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

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.

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 for frenotomy. There is a strong industry-led (or commercial) component to this trend.

Such highly pathologised approaches are based upon many inaccuracies, including about the biomechanics of infant suck. Yet these treatments for 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).

Parents might feel frightened into using these approaches because they've been warned 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, 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 traditional 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 have featured prominently in social media forums related to breastfeeding.

The industry of interventions for ankylofrenula has its own internal logics

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. Everyone still wants the absolute best for you and your baby - this is a much bigger health system problem. You can find out about some of the beliefs which form part of this internal logic here and here.

For many years, breastfeeding support professionals who believe in the power of frenotomy and traditional bodywork therapies to help mothers and babies 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. It's worth being aware of this, as you make your own decisions.

Market forces drive overdiagnosis and overservicing

There is nothing bad about, and lots to celebrate in, 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 mostly occurs in the private sector which operates out 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 by the same need to make a profit which permeates every part of healthcare including in government-funded settings. Health professionals on the ground are often unaware of this.

• 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 need to offer conferences and presentations which will be popular and therefore financially successful. This usually means avoiding the 'troublemakers' - that is, avoiding genuinely critical debate and analysis of the research.

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 (remembering that non-profits and charities operate as businesses too), profits, and how this shapes the kind of research and education that is available to your breastfeeding support professional.

What needs to change?

If we want to minimise unnecessary treatments for 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 minimise unnecessary treatments of and interventions for our little one's sensitive bodies and mouths.

Recommended resources

Traditional bodywork therapies have been fundamental to my own, my family's, and my patients' health and healing

Why there's a need for Complementary and Alternative Medicines and my own (medical) profession to learn from each other

How evolutionary bodywork helps repair breastfeeding problems

Extrapolating the benefits of traditional bodywork therapy back to breastfeeding babies isn't consistent with evolutionary and neurodevelopmental science nor with breastfeeding as a global health priority

What does the research tell us about traditional bodywork for diagnoses of restricted oral connective tissues in babies with breastfeeding problems?

Is infant frenotomy for breastfeeding problems an evidence-based solution?

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.