The views and opinions expressed in this blog are my own. I wanted to write this to get my own thoughts on this issue clear in my mind. It may be useful to parents in understanding all the issues that this pandemic is raising and why services are being disrupted. I hope it may also be helpful to other tongue-tie practitioners who are having to make decisions about their services going forward.
When the Prime Minister first announced social distancing measures and directed bars, clubs, cafes and restaurants to close a little over a week ago my initial reaction was that I would continue to offer my service providing breastfeeding support and tongue-tie division. However, I decided to move all breastfeeding support work to online consultations and only see those babies requiring division face to face. For the last few weeks I have had extra infection control measures in place so in addition I planned to tighten this up by only allowing mum and baby to attend appointments, not allowing more than one mum and baby in the clinic at any one time, spacing appointments to facilitate this, screening families before seeing them for symptoms of COVID19 and so on.
However, as the week has gone on things have been changing daily and along with it so have my intentions. One problem I now face is access to clinics. My clinic venues are all closed. I no longer have access at all to my Suffolk clinic. I feel my Norfolk clinic is too far from home for me to justify the journey given that we should all be restricting our travel. Although, of course, this would be travel for essential work and as a healthcare professional I am defined as a keyworker. However, is my work essential?
The positive impact breastfeeding has on the physical health and mental wellbeing of mothers and babies is well documented and cannot be argued. We know that many cease breastfeeding before they wanted to due to a lack of skilled help and support. Tongue-ties can have a devastating impact on a baby’s ability to latch successfully and feed effectively at the breast. Tongue-tie division often transforms feeding and without it many mothers would say their breastfeeding journey would have ended prematurely and they would have been left with the grief that accompanies that. We know that breastfeeding is highly protective against infection. When a mother and baby are exposed to a bacteria or virus via the respiratory or gastrointestinal tract the mother’s body immediately begins to produce antibodies which are passed via her milk to the baby in order to protect them. So, in a pandemic breastfeeding and support for breastfeeding is surely more vital than ever?
This is not how everyone sees it. There are still many people, including healthcare professionals, who see breastfeeding as a lifestyle choice, rather than something that should be supported and protected due to its huge positive impact on public health. Whilst we know that tongue-ties were being divided back in the 18th century and probably earlier, and that throughout the nineteenth and early part of the twentieth century tongue-tie division in infants to facilitate breastfeeding was fairly common, there has been an uphill battle to get the modern medical profession to accept the link between tongue-tie and feeding issues and the effectiveness of division. This is despite there being NICE Guidance in place since 2005 and a growing body of research.
So, my first dilemma since the social distancing restrictions came into force on 23 March has been how essential is what I do, and can I justify leaving the house to do it? As the week has gone by this question has been re-ignited by the closure or severe scaling back of many NHS tongue-tie services, including one close to me. This is a service I respect and have close links with. Their reasoning is as follows:
• Bringing families into a hospital environment where COVID 19 patients are treated increases the risk of infection for those families
• We do not know how the COVID 19 virus will behave in relation to an open wound in the mouth
• There may not be the resources readily available to manage the rare but potential complication of bleeding post division
• Oral examination and procedures are known to pose significant risks to healthcare professionals who may pick up the infection, even if a patient shows no symptoms as we know that in some people, especially babies and children, they can carry and shed the virus without showing signs of illness.
As someone in private practice this raises questions for me. I routinely do divisions in clinics, rather than the home. In clinics I can see families from a wider geographical area, they make better use of time and I can ensure the environment is clean, has adequate lighting, and so on. I rarely do divisions within the home. Do I need to reconsider this? No I don’t think so. I can ensure adequate standards of hygiene and infection control within my clinic settings. I feel this will be much easier than in a home environment, but other practitioners may have a different view. I have exclusive use of the clinic setting I plan to use during this crisis so families will not be exposed to others and I can control who comes into the clinic.
