Conclusions of Ghaheri's Study That Laser Surgery for Posterior Tongue and Lip Ties Improves Breastfeeding Are Not Substantiated

Editor's Note: The diagnosis and treatment of tongue and lip ties remains a topic of much and at times heated debate. The following correspondences, which take opposite sides of the argument as to the value of laser surgery, are symptomatic of this still unresolved and hotly contested subject. Breastfeeding Medicine is of the opinion that it should serve as a platform for the presentation of both sides of the issue so as to provide information that will assist clinicians in their management decision.

—Arthur I. Eidelman, MD Editor-in-Chief

Dear Editor:

In Ghaheri et al.'s 2016 study, breastfeeding mothers self-reported improvements on the Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF), on a visual analog scale for breastfeeding pain, and on the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R) 1 week and 1 month after Ghaheri performed laser surgery for oral ties. This letter concerns the 179 infants who were treated for upper lip-tie (ULT) and the 184 treated for posterior tongue-tie (PTT). ¹

Unfortunately, chart reviews and pre-post studies are notoriously biased research methodologies, in part because expectation has known neurobiological effect on both health professional and parental experience. ²

Ghaheri et al. confuse association with causality, resulting in a study that is fundamentally flawed. BSES-SF has been shown to improve over time without intervention, and also with nonsurgical breastfeeding interventions. It measures psychological confidence, affected by multiple factors, and does not always correlate with improved breastfeeding outcomes. ³ Nipple pain has been shown to decrease in the first 7–10 days postpartum without intervention (although in the absence of classic tongue-tie, nonsurgical clinical intervention is vital). ⁴ Ghaheri et al. do not quantify or control for the contribution of lactation consultant interventions before the referral for oral surgery nor for clinical support offered in the subsequent month.

There is no evidence to suggest that air in the stomach is a cause of increased frequency or noxiousness of refluxate, or of esophageal pain. Barium X-ray studies, manometry, and esophageal pH monitoring over the past three decades in babies diagnosed with breastfeeding and reflux problems, and recent ultrasound studies of babies diagnosed with ankyloglossia, have not shown that babies with breastfeeding or latching difficulties swallow more air than others. ⁵ I-GERQ-R scores do not correlate with esophageal discomfort or pain in infants in the first 12 months of life because frequency of reflux, back-arching, or unsettled behavior do not correlate with esophagitis in this population. Also, the placebo effect of interventions for the cluster of behaviors assessed by the parent-reported I-GERQ-R is particularly high, between 50% and 87%. ⁶

An ill-defined subgroup was also noted by Ghaheri et al. to have increased milk transfer, but milk transfer is expected to increase over time without intervention in the 59% of infants who were <4 weeks of age. ⁷

Ghaheri et al.'s study is based on multiple unproven assumptions concerning the validity of the diagnoses of PTT and ULT and the causes of measured outcomes. A randomized controlled trial (RCT) comparing oral surgical intervention with a standardized breastfeeding fit and hold (attachment and positioning) intervention would address these assumptions and is urgently required.

Remarkably, the authors state that they “did not incorporate a control group … because … many experts do not feel it ethical to offer an untreated control study arm.” Yet it has not been established that the diagnoses of PTT and ULT are valid or useful; it has not been established that frenotomy for PTT and ULT is beneficial. ⁸ Similarly, it has not been established that the risk of laser frenotomy for PTT and ULT and associated wound-stretching exercises is low, as the authors' claim. Moreover, the financial burden of infant oral surgery for both parents and the health system is significant.

Breastfeeding women and their babies deserve the very best of 21st century science, not expensive and unproven technological “quick fixes.”