concern. So it's not just private practice, where finance may come into it, it's even in the NHS.

Emma Pickett  59:53

So it really comes down to the ethics of the individual practice. And that's why it's so important that your voices out there, so because you're absolutely the epitome of that, and thank you for your voice in in this space 100% Because it's just you just need one dodgy local practitioner and environment of tongue ties colored and affected by people thinking that tongue ties a scam. And, you know, I've met lactation consultants who are really angry about private tongue practitioners because they've they've just got one, you know, Apple in their local area who always divides never says let's watch and wait. Yeah, but that's good. That's why the ATP is important because that we're talking about a tiny minority. And if the peer group as a whole is giving the positive messaging and focusing on the ethics, though, you know, that's going to become less and less acceptible.

Sarah Oakley  1:00:41

Yeah and it is a minority. Absolutely. But yeah, it is certainly something that we need to acknowledge does happen.

Emma Pickett  1:00:47

So if somebody is like me, they're not a tongue tie specialists. They're not a health professional. They're sort of IBCLC from a non health professional background. I know that you offer training, is that right to help people have greater awareness. Tell me a bit more about that.

Sarah Oakley  1:01:00

I do study days, I will do you know, if you've got a group of ibclcs or breastfeeding supporters or health professionals who want a study day, I can do it online or I can do it, you know, come to you come to your venue and do it for you. I do study days that can be accessed by anybody. I have osteopathic conferences. I've speech therapists, I have dentists I have, I've had GPS come to them. ibclcs, breastfeeding counselors, peer supporters, you know, the whole lot. And I try and write my training in a way that it's accessible for everybody, and everyone's gonna get something out of it. But I also have an online course. That is, it's 10 hours, and it's got 10, 10 SERPs attached to it. 10 l certs. And I do go out and do stuff for NHS Trust. So at the moment, I actually went on Wednesday down to London, to teach health nurses and midwives from the Lambeth southern areas. And I'm going back to do another couple of sessions for them later in the year. And I'm doing some work. I'm in Barnsley, at the moment, I have an ongoing rolling program with Ken and things. So there are NHS Trusts all over the place over the years that I've done some training for, but I'm always up for doing, you know, training with anybody, I do get organizations approaching me saying, Will you write some training for us? Or will you do a study day for our staff or our members, I'm happy to do that kind of thing. I do definitely prefer face to face rather than zoom.

Emma Pickett  1:02:12

My gosh, Zoom is everywhere. We all got zoomed out in the pandemic. Yeah, I've I've heard you speak several times at different conferences and events. And I know that you're, you know, really valuable speaker and you're and you give such concrete down to earth information. But it's always backed up by evidence you are very much focused on on the research and the evidence. And and you're, you know, you have been today you're really open when evidence doesn't exist. And that's what we need in this whole field of lactation support. We need the people who hold their hands up and say, I don't know. Yeah, so let's let's look at what other people think let's look at good practice. Let's look at what does no harm. But you know, this is what seems to help. No, that's what we need to do. And I know that you're gonna continue to help very much in this space. Is there anything we haven't talked about today? Whether we're talking to parents, who might be worried their childhood has a tongue tie or whether we're talking to breastfeeding supporters? Is there anything we haven't covered that you want to make sure we mentioned?

1:03:03

The practitioners, I think, you know, be, like we've said, Be honest about where there's a lack of evidence, but also be honest about your own limitations. You know, I do think sometimes when, you know, I think sometimes with doctors, when they're approached by a mum with a tongue tied a query around a tongue tied, they'll often kind of not want to say I don't actually know how to assess for Dongtai. So they'll kind of come up with, well, you know, I think there might be something there, but I wouldn't worry about it. And, you know, it's better to actually just say, I'm not trying to assess, or it's outside of my scope of practice to be assessing, you know, but I can refer you on and, you know, we all see Bay, I see baby signs, where I think, do you think need a friendly ottoman? Or is it really going to benefit and been very open with the parents where they're very borderline? You know, and I'll say, you know, I'm kind of sitting on the fence with this one. And we have a discussion around that, um, you know, we'll try other things first, and then maybe do the division if it doesn't work, or whatever, but I think just be really honest. And I see babies that are completely fogged by I saw one yesterday, actually, I'm completely foxbat. So, you know, pediatricians are gonna look at that one, because, you know, we can't have all the answers, can we?

Emma Pickett  1:04:03

Yeah, no, that's for sure. And also, I will say, with my ibclc hat on is that if someone has an ibclc qualification, it does not mean they are trained to assess tongue tie, that is not the same thing. pass the exam and be an IBCLC and know very, very little about tongue tie.

Sarah Oakley  1:04:20

There were really only 1 or 2 questions on it and when and when I sat it and probably when you sat at the first time tonight, it wasn't about the curriculum. 

Emma Pickett  1:04:23

Yeah. Yeah. So yeah, you need to you need to hunt to find your people. But that's one of the joys of social media is you can go out there and find the right people and and if you happen to be in the Cambridgeshire vicinity ceremony might be the person you end up with, but there are lots of fantastic interprets around the UK. We're very, very lucky. So thank you very much to you to you and your colleagues. Thanks very much for today. So I really appreciate you give me your time.

Sarah Oakley  1:04:48

Thank you Emma. It's been a real pleasure. Thank you very much.

Emma Pickett  1:04:56

Thank you for joining me today. You can find me on Instagram at Emma Pickett IBCLC and on Twitter @MakesMilk. It would be lovely if you subscribed because that helps other people to know I exist. And leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast. This podcast is produced by the lovely Emily Crosby Media.