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I refer to the recent article entitled “The value of frenotomy for ankyloglossia from a parental perspective” by S Illing, et al published in the New Zealand Medical Journal (16 August 2019, Vol 132 No 1500).1 The authors report primarily on the parental perspective after frenotomy at their practice, but include several other conclusions that are not justified based on the study design. I am writing to express my concern that this was published by the Journal.

This study as published has several methodological flaws. The authors did not include a control group and it is therefore inappropriate to conclude that the frenotomy procedure resulted in any improvement in breastfeeding. The authors state it would have been too difficult to include a control group. I disagree, as many parents are likely to accept an alternative approach in order to avoid an invasive procedure. In addition, most of the reasons listed for attending for assessment (Table 3) are common breastfeeding problems which can usually be resolved with input from a lactation consultant (LC). Were alternative approaches to frenotomy discussed as a part of informed consent to participate in this study, which would certainly be required ethically?

The paper does not detail if any breastfeeding support was given when infants were seen by the LC. It is good practice to offer these parents breastfeeding support, rather than an immediate surgical procedure, especially as more than half of referrals did not come from an LC. If breastfeeding support was given, what did this involve—how many appointments and over what time period? Did they observe and assess every baby breastfeeding before a procedure was offered? Furthermore, the authors do not report how many parents attended their clinic for breastfeeding support and were not offered the frenotomy procedure, and if any such clients exist, what were their outcomes.

The paper mentions that a statistician and a paediatrician were involved in the study through designing the data collection forms, but it appears they are not listed as authors or identified in the manuscript. I note that their ‘tongue tie questionnaire’ (Appendix A) has a section documenting lip frenulum examination. The study does not contain information about what was found on the lip examination. It is normal to find a lip frenulum in an infant2 and there is insufficient evidence to support the surgical release of the labial frenum in infants to assist with breastfeeding difficulties.3 Their lip frenulum assessment tool appears to be very subjective, and an unnecessary examination given the lack of evidence to intervene.

The first line of the conclusion states that “Frenotomy for infants with ankyloglossia and related feeding issues appears to be a safe and effective practice”. This can in no way be concluded from the study design. This is a consumer satisfaction survey at best that can report simply on whether parents who paid for a frenotomy procedure were glad they had done so. The outcome that “98% of parents reported that if they were in similar circumstances again would choose a frenotomy” does not equate to the procedure being a success, particularly as the intervention has no comparator in this study. These are parents who are desperately seeking help, are paying money, and have often travelled a long way. The self-reported reduction in breast pain is very subjective and subject to bias and memory recall. An objective measurement of feeding time should have been used had the authors wished to report on this outcome. Self-reported feeding time typically reduces as the baby gets older, but the age of the baby in relation to feeding time wasn’t reported, and neither was length of time post-procedure. Even if the design was appropriate to report this outcome, the authors need to report whether this finding was statistically significant.

Finally, the authors declared no competing interests are listed but receive financial benefit from patients seeking frenotomy at their practice. This is clearly a conflict of interest which of course doesn’t preclude research in this area, but should be stated as such.

In summary, I am surprised that the Journal considered this manuscript appropriate for publication and am concerned that the conclusions, reported widely in the media since, are misleading. The above multiple serious flaws to the study as published undermine the validity of all but very superficial conclusions around customer satisfaction.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

- - Rona Carroll, General Practitioner, Mauri Ora Student Health, Victoria University, Wellington;- Whitney Davis, General Practitioner, Tauranga; Katie Fourie, General Practitioner and Lactation Consultant, Victoria Clinic, Hamilton; Nadya York,

Acknowledgements

Correspondence

Dr Rona Carroll, General Practitioner, Mauri Ora Student Health, Victoria University, Wellington.

Correspondence Email

rona.m.carroll@gmail.com

Competing Interests

Nil.

  1. Illing S, et al. The value of frenotomy for ankyloglossia from a parental perspective. N Z Med J 2019; 132(1500):70–81.
  2. Santa Maria C, Aby J, Truong MT, Thakur Y, Rea S, Messner A. The superior labial frenulum in newborns: what is normal? Global pediatric health. 2017 Jul 10; 4:2333794X17718896.
  3. Association of tongue tie practitioners statement on lip tie available at www.tongue-tie.org.uk/lip-tie.html accessed 20 Aug 2019.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

I refer to the recent article entitled “The value of frenotomy for ankyloglossia from a parental perspective” by S Illing, et al published in the New Zealand Medical Journal (16 August 2019, Vol 132 No 1500).1 The authors report primarily on the parental perspective after frenotomy at their practice, but include several other conclusions that are not justified based on the study design. I am writing to express my concern that this was published by the Journal.

