21 June 2017 I’m updating this post whenever I hear of a new conjecture from tongue-tie enthusiasts or interesting publications on the topic. Please feel free to add any others in the comments.

Photo: Bronwyn and Ruby by Lisa Trocchi

Tongue-tie, lip-tie, ‘tethered oral tissues’ (or ‘TOTs’—I’m almost tempted to add an emoticon …) are terms tripping off many a health professional’s tongue today. If you are a breastfeeding advocate in the lactation field, or a mother struggling to breastfeed and searching for support or solutions, the popular discussion of these congenital anomalies will likely not have escaped your attention.

A tongue-tie exists when the tissue (frenulum) connecting the underside of the tongue to the floor of the mouth compromises tongue mobility. Restoring optimal tongue movement may be achieved by performing surgery that involves either cutting with scissors or lasering the lingual frenulum or the upper lip frenulum (the tissue connecting the inside of the lip with the gum). While tongue-tie is a mild anomaly that may cause feeding issues, it is not the cause of the majority of breastfeeding challenges. There are very often breastfeeding solutions to breastfeeding problems.

Mothers report improvements in breastfeeding following surgical procedures on their babies to release ties, believing that such releases saved breastfeeding, and without which breastfeeding would not have been possible. Some mothers report no improvement to breastfeeding following surgical procedures, and others say that things have become still worse, and that breastfeeding is no longer possible as a result. I am not going to speculate on when or to what degree tongues need releasing—there are plenty of others doing that—and possibly sometimes tongues may need snipping. I am, however, sceptical about the rapidly growing numbers.

To date, there exists a paucity of reliable evidence regarding the diagnosis and the treatment or otherwise of tongue-ties upon which to make fully informed decisions, either as a health professional or a parent.

‘A kind of pseudo-science prevails concerning this topic, where poor research methodologies are ignored or not comprehended by prominent and authoritative advocates of deep-tissue incisions, where the need for theoretical frames are derided, where articles are thrown around the internet as proof without any credible analysis of the data, that is, without critical thought about how that data is interpreted.

Worst of all, a poisoned, divisive discourse dominates, with advocates of deep-tissue frenectomies unashamedly questioning the competence or experience of those health professionals who are more cautious …  Lactation consultants … who are sceptical about the value of these deep cuts fear to speak out. Being labelled incompetent by colleagues or by parent groups online … Our tongues have been tied. A disturbing and anti-intellectual group has taken hold in the field of breastfeeding support.’ Pamela Douglas

For more than 99% of our existence as a species, all human infants have obtained their main nutrition through breastfeeding and as mammals we have an evolutionary history of lactation that is even more ancient. (Stuart-Macadam, Introduction to Biocultural Perspectives  Walter de Gruyter, Inc. New York).

‘Unfortunately, the power of social media and the manipulation of parental emotion have caused an increase in diagnosis of [tongue-tie], well beyond its actual incidence.’ Alison Hazelbaker

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The Politics of Breastfeeding

The tongue-tie controversy really is a new chapter in the politics of breastfeeding. I’ve been re-reading Gabrielle Palmer’s books, The Politics of Breastfeeding and Why the Politics of Breastfeeding Matter, in which the author describes how a thirst for profit systematically undermines a mother’s confidence in her ability to breastfeed and challenges our complacency about how we feed our children, encouraging us to reappraise the whole subject.

There are some striking parallels between the promotion of artificial baby milk and of tongue-tie release. These are just a few that spring to mind.

  • How in the last century, it’s a sad fact that the more contact mothers have had with health workers the less they have breastfed. (I’m not saying health workers should stop trying, this is just an observation.)
  • How it is often easier, and more lucrative, to work out a stopgap way of alleviating a problem than it is to discover why it occurred in the first place.
  • Our reliance these days on technological solutions and how women in industrialised countries crave instructions as a direct measure of their lack of confidence.
  • How very often mistakes become sanctified because they are in print.
  • How the medical profession strives to be neutral, yet manages to ignore the integration of commercial interests with medical issues.
  • The confusion between philanthropy and vested interest and how many are so caught up in the whirlwind of career progress and profit seeking that they seem unable to review the damage they do.

Informed choice is the mantra of western society and is seen as a right, but few parents are fully informed.

