I want to be a tongue-tie practitioner
‘I want to be a tongue-tie practitioner. How do I get trained to do this?’ There is rarely any information within the email which suggests the sender would be an appropriate person to provide tongue-tie division.
I get at least one email per week like this. My immediate reaction when I read these emails is that the sender is asking the wrong question.
I trained to do tongue-tie division at Southampton back in 2011. Back then awareness of tongue-tie and its potential impact on breastfeeding was still confined to those with a passion for breastfeeding. It was not really in the ‘mainstream’. NHS services were limited and most healthcare professionals working outside of specialist infant feeding roles had not heard of it. Tongue-tie wasn’t mentioned at all in my ABM Breastfeeding Counsellor training back in 2004 and was not part of the curriculum for International Board Certified Lactation Consultants (IBCLCs) when I sat the exam in 2009.
As awareness has grown and both NHS and private provision has expanded interest from both professionals and the general public has grown in the procedure to divide tongue-ties. So much so that this seems to have become an end in its self.
Tongue-tie division (frenulotomy) is a surgical procedure that provides us with an opportunity to improve breastfeeding and is some cases bottle feeding. But it is not a standalone intervention that guarantees successful feeding. It is a tool which should form just a small part of a much more holistic approach to ensuring parents and babies enjoy healthy, satisfying and comfortable feeding. There is not one shred of evidence that simply dividing a restricted lingual frenulum (tongue-tie) will achieve this.
Parents and babies need robust assessment and support. I frequently see babies who are struggling to latch at the breast. Some may not be able to latch at all and some may latch but cause nipple pain and damage in doing so. Some of these babies will have tongue-tie and will benefit from a frenulotomy but this procedure will not provide a successful outcome if the mother does not have the positioning and attachment skills to put the baby to the breast in a way which will facilitate a comfortable and effective latch. It will not provide a successful outcome if the baby continues to struggle to open his mouth wide due to jaw tension from a traumatic birth. It may not be successful if the mother has very flat or inverted nipples and isn’t given strategies to help baby latch with these. It won’t provide a successful outcome if mum has suspended breastfeeding whilst waiting for the frenulotomy and not continued to establish and maintain her milk supply via expressing.
In another example I often see babies with poor weight gain. They have a tongue-tie which is making transferring milk from the breast difficult. Again it will not lead to successful breastfeeding if I overlook the fact that the mother has been supplementing with formula since day 2, has had breast reduction surgery, or has mammary hypoplasia (under developed breast tissue) or has a history of polycystic ovary syndrome as all of these issues can affect milk production.
In cases where there has been nipple pain and damage immediate relief from discomfort may not be seen post tongue-tie division if the wounds in the nipple have become infected, or the mother still needs coaching in positioning and attachment, or the baby is waiting to see a bodyworker to address neck and jaw tensions. In cases where there have been poor weight gain and/or supply issues and/or a failure to establish a milk supply the baby will not thrive simply because the tongue-tie has been divided. In addition, they will need to optimise positioning and attachment and implement strategies such as compression to ensure good milk transfer. They will sometimes need supplementation for a while and parents will need information and support on increasing milk supply and gradually reducing supplements. In more complex cases the feeding issues may not simply result from a tongue-tie but may relate to low muscle tone, developmental and neurological conditions, prematurity, cardiac conditions or other illnesses in the baby. Feeding issues knock parental confidence, particularly when a well-meaning friend or relative suggests baby may be happier or sleep better on a bottle or an ill-informed healthcare professional suggests that maybe breastmilk isn’t calorific enough for the baby. So, parents are going to benefit from access to an ongoing source of knowledge and support.
So how is training in a surgical procedure going to prepare an individual to provide all of this? The answer is it won’t. Parents and babies need so much more than that. Not only to maximise their chances of feeding success but also to ensure that tongue-tie division is only performed when needed and when it is likely to be of benefit. Almost all babies have a lingual frenulum (Haham et al 2014) so in almost all babies there will be a membrane that can be divided, but only around 3-5% (Haham et al 2014, Todd & Hogan, 2015) will require a division due to feeding issues.
So, is it appropriate for anyone, whether they be a healthcare professional or lay person, to be asking about training in division if they do not have the necessary infant feeding knowledge and skills on offer? There are many tongue-tie services in the NHS and some in the private sector that are run by surgeons, doctors and dentists who do not have the infant feeding skills. That is not an issue provided that the mother and baby are assessed thoroughly before division by someone who does have these skills and there is access to skilled feeding support afterwards. I would add though that ethically and morally this assessment and support should be funded by the NHS or provided as part of a private service and not left at the doors of the voluntary sector as is too often the case.
My concern with most of the enquiries I get is the fact that frenulotomy is performed in babies solely to assist with feeding, yet the need for infant feeding skills is overlooked. Furthermore, why would a landscape gardener, a baby massage teacher, or a placenta encapsulator think it appropriate for them to be trained to perform a surgical procedure, an activity regulated by the Care Quality Commission. When a midwife, nurse, doctor, surgeon or dentist performs frenulotomy they are governed by their professional codes of conduct which require that they demonstrate competence in the procedure and are insured. The regulatory bodies for these professionals will take action if a practitioner’s competency is called into question to protect the public. There would be no such protection if lay people were out there performing this procedure.
I like to think these enquiries come with good intentions and a desire to help families but then the question should be ‘can you advise me on how I can help support families experiencing feeding issues due to tongue-tie’. This may be by volunteering at a breastfeeding group, training as a breastfeeding peer supporter or counsellor, setting up a petition to send to the local commissioning group requesting better infant feeding support services with easier access to tongue-tie division, or writing to an MP requesting more resources for infant feeding support, including have more IBCLCs available in the NHS.
The cynical side of me feels that 10 years ago, almost without exception, those seeking to train in division were passionate about infant feeding and had the necessary knowledge and skills and saw this as simply another tool in their toolbox to assist families. Now it is seen as an opportunity to make a quick, easy buck and/or escape a stressful work environment. How utterly disconnected from the reality of providing private tongue-tie services that view is will be the topic of another blog.
Further information on training can be found at this link here
Haham et al (2014) Prevalence of Breastfeeding Difficulties in Newborns with a Lingual Frenulum: A Prospective Cohort Series https://www.researchgate.net/publication/265859110_Prevalence_of_Breastfeeding_Difficulties_in_Newborns_with_a_Lingual_Frenulum_A_Prospective_Cohort_Series
Hogan M, Westcott C, Griffiths M (2005) A randomised, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health; 2005 https://www.ncbi.nlm.nih.gov/pubmed/15953322
Sarah Oakley RN RHV IBCLC Tongue-tie Practitioner (Independent) 21/8/19