Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

Should all newborns be checked for tongue tie?


Recently there has been lots of talk about tongue and lip ties - and rightly so given the first particularly can be a significant cause of breastfeeding problems, I've been known to blog about it myself a time or three.  But recently tongue tie talk has taken a turn that has left me feeling a little uncomfortable - a call for every baby to be checked at birth for tongue tie, and divided if identified..

Logically this appears to make sense - snip them all and things will be well with the world, but I fear in practice the reality is not so.  For me there are really important issues that we could focus on first, should we want to promote a change in the current standard of lactation care offered.  This means starting at the beginning not halfway up the ladder.

Firstly - we are still currently in a position that many many mums with nipple pain/cracking/bleeding/feeding problems are not even getting this flagged as a problem - no really.  They are told positioning and attachment look great, perhaps their nipples are just more sensitive, baby has a "hoover suck", baby is too big/small/hungry/lazy, it takes time for them to learn how to feed well, not all women can breastfeed and don't feel bad if you're one of those that can't.

Far before we move on to tongue ties, I believe we need to be in a position that whomever is caring for mum can identify there is a need for proactive support, if this isn't something that will improve over time.  Furthermore they then need to be able to identify the signs a baby needs some extra help, that they're not transferring milk well - without this fundamental basic knowledge, the rest can only come crashing down.

Secondly the reality of our current care system means that many midwives are already so stretched that there are ongoing campaigns and petitions about the continuity of care women receive, quality of antenatal information, how many midwives are looking after each labouring mum.  Midwives themselves talk about how little time they have to spend with each new mum, 6 hours in hospital pre discharge for some straight forward births and community visits are shorter.  On top we now want them to be trained to effectively check every new baby for tongue tie?  If so then there surely needs to be a way to clearly demonstrate this improves outcome, and I'm not convinced it's that clear cut.

Checking for tongue tie requires someone to place their fingers into a newborns mouth, when would this be done?  Before baby meets mum?  During the routine checks that so often themselves interfere with breastfeeding initiation because baby is removed from mum - something we know impacts?  What about the risks of introducing foreign bacteria to a baby's mouth straight after birth?

Babies who have tongue tie are often orally sensitive, they may gag easily and babies often clearly demonstrate that lifting the tongue to check for a restricted frenulum isn't pleasant.   My 5yr old describes it as "burny", which I would suspect it would if you are stretching a piece of skin to check its maximum extension.  But we do this to all newborn babies just in case?

What's more newborn oral anatomy can change in the early days as they recover from the birth, pregnancy, labour and delivery can all impact - whilst an anterior tie isn't going anywhere, posterior tongue function CAN change with healing, one has to be able to identify whether the birth impact to affect tongue function and try other measures first.

The biggest flaw as I see it is that whilst some ties are tight and at or near the tip of the tongue, thus easily identifiable - ties further back become much more difficult.  As it stands they can be missed or disregarded by everyone from Consultants, to Surgeons, Midwives and Health Visitors - with some only acknowledging ties that sit right on the tip of the tongue.

Will a mother think to get her baby checked elsewhere if she believes he has already been checked at the hospital?

Many people have a frenulum(s) that does not impede tongue function - a tongue (or lip) is only "tied" if that frenulum is too short and tight to allow proper function.  Simply seeing a piece of skin between the tongue and the floor of the mouth, or the lip and the gum means nothing - therefore one has to be able to ascertain how the tongue is functioning and how (if at all) that impacts on feeding.

Not all frenulums need dividing...

The NICE guidelines clearly state that a frenulum needs to be causing a problem ie there has to be a reason for division.  How do current care providers decide if a frenulum is causing significant problems to feeding or is division worthy, if they are unable to identify good feeding versus not to start with or if the baby is just hours old?

Are all babies to be checked regardless of how mum wants to feed and if so what criteria will be used to establish which need dividing?  Lactation Consultants don't just look for a tongue tie - they check the tongue function, whether baby's suck is organised, what else apart from the frenulum may be impacting? What impact has labour and delivery had? Is baby struggling one side more than the other and if so what is causing this? What does baby do at the breast during the whole feed?  How does this tie in with an oral assessment of baby's sucking skills?  The skill is piecing together all the information, to understand the big picture.

