Making Sense of Studies That Claim Benefits of Frenotomy in the Absence of Classic Tongue-Tie

Controversies and Conundrums in Newborn Feeding

Breastfeeding is the biologic norm for newborn feeding, and exclusive breastfeeding for the first 6 months of life is universally endorsed by leading global and national organizations. Despite these recommendations, many people do not meet their breastfeeding goals and controversies surrounding breastfeeding problems exist. Medical issues can present challenges for the clinician and parents to successfully meet desired feeding outcomes. There are studies evaluating these common controversies and medical conundrums, and clinicians should provide evidence-based recommendations when counseling families about newborn feeding.

Labial Frenotomy for Symptomatic Isolated Upper Lip Tie

BACKGROUND

The benefits and challenges of successful breastfeeding for both mother and child have been well-established in the literature. While ankyloglossia, or tongue tie, alone or in combination with upper lip tie has been the focus of several previous studies, very few have directly addressed isolated symptomatic upper lip tie and the role of surgical correction for breastfeeding difficulties.

MATERIALS AND METHODS

Seven infants with isolated upper lip tie and breastfeeding difficulty were taken to the operating room for labial frenotomy. These infants were assessed at their follow-up visits for their degree of weight gain since their procedure. Their mothers were surveyed regarding their experiences with breastfeeding since the frenotomy was performed.

RESULTS

In this article, we present seven infants with isolated upper lip tie and breastfeeding difficulty who were treated with labial frenotomy. Subsequently, these infants demonstrated improved weight gain, and all mothers reported increased ease of breastfeeding.

CONCLUSION

These findings implicate lip tie as an underrecognized cause of breastfeeding difficulty and suggest that labial frenotomy is an effective treatment in these patients. Larger-scale randomized controlled studies are necessary to further evaluate this topic.

Re-thinking lactation-related nipple pain and damage

Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple-areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal. Keratinocytes lock together when mechanical forces exceed desmosome yield points, but if mechanical loads continue to increase, desmosomes may rupture, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple-areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

Primum non nocere: lingual frenotomy for breastfeeding problems, not as innocent as generally accepted

The frenotomy or surgical release of the lingual frenulum is performed with increasing frequency. Restricted tongue mobility, ankyloglossia, is the main indication for this procedure. This clinical diagnosis is often used as synonym for tongue-tie which is blamed for many feeding difficulties resulting in an increase in performed frenotomies. Until recently, little was known about the anatomical structure and normal variation of the tongue-tie. Different grading systems have been developed. Some are exclusively based on appearance of the tongue-tie; others also include functional elements. There is, however, no established relation between the tongue-tie score and the observed feeding problems or outcomes following frenotomy. Therefore, caution is warranted before submitting babies to this procedure.Conclusion: This narrative review aims to give an overview of current knowledge and concerns regarding the tongue-tie, which need to be considered before referral for a frenotomy. What is Known: • The presence of a tongue-tie is associated with a higher frequency of breastfeeding problems. • Hence, frenotomy is advocated and increasingly performed in infants with breastfeeding problems. Current tongue-tie classifications do not allow to predict breastfeeding problems. What is New: • New anatomy insights caution for possible complications resulting from this seemingly innocent practice of frenotomy. • Frenotomy should only be performed after multidisciplinary evaluation of feeding problems, following exclusion and remediation of other causative factors.

Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants

BACKGROUND

breastfeeding optimises health outcomes for both mothers and infants. Although most women want to breastfeed, they report commencing infant formula because of nipple pain, unsettled infant behaviour, and infant growth concerns. To date, existing approaches to fit and hold ('latch and positioning') have been demonstrated not to help breastfeeding outcomes, and women report widespread dissatisfaction with the quality of support and conflicting advice they receive. Breast and nipple pain, difficulty with latching and sucking, fussing at the breast, back-arching, marathon feeds, excessively frequent feeds, poor weight gain, breast refusal, and crying due to poor satiety often signal suboptimal positional instability and impaired milk transfer, but may be misdiagnosed as medical conditions. Over the past two decades, there has been an exponential increase in numbers of infants being treated with medications, laser or scissors frenotomy, and manual therapy for unsettled behaviour and breastfeeding difficulty. New approaches to clinical breastfeeding support are urgently required.

METHOD AND RESULTS

we analyse the findings of a literature search of PubMed and MEDLINE databases for ultrasound studies measuring sucking in term and preterm infants. The findings demonstrate that the Stripping Action Model of infant suck during breastfeeding, and the resultant Structural Model of infant suck dysfunction, are inaccurate. Instead, ultrasound data demonstrates the critical role of intra-oral vacuum for milk transfer. We integrate these two-dimensional ultrasound results with clinical experience of the third dimension, volume, to propose a Gestalt Model of the biomechanics of healthy infant suck during breastfeeding. The Gestalt Model hypothesises that optimal intra-oral vacuums and breast tissue volumes are achieved when mother-infant positional stability eliminates conflicting intra-oral vectors, resulting in pain-free, effective milk transfer.

CONCLUSION

the Gestalt Model of the biomechanics of healthy infant suck during breastfeeding opens up the possibility of a new clinical method which may prevent unnecessary medical treatments for breastfeeding problems and related unsettled infant behaviour in early life.