Leave their tongues alone!
NCT calls for more newborn cutting!
The normally sensible National Childbirth Trust has just launched a campaign (click here*) for more NHS doctors and midwives to cut the frenulum, the fold of skin joining the tongue to the floor of the mouth, for babies having trouble breast feeding. They reckon 3 to 10% of babies need it doing. If they are right, that would amount to between 18 and 60 thousand babies a year in theUK. Their website (click here) reads like a circumcision site for tongue-tie cutters!
“It’s quick and simple, and young babies usually don’t need any pain relief. […] Although some babies may cry briefly, the procedure doesn’t seem to cause discomfort or distress. […] Research has shown that […] division results in improved feeding for the majority of babies. […] there are some risks, such as significant bleeding rather than a few drops of blood when the cut is made, but the chances of this happening are small.”
NCT spokespeople make much of the fact that the National Institute for Clinical Excellence (NICE) has issued guidance (click here) that there are “no major safety concerns about division of ankyloglossia (tongue‐tie) and limited evidence suggests that this procedure can improve breastfeeding.”
But this is a long way from a recommendation. Cutting tongue-tie is an old-fashioned procedure, of doubtful scientific rationale, which has crept into use without proper evidence. NICE conducted their review to check if there was sufficient evidence of harm to advise stopping it. There was not.
But the evidence for benefit remains very thin. There is no Cochrane review. One non-Cochrane review (click here) included the following four randomised trials. They are not pretty! All were tiny, two were never registered at all and two were registered late, none used independent third party randomisation, and none reported any hard endpoints. Importantly the researchers and parents were so convinced of the benefits that they all cut the control babies within a few days!
Hogan et al. 2005 (click here) randomised 58 babies with breast feeding problems to immediate cutting (n=28) or cutting after 48 hours, using sealed envelopes. Apparently 27/28 early, and 28/29 delayed “improved” within 24 hours of the procedure! Full text pdf available here tongue tie trial hogan.
Dollberg et al. 2006 (click here) randomised 25 babies to real (n = 14) or sham (n = 11) cutting using sealed envelopes. The mother’s nipple pain score was reduced after the real cutting. Again the control group also got cut – this time delayed by one feed! Full text here tongue tie dollberg.
Berry et al 2012 (click here) registered their trial (click here) seven years late! Conducted between 2003 and 2004 and registered in 2011! Sixty breastfed babies were randomised using sealed envelopes to cutting or not. 21/27 in the cutting group reported improvement in feeding compared with 14/30 controls. Again the controls got cut one feed later. Full text here tongue tie berry.
Boryuk et al 2012 (click here) registered here in August 2009 after recruitment (Dec 2007 – Dec 2008) was complete. 58 patients were randomised using “a random number generator […] implemented by a research assistant” to frenotomy (n=30) or sham (n=28) operation. Short term breast feeding scores were better in the frenotomy group but by 2 weeks all but one patient in the control group had also undergone frenotomy. Full text here frenotomy boryuk rct.
In summary no randomised trial, comparing cutting with no treatment, has measured any outcomes beyond 48 hours! There’s no data at all on rate or duration of breast feeding, weight gain, stress to the baby, speech, or any other baby health outcome. Nor can there be, because all the controls got cut as well. This evidence cannot possibly justify cutting thousands of babies. The NCT should call for decent research, not more widespread use.
Jim Thornton
*5th May 2014 update. The link above is now dead (thank you SouthwarkBelle) and the NCT campaign seems to have been quietly dropped. Sadly their tongue-tie advice (click here) remains uncritically supportive of frenotomy. Further update, see comment below, the campaign apparently continues.
Ripe-tomato.org 
I’m neither a medic nor a midwife, but the comment that ‘young babies don’t usually need any pain relief’ feels very wrong to me, particularly as Britain is the source of leading edge research demonstrating the intensity and the seriousness of neonatal pain experiences (Prof Fitzpatrick et al, funded by the Wellcome Trust). When a professional organisation throws a cultural myth into a policy statement like that, think it’s a fairly safe bet that they’ve not fully engaged their critical faculties in writing it….
You’re encouraged to feed directly after and breastmilk is a natural analgesic. Besides, few seconds of pain followed by immediate comfort at the mother’s breast, versus a possible lifetime of difficulties and/or a more risky procedure under GA. I know which I would rather personally and which I chose for my son.
