The kindest Cut? Part 1.
The Emotional Impact of the Tongue Tie Maze
We are grateful to Maddie for allowing us to publish her article on the issue of tongue tie. Its a subject that does not receive much attention but for our growing numbers of new-Mums we feel its worth a post! Maddie’s article will be posted in three parts; 1. The Emotional Impact of the Tongue Tie Maze 2. Stories from the real world and 3. Navigating the tongue-tie maze.
On one fairly routine day for a postnatal doula I found myself ringing the doorbell of a potential client. Her baby was 2 months old and she wanted some support with the baby while she rested. As I greeted her and cast my eyes around the house, I could see with a glance that all was not right. Usually by 8 weeks in, mothers are getting into the swing of things, feeding is more or less established, baby’s sleep and waking patterns becoming slightly more predictable. Generally by now, they are waving goodbye to their postnatal doulas, not calling one in. It only took me a moment to get an idea of what had been occurring here. One look at the baby and my heart sunk. There was the characteristic heart-shaped tongue. As I looked more closely I saw the flash of frenulum I have become so familiar with. It was attached right at the tip, tethering his tongue cruelly to the floor of his mouth. As she gently touched the bottle teat to her son’s mouth, I watched as he drank greedily but in an uncoordinated fashion, milk dripping from the corners of his mouth. Diplomatically I asked how things were going and listened carefully as the whole, sorry story spilled out. Many reading this will be all too familiar with her tale. After a worrying start with her newborn not latching, readmission to hospital for weight loss of over 10%, the introduction of formula top ups and finally a diagnosis of tongue tie at 4 weeks by a Health Visitor at a breastfeeding drop-in, she was now waiting a month for an appointment to have the tie divided on the NHS. Of course, during that month her supply had dipped more and more, with formula becoming an increasingly large part of her son’s diet – until I rang her doorbell that day, a few days into exclusive formula feeding. The largest part of a doula’s work is listening. We listen to the stories of mothers and fathers; the narratives of the birth, the emotions of new parenthood, the highs and the lows of life with a baby. But that day I realised I’d listened to one too many tongue tie stories. It was time to give all these women a voice. I came home and announced on facebook that I wanted stories from parents about their tongue-tied babies. Not even I could have predicted the pain and suffering that appeared in my inbox over the next few weeks. Much has been written about ankyloglossia, commonly known as tongue-tie, in infants. The controversy surrounding this subject has been well documented and, despite NICE guidelines stating that the impact on breastfeeding warrants the tie being released, many health professionals remain ignorant of the obstacle that this small oral anomaly can present to successful breastfeeding. A quick search of an online medical dictionary returns this simple definition. tongue–tie Function: noun : a congenital defect characterized by limited mobility of the tongue due to shortness of its frenulum Here’s how the National Institute for Clinical Excellence defines it: ‘Ankyloglossia, also known as tongue-tie, is a congenital anomaly characterised by an abnormally short lingual frenulum; the tip of the tongue cannot be protruded beyond the lower incisor teeth. It varies in degree, from a mild form in which the tongue is bound only by a thin mucous membrane to a severe form in which the tongue is completely fused to the floor of the mouth. Breastfeeding difficulties may arise as a result of the inability to suck effectively, causing sore nipples and poor infant weight gain.’ Why does this insignificant-looking frenulum cause all this debate? Generations ago it was a well-known routine procedure. These days, it seems, it’s very existence is often questioned. Certainly the medical literature seems to suggest that tongue-tie doesn’t affect breast-feeding. Mervyn Griffiths, a pediatric surgeon who practices at Wessex Regional Center for Pediatric Surgery in Southhampton is a leading light in the field. Back in 2007, his prospective double-blind, randomized controlled trial seemed to prove both the critics and the textbooks wrong. In the trial, two groups of babies were immediately returned to their mothers for breast-feeding, either after division of the tongue tie or without treatment. During interviews, 21 (78%) of 27 women whose infants received treatment said breast-feeding had improved compared with 14 (47%) of 30 mothers whose infants were not treated. The experiences of 3 women were excluded because of a loss of blinding. The results were statistically significant ( P < .03). Follow-up surveys a day later found that 90% of mothers reported improved feeding, with 3.3% reporting a full resolution of problems. Repeat interviews after 3 months revealed that 90% of the mothers still experienced improved feeding compared with their pre-surgical experiences, but now 55% said that their breast-feeding problems were fully resolved. Pretty impressive, eh? But it seems that many in the field are not singing from the same hymnsheet, despite NICE Guidance: 1.1 Current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support the use of the procedure provided that normal arrangements are in place for consent, audit and clinical governance. When asked for their stories, mothers bear out the research; tongue-tie is by no means a simple subject. The impact on breastfeeding can range from no impact at all to the complete cessation of breastfeeding. Add to that the fact that problems do not correlate in any neat fashion with the severity of the tongue-tie and it’s hardly surprising that many parents find it difficult to find anyone who can help them get to the bottom of their breastfeeding problems. But all this jargon, all this abstract talking about frenulums, breastfeeding difficulties and ‘division’ hides the real stories from the trenches. And ‘trenches’ seems like an adequate image for it appears there’s a war going on; between the pro- and anti-snippers. Thing is, it’s the parents and babies who are all too frequently stuck in no-man’s land, caught in the crossfire.