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Babies 'don't need tongue-tie surgery to feed' - Rapid Response

"Babies 'don't need tongue-tie surgery to feed" is today's BBC headline, which had reached my inbox before I opened my eyes this morning (thank you readers).

We know the media sensationalise studies, so you want to know what it really says right?

Course you do, let's go.

112 babies who had been referred for tongue tie treatment, were assessed by "Speech and language pathologists, who examined the infants' ability to breastfeed prior to a surgical consultation".

112?  That's really one step beyond "large classroom experiment".

My next thought was:

Wow, do Speech and Language Therapists (SALTs) have breastfeeding training in the US?

So I of course asked the man in the know, Dr Ghaheri. His reply:

"Er no".

Errrrrm ok then.

He continues:
"Their professional organization (ASHA) doesn’t recognize TT as being a problem in breastfeeding, solid foods or speech. They are not the practitioner of choice when it comes to breastfeeding pathology either."
I want to clarify this early on (then probably repeat it 10 times throughout this piece for those who will still miss it) - NOT ALL BABIES WITH A TONGUE TIE NEED A RELEASE TO BREASTFEED WELL. At least I'm assured this is the case - people rarely ring an IBLC to say their baby has a tie but hey, they're feeding great and don't need our support.  

This study is exploring infants who were diagnosed as tied and symptomatic with feeding problems, thus had been referred and recommended for release. This means anyone not experiencing a feeding problem from their tie, wouldn't be included in this study.

I pushed on. The SALTS then:  
"offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures."
Ok, that sounds fair enough right?  Try other techniques such as improving attachment, positioning and so on. Indeed these interventions are listed. 

Brace yourself.
"If sleep state regulation was determined to be the primary issue (with the baby falling asleep and transitioned to a nonnutritive sucking pattern causing maternal nipple pain/ injury/prolonged feeding), interventions included arousal actions such as applying a wet facecloth or tapping the infant’s foot."
I had to stop and take a moment here to suck air through my teeth.

News flash - babies fall asleep when the flow of milk isn't worth staying awake for because their attachment is shallow. Tapping a baby or applying a cold wet cloth, may temporarily wake the baby, who will take a few more sucks/swallows before nodding back off again.

"If volume or rate of breast-milk flow (tongue clicking, gulping, or pulling off the nipple) appeared to be the primary issue, modifications included the following strategies to slow the flow of milk: placing the mother in a supine position (gravity to slow flow), expressing milk prior to breastfeeding, and/or placing the mother and baby in a side lying position."
If a baby is in a shallow latch, they will often perceive the breastmilk supply to be too fast. We can see video examples of that here: with a tongue tie. However with a deep latch, the flow is easily tolerated as we can see here: post tongue tie release.
"If previously-diagnosed reflux appeared to be the primary issue (eg, arching, pulling off nipple), verbal reassurance to continue gastroesophageal reflux disease medication treatment was provided"
Woah woah woah. Wait a moment.

First - pulling on and off the nipple and arching can mean many things.  It can mean "hey the milk has stopped", "I have trapped wind/gas" (top or bottom end), "my mouth is sore" or "my neck is stiff in that position".  Since when did the assumption these symptoms mean reflux become a given?

Shallow latch and feeding technique can cause reflux (NICE) - indeed the baby in the clips above was symptomatic prior to release. It seems though we're just ignoring that in this study and carrying on with medications.

This is where my alarm bells really started ringing.

The authors opened this paper with the statement:
"Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding
This is a rather confusing claim, since there are really quite a lot of studies exploring tongue tie and breastfeeding (1-15), my list isn't exhaustive. They consistently demonstrate breastfeeding improvement, none evidence any risk of significant harm and they include is comments such as:
 "No complications were reported with frenotomy."(2)
"Ankyloglossia, which is a relatively common finding in the newborn population, adversely affects breastfeeding in selected infants."(4)
"This review of research literature analyses the evidence regarding tongue-tie to determine if appropriate intervention can reduce its impact on breastfeeding cessation, concluding that, for most infants, frenotomy offers the best chance of improved and continued breastfeeding. Furthermore, studies have demonstrated that the procedure does not lead to complications for the infant or mother." (6)
"Frenotomy is a safe, short procedure that improves breastfeeding outcomes, and is best performed at an early age" (7)
"After lingual frenotomy, changes were observed in the breastfeeding patterns of the the tongue-tied infants while the control group maintained the same patterns. Moreover, all symptoms reported by the mothers of the tongue-tied infants had improved after frenotomy."(8)
"Tongue-tie is not uncommon and is associated with breastfeeding difficulty in newborn infants." (10)
This should provide convincing evidence for those seeking a frenotomy for infants with significant ankyloglossia.(15)
Apparently not.

