In the UK there is currently considerable debate about appropriate aftercare following frenulotomy (treatment of tongue tie). At one end of the scale is the do nothing approach, sometimes not even providing a contact number for parents. At the other end is an intense schedule of lifting, stretching, "popping" and massage - the aim being to keep the wound open, using force to "tear" healing fibres apart if needs be.
In between are a range of practices: watching the wound but not touching unless significant tightening down occurs; tongue exercises; sweeping the area without pressure.
The general consensus from parents (and often infant feeding specialists too) is confusion. Who is right and what should they do?
I've split this entry into two parts; general discussion of aftercare, and coming up in part two, other things to consider.
Typically when it comes to intervention, the onus is on demonstrating a benefit; in this case that stretching/massage etc proffers better outcome than doing nothing, or waiting and watching. We can then read through the pros and cons and make an informed choice.
This is where we hit the first roadblock because realistically at the moment there isn't any.
Different practitioners may claim their own clinical experience is evidence, but realistically it's not; it's anecdotal and not free from bias (if someone believes something will or won't work, this can inadvertently influence their judgement).
Their theories may be accurate and intervention important, but without published trials including controls and adjusting for other potential influencing factors, this isn't research but theory.
We must first decide how we define tongue tie and what the overall aims of the initial procedure are, so we have a basis on which to gauge outcome.
Which is where we hit stumbling block number two.
So let's start at the beginning.
When identifying a tongue tie initially, it's not as simple as identifying a membrane and assuming all problems stem from that.
Many people have some sort of frenulum under their tongue. Only when it appears tight or short, and impeding full tongue movement , can it be classed as tied or restricted.
To make matters more interesting, even if there is apparent restriction of the tongue this isn't always caused by tongue tie, and even if there is a tie this isn't necessarily the cause of the feeding problems.
Still with me?
The NICE guidelines state:
"Many tongue-ties are asymptomatic and cause no problems. Some babies with tongue-tie have breastfeeding difficulties. Conservative management includes breastfeeding advice, and careful assessment is important to determine whether the frenulum is interfering with feeding and whether its division is appropriate."and
"It was recognised that breastfeeding is a complex interaction between mother and child, and that many factors can affect the ability to feed. Skilled breastfeeding support is an integral part of the management of breastfeeding difficulties."I would ideally like to repeat this phrase a thousand times, so many people assume presence of frenum alone is problematic (even if they're not having any problems), and that as long as it's removed problems resolve.
This is why I assume there are now several practitioners treating frenums without needing any sort of referral other than the parents picking up the phone.
In the UK a rationale is required to perform tongue tie revision on babies, one can't just go about dividing frenulums willy-nilly. It isn't just about what a frenulum looks like, but how it affects feeding and what problems result. Yet we're in a situation where people are treating for a feeding reason, yet the parents have sometimes not seen a single person qualified in providing feeding support! Nobody is ensuring adequate feeding assessment or that these mums have someone who specialises in feeding issues to go back to.
Once the frenum is treated, do we have reason to believe that post procedure we should focus purely on whether a single strand of tissue has reattached? If many people have a frenulum, do we have sufficient evidence we need to be aiming for zero attachment in all cases? No.
A couple of cases spring to mind. First a baby just a few weeks old and mum contacted me regarding a third revision. The mum had been advised (after showing a photo) that the two previous surgeries had apparently failed.
Yet whilst there had been regrowth of tissue at the site of the cut frenulum and there were still issues, ultimately it wasn't the new tissue underneath that was the cause.
If I had seen that tongue prior to any treatment, I wouldn't have considered it tied - so why when it comes to regrowth should different rules apply?
Second was a slightly older baby. All problems had resolved following treatment, but mum was concerned that she could see regrowth when she lifted the tongue. Indeed there was a frenulum, but where is the rationale to treat further when life is sweet?
This means any research surrounding appropriate post procedure treatment has to define criteria.
Is the treatment taking place to resolve feeding issues, or is it to obliterate any trace of frenulum with success being measured based on what we can see?
When it comes to promoting rigorous aftercare, I've heard the argument that lots of medical interventions aren't evidence based and yet work; that lack of evidence don't mean lack of efficacy. Indeed this is true, but conversely neither can we guarantee lack of harm.
Whilst oral mucosa heals with a less fibrous response than skin, what if aftercare that involves "disturbing the wound" creates deeper scarring than doing nothing, increasing risks of palpable scar tissue and/or reattachment?
Do all babies despite age and position of frenulum need the same post procedure care, and is there the potential to improve outcome in some whilst causing problems for others by intervening?
Is there any risk of rigorous rubbing of a deep revision causing oral damage? How much do tongue exercises help? How does watching and intervening later compare with forceful disruption from the start or doing nothing?
Is there risk of causing further inflammation? Is there an infection risk from rubbing a wound to the point it bleeds without sterile hands or gloves?
Are we absolutely sure this is necessary?
Without studies we simply don't know. It seems different practitioners have different theories and I personally need more assurance than "because I say so!"
What I do know is that plenty of babies have suffered reattachment even with "hardcore" aftercare, whilst others haven't; similarly some frenulums never reattach even if mum doesn't do anything, whilst others do.
We simply are not in a position to say with any certainty that reattachment or unresolved problems are due to inadequate intervention by caregivers. For me that's just a guilt trip too far.