Breastfeeding and Tongue Tie: Business or Medical Model

Conventional wisdom is that by the time that the mainstream media describes a phenomenon as a new or novel activity, in reality it is already a well-established if not a normative practice and that the media blast is not a revelation but rather just a confirmation of the reality. Thus, one must relate to the recent front-page article in the New York (NY) Times describing the practice of the “cutting” of the infant's tongue that has “exploded” over the past decade and how it has been commercialized by a variety of medical professionals. ¹

The authors of this “exposé” describe this activity primarily as one of the involvement tongue evangelists who attribute all breastfeeding difficulties to such ties or who perform the procedure simply based on anatomical finding of ankyloglossia (tongue ties in all its variants) even in asymptomatic infants. No less so, the NY Times authors suggests that there is an economic motive that may be driving the decision to perform this procedure, that is, the cut (or snip) for a fee approaching $1000.

The increasing popularity of this of surgical treatment of the tongue tie has not been matched by any accumulation of evidenced-based data to justify the cutting.^2.3 In fact, a recent attempt to generate a consensus statement regarding the management of tongue ties was unsuccessful given the lack of agreement of the “specialists” in fields as to the definitions of what is a clinically significant tie, let alone what and how this entity should be managed. ⁴

Most disturbing is the increasing involvement of dental and other “specialists” who are performing the surgical procedure but who have not undergone any training in the “science” of breastfeeding medicine or have any practical experience in clinically evaluating the maternal–infant dyad, the mechanics of nursing, or the general medical status of mother and infant. As a result, as reported anecdotally by Thomas, the reliance on an anatomical diagnosis rather than a functional diagnosis has led to surgical “cures” that are too often unnecessary invasive procedures, with frequent attendant counterproductive complications and with no clinical improvement in breastfeeding exclusivity rates or duration.

Most interesting, while acknowledging that there is at time justification for cutting the tongue (e.g., maternal pain and discomfort), the recent update of Academy of Breastfeeding Medicine protocol on this subject has emphasized that:

the decision to treat is one that requires a high level of clinical skill, judgment, and discernment…(and that) There is an ongoing need for high-quality research in these specific areas related to the treatment of tongue-tie. ⁵

Thus we are most gratified to note that this month's issue of Breastfeeding Medicine presents a most welcomed study that addresses two critical issues that should help in formulating a balanced clinical management protocol:

What is the prevalence of tongue ties as defined uniformly by a standardized evaluation score?

Feldens and colleagues prospectively studied a cohort of infants from three baby-friendly hospitals in Brazil. All the infants per routine care in nursey were evaluated by the standardized Bristol score for the presence of a tongue tie (defined anatomically). All mother–infant dyads received intensive structured breastfeeding support and none underwent any surgical procedure irrespective of their Bristol score (even those who were prospectively labeled with an absolute diagnosis of ankyloglossia).

The results were as follows: The prevalence or rate of ankyloglossia was 1.0%, whereas another 4.8% of the infants were defined as “suspect” based on their intermediate score. Most importantly there was no difference in the exclusive breastfeeding rate at 1 month or the percentage of infants who were breastfeeding at all 6 months between those infants diagnosed (anatomically) with any degree of tongue tie and those infants who have no anatomical findings. To emphasize, these were the results despite the fact that there was no surgical intervention, as the maternal–infant dyad received “only” an ongoing intensive breastfeeding support program.

As usual, there are some limitations to the study: The cohort sample was relatively small and no data as to mothers' symptoms were presented. Additionally, one must ask whether it is appropriate to extrapolate the findings from one specific country to others worldwide.

However, as presented, the data should hopefully support those who wish to temper the undue enthusiasm for surgical intervention and the degree of commercialization and financial considerations that are present in the management decisions of this ubiquitous infant anatomical variant.