Do our babies need deep cuts under their tongues and upper lips in order to breastfeed successfully? Dr Pamela Douglas 26_1_16

Dr Pamela Douglas responds to today’s article in the Courier Mail, ‘A warning has been issued to new parents about the practice of tongue snipping in newborn babies’

It’s a health system problem, really – a long-standing failure to prioritise clinical breastfeeding research.(1)

A lot of effort has gone into establishing the marvellous health benefits of human milk over the past half century, but that doesn’t help those many women who are unable to transfer the milk from their breasts into their babies without pain. (If you haven’t experienced it, imagine a blade scraping flesh off an exquisitely sensitive part of your body over and over throughout the day; think bleeding nipples, and pus; think excruciating cracks, blisters, crevices, ulcers; think pain radiating and stabbing, like a knife; think agonising lumps and fevers – believe me, when women say they can’t go on, they really can’t.)

And pain aside, if breastfeeds are going awry, many other aspects of life with the baby can go awry too, since feeds are profoundly interconnected with sleep, with arousal of the stress response system (the sympathetic nervous system and hypothalamic-pituitary-adrenal axis), with expressions of distress and protest such as back-arching and fussing and then of course, with crying. Lots of crying. Many babies are unsettled because they are hungry, even though they are gaining weight adequately. A lot of our babies slip into crying loops because feeds just aren’t coming together and this means that their stress thresholds are lower, that they wind up easily. They might puke a lot too, with all this arousal of their sympathetic nervous system, though fortunately the reflux is not noxious in babies in the first months of life (and very laid-back babies can also vomit often).

Clinical breastfeeding support (that is, health professional skills for helping a woman and her baby breastfeed) remains a pioneering endeavour. We can land a spacecraft on Mars, we can activate robotic arms with our minds, we can transplant the human heart. But those who fund research don’t prioritise studies that aim to sort out the best way to support breastfeeding in the community. Clinical breastfeeding support is not a sexy topic for research decision-makers – they would much rather investigate the properties of an obscure and miraculous micronutrient or immune factor in the breastmilk, than deal with the complex problem of how to ensure it flows comfortably from a woman’s breast directly into her baby's mouth and gut!

In this knowledge vacuum, dedicated health professionals come up with ideas and one of the latest ideas is that deep laser or scissors cuts under the tongue and upper lip free up the oral connective tissue, let the tongue and upper lip work better, and improve breastfeeding. Parents are also told that this surgery will protect the child not only against those ghastly breastfeeding difficulties, but also against orthodontic and speech articulation problems later on. This is a rather hopeful (and now very popular) extrapolation of the research prior to 2005 which clearly demonstrated the benefits of prompt release of a classic (or ‘anterior’) tongue-tie for breastfeeding.

Since 2005 research methodologies concerning tongue-tie have become very confused and cannot be relied upon. There are reasons for this. To understand what is going on, it is important to know how to read research methodologies, to understand research designs, and to identify confounders. Studies that aim to investigate tongue-tie confuse the classic (or ‘anterior’) tongue tie, which needs prompt and simple release, with the new diagnosis of ‘posterior’ tongue-tie, popular from 2004. Now, those who are convinced by the importance of frenectomies claim that behind every ‘anterior’ tongue-tie there lies a ‘posterior’ tongue-tie that needs to be cut, that is, severed and allowed to scar over - and that almost every tongue-tie is accompanied by an ‘upper-lip tie’.

Since doing these deep cuts by laser and scissors is, to be frank, lucrative for those health professionals who specialise in it, their websites tend to be glossy and impressive. It's hard to question something when everyone seems so certain. And unfortunately, advocates are often quite derogatory about the competence of those who dare to question the way the research is being interpreted. A new norm has emerged. Now, if a woman has breastfeeding difficulties, her baby’s tongue and upper lip frenula will be labelled with the one simplistic if convenient category, ‘tongue-and-lip-tie’, requiring the quick-fix of the deep cuts.

Dr Thomas Lynons, from the Eagleby Medical Centre, has raised certain concerns about this in today’s Courier Mail. These are my perspectives on the issues raised in that report, based on my clinical experience and my knowledge of the research literature.

1. A frenotomy (snip of a classic ‘anterior’ membrane, a congenital remnant) is not painful to babies and protects breastfeeding. At Possums, we do this kind of frenotomy as soon as possible after birth, in an effort to prevent nipple damage.
2. Tearing apart the wound multiple times a day for a fortnight or more after the frenectomies to prevent re-adherence of the cut, as parents are instructed, is painful to babies.
3. These experiences of oral pain worsen feeding problems and oral aversion in some babies. NDC Accredited Practitioners do not do deep tissue frenotomies; if we really thought this was necessary for severe and syndromic congenital abnormalities of the floor of mouth fascia, we’d refer on to an ENT surgeon, due to the risks of bleeding and of damage to the branches of the lingual nerves.
4. There is no methodologically sound evidence that oral connective tissue surgery - other than a simple frenotomy for classic ‘anterior’ tongue-tie - improves breastfeeding, or speech articulation in later childhood.
5. Breastfeeding protects orthodontic and orofacial anatomic outcomes, but that doesn’t mean that frenotomies improve orthodontic anatomic development.
6. Breastfeeding problems are linked with unsettled infant behaviour, reflux, and wind, but that doesn’t mean that tongue-tie causes unsettled infant behaviour, reflux and wind. At Possums, in a preliminary study of 20 mother-baby pairs, our integrated approach to unsettled babies halved crying and fussing: what we do is not a quick fix, but a careful consideration of the multiple factors involved.

For more information, please see an overview article in The Conversation, or for an in-depth analysis with comprehensive citations in 'Tongues tied about tongue-tie' in the Griffith Review Online March 2016.

(1) Douglas, P. S. (2013). "Re-thinking 'posterior' tongue-tie." Breastfeeding Medicine 8(6): 1-4.

[Please note that subsequent to this article, Dr Pamela Douglas has published multiple articles concerning oral connective tissue restrictions and breastfeeding.]