NICE guidelines only cover breastfed infants, many areas will only divide frenulums for breastfeeding infants as a means to preserving breastfeeding, so where will the provision (and the funding for it) come from for the thousands of divides that appear if all infants are to be divided?

Not all parents want their baby assessing for tongue tie as standard, nor it dividing if there are signs of restriction but no problems - so midwives would also need to be fully educated to provide enough information to facilitate an informed choice.  We're not even there yet with breast v substitutes, let alone how a restricted frenulum can impact on feeding.  

Wouldn't it make more sense to ensure those at the first point of contact could recognise a problem, including key indicators of tongue tie that can be apparent without fingers ever going in a mouth,  and if so refer to someone with relevant expertise in that area?

Whilst anyone and everyone has an opinion on breastfeeding, like podiatry, osteopathy or a speech and language therapist - lactation is a specialist field and indeed a pretty sound science.  But we still don't recognise lactation as a specialist field beyond lip service, it's open for anyone and everyone to give advice.

Why can't parents expect qualified help?  As someone a few years ago said (and I'm sorry I can't recall who) You wouldn't expect to go to the hospital with a broken ankle and instead of seeing a qualified doctor, be referred to someone who had broken theirs a few years ago and done a few weeks training.  Feeding is the cornerstone of longterm health! Peer Supporters have a significant and valuable role to play - but this isn't in the role of someone providing all the lactation education and support both pre and post natally, diagnosing tongue ties because they are significantly cheaper to employ than someone appropriately trained and experienced.

In a city close to me recent economic changes have meant the NHS no longer provides three full time Lactation Consultants, instead it employs one part time with a Peer Support network.  One LC for a whole city with many more unsure where future cuts will leave them.

A mum on Facebook today said:
"We are losing our NHS lactation consultants from 3 counties in South Wales this year and they won't be replaced. Other than Health Visitors, a couple of Breastfeeding Counsellors and the Peer Supporters, that is it for breastfeeding support"
Yet all women are advised during pregnancy to consider breastfeeding, many say the pressure to at least give it a try is great - yet where is the support for mums to succeed?  Without the voluntary organisations, the private sector and passionate parents - what would we be left with in terms of the NHS?  Think of all the breastfeeding information you read and share online - who produces all that?

Magic Bullet
The trouble with perceiving anything breastfeeding related as a magic bullet to all problems, is that for many it simply doesn't work like that.  Years ago thrush (Candida) was the magic bullet, and everyone and anyone with nipple pain (which extended to deep breast pain too) was diagnosed and medicated for thrush.  Even now we see women who don't have any risk factors for thrush, no visual presentation - who are medicated due to pain with similar presentation..

The fact there can be numerous causes of pain both during and after a feed beyond fungal.

The risk with medicating all dyads for thrush regardless (beyond exposure to unnecessary medication)  is the real cause of pain remains unidentified - when the thrush treatment doesn't work, the medication doses get larger and more prolonged, with large doses of oral Fluconazole (which in my opinion also potentially carries risks) so who has it helped?

Tongue tie just like thrush treatment for some women is the magic bullet - if that is the only cause of their problems, dividing it often resolves.

But I really don't think it's that simplistic.  Firstly we see mums who have an "incomplete divide" ie the front of the tie has been snipped, but the surgeon hasn't gone far enough back to free up the tongue (many having no understanding of what function the tongue needs to feed effectively).  These mums will often note no improvement post division, and at times things can even get worse as the baby can no longer use the compensatory skill they have been using.  Tongue ties all have the ability to regrow - yet this isn't regularly checked for on the NHS, some surgeons will readdress if it happens and mum goes back, (if she has been told this can happen) others don't acknowledge they can reoccur and there's a good chance mum can come away thinking division didn't work.

But what's just as important is that there can be other things rather than, or as well as the frenulum causing problems - but if the person identifying the tie to start with is purely looking for a frenulum, this is very likely to be missed.  In this case division may yield some improvement, with other issues remaining - or may note no improvement at all.

I saw a 16 day old baby this week who had tongue tie division at 3 days old, I saw them because they still had severe feeding issues.

