Tongue tie and a freedom of information request

Here is a common scenario I see or hear about often. New parents say to me so many people have checked the latch and said it’s perfect, the midwife has checked for a tongue tie and there isn’t one, so why are my nipples still cracked and feeding is agony?

This might be a familiar exchange between yourself and the families you support? Or perhaps this is what happened for you as new parents? As an NHS midwife I find it incredibly frustrating. I qualified as a midwife in 2011 and have worked in a variety of settings, hospital and community based as well as within the infant feeding team, in the background of these different clinical settings is the on-going support and mentoring of students. Not once had I heard of students being taught to assess for a tongue tie, yet via social media I was hearing from midwives who deemed themselves able to do so. I wondered if I was living in a London bubble, so I decided to investigate a bit further, you could say I had a bee in my bonnet. Because I’m sure you will have heard, as I have, that this ‘assessment’ by the midwife may well be inaccurate. Which can delay referral to tongue tie services or families are left confused and lose faith in lactation support when a full intra oral assessment finds a visible frenulum with no restriction. I hear from countless families, frustrated and angered by how their breastfeeding journey has been made more challenging by the information given to them by a well meaning midwife.

So what I really wanted to know, was, has the student midwife training on tongue tie changed since I’d been a student? So I send a freedom of information (FOI) request to all of the universities in the UK that teach undergraduate midwifery Batchelor of Science degrees. I’ll be honest, I didn’t have a clue what I was doing and it was more curiosity than a properly planned investigation, the results I received reflect this. But I think you’ll agree, it makes for an interesting read.

I approached 40 universities – I received 26 responses within the allocated response time. 2 universities declined to answer my questions as I hadn’t worded the questions in the appropriate manner for a FOI, who knew it was so complex! From the 24 responses I received, 2 out of the 24 did not do any  specific teaching on tongue tie (they answered later questions despite this, hence the numbers sometimes not adding up), the others all did. I asked how many hours of teaching on tongue tie was given to students, 8 said it was too hard to calculate, as it was just a part of a breastfeeding lecture, 1 declined to answer this question, 3 did equal to or less than 60 minutes and 8 did between 2-3 hours (3 hours was the maximum).

My next question asked who performed the teaching? 16 responded to say a midwifery lecturer, some of who were breastfeeding initiative (BFI) trained. As I’m sure you’ll know BFI does not stipulate any thing on the subject of tongue tie training, assessment or access to services, so that does not mean their knowledge is anymore specialist in tongue tie than a standard midwife.  4 universities taught via a trained frenulotomist and 4 by a IBCLC or infant feeding team midwife. I then went on to ask, do they consider their students once qualified to be able to assess for tongue tie: 3 said yes, 1 declined to answer, 20 said no. Out of the 3 that said, yes their students were adequately trained to assess for a tongue tie, one taught for less than an hour on the subject, another said yes because they were BFI gold accredited. As I’ve mentioned previously BFI training or accreditation makes no reference to tongue tie education or provision of services for families, so this correlation bares no link to high quality tongue tie education. Finally, I asked, are students assessed and signed off as competent, on tongue tie assessment, as they would for other skills used such as positioning and attachment or assessing milk intact. All universities responded no to this question, one university added as their students are now qualifying as NIPE trained midwives, they are deemed trained in assessment. A NIPE check, is the Newborn Infant Physical Examination, offered to all newborns, performed by either a neonatologist or a trained midwife.

So this was the next avenue I explored, am I determined or stubborn?! So firstly I checked the Nursing and Midwifery Council’s student requirements around infant feeding. Absolutely no mention of tongue tie; hence why it is not a skill that requires signing off as achieved, in order to qualify. I then looked at what Public Health England expected around tongue tie from the NIPE check – the infant’s palate, tongue and gums are to be visualised. There is no mention of tongue tie and we know that tongue tie can’t be assessed visually. My final point to check was the MORA – the midwifery ongoing record of achievement, which is the students record of competencies, assessments and skills student midwives have to achieve over the course of their degree in order to qualify as a midwife (the vast majority of universities now use this document). Student midwives have to perform 100 newborn checks in order to qualify and in this document, one area they have to assess and comment on, is the mouth – tongue tie is provided as a prompt for them to comment on. Finally, I’ve found some mention of tongue tie, but not in the way I hoped for, student midwives are completing these checks, thinking they are visually able to assess and comment on tongue tie. When in fact this is not an NMC requirement therefore not a taught part of the midwifery degree, or NIPE course curriculum. This explains the confusion that many midwives experience, they’re thinking - well its mentioned in my assessment document required for me to qualify, therefore it’s an assumed part of their role, but actually they’ve never seen or heard of a proper intra-oral assessment or any of the commonly used assessment tools. So, my next step, to try and feed back to the creators of the MORA document, but I think I’ll leave that for another day.

I feel I should explain, I hope it doesn’t appear that I’m criticising my over stretched, hard working and caring colleagues. I feel we have found ourselves at this point, because the complexity of lactation and tongue tie are not full understood by midwives – as seen from my findings, for many of us, the training is absent or very little. Do I think midwives should be trained to assess for tongue tie? No I don’t, because we are the specialists at normality, when breastfeeding takes off without issues, our knowledge and skills are great at supporting these dyads. But when things are more complex, when we’re exhausted our skills at positioning and attachment, frequency and length of feeds, we need to be able to refer on, to specialists in the area, as we would with obstetric complications for example. As a profession we are exhausted and so incredibly time short, so if we added tongue tie assessment to our skill set, I fear we would jump to that. As it’s something to be ‘fixed’, however as we all know, unless we master our positioning and attachment first, in many cases the release of a restricted frenulum is going to make little or no difference to the issues the dyad is experiencing. We need as midwives to be supported in mastering our skills in normal lactation and cross our fingers that we have a skilled and accessible infant feeding service to refer on to if issues are identified.