They created the surgical procedure with the best of intentions. They wanted to prevent serious problems and it seemed to them the best way to do it. Unfortunately they were wrong and a lot of unnecessary suffering was the result.
I’m talking about episiotomy, but I could be talking about painful newborn tongue-tie surgery.
How did good people get things so wrong?
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If you wouldn’t willingly undergo a painful episiotomy because it “might” be helpful, don’t force your baby to undergo painful tongue-tie surgery because it “might” improve breastfeeding.[/pullquote]
Episiotomy was created to prevent both short term and long term complications of childbirth. Episiotomy was created on the theory that a controlled tear made by a scissors would create enough room at the vaginal opening so that the baby’s head would not tear it further down to the anal sphincter (3rd degree tear). The theory made sense.
It was also designed to prevent serious long term complications of childbirth like uterine prolapse and urinary incontinence. That theory made sense, too.
Unfortunately, both theories turned out to be wrong. Not only did episiotomy fail to prevent uterine prolapse and urinary incontinence (which are cause by weakening of muscles far above the vaginal opening) but — in an ugly irony — cutting an episiotomy actually made 3rd and 4th degree tears MORE likely.
Once routine, episiotomy is now recognized as only appropriate in some very specific situations such as the use of forceps.
Tongue-tie surgery was also created with the best of intentions.
What is tongue-tie?
If you look carefully at the photo above, you will see that underneath the infant’s tongue there is a small vertical membrane that connects the tongue to the floor of the mouth. Tongue tie occurs when the membrane (the frenulum) is abnormally shortened and or thickened, restricting the movement of the tongue itself. Since the motion of the infant tongue is critical in breastfeeding, it’s easy to see how tongue-tie can cause problems breastfeeding.
Signs and symptoms of tongue-tie include:
- Difficulty lifting the tongue to the upper teeth or moving the tongue from side to side
- Trouble sticking out the tongue past the lower front teeth
- A tongue that appears notched or heart shaped when stuck out
The natural incidence of tongue-tie has been estimated as 1.7-4.8%.
There has been a recent dramatic surge in tongue-tie surgery. According to lactation consultant Nancy Mohrbacher:
What started as a problem for a small percentage of babies seems now to be an epidemic. Health-care providers report increasing numbers of breastfeeding mothers self-diagnosing tongue and lip ties in their babies, often based on online information, and asking for a tongue- or lip-tie revision …
The surgery can be very painful for babies, leading to a large open wound beneath the tongue as this photo shows:
Think about how painful biting your tongue it; now imagine a gaping wound like that. Some babies who have undergone tongue-tie surgery have developed oral aversion. Breastfeeding (and even bottle feeding) are associated with so much pain that the babies refuse to eat even after the wound has healed.
The worst part is that — like episiotomy — tongue-tie surgery doesn’t work as this 2017 paper in Breastfeeding Review explains.
A 2014 systematic review by Power and Murphy concluded that half of breastfeeding babies with tongue-tie will not have problems. If there were difficulties, mothers reported improvements after frenotomies or frenectomies. But the authors note that it is difficult to determine how much of this effect is placebo.
A 2015 systematic review by Francis, Krishnaswami and McPheeters concluded that a small body of low to insufficient quality evidence indicates that frenotomy is associated with mother-reported improvements in breastfeeding and nipple pain, noting that the studies are short-term and of inconsistent methodology.
Even worse, the surgery is now being recommended in the absence of classic tongue-tie for conditions known as “posterior tongue-tie” upper lip-tie. Supposedly, these ties cause reflux due to air swallowing. As physician/lactation consultant Pamela Douglas notes:
…[T]here is no reliable evidence that the diagnoses of posterior tongue-tie and upper lip-tie are meaningful or useful for breastfeeding pairs.
And:
…[T]he hypothesis that reflux is caused by excessive air swallowing in infants with poor latch due to posterior tongue-tie and upper lip-tie … lacks credible physiological mechanisms or supporting evidence… This article argues that our breastfeeding women and their babies deserve the most rigorous scientific methods available, and acknowledgment of the biases inherent in less rigorous research, if we are … to prevent unnecessary oral surgery.
Tongue-tie surgery — like episiotomy — is appropriate in certain specific situations such as classic anterior tie that prevents a baby from moving her tongue to her teeth (and may contribute to future speech impairment).
But tongue-tie surgery is big business and its practitioners promote it. The surgical fee for frenectomy/frenotomy is $850. I presume that $850 is what the doctor bills; what he or she is actually paid probably varies by insurance company. Those mothers who don’t have health insurance may be forced to pay the entire fee out of pocket.
Why has there been a dramatic increase in the diagnosis of tongue-tie and a dramatic increase in expensive surgery to correct it?
Dr. Bobby Ghaheri insists that Diagnosing Tongue-Tie In A Baby Is Not A Fad:
One of the most frequent things I hear is that primary care providers say something to the effect of “Oh, diagnosing tongue-tie is just a fad” or “This tongue-tie business is just something new that some people are doing”.
So if pediatricians and ENT specialists think most tongue-tie surgery is unnecessary, who’s making the diagnoses? Mothers and lactation consultants.
Is tongue-tie surgery the new episiotomy?
I’m afraid it it. It’s a painful procedure created with the best of intentions, useful in certain specific circumstances, but it has become widespread without solid evidence that it works.
So if you wouldn’t willingly undergo a painful episiotomy because it “might” be helpful, don’t force your baby to undergo painful tongue-tie surgery because it “might” improve breastfeeding.
