Response to Sunday Times Article of 4 August 2024 on Tongue-tie

What is it with journalists? Back in January I spoke to Samira Shackle from The Times about tongue-tie division in babies. I kept notes of that conversation. She gave the impression she was going to produce a carefully researched, balanced article on the topic. I think most readers will agree she hasn’t. Certainly, the parents I have spoken to who have read this article were not impressed. The article can be read here.

Unfortunately, despite the rhetoric we get from journalists about objectivity, fairness and impartiality, my experience of late has been that they have set out their position before opening their laptop. When it comes to tongue-tie and infant feeding this is the narrative they all seem to be following:

• Tongue-tie rarely impacts feeding and where it does formula feeding will be the answer.
• Divisions are being carried out unnecessarily and this applies to most divisions being done.
• The majority of babies are not seeing any benefit from the procedure and are suffering complications.
• Parents are being forced to breastfeed and are being misled into thinking breastfeeding offers health advantages over formula feeding.
• The pressure to breastfeed is what is driving parents to seek out tongue-tie division.

They are totally overlooking the fact that breastfeeding is a normal biological reproductive function, just like having the baby in the first place. They are also completely ignoring the fact that the innate desire to breastfeed can be as strong as the longing for a baby. Do we talk about parents being pressured to have babies or scorn those who seek medical treatment when pregnancy doesn’t happen. They are also ignoring the fact that tongue-tie can have a detrimental impact on formula feeding too.

Let’s address the inaccuracies and issues within this article:

According to Shackle ‘anyone’ in the UK can become a tongue-tie practitioner. This is not true. As the NICE Guidance (2005) states, only ‘registered healthcare professionals who are properly trained’ should perform this procedure.

Courses in tongue-tie division are not registered with the Care Quality Commission. Shackle states that they are. All services providing tongue-tie division, whether they provide training or not, have to be registered with the CQC as it is a surgical procedure and therefore a regulated activity under the Health and Social Care Act 2009. Educational programmes are not the remit of the CQC.  

As a surgical procedure division has risks like other surgical procedures. It is not accurate to say, ‘There is always a risk of bleeding, infection or damaging healthy tissue if it’snot done properly’. Even when done properly the risks remain. The anatomy influences the level of bleeding as it does in most surgical procedures. There will occasionally be a hidden blood vessel that may get accidentally damaged. We know from the detailed work done on frenulum anatomy by New Zealand ENT surgeon Nikki Mills and her team (Mills, et al, 2019) that some frenula contain muscle fibres. So, these will bleed more when divided.

Infection may occur if an aseptic technique is not observed. But the feeding method will have significant impact on whether an infection occurs or not. Breastfed babies are protected from infections by the anti-microbial properties of breastmilk. Formula, which may be contaminated with bacteria due to incorrect preparation, can cause infection and I have seen this in a baby post tongue-tie division.

Audit data collected by the Association of Tongue-tie Practitioners suggests that less than one in 12000 divisions will result in infection, and around one in 7000 babies will have a significant bleed requiring the topical application of Adrenaline or Tranexamic Acid. In the 7 years ATP has collected incident reports on complications from members there have been no reports of damage to salivary tissue or apnea although these complications are mentioned in the literature. But are clearly rare.

Oral aversion is also rare. In my thirteen years of practice, I have had a handful of babies who have refused to latch after division having latched before division, and I don’t recall any, where the families came back to me for follow up support, who did not re-establish breastfeeding, who have not gone on to latch again. The difficulty is usually short-lived and temporary with the right support.

Shackle suggests there is a lack of research on tongue-tie division.  Back in 2005 when the NICE Guidance was written the scientific evidence available at that point was considered adequate by the panel of experts.

Since then, there have been dozens of papers published on this issue. We have six randomised control trials and there have been nine Systematic Reviews with the most recent concluding ‘Results support that infant frenotomy is effective for improving standardised scores on breastfeeding difficulty and maternal pain scales and could improve breastfeeding outcomes.’ (Bruney, et al, 2022)

From these there is clear evidence that tongue-tie division can help improve latch and resolve nipple pain. Four studies on reflux, one focusing on bottle fed babies (Hand, et al. 2023). have concluded that tongue-tie division helps resolve or reduce reflux symptoms in the majority of babies where tongue-tie was present, and these improvements were sustained at 6 months post division. Given the side effects of the unlicensed medications currently being offered to these babies (Lassalle, et al, 2023) and the cost to the NHS of reflux and allergy formulas (which I often see prescribed when the reflux is not allergy related) a thorough feeding assessment as per NICE (2015), including an assessment for tongue-tie, ought to be carried out prior to writing prescriptions.

There have also been studies done using ultrasound and MRI (Watson Genna et al, 2021 and Mills et al, 2020) which have established how a baby uses their tongue during breastfeeding and indeed bottle feeding, and how the function of the tongue is impaired in tongue-tied babies.  Elevation, peristalsis, extension and cupping have been identified as the key movements involved in latching to and transferring milk from the breast. Palate shape will also impact, with a high arched palate exacerbating the impact of a restriction in tongue elevation. We have the long established Hazelbaker Assessment Tool for Lingual Frenulum Function which has been evaluated for reliability and validity (Amir et al, 2006) and includes these movements identified in the ultrasound and MRI studies. This tool can help aid assessment and decision making. 

Disappointingly, rather than looking at the original research papers and seeking views from academics in the field of lactation and infant/maternal health, Shackle chooses economist Oster’s book ‘Cribsheet’ as her reference source.  My friend and colleague Dr Caroline Zwierzchowska-Dod wrote a critique of ‘Cribsheet’ which parents, and indeed journalists, should find helpful to read here.

