The New York Times published an interesting story about a year ago. More recently, a blog post was published that came up on the news feed I follow. The headline The Tongue Tie Conundrum, drew me in and led me to the Times story Is Tongue-Tie Surgery Necessary. With a title like Tongue Tie Conundrum, perhaps the draw is irresistible? Breastfeeding is an issue that has gained ground in recent years. Every new parent is confronted with it, but it is really a mother's decision. It has demonstrable health implications for mother and child, and impacts upon the mother in ways no father will ever truly comprehend.
It makes the news in the employment world from the aspects of leave time, reasonable accommodation, and more. Part of the newsworthiness is likely in prevalence. That is, if only a few people were striving to do it, there would likely be less discussion of it. The prevalence is notable. The CDC reported in 2013 that "the percent of babies breastfeeding at six months increased from 35 percent in 2000 to 49 percent in 2010." The CDC Director noted that was "great news for the health of our nation."
Breastfeeding is a natural process that way too many people become concerned about in terms of public observation. In truth, people and our precursors have been breastfeeding for about 6 million years. It is a time-tested paradigm, and people that do not want to see it might do well to simply avert their eyes. Certainly affording someone a safe, clean environment for the activity has merit. The topic is sufficiently high-profile that a bill (SB 196) was introduced last year to require "lactation space" in each Florida courthouse by 2022. The sponsor explained the law would improve quality of life - in an interview with The Florida Bar News. The challenges of child care impact professional responsibilities. That is a topic worthy of more attention also. The bill failed to pass, but its introduction illustrates the societal focus on the topic.
Back to the New York Times and the "tongue-tie." This is a congenital physical condition that has been identified by the experts. It is not a new diagnosis and the prevalence is not seemingly increasing. It is essentially a " short or tight band of tissue that connects the underside of the tongue to the floor of the mouth." There are those who are consulted "when a baby has difficulty breastfeeding." This is often a physician, but may also be a "lactation consultant," or a dentist. When consulting regarding challenges with breastfeeding, they "will often look for evidence of tongue-tie."
There is a thought process of some prevalence that this condition causes challenges, and that "a quick surgical procedure to release the tie, can make a big difference." The procedure, and its prevalence, are not universally accepted, however. The Times notes that some are doubtful and conclude that "tongue-tie rarely affects feeding." Thus, patients (or their parents) are faced with a medical challenge. They are faced with some championing surgery, and others questioning efficacy. And, they find themselves in a medical situation too lean on science and too prone to consensus. Who should the patient listen to? When should a second opinion be considered? What is the right decision for this patient? What are the odds of success?
Not to get too far off-topic, but that dilemma has played out repeatedly in the totally unrelated arena of workers' compensation over the years. Sarcasm, I know. But this is fodder for those who enjoy contacting me about posts and question "What does this have to do with workers' compensation?" Comedian Christopher Titus is known for saying "just because you don't get it does not mean it isn't funny." I think of that every time the critics ask "What does this have to do with workers' comp?" Just because you don't get it does not mean it isn't relevant.
However, some will remember the controversy regarding spinal surgery for back pain, a persistent workers' compensation issue and diagnosis. After literally hundreds of thousands of patients have undergone surgery, studies question the efficacy. Despite the questions, the prevalence of surgery continues to increase. In that arena, one study concluded that "2 types of spinal fusion surgery were no more effective than supervised exercise or physical therapy." Read that last sentence again and think about whether you would prefer some therapy or a significant surgery with its potential for complications, expense, and other risks. Are those surgeries being performed because the science supports their efficacy? Are those patients being made aware of the potential and probabilities? Is there framing bias, confirmation bias, anchoring bias, or other mindset unconsciously impacting our decisions?
Thus, the breastfeeding challenge and surgery recommendations continue. The two articles support that the surgical intervention remains controversial. Despite that controversy and dissent the prevalence of the surgery is increasing dramatically. This does not appear to be related to some increase in the number of babies with the condition. Possibly, those with it are more prone to diagnosis due to the increased interest in breastfeeding?
But, in a striking similarity with the back surgery example the Times notes a "a new study suggests that the medical community ought to think more critically" about diagnosis and surgery. This study concluded that "nearly 63 percent of the infants did not need the surgery," despite having been referred for a surgical consultation. That is almost "two-thirds" to you and me, not just a majority. Those children were instead aided by "strategies to help improve" other issues rather than surgical intervention. That is reminiscent of the spinal surgery conclusions of "ineffective and unnecessarily expensive."
Notably, "everyone has a small fold of tissue beneath the tongue called the lingual frenulum." The issue being addressed is whether some baby's frenulum is too tight. Similarly, a great many people have back pain, but can its cause be surgically improved? The frenulum challenge is in how much the tongue can be moved. Its impact may not be limited to breastfeeding; the article notes other challenges in which this condition is implicated may surface later in life. But, the immediate issue remains for parents - surgery or not. And, it seems the trend is surgery. One study found an 800% increase in the frenulum release procedures over a fifteen-year period. One physician claims this vastly understates the prevalence because it excludes those "done in outpatient settings."
One of the authors of that study was cautionary. He asks “are we critically thinking about treatment options? Are we looking for a quick fix?” That challenge is likely present in any decision regarding surgery or conservative care. In this instance, one complicating factor is the diagnosis is largely subjective. There is no objective standard for "what constitutes tongue tie." Thus, the decision maker (parent) is faced with a challenge, and the medical advice may be less than scientific. As a side note, it is interesting that some are getting a portion of their advice instead from lactation consultants." Who knew there was such a profession?
One mother interviewed by the Times elected to have the surgery performed. Her dentist charged "$900 out-of-pocket." Despite the intervention, the child "still had difficulty with both breast- and bottle-feeding," which was eventually solved after locating a particular type of bottle "that worked." Thus, after the surgical intervention, recovery, and expense, the challenge remained. The mother, however, expresses no regret about the intervention. but "only regret . . . it because it didn’t solve the problem.”
What remains is that tough question: "Are we looking for a quick fix?” Whether in this instance, the back fusion surgery, or a variety of other medical challenges, is medicine bringing us science or consensus? Is diagnosis being made upon some objective standard (what is the child's tongue range of motion) or are we in a mindset of "we must try something?" It seems possible, although the cited studies are not necessarily conclusive, that in fact, the science does not support surgical intervention. Despite that, in both tongue-tie and back fusion, surgeries appear to be occurring daily.
In a world in which we are bombarded with the rallying cry of following the science, are we being sufficiently critical in our thinking? Are we asking about the science? Or, are we following the scientists because we hope they cannot collectively (consensus) be wrong? Are we making good choices, scientific choices, when we decide how to approach our health and care? For my personal medical decisions, keep your consensus and "show me the science." (apologies to Rod Tidwell for stealing, and altering, his quote).
