Dr Bob Underwood (Host): Welcome to Pediatrics in Practice, A CME podcast. I'm your host, Dr. Bob Underwood. Before we introduce our guest, I'd like to remind you to claim your CME credits after listening to today's podcast. You can do so by visiting c kc.link/. CME podcast and then click the claim CME button. With me today is Doctor of Occupational Therapy and International Board certified lactation consultant Jira Godell Jira.

Welcome to the Pediatrics and Practice Podcast.

Dr Jairrah Godsil: Thank you for having me.

Dr Bob Underwood (Host): You know, we're looking forward to hearing about your expertise. I mean, as a doctor of occupational therapy who works closely with infants and families navigating lip ties and other feeding challenges. We're gonna call on your expertise today.

Dr Jairrah Godsil: Perfect.

Dr Bob Underwood (Host): So let's start with the basics. Can you explain what a lip tie is and how it differs from other tethered oral tissues like tongue ties?

Dr Jairrah Godsil: Yes. So, a lip tie is basically tissue that connects the upper lip to the gums and that can be too short, too thick, or too tight. And it's also called a maxillary labial frenulum tongue ties. It differs from that because that's just tissue connecting from the base of the tongue, to the floor of the mouth.

And that's also called ankyloglossia. there is one other tie caught the buckle tie. So those are the three types of ties that we see and I would say I probably see lip ties the most, but that can be described as, kind of a normal feature of anatomy. And we also have the buccal ties and tongue ties as well.

And those are the ones that we can see that can be a little bit more problematic, especially the tongue ties.

Dr Bob Underwood (Host): Yeah, you bet. and so that kind of builds into the next question is from an occupational therapy perspective. What are the most common functional challenges that you see with infants with ties, and is it usually upper or lower or both? and how does that affect the function, that we need to get from babies, especially feeding.

Dr Jairrah Godsil: Yes. So typically it's the upper, tie that we see for lip ties and the biggest. Functional issue that I see, it can be with lip sil at the breast if they're breastfeeding or lip sil when they're bottle feeding. so if the seal is kind of affected, you can have anterior loss of liquid when the baby is sucking and trying to swallow.

So they're really not able to manage, the volume and the flow as if it wasn't as tight. so that's probably the biggest one that we see. And, As well. If that is too tight, we can see babies kind of shut down in a way or come off of the feeding source that they're given, and that's where we can have babies that are just overwhelmed a little bit.

Dr Bob Underwood (Host): So how does it affect breastfeeding or bottle feeding? Is it latching on, is that the effect that a parent would maybe see or that you would see when you're doing attempts, in the hospital before going

Dr Jairrah Godsil: Yes. The primary thing that I see is the actual latching onto the breast for breastfeeding. Yes. just because they're just not able to get that good open mouth and also able to grade the force or actual grip and latch on. And then also coordinating how to suck at the same time. So that's where I see the biggest challenge there.

But I can say a lot of babies are born with very tight, compact, anatomy. They're structurally tight, close knit. And so we do see a lot of. Tighter mouths when babies are first born. But as they practice eating and, latching on at the breast, that naturally starts to kind of elongate and babies tend to do better after they had that introductory, timeframe of practicing.

Dr Bob Underwood (Host): So is there anything that pediatricians themselves ought to be looking for in a routine visit?

Dr Jairrah Godsil: Yes. I think the biggest thing, when they're asking questions is one, is the baby able to latch when they're feeding? And the second thing too is if they are able to, can they maintain the latch? Because sometimes we'll hear a family say, yes, they're able to latch, but maintaining that over time, that's where they have the issues.

And babies can fatigue out if it is a struggle just to maintain where they're positioning. and so usually we recommend for another set of eyes to kind of look at feeding initially if that wasn't already, done before they see the pediatrician again.

And.

The other set of eyes, typically we're looking at, a lactation consultant or an occupational therapist or a speech therapist, someone that is savvy, especially for talking about breastfeeding, just to get the functional assessment first. and then that will be able to help the pediatrician see, okay, if they tried some of these things and if this is still an issue, maybe there's something else that we need to look into.

Dr Bob Underwood (Host): Yeah. And that kind of feeds into another topic is, this is really a multidisciplinary approach into diagnosing and treating, lip ties. what does that look like? And, where does OT fit into that team?

Dr Jairrah Godsil: Yes. The great thing about occupational therapy, I'm a little biased since that's what I do. we're able to look at the overall picture, functional, feeding and also looking at positioning. And then we're also getting information by the pediatricians and others about how much the baby is, intaking so we can look at everything and then kind of, trial positions or different things to see if this makes a difference or not.