What we should perhaps also explore some other stats too.

Prescriptions of a a child-friendly liquid formulation of a popular reflux medication (PPI), saw a 16-fold increase in use between 1999-2004.  Between 2006 and 2016, prescriptions of specialist formula milks for infants with cow’s milk protein allergy (CMPA) increased by nearly 500%. (16)

If we want to talk about things lacking an evidence base - let's start here.

"There was no significant difference for both outcome measures while taking either omeprazole or placebo.  Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability." (17)
"PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking." (18)
"As more extensively discussed below, the inappropriate use of acid suppressive drugs has been indeed associated with consistent modifications in the intestinal microbiota by inducing gastric hypochlorhydria, delaying gastric emptying and increasing gastric mucous viscosity [48]. In adults, chronic acid suppression has been linked to an increased risk of small intestine bacterial overgrowth (SIBO). Although not reaching statistical significance, a trend towards an increased risk of SIBO has also been recently observed in children under long-term PPIs therapy (6 months) [49]. Apart from SIBO, the chronic use of acid suppressive agents is a well-known risk factor for gastrointestinal (acute gastroenteritis, Clostidium difficile infection, candidemia and necrotizing enterocolitis) and extra-intestinal (lower respiratory tract infections, community acquired pneumonia) infections, particularly in infants." (19)
"Several micronutrients require an acidic environment for optimal absorption. Iron, vitamin C, and vitamin B12absorption are dependent on the intestine's acidic environment. Several studies and case reports describe associations of omeprazole with altered calcium, magnesium, and vitamin B12 absorption. To date, there have been no prospective trials evaluating the effect of proton pump inhibitors (PPIs) on iron absorption.
Existing data support the conclusion that the acid-suppressing effect of omeprazole can have important clinical implications for vitamin and mineral therapy. Clinicians should be cognizant of this issue in practice. Further studies exploring the relationship of PPIs and iron deficiency are warranted, especially in high-risk populations such as the elderly." (20)
And presumably infants.

I won't bore you with however many more studies and turn this into a reflux post, if you're interested you can read more here. The point is, there are recognised and potentially significant risks associated with reflux medications. As a result, current recommendations are to minimise use whenever possible, giving as a last resort not a first line response; it makes no logical sense as a preferred treatment pathway compared to frenulotomy.

The question this study really asks is - can we breastfeed tongue tied infants ie, provoke weight gain and not suffer nipple trauma, even when the baby is tied.

We of course all know that a lot of the time - yes you can!   2/3rd of the time according to this study. We can employ multiple compensatory strategies. 

Many do constantly jostle their babies awake and feed them 20 times per day to provoke gain or because it's the only way baby settled.

They may give reflux medications, keep baby upright an hour after feeds, use a specialist milk or undertake a restricted diet, at times completely unnecessarily:
"Inappropriate elimination diets have been imposed on pregnant and lactating women and their infants to prevent allergies without scientific evidence proving their efficacy. Even when well indicated in infants and children diagnosed with an allergy, the type of dietary products to eliminate and the duration of such elimination are not always logical."(21)
They may accept their baby is "higher needs" and sleeps badly or has "wind" or is "fussy" as they won't be put down or settle for long.

They may use techniques such as expressing before a feed, reclined feeding or catching the first "letdown" in a muslin.

They may accept they won't take a bottle and feed hourly.

Any family being offered tongue tie division should always be offered the option of doing nothing -  to carry on managing the situation as they have been up until this point, with added tips and tricks for positioning, wind and colic management, expectations and so on.

The problem though is, especially in the patriarchal world of medicine - often the only things valued as markers of "successful breastfeeding" are weight gain and nipple pain. "Symptoms of reflux" are medicated rather than looking the resolve the problem and mothers are told to rub their baby with wet flannels to keep them awake.

These studies don't consider maternal satisfaction levels and overall well-being - is this sustainable in terms of getting through a day?  Is this situation conducive to good mental health for family members?

