Frenotomy and human factors science
Last week, a woman in New South Wales took her baby in for a frenotomy.
Not long afterwards, in a heartbreaking Instagram post, she wrote that her child was being ventilated right there and then during transfer to a children’s hospital. A blood vessel had been cut during the frenotomy, the baby was rushed by ambulance to an Emergency Department for resuscitation, and they were now on their way to an intensive care unit. Like everyone who read it, my heart went out to that little one and his family.
My heart also went out to the practitioner who performed the frenotomy, because he will be, surely, managing his own great distress. A health professional’s life can be defined by an event like this.
Mistakes are inevitable in medical or dental practice. This is why the new ‘human factors science’ addresses health system problems in order to both minimise error, and prepare for it.1
The post was forwarded to me by health professionals who had already been worrying a lot about the frenotomy industry. They’d been worrying about the oral aversion that they were regularly seeing in babies afterwards. They’d been worrying because of reports of infection and haemorrhage, and because of new work about the risk of front of tongue numbness due to lingual nerve damage. They’d been worrying because my team published a study showing a 420% increase in Medicare-rebated frenotomies in 0-4 year-olds between 2006-2016, mirroring overseas studies – and ours couldn’t track frenotomies by dentists, who may be performing the majority.2-4 They’d been worrying because this pattern, as the epidemiologists tell us, is characteristic of gross overtreatment. And they’d been worrying because when there is an exponential increase in the number of times a surgical procedure is performed, the risk of mishap rises dramatically.
Though there is the occasional classic tongue-tie that requires a scissors frenotomy, many of our babies are referred for oral surgery, including for expensive and painful laser oral surgery under the upper lip and tongue, for common breastfeeding problems and related unsettled behaviour. This surgery is justified by outdated biomechanical models of infant suck, or by methodologically weak (that is, biased) research which providers claim as ‘proof’ of the benefits.5 Australia’s most well-known breastfeeding education organisations continue to showcase studies or audits which are full of methodological flaws (that is, bias), as proof to health professionals of the benefits of frenotomy in the absence of classic tongue-tie.
The international frenotomy industry is lucrative, and powerful, and exercises control over dissenting practitioners’ income through insidious social media lists of tongue-tie friendly or tongue-tie competent professionals, alongside condemnation of those incompetent, breastfeeding-ignorant professionals who ‘miss’ the tongue and upper lip-tie. Because of the lack of control that can be exercised across international borders, someone like myself who has spoken out about the anatomically inaccurate and clinically unhelpful diagnosis of ‘posterior tongue-tie’ or the anatomically inaccurate belief that ‘behind every classic tongue-tie there is a posterior tongue-tie’ or the pathologizing of normal labia frenula as ‘upper lip-ties’ can be defamed by overseas personalities who have huge followings, without consequence.6-8
Recently, an organisation I’ve belonged to for many years, Lactation Consultants of Australia and New Zealand, agreed to circulate a paid advertisement of our charity's Masterclasses, which teach a new approach to breastfeeding support that does not require oral surgery for babies (unless there is a classic tongue-tie) - and then two days later sent an email of retraction to all members, instructing them to delete it, falsely claiming our Masterclasses violated their by-laws. When highly respected academic and leader Professor Laurence Walsh AO, who first taught Australian dentists to use laser technologies, raised concerns about tongue-tie and fringe science on SBS’s ‘The Feed’, the practice manager and husband of a dentist who appeared on that same program wrote on a tongue-tie professionals’ Facebook page that ‘perhaps in his advancing years [Professor Walsh] is losing the plot.’
Such outrageously disrespectful behaviour towards dissenting colleagues remains widespread amongst breastfeeding support professionals who refer regularly for frenotomies, and amongst those who identify as tongue-tie professionals. The income and status of those who specialise in diagnosing infant oral restrictions or providing infant frenotomy depends on persuading the public that health professionals who question surgical intervention cannot be trusted.
