I think Kathy missed a part of my post about FOLLOWING UP with proper research.  RESEARCH is something you do on many levels.  Qualitative research, properly designed, can be very good for exploring attitudes and practices and for exploring our theories.  Before and after studies can tell us that our ideas are PLAUSIBLE.  Yet still, in the end if we really want to establish causality we have to go the final step to clinical trials which, properly designed, tell us the PROBABILITY that the intervention in question is efficacious and then INTERVENTION trials to tell us that it is not only efficacious but EFFECTIVE.

Yes, there is research on tongue tie and we all know cases where it really appears to make a big difference.  Nevertheless I get women who come to my clinic all the time who do NOT get immediate relief or even WORSE. If you take the short term approach of seeing what happens immediately after and apply the same logic, you would conclude that the procedure was harmful.  On this list, I have read many people stating reasons for this such as needing suck swallow training or the wound closing back together or needing other body work on the infant. So, if you take a longer view, it could be that the procedure itself is not sufficient.  You need to couple it with additional interventions.  Yet, is it all the interventions?  Some of the interventions?  Or merely more time on the breast that makes a difference? 

To flip the example, this type of before after thinking is what makes many people decide that formula feeding is not risky.  They feed formula to a baby that hasn't been getting enough because of the widespread practices of generations of formula feeding that make it hard for women to put in place the actions that lead to establishing their milk supply.  The hungry baby stops crying. The hungry baby doesn't get sick.  The time between the action and the negative outcome occurs, months, years, or even decades later.  Yet the research on this is solid.

So, if we are to argue that we should really look at solid research that shows that the long term effects of formula feeding are negative, we should not then apply the same faulty logic when we are trying to build up our own evidence base.  Of course on a clinical basis you are going to try things that are plausible.  And certainly we do have a small research base on tongue tie.  But RESEARCHERS should be doing the next step to clarify when this important intervention is really beneficial and what additional measures make make the difference in its success.  We should be confident enough to put our interventions to the test to make sure that they really are working the way it appears they are.  This will not only improve our ability to refer to competant professionals who do this procedure because more will be convinced, but it will also improve our ability to use the appropriate additional measures to ensure that feeding improves. By eliminating those that do not need the procedure we will also prevent mothers from being disappointed about an outcome that doesn't happen and potentially redirect towards other interventions.

So, in going back to tongue tie -- and whether or not the intervention is harmful -- there are two examples to look at.  
One is jaundice.  There are plenty of studies on how hospitalization changes how parents perceive their infant and feeding their infant.  I have seen mothers with perfectly fine milk supplies that are so traumatized by the process of hospitalization that they give up breastfeeding.  The intervention may very well have been necessary, but the process of the hospitalization itself has a negative impact.  Hence, alternatives like the bili blankets are an improvement that may reduce this side effect.  By really truly thinking about the intervention, improvements can be make to remove or reduce negative side effects.

The other is test weighing - which is really not an intervention at all it is an assessment tool.  There has been zero research to show that it traumatizes mothers.  There has been a lot of observations (which I truly believe reflect the situation in those particular populations) that it can be stressful when used improperly.  And I truly believe that a lot of practitioners DO use it improperly by the repeated reports on Lactnet.  The only research shows that, when PROPERLY USED, it reassures mothers.  Yet, there is a firm widespread belief that it is harmful.  Without the research to show HOW to use it and WHEN to use it, it is unlikely to be used appropriately.  Thus reconfirming the beliefs among those who think it stresses out mothers, and perhaps leading to overuse or improper use among others who are convinced it is helpful.  

Now, for tongue tie. In Manhattan, this usually involves making an appointment.  I've only seen one baby have the procedure done in the hospital to date and I'm still on the fence about whether or not it was done well.  If the baby is very young it adds stress to the mother because she must make the appointment and go to someone's office and wait in that office right during the period when she is recovering from the delivery and really should be snuggling in with her infant.  In some cultures, the thought that a baby might have a "deformity" can be very stressful psychologically.  This procedure still does involve cutting tissue -- which can be very traumatic for parents to consider even though WE know that this is often a minor cut.  When it is a posterior tongue tie, it is not as minor.  Sometimes the procedure needs to be redone -- which again may have psychological effects on the parents.  Usually the posterior tongue ties take longer before feeding becomes effective -- which then leads some parents to question the procedure.  Can we really be so cavalier that we do not consider this and really delve deeper to ensure that we assist our clients to minimize these feelings?  

The reason why I am taking on this topic is because I have seen that some procedures that we develop become the "next big thing".  I love biological nursing, but I have seen people grab hold of this idea and apply it inappropriately when a mother needs different positioning.  And I have seen some practitioners label everything a posterior tongue tie and send mothers in for a procedure -- when it wasn't necessary.  And I've listened to these mothers after they went on to beautifully breastfeed as they recuperated from the thought that their baby had something wrong when it WASN'T the case.  I think we are in the beginning phases of really understanding the role of tongue tie.  We know its important.  We know its been neglected.  We know that there are many types.  But I think we, as a group, still would benefit from exploring the issue of how and when to use this procedure appropriately in far more depth.  And this requires BOTH experience AND evidence.

I keep thinking of a comment someone on Lactent said speculating about whether or not the impact of variations in the frenulum may not have been as important in societies where more biological nursing is practiced - -unlimited access to the breast, skin to skin contact, etc.

I do think it is important to not just go through assuming everything we do works without constantly reassessing what we are doing and how to improve it.  It is easy to get into a comfortable groove assuming we're great and not really challenging ourselves to improve.  And I think we should be applying the same standards to everything we do.  Interventions should not be a popularity contest.  Interventions should be evaluated by solid criteria whether or not they are popular, appear to have immediate impact, or may not appear to have any impact until long after the intervention.

Best, Susan Burger

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome