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Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3928 (Published 26 November 2020) Cite this as: BMJ 2020;371:m3928

Rapid Response:

Re: Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain

In reference to the article entitled
“Posterior tongue-tie and lip tie: a lucrative private industry where the evidence is uncertain” published 26th November 2020 as an abridged version of an earlier article published in the BMJ Opinion on 2nd October 2020.

Dear Editor,

The Association of Tongue-tie Practitioners (ATP) is a UK organisation which was set up in 2012 by a group of tongue-tie practitioners from the NHS and independent sectors. We aim to promote the awareness of tongue-tie as an infant feeding issue, providing educational opportunities for healthcare professionals and infant feeding supporters. We provide support and opportunities to share best practice for those dividing tongue-ties working both independently and within the NHS. We provide information for parents and facilitate them to access safe and effective care regarding tongue-tie. We read the article mentioned above and would like to make some comments.

The article states that division of a tongue-tie is carried out “usually in an ENT outpatient setting”. We would disagree, as the majority of divisions are performed outside of the ENT setting. Examples would be children outpatient departments, hospital wards, private and NHS community clinic settings, dental surgeries and in private homes.

Despite many audits and parental feedback surveys carried out by our members confirming the positive impact of tongue-tie division, we do agree with the need for further randomised controlled trials of high methodological quality.

Many of our practitioners are now reluctant to use the term posterior tongue-tie; favouring terms such as ‘restrictive or non-restrictive frenulum’ but may use it to describe a frenulum that is visible but inserts behind the sub mandibular gland openings. The article states “the concept is generally thought to represent a tight – non-visible submucosal band of tissue at the very base of the ventral tongue that is palpated rather than seen”. Many tongue-tie practitioners would question this definition now in light of new work by Mills et al 2019 (1) which is not even referenced by the authors and most relevant to the discussion. This anatomical research has helped us understand the structure of the frenulum and goes as far as to say that the term posterior tongue-tie should not be used.

We do acknowledge that many babies are misdiagnosed with tongue-tie when in fact they have other fascial tensions that could be resolved with physical therapies and skilled feeding assessment and support. Taking a detailed birth and feeding history and using a validated tongue-tie assessment tool such as the Hazelbaker Assessment Tool for Lingual Frenulum Function (2) (3) will help identify whether tongue-tie division might be indicated. Not all breastfeeding support workers are trained to assess for tongue-tie so undoubtably there may be some referrals whereby tongue-tie is suspected but not actually present on full assessment.

The article states “posterior tongue tie is generally not recognised or treated currently by professionals within the NHS setting”. We have many NHS tongue-tie practitioners in our association who would disagree with this assumption. We would have expected the authors to have produced an audit of all NHS practitioners before generalising in this way. It is worth noting that all private practitioners will have been trained to divide all types of tongue-ties within the NHS setting before working in private practice.

Lip tie division is very rarely carried out in this country, and most of our members are of the opinion that lip tie does not affect feeding. Most are of the opinion that lip tie division should only be considered if orthodontics work is required in the older child. We are only aware of a couple of dentists who divide lip ties and ATP have issued a statement on lip tie (4) as we do not believe there is sufficient evidence for lip tie division to help breastfeeding at present.

The article states “usually for a fee of several hundreds of pounds”. This is a very general statement and whilst the authors may well be able to identify certain practitioners who do charge such large fees, many do not. Most private practitioners earn a modest wage which covers the procedure, the skilled assessment and feeding support. Many include ongoing support and advice as part of their charges and have been a great source of help to parents where breastfeeding and tongue-tie services have been more limited within the NHS, especially during the pandemic.

The article states “a quick online search uncovers scores of private practitioners willing to travel to assess and treat newborns for posterior tongue tie….” Practitioners will travel to provide a service, yes, but they are health professionals, working within their professional regulatory body’s code of practice and regulated by the CQC. There is no evidence that any private practitioner specifically mentions or markets themselves as dividing posterior tongue-ties. Most are of the opinion that it is either a tongue-tie or not and that will be determined by skilful assessment. Tongue-tie division will normally only be carried out with the fully informed consent of parents, having explored all other options.

Chair ( Luci Lishman IBCLC RGN RM) representing the committee of the Association of Tongue-tie Practitioners.

References

1. Mills, N., Keough, N., Geddes, D., Pransky, M., Mirjalili, S.A., (2019) Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy 2019 https://doi.org/10.1002/ca.23410
2. Amir, L.H., James,J.P.,Donath, S.M. (2006) Reliability of the Hazelbaker Assessment Tool For Lingual Frenulum Function. International Breastfeeding Journal 2006
3. Hazelbaker, A.K (2010) Tongue-tie: morphogenesis, impact, assessment and treatment. Aiden and Eva press.
4. Association of Tongue-tie Practitioner’s website ATP Statement on lip tie – 2014
https://www.tongue-tie.org.uk/atp-statement-on-lip-tie/

Competing interests: I work as a private Tongue-tie Practitioner

16 February 2021
L E L Lishman
Tongue-tie Practitioner RM RGN IBCLC
Chair of the Association of Tongue-tie Practitioners
Buckinghamshire