CME | Tiny ties and big opinions: Hot takes in peds

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I'm Lauren Birch Berchtold, and I'm the program director for VCME Family Medicine Residency in Modesto, California. And I'm Jason Marker. I'm an associate director here at the Family Medicine Residency Program at Memorial Hospital in South Bend, Indiana. And I'm Taman Osborne Roberts, a family medicine, lifestyle medicine, and obesity medicine physician for the underserved here in Denver, Colorado.

I am so happy to be here with you this week, and I'm really excited about this podcast because I think we're gonna have a good time. Chatting through some things. So I am bringing a case this week in which we, as the great family doctors that we are, are seeing a long-term patient of ours that we followed through her recent pregnancy and did her prenatal care as family docs can and certainly do.

Do. Mm-hmm. And what she is doing is she, she's here five days postpartum and she's asking you about some worries about breastfeeding. She is saying that she's not feeling like her baby is getting enough nutrition. Doesn't get enough milk that it's really painful to breastfeed. And she's like not sure that she wants to keep doing this because these first five days have just been really difficult on her and her kiddo, and she's worried about her kiddo and about her own ability to do this.

What are y'all gonna do with this patient that you're seeing in your clinic room? I pretty much pause in my tracks and say, I need to be as curious as I could possibly be as a doctor right now, because this set of complaints is very, very common, and it can be a whole spectrum of things. There's a whole range of concerns here.

Is this a woman who is truly concerned that her baby's not getting enough calories and. On the all end of the spectrum is, is this woman who's got postpartum depression and is questioning her whole worth as a human being over these things. It is a whole spectrum, and I don't know that I could ever guess where to begin except to say, tell me a little bit more about this.

Hmm. Where are you getting advice from right now? What advice do you think that you need? What do you think the right answers are? Because I wanna partner with you on exploring what the science says about this. And if I know in advance what my community resources are for some of the commonest things that she really has on her mind, I think I'm gonna be able to get her some resources that will really be helpful for her.

I, I need to listen more than I need to talk. Yeah, I, I completely agree with that, Jason. There are so many different places that patients get medical advice of different types from, and definitely when it comes to trial error, it's this kind of odd mixture of getting way too much advice from way too many places and feeling like you have no handbook, you have no idea to do it.

Which, you know, I, I, I think all of us as parents have definitely felt some point or another in, in, in raising kids. I, I think that there's so much like, you know. It relates to patient's national origins. There are very different takes on all parts of early child rearing, especially breastfeeding, depending on the countries that people are coming from, even amongst purely domestic patients.

Patients with a US background, there are subcultural differences between different communities. There are socioeconomic differences. Some patients may have. Access to hospital programs and prenatal programs that others don't have. Other patients may be relying on WIC, where there's a variety of different sorts of pieces of advice.

So I, I agree with you. The most effective thing you can do is, is say, well, tell me what's on your mind. Talk to me about what you're thinking. You know, really understand where patient is coming from and, and what's going through. Because the voices are so diverse, and despite that, people oftentimes feel like they're out there doing this alone.

That was pretty good. Thank you. It's almost like you're really good family docs who, who, who were prepped for this. Did you guys get formal training in how to approach this question? A, a little bit. Not as much as I would've liked. I did have an opportunity to work with some lactation consultants during residency, just a few days.

It was the extensive, as might have been helpful. Mm-hmm. I feel really optimistic about the training that I got when I was a resident around this. We had a, actually a couple of OBGYNs in our community and they did a really nice job of understanding the whole. During postpartum visits, which was great to see them really lean hard into these sorts of things almost proactively often.

I just learned a huge amount from them and I'm very grateful for that. That's amazing. I will say that I had a really different experience. I remember that I checked a box for baby friendly. Hospital training, but I don't remember any other explicit training in breastfeeding conversations or breastfeeding assessment.

And the reason that's a little bit extra funny is I did an extra year of a maternal child health fellowship. Mm-hmm. As an OB fellowship equivalent. And so even within that, I don't remember any explicit training. The training that I have, the reason I feel comfortable with this today is some modeling from my predecessors, but really it was having a kiddo and really struggling through my own breastfeeding journey.

And so with that, and subsequently I realized that there are a couple of really brief, easy to remember tips and recommendations that can be taught to colleagues and to patients in the exam room that can make this, this whole breastfeeding thing just a lot easier for us and for our patients. I wanna talk about what some of those specific things are because if a family doctor knows even a small handful of very concrete things that are, are well evidenced to be able to be helpful for a, a person who's breastfeeding, we want to get to those.

