Pondering the fast growing number of diagnoses of ties. And taking a look at: Douglas, P. (2017). Making sense of studies that claim benefits of frenotomy in the absence of classic tongue-tie. Journal of Human Lactation, 33(3) 519–523, published this week.
A few days ago, I read a post from an American, who runs a lactation clinic at a birth centre, on the public Facebook of the Oregon otolaryngologist (ENT)—formerly self-styled Wrinkle Whisperer—Bobby Ghaheri MD, ‘I agree with everything you say every time you post.’ she started, and went on:
‘Every baby born at the clinic and almost every breastfeeding dyad I see is having symptoms of a tongue tie. My question for you is: is it possible that 90% of babies have tongue ties? Every time the parents that I see chose a revision for their baby the symptoms disappear and things improve but it just seems so crazy that the percentage is that high.’
While pointing out there can be difficulty in early diagnosis, Ghaheri and his followers did nothing to refute this poster’s supposition that there is such a high percentage of babies born with oral problems. Possibly other readers might have come forward to point out that the enormous rise in incidence of diagnoses of ties may have more to do with poor breastfeeding support than with any actual increase in the number of faulty babies, but they would have needed guts to face the inevitable confrontation that such a comment would have sparked amongst the tongue-tie enthusiasts that currently frequent social media. I can think of one or two women who might have ventured a provocative comment along those lines had they not already been banned (or frightened off) from posting on that page, or indeed on any other forum where the subject of ties is under discussion. Like me, they have been ejected and (sometimes) effectively silenced because their contributions challenging the status quo are mostly unwelcome.
The prospective cohort study of Ghaheri, Cole, Fausel et al. (2017) claimed to demonstrate the efficacy of laser frenotomy for infants who had been diagnosed with oral ties for the improvement of breastfeeding problems. Yet those potential benefits for a mother-baby pair that the high profile study purports to show remain unsubstantiated. Pamela Douglas, MBBS, FRACGP, IBCLC, PhD in her latest paper, published this month in the Journal of Human Lactation, ‘Making sense of studies that claim benefits of frenotomy in the absence of classic tongue-tie’, provides an in-depth, well-referenced analysis of Ghaheri et al. to demonstrate its serious methodological weaknesses.
In her introduction, Douglas points out that the exponential increase in tongue-tie diagnoses in the past decade is peculiar to high-income countries and later concludes that overtreatment has been recognised as a serious problem in the provision of healthcare in such countries (Brownlee et al., 2017).
The problems that the mothers brought to Dr. Ghaheri are very often seen in breastfeeding babies and have multiple causes other than oral ties. Douglas and her colleagues have observed that—
‘normal anatomical diverse, lingual and maxillary labial frenula are commonly diagnosed as posterior tongue-tie (PTT) and upper lip-tie (ULT) and referred for frenotomy, although underlying problems of fit and hold (latch and positioning) remain evident and respond well to clinical intervention … [A]pproaches to fit and hold that have been demonstrated to increase the risk of nipple pain more than 4-fold continue to be applied by many breastfeeding specialists, who then recommend frenotomy for PTT and ULT if problems persist.’
This suggests to me that breastfeeding is a dying art.
In an earlier paper (published in March in the Breastfeeding Review, Douglas challenged Ghaheri’s findings as lacking any credible scientific basis. Ghaheri et al. stated that their ‘study design did not incorporate a control group . . . because . . . many experts do not feel it ethical to offer an untreated control study arm.’ Douglas points out that this
‘contradicts the basic principles of good science.’
I think a reliance on ethics is somewhat iniquitous because laser surgery is not without its own risks when used to treat tongue and upper lip-ties. These risks, which remain unexamined, are often reported as having transpired and include:
- oral aversion
- wound infection.
And what about the long-term potential harm of lasering oral tissue? It is too soon to discover what the extent of any damage may be to the individuals whose frenula have been released in this way as the procedure is less than a decade old. I am not alone in noting the toll on mothers’ mental well-being after subjecting babies to such surgical treatment when they have found no relief for their breastfeeding problems. Disappointingly, the advice on social media mothering networks is often to go for repeat surgeries or to practise harsh aftercare. Breastfeeding solutions for breastfeeding problems? Obviously those mothers have tried ‘everything’ already. Clearly compassion has been dished out in buckets before these vulnerable parents seek out ‘educated’ support and surgical intervention from the ‘tie savvy’.
Not only are studies on the efficacy of frenotomy poor quality and characterised by author bias but there is no reliable evidence that the diagnoses of PTT and ULT are meaningful or useful in the first place, since any definition of such ties is at best confused.
Douglas’ analysis relates to the 179 infants who were diagnosed with and treated for ULT in the study, and the 184 who were diagnosed with PTT. Mothers self-reported improvements one week and one month after surgery on a self-efficacy scale, a visual analogue—also subjective—scale for breastfeeding pain severity, and on a questionnaire about infant reflux (ditto re subjectivity). Douglas illustrates with supporting studies how Ghaheri et al. confuse association with causation by failing to control for multiple potential confounders and how interpretive bias may well have affected the reporting of their data.
The study fails to control for the effects of expectation; the effects of time with regard to psychological confidence, nipple pain and milk transfer; as well as the effects of caring attention, validation and lactation consultant support. It ignores the extensive research over the past three decades on infant reflux, which has established that reflux in the first 6 months of life is a normal physiological event, despite unsettled infant behaviour. Infant reflux is modulated by a range of factors that are not taken into account in this study.
The authors hypothesise that reflux is caused by excessive air swallowing when babies are unable to latch well at the breast due to PTT and ULT. Douglas cites a number of studies and explains in some detail why such a hypothesis is unreliable. There is no evidence of air being swallowed during ultrasound assessments of successful breastfeeding, of breastfeeding with tongue-tie, or of breastfeeding with nipple pain. Refluxate is close to pH neutral for 2 hours after breastfeeds and does not cause acidic discomfort. Babies cry because of sensory need.
‘Labeling reflux as a medical condition increases parents’ desire for medical intervention, even when they are told that the treatment will not be effective (Scherer, Zikmund-Fisher, Fagerlin, & Tarini, 2013).’ (See the paper for the other two pages of supporting references.)
Douglas’ conclusion? Given the increase in the number of frenotomies for purported PTT and ULT, and the failure to substantiate the claims for using surgery, there is an urgent need for a randomized controlled trial to compare surgical intervention with a standardized breastfeeding fit and hold intervention in order to address the methodological problems inherent in Ghaheri et al.
‘Breastfeeding families deserve the best possible science so that infants do not receive unnecessary surgical interventions when problems arise.’
More Pondering on Tongue-Tie
References (See the paper for two pages of supporting references.)
Douglas, P. (2017). Making sense of studies that claim benefits of frenotomy in the absence of classic tongue-tie. Journal of Human Lactation, 33(3) 519–523.
Ghaheri, B. A., & Cole, M. (2017). Response to Douglas re: ‘Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improves breastfeeding are not substantiated.’ Breastfeeding Medicine, 12(3).
Wattis, L., Kam, R. and Douglas, P. (2017). Three experienced lactation consultants reflect upon the oral tie phenomenon. Breastfeeding Review, 25(1), 9-15.