My frenulum was cut by my grandmother when I was a young child. There was no pain medicine given to me, in fact I don’t believe there was much pain at all. I was old enough to remember this and remember having trouble forming my words. When she cut the small piece of skin under my tongue it was easier for me to form words. I have had no trouble from it and there were no nasty side affects. This is NOTHING like circumcision.
Had it not been for my son having is TT cut he would not have been able to breastfeed. He has CMPI, and soya allergy so therefore cant have formula either. I am 100 % cutting TT if there are present. It basically saved my sons life.
The “normally sensible” NCT are making sense here too! Tongue tie does cause major breastfeeding difficulties, and can cause later issues such as speech impediment, jaw pain, dental problems and many more. My son had a tongue tie which was corrected with the scissors cut as described in article, like most newborns having this procedure he did not cry at all (some will cry for a few seconds). At the newborn stage being held and fed is more important than medication for pain relief – blood tests or needles for newborns are often administered while baby is being fed to distract them. Before my son’s frenlumectomy he was struggling to feed, had lost more weight than considered healthy and I was in absolute agony from the pain of breastfeeding (I was literally screaming and crying during feeds!). Instantly afterwards my son could latch much better than before, I was much more comfortable and he has been gaining weight well. Without it we would’ve given up by now and turned to formula.
Would it be ethical to do a randomised controlled trial if it led to a baby being prevented from getting breastmilk due to their inability to latch with an uncorrected tie, given that breastmilk is widely considered to be one of the most important factors by the likes of the WHO and UNICEF? Even if a mother could pump to allow the baby to have breastmilk in a bottle some tied babies cannot even effectively bottle feed, are they just to be starved in the name of research?
Do you have any idea the kind of problems an uncorrected tongue tie can cause?
After my son was born I had three bouts of infective mastitis (this is a serious illness, not ‘sore boobs’), and ended up with a golfball-sized abscess that required multiple treatments in hospital to drain. I then had recurrent blocked ducts for over a year (one or two a week).
This is not to mention the anguish of listening to your tiny baby scream in hunger and exhaustion – because getting enough milk takes him hours instead of minutes – and not know why or how to help.
All this could have been avoided had his tongue tie been detected and snipped at birth or soon after.
I suggest you confine your ill- informed opinions to matters on which you have some knowledge.
Firstly, this is NOT just a breastfeeding issue, tongue affects bottlefeeding to, try swallowing a fast flow of milk when your tongue is tethered to tightly to the bottom of the mouth, then try breathing and swallowing…
I see A LoT of babies every week who struggle with weight gain, or mum is in agony or babies leek milk and take along time to take a bottle. It can also cause problems with food and dental hygiene, try getting food out of your teeth if it doesn’t reach them.
Look on http://www.tonguetie.net for the issues it can cause right up into adulthood including speech issues and dental problems.
Then suggest it doesn’t doing, especially when you see as many much happier families after its been divided.
Deciding to get a part of your baby cut with scissors is not a decision any parent takes lightly but tongue tie division can make a huge difference to how efficiently a baby transfers milk alongside improved levels of comfort for the mother.
Breastfeeding is important for both child and maternal health and tongue tie sometimes presents a significant barrier to infant feeding. The NCT isn’t recommending cutting the tongues of all newborns, only those in which feeding is affected. If it is not done many mums will stop breastfeeding, either through pain, supply issues (due to ineffective drainage if the breast) or because they simply cannot stand to see their baby in distress. This is not only a problem for that individual baby, but for any subsequent children she may have – problems feeding their firstborn is more likely to lead to them not even initiating breastfeeding a second, third or fourth time etc. And thus the myth is perpetuated – ‘lots of women just can’t breastfeed’. That may end up being the case but early intervention in the form of support, oral assessment and tongue tie divisions when necessary could all lead to a very different, and much more positive, outcome.
Whilst I agree I’m shocked by the babies not needing pain relief comment I had my tongue tie cut at 16 and whilst it was uncomfortable to eat because f the tongue movement for several weeks it didn’t hurt as such and after the anesthetic wore I required no pain relief just liquid food which is what a baby has.
I am guessing, of course , you have never fed a baby with a tongue tie ….
I have fed a baby with a tongue tie , and also one without … Let me assure you it does dramatically affect feeding .
For a baby to go from losing 3oz a week to having a tongue tie divided and putting on 1lb in 5 days is not a coincidence.
