Strengthening the evidence base on frenulotomy
Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie. Edmond et al (2014)
Dear Editor, I read this report on frenotomy to support breastfeeding with great interest as currently there is limited evidence to support this procedure. The outcomes contrast considerably with my own experience and audit data, particularly with regard to persistence of breastfeeding for more than 5 days with painful breast and objective improvement in breastfeeding at 5 days. Of course, it is not uncommon for mothers and babies to attend for frenotomy after 5 days as time is needed to learn the art and skill of breastfeeding before intervention, but that was not the scope of this report. That mothers report improved self-efficacy after frenotomy certainly fits with my experience and data, but I find that most continue to breastfeed as their babies can latch, and both enjoy breastfeeding post -frenotomy. I have run frenulotomy clinics for the north west region of England for six years, using validated assessment tools for frenulotomy , latch, self- efficacy and pain. The women's experience of feeding is assessed pre- operatively and immediately post-frenulotomy, and then by telephone at 24- 48 hours and again at 3 months. Of 2048 babies that were in need of frenuotomy (November 2008 to January 2014), 62.7% of had 100% tongue-tie (to the tip of the tongue), 12.2% had 75% tongue-tie, and 15.7% had a posterior tongue-tie. All were referred for assessment and division by a person skilled in infant feeding and following support with positioning and attachment to improve breastfeeding. If the baby was formula milk-fed by bottle, the referring practitioner had provided support with the technique. Assessment carried out by two International Board Certified Lactation Consultants indicated that the babies referred with notable feeding challenges had limitations when extending, lifting and lateralising their tongues. Following frenotomy, 96% of mothers reported an immediate difference with feeding. For example, breastfeeding mothers reported reduction in pain, improved latch was noted, and later improved contentment and in some cases weight gain. Bottle-feeding mothers suggested improvements such as baby not chomping on the teat, no spurting of milk from the sides of the baby's mouth, and more controlled and faster feeding. At 48 hours, 71% of mothers who responded continued to experience improved feeding, 29% of the sample either did not answer the phone, or were already managing problems such as fungal infections, sore nipples or low milk supply that would take time to resolve. At 3 months the sample size was poor: only 21% of mothers answered the call. Yet 43% of this group were continuing with exclusive breastfeeding and suggested that without frenulotomy they would not have achieved this. A study to provide stronger evidence of these outcomes is being submitted for funding, and a comparison of results will be interesting. The reasons for differences in outcomes will be important in enhancing frenulotomy and breast-feeding support services.
Dr Val Finigan MBE Consultant Midwife infant feeding Pennine Acute NHS Hospitals Trust Rochdale Road Oldham OL1 2JH
Conflict of Interest: