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 tie¹ in the same month that NICE² 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,^3,4 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 bottle feeding, 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 (three weeks) as many mothers may give up before then (we waited till the mothers asked for help, and accept that some (13/88, 15%) did give up before we could randomise them).⁴

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 practised in this country. However, the national or local rate of breastfeeding is well documented⁵ and should be an objective measure of pain-free, successful breastfeeding. This group of mothers are struggling to breast feed because of the pain and the time it takes. If the tongue tie is divided but there is no improvement in symptoms, there is no reason for the breastfeeding rate to be different from the national average or even lower. In both my studies^3,4 and that of Masaitis and Kaempf,⁶ 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 American Academy of Pediatrics Section on Breastfeeding Bulletin,⁷ 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 breast feed 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 breast feed painlessly for as long as possible.