There is a higher instance of tongue ties now because all mothers are told to take folic acid , therefore strengthening the midline , and although this does help to prevent spina bifida it can cause tongue /lip ties .
I think you failed to mention this in your article .
There IS a need for cutting tongue ties because my 3rd baby had one & it MASSIVELY improved comfort for me during feeding & drastically improved his worryingly slow weight gain. Midwives & health professionals used to be very well aware of this issue but due to decreasing breastfeeding rates the demand has decreased because bottle fed babies don’t tend to suffer with problems getting the milk from a bottle so it goes unnoticed. I think what they are calling for is for staff on the NHS to take it more seriously because believe me lots of them don’t & it can seriously impede & more often than not cut short a breastfeeding relationship because health staff dismiss it! Even my own Health Visitor admitted they have no knowledge or training of Tongue Ties when I returned after having my son’s cut privately and was amazed at the difference it made. If you haven’t been on the receiving end of a baby desparately trying to get milk from your breast without the full mobility of it’s tongue to be able to do so ending in cracked, bleeding nipples and excrutiating pain I don’t think you are in any position to say it should be stopped!
The reason why the trail probably didn’t go past 48 hours is obvious if you have ever breastfed a tongue tied baby. Both my boys were tongue tied both were snipped within 72 hours old. Without the snip they would not have been breastfed past 72 hours with it my boys were breastfed for 8 months with the first & 14 with the second.
Talk to real mothers the evidence will speak for itself!
You are clearly male. You have never suffered weeks of nipple thrush which could not be treated because the drugs are not licenced in the uk. You have not suffered weeks of mastitis. You have not had the skin ripped of your nipples which your baby screams to be fed but can’t suck properly. You have obviously never watched your baby try to suck a bottle but not get milk either. You have never had to watch you babies weight drop rapidly whilst you sit unable to help. You haven’t stood outside a breast feeding clinic, seen 6 midwifes, 4 doctors all in tears asking for help when they say nothing is wrong. You have never felt that you cannot bond or that you resent your screaming baby that you have carried for 9 months yet you cannot feed. If you think that tongue tie is fine, if you think that is causes no problems walk 12 weeks in those shoes and then write your article.
I am in absolute agreement with you that tt division is over rated. I can see that in severe cases division may be of assistance, but I have seen a huge increase in the number of divisions performed locally. Even with an estimate of 11% requiring division, current local practice exceeds this. A local midwife has qualified recently to perform division and provides this service in a private basis. She works at the local hospital on the postnatal ward, and many if the women have been given appts for division before they have left the hospital. Costing approx £150, divisions are being performed very early, within 24/48 hours of birth. How are these parents meant to have time to consider their options? How many of them have actually had a chance to see if they will have difficulty breastfeeding, or if the tie might stretch without the need for division (as happened with my own children). Some of these babies are bottle feeding with no issues and yet parents are being warned of potential speech difficulties and are also having the procedure performed on their children. Again – if there is true need with breastfeeding difficult despite help, speech difficulties later in childhood, and a clear severe tongue tie that has been accurately graded then I agree there may be some place for tt division to be performed. However, I also strongly feel that the provision should be more stringently monitored and supervised too. Parents at least need time to consider, absorb and understand all the ramifications, research evidence and options before having a practitioner attend to perform the procedure at haste.
That is in complete contrast to my area, in which tongue tie was not even recognised as a barrier to breastfeeding, or bottle feeding.
I would have loved to have had the option to have the procedure within 24/48 hours of his birth. It would have spared me months of incredible pain, mastitis, and vasospasm because all the positioning and attachment help in the world would have made little difference to a tongue with no function.
If pain or difficulty is being experienced, then the sooner the tie is revised the better, surely? Please don’t think that any mother undertakes this procedures lightly. It comes from a deep desire to breastfeed and care for their infant in the biologically normal way.
So, you’ve never tried to breastfeed a baby with a tongue tie, then? That’s the evidence based research. Breastfeed a baby without a tie, then along comes your next baby with a tie. Pain, weight gain problems, and misery for mother and baby. Revision is no quick fix, although it can be for some, but gradually baby learns to use their tongue fully. Life gets easier. Currently, the main problem is getting the medics to take it seriously, or finding the cash to go private.
Utter nonsense. Obviously written by a man who’s never tried to breastfeed a tongue tied baby. Or had them be able to feed easily once its been sorted. Despite 10 weeks of agony feeding a tongue tied baby I persisted (many would not) and once it was sorted he was feeding happily and is healthier as a result. The NCT are finally getting this out there – most mums are not aware it exists in the first place.
