A fault in babies’ mouths? What is the current problem?
This month began with World Breastfeeding Week and this year’s World Health Organisation slogan, ‘Breastfeeding: Foundation of life’ recognises that in a world full of inequality, crises and poverty, breastfeeding offers the same healthy start to us all. Why then do breastfeeding rates remain so pitifully low? What prevents so many of our babies from obtaining their milk as Mother Nature intended? Nowadays, the majority of mothers do intend to start off breastfeeding and more and more hospitals and health professionals who work with new mums and babies are trained to be breastfeeding-friendly. What is stopping mothers, many claim, is not motivation, rather it is ankyloglossia, otherwise known as tongue-tie.
Until recent years, tongue-tie was rarely a problem for lactating mothers. At present, it appears to be something new mothers cannot fail to hear about. Facebook hosts more than a hundred very active groups whose sole focus is this condition du jour.
The modern epidemic of this oral fault in infants has sparked controversy amongst health professionals and parents alike, who disagree fiercely over what the condition is, what the implications of having a tied tongue are, and whether or how it should be treated.
Tongue-tie proponents believe that tongue-tie prevents a baby from breastfeeding and that left untreated such an abnormality will have serious repercussions. They attribute an ever-growing number of ailments to the anomaly — from fussing in the car-seat to leukaemia. Sceptics advocate for differential diagnosis and recommend not jumping to conclusions because everything troublesome cannot be connected with tongue-tie. The proclivity for associating a plethora of ills with oral restrictions — from spitting up to SIDS — is nevertheless the ‘in thing’. Now that artificial infant formula or expressed mother’s milk have become the normal ways to feed babies, do many even remember the old-style common sense that did the trick for the previous six million years? Better positioning and attachment, gentle guidance and support, along with a tincture of time. Those are the things that enable comfortable breastfeeding, whether or not a tongue is tied, in the majority of cases.
What exactly is tongue-tie? The frenum is what ties the tongue. Oral tissues (or frena) connect the tongue to the floor of the mouth and the lips to the gum, and the cheeks to the gum. This tissue is what restricts the motion of the tongue. It secures the motion of the tongue too and functions as a protective, connective anchor. It is a ‘tie’ when the frenum limits the range of movement of the tongue, when this restriction is judged to be interfering with breastfeeding (or speech). Anxious parents are left to rely on widely differing clinical judgements, because, to date, there is: NO universally agreed definition of what constitutes a tongue-tie, NO standardisation of protocol for its assessment, and NO reliable data to inform clinical decisions. When examining a baby’s tongue, NO clear distinctions exist between what’s pathological and what’s plain normal.
Google ‘tongue-tie’ and articles often start with the assertion that it is a congenital abnormality, so that is something you are born with, and which may or may not be inherited. Yet it has by no means been established that these variations are abnormal . A good illustration of how something becomes accepted as fact if it is repeated often enough.
What seems more plausible to you: that there has been an 834% increase in the number of faulty babies’ tongues over the last few years or that those looking in babies’ mouths are simply seeing a wide range of normal tongue function and appearance?  Does it make sense that so many babies are suddenly being born with abnormal oral tissues? The skyrocketing of the number of diagnoses of tongue-tie is peculiar to high-income countries. This might be what researchers in evidence-based practice Doctors Hoffmann & Del Mar mean by ‘an unjustified enthusiasm’. They discovered that clinicians more often than not underestimate harm and overestimate benefits of a wide range of medical treatments. The existence of therapeutic illusion is, they found, a major contributor to the inappropriate use of medical interventions .
In increasing numbers, health practitioners diagnose frena as abnormal in infants with breastfeeding problems or unsettled behaviour, and refer them for frenotomy with scissors or laser . The idea is that by cutting this tissue with scissors or eliminating it with a laser this will get rid of the restriction and in doing so make breastfeeding easier.
