Summary
There is some dispute about how much tongue-ties affect breastfeeding, where treating physicians and paediatricians have dramatically different perspectives than the lactation experts. In particular, the Canadian Paediatric Society (CPS) takes the position that clipping a tongue-tie (frenotomy) should essentially never be recommended. I am skeptical of this conclusion of the CPS.
Background
My wife and I just had a newborn and my wife is attempting to breastfeed. Unfortunately our newborn arrived with a tongue-tie, and it has been a tremendous effort by my wife and I to get the tongue-tie fixed by a physician.
I became skeptical because the lactation consultant at the hospital of delivery, two subsequent independent lactation consultants, a doula, a registered nurse who is a breastfeeding specialist, and ultimately the physician specializing in ear-nose and throat who performed the 30 second operation to clip the tongue-tie, stated that the tongue-tie was inhibiting – if not altogether precluding – effective breastfeeding. My google search indicated that this position is supported by many institutions, such as the Canadian Breastfeeding Foundation.
In contrast, the four paediatricians and the family physician who examined our newborn concluded that the tongue-tie would not inhibit breastfeeding and as a result they refused to recommend clipping it. Their opinion was unanimous, yet none of the observed or offered to observe the newborn attempting to latch or breastfeed. Further, of the four paediatricians consulted only one offered, after my probing to the point of having to be rude, a rational explanation for their policy: It's what the Canadian Paediatric Society recommends.
Position statement of the Canadian Paediatric Society
So I searched for the CPS position statement, which led me to a 2011 paper on the Canadian Paediatric Society website entitled POSITION STATEMENT: Ankyloglossia and breastfeeding, which offers in its summary:
Associations between tongue-tie and breastfeeding problems in infants have been inconsistent, and are a longstanding source of controversy in the medical community. Definitions of ankyloglossia vary, and management suggestions are not based on randomized controlled trials. Surgical correction involves cutting the lingual frenulum (frenotomy). Based on current available evidence, frenotomy cannot be recommended.
The report suggests the risks of simple clipping of the tongue-tie (frenotomy):
There is a risk that postoperative scarring may limit tongue movement even more, necessitating reoperation [25][26][27].
...
[25] Levy PA. Tongue-tie: Management of a short sublingual frenulum. Pediatr Rev 1995:16:345-6.
[26] Hay W Jr, Levin MJ, Deterding RR, Sondheimer JM. CURRENT Diagnosis & Treatment in Pediatrics, 20th Edition. New York: McGraw-Hill Professional, 2010.
[27] Klockars T, Pitkäranta A. Pediatric tongue-tie division: Indications, techniques and patient satisfaction. Int J Pediatr Otorhinolaryngol 2009:73:1399-1401.
However, the report does not state the likelihood of those risks, whether the risks are predictable & avoidable, or the cost-risk of reoperation. Further, it makes no mention of the cost of preventing a child from breastfeeding i.e. the loss of the lengthy list of breastfeeding benefits.
Skepticism
I am skeptical of the position of the Canadian Paediatric Society that frenotomy should never be recommended, with my skepticism being conceptually rooted in:
The methodology of the position paper in assessing the prevalence of the problem (i.e. are tongue-ties that cause breastfeeding issues more common than the paper states, was there sampling error or a genetic sampling bias);
The contrast of the benefits described in the CPS paper versus other well-reputed journals (i.e. are the benefits of frenotomy on breastfeeding more certain than the paper suggests);
The absence of discussion of the cost-risk of frenotomy (i.e. the risks are marginal probability or insignificant benefit, contrast the consequences of raising a baby who has not had the benefit of breast milk); and
The overstatement or misstatement of actual risks associated with frenotomy.
The sweeping recommendation "cannot be recommended" also reminds me of the hallmarks of bad logic, namely ... sweeping statements (ad dictum simpliciter).