My son struggled to breastfeed so i was having to express and top up with every feed. I then had to use nipple shields for him to latch. Since having his tongue tie released he is now part feeding without the shield and we should be off them altogether soon. He screamed for about 2 mins, fed straight away off the nipple shield for the first time and that was all. I gave him arnica and some other homeopathy and that was all that was needed. He slept as uaual that night and fed more the next day. For me and our breastfeeding relationship i’m so glad we had it done as expressing for every feed long term is not doable. More people need educating in tongue ties as it would solve a lot of breastfeeding issues.
Without my children’s tongue ties being snipped, my breastfeeding journeys would have lasted weeks and not months.
I do like research but I trust the views of mothers who have been in the situation – including my own evidence.
Not cutting tongue ties can lead to severe breast / nipple issues for the mother, teeth decay in children (esp if lip ties are not cut), separated teeth, speech impediments for children in later life
Scientific research is all well and good but why not ask those who have been affected for their own research
My son needed to have his tongue tie clipped in order to make breastfeeding more effective and to stop damaging my nipples so that I could continue to breastfeed. If it weren’t for getting his tongue tie clipped over a year ago he would not still be breastfeeding at 18 months old. I am so thankful he had his tongue tie clipped.
Comparing a tongue tie clip in ANY WAY to circumcision is absolutely ridiculous.
I have a 13 month old boy that has a severe tongue tie and lip tie. I really wanted them to be clipped, as it was extremely painful to breastfeed him. A pediatrician helped with his latch and we weighed him to see that he was getting lots of milk. I continued to see this doctor once a week for 4 weeks. Now we are enjoying the experience without the need to cut him. He is still nursing & there is absolutely no pain 🙂 He has actually stretched out his tongue on his own & can do some pretty funny things with it. I don’t think it will have an effect on his speech as he can make sounds that require the tongue to touch the roof of his mouth. I am glad that we took the wait & see approach 🙂
Let’s hope he had no speech issues and swallowing solid issues. Humans are very adaptable. Hope it continues to work for you
Yes I hope that there are no problems in the future. He has no problem eating all the foods that I eat. So far, so good. I definitely believe that it should be done in some circumstances, but for us, we didn’t need to go that route…..yet.
I would like you to go through the nipple pain and emotional trauma that I went through for 10 weeks, fighting to find a solution to the pain. Midwifes, hospital infant feeding co-ordinators and the NHS were absolutely terrible. I ended up having to go private and pay over £350 to get the tongue tie clipped and aftercare-that is how much I wanted to carry on breastfeeding. The pain and emotional effect and fighting with the NHS to get his tongue tie recognised almost led to PND. More midwifes and so called health professionals should be better trained about tongue ties so that they can be effectively clipped if needed. Maybe the author should try actually speaking to women who have had ongoing problems with breastfeeding and how a tongue tie actually affected them instead of quoting studies. We can all find good and bad studies, can we actually find the truth!!
My second child had tongue tie diagnosed at 2 days old. Feeding was very painful but I didn’t know why. He was clipped at 4 days old and the difference was instant. I am not saying that all babies must have it but it has got to be difficult to run a conclusive trial for a lengthy period when it causes so much pain for those not clipped. This could seriously affect the ability to breastfeed and be very detrimental so cant imagine many mothers wanting to do this
I think this article is nonsense, I would have loved to have the option to get my son’s tongue tie fixed sooner. Instead I had to wait almost 2 painful months, Latching was so difficult and my boobs hurt so bad and pumping for a newborn while taking care of two other children was not easy. & yet coming to the decision to get my son’s tongue tie fixed was still not and easy decision I weighed all of my options very carefully and chose what was best for my son. Also this article says that there is no proof that that it will disrupt speech, but is it better to wait until they are 3-4 years old and find out? Then it will be a major surgery where my son would have had to be put asleep and since he no longer be breastfeeding also would have had to have pain medication afterwards not to mention the fear he would have experienced since he was old enough to understand everything thing going on around him. At 2 mos. it was a simple procedure, he cried for the 2 seconds it occured barely bleed and then nurse happily and never once cried about it again. Now he’s a 9 month old little boy who loves to mimic me and stick his tongue out at me, something he wouldn’t be able to do had I not made the choice I did. If you have not been through a journey with a child in the predicament, then I feel you have no facts and no experience.
Wow Jim what’s your background? How you can compare the cutting of the foreskin to releasing a tight tongue frenulum is astounding. You do realise that the tongue should not be restricted? Or did you bypass that in your research? Tongue tie of all forms can cause not only breastfeeding difficulties but also speach issues swallowing issues digestive issues etc. Perhaps do a bit more study and or research before you make comments on something you clearly have no clue about. Likening tongue tie to circumcision Ha Ha clearly you have no clue. Maybe interview Dr Bobby ghaheri or Dr kotlow before writing a one sided article.. Better yet why not interview parents who had their children revised and see what they think? I will assume you are not a journalists or were asleep when they were giving the “unbiased reporting” lecture. Haha Ha I still can’t believe you linked tongue tie revision to circumcision.
Hope the author never gets a tongue tied baby to see how much fun that is….
So, you’re saying that without the research, tongue tie procdeures should not take place? And even more ridiculously without any scientific rationale you compare circumcision with frenulotomy? What exactly our you basing your bias on? I base my own bias on trying to breastfeed a baby who couldn’t latch properly resulting in constant excess wind and discomfort, who wouldn’t stay latched resulting in us implementing an exhausting expressing regime which only just maintained his weight on the scale. For 16 weeks. 7 of those weeks we were up every 1.5 hours every single night because he was too hungry and uncomfortbale to sleep, and they weren’t even the newborn ‘nights’ when he actually slept ok. At 16 weeks he had severe posterior tingue tie diagnosis and frenulotomy and the feeding was instantly different with the trapped wind disappearing literally overnight. 2-3 weeks after the op and after getting used to his newly freed tongue he was on 50th percentile where he has stayed throughout weaning. We are happily still breastfeeding at 12 months. I wish we had had the diagnosis and procedure at birth because I feel those first 16 weeks of hell we both endured could have been a lot easier and happier for both of us.
So, you’re saying that without the research, tongue tie procdeures should not take place? And even more ridiculously without any scientific rationale you compare circumcision with frenulotomy? What exactly our you basing your bias on? I base my own bias on trying to breastfeed a baby who couldn’t latch properly resulting in constant excess wind and discomfort, who wouldn’t stay latched resulting in us implementing an exhausting expressing regime which only just maintained his weight on the scale. For 16 weeks. 7 of those weeks we were up every 1.5 hours every single night because he was too hungry and uncomfortbale to sleep, and they weren’t even the newborn ‘nights’ when he actually slept ok. At 16 weeks he had severe posterior tingue tie diagnosis and frenulotomy and the feeding was instantly different with the trapped wind disappearing literally overnight. 2-3 weeks after the op and after getting used to his newly freed tongue he was on 50th percentile where he has stayed throughout weaning. We are happily still breastfeeding at 12 months. I wish we had had the diagnosis and procedure at birth because I feel those first 16 weeks of hell we both endured could have been a lot easier and happier for both of us.
The many comments above, in favour of tongue tie division, are heartfelt, but do not in themselves provide much evidence one way or the other as to whether it does more good than harm.
My point was that the randomised trials, which purportedly showed immediate relief in almost all women, were poorly designed and their results implausibly good. One only has to visit T-T discussion boards to read about less good outcomes. The only trial https://ripe-tomato.org/2014/02/20/another-tongue-tie-trial/, which delayed division for 5 days in the control group, showed no difference in the LATCH, or any other breast feeding score, at that time point.
I’m sorry if my comparison of the NCT website’s enthusiasm with that of similar circumcision advocacy sites caused offence. Although I did not equate the two procedures, the strong opinions here suggest I may have struck a raw nerve. Is this “the elephant in the room”?
If I have any expertise, it is in evidence-based medicine, not tongue-tie. Parents should take clinical advice from breast feeding and tongue tie experts, not me. However, if such experts have a financial stake in performing the procedure, they might wish to take their advice with a pinch of salt.
Well I assure you that here in Ontario, Canada where the pediatricians who perform this procedure get $12 to do it if done on the first visit and nothing for the procedure when it’s done on the follow-up visit, that we still do it quite often because of the positive effects and outcomes for patients. And unless there is significant reason to release on the first visit, we often send patients home with information, websites, and reasoning behind why we think it might be a good idea for them to consider and come back for. Some providers do charge quite a bit of money for this procedure, but they must charge what the practice requires. Again, with provincially funded health care and almost zero dollars compensation, we’re definitely not just doing it for the money.
