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• Prejudice against test weighing, like tongue-tie division, should be re-assessed
  Barbara Wilson-Clay
  Published on: 22 March 2016
• Tongue Tie- Further observations
  Anthony L H Moss
  Published on: 22 March 2016
• Authors' reply: Tongue-tie - more research needed
  David M B Hall
  Published on: 22 March 2016
• Tongue-ties and breastfeeding
  D Mervyn Griffiths
  Published on: 22 March 2016
• Ankyloglossia intervention in outpatients is safe - our experience
  Richard Hansen
  Published on: 22 March 2016

• Published on: 22 March 2016

  Prejudice against test weighing, like tongue-tie division, should be re-assessed

  • Barbara Wilson-Clay, lactation consultant, clinical photographer

  Dear Editor,

  I read with interest the dialog stemming from Hall and Renfrew's article about tongue tie, and the interest in designing trials to empirically measure the effects of tongue-tie upon breastfeeding. I have photographed many tongue-tied babies. It is my impression that the degree of lift and ability to sustain lift of the tongue provides information about tongue mobility. Measuring lift is described in t...

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  Dear Editor,

  I read with interest the dialog stemming from Hall and Renfrew's article about tongue tie, and the interest in designing trials to empirically measure the effects of tongue-tie upon breastfeeding. I have photographed many tongue-tied babies. It is my impression that the degree of lift and ability to sustain lift of the tongue provides information about tongue mobility. Measuring lift is described in the literature (Lalakea, 2003)and may prove a useful diagnostic indicator. Ultrasound studies provide another fruitful area of research, and preliminary studies by Ramsay demonstrate changes in the breastfeeding behavior of tongue-tied infants before and after frenotomy.

  Secondly, I disagree with the prejudice that test weighing creates undue parental stress and must therefore be ruled out as a way to describe deficits and improvement in feeding behavior. Having used smart scales for many years in my private practice, I find them to be quite effective in terms of helping identify infants who are transfering milk poorly and growing at below reference standards. While the place to begin assisting any breastfeeding problem is with correcting the latch and helping poor feeders obtain more access to the breast, test weights provide a very useful tool. They often confirm parental impressions that their baby is struggling to get enough to eat. This confirmation has not, in my experience, stressed the mothers. They are already stressed owing to painful, unhappy feeds. Information helps everyone know where they stand, affirms the mother's concerns, and provides a starting place to find a solution.

  Test weights of the same infant pre- and post frenotomy provide one way to measure improved ability to breastfeed. Good counseling skills help support the parents when weighing is undertaken. Other researchers have found test weighing to be useful and non-stressful.

  Barbara Wilson-Clay, BS, IBCLC
  Austin Lactation Associates
  12710 Burson Dr
  Manchaca, Texas
  US 78652

  Email: bwc@lactnews.com

  References:

  Hurst N, Meier P, Engstrom J, Myatt A: Mothers Performing In-Home Measurement of Milk Intake During Breastfeeding of Their Preterm Infants: Maternal Reactions and Feeding Outcomes, J Hum Lact 2004; 20(2):178-187.

  Lalakea M, Messner A. Ankyloglossia: does it matter? Pediatric Clinics of North America 2003; 50(2):381-387.

  Ramsay D, Langton D, Gollow I, et al. Ultrasound Imaging of the effect of Frenulotomy on breastfeeding infants with Ankyloglossia, proceedings of the 12th International Conference of the International Society for Research in Human Milk and Lactation (ISRHML) Sept. 10-14th, 2004, Queens College, Cambridge, UK.

  Sachs M, Oddie S: Breastfeeding – weighing in the balance: Reappraising the role of weighing babies in the early days, MIDIRS Midwifery Digest 2002; 12(3):296-300

  Scanlon K, Alexander M, Serdula M, Davis M, Bowman B: Assessment of Infant Feeding: The Validity of Measuring Milk Intake, Nutrition Reviews 2002; 60(8):235-251.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Tongue Tie- Further observations

  • Anthony L H Moss, Consultant Paediatric Plastic and Reconstructive Surgeon

  Dear Editor

  Having read the recent responses to the Hall and Renfrew article, I would like to add certain observations.

  1. The degree of tethering does not equate to the degree of sucking difficulty

  2. The sucking mechanism for the breast is different to that of bottle feeding

  3. We should not ignore the views of mothers, although subjective, as we do not always have the means of objective meas...

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  Dear Editor

  Having read the recent responses to the Hall and Renfrew article, I would like to add certain observations.

