Tongue-Tie Epidemic Poses Risk to Community

Is the incidence of tongue-tie increasing? Why are health professionals identifying ties more often? What risk is there from this simple operation?

Large temporal increases and substantial spatial variations in ankyloglossia and frenotomy rates have been observed that may indicate a diagnostic suspicion bias and increasing use of a potentially unnecessary surgical procedure among infants (Joseph, Kinniburgh, Metcalfe, Razaz, Sabr, & Lisonkova, 2016).

Increase in the number of faulty babies?

The figures suggest that currently there exists an epidemic of over diagnosis and over treatment of tongue and lip-ties.

In Australia, between 2006 and 2016, there was a 420% increase in the rate of frenotomies per 1,000 children aged 0 to 4 years (Kapoor, Douglas, Hill, Tennant, & Walsh, 2017).
Similarly, in the U.S.A. there has been an 834% increase between 1997 and 2012 (Walsh, Links, Boss, & Tunkel, 2017).
Canada has seen an 89% increase from 2004 to 2013 (Joseph et al., 2016).

There are no data to indicate any underlying changes in recent years in the prevalence of tongue-tie, says Australian Dental Association Queensland (ADAQ) President Gary Smith and goes on to express concern over those practising ‘at the fringe of dentistry’ who ‘have linked in their minds the release of lip and tongue ties to all manner of long term health issues’ in, for instance, orthodontics, speech, posture, and sleep.

Following these and other concerns relating to this widespread therapeutic illusion, the ADAQ Council has approved a submission to the Dental Board of Australia requesting guidance for dental practitioners on tongue and lip-tie surgery. It refers to bias and self-promotion by practitioners who have made a considerable income and built their professional reputations from surgically treating tongue-tie and promoting others to do likewise [one popular U.S. practitioner is named as an example].

“Not surprisingly, there are many half-truths and fallacies pushed by those who promote tongue tie surgery for financial gain.” ADAQ News (December 2017) 643, 5-6.

Risk to the community

In June this year, a dentist performed upper lip-tie surgery on a baby. When the baby was back home and eight hours away, the dentist reported on social media that the patient had developed a delayed bleeding episode. Having no idea what to do, the dentist was asking for help in a Facebook group alongside a disturbing photo of the baby wearing a blood covered bib and bleeding from the corner of its mouth. The child was clearly in considerable distress and a second close-up photo of the crying baby’s mouth revealed an inflamed wound.

The dentist was communicating via Skype with the baby’s parents and had recommended a tea bag compress and keeping the child in an elevated position. Wondering whether the parents might see a local dentist had caused this dentist to fear that the new dentist might ‘freak out’ making ‘matters worse’. Participants in the Facebook group offered various suggestions but it was some time into the conversation before any one recommended taking the baby to hospital. This baby might easily have died. The dentist is popular and well known, a so-called ‘preferred provider’ and is still practising as a prominent speaker in tongue-tie education.

Researchers at the University of North Carolina, Department of Otolaryngology, recently published a study describing two cases of hypovolemic shock following outpatient labial and lingual frenulectomy. (Hypovolemic shock is an emergency condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.) The patients required emergency interventions of cardiopulmonary resuscitation and blood transfusion. These rare, but life-threatening outcomes warrant recognition as potential complications illustrate the real harm that can follow this presumed benign and low-risk procedure (Tracy, Gomez, Overton, & McClain, 2017).

Those examples are extreme. However, you can read, daily, on Facebook posts from mothers reporting the anguish their babies go through following these surgeries; here are just two examples:

A dentist told parents of an 11-week-old that it would take a maximum of ten minutes to laser his tongue and lip-ties, and whisked him off, only to return him forty minutes later, ‘shaking and screaming like crazy’. Rather than handing the baby to his mother, the parents were first shown how to do stretches on his wounds. (There is no evidence to support the efficacy of post surgical stretches that further traumatise a wound.) The baby was difficult to calm and the parents were informed that the tie had been ‘severe’, ‘all the way down to the muscle’. The baby, who had been quite settled prior to the surgery, remained unhappy and crying in between bouts of sleep and refused to breast or bottle-feed. The parents visited the cranial sacral therapist and chiropractor recommended by the dentist and when nothing they did helped, they went to the paediatrician four days later, who found the wound in the baby’s mouth to be deep and aggressive.
We had an upper lip-tie and posterior tongue-tie lasered on Friday. The dentist and lactation consultant said his tongue was connected right up to his lower gum line, which I assume means it was a more severe restriction. Immediately after the procedure, he was fine. However, by evening he was inconsolable and wouldn’t feed. We started using pain relief medication and without it he refused to feed at all. It’s now Wednesday evening and I stopped giving pain meds earlier today and he is inconsolable. I am worried he is in pain. Is this normal? How long do more severe tongue-ties take to heal up and stop hurting?

What is a ‘severe’ tie? How long is the pain following surgery expected to last? How many parents report the practitioner when the surgery did not go well? How many practitioners would report another practitioner for carrying out a surgery they believed was unnecessary or bungled? Whose job is it to identify a tongue-tie and how? There are a lot of questions.

Not infrequently tie surgeries do not facilitate easier breastfeeding, which is often the purpose for carrying them out. Some parents subject babies with no feeding problems to tie surgery in fear of future ramifications. You can find memes on Facebook listing supposed problems that will transpire in the coming years if you don’t laser or cut restrictive oral tissues, yet there is no evidence to support any claims of these supposed future consequences.

Let’s start calling these severing procedures ‘surgeries’ rather than trying to soften the nature of the invasive intervention. After all, even when skilfully and painlessly performed, these are body modifications. And sometimes they are mutilations.