Back in the 1950s, doctors persuaded mothers that artificial feeding was ‘scientific’. They added mystique by presenting gobbledygook to impress. Breastfeeding failure became accepted as a common flaw in women’s bodies, and now tongue-tie is becoming accepted as a common problem in infants’ mouths. Effective distribution of promotion by a universal means of communication creates a market. Where are mothers able to find consistent and impartial information? On Facebook?

hammer-1629587__340And it is fascinating to follow the social media discourse on the topic: the conjectures of some enthusiasts who believe that air swallowed because of tongue or lip-tie leads to leaky gut, food intolerances, and other digestive problems. ‘Restless foetus’, bed wetting, late crawling, sleep disturbances, spinal deformity, ADHD and  erectile dysfunction have been blamed on tied tongues. A new device on sale for training babies’ tongues lists a connection between tongue-tie and leukaemia in its marketing promotion. There’s a growing number of claims cited in chat groups for what tongue-tie release can cure, including, but not limited to, nut allergy, umbilical hernia, craniosynostosis, motion sickness, hating the car seat and nappy changes. It can even prevent SIDS… Adults too are benefiting from having their tongues released to cure headache and neck tension. Some hypothesise that releasing a tie can shorten the menstrual cycle and shrink nodules in the thyroid through some connection with pituitary function. Perhaps tongue-tie is at the root of all hormonal problems? (I’ll keep an eye out!) One woman wrote that after the procedure, not only was her posture improved but her breasts were perkier too. What next? Perhaps a connection between tongue-tie and autism? Indeed, such a connection has already been made, I missed that one … Schizophrenia even!

I recently heard a lactation consultant relate how she had seen flyers from a provider of tongue-tie surgical procedures handed out to pregnant women at a mother and baby fair.

‘If advertising simply provided information, it would be hard to object. But a lot of advertising makes us feel we need something that previously we didn’t need.’ Richard Layard

Discussing artificial baby milks, Palmer notes that in spite of the lack of evidence that the ingredients are essential or even safe, no company has ever put a label on the tin that reads:

‘This product is as yet unproven to be completely safe, thank you for letting us use your baby as a guinea pig.’

She rightly judges controlled experimentation on babies to be unethical.

Since publishing my initial version of this post in January, in addition to the ever growing list of conjectures above, there has been a proliferation of opportunities for education: conferences, symposia, and ‘master’ classes at which advocates of these surgeries sell their promotion and encourage professionals to further their beliefs. ‘Generous’ donations are being publicly presented by providers of laser surgery, a percentage per procedure carried out, to perinatal mental health charities who support mothers with postpartum depression to show how much they care for these vulnerable new mothers …

Do the benefits of surgical procedure outweigh the risks? And what actually are those risks?

Is it right to recommend release without full, impartial information, for which we need to know that a procedure is safe AND effective in doing what it is supposed to do?

When  professionals carrying out tongue-tie surgery are doing procedures with the intention of improving breastfeeding and breastfeeding does not improve, how can a mother fail not to feel undermined and anxious?

As a mother who cares about babies and wants mothers to breastfeed, and as someone who has no financial interest in whether they do or not, I cannot ignore the stories I hear, the ones about babies suffering from oral aversion following (often repeated) tongue-tie release surgeries, stories of botched procedures, wounded babies and harsh aftercare, and those with excessive bleeding.

I do not deny there may in some instances be a connection between tethered oral tissues and effective breastfeeding. What I am doing is to recommend caution and ask for a more rigorous and a more open dialogue between professionals and between mothers over what the evidence reveals with regard to these surgical procedures.

Babies and their mothers are vulnerable, their protection is paramount, even if saying so has cost me a lot of friends as well as my job.

My tongue won’t be tied.

Worth reading

March 2017: from the Australian Breastfeeding Association’s professional journal, Breastfeeding Review 2017; 25(1): 9-15, a paper reflecting upon the oral tie phenomenon by Renee Kam, Lois Wattis, and Pamela Douglas, which includes the serious methodological shortcomings of a number of recent and popularly cited studies.

My post reflecting on this and the lack of credibility.

Cochrane Review 11 March 2017. Frenotomy for tongue-tie in newborn infants ‘The small number of trials along with methodological shortcomings limits the certainty of these findings.’ ‘No consistent positive effect on infant breastfeeding.’

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