The experts in my area are either volunteers, or are only paid by the NHS. What financial stake do they have in diagnosing tongue- or lip-tie?
As a breastfeeding peer supporter, I have identified tongue-tie in a number of babies, and suggested that the parents contact the local midwifery unit who can properly diagnose and treat the condition. It’s generally been pretty easy to identify as a) the baby either has massively restricted tongue motion or cannot flange the top lip, and b) the mother has classic tongue-tie injuries – generally deep bleeding fissures up to an inch long across the nipple.
Where it has been treated, the babies have started feeding properly almost immediately and the mothers have started healing – generally within 1 week pain has reduced considerably, as these wounds are no longer being worsened by an incorrect latch. (please note that in one case, the mother had exclusively breastfed for 6 weeks, despite the pain. This had caused the worst injuries I have ever seen on a nipple, and I am full of admiration for her determination – but are you suggesting she should have continued without intervention in case it “fixed itself”?)
I would state that there are valid reasons for medically-necessary circumcision, and for medically-necessary frenulotomy. There is absolutely no reason for non-medically necessary surgery of any nature, and the NCT is not advocating this. The NCT is advocating that more HCP’s are trained in recognising and treating TT, so that mothers are able to breastfeed without excruciating pain, and their babies can extract milk efficiently in order to maintain health & grow.
I know of several areas in the country where tongue- & lip-tie surgery is not performed on any child under the age of 2, as it is regarded as impacting on speech only. This means that if you live in this area and your child is not able to breastfeed due to tongue-tie, that you will be told to give them bottles. No other option. This is appalling, when minor surgery could enable a healthy breastfeeding relationship to continue for as long as mutually desired.
Please consider that your article, although you believe it is only talking about the methodology and reliability of research, will be found by new parents desperate to alleviate pain and desperate to help their baby feed. Your article reads as if there is no benefit to this surgery, when there clearly is, as is evidenced by the number of replies you have received. Yes, you have hit a nerve, but that nerve is one of remembered pain – that’s physical pain from feeding, and emotional pain from feeling as if you cannot do what is right for your baby.
I agree this article could be very damaging to parents just learning about their baby’s tongue or lip tie. It is written without knowledge or education on the subject – bad “journalism” in any circumstance but dangerous when it concerns medical topics.
I’d also like to ask how these paragraphs, from the NCT site you link to, read like a pro-circumcision site? It reads to me like any of their campaigns – increase awareness, and increase resources.
“We are concerned that a diagnosis of tongue-tie is often taking weeks or even months and the problem is not being picked up by health professionals. This can lead to babies not being able to feed properly and prevent them from gaining weight in their crucial first weeks.
We have written to Health Minister Dr Dan Poulter MP calling on him to improve the diagnosis and treatment of tongue-tie in the UK, saving the NHS money and parents and babies stress and anxiety. We’re calling for NCT wants to see more professionals trained to recognise and deal with the problem as current NHS treatment is often patchy and sometimes non-existent. “
Tongue tie, or ankyloglossia, refers to the presence of excessive sublingual frenular tissue, usually causing a short, tight, frenulum. The result is an incomplete separation of the tongue from the floor of the mouth. This separation should occur through apoptosis during embryogenesis (O’Callahan et al. 2013). Ankyloglossia is graded due to its severity. Type I anterior ankyloglossia is characterised by insertion at the tip of the tongue. Type II anterior ankyloglossia inserts slightly behind the tip of the tongue (O’Callahan et al. 2013). Type III is a posterior ankyloglossia, and is characterised by a thickened frenulum or a submucosal frenulum. This forms a broad, flat mound without protruding frenular tissue in type IV ankyloglossia, and restricts movement at the base of the tongue (Coryllos et al. 2004, Knox 2010). Most literature refers to the anterior types and rarely reflects the existence and relevance of the posterior types (Coryllos et al. 2004, Knox 2010, Hong et al. 2010 and O’Callahan et al. 2013). Lip-tie, or maxillary tie, is also a restrictive upper labial frenulum to the maxillary gingival tissue. This is a condition that is often overlooked and undiagnosed (Kotlow 2013).
