An Honest Discussion on the AAP’s Report on Tongue Tie and Breastfeeding

As a healthcare professional deeply involved in the field of breastfeeding and tongue tie, I believe it's crucial to have open, honest conversations about important reports that shape our practice. Recently, the American Academy of Pediatrics (AAP) released a clinical report on the identification and management of tongue tie, also known as ankyloglossia, and its impact on breastfeeding. While I appreciate many points they raise, there are also areas that warrant discussion, as well as some misunderstandings that need clarification.

Glaring Omissions

First off, the AAP considers Ankyloglossia, or tongue tie, to only affect breastfeeding. It also, very often, affects bottle feeding and solid feeding.

The other huge omission from this report is the mention of airway. Airway disorders, starting with inability to nose breath, often start in infancy and can be related to tongue tie. There is a definite gap in understanding of airway issues, which needs to be addressed, and isn’t in this document.

Positive Aspects of the Report

The AAP supports exclusive breastfeeding for about six months, with continued breastfeeding for two years or as long as desired by both mother and infant. This is a great starting point and something I agree with wholeheartedly. They also acknowledge the importance of a team approach to managing tongue tie, though they could have elaborated more on who should be part of that team.

Another point I agree with is that there is a lack of consensus in the treatment of tongue tie. Our field has a long way to go in terms of standardizing care. However, organizations like ICAP (International Consortium of Ankylofrenula Professionals) are making great strides in research and creating consensus statements that can help guide us towards a more unified approach.

Over Diagnosis and Under Diagnosis of Tongue Tie

Here’s something I do agree with: in some cases, tongue tie is overdiagnosed but I will argue, it is also underdiagnosed. That sounds contradictory, but it’s true. Some infants are being diagnosed and treated without the necessary care that they need, while others who genuinely need treatment are being missed. The AAP report focuses heavily on the overdiagnosis side, but that doesn’t negate the fact that many cases go unnoticed or untreated. It’s not an either-or situation. Overdiagnosis and underdiagnosis can happen simultaneously, and they’re not mutually exclusive.

The report provides a thorough discussion of the anatomy of the frenulum, and while some parts are beyond my scope as a lactation consultant, the AAP taking issue with terms like "posterior tie," I feel is nitpicking. We need to avoid getting hung up on terminology and focus on function and treatment plans that benefit the mother and baby.

A Problem with Old References

One of the things that is disappointing about the AAP report is the reliance on outdated references. Some of the studies they cite are over 15 years old, which feels like they’re pulling from the past when there is more up-to-date research available today. As someone who has been asked to use only references from the last five years for professional presentations, this is a bothersome issue for me.

Defining Tongue Tie and the Lack of Clear Guidance

The AAP defines symptomatic ankyloglossia as a restrictive frenulum causing difficulty with feeding that does not improve with lactation support. This is a reasonable definition, but they fail to explain what “lactation support” means. Does it involve comprehensive assessments? Are we talking about IBCLCs or other lactation professionals? The lack of clarity is a problem.

Their focus on weight gain as a major marker of breastfeeding success is concerning, as well. Not every breastfeeding problem is reflected in a baby's weight gain, and there are other signs that should be evaluated. Nipple pain, for instance, is too often dismissed, but for anyone who has experienced breastfeeding pain caused by tongue tie, this dismissal is insulting.

Disrespect for IBCLCs

The AAP does recognize the importance of multidisciplinary care, yet they don’t specifically mention IBCLCs (International Board Certified Lactation Consultants). Instead, they use general terms like “lactation support” and “specialists.” This omission is troubling, given the rigorous training and certification that IBCLCs go through.

An IBCLC is a healthcare professional who specializes in the clinical management of breastfeeding. Our certification requires years of education, hands-on training, and recertification every five years. The AAP should be highlighting IBCLCs by name because we play a critical role in managing breastfeeding challenges, including those related to tongue tie.

Dismissing Bodywork and Non-Surgical Interventions

One of the most concerning parts of the AAP report is their dismissal of non-surgical therapies, such as craniosacral therapy, as "non-evidence-based." This is not only insulting but also shortsighted. Many non-invasive treatments can be valuable tools in managing tongue tie and avoiding unnecessary surgeries. These treatments, in many cases, optimize results. By focusing solely on surgical interventions and billable providers, they miss the opportunity to advocate for comprehensive care.

The Role of Social Media and Parents' Intuition

The AAP also mentions that pediatricians should be "aware" of parents who arrive with a diagnosis based on social media information. This feels dismissive of parents' concerns and instincts. Parents know their babies best, and they often seek information from reputable sources online. Rather than discouraging these parents, pediatricians should honor their instincts and work with them to find solutions that align with their goals.

The Gold Standard: Comprehensive, Team-Based Care

One of the key takeaways from this discussion is that breastfeeding issues are complex and require a comprehensive evaluation. The current gold standard for me remains the ICAP position statement, which emphasizes the need for functional assessments, individualized treatment plans, and collaboration among multidisciplinary teams.

The AAP does mention in its report that a full breastfeeding assessment should be done before any treatment is offered. This is a critical point and one that should be more prominent in their recommendations.

Final Thoughts

While the AAP’s clinical report offers some valuable insights, it falls short in several critical areas, particularly when it comes to the inclusion of IBCLCs, the acknowledgment of non-surgical interventions, and the over reliance on outdated references. As professionals working in this field, it’s important for us to continue advocating for comprehensive care that puts the mother and baby at the center of the conversation.

At the end of the day, the goal should be to help families thrive in their breastfeeding journey, whether that involves a surgical release, bodywork, or ongoing lactation support. The conversation around tongue tie is far from over, and I encourage you to stay informed and engaged as we continue to learn and grow in this field.

References:

• Jennifer Thomas, Maya Bunik, Alison Holmes, Martha Ann Keels, Brenda Poindexter, Anna Meyer, Alison Gilliland, SECTION ON BREASTFEEDING, SECTION ON ORAL HEALTH, COUNCIL ON QUALITY IMPROVEMENT AND PATIENT SAFETY, COMMITTEE ON FETUS & NEWBORN, SECTION ON OTOLARYNGOLOGY-HEAD AND NECK SURGERY; Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report. Pediatrics August 2024; 154 (2): e2024067605. 10.1542/peds.2024-067605
• What is an IBCLC? Retrieved from https://iblce.org/about-iblce/
• Smart, S., Tseng, R., Kittrell, A., Merkel-Walsh, R., Chan, J., Jones, N., Altemara, J., and Hartwick, E. (2024). International Consortium of oral Ankylofrenula Professionals (ICAP): Position Statement on Ankylofrenula. https://icapprofessionals.com/