  1. The degree of tethering does not equate to the degree of sucking difficulty

  2. The sucking mechanism for the breast is different to that of bottle feeding

  3. We should not ignore the views of mothers, although subjective, as we do not always have the means of objective measurements. Some treatments are diagnostic as well as therapeutic, particularly with low complication rates.

  4. We need to overcome traditional prejudices and historical dogmatic perceptions, where the difficulty many mothers are having in getting adequate, timely and appropriate advice is unacceptable. Is it right that a family should travel 6 hours one way for a simple division of the tongue tie, with immediate and sustained relief of breast feeding difficulties?

  We are in the process of auditing our own series, with a slightly different technique described. Hopefully, when complete, we will be able to submit these for review.

  I would be happy to be included in any study to help clarify the questions asked in this correspondence. Perhaps Prof Hall could design an appropriate multi centre study?

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Authors' reply: Tongue-tie - more research needed

  • David M B Hall, Paediatrician
  • Other Contributors:
    • David Hall and Mary Renfrew.

  Dear Editor,

  We welcome the interest in our review of tongue tie. Hansen, MacKinlay and Manson confirmed the observation of others that division of tongue tie is a simple and safe procedure. We agree with Griffiths that although more remains to be learned about tongue tie, the clinical practice and research described by him and his colleagues have sufficient support to justify it and work on this topic is cert...

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  Dear Editor,

  We welcome the interest in our review of tongue tie. Hansen, MacKinlay and Manson confirmed the observation of others that division of tongue tie is a simple and safe procedure. We agree with Griffiths that although more remains to be learned about tongue tie, the clinical practice and research described by him and his colleagues have sufficient support to justify it and work on this topic is certainly not "unethical".

  Griffiths asked two questions. First, he asked about case definition and partially answers his own question by suggesting a triad of features. We would put the question back to him and ask whether all three features are necessary and whether he considers that all three together are diagnostic or merely suggestive. We note that he does not actually refer at all in this triad to the physical appearance of the tongue and while we understand the reasons for this and commented on the difficulty of interpreting the static appearance of the tongue tie in our review, it would seem strange to ignore physical appearance altogether. We agree that maternal reports of pain are a crucial measure, subjective as this obviously is. Added to this it would seem essential to use independent blinded observers to assess feeding and any associated problems. The collection of serial observations of feeding, weight gain, infant distress and maternal assessment over a period of time would identify whether changes are sustained. In addition, more work is needed to determine the place of dynamic studies using ultrasound or milk flow studies; these also would need analysis of inter-and intra- observer reliability.

  We do not pretend that the design of any further research studies would be easy but, as Griffiths refers to the unit’s breast-feeding rate in support of his team's practice, one possible approach might be to compare departments, perhaps using a design similar to that undertaken by Kennedy and colleagues in their excellent trial of newborn hearing screening (1) (which coincidentally was also undertaken in Southampton)].

  David Hall and Mary Renfrew.

  References

  1. Kennedy CR. Neonatal screening for hearing impairment. Arch Dis Child 2000; 83: 377-383.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Tongue-ties and breastfeeding

  • D Mervyn Griffiths, Paediatric Surgeon

  Dear Editor,

  The humble tongue-tie, like the foreskin, generates enormous quantities of hot air, with little evidence to support it. I welcome the decision by the Archives of Disease in Childhood to commission a Perspective on Tongue-tie in the same month that NICE (1) has issued its positive guidance on the same topic.

  Hall and Renfrew begin by stating their bias. Mine is that the Archives of Disease i...

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  Dear Editor,

  The humble tongue-tie, like the foreskin, generates enormous quantities of hot air, with little evidence to support it. I welcome the decision by the Archives of Disease in Childhood to commission a Perspective on Tongue-tie in the same month that NICE (1) has issued its positive guidance on the same topic.

  Hall and Renfrew begin by stating their bias. Mine is that the Archives of Disease in Childhood rejected my two articles on tongue-tie, a prospective series and a randomised control trial (2,3), both now published by other peer reviewed journals, but which the Archives of Disease in Childhood rejected following very poor quality “peer review”, and compounded the error by referring me to my Medical Director as someone who was performing procedures which were unethical. This charge was rejected by my Trust.