This study as published has several methodological flaws. The authors did not include a control group and it is therefore inappropriate to conclude that the frenotomy procedure resulted in any improvement in breastfeeding. The authors state it would have been too difficult to include a control group. I disagree, as many parents are likely to accept an alternative approach in order to avoid an invasive procedure. In addition, most of the reasons listed for attending for assessment (Table 3) are common breastfeeding problems which can usually be resolved with input from a lactation consultant (LC). Were alternative approaches to frenotomy discussed as a part of informed consent to participate in this study, which would certainly be required ethically?

The paper does not detail if any breastfeeding support was given when infants were seen by the LC. It is good practice to offer these parents breastfeeding support, rather than an immediate surgical procedure, especially as more than half of referrals did not come from an LC. If breastfeeding support was given, what did this involve—how many appointments and over what time period? Did they observe and assess every baby breastfeeding before a procedure was offered? Furthermore, the authors do not report how many parents attended their clinic for breastfeeding support and were not offered the frenotomy procedure, and if any such clients exist, what were their outcomes.

The paper mentions that a statistician and a paediatrician were involved in the study through designing the data collection forms, but it appears they are not listed as authors or identified in the manuscript. I note that their ‘tongue tie questionnaire’ (Appendix A) has a section documenting lip frenulum examination. The study does not contain information about what was found on the lip examination. It is normal to find a lip frenulum in an infant2 and there is insufficient evidence to support the surgical release of the labial frenum in infants to assist with breastfeeding difficulties.3 Their lip frenulum assessment tool appears to be very subjective, and an unnecessary examination given the lack of evidence to intervene.

The first line of the conclusion states that “Frenotomy for infants with ankyloglossia and related feeding issues appears to be a safe and effective practice”. This can in no way be concluded from the study design. This is a consumer satisfaction survey at best that can report simply on whether parents who paid for a frenotomy procedure were glad they had done so. The outcome that “98% of parents reported that if they were in similar circumstances again would choose a frenotomy” does not equate to the procedure being a success, particularly as the intervention has no comparator in this study. These are parents who are desperately seeking help, are paying money, and have often travelled a long way. The self-reported reduction in breast pain is very subjective and subject to bias and memory recall. An objective measurement of feeding time should have been used had the authors wished to report on this outcome. Self-reported feeding time typically reduces as the baby gets older, but the age of the baby in relation to feeding time wasn’t reported, and neither was length of time post-procedure. Even if the design was appropriate to report this outcome, the authors need to report whether this finding was statistically significant.

Finally, the authors declared no competing interests are listed but receive financial benefit from patients seeking frenotomy at their practice. This is clearly a conflict of interest which of course doesn’t preclude research in this area, but should be stated as such.

In summary, I am surprised that the Journal considered this manuscript appropriate for publication and am concerned that the conclusions, reported widely in the media since, are misleading. The above multiple serious flaws to the study as published undermine the validity of all but very superficial conclusions around customer satisfaction.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

- - Rona Carroll, General Practitioner, Mauri Ora Student Health, Victoria University, Wellington;- Whitney Davis, General Practitioner, Tauranga; Katie Fourie, General Practitioner and Lactation Consultant, Victoria Clinic, Hamilton; Nadya York,

Acknowledgements

Correspondence

Dr Rona Carroll, General Practitioner, Mauri Ora Student Health, Victoria University, Wellington.

Correspondence Email

rona.m.carroll@gmail.com

Competing Interests

Nil.

  1. Illing S, et al. The value of frenotomy for ankyloglossia from a parental perspective. N Z Med J 2019; 132(1500):70–81.
  2. Santa Maria C, Aby J, Truong MT, Thakur Y, Rea S, Messner A. The superior labial frenulum in newborns: what is normal? Global pediatric health. 2017 Jul 10; 4:2333794X17718896.
  3. Association of tongue tie practitioners statement on lip tie available at www.tongue-tie.org.uk/lip-tie.html accessed 20 Aug 2019.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

I refer to the recent article entitled “The value of frenotomy for ankyloglossia from a parental perspective” by S Illing, et al published in the New Zealand Medical Journal (16 August 2019, Vol 132 No 1500).1 The authors report primarily on the parental perspective after frenotomy at their practice, but include several other conclusions that are not justified based on the study design. I am writing to express my concern that this was published by the Journal.

