In late 2016, I wrote this blog article about existing division of tongue tie rates in Ireland. Like most people, I was really worried that too many babies were having frenotomies (the procedure during which tongue ties are divided). At the time of writing the post, I was concerned that I had opened a can of worms by highlighting the lack of public services for these babies.

 

It certainly seemed, at that stage, that we were not overdoing it, yet, this niggling concern remained as I saw increasing numbers of babies having divisions without due process. By that I mean, not opting for division before introducing mother and baby to efficient lactation help by an IBCLC, identifying other factors that appear like tongue tie, or which may be the real reason for pain or low milk supply.

 

It is my opinion that, in Ireland today, there is a prevalence of under diagnosis and recognition of anterior tongue ties. This is paired with an over eager tendency to treat posterior tongue ties. In my own practice, I have become more conservative about referring posterior ties and find over 50% of these cases successfully breastfeed with meticulous attention to positioning and attachment. Parents also need support and to know that they can access a frenotomy clinic without delay if the arrangement is not working well for them.

 

Increasingly, I am hearing of lots of babies who are unhappy breastfeeding after frenotomy. Using our tongue tie Facebook groups as a sample, there are many posts where babies are crying with pain and where mothers are terrified that they are not doing it right after frenotomy. This is causing the mother to wonder about reattachment. It is common for mothers to believe that the tongue tie procedure has not worked because they didn’t do the stretches they were told to, or sometimes they are afraid to go back for a checkup because they didn’t follow the instructions given by the provider.

 

Tongue tie is a quick procedure where a baby has momentary pain (akin to a heel prick) to free their tongue from the floor of the mouth. In Blackrock Clinic Tongue Tie Service, our success rate is over 90% and we do not do these types of ‘stretches’. In fact, at our clinic, we actively advise parents against stretching. As far as I am aware, we are the only clinic in Ireland to adopt this policy of actively advising against interfering with the wound.

Stretching the tongue tie site involves the parent lifting up the baby’s tongue and separating the wound underneath where the incision or laser has removed the restriction during frenotomy. They are instructed to do this at least 4 times per day for up to 2 weeks after the procedure. Not only is there no evidence that this is necessary, we do not know if it causes trauma to babies. We don’t know whether it could potentially cause more scar tissue on the frenotomy site. What we do know is that it is painful for the baby no matter how quickly the parents “get in and out”.

I see mothers posting on social media saying their baby hates the exercises. Others claim that you have to be cruel to be kind. I have also heard it said that if the mother is anxious it will upset the baby more and that you should sing and smile while doing it. This is just not true. If you are opening a wound, it will cause pain, no matter how much you sing, smile or do cartwheels while doing so.

Imagine if you had a gash on your knee, you probably have had at some point. It is bad enough when someone tries to dress it, but what if they pulled open – would you be happy? What about if they did it repeatedly over the coming days? As an adult, you would probably be ready to take their head off! I certainly wouldn’t let anyone do this to me.

Nobody wants to inflict pain on their baby, but when a medical professional tells you that this is a vital part of aftercare, of course parents will do what is necessary to avoid reattachment. I wish more people would speak out against this practice. Professionals use terminology such as “the jury is out“ or “there is no consensus yet”. If you are in a position of authority on this matter, please stand up and say “you do not have to do this“.

I have watched this debate go on for years – so I want to be clear about this now, I do not believe that wound management that includes performing exercises or stretches on your baby’s tongue after tongue tie division makes any difference to the outcome. Please tell any new parents and anyone else that will listen that this is not necessary. Help them to be fully informed. First do no harm.

 

Reattachment occurs when the tongue tie tightens up again at the base of the tongue after release. Tongue ties don’t grow back. In my experience, some babies have tighter, more fibrous ties and, no matter how much tissue is released, they cannot be assured of a straightforward outcome afterward.

 

Providers who advise wound management post tongue tie release claim that it reduces their reattachment rate by 10%. However, there is no published evidence of this. Is it right to subject all babies to this treatment when it might help less than 10%?

How can we be sure of reattachment rates? Unless we examine every frenotomy site afterwards, we cannot ascertain accurate rates. I suspect that many parents don’t want to admit that they didn’t do the wound massage and feel they can’t say anything out of guilt.

I have read material by some providers in which they ascertain that clinical experience is more important than published evidence. While I agree with this to a point, from my standpoint it is more important that we first do no harm until we are 100% confident that we are not causing unnecessary trauma.

Hand on heart, I can no longer stand by and not speak out about this. I became an IBCLC because I love babies and know that breastfeeding parents need high levels of support and expert care. I do not want any baby to be subjected to unnecessary pain because I have campaigned for more access to frenotomy services in Ireland.

So, I’m asking my colleagues to speak up, speak out and stop whispering your concerns – most of us feel worried about this. It is time to speak your truth.

Yours sincerely,

Nicola.

 

 

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