What drives overdiagnosis and overtreatment of restricted oral connective tissues in breastfeeding babies?

Referrals for bodywork therapy and frenotomy to treat diagnoses of restricted oral connective tissue are now very common if you have breastfeeding problems

Around the English-speaking world there are currently dozens of breastfeeding conferences and workshops and hundreds of publications in which bodyworkers, lactation consultants, dentists, Ear Nose and Throat surgeons, speech pathologists and others discuss what they diagnose as abnormal infant anatomy, abnormally tight connective tissue and fascias, muscle tightnesses, and cranial nerve dysfunctions. These providers promote the need for expensive and time-consuming bodywork exercises and frenotomy. There is a strong industry-led (or commercial) component to this trend.

Such highly pathologised approaches are based upon many inaccuracies, which thousands of lactation consultants and other health professionals around the world have come to believe are factual, including concerning the biomechanics of infant suck. Yet these ways of thinking about why a baby has breastfeeding problems haven't been shown to actually help women and their breastfeeding babies any more than the passage of time (at least, not in methodologically strong research).

A 2024 study shows that the rate of frenotomies for upper lip-ties have increased by 3500% and performance of maxillary frenotomy for the lip-tie increased by 390% between 2009 and 2023. The average age of these babies diagnosed with lip-tie and treated with frenotomy was about 12 months of age.

Worse, parents are frightened into using these approaches because providers and lactation consultants warn that their baby will suffer a range of developmental effects if they don't

Even the latest position statement and practice guidelines by the International Consortium of Ankylofrenula Professionals (ICAP), published in a Complementary and Alternative Medicine journal which at this time appears to lack an impact factor), acknowledge that

1. There is no agreement about how to define tongue-tie

2. There is no evidence to support the diagnosis of buccal ties

3. There is no evidence to support the diagnosis of lip ties

4. There is no evidence to support the use of wound-stretching exercises or bodywork exercises in the care of breastfeeding babies.

Nevertheless the ICAP guidelines build a business case for multi-disciplinary care of breastfeeding women and their babies, to deliver exercises and bodywork therapy, and to prepare for and deliver frenotomy and frenotomy after-care with exercises and bodywork therapy. The ICAP guidelines feature prominently in social media forums related to breastfeeding.

The industry of ankylofrenula professionals, which includes many breastfeeding support professionals, has its own internal logics and defences

As soon as it's suggested your baby has fascial or oral connective tissue restrictions, it's helpful to be aware that you have set foot inside an industry which, like many industries, has its own internal logics, professional organisations, clinical guidelines, and intellectual defences. You can find out about some of the beliefs which form part of this internal logic here and here.

The international frenotomy and infant bodywork industries are lucrative, and powerful. For many years they have exercised control over dissenting practitioners’ income through social media lists of "tongue-tie friendly" or "tongue-tie competent" or "tongue-tie informed" professionals, alongside condemnation of breastfeeding-ignorant professionals who "miss" the tongue or upper lip-tie. The income and status of those who specialise in identifying infant oral restrictions or providing infant frenotomy depends on persuading the public that health professionals who question surgical intervention cannot be trusted.

You can find out how in the past few years the international organisation which exercises a monopoly on attributing continuing education points (known as CERPs) to International Board Certified Lactation Consultants has "cancelled" dissenting research-based practitioner-educators here.

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 understand how to interpret evidence and identify bias and methodological weakness. 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 concerning clinical breastfeeding support. This is how we will reduce human factor error, and minimise unnecessary surgery in our baby’s sensitive little mouths.

Market forces drive overdiagnosis and overservicing

There is nothing bad and lots to celebrate about setting up a small business to support families - small business is, as things stand currently in many countries, a vital part of our healthcare system. In many countries with advanced economies, the care of families with breastfeeding babies is left to the private sector operating in the community. (This is the case, for instance, in my home country of Australia, where primary health care and general practice are provided through a small business model.)

However, although every clinician intends the absolute best for you and your baby, the ankylofrenula industry is driven in the big picture by profit motives, which are now permeating every part of healthcare including in government-funded settings. Health professionals on the ground are often unaware of this. Unfortunately, a groupthink dynamic is often at work, although again, most health professionals aren't necessarily aware of it.

• Wellness and health movements are profit driven through both social media and private education businesses, and become a dominant source of education for health professionals within government funded services as well, driving overdiagnosis and overtreatment.

• Private breastfeeding and lactation educators and organisations offer conferences and presentations which will be popular and therefore financially successful whilst avoiding the 'troublemakers' - that is, avoiding genuinely critical debate and analysis of the research.

The peak organisation which certifies International Board Certified Lactation Consultants actively 'cancels' or suppresses certain kinds of evidence-based breastfeeding and lactation research and education

Most significantly, the peak international organisation for lactation consultants which was founded in 1984 now exerts a global monopoly over the world's 37,000 International Board Certified Lactation Consultants, controlling what kind of breastfeeding and lactation education these providers can access for their vital continuing professional development points.

For a number of years now, IBLCE has banned a signficant and growing number of international-leading researchers and clinicians from providing education for IBLCE's CPD points. You can find out more here.

You can see that the same forces which drive overdiagnosis of restricted oral connective tissues in breastfeeding babies - and then the subsequent overtreatment - are, in the big picture, the same market forces which are currently threatening the future and the wellbeing of the human on this small blue planet. It's all to do with business, profits, and how this shapes the kind of research and education that is available to your breastfeeding support professional.

Selected references

Ellehauge E, Schmidt Jensen J, Gronhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.

Jin RR, Sutcliffe A, Vento M. What does the world think of ankyloglossia? Acta Paediatrica. 2018;107(10):1733-1738.

Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018;208(2):88-89.

Lisonek M, Shiliang L, Dzakpasu S, Moore AM, Joseph KS. Changes in the incidence and surgical treatment of ankyloglossia in Canada. Paedaitrics and Child Health. 2017;22(7):382-386.

Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020:https://doi.org/10.1177%1172F0194599820925415.