Publications this month examining the scientific evidence reveal the recommendations for revisions are based on little more than the placebo effect.
Three experienced and well regarded lactation consultants, Lois Wattis RN CM FACM IBCLC, Renee Kam IBCLC BPhysio IBCLC Cert IV Breastfeeding Education (Counselling), and Pamela Douglas, Medical Director, Associate Professor (Adjunct), Griffith University Senior Lecturer, have written an illuminating paper that has just been published in this month’s issue of the professional journal of the Australian Breastfeeding Association, Breastfeeding Review (2017) reflecting upon tongue-tie. It costs only $4 to access, so if you work in the lactation field or are an interested parent, do pay to read this peer reviewed piece.
The article opens with a scene in a café, in which one mother raises the suggestion of tongue-tie as the potential cause of another mother’s breastfeeding difficulties, with nothing but the scantest information to go on. It’s an illustration of a scenario that repeats itself at an alarming rate, both in real life and online. In this example, the struggling mother luckily meets with a knowledgeable breastfeeding supporter who is able to provide the simple guidance she needs to begin to manage her problem. A slight adjustment to positioning and attachment is all it takes.
Sadly, we live in a world where the normal way to feed a baby is fast becoming a lost art. Many mothers experience challenges when they begin breastfeeding. The difficulties often occur following a cascade of interventions during the birth and/or early separation in the first hours following it, and many mothers are not fortunate to avoid the experience of traumatic birth or to encounter good, skilled help to discover breastfeeding solutions to their particular breastfeeding problems.
The Breastfeeding Review paper is particularly concerned with the role of the IBCLC in relation to the growing popularity of what the authors diplomatically call ‘the oral tie phenomenon’ by which they mean the current tongue-tie trend.
The authors examine the difference between a frenotomy and a frenectomy, how oral restrictions are assessed, and how one determines whether or not they require releasing. They discuss the prevalence of the condition and take a close look at what the research actually tells us.
My own reflection on the tongue-tie ‘phenomenon’ and the enthusiasm with which information about ‘ties’ is shared might focus on social media chat. Mother-to-mother help is a fundamentally female approach to problem solving that has served our fair sex well, since the beginning of time. Never underestimate the value of sharing our stories and experiences in the realm of motherhood. Hearing one small and seemingly insignificant moment of another woman’s life, or one tiny suggestion may have the power to transform another woman’s life, along with those of future generations, no less. For instance, something as simple as, “Don’t look at the clock in the night” may actually serve to save a mother’s sanity as well as her breastfeeding relationship. The flip side of sharing what we have learnt through experience is that it may not be relevant—it is a common human trait to recognise your own troubles in someone else’s. A mother needs first to tell her own story before hearing ours, to be heard before anyone can begin to work out where her individual difficulties may lie. Listening is critical. A sensitive consultant, counsellor, or mother who has breastfed her own babies may have the skills to find what the problem is, through observation and questioning, and only after such assessment can she offer useful suggestions.
Breastfeeding challenges arise from a variety of factors, and similar symptoms can have different causes. Mothers and babies are all different and there is rarely one right answer. A tincture of time and perseverance with caring support and reliable information from the start can give a mother the confidence to make breastfeeding work well. In other words, on social media, when a mother reports that her baby is unsettled or can’t latch on well, those who (in droves) immediately suggest that tongue-tie is the problem are better ignored.
Determining whether a baby has a tongue-tie (the definitions of which vary) is not possible from a photo or a list of symptoms. Even when a baby’s tongue movements are restricted, he may very likely still breastfeed or learn to breastfeed comfortably without any surgical intervention. From an evolutionary perspective, common sense tells me that such a genetic abnormality would not have been passed on in such fantastically ever-increasing numbers if it really prevented babies from feeding. More importantly, introducing the idea of tongue-tie worsens parental anxiety and very often pathologizes normal anatomic variants.