But I would say that. By the time you're having this conversation in the postpartum setting, there have been many, many opportunities to not have to have the conversation already. Even when I was doing my new OB intake visits in private practice, assuming that I had the time to do it, I was talking about breastfeeding from the OB intake visit, trying to get a sense of where this family was coming from in their interest in breastfeeding after the baby was born, what their family history was around this, what their thoughts were, what their concerns and worries were.

And actually spending time trying in each trimester to have a little bit more of that conversation so that when we got to the point where they had this baby in their arms, like that wasn't the first time I was having the conversation. I think that's really important for us to try to remember starting early and having the conversation often along the way.

So something that oftentimes comes up when we're discussing these sorts of issues is the concept of baby friendly hospitals and really what that means. And it's, it's a, a system of of care that, that encourages breastfeeding, doing things like not jumping to formula, not allowing pacifiers, encouraging as much time between infants and mothers as possible.

And these are all, as we know and as we typically promote in our practices, really wonderful things. Promoting breastfeeding is great and, and promoting mother child bonding is, is fantastic. It's important to understand that while these are incredibly important things to promote, there's also a place where they can become a little bit extreme, and there actually have been instances of evidence of harm that have occurred where these practices have been taken to the extreme.

Things like hyperlipidemia, brain injury, secondary to hypoglycemia, potentially infant falls or sun and unexpected postnatal collapse. SUPC, you know, essentially child suffocation because children who were struggling were not necessarily allowed for formula supplementation or that, uh, children were monitored adequately and, you know, uh, were sleeping in a prone position.

Uh, ended up with, with su pc. So while. It's incredibly important to support all of these wonderful practices. It's also important to remember that oftentimes extremes don't necessarily work well in clinical practice. There's a time in the place for extremes. Surgery comes to mind, but the reality in cognitive clinic, not a presupposed situation.

So if mother and and infant are struggling substantially. With breastfeeding and it's leading to nutritional difficulties of potentially health issues. Formula's not evil. Yeah. You know, it's important to, to promote breastfeeding, but it's not the only way and it's, it's an important thing to also have treatment in line with the best practices, the needs and the desires of the patient or patients by each year.

Absolutely. And outside of the medical harms that we can occasionally see, I'll, I'll throw in the emotional like baggage that comes with breastfeeding that women already. Can be prone to feel guilt for, am I, am I doing this whole mothering thing good enough? And if, if they're going to have internalized guilt about their inability or lack of desire to breastfeed and we as medical professionals are sort of piling on top of that, there, there are some, some real.

Temporary issues and there's potential long lasting guilt. And I'll, I'll share, I exclusively breastfed for six months. I only supplemented or, or fed with, with breast milk through a year. And if I could go back in time, I would've stopped. I would've stopped way before a year because I felt like I was killing myself to get there.

And so there's some interesting conversations to be had here now. Let, let's roll this back to what I was talking about at the very top of the episode though, that how do we actually assess, like is there a problem going on with breastfeeding? Not talking about the guilt, not talking about the fact that it's hard, like the mechanics of breastfeeding and we have amazing lactation consultant colleagues that we can refer to potentially in the hospital, potentially in our community, and we can and should be using those colleagues.

But when we are in the room with our. Patient as that N of one relationship. What we can be doing is going in and saying like, can I see how you're feeding your baby? That might feel awkward. We're physicians like not helping our patients feel more awkward about this. Explaining like, I just need to watch to see how your latch is going.

Right? How is the suck happening? And so here's my quick tips and we're gonna make sure that you have some show resources for helpful images and videos as well. When your patient is working on, on having their baby latch to the nipple, what you wanna make sure is that the baby's mouth is open. With that tongue out and pointed down and away from the nipple, the nipple is going to be inserted into the baby's mouth with the nipple pointing up towards the roof of the, of the mouth, towards that soft palate.

And as you obtain a latch, you want the entire areola, not just the nipple to actually be in the child's mouth. And when they're sucking, you should hear a suck, not a click or a smack if. You have a child who is unable to take a full latch who is only trying to feed based on the nipple, they're really unable to express that milk.

And that can lead to hunger and that can lead to pain. And those are some of your biggest issues is, is with that latch and making sure that it's adequate. Again, some of you might be like, all those words meant nothing to me. I gotta see a picture, I gotta watch a video. So we'll make sure that you have resources.

All very good points, Lauren. There are actually also some other things that we can do while we are working to try and get our patients in to see a, a lactation consultant or another lactation expert, a nipple shields that help a number of patients in regards to decreasing pain. So the breast ice packs, lanin can be very, very helpful for.