If you want your work to be taken seriously, I would think looking beyond Amazon reviews, and how many followers someone has on Instagram, when looking at sources of information, would be a good place to start.

Shackle states that the vast majority of divisions take place in the private sector. Given that NHS England cannot provide accurate data on how many divisions the NHS does each year and no one collates data from private practitioners this is speculation. But that is not made clear in the article.

The British study referred to by Shackle is the FROSTTIE study which was presented to the Association of Tongue-tie Practitioners before it was launched. Members at that meeting raised several concerns about the study design which were ignored and that is why it failed. Poor design. It is wholly unfair to lay the blame for the failure of the study on mothers. When the mothers attended the NHS services participating in the study, they had already endured weeks of feeding difficulties and inconsistent feeding support. Who can blame them for opting for an intervention, which the published research confirms can help some babies, rather than allowing themselves to be allocated to a control group for further months of struggle.

It is notable that Shackle doesn’t quote a story from anyone who had a positive, straight forward outcome from a tongue-tie division. Yet, all of us providing tongue-tie division must be CQC registered and as part of that carry out follow-up surveys with our clients so we can demonstrate to the CQC that we are being effective. Virtually all my clients come to me after recommendations from friends and family, or healthcare professionals and breastfeeding supporters, who have experienced or witnessed the positive outcomes that are achieved in the majority of cases. This holds true for many of my colleagues.

Parents are naturally protective of their babies and don’t, in my experience, take the decision to put their babies through a procedure lightly. They do their research. They read, they ask other parents, they talk to healthcare professionals. Shackle would have us believe that parents are blindly pursing tongue-tie division based on having the benefits of breastfeeding ‘drummed’ into them. Well, that ‘drumming’ is failing miserably when you look at the UK breastfeeding rates which Shackle herself quotes as being ‘extremely low’ with 81% of women choosing to initiate breastfeeding and only 12% still exclusively breastfeeding at 4 months. So, isn’t the story here as much about the failure of our healthcare system and society to support these women in their choices, rather than just about babies being put through needless procedures?

Sarianah’s story within the article demonstrates the lack of decent breastfeeding support even in private hospitals which are not under the pressures faced by the NHS. I absolutely acknowledge that there are tongue-tie divisions being done unnecessarily and that a lot of the poor outcomes we see after division are down to a failure to adequately assess, identify and address all the factors contributing to the presenting feeding difficulties. This was something I was at pains to explain to Shackle when I spoke to her.

Shackle goes on to talk about the use of exercises before tongue-tie division or as an alternative to tongue-tie division. Having suggested there is ‘inconclusive’ evidence of tongue-tie division being helpful in addressing feeding difficulties, despite the published papers on this, she overlooks the fact there is currently no published evidence to support the exercises approach. I have seen families where practitioners have suggested they follow a regimen of exercises for weeks, or in some cases months, before a division or as an alternative to division and there has been no improvement in feeding. In fact, in most of the cases that have come to me, feeding has deteriorated with mothers moving from fully breastfeeding to combination feeding or formula feeding before finally coming to me for a division. Upon assessment these babies have still had significant restriction in their tongue function. I have colleagues who have had the same experience. Whilst a lot of us advocate exercises post division, and there may be some value in starting these pre division, I am not aware of a single piece of published research suggesting there are any specific exercises that are an effective alternative to tongue-tie division where tongue function is significantly compromised by a tight lingual frenulum and impacting feeding.

I think many breastfeeding mothers who have experienced excruciating nipple pain and seen their babies lose weight because of a tongue-tie would disagree with the assertion that tongue-tie division ‘is not an emergency procedure’ and the suggestion that we can spend weeks on unproven exercises. In some cases, where a tongue-tie is causing severe difficulty with establishing breastfeeding, early intervention with a tongue-tie division will be crucial in helping mothers sustain breastfeeding.  David Todd (2015) a neonatologist in Australia published audit data which confirmed the negative impact on breastfeeding duration when division is delayed and not offered in acute cases in the first few days of life.

What many practitioners and families do report as useful is body work (cranial osteopathy, cranial sacral therapy and chiropractic). I avoid a significant number of divisions be referring to body work first, alongside feeding management strategies, and see significant improvements when this therapy is combined with tongue-tie divisions in cases where the baby has muscular and fascial tensions related to in utero positioning and the process of birth. We have a growing body of published research on the role of bodywork in addressing infant feeding difficulties. Yet, Shackle doesn’t mention this at all.

We need to be asking questions about the apparent rise in the numbers of babies being diagnosed and treated for tongue-tie. We need to ask questions about why parents are being offered frenulotomy in babies for issues other than feeding when there is no evidence to support this. We need to be looking at how babies are being assessed and how families are being supported with feeding prior to being offered divisions. We also need to be ensuring there is skilled support offered to them afterwards. We certainly need to be looking beyond the lingual frenulum and frenulotomy for answers to feeding difficulties. We absolutely should not be questioning the desire pf mothers to breastfeed or whether breastfeeding is beneficial to babies. The research on that is clear and not up for debate. We should be demanding better care and support for all families. However, they choose to feed their babies because both breastfeeding and formula feeding can present parents with huge challenges and families continue to be failed and deserve better.

As for journalists they need to set their own experiences and prejudice aside and open their minds. I am horrified that the editor of The Sunday Times allowed such a biased article to be published. What else is The Times misleading us all on? Within this article there are very valid points and issues raised that warrant further exploration, but this journalist’s preset agenda has got in the way of that.