As usual, social media comments sum things up best:

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  1. Ghaheri BA, Cole M, Fausel SC, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 2017;127(5):1217–1223. doi:10.1002/lary.26306
  2. Srinivasan, A., Al Khoury, A., Puzhko, S., Dobrich, C., Stern, M., Mitnick, H., & Goldfarb, L. (2018). Frenotomy in Infants with Tongue-Tie and Breastfeeding Problems. Journal of Human Lactation.
  3. Emond A, Ingram J, Johnson D, et al. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie Archives of Disease in Childhood - Fetal and Neonatal Edition 2014;99:F189-F195.
  4. Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia: Incidence and Associated Feeding Difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36–39. doi:10.1001/archotol.126.1.36
  5. Elvira Ferrés-Amat, Tomasa Pastor-Vera, Paula Rodríguez-Alessi, Eduard Ferrés-Amat, Javier Mareque-Bueno, and Eduard Ferrés-Padró, “Management of Ankyloglossia and Breastfeeding Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and Frenotomy,” Case Reports in Pediatrics, vol. 2016, Article ID 3010594, 5 pages, 2016.
  6. Edmunds, Janet & Miles, Sandra & Fulbrook, Paul. (2011). Tongue-tie and breastfeeding: a review of the literature. Breastfeeding review : professional publication of the Nursing Mothers' Association of Australia. 19. 19-26.
  7. Sharma, S., & Jayaraj, S. (2015). Tongue-tie division to treat breastfeeding difficulties: Our experience. The Journal of Laryngology & Otology,129(10), 986-989. doi:10.1017/S002221511500225X
  8. MARTINELLI, Roberta Lopes de Castro, MARCHESAN, Irene Queiroz, GUSMÃO, Reinaldo Jordão, HONÓRIO, Heitor Marques, & BERRETIN-FELIX, Giédre. (2015). The effects of frenotomy on breastfeeding. Journal of Applied Oral Science, 23(2), 153-157.
  9. BAXTER, R., HUGHES, L.. Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. International Journal of Clinical Pediatrics, North America, 7, jun. 2018. Available at:<>
  10. Sopapan Ngerncham, Mongkol Laohapensang, Thidaratana Wongvisutdhi, Yupin Ritjaroen, Nipa Painpichan, Pussara Hakularb, Panidaporn Gunnaleka & Penpaween Chaturapitphothong (2013) Lingual frenulum and effect on breastfeeding in Thai newborn infants, Paediatrics and International Child Health,33:2, 86-90, DOI: 10.1179/2046905512Y.0000000023
  11. Hogan, M. , Westcott, C. and Griffiths, M. (2005), Randomized, controlled trial of division of tongue‐tie in infants with feeding problems. Journal of Paediatrics and Child Health, 41: 246-250. doi:10.1111/j.1440-1754.2005.00604.x
  12. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad
  13. Jeanne L. Ballard, Christine E. Auer, Jane C. Khoury
    Pediatrics Nov 2002, 110 (5) e63; DOI: 10.1542/peds.110.5.e63
  14. Shaul Dollberg, Eyal Botzer, Esther Grunis, Francis B. Mimouni,Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study,Journal of Pediatric Surgery,Volume 41, Issue 9,2006,Pages 1598-1600,ISSN 0022-3468,
  15. A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. Janet Berry, Mervyn Griffiths, and Carolyn WestcottBreastfeeding Medicine 2012 7:3, 189-193
  16. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial Melissa Buryk, David Bloom, Timothy Shope Pediatrics Aug 2011, 128 (2) 280-288; DOI: 10.1542/peds.2011-0077
  17. Van Tulleken Chris. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers BMJ 2018; 363 :k5056
  18. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. Moore, David John et al. The Journal of Pediatrics, Volume 143, Issue 2, 219 - 223
  19. Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review. Rachel J. van der Pol, Marije J. Smits, Michiel P. van Wijk, Taher I. Omari, Merit M.Tabbers, Marc A. Benninga. Pediatrics May 2011, 127 (5) 925-935; DOI: 10.1542/peds.2010-2719
  20. Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-Esophageal Reflux in Children. Int J Mol Sci. 2017;18(8):1671. Published 2017 Aug 1. doi:10.3390/ijms18081671
  21. Humphrey, M. L., Barkhordari, N., & Kaakeh, Y. (2012). Effects of Omeprazole on Vitamin and Mineral Absorption and Metabolism. Journal of Pharmacy Technology, 28(6), 243–248.
  22. Lifschitz, C. & Szajewska, H. Eur J Pediatr (2015) 174: 141.

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