Ankyloglossia in infants present with breastfeeding difficulties. It often results in a characteristic set of maternal and infant symptoms and physical findings (Forlenza et al. 2010 and O’Callahan et al. 2013). Ankyloglossia can manifest as maternal nipple trauma and latching difficulties, resulting in poor infant feeding, continuous feeding cycle and poor infant growth parameters (Griffiths 2004). Infants with maxillary tie have a thicker frenulum that inserts into the papilla and restricts lip splay, resulting in a poor seal and inefficient feeding (O’Callahan et al. 2013, Kotlow 2013). These problems often result in the application of medical alternatives, breast milk pumping and additional feeding methods, which often lead to breastfeeding cessation (Hazelbaker 2010, Griffiths 2004, Forlenza et al. 2010).
Several publications exist to support the contention that frenotomy is simple, efficacious, and necessary in achieving the breastfeeding WHO and APA recommendations (Yeh 2008, Amir et al. 2005, Dollberg 2011, Buryk et al. 2011, Geddes et al. 2008, Horgan et al. 2005 and Hong et al. 2010).
While I would LOVE to have more good research on tongue tie, I call into question anyone’s ethics who thinks that waiting for statistics is more important than relieving mothers’ pain and babies’ suffering. Families’ improved lives is evidence enough for me in the meantime.
As one of the authors of 2 of the papers you cite, I should like to add a few comments;
1. Your bias that tongue-ties do not need dividing stems from the laudable, but evidence-free and completely unscientific desire of Paediatricians in the 1950’s to prevent trauma to babies (and promote bottle-feeding). For the previous millenia, tongue-ties had been known to be a source of problems with breastfeeding and had been routinely divided.
2. All the scientific papers since 1990 have agreed that tongue-ties can cause a problem with breastfeeding. Randomising mothers who have sore breasts with babies who won’t feed to a control group, and then forcing then to the bitter end where they have to give up and bottle-feed, is classically scientific, but unethical, so all studies allow them to have a division if the feeding doesn’t improve. This is called equipoise.
3. All the mothers who have replied here have conducted their own personal, observational, detailed, sceptical study of their own baby’s feeding and they all agree. Although they never wanted anyone to treat their lovely baby with a pair of scissors, the end-result is a dramatic improvement in breastfeeding with studies showing a longer period of breastfeeding than would have been possible otherwise. (This is an objective improvement)
4. If a baby has a tongue-tie which is symptomatic, with painful feeds, latching on and off, and short feeds with short gaps between the feeds, then all Lactation Consultants and Infant Feeding Advisors know that the baby needs tongue-tie division. This is simple, safe, and stunningly successful.
5. The best way to convince a male tongue-tie sceptic is for them to see the dramatic improvement in breastfeeding in their own, or their grand-child’s breastfeeding, and the relief in the face of their wife or daughter. This works far better than science…
Thanks for writing Mervyn. I fear we are a little way apart. Many years ago you said “The humble tongue tie, like the foreskin, generates enormous quantities of hot air, with little evidence to support it.” I’ve suggested how someone might collect such evidence. https://ripe-tomato.org/2014/03/09/a-tongue-tie-trial/ Is it possible?
The first paragraph states the risk of excessive bleeding. Unless the nhs official literature is incorrect there has so far never been a single case of this.
I believe evidence based medicine and advise needs to be three fold. Randomised controlled trials absolutely have their place but patient feedback and practitioner experience are invaluable aspects that these days are often dismissed yet are a huge part of the evidence base that should inform policy. In the case of TT no parent in their right mind would agree to leave their child struggling to feed for the sake of of RCT. I agree that a TT cut within 24-48hrs of birth is perhaps too quick, many babies adapt if breast feeding can be established, but I would not hesitate to go ahead with the proceedure if correctly diagnosed. The NCT maybe being a little gunghoe in some of their recommendations, but depriving your child and yourself of the opportunity to exclusively breast feed due to the suggestion that there is ‘a lack of evidence’ is simple madness.
If my child’s 80% tongue tie had not been cut at the NCT breastfeeding clinic at 9 days I would have been forced to stop breastfeeding out of sheer pain. 17 months on and we are still breastfeeding.
What is the motivation for this blog? We mothers are best placed to decide what our babies need, not you JimThornton. Stop discrediting the NCT, they are much needed.
Evidently you have no experience of breastfeeding a tongue tied baby. When baby can’t latch and is clearly distressed, cutting the frenulum is the greatest relief a mother and her baby can experience. Given the known inadequacies of formula, why would this be a preference over a quick procedure, a small amount of pain and a drop of blood?