Folks who are unaware of what lain is, it actually comes from wool. It's essentially kind of the moisturizing component of that. And so if you have a patient, and this is a serious point, who's allergic to wool or lamb, you may not want to use it, but it can help to decrease a nipple cracking and a a baby safe approach to use.

So it's also actually important to consider when pain breastfeeding might be related to some sort of underlying issue, say a ton. It's men. You're stealing the words right outta my mouth. Tongue tie is, is what actually, in our case, to go back to our case, you end up doing an assessment and referring to your lactation consultant, but saying like, Hey, I, I think there might be a tongue tie that's contributing to pain and difficulties with breastfeeding in the patient that we had at the top of the episode.

So, tongue Tai, the technical name is an alosia, and what that means is it congenitally tight. Lingual frenulum limiting the motion of the tongue. The prevalence of tongue tie is around 8% in infants under a year old. But the big question that matters clinically is whether the tongue tie is symptomatic, meaning causing difficulties with breastfeeding, like difficulty obtaining milk or causing pain to the mother.

And so there, there's a pretty decent amount of concern about like, Hey. Are we over diagnosing a symptomatic tongue tie and, and are we then doing things like unnecessary ectomy, which is clipping of that tongue tie. Data has shown that fewer than 50% of infants with physical findings that look like in Glossier actually do have difficulty with breastfeeding.

I'll throw, I, I throw that out there, but we'll also follow it up to say like, again, I shared earlier I had a lot of difficulty with breastfeeding. I had severe pain with breastfeeding, and my daughter was diagnosed with tongue and lip tie and had to get clipping of all of those at about seven days of life.

And it dramatically changed my early breastfeeding journey. And so that really benefited my daughter and I, Jason, I, I don't do ectomies, but you said that your ACT office actually does a lot of these procedures, and I'm curious if you could tell us more. I was kinda surprised when we were talking about this last week that just kind of part of our scope of medicine here in Northern Indiana.

I was asking a few of our residents yesterday just to sort of make sure I wasn't off base about that, but most of them have been in one of those procedures and and done that. It's pretty straightforward sort of thing. We use beninger and followers procedures manual, which a lot of family medicine doctors have in their office already.

Maybe you used it when you were in residency, but the, the idea is pretty straightforward is you can use a lidocaine soaked gauze or spray some topical anesthesia onto a condi applicator and have that held in place often by a parent in the area that's gonna need to be clipped either at the lip or the tongue tie.

Then you're gonna. Hold onto that tongue with a bit of gauze as you would in other ENT procedures as you've seen done. And then either you just do simply a freehand snip with a, a curved pair of scissors, or there is a thing called a grooved tongue tie director, which looks like a flat. Little plate about an inch by an inch.

It's got a groove in it that the frenulum fits into that groove to make sure you're out of the way of snipping any other tissue that's in that area there? Generally when we're doing this in the neonatal period, we do the little snip. It's just a very, it's like literally one snip with the scissors, and we put the baby right to the breast.

And there's an episode of of breastfeeding. We have those babies come in ready to breastfeed. We do the little procedure and put the baby to the breast and it's all done. Older children sometime will get some ice, ice chips or a red popsicle. Nobody likes to see a little bit of blood there. There's going to be a little bit, but that's the key word there, and it's done.

It's pretty straightforward sort of thing. We do that in our residency clinic all the time. That's amazing because that is not my experience. This is something that is either paid out of pocket or requiring referral, and I think it speaks to the breadth of family medicine that, that we can and, and potentially should be doing, and how that has some cultural or or location specific norms.

What I can also imagine is that you're having conversations with those parents about this procedure and do we need to do it? Although if they're being referred, they might come in with some really strong opinions about the need for this, right. We've found ourselves in this place because we have a group of lactation consultants that seem to be fairly assertive about looking for a link between any bit of tongue tie they perceive and the breastfeeding difficulties that are being pointed out to them in lactation consultation.

So one of the hardest parts for our residents, and I think it would be hard for any of our listeners too, is families are getting two different opinions, maybe like we have a more conservative opinion sometimes about whether this. Quote, unquote, needs to be done. Lactation consultants may have a little bit more progressive thought about whether it needs to be done, and we just have to be open-minded and thoughtful about our relationship with our paraprofessionals in the lactation consulting space and, and make sure that we're doing good shared decision making to help these families make the best decision they can.