Armed with suspicion and some cynicism, I did a bit of research, to make sure that my concerns were somewhat valid and came up with:
Effects of tongue ties on breastfeeding
A 2008 article in the Official Journal of the American Academy of Paediatrics entitled Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound states:
For all of the infants, milk intake, milk-transfer rate, LATCH score, and maternal pain scores improved significantly postfrenulotomy. Two groups of infants were identified on ultrasound. One group compressed the tip of the nipple, and the other compressed the base of the nipple with the tongue. These features either resolved or lessened in all except 1 infant after frenulotomy.
Risks of frenotomy
The risks of Frenotomy, according to the Canadian Breastfeeding Society are:
Research shows that “frenotomy”, or clipping of the tongue-tie, is a safe and effective treatment. Frenotomy, like all procedures, may present some risks. They include bleeding at the incision site, infection, and salivary gland trauma.
Those risks sound less problematic than those stated in the CPS position paper.
The answer sought
Not having any particular medical expertise, I am left only with my feeling that the CPS position is not adequately supported by evidence (and, to some extent, logic), my layman reading of papers like the above, and my anecdotal experience.
So is my feeling unfounded and in fact the CPS paper is a solid analysis of the available evidence that supports the conclusion that the appropriate times for frenotomy for breastfeeding is: never; or, is the balance of the medical community more aligned with my suspicion that the conclusion of the CPS position paper is scientifically unsound and the CPS has gotten its recommendation wrong?
EDIT
Since DJClayworth (and likely others) believe that the "other side" of the CPS argument is my opinion, here are some supplemental sources that support my question (which is, in some ways, answering my own question, but there you have it):
1.) Tongue tie and breastfeeding: assessing and overcoming the difficulties, J Hum Lact 1990 Sep; 6(3): 117-21.:
(abstract) Tongue tie, a condition in which the tongue's mobility is restricted, may reduce the ability of babies to breastfeed successfully. In this age of mass artificial feeding, the management of this condition has been, until recently, overlooked. This article highlights the effects of tongue tie on breastfeeding and what health professionals should be doing to assess and manage any difficulties
2.) Neonatal frenotomy may be necessary to correct breastfeeding problems., J Hum Lact. 1990 Sep;6(3):117-21.:
(abstract) A review of cases of short frenulum (tongue-tie) seen in a recent year at the Lactation Institute and Breastfeeding Clinic provides data about its relationship to sucking and breastfeeding problems such as insufficient infant weight gain and reduced milk supply, sore nipples and repeat bouts of mastitis in the mother. Frenotomy was recommended for ten of 13 babies who appeared to have a short frenulum. Three mothers chose not to hae*(sic)* the frenulum clipped and either gave up breastfeeding or continued to experience problems. Breastfeeding was successfully established by the five healthy babies whose frenulum was clipped. The two babies for whom frenotomy did not completely correct breastfeeding problems had severe birth defects.
3.) Tongue tie division in infants with breast feeding difficulties, Int J Pediatr Otorhinolaryngol. 2006 Jul;70(7):1257-61. Epub 2006 Mar 9.
(conclusions) ... The procedure is quick and simple, not requiring any analgesia or anaesthesia and can be performed in the outpatient clinic. Although not conclusive, this case series suggests a possible benefit of tongue tie division in symptomatic infants.
4.) Clinical inquiries. When should you treat tongue-tie in a newborn?, J Fam Pract. 2010 Dec;59(12):712a-b.:
(abstract) Consider treatment when the infant is having difficulty breastfeeding. ... Complications from the procedure are minimal.
5.) Tongue-tie and breastfeeding: a review of the literature., Breastfeed Rev. 2011 Mar;19(1):19-26.:
(abstract) ... This review of research literature analyses the evidence regarding tongue-tie to determine if appropriate intervention can reduce its impact on breastfeeding cessation, concluding that, for most infants, frenotomy offers the best chance of improved and continued breastfeeding. Furthermore, studies have demonstrated that the procedure does not lead to complications for the infant or mother.