This study as published has several methodological flaws. The authors did not include a control group and it is therefore inappropriate to conclude that the frenotomy procedure resulted in any improvement in breastfeeding. The authors state it would have been too difficult to include a control group. I disagree, as many parents are likely to accept an alternative approach in order to avoid an invasive procedure. In addition, most of the reasons listed for attending for assessment (Table 3) are common breastfeeding problems which can usually be resolved with input from a lactation consultant (LC). Were alternative approaches to frenotomy discussed as a part of informed consent to participate in this study, which would certainly be required ethically?

The paper does not detail if any breastfeeding support was given when infants were seen by the LC. It is good practice to offer these parents breastfeeding support, rather than an immediate surgical procedure, especially as more than half of referrals did not come from an LC. If breastfeeding support was given, what did this involve—how many appointments and over what time period? Did they observe and assess every baby breastfeeding before a procedure was offered? Furthermore, the authors do not report how many parents attended their clinic for breastfeeding support and were not offered the frenotomy procedure, and if any such clients exist, what were their outcomes.

The paper mentions that a statistician and a paediatrician were involved in the study through designing the data collection forms, but it appears they are not listed as authors or identified in the manuscript. I note that their ‘tongue tie questionnaire’ (Appendix A) has a section documenting lip frenulum examination. The study does not contain information about what was found on the lip examination. It is normal to find a lip frenulum in an infant2 and there is insufficient evidence to support the surgical release of the labial frenum in infants to assist with breastfeeding difficulties.3 Their lip frenulum assessment tool appears to be very subjective, and an unnecessary examination given the lack of evidence to intervene.

The first line of the conclusion states that “Frenotomy for infants with ankyloglossia and related feeding issues appears to be a safe and effective practice”. This can in no way be concluded from the study design. This is a consumer satisfaction survey at best that can report simply on whether parents who paid for a frenotomy procedure were glad they had done so. The outcome that “98% of parents reported that if they were in similar circumstances again would choose a frenotomy” does not equate to the procedure being a success, particularly as the intervention has no comparator in this study. These are parents who are desperately seeking help, are paying money, and have often travelled a long way. The self-reported reduction in breast pain is very subjective and subject to bias and memory recall. An objective measurement of feeding time should have been used had the authors wished to report on this outcome. Self-reported feeding time typically reduces as the baby gets older, but the age of the baby in relation to feeding time wasn’t reported, and neither was length of time post-procedure. Even if the design was appropriate to report this outcome, the authors need to report whether this finding was statistically significant.

Finally, the authors declared no competing interests are listed but receive financial benefit from patients seeking frenotomy at their practice. This is clearly a conflict of interest which of course doesn’t preclude research in this area, but should be stated as such.

In summary, I am surprised that the Journal considered this manuscript appropriate for publication and am concerned that the conclusions, reported widely in the media since, are misleading. The above multiple serious flaws to the study as published undermine the validity of all but very superficial conclusions around customer satisfaction.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

- - Rona Carroll, General Practitioner, Mauri Ora Student Health, Victoria University, Wellington;- Whitney Davis, General Practitioner, Tauranga; Katie Fourie, General Practitioner and Lactation Consultant, Victoria Clinic, Hamilton; Nadya York,

Acknowledgements

Correspondence

Dr Rona Carroll, General Practitioner, Mauri Ora Student Health, Victoria University, Wellington.

Correspondence Email

rona.m.carroll@gmail.com

Competing Interests

Nil.

  1. Illing S, et al. The value of frenotomy for ankyloglossia from a parental perspective. N Z Med J 2019; 132(1500):70–81.
  2. Santa Maria C, Aby J, Truong MT, Thakur Y, Rea S, Messner A. The superior labial frenulum in newborns: what is normal? Global pediatric health. 2017 Jul 10; 4:2333794X17718896.
  3. Association of tongue tie practitioners statement on lip tie available at www.tongue-tie.org.uk/lip-tie.html accessed 20 Aug 2019.

Contact diana@nzma.org.nz
for the PDF of this article

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