And, occupational therapy also has expertise in enabling, being able to do it. So sometimes if families do not have someone to help show them these are other ways to do it, that's where Occupational Therapy can definitely come in. And also having the knowledge about structural anatomy into the oral cavity coordination of feeding, sucking and swallowing and breathing.

and then also knowing how the tissues move. Is another area that occupational therapy can help out. 'cause we can provide exercises and also positioning to help facilitate optimal latching and sucking. And we're looking at the lips, how they move the tongue, how they move, the cheeks, how they move, and then how they all play together at the same time while the baby is feeding.

Dr Bob Underwood (Host): So would all of those features really kind of play into a typical feeding therapy plan for an infant who's been diagnosed with a lip tie?

Dr Jairrah Godsil: Yes, absolutely.

Dr Bob Underwood (Host): so what would that plan look like?

Dr Jairrah Godsil: the first initial plan would be first step, looking at the positioning, aspect as it, and then showing families, okay, your baby does best in this position, and then also. especially for breastfeeding, the lactation consultant, especially if they're there at the same time, that's amazing.

'cause we can collaborate. So if the mother has a, specific anatomy with her breast, shape and form, we can also use that as a, tool for us to be able to maximize how the baby can latch at the breast, especially if they have a, lip tie. So one. Positioning that we can do. It's called biological nurturing position, and that's basically, it sounds a little.

Weird when I say it out loud because you don't think about babies feeding on their bellies, but it's basically they're prone on their belly on the mom's, chest basically, and they're feeding in that position. So Gravity provides support and stability for the baby, and it can also enable. Kind of elongation of those, structures to allow for expansion.

 and also for the breast tissue to fill in the oral cavity to provide additional support. So that's where we can, maximize the positioning aspect for, breast or bottle feeding with a lip tie. And then also a lot of times they'll have a lip and a tongue tie, and so it kind of does both of them at the same time.

Dr Bob Underwood (Host): Nice. And so you alluded a little bit earlier to the tissues loosening up, but yet there's a little controversy around overdiagnosis and unnecessary procedures. So how do you approach the balance between structure and function when you're evaluating a baby with ellipti?

Dr Jairrah Godsil: Yes, that is a very good point. I think kind of what I mentioned earlier, talking about how babies are naturally kind of tighter. I think if we wait a little bit to see how the baby does, if we give them time to practice to see how they do. So if we give them a little bit of time and then, also trialing the different positions, then that can give us another idea saying, okay, we tried these things and we're not having that natural elongation.

Maybe there's a secondary thing we need to look into. Maybe a tongue tie specialist. going to an OT or a feeding specialist that specializes in tongue tie, ENT. maybe a dentist, because they can also look at those as well. So that would be my first step that I would do. And then we also know that there is also research published last year that a lot of lip ties specifically may not need surgical intervention.

sometimes tongue ties can be a lot. More difficult because you are not getting any type of tongue elongation or cupping. So that is, something that we can look into and say, okay, well maybe they have a lip and a tongue tie. But if it's just an isolated lip type, there may not be anything that needs to be done.

Dr Bob Underwood (Host): Okay. So let's talk long term in terms of development. What kind of concerns might arise if Ellipti goes untreated and how can early intervention help?

Dr Jairrah Godsil: Yes. So one of the biggest, things that may occur for an untreated lip tie is that it's dental formation. so the baby may have a gap In the front two teeth if it is severe. So those are only the severe lip ties. most lip ties are not that severe, so those are the ones that can have the long-term, formation of just dental alignment.

another thing too, there is kind of inconsistent research showing about speech. It can affect that long term.

and that's just the enunciation pronunciation of words and then how the lip is, placed when speaking. but speech therapy would be a great early intervention source for a baby that has an untreated lip tie.

So I would definitely recommend a referral to that. And then as far as feeding specifically, may need some occupational therapy or feeding specialist that can help facilitate looking at lip sil, puckering the lips, movement of the lips, and then how it's used in conjunction with the tongue. And so those are kind of the long-term things that we would look for to just be on top of feeding and also speech.

Dr Bob Underwood (Host): so much of the fine motor movements around the mouth and feeding, we take for granted until you dig deep into it, as you do as an occupational therapist. Is there anything else you'd like to add, as we close up for today?

Dr Jairrah Godsil: one other part I didn't really touch on weight gain, so that's one issue too that may be a factor, but I see that less with lip ties versus tongue ties. but that can be something else. and also that is kind of a high stress for families if their babies aren't gaining weight. so that's another thing that we

factor in.

Dr Bob Underwood (Host): Absolutely. Thanks for being with us today. I appreciate it.

Dr Jairrah Godsil: Yes. Thank you so much.

Dr Bob Underwood (Host): Absolutely. And to our listeners, as a reminder, claim your CME credits after listening to this very informative episode today. You can do so by visiting CM kc.link/cme podcast and click the claim CME button. And for more information or for other important topics, you can visit that same site, CM kc.link/cme podcast.

If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library. For topics that might be of interest to you. I'm Dr. Bob Underwood, and this is Pediatrics in Practice, A CME Podcast.