On the issue of the virus in relation to the open wound we simply have no evidence whether this poses any additional risk at the current time. We do have plenty of evidence that not breastfeeding increases the risk of many types of infection, including respiratory infections. But it is an unknown at this time and as such will be included in my consenting process so parents can make an informed choice and I will only consider division in the most severe cases where conservative management to delay division is not viable.
On the issue of bleeding this is a real concern of mine and will worry others. I have colleagues who will say they have never had a significant bleed. They either haven’t done many divisions or have been extremely lucky. I have been refused an ambulance in the past and the family and I had to take baby into hospital by car. This was during summer when the NHS was not under any unusual strain. This is another reason why I prefer to work in clinics which are situated close to Accident and Emergency Departments.
The fact that oral examinations and procedures may pose a risk of transmission to healthcare professionals raises the issue of safety of others having contact with the healthcare professional and the use of appropriate Personal Protective Equipment. I know several healthcare professionals personally who have contracted what they believe to be COVID 19 (in the absence of testing) and some have been very ill with it. Some doctors have died after contracting the virus, including an ENT surgeon in the UK. If a healthcare professional contracts this virus from a patient that is not only a risk to the health of that professional, but to all those who come in to contact with them, including patients and family members. Many healthcare professionals have chronic disease and are in an ‘at risk’ or vulnerable category themselves and many more have family members who are and so they really don’t want to take this virus home with them. My husband has diabetes which means his ability to fight infections is impaired, and I have a son with autism who would not cope well with a hospital admission where I could not stay with him and advocate on his behalf. My daughter is in a frontline job with an emergency service and may well bring this virus home to us at some point, despite the care she is taking to avoid this. This then has implications if I pick up the virus and take it to work with me and pass it on to mums and babies. These are the complex factors we must consider when deciding who we see and under what circumstances and what care we provide.
The use of Personal Protective Equipment (PPE) will mitigate some of the risks already discussed but as we all know this is in very short supply and quite rightly any supplies are being allocated to the NHS as a priority. Furthermore, guidance on what is appropriate PPE to wear for oral examinations and procedures to protect healthcare professionals is conflicting at present. Within the last week we have moved from thinking our current PPE of gloves and aprons may be adequate to questioning whether we need to wear surgical or FPP3 masks and where will we get them from.
This situation is extremely hard on parents who want to breastfeed and do the best for their baby. It is frightening to find that postnatal support services, including infant feeding support and tongue-tie division, are being restricted. But all healthcare professionals involved in infant feeding and tongue tie division are passionate about what they do and are trying to make decisions that are not just in the best interests of their patients (the parents and babies), but in the best interests of the wider community and themselves as this virus has no boundaries and is having life changing consequences for us all. It is an unprecedented situation and we are working with limited information about this virus and recommendations and knowledge relating to it is changing daily.
So, when you contact a healthcare professional about tongue-tie division please understand that they will have agonised about whether to continue their service or not. If they are continuing the way that service is run may vary from practitioner to practitioner, depending on their circumstances, Provision of services may change rapidly as we learn more. No one is limiting or closing services without very good reasons and without many sleepless nights.
For anyone wanting to access my support with breastfeeding or tongue-tie concerns I plan to return from a two-week break on Monday 6 April. All clients need to book a video consultation first which can be done online here www.sarahoakleylactation.co.uk/booking/ so we can take the history, assess feeding, assess the need for division and so on. In most cases I expect to put a plan in place to manage the feeding and delay division. It is important to remember that in normal circumstances around 25% of the babies I see who have booked for division don’t require one and we address any feeding issues through breastfeeding management strategies, sometimes in conjunction with osteopathic or chiropractic intervention. Many of the other babies I see could be managed in the short term with breastfeeding strategies. Not all tongue-ties require urgent division. The more we all comply with the restrictions in place the quicker we will all be able to get back to normal and more importantly the fewer lives that will be lost.
Sarah Oakley RN HV IBCLC Independent Nurse/Health Visitor, Lactation Consultant and Tongue-tie Practitioner. Written on 29/3/2020.