Parents dealing with the distress of breastfeeding problems and related unsettled infant behaviour typically do not need to take their babies to dentists or others who perform frenotomy. But sadly, they often need help beyond what is on offer from our breastfeeding support professionals. The research demonstrates that current approaches to latch and positioning are often ineffective,9-11 and may even cause unsettled infant behaviour or nipple damage.12 No-one is to blame for this - clinical breastfeeding support remains a research frontier, rarely prioritised, for historical reasons, by funding bodies.
But it did seem to me when I first began to publish about the inappropriateness of oral surgery for breastfeeding babies in the absence of classic tongue-tie, that I also had a moral responsibility to do my very best to bring to breastfeeding women effective therapeutic alternatives. Now, our Neuroprotective Developmental Care offers a gestalt approach to breastfeeding built on a new biomechanical model of infant suck and swallow derived from ultrasound studies.13,14 Day by day, in my clinic over many years now, I have watched breastfeeding relationships transform with careful fit and hold work based on the gestalt biomechanical model and a neuroprotective developmental care approach to complex, breastfeeding-related problems. Without surgery. Without pharmaceuticals. Without risk.
If we want to minimise the chance of human factor error causing harm to our breastfeeding babies then we, as breastfeeding support professionals and advocates, need to get serious about understanding how to interpret evidence and identify bias. We need to treat dissenting colleagues with respect and listen to their point of view – we need to invite them in, rather than attack them or close ranks and exclude them! We need funding bodies to invest in innovation and high calibre research. This is how we will minimise unnecessary procedures and reduce human factor error.
Many who care very deeply about the clinical support of breastfeeding women are hoping that now, finally, our regulators will step in, as has begun to occur in the United Kingdom.
Is anyone with the power to regulate the Australian frenotomy industry listening?
GP-Lactation Consultant and Researcher; Medical Director of The Possums Clinic, Possums Education and Research Centre, Greenslopes, Brisbane www.possumsonline.com
Adjunct Associate Professor, Maternity Newborn and Families Research Centre MHIQ Griffith University; Senior Lecturer, Discipline of General Practice, The University of Queensland
1. Russ AL, Fairbanks RJ, Karsh B-T, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Quality and Safety. 2013;22(802-808).
2. Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018:88-89.
3. Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and lingual frenotomy: national trends in inpatient diagnosis and management in the United States, 1997-2012. Otolaryngology Head and Neck Surgery. 2017;156(4):735-740.
4. Joseph KS, Kinniburg B, Metcalfe A, Raza N, Sabr Y, Lisonkova S. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open. 2016;4:e33-e40.
5. Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie. Journal of Human Lactation. 2017;33(3):519–523.
6. Douglas PS, Cameron A, Cichero J, Geddes DT, Hill PS, Kapoor V, et al. Australian Collaboration for Infant Oral Research (ACIOR) Position Statement 1: Upper lip-tie, buccal ties, and the role of frenotomy in infants. Australasian Dental Practice. 2018;Jan/Feb 144-146.
7. Mills N, Pranksky S, Geddes DT, Mirjalili SA. What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clinical Anatomy. 2019:doi:10.1002/ca.23343.
8. Douglas PS. Re-thinking 'posterior' tongue-tie. Breastfeeding Medicine. 2013;8(6):1-4.
9. Schafer R, Watson Genna C. Physiologic breastfeeding: a contemporary approach to breastfeeding initiation. Journal of Midwifery and Women's Health. 2015;60:546-553.
10. Woods N, K, Woods NF, Blackburn ST, Sanders EA. Interventions that enhance breastfeeding initiation, duration and exclusivity: a systematic review. MCN. 2016;41(5):299-307.
11. Svensson KE, Velandia M, Matthiesen A-ST, Welles-Nystrom BL, Widstrom A-ME. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial. International Breastfeeding Journal. 2013;8:1.
12. Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth. 2016;29:336-344.
13. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
14. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.