Why is there such controversy around frenotomy and tongue tie?
Updated: Nov 3, 2022
So, it's definitely complicated and this is just my take on it from my experiences, observations, and conversations. I've been a La Leche League Leader, a WIC Peer Counselor, an educator in the hospital system, a parent!, a consultant for multiple providers, a professional educator and presenter on lactation topics, and a clinical Lactation Consultant who has worked in hospitals, pediatric clinics, public health clinics, and in private practice. I've seen a lot and worked with many, many babies and talked with their doctors about their tongue ties. So here is my take on why frenotomy and tongue tie seem surrounded by differing opinions, recommendations, and even controversy! Starting in the first few decades of the last century, around the 1930s, some physicians started formulating replacement milk for infants. The age old practice of wet nursing and sharing infant feeding was moving out of practice due to big cultural and political changes. Wealthier women were used to having others (read: enslaved and impoverished women who had to sacrifice feeding their own babies - we will address this barbaric topic soon) feed their babies for them. We didn't understand, at that time, that lactation and natural term nursing offers essential protection from reproductive organ cancers, cardiovascular disease, and lowers risk of developing many chronic diseases. What we did value, however, were having lots of children and heirs. So when wet nursing declined, we needed an alternative and that's where formula was invented. There was competition and pretty soon families of lower socio-economic class were convinced that artificial feeding was actually better for babies. By the mid-19th century, science had caught up to what our ancestors must have always known: providing human milk to human babies is biologically normal and makes for a healthier population and individual. The practice of nursing our own babies started to increase in the 1970s as US ideas about health and nutrition evolved. But the practice of bottle feeding was so very "normal" to us that when breastfeeding didn't last long or someone ran into problems, it seemed totally "normal" to bottle feed instead. We believed some babies just can't breastfeed. We believed some parents just don't make milk. By the early 2000s, when I was having my first child, there was HUGE cultural shift. Parents started adopting a more "natural" lifestyle and found the benefits of babywearing, natural term nursing, and grinding up our own baby food which our little people dutifully deposited into soft, cotton diapers after digestion. This shift to the natural came with resistance to the idea that "some babies just can't breastfeed". We wanted....no, we demanded answers. We turned to our Lactation Consultants and pediatricians thinking they had the answers.
The latch looks good from the outside so why is this painful? Why does this baby have sooo much gas and spit up? Why is this baby constantly thrusting their tongue every time we try to latch? How come this baby can't gain weight but the parent can pump a ton of milk? We were puzzled. This didn't make sense. It went against all our training and understanding. We didn't know yet that we simply didn't know enough about actually normal infant feeding. The answers seemed impossible...until a connection was made. It's not like tongue tie and frenotomies just went away. The practice, which historical was done nearly immediately after birth prior to the mid-1900s, was still performed but not so often for feeding problems. It would pop up later in children and adults with speech, dental, or swallowing problems. Dentists and ENT physicians were frequently performing frenotomies and some of them started to make connections. These same children and adults with dental, speech, and feeding problems had the problems since early childhood...even infancy. Working together- infant feeding specialists, dentists, and some doctors - realized that releasing tethered oral tissue in infancy was not only a very low risk procedure but it had the high reward of improving infant feeding function quickly and effectively. Lactation Consultants, breastfeeding supporters like LLL leaders, and providers who had been working with families facing nursing problems for years realized the missing piece to a great number of mystery cases. We understood, for the first time, why that baby kept thrusting their tongue and why that other baby could never seem to gain weight despite great milk production. We saw the reflux reduce, the mastitis stop coming back, and we saw feeding actually improve for infants we were unable to offer solutions for before! This was exciting! This was a paradigm shift! We (Lactation Consultants, that is) heard from parents about the major improvements to feeding problems, pain, and overall infant comfort. We could functionally see babies feeding better, transferring more milk in less time, and seeming content while they did it.
But not everyone was on board the Paradigm Shift Express.
Many pediatricians were cautious and skeptical because they didn't learn about tongue tie's impacts to infant feeding in medical school or residency. They observed and were taught about the more complicated procedure done on older children and adults which involved anesthesia, stitches, and months/years of therapy to get to functionality. A paradigm shift births controversy. A change this big is RADICAL No one wants to harm infants or subject them to a procedure they may not need or which might not work...After all, some babies just can't breastfeed (this is the old paradigm and while it's not technically wrong - some babies truly cannot breastfeed - we should still figure out why such a high number are not meeting medical recommendations for duration and exclusivity...but that's a completely different discussion for another day!) Ahem. As we (infant feeding specialists like IBCLCs, OTs, SLPs, and physicians) have learned more about what babies need to feed functionally, it's brought about cautious experimentation and collaboration. For those us who realized that tethered oral tissue was the common factor in many of the problems we treat, we started talking and working together to bring our special skills, knowledge, and techniques to develop The Best Model for improving infant feeding pre- and post-frenotomy. Unfortunately, this is not how tongue tied infants are treated and supported everywhere...which is where problems and controversy come in. The best outcomes for infants with tongue tie and tethered oral tissues include care from many professionals: 1. Lactation Consultants who identify feeding dysfunction, develop feeding plans for the dyad, support milk production, guide suck training/oral motor exercises, and refer to specialists as needed.
2. Release providers like ENTs, dentists, and pediatricians who perform skilled and complete releases of tethered oral tissue and encourage care coordination.
3. Bodyworkers who provide manual therapies like chiropractic, cranial sacral therapy, or OMT to address body tension, compensations, and dysfunction stemming from feeding dysfunction.
4. Primary care providers who care for the infant's overall health, recognize early feeding problems, and refer to specialty providers for detailed and thorough assessment and treatment.
5. Additional specialty providers like OTs, PTs, and SLPs who use their knowledge, techniques, and skillset to support normal function.
Teamwork makes the dream work! <3
Unfortunately, not every baby and every parent has access to all the providers they need. Some areas lack providers with the necessary knowledge, training, and skills to adequately help. Financial and insurance barriers limit care. Or some providers simply don't realize it's not just a clip.
This is the root of the controversy
Imagine, for a moment, you are a doctor and you've worked with lots and lots of babies who have feeding difficulties. Some of these babies are identified by IBCLCs as "tongue tied" and get their ties released but their feeding problems don't go away.
If you didn't know that other team members -with extra education and training- are needed on the roster to see feeding improvement and get the best results, you might conclude that frenotomy isn't helpful. And since no one wants to subject an infant to a procedure they don't need, you might conclude that infants with ties don't need frenotomies.
This doesn't actually mean frenotomies are not helpful and don't work. It does mean we need to communicate better and increase access to specialty providers with adequate training, knowledge, and skills to properly help these babies get the best outcomes.
Really, we are all on the same team.
This is team babies who are thriving, growing, healthy, and content. This is team parents who are recovering, resting, connecting, and who enjoy nursing.
Teamwork, communication, care coordination lead to REVOLUTION. This revolution expands beyond individuals and changes care completely for new families to a thrive model. This revolution brings back our historical knowledge of caring for and feeding our babies. It improves the physical and mental health of our families and whole communities. This is possible. This revolution in infant feeding and thriving families is starting now.
We are still learning and cautiously experimenting to find the very best therapies and methods to get to The Best Model. We are listening to parents. We are watching babies who communicate their needs. We no longer accept "some babies just can't breastfeed" without a reason.
And we are using frenotomy when it's needed along with care coordination to get to functional feeding.