Does Postoperative Wound Massage Improve Outcome of Frenulotomy for Breastfeeding Difficulties in Infants?

Does Postoperative Wound Massage Improve Outcome of Frenulotomy for Breastfeeding Difficulties in Infants? Slothouber Galbreath et al, JHL, Volume 30, Number 4, page 501, November 2014

Dear Editor Re: Does Postoperative Wound Massage Improve Outcome of Frenulotomy for Breastfeeding Difficulties in Infants? Slothouber Galbreath et al, JHL, Volume 30, Number 4, page 501, November 2014.

The Association of Tongue-tie Practitioners is a UK organisation which was set up in 2012 to promote the awareness of tongue-tie as a feeding issue, provide educational opportunities for healthcare professionals and lactation supporters, provide support and opportunities to share best practice for those dividing tongue-ties and provide information for parents. We currently have 97 members. We read the abstract mentioned above with interest and would like to raise some issues which we have set out below.

The Abstract by Slobothouber Galbraith, Fisher and Patel (which we understand was presented at the ILCA Conference 2014 and then printed in the JHL) relates to a study which aimed to assess the compliance, tolerance and efficacy (prevention of recurrence) of disruptive wound management (DWM) following tongue-tie division.

To our knowledge, there are no published controlled trials on DVM. But wound massage and/or stretching following tongue-tie division is advocated by some practitioners including dentist Larry Kotlow (http://kiddsteeth.com/dental_topics.html#breastfeeding_health). But actively disrupting the “wound adhesions in situ” seems to be a step further.

The abstract refers to the methodology as a ‘single operator study’. Members of the Association of Tongue-tie Practitioners attended the 2013 Tongue-tie Symposium held at King’s College Hospital, Croydon where the authors of this abstract did a presentation on this study. It is our understanding that Katherine Fisher (one of the aforementioned authors) was the ‘single operator’ and that no-one else was directly involved in the assessment, treatment and follow up of the breastfeeding dyads. Ms Fisher is a committed believer in DWM and actively trains and firmly encourages all parents to perform it post division. (See Tongue-tie Guide at http://katherinefisher.co.uk/videos-and-downloads/.) Hence you would not expect the parents to admit to her or any researcher connected to her that they did not comply. An independent researcher is essential. Of the original 126 dyads, 47 did not reply, and a further 19 responses were “unsuitable”. We would be interested to know why only 60/126 (48%) of parents replied fully?

The results section of the abstract talks about ‘tolerance’. But tolerance is not assessable. Of the 60 “suitable” replies, two thirds (40/60) said that the DWM was tolerable, suggesting that the other third found it intolerable. This group is in addition to the non-responders who may also have found it intolerable. To ask parents to perform an intolerable procedure for no proven gain is ethically difficult and many tongue-tie dividers find impossible to support.

Efficacy is measured by the lack of recurrence and breastfeeding rate. Most tongue-tie dividers accept that there may be a small (<3%) recurrence rate for anterior tongue-ties, not all of whom are symptomatic. For there to be no recurrences in 60 is therefore to be expected and is not evidence for any increased efficacy.

The breastfeeding rate of 92% at 6 weeks is very good, but includes the third who found the DWM intolerable. We do not know if this is 100% breastfeeding, which would be spectacularly good, or just one feed a day. What happened to the ones who did not reply? The actual proven breastfeeding rate is 55/126 (43%), not 92%. A breastfeeding rate at 3 months for all 126 would have been much more useful.

Members of the Association of Tongue-tie Practitioners have received reports of mothers who have been trained to do DWM who were traumatised, whose babies’ tongue-ties have recurred and who then feel to blame for failing to perform the DWM correctly. This is unsatisfactory. The subject of Disruptive Wound Management is so divisive that it is critical that any study published is scientifically useful, so that we can assess if the procedure is one which we should teach our parents. This abstract confirms the views of those who do not think that the trauma of DWM has any use in anterior tongue-ties and has yet to be proven in posterior tongue-ties, whose recurrence rate is higher.

To allow equipoise in a randomised controlled trial of DWM against a control group, you need to be able to show that the intervention group (DWM) is no worse than the control group, has no side-effects which would deter participants and might have a better outcome. From this abstract it is not clear that this study is able to provide this evidence.

Yours faithfully

Suzanne Barber RM IBCLC and Sarah Oakley BA (Hons) RN RHV IBCLC
On behalf of the Committee of the Association of Tongue-tie Practitioners

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