‘Can I just pay for the snip because someone else has already done an assessment?
I have been asked this twice this week. Whilst I completely understand the financial pressures facing us all at the moment due to the pandemic, I thought it may be helpful to explain why it would be wrong for me to accept any client on this basis.
Firstly, most healthcare professionals working with mothers (including Midwives, Health Visitors, GPs, and Paediatricians) are not trained in the proper assessment of tongue function using evidence-based tools. They may be able to identify signs of tongue restriction, sufficient to refer a baby on for further assessment and division if appropriate. But in general, most are not competent to diagnose a tongue-tie (restricted lingual frenulum). Some Lactation Consultants [IBCLCs), Breastfeeding Counsellors and Peer Supporters may have more education and awareness in relation to tongue-tie. However, diagnosis of tongue-tie is outside of their scope of practice.
Secondly, there is far more to assessing prior to tongue-tie division than looking at tongue function. A full feeding assessment needs to be carried out by a professional with advanced skills in infant feeding, such as the IBCLC qualification, to ascertain that the feeding difficulties are related to deficits in tongue function and to ensure that other factors that are impacting on feeding are not overlooked.
This is extremely important as the following case study highlights:
I was approached by the mother of a baby with poor weight gain. This baby had had two tongue-tie divisions performed by the local hospital. One was done early on at about two weeks and the second one was done at 6 weeks. The poor weight gain was blamed on reattachment of the tongue-tie hence the second division. Weight gain remined poor. No one had considered that the early difficulties with latch and feeding may have compromised supply and that this may impact weight gain. No one had considered that a baby that is undernourished will be energy depleted and this will affect their ability to suck and remove milk from the breast effectively. I took a history and assessed feeding and a plan was implemented to feed the baby some supplements and increase milk supply. Weight gain, latch and feeding efficiency rapidly improved. I then saw baby face to face and assessed tongue function and suck. The division site had healed well and function was good. A plan was implemented to wean off the top ups. The ‘snips’ in this case had been successful procedures. They improved tongue function. But, without appropriate feeding support the baby continued to have difficulty getting enough milk.
Thirdly, given that a lingual frenulum (the membranous structure which stretches from the under surface of the tongue into the floor of the mouth) is normal anatomy and the majority of babies are thought to have one (Haham et al 2014), there is a huge risk of over diagnosis by those who are not sufficiently trained and experienced in assessment and division of tongue-tie (restricted lingual frenulum). To put this in context around a third of all babies I see who have been diagnosed by someone else as having a tongue-tie do not require a division because other factors, not a restricted lingual frenulum, lie behind the feeding difficulties. Of course, if I did not bother to do my own assessment and simply did a snip, based on someone else’s opinion, then these babies would be going through a surgical procedure for little or no benefit and their parents would be paying for something that is unnecessary. Within the medical profession there are many who question the efficacy of tongue-tie division and these unnecessary divisions are the ones that fuel their argument.
Fourthly, frenulotomy (tongue-tie division) is a safe surgical procedure but it is not without risk. Risks include prolonged and heavy bleeding, infection, damage to other structures in the mouth (such as the salivary glands) and recurrence of the tongue tie due to excessive scarring. So, there must be justification for doing this procedure. If the reason for a division is questioned, perhaps in the context of a complication or complaint, then the practitioner who did the procedure needs to be able to provide a rationale for why they did it. Furthermore, it is a legal, ethical and professional requirement that parents are given informed consent (NMC,2018). Parents need to know how tongue-tie is impacting feeding, how division may benefit their baby and what the alternatives may be, as well as being aware of the risks. I am not sure how any practitioner could fulfil these requirements without doing their own thorough assessment first.
There may be practitioners who will cut corners and offer a 20-minute appointment for a quick snip. I am not one of them because your baby deserves better.