References

Joseph, K. S., Kinniburgh, B., Metcalfe, A., Razaz, N., Sabr, Y., & Lisonkova, S. (2016). Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004–2013: A population-based study. CMAJ Open, 4(1), E33–E40. doi:10.9778/cmajo.20150063

Kapoor, V., Douglas P. V., Hill, P. Tennant, M., Walsh, L.J. (2017). Australian national and state trends in paediatric frenotomy rates for tongue-tie, 2006–2016: Early evidence of an apparent epidemic? Med J Aust. in press.

Smith, G., Australian Dental Association Queensland President (December 2017) ADA News Bulletin, 643, 5–6.

Tracy, L. F., Gomez, G., Overton, L. J., & McClain, W. G. (2017). Hypovolemic shock after labial and lingual frenulectomy: A report of two cases. International Journal of Pediatric Otorhinolaryngology, 100, 223–224. doi:10.1016/j.ijporl.2017.07.013

Walsh, J., Links, A., Boss, E., & Tunkel, D. (2017). Ankyloglossia and lingual frenotomy: National trends in inpatient diagnosis and management in the United States, 1997–2012. Otolaryngology-Head and Neck Surgery, 156(4), 735–740. doi:10.1177/0194599817690135

AND good to see this online now:

Douglas, P., & Geddes, D. (2017). Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants. Midwifery. doi:10.1016/j.midw.2017.12.007

A list of my blog posts

Always Ask Questions: Don’t Let Your Tongue Be Tied

Censorship on Tongue-Tie. Whose Tongues Are Tied?

Does Tongue-Tie Disempower Mothers and Damage Babies?

How Credible Is The Current Oral Tie Trend?

Is The Current Breastfeeding Problem a Fault in Babies’ Mouths?

Is The Treatment of Tongue-Tie an ‘Unjustified Enthusiasm’?

Reading Between the Lines Post-Tie Surgery

Snipping Tongue-Ties. Whose Business?

Spinning a Web: Spiders and Tongue-Ties

Surgery on Babies: Does it Hurt?

The New Sucking Model and Tongue-Tie

Tongue-Tie Epidemic Poses Risk to Community

Tongue-Tie Politics of Breastfeeding

Too Many Tongue-Ties?

When Releasing Tongue-Ties Does Not Fix Breastfeeding

Who Diagnoses Tongue-Ties that Interfere With Breastfeeding?

Why Upper Lip-tie Isn’t a Thing

4Comments

Add yours

1

Ann S VerSteeg on December 20, 2017 at 7:44 am

I’m curious how many cases you’ve seen. Maybe lots, maybe a few, maybe those that have a a less than stellar outcome. Much like birth, which doesn’t bring forth the plan you had in mind, or even had a dab outcome. Every once in a while, in my experience, frenotomies May not give us the outcomes we had hoped for, but at least 93% of the time we see great improvement. Sometimes the revision need more work in terms of therapy, often times we have get the flow under control, get the baby back to the breast. Regulating the flow may be a daunting task.
I’ll nevervstop working with ties, never. I can’t stand mamas not being able to breast feed because of a short frenulum. She no doubt has some pretty raw and very sore nipples, a hungry crank baby . Yup, they deserve our REAL help because that is what I do!
Your article makes it sound like all ties are bad. They really aren’t. They are simple procedures and go well 93% of the time.
Please come hang with us! We will show you the ropes!
Annie VerSteeg IBCLC.

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2

Barbara on December 20, 2017 at 1:23 pm

Douglas, P., & Geddes, D. (2017). Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants. Midwifery. doi:10.1016/j.midw.2017.12.007 confirms the epidemic in diagnoses and surgeries.
Diverse variants of normal oral connective tissue are now frequently labelled as posterior tongue-tie, upper lip-tie, or even buccal ties in the presence of breastfeeding difficulties. These patients are referred for frenotomy in the absence of reliable evidence demonstrating benefit, and despite risk of unintended outcomes including oral aversion.
Analysis of existing ultrasound studies demonstrate that the mechanisms upon which the Stripping Action Model of sucking are based are inaccurate.
The term ‘peristalsis’is not appropriately applied to discussions of the biomechanics of the infant oral cavity and tongue movements. The authors propose that the diagnoses of posterior tongue-tie and ‘upper lip-tie’ are unhelpful, since they pathologise the wide range of diverse but normal anatomic variants of lingual and labial frenula.
No evidence of air being swallowed in ultrasound assessments.
Altered suck dynamics post-frenotomy may have multiple explanations other than the effects of connective tissue release, i.e. behavioural and psychological reasons, which would be expected to impact upon intra-oral vacuum, breast tissue volume and therefore tongue shape. There is no evidence that breast milk production increased post release.
Observed bumps, humps, and furrows of the tongue, and notches in the tongue tip, are not signs of limitations in the tongue’s capacity to play a moulding, cushioning, responsive role during breastfeeding, other than in the case of classic tongue-tie. Infants may also have anterior membranes visible under the tongue which do not impact functionally on either the tongue or breastfeeding, and are therefore not a tongue-tie.
Future studies investigating the efficacy of frenotomy and manual therapies should aim to compare those interventions with the effects of optimal fit and hold.

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3

Tongue-Tie Politics of Breastfeeding – Pondering on December 23, 2017 at 3:43 pm

[…] to speculate on whether, when or to what degree tongues need releasing. I am sceptical about the rapidly growing numbers of apparently faulty […]

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4

Reading Between the Lines: Post Tie Surgery – Pondering on December 23, 2017 at 5:08 pm

[…] you are familiar with my other posts on this blog, you will know I think oral ties are overdiagnosed and that, where they do exist, I remain sceptical about the intervention that a growing number of […]

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