• tongue-tie
• breastfeeding
• ankyloglossia
• frenulotomy
• frenotomy

As a medical student I was taught by an eminent paediatric surgeon that tongue-tie never required treatment “unless they wanted to play the trumpet” and as a registrar I was appalled to find that a consultant paediatrician was snipping tongue-ties in the clinic—a practice I had been taught was “unnecessary, dangerous and cruel”. However, when approached 10 years ago by an experienced midwifery colleague whose own tongue-tied infant was having great difficulty in breast feeding and failing to thrive, I was surprised to find that, although not of high quality, there was reported evidence for the treatment of tongue-tie to help breast feeding and no published scientific information against it. Since then further evidence has been collected and the paper by Emond et al 1 adds to our knowledge.

Although considerable effort is expended on breastfeeding promotion in the UK, there is still frequent failure to support mothers who have already decided to breastfeed, but meet difficulties. Initiation rates have risen to >80%, but exclusive and partial breastfeeding rates still fall rapidly in the first week and 6 weeks, with exclusive breast feeding until 6 months, as recommended by the WHO, being a rarity. This suggests that promotion is not now the most important step, but rather support and intervention to correct early problems stopping a mother and baby from achieving successful breast feeding. Tongue-tie is an abnormality associated with less successful breast feeding and evidence suggests that intervention is likely to lead to improvement in 75–80%.

The history of medicine is full of fashionable diseases and interventions that now seem to be unnecessary or even dangerous and we have a responsibility to make sure that we are not just joining a current trend. It is also hard to understand why an abnormality which, prior to relatively safe artificial feeding, would have significantly decreased an infant's chance of survival, should be so common in the population, but there does not seem any advantage to being tongue-tied. Bottle fed infants with tongue-tie seem to have difficulties less frequently, but when they do, the success rate of treatment in our audited series is similar.

The technique for division of tongue-tie as described by Bowley and Arul2 in Education and Practice offers a simple and quick treatment. In our clinic, mothers have always been welcomed to remain with their babies during treatment and this has allowed us to collect feedback about the amount of distress caused. Most parents have assessed the degree of upset as being the same or less than the Guthrie heel prick or an immunisation injection which are both quick, but painful interventions promoted by British paediatricians for future health benefits. Infants whose feeding has been severely affected such that they have had to undergo blood tests for jaundice or dehydration, placement of a nasogastric tube or an intravenous cannula for fluids are considered by their parents to have had a more distressing experience than tongue-tie division. Parents with older siblings who have undergone division under general anaesthetic are often keen to avoid the anaesthetic and intervention at an age which may allow the child to remember the incident. In contradistinction, parents with older siblings who had frenotomy in early infancy often request this for their subsequent children. In Emond's study this was a common reason for refusing randomisation.

Emond's study shows no significant advantage for early frenotomy against intervention at 5 days in infants with mild to moderate tongue-tie. At present many mothers throughout the UK are waiting significantly longer than 5 days for diagnosis and longer still for treatment. Emond's findings may only apply to the study group with mild or moderate tongue-tie and cannot be extrapolated to infants with more severe tongue-tie. Even in this mild to moderate group, 17% could not wait 5 days because of maternal pain and a higher percentage of those who did wait had changed to bottle-feeding. It is also important to realise that the study was performed at a hospital with well-established lactation support and lactation specialists experienced in using assessment tools for tongue function and such expertise cannot be assumed in all maternity units. There is a risk that infants with severe tongue-ties may not be offered timely treatment which would protect their breast feeding. Mothers in this study knew that they would be seen in 5 days and this allowed some to keep going (reported text) but if a mother is discharged from maternity care without establishing feeding or in pain without a diagnosis or treatment plan, it is less likely that they will manage to persevere. If babies are fed by bottle as a supposed short-term measure, less advantaged mothers without a supportive family or peer group may be even more likely to give up breast feeding completely. There is a considerable difference between areas even in one health region in the support given to mothers in this situation, with some being provided with electric breast pumps to maintain their milk supply and regular support until they are treated and others simply discharged feeding artificially.

There remain a number of questions about tongue-tie for which we have very little researched evidence. In posterior partial tongue-ties there is a crescent of tissue under the tongue, but the frenulum does not reach the tip. This variant does seem to be associated with breastfeeding problems, especially pain, but do posterior ‘cords’ and ‘sub-mucosal’ tongue-ties also cause problems? Many mothers and lactation experts are convinced that they do, but anatomically it is hard to differentiate such tongues from the normal range. A second question concerns the increasing numbers of babies with a prominent upper lip frenulum being referred to tongue-tie clinics. Very occasionally the frenulum is so tight that the baby is completely unable to turn the upper lip out when feeding, but we do not yet have scientific information about which, if any, babies would benefit from treatment. Finally, many parents are concerned about the risk of speech difficulties and there is surprisingly little robust information about this in either paediatric or speech therapy literature. Tongue-tie can be a familial condition and parents who needed speech therapy themselves are often particularly keen to have early treatment. It is disingenuous to tell parents that there is no evidence for this association if we have not looked for it.

Tongue-tie is a common condition found in 2–5% of the population. There is potential for more research to ensure that the correct babies are treated at the right time and fashion does not dictate unnecessary interventions. However, nationally equitable arrangements need to be made for easy and prompt access to treatment for all those infants whose feeding is compromised. Management pathways can still too often be dependent on local prejudice despite evidence that frenotomy is not only for potential trumpet players.