  The interesting question here is how to persuade an intelligent, professional body (in this case, paediatricians), that what they were taught has no evidence to support it. The old textbooks, as well as advocating bottlefeeding, state that tongue-ties essentially never cause a problem. Hall and Renfrew have looked at the new evidence and conclude that the textbooks are partially right – many babies with tongue-ties can feed adequately or normally – but that the textbooks are wrong to say that tongue-ties never cause a problem. Some babies do indeed have a problem which can be solved by a suitably trained person dividing the tongue-tie. It is not necessary to look for tongue-ties at birth, but if feeding problems are noticed then anyone skilled in helping mothers to feed will need to exclude tongue-ties as one of the many possible causes. Division is not advised at delivery, as babies can take several days to establish the correct feeding rhythm, but do not wait as long as us (3 weeks) as many mothers may give up before then (we waited till the mothers asked for help, and accept that some did give up before we could randomise them,(13/88, 15% )(3).

  I would ask two questions. Firstly, what do the authors mean by “precise case definition”. I think this is the identification of the problems caused by a symptomatic tongue- tie, and suggest a triad of poor latch (which includes signs of frustration, like head-banging), painful nipple feeding (including ulcerated, bleeding, cracked nipples, mastitis, and lipstick nipple) and frequent or continuous feeds. Secondly, I am keen to hear their suggestions for objective measures of improvement in order to study “inter-observer reliability of pre and post intervention assessment”. The Archives of Disease in Childhood when pressed on this issue previously, could not suggest anything. Maternal pain scoring produces a quantifiable number, but is subjective. Test weighing babies is known to be stressful and is not practiced in this country. However, the national or local rate of breastfeeding is well documented (4) and should be an objective measure of painfree, successful breastfeeding. This group of mothers are struggling to breastfeed because of the pain and the time it takes. If the tongue-tie is divided but there is no improvement in symptoms, then there is no reason for the breastfeeding rate to be different from the national average or even lower. In both my studies (2,3) and that of Masaitis (5), the breastfeeding rate at 3-4 months was at least 60% (twice the national average). Arguably, it may be that, like pain scores, all assessments should be subjective, as only the mother can really assess the quality of the feed.

  Like the AAP Section on Breastfeeding Bulletin (6), Hall and Renfrew conclude that tongue-ties which cause problems exist, and that these problems cannot be predicted by a static view of the tongue-tie. The problems are relieved by division, which is simple, safe and successful, and should be performed by a suitably trained health professional. These are all very reassuring conclusions to those involved in ensuring that as many babies as possible are able to breastfeed successfully. Now that the Archives and NICE have concurred that the division of tongue- ties in symptomatic babies is no longer unethical, I hope that more units will allow their Infant Feeding Specialists to be trained, so that mothers and babies in the future will be able to breastfeed painlessly for as long as possible.

  Yours sincerely,
  M Griffiths MCh FRCS
  Consultant Paediatric & Neonatal Surgeon

  Child Health Directorate
  Wessex Regional Centre for Paediatric Surgery, G Level
  East Wing
  Mailpoint 44
  Southampton General Hospital
  Tremona Road
  Southampton
  SO16 6YD

  Tel: 023 8079 6489
  Fax: 023 8079 8688

  References

  1) NICE Interventional procedure guidance 149 (http://www.nice.org.uk/ipcat.aspx?o=222016)

  2) Griffiths DM (2004). Do tongue ties affect breastfeeding? J Hum Lact 20(4): 409-14

  3) Hogan M, Westcott C, Griffiths DM (2005). Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health 41 (5-6), 246-250.

  4) Hamlyn B, Brooker S, Oleinikova K, Wands S. Infant Feeding 2000. The Stationery Office Norwich. HMSO 2002.

  5) Masaitis NS, Kaempf JW. Developing a frenotomy policy at one medical centre: A case study approach. J Hum Lact 1996; 12:229-32.

  6) Corrylos E, Genna C W, Salloum AC. Congenital tongue-tie and its impact on breastfeeding AAP Section on Breastfeeding Bulletin summer 2004.

  http://www.aap.org/advocacy/bf/8-27newsletter.pdf

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Ankyloglossia intervention in outpatients is safe - our experience

  • Richard Hansen, Experienced Senior House Officer in Paediatrics
  • Other Contributors:
    • Gordon A. MacKinlay, William G. Manson

  Dear Editor,

  Hall and Renfrew rightly describe the literature with relation to ankyloglossia as containing "little high quality objective evidence," they also describe the difficulties in study methodology in this setting with particular reference to concealing the diagnosis from parents in control studies. With regards to intervention, they note that “…frenulotomy in the newborn is a low risk minor procedure, performed...