On social media, tongue-tie is often the first suggestion when a mother relates her breastfeeding problems. Mothers get diagnoses of ties from one another on the strength of a photo or a list of symptoms. If surgery appears to provide the magic solution, mothers go on to urge other mothers to subject their babies to the same procedure. No one has yet established whether untethering a tongue is what fixed breastfeeding. Post hoc ergo propter hoc.
I don’t want to trivialise the very real trauma these families experience but perhaps a short sharp slap might be equally effective as a quick snip. I’m not suggesting substituting one act of brutality for another. I am suggesting that frenotomy in all but the rarest of cases where it may be required is no more than a placebo. Breastfeeding is, after all, very largely a confidence trick.
Some mothers report improvements in breastfeeding following surgery on their babies to release ties, believing that this is what saved breastfeeding, and without which breastfeeding would not have been possible. Some mothers report no improvement to breastfeeding following surgery, and others say that things have become even worse, and that breastfeeding is no longer possible as a result.
Mothers for whom the surgery didn’t fix anything are encouraged to seek repeat surgeries in the belief that the cuts didn’t go deep enough or because the ties have ‘reattached’. And what exactly is the difference between reattaching and healing? Mothers are told that this is a multi-factorial issue that requires a multi-disciplinary team of experts and are advised to seek the services of additional, often private and expensive, health practitioners for various ‘bodywork’ and other therapies. They are instructed to persevere with repeated wound stretching exercises to traumatise the wound and stop the healing and reattachment of the frenum. The exercises (or ‘games’ as some have euphemistically named them) are scheduled daily for up to 3 weeks, although there is no evidence to suggest the efficacy of such after ‘care’.
There is still no definitive explanation over what the role of the tongue is in effective breastfeeding or for how maternal pain, injury, low milk supply, long and ineffectual feeds, and slow weight gain ‘fit with’ and explain breastfeeding problems with reference to ties. Of course, there is a lot of conjecture. A paper published in March  reinterpreting ultrasound scans reveals that when breastfeeding, a baby’s tongue moves only a matter of millimetres. This indicates the degree of restriction is actually an irrelevance.
Although it’s generally accepted that breastfeeding offers the optimal start for babies, there is no getting round the fact that it can be a difficult skill to master, particularly following high intervention birth (and there are a lot more of these happening nowadays too). It’s not unusual for comfortable breastfeeding to take a few months to accomplish. Many mothers have already decided when to stop breastfeeding before they have even begun and if they encounter difficulties are naturally attracted by what appears to be a quick solution. Why not snip it and see? It might be worth the gamble, a leap of faith.
In the current environment, where mothers are being encouraged to believe this minor operation could possibly be the answer, health professionals are responding pragmatically. And how many are keeping their scepticism about this miracle ‘cure’ to themselves? Quite a few have told me in confidence that they dare not speak up because clients or medical colleagues want these procedures. Careers need protecting.
In the absence of good science to recommend frenotomy , and aside from the ethical and political questions with regard to adapting a baby irreversibly to fix a problem in its mother, health carers who support mothers and babies genuinely love to see breastfeeding succeed. One paediatric dentist summed up why surgical intervention for tongue-tie is proving to be so popular, ‘It is not so much kickbacks but the club of “feel good” — practitioners want to believe they are saving mothers and babies from a life of hell.’
 O’Shea, J. E., Foster, J. P., O’Donnell, C. P., Breathnach, D., Jacobs, S. E., Todd, D. A., & Davis, P. G. (2017). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd011065
 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; 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. S., Hill, P. S., Walsh, L. J., & Tennant, M. (2018). Frenotomy for tongue-tie in Australian children, 2006-2016: an increasing problem. The Medical Journal of Australia, 208(2), 88–89. doi:10.5694/mja17.00438
 Hoffmann, T. C., & Del Mar, C. (2017). Clinicians’ expectations of the benefits and harms of treatments, screening, and tests. JAMA Internal Medicine, 177(3), 407. doi:10.1001/jamainternmed.2016.8254
 Douglas, P., & Geddes, D. (2018). The latest practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants. Midwifery, 58,145–155. doi:10.1016/j.midw.2017.12.007
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