The Cochrane review (2017) (also published this month) is clear that improvements in feeding following revision of ties are questionable. None of the research has been able to demonstrate that any of the mother reported improvements are attributable to surgical interventions and could well be due to no more than the placebo effect. “The small number of trials along with methodological shortcomings limits the certainty of these findings.”
Wrinkle Whisperer Bobby Ghaheri’s prospective cohort study (2016) is singled out in the Breastfeeding Review paper for particular examination and shown to be seriously methodologically flawed, with demonstrated bias.
The authors point out the lack of any evidence to support the release of ‘posterior‘ ties, adding, “It is not currently known what degree of release of a tongue-tie is required to optimise function in individual babies”.
There is currently no evidence to demonstrate the efficacy of wound stretching exercises to help avoid wound reattachment during healing. These exercises are distressing both to parents and babies—unwarranted, as well as cruel.
Hot air? Kotlow’s (2011; 2013; 2016) theorising does not escape scrutiny either, and both he and Siegel (2016) have overlooked the considerable literature that explains the physiological mechanisms of infant reflux. There is no evidence to suggest that babies who have difficulty latching at the breast swallow more air than do any others.
Much is made by tongue-tie enthusiasts of the long-term dire consequences of the untreated condition. Yet there is a lack of data on long-term breastfeeding improvements following revisions, as well as very limited evidence that tongue-tie contributes to any long-term problems that are not connected with breastfeeding.
The use of lasers to correct ties is a practice that has been around for less than a decade and there is little (or, more precisely, nothing) to support this expensive business. The authors refer to a growing number of babies with oral aversion following laser procedures. A quick Google search reveals some horrific injuries to babies that really are shocking.
The rising popularity of cutting and lasering babies’ ‘ties’ lacks any credible scientific basis.
Unfortunately, inserting a simplistic intervention into an evolving and complex system such as the breastfeeding mother-baby pair is known to risk unintended consequences. (Douglas, 2016)
Douglas, P. (2016). Tongues tied about tongue-tie. Griffith Review. Retrieved 14/6/16 from https://griffithreview.com/articles/tongues-tied-about-tongue-tie/
Ghaheri, B. A., Cole, M., Fausel, S., Chuop, M., & Mace, J. (2016). Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. doi:10.1002/lary.26306
Kotlow, L. (2011). Infant reflux and aerophagia associated with the maxillary lip-tie and ankyloglossia (tongue-tie). Clinical Lactation, 2–4, 25–29.
Kotlow, L. A. (2013). Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation, 29, 458–464.
Kotlow, L. A. (2016). Infant gastroesophageal reflux (GER): Benign infant acid reflux or just plain aerophagia? International Journal of Child Health and Nutrition, 5, 10–16.
O’Shea, J.E.,Foster, J.P., O’Donnell, Colm, P.F. et al. (2017). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews. NO: 3. John Wiley & Sons, Ltd DOI:10.1002/14651858.CD011065.pub2.
Siegel. S. (2016). Aerophagia induced reflux in breastfeeding infants with ankyloglossia and shortened maxillary labial frenula (tongue and lip tie). International Journal of Clinical Pediatrics, 5(1), 6–8.
Wattis, L., Kam, R. and Douglas, P. (2017). Three experienced lactation consultants reflect upon the oral tie phenomenon. Breastfeeding Review, Vol. 25, No. 1, Mar 2017: 9-15. Availability:<http://search.informit.com.au/documentSummary;dn=704771949095754;res=IELHEA> ISSN: 0729-2759. [cited 30 Mar 17].
Another blogger looking at the myths
This is a request for (anonymous) photos of the labial (maxillary) frenulum, that’s the band of connective tissue underneath the upper lip. If you are breastfeeding or have breastfed a baby (partially or exclusively) to the point of experiencing comfortable feeds without nipple trauma or latching problems, Anne Cullen IBCLC would like your help, please. She wants to see as many different frenulums as possible, ones that have not had a frenotomy, whether or not there is a tie.
If possible, photograph as in this example, with the lip held up. Please include age of baby and age now if different. Please email to firstname.lastname@example.org and she will send you a consent form. Thank you.
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?