Amazing, amazing. As we think about a theme of this episode, it's really that of shared decision making, counseling supports, communication, and we've talked about two. Of, of these topics. But the final topic for today is something that requires all of those things and it also really adds the potential for being a more charged or misunderstood issue.

And so what we're gonna talk about is that this baby that you saw at five days postpartum with the breastfeeding difficulties, who ended up potentially having a tongue tie is, is a male child. And that the parents are now asking you, Hey, like can you, could you do a circumcision for me? And so to, man, I'm wondering if you can introduce us.

Into this topic of neonatal circumcision, please. Yes. Uh, before I do so I'd, I'd like to publicly and profusely thank you for assigning me a topic that is probably the single most fraught topic in all of pediatric medicine. This is really, really public. I fear I'll never be able to run for public office after this discussion, but that's probably for the best.

Regards to circumcision. I, I, I, I think that kind of gets at it a little bit, really given, the first thing to do, I think, is to look at the official and current official stance of the American Academy of Pediatrics. According to the American Academy of Pediatrics, it is a culturally and religiously based.

Elective procedure. Now, various words in there, you know, cultural, religious elective can have a a, a lot of import for people and create a lot of strong feelings. But I think it's important to look at the nature of the procedure. Its benefits and at risk. And I won't talk specifically about those. We'll head into that a little bit later.

But it's important to understand that in general it should be recognized. There are some. Benefits to neonatal circumcision. There are also risks to neonatal circumcision, and both the benefits and the risks are relatively small and either easily substituted or easily treated. Given that, and given that the benefits outweigh the risks, it's in medically appropriate procedure, but given that.

The overall benefits and risks are relatively small. It is also not a medically required procedure. People tend to feel very strongly about this particular procedure. Some people who, uh, are in favor of the procedure have very cultural and religious reasons to engage in it that have been present. For thousands of of years.

This is not an insignificant thing for, for people or communities choosing to have this procedure done. To on the other side of it, there are people who feel very, very strongly on the other side that this is an unnecessary procedure and in some cases, some communities use the word mediation to refer to it.

So as you can imagine, very strong feelings on both sides, but from a medical standpoint, it is an appropriate elective procedure given the risk benefit profile, but not a necessary procedure given the relatively small benefits. I think you took us through that nuance really well, Tam, man, so thank you.

Thank you. Some people might argue that the most significant benefit to circumcision is that with a circumcision you have a decreased risk of HIV transmission. But the data that shows that has really been born out in developing nations and has not been born out in the US and so that's something that's important to know.

The other two most commonly cited benefits are a reduced risk of penile cancer. And a reduced risk of infant UTIs. And what I'll say to y'all, and what I tell all of my residents is like, how common do we actually see penile cancer and how commonly do we actually see neonatal UTIs in males? And so we took extraordinarily rare things with those two conditions and made them statistically more rare.

And so those, those are really the things that I like to talk about with regards to benefits. There are risks with this procedure as well as with any procedure risks of pain, bleeding, infection. Particularly for circumcision though, the two things that I call out in particular is for cosmetic outcome, where parents say, I don't think this looks right.

This is uneven. This is not what I envisioned. There's risk of taking too much skin in circumcisions, et cetera, and then also risk of permanent damage to the penis and surrounding structures. And we have to be calling those particular risks out. Those are extraordinarily uncommon, but they do still exist, and so this is not a no risk procedure, although it is a low risk procedure.

I just am entirely fascinated by the last five minutes of conversation that you two have been having. Well, I was talking to our residents yesterday about this whole tongue tie thing. I took a moment to sort of ask them about what percentage of the babies that they're delivering are getting circumcisions and things like that.

And in, in my community up here in known Indiana, we have about a 95% circumcision rate. And our residents know how to do this shared decision making, consenting conversation, and most of the families that we're working with do not want to have this conversation. They have decided well in advance that this child is going to be circumcised or maybe not, as the case may be that that's the decision that is cut and dried and made.

And sometimes they feel like they're sort of forcing a. Consent, shared decision making conversation with a family that knows what they're going to do already. It, it's very, it's a very different sort of situation. So what you two have just said, I, I love that it's in this podcast because it's a good reminder for me.

Like these are the things that we need to do. But my whole career has been around those, those are not what helps families make decisions in my community. This child is going generally to look like his dad when it's all said and done. And that's about as far as many families I've worked with want to have in the conversation.

Oh. Mm-hmm. Mm-hmm. It's a great point. And I'll say that I am in the Central Valley of California, which is a, a pretty conservative area for, for California, and it's been interesting to talk to families who are starting to explore, what if my male child does not look like? Their father, and I've had those conversations with the father.