I saw a baby last week that has been readmitted to hospital twice for low gain/weight loss (which carries huge psychological implications for mum and dad) - supplemented and then sent back into community with no extra plan, support or change to what was happening before they were admitted!

Mums need more than a pair of scissors and a free frenulum - we need to be campaigning for all mums to have access to qualified, effective lactation support.

10 comments:

  1. Thank you Charlotte. People need to know this stuff!
    Your point about lack of bf support is crucial. Whilst it's lovely that so many midwives refer women to me, I can't help feel I shouldn't be doing their job. I believe breastfeeding counsellors are there to complement the skilled help women should be receiving from their community midwives and health visitors. If you de-skill these professionals, the result is people like you and I trying desperately to fill the gap.
    Often-times, those who have only part of the knowledge or skill can only provide 'support' that is worse than no help at all - checking for TT when you've no idea what you're looking at, or have the skill, experience or knowledge to accurately assess the whole feeding picture is, in my experience, like trying to cook a soufflé without the eggs...

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  2. I was told by an old midwife that traditionally they always kept one fingernail long specifically to nick the frenulum after birth if need be. And would routinely check for this at birth too! Whereas my first grandson was born almost completely tongue tied and it took 2 weeks of arguing and me finally tracking down a prvate surgeon to fix the problem. He could not attach at all before this was done...and my poor daughter was bullied by nursing and medical staff who were furious that she refused to bottle feed. When I told them he was tongue tied, I was informed that "this was no longer acknowledged as a problem nowadays" and that the hospital would not cut his frenulum!

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  3. Yes I've heard this too, and if anyone has evidence of this (written or a midwife who did it) I would be interested - only after watching many TT revisions with sharp scissors, I wonder just how sharp the nail would have to be and how much hacking would be required! Plus why would she have used this rather than say a scalpel?

    Checking for tongue ties at the front of the tongue is also v different to checking for tongue tie full stop - a large number of tongue tip ties are now identified in the community.

    AA

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  4. Excellent!! Where can I get more info on healing for a posterior tongue tie?

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  5. The Paediatrician's neonatal check already involves a (clean) finger in the mouth to check for cleft palate. It would be trivially easy to check the tongue at the same time.

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  6. Tongue tie and the need to treat is based on function, not just appearance

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    1. And some tongue ties can't be felt, particularly in newborns...

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  7. Some great points here I have only just found out that both my boys have top lip ties and the youngest also has something wrong with the tounge but she was unable to diagnose what, I think a routine check at birth would have saved me months of stress pain guilt of not being able to feed properly I expressed for 7 months for my first and only 8 weeks with my second if I knew it could of been fixed easily all our problems I'm sure would if been solved. both times I had bad experiences from the midwives in regards to breastfeeding basic made to feel stupid and useless because I couldn't do it right, I also asked twice to see a lactation consultant with my second but was told she was busy and only came on a certain day of the week. So I'm all for checking at birth!

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  8. Some great points here I have only just found out that both my boys have top lip ties and the youngest also has something wrong with the tounge but she was unable to diagnose what, I think a routine check at birth would have saved me months of stress pain guilt of not being able to feed properly I expressed for 7 months for my first and only 8 weeks with my second if I knew it could of been fixed easily all our problems I'm sure would if been solved. both times I had bad experiences from the midwives in regards to breastfeeding basic made to feel stupid and useless because I couldn't do it right, I also asked twice to see a lactation consultant with my second but was told she was busy and only came on a certain day of the week. So I'm all for checking at birth!

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  9. Some great points here I have only just found out that both my boys have top lip ties and the youngest also has something wrong with the tounge but she was unable to diagnose what, I think a routine check at birth would have saved me months of stress pain guilt of not being able to feed properly I expressed for 7 months for my first and only 8 weeks with my second if I knew it could of been fixed easily all our problems I'm sure would if been solved. both times I had bad experiences from the midwives in regards to breastfeeding basic made to feel stupid and useless because I couldn't do it right, I also asked twice to see a lactation consultant with my second but was told she was busy and only came on a certain day of the week. So I'm all for checking at birth!

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