I have been on the verge of tears over the fact that my 3 week old son has ULT and most likely a PTT. On the verge of tears mosty because I know I will likely have to have them revised. And although this is a minor surgery, I am terrified for him. But I truly believe that the pain he will feel from the procedure will never amount to the pain he is going through daily with his stomach. He has to BF endlessly to fully drain my breasts. He doesn’t sleep well. And because he is in pain he also wants my comfort 24/7. I would never jump into a procedure, no matter how minor, on my fragile and precious LO. He is not circumcised. Circumcision and ULT/TT are not comparable. You should be more sensitive to the parents who have to go through this as well as their LOs. It’s not easy for anyone.
Really interesting to read what (little) science there is behind this.
I had a baby who really struggled to breast feed, lost weight etc. etc. at the time I had never heard of TT so I soldiered on and eventually she got better at it. In the end I breast fed her for 14 months and she’s now a healthy and very chatty 4 yr old with a sister who fed like a pro from the moment she was born.
At the time though it was utter, utter, agonising hell. If someone had told me that a TT snip would have made it better I would have paid them my last penny.
Which makes me wonder, there are no doubt real cases where it’s needed. But how many women, in a situation like mine, choose to have this done because they are desperate for a quick fix and were getting little or no other help?
Post natal care was pretty dreadful. I got patchy and very inconsistent advice from midwives and health visitors until one took the time to finally help the baby latch properly. I wonder if some of these cases could better treated or even prevented, with good quality consistent post natal care?
Similarly I wonder if those people doing the procedure actually do more good by just listening to desperate mothers and by helping them to latch the baby correctly?
Perhaps if participants are unwilling to be untreated controls in a trial, the trial could instead compare TT snip with a control group who receive breast feeding help from an experienced professional?
One of the few bits of good advice I got from my NCT teacher was that breast feeding can be horrifically hard, and that if it is, you will at some point think there is something physically wrong with you, but keep at it, it really is just that hard. That helped me get through it.
BTW, like another poster, I also know of a midwife in a local NHS hospital who is diagnosing tongue tie in newborns and directing parents to her own private service.
BTW2 – your first link to the NCT website isn’t working.
SB
SB. Thanks for your comments. And yes indeed, first link is now dead. Hopefully the campaign has been quietly dropped. I’ve added a note. Jim
The campaign has NOT been “quietly dropped” – the link on the nct website is here:
http://www.nct.org.uk/parenting/tongue-tie
Southwarkbelle I am glad you managed a successful breastfeeding relationship, sometimes tongue tied babies do indeed eventually learn to compensate and can bf, especially if their tt are less severe. Not everyone is so lucky. I fought on with ny daughter for 3 months in absolute agony, her completely frustrated, until she stopped even trying anymore. It was only 3 years later when my son was diagnosed with tongue tie at birth, that I looked under her tongue and saw what the problem had been.
Tongue tie is not just a breastfeeding issue, when your tongue is restricted it can hinder speech, it can prevent the natural almost subconscious act of sweeping your teeth of food debris after eating, leading to tooth decay. It’s even associated to sleep apnea (breathing problems).
Oh and this is not just an NCT campaign. The nhs is highlighting the need for more awareness amongst their lactation consultants and breastfeeding workers – I’ve seen some of the material while I was at at my local breastfeeding support clinic a couple of months ago, and have had midwives and health visitors mention that there have been seminars etc. This is a real medical issue (unlike routine circumcision, in case you are confused about the difference Mr Thornton).
Oh dear.
The evidence that adult circumcision reduces HIV infection http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003362.pub2/abstract is much stronger than the evidence that frenotomy for tongue-tie helps breast feeding, speech, dental health or sleep apnoea. It still doesn’t justify neonatal circumcision of course.
Will you please recind your comment that the campaign has been dropped, since it is incorrect (and was only ever assumption with no fact checking behind it).
A lactation consultant advises EVERYONE to snip their babies tongue even against their pediatricians recommendations. She also refers her clients to a specific oral surgeon. She frightens new mothers that if they will not snip their babies tongue now the baby will have breathing and other issues later on in life. Is she doing anything illegal? Is there anything legal I can do to stop her?
Hi Solu,
Good question. I doubt you can do much about the advice to snip. But if she always refers to one pediatrician it might be worth exploring their financial relationship. If she was taking a cut and not revealing it, that would be unprofessional, although probably not illegal. Alternatively tell us her and the pediatrician’s names. Delighted to “name and shame” on Ripe-tomato.org.