I have taken care of families where I've circumcised the first male born child and they've declined to circumcise their second child. And so it's an interesting conversation that truly does require a conversation. There's not a right answer. What I I, yeah, that's exactly true and I love that. The other thing that I've noticed, because my career's been a little bit longer than, than your twos yet, but we are keeping babies in the hospital for a shorter and shorter period of time, and that seems to be a pretty convenient time to do a circumcision.

But I. I've also done a half a dozen in my office, you know, seven days old, 10 days old, 14 days old. And this is not a decision that has to be made in the first 24 hours of life when maybe that baby's ready for discharge. And so think about whether it's reasonable to have a conversation with the family in the hospital and then.

Again, at a one week well visit to finalize the decision and give plenty of people the chance to weigh in on this decision that they may wanna make and take the time to do the pros and cons, risks and benefits conversation, and do that, right? So we sometimes feel like, well, we gotta get this done. This baby's going home.

And actually, no, we don't, we, we can do these things in the out of hospital setting. Absolutely. I have done circumcisions for at least 10 years in a couple of different settings and in one of those settings where where I was training, we exclusively did circumcisions in the hospital before this patient was discharged, and so it was pretty wild.

We'd like have a line of six or eight babies and we would just. Take care of this in about an hour in the morning and, and then we would go on with the rest of our day. Where I worked most recently for the last eight years, we exclusively did circumcisions at the two to four week mark. So we never circumcised babies in the hospital.

We were always in the clinic. And the point that I'd like to make here is that what our listeners are hearing is that family docs. Can and do, do circumcisions for neonatal circumcisions in particular. This is very, very much within our wheelhouse if you are trained in doing this procedure, and there are some guardrails around that, that as babies get older, some people will argue four weeks and some people argue six weeks of life past that there is an increased risk of bleeding over about 12 pounds.

There is an increased risk of bleeding. And so those complications are going to lead to you setting or or needing to be setting some internal guardrails around what your office will do. And then the other thing is that we can sometimes forget, we can get into the groove where we're just like doing the procedures that we're being asked to do by our patients, but making sure that the patient who is, again, under that four to six week age of life mark, and under that 12 pound mark.

Has normal penile anatomy so that we can move forward with doing the circumcision, right? Things like hypo, things like the frenulum being rotated pretty significantly over to that three or nine o'clock area are going to be reasons that you either A, want to keep that, that skin that we would normally be taking away in circumcision for repair of hypos fabius later.

Which will be with a urologist, or if you have frenulum rotation, you're going to be thinking about risks of bleeding in that procedure. Again, that can be very difficult to control. I have, I have put stitches in, into the penis and the, the skin after a circumcision, and it is not fun. I do not like doing it, and so being really mindful, but in the appropriately chosen patient, we can be doing this in the hospital.

We can be doing it out in the clinic. Tam, man, I'm curious what your experience has been. Uh, no. I don't think I have too much to add to what both of you have said. I'd just like to thank you both for this circumnavigation and circum location of the circumstances for circumcision. How long did it take you to come up with that?

About three minutes very year.

So my friends, we have reached the end. We have talked about breastfeeding. We have talked about tongue and lip ties. We have talked about neonatal circumcision. These are big topics. We are giving you our hot takes on in this, in this short episode, but this is, this is like our wheelhouse, friends of we are able to have great conversations with the patients that we've potentially have been taking care of throughout their pregnancy or their fertility journey.

Being, taking care of kiddos who are coming into our office to establish care right as soon as they're born. Like these are some of the things that I live to talk about with my patients. And so I'm hopeful that we've given you guys some interesting things to talk about today and potentially, you know, exploring things like, how can I support breastfeeding in particular with some real specific guidelines and, and potentially procedures to be adding to your practice.

And so I'm gonna bring us into gratitude to, man, will you start us off? So, you know, this week I'm grateful for children, especially mine. Keep it short. Mm. Mm-hmm. Jason, what about you? I'm so grateful to be working at a residency program that really continues to take seriously the scope of practice that is possible for family medicine.

And these are all three things are, are areas that not every family physician does, but that every family physician could do. And I'm pleased to be part of an educational system that holds the value in teaching that to residents so they can make those decisions about what fits in their practice when they get into the communities they serve.

Yeah, certainly, and I'll say that I'm grateful for the difficulties that I had just personally with some of my breastfeeding journey, because I have become a better teacher and a better physician to my patients because of the, the learnings that came out of those harder times. And so with that, that's all the time we have today, my friends.

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