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• Response to the two letters regarding tongue-tie, from Dr Essex and Mr Mercer
  Alan Emond
  Published on: 22 March 2016
• The child has rights!
  Nigel S G Mercer
  Published on: 22 March 2016
• Most tongue tie is the medicalisation of childhood
  Charles Essex
  Published on: 22 March 2016

• Published on: 22 March 2016

  Response to the two letters regarding tongue-tie, from Dr Essex and Mr Mercer

  • Alan Emond

  Dr Essex and Mr Mercer highlight many of the reasons why we undertook the Bristol Tongue Tie trial. Ankloglossia is a spectrum condition, which overlaps with 'normal' variation in anatomy, and milder forms do not result in feeding impairment. There is very limited evidence of the need for frenotomy in mild-moderate degrees of tongue tie. However, it is also true that at the severe end of the spectrum infants can be limi...

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  Dr Essex and Mr Mercer highlight many of the reasons why we undertook the Bristol Tongue Tie trial. Ankloglossia is a spectrum condition, which overlaps with 'normal' variation in anatomy, and milder forms do not result in feeding impairment. There is very limited evidence of the need for frenotomy in mild-moderate degrees of tongue tie. However, it is also true that at the severe end of the spectrum infants can be limited in their ability to breastfeed efficiently because they are not able to latch effectively.

  We agree that it is easy to blame a visible tongue tie for breast feeding difficulties which may be due to other factors, and entirely support the view that good breastfeeding support is essential in helping mothers with feeding difficulties.

  The inequity in the use of frenotomy worldwide and within the UK is exactly why well conducted trials are needed, to clarify which babies should be offered frenotomy and when. The widespread use of social media, and campaigning by some pressure groups, has resulted in an increase in demand for the procedure. Good quality evidence from randomised trials is needed to inform evidence- based clinical practice and the rational commissioning of services.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  The child has rights!

  • Nigel S G Mercer, Cleft Surgeon

  Sirs

  The tongue remains with in the boundaries of the mandible during suckling and so it is difficult to see the anatomical or the physiological basis for how a frenulectomy works in reducing breast and nipple discomfort during feeding. This randomised trial does not seem to assess the potential, positive psychological impact of the mother being told their child has had a frenulectomy. That is the question that...

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  Sirs

  The tongue remains with in the boundaries of the mandible during suckling and so it is difficult to see the anatomical or the physiological basis for how a frenulectomy works in reducing breast and nipple discomfort during feeding. This randomised trial does not seem to assess the potential, positive psychological impact of the mother being told their child has had a frenulectomy. That is the question that must be answered before a procedure performed on the most sensitive organ in the body, with out anaesthesia is undertaken routinely.

  Tongue tie is not proven to impact upon speech and if a release is performed in a child with a small chin, with or without a cleft palate, it can cause airway obstruction. A significant tongue tie causes social embarrassment in later life but it has no other proven physical impact on the child and so more concrete evidence of benefit for the procedure being performed upon a neonate, with out anaesthesia, must be provided before the practice is offered routinely. Every surgical procedure has complications and surely there must be greater proof of benefit than relieving nipple pain in the mother? When else is a procedure inflicted on any patient, let alone a child, for the benefit of reducing discomfort in a third party? With out this additional proof, practitioners may well be performing unnecessary procedures on a defenceless infant.

  With out a "sham" group, the psychological impact on the mother cannot be excluded.

  Nigel Mercer

  MB ChB ChM FRCS FRCPCH

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Most tongue tie is the medicalisation of childhood

  • Charles Essex, Consultant Neurodevelopmental Paediatrician

  Lawson's editorial and Emond and colleagues' article exposes potentially bad medicine: lack of knowledge of normal and variations of normal; lack of knowledge of the natural history of a condition; a desire to do something - Ulysses syndrome (1); medicalising the child by giving the condition a name; and then ascribing any improvement to the intervention, forgetting that association does not mean causation.

  Th...

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  Lawson's editorial and Emond and colleagues' article exposes potentially bad medicine: lack of knowledge of normal and variations of normal; lack of knowledge of the natural history of a condition; a desire to do something - Ulysses syndrome (1); medicalising the child by giving the condition a name; and then ascribing any improvement to the intervention, forgetting that association does not mean causation.

  This writer did many years of community child health clinics seeing babies with a variety of problems that never went near a hospital: a W- shaped tongue [M-shaped from the baby's perspective] is a normal finding. To describe it as tongue tie and to intervene are medicalising normality in the majority of cases. As Illingworth says in The Normal Child (2) [which should be required reading for all health professionals involved with children] "The tongue is always short at birth but as the infant grows the tongue becomes longer and thinner. Many mothers [and health professionals - my insertion] ascribe their children's feeding difficulties and lateness in speaking to tongue tie".

  Unfortunately blaming tongue tie becomes self-perpetuating. The fact that parents want subsequent children to have a frenotomy after their first child has had one and doctors acquiesce to this or lactation experts believe it is the cause of breastfeeding difficulties does not represent proof nor does it justify performing the operation. Countries with initial and sustained high breastfeeding rates such as New Zealand, where this writer worked for several years, do not have high rates of frenotomy to ensure that breastfeeding is successful. Rather it is good breastfeeding support.

  Recently a tongue-tie service was set up in my local area. I can predict the outcome. In 12 months' time those who promoted and run the service will announce how many tongue tie operations they done, how parents are pleased and feel the baby is feeding better and how "successful" the service is. The specious conclusion will be that tongue tie was a significant problem for these babies which frenotomy cured. I consider this is 21st Century charlatanism.

  Signed

  Dr Charles Essex Consultant Neurodevelopmental Paediatrician Suite 115 41 Oxford Street Leamington Spa CV32 4RB

  References

  1. Essex C. Ulysses syndrome. BMJ 2005; 330: 1268.

  2. Illingworth RS. The Normal Child. Churchill Livingstone, Edinburgh 1983.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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