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  Dear Editor,

  Hall and Renfrew rightly describe the literature with relation to ankyloglossia as containing "little high quality objective evidence," they also describe the difficulties in study methodology in this setting with particular reference to concealing the diagnosis from parents in control studies. With regards to intervention, they note that “…frenulotomy in the newborn is a low risk minor procedure, performed without anaesthetic” and that “…significant venous bleeding could occur if technique is not meticulous but we found no reports of serious adverse events.”

  Ankyloglossia intervention in the out-patient setting has been performed for over 20 years in Edinburgh without anaesthetic. We recently reviewed 28 months of patients (February 2002 - June 2004) who underwent the procedure to assess the complication and success rates. We fully acknowledge that our study was neither controlled nor had objective measures of outcome; nevertheless, it is the only study we know of to specifically investigate the safety of out-patient intervention in this country.
  Patients were identified from out-patient correspondence to general practitioners if they were initially referred for consideration of ankyloglossia as a cause of feeding difficulties. If appropriate the tongue tie was divided in the clinic by one of two consultant paediatric surgeons using the following method:

  The baby is firmly swaddled in a blanket and held (by an experienced nurse) across the examination couch with his head towards the surgeon. The baby’s head is steadied by the nurse who can also assist in pulling down the chin with her thumb to encourage the mouth to open. The surgeon’s left index finger elevates the tongue placing the frenulum under tension. The transparent part of the frenulum is divided with iris scissors. Care must be taken to avoid cutting into the thicker posterior part of the frenulum which carries the blood supply. Bleeding should be minimal or nonexistent. The baby is fed by the mother in another room and checked again by the surgeon before leaving the clinic.

  The mothers of the study patients were telephoned to complete a brief telephone questionnaire relating to possible complications and some subjective indicators of success after a minimum 14 day period. 44 (of a possible 51 study patients) were successfully contacted.

  The mean age of infants on the day of tongue tie division was 49 days (SD 41days, Mean 38, Mode 38) with the youngest infant being 3 days old and the oldest 202 days old. The study group consisted of 25 males (57%) and 19 females (43%).
  The type of feeding before the procedure was documented and included all types of feeding attempted by the mother until the date of tongue tie division. 40 mothers were at least partly breastfeeding, 4 infants were exclusively formula fed. Of the 40 breastfed infants, 35 (88%) had problems latching on. 33 (83%) of the mothers had sore nipples and 15 (38%) had mastitis. 35 (80%) of the 44 mothers noted an improvement in the ease of feeding after the procedure with 28 (64%) also noting an improvement in the time taken for a feed. 3 of the 4 formula fed infants were improved in both these areas.

  With regards the complication rate (Fig. 1) any pain or bleeding after leaving the clinic was considered significant as well as any episodes of infection, any need to seek medical advice and any repeat procedure required to release the tongue tie. The mean time of leaving clinic after the procedure was 29 minutes (SD 21 minutes) with the shortest wait 0 minutes and the longest wait 120 minutes in an infant whose mother was awaiting delivery of a breast pump from stores. Excluding this infant, the longest wait was 60 minutes.

  One infant had bleeding after leaving the clinic. The bleeding was minimal and self limiting. The baby did not require any further medical attention and had left the clinic 15 minutes after the procedure.
  One infant was reported as being in pain after the procedure and was given a single dose of paracetamol with good effect. There were no incidents of infection and no requirement for further medical advice after the procedure. 2 patients required a repeat procedure which was performed in the same way on a separate day. Both repeat procedures were successful.

  Fig. 1 - Complications After Leaving Clinic

  Complications After Leaving Clinic		Yes	Yes (%)	No	No (%)	Total
  Bleeding		1	2	43	98	44
  Pain		1	2	43	98	44
  Infection		0	0	44	100	44
  Further Medical Advice Needed		0	0	44	100	44
  Repeat Procedure Needed		2	5	42	95	44
  Total		4	9	40	91	44

  This study demonstrates that frenotomy in out-patients is both effective in releasing tongue tie and safe in terms of potential complications (9% overall complication rate). We suggest that the consideration of ankyloglossia is important in the differential diagnosis of an infant with difficulties feeding or a mother having pain breastfeeding. If diagnosed in either of these situations, the ankyloglossia can be easily treated in the outpatient clinic setting with a low complication rate. We would recommend the mother be encouraged to remain in clinic for a minimum of 30 minutes after the procedure in which time a test feed be performed. Routine out-patient follow-up is not required.

  Richard Hansen
  Princess Royal Maternity Hospital
  Glasgow

  Gordon A. MacKinlay and William G. Manson
  The Royal Hospital for Sick Children
  Edinburgh

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  Conflict of Interest:
  None declared.

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