Hamming, Inge

Meijer, Jiska

Raghoebar, Gerry M

Slagter, Kirsten W

Vissink, Arjan

English

ARTS repository - University of Groningen

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. Advance online publication.https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 10-09-2023LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

Reply to the editor concerning:Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospective longitudinal cohort study

University of Groningen

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 20-11-2022LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

Proceedings - University of Groningen

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 04-06-2022LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

NARCIS 

Reply to the editor concerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospective longitudinal cohort study

Dissertations of the University of Groningen

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. Advance online publication.https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 01-11-2023LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 05-12-2023LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 07-06-2022LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

   University of GroningenReply to the editor concerningSlagter, Kirsten W; Raghoebar, Gerry M; Hamming, Inge; Meijer, Jiska; Vissink, ArjanPublished in:Clinical Oral InvestigationsDOI:10.1007/s00784-021-03974-wIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Reply to the editorconcerning: Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospectivelongitudinal cohort study. Clinical Oral Investigations, 25, 5115-5116. https://doi.org/10.1007/s00784-021-03974-wCopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 05-06-2022LETTER TO THE EDITORReply to the editor concerning: Effect of frenotomy on breastfeedingand reflux: results from the BRIEF prospective longitudinalcohort studyKirsten W. Slagter1 & Gerry M. Raghoebar1 & Inge Hamming2 & Jiska Meijer3 & Arjan Vissink1Received: 18 March 2021 /Accepted: 30 April 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021Dear Editor,We read the concerns of Paul and Heaton [1] on our assess-ment of the Efficacy of Frenotomy with regard toBreastfeeding and Reflux Improvement (BRIEF) in infantswith breastfeeding problems with great interest. The BRIEFstudy highlighted the importance of a systematic, sound, andexperienced clinical judgment to determine whether surgicaltreatment might be valid when a non-interventional profes-sional support does not suffice in patients with breastfeedingdifficulties [2]. We agree with Paul and Heaton [1] that clin-ical decision-making should be based on evaluation of theentire evidence base on the subject. Therefore, we advocatethat the decision to perform a frenotomy is taken only after amulti-disciplinary team has provided non-interventional sup-port first regarding breastfeeding difficulties, including a thor-ough oral and physical investigation, and the indication for afrenotomy is not only made on, e.g., the appearance of theanatomy of the tethered oral tissue (regardless of the gradingsystem used). By following the systematic work-up we per-formed in the BRIEF study [2], the risk of overtreatment orundertreatment can be reduced to the minimum as well as therisk of (severe) complications.One of the most clinical important findings of our studywas that the infants who presented with breastfeeding difficul-ties all had a combination of a tethered lip-tie and posteriortongue-tie [2]. This means that based only upon the anatomicappearance of oral tethered tissues, it is impossible to predictthe amount of breastfeeding problems. From a clinical point ofview, the surgical release of the tethered oral tissues resulted insignificant improvements of the breastfeeding problems andgastroesophageal reflux; the latter reflux is also related tobreastfeeding difficulties. The improvements resulting fromfrenectomy occurred early and lasted. Improvements weredemonstrated in both infants with classic anterior and posteri-or tongue-ties. Based on this observation, clinicians shouldmark a posterior tongue-tie as a potential etiology forbreastfeeding difficulties in case a tongue-tie is not a classicanterior tongue-tie.Gastroesophageal reflux is also a common phenomenon ininfants, but the differentiation between gastroesophageal re-flux and gastroesophageal reflux disease (GERD) can be dif-ficult [3]. Symptoms of reflux are non-specific, and there isincreasing evidence that the majority of symptoms may not beacid-related, but are associated with infant gastroesophagealreflux symptoms via aerophagia. Further investigation is war-ranted between the correlation of oral restrictions and refluxsymptoms via aerophagia and not GERD.Following the strict protocol of non-surgical support bya multidisciplinary team first before deciding to proceedwith a frenotomy, we concluded that the frenotomy of atongue-tie and/or lip-tie is a safe procedure with, in theBRIEF study, no reported post-operative complications,when a non-surgical approach was not effective and whenperformed by an experienced surgeon [2]. This means thatonly experienced surgeons should perform these proce-dures with deep knowledge of the oral anatomy. Afrenotomy should be performed as such that no damage iscaused to the surrounding tissues and structures. As wethoroughly described in the BRIEF study [2], it is impor-tant not to disturb the fascia of the underlying genioglossusmuscle in case of an anterior or posterior tongue-tie. We donot advocate deep submucosal incisions due to the risks of* Arjan Vissinka.vissink@umcg.nl1 Department of Oral and Maxillofacial Surgery, University ofGroningen and University Medical Center Groningen,Groningen, the Netherlands2 Imedi, Groningen, the Netherlands3 General Practitioners Research Institute, Groningen, the NetherlandsClinical Oral Investigationshttps://doi.org/10.1007/s00784-021-03974-wdamage or bleeding as brought up by Paul and Heaton [1]in their letter to the editor. According to our technique, themaxillary labial frenulum was released off the alveolarridge up to the mucogingival junction in case of superiorlip-tie. If a frenotomy is performed otherwise, there is amuch higher risk on complications and unfavorable out-comes as Paul and Heaton [1] pointed out.We agree there is a need for additional studies. Of note, theCochrane review of O’Shea et al. [4] and the study of Franciset al. [5] did not mention serious complications afterperforming a frenotomy. The observations in the case studiesregarding complications [6–9], as mentioned in the letter tothe editor by Paul and Heaton [1], have to be taken into mindby the surgeons who perform frenectomies, but are not repre-sentative for frenectomies performed by experienced sur-geons. In the case series cited, the treatment protocol applied,whether a complete oral and physical investigation is per-formed, and whether a non-interventional professional sup-port by a multi-disciplinary team was in place are not men-tioned, all of which could have prevented these complications.Furthermore, many of the mentioned complications in thestudy using New Zealand Paediatric Surveillance Unit(NZPSU) registry [10] occurred in patients in whom thefrenotomy was performed in hospitals. As such, also in hos-pitals, it is important that only experienced surgeons perform afrenotomy according to a strict surgical protocol in newbornsin whom non-surgical support was insufficient and in whom amultidisciplinary team has indicated the frenectomy. Whenfollowing the protocol described in the BRIEF study [1], nocomplications after performing a frenotomy were observed inour medical center. Also after 6 months, no complications inoral or motor development, for example, when swallowing ofsolid foods, were observed. However, the serious conse-quences of undiagnosed tethered oral tissues at a later age,such as speech problems, swallowing problems, maxillofacialgrowth problems [11], and pediatric sleep apnea [12], werealso seen in our medical center. Therefore, a multidisciplinaryteam should always be the standard of care for any patient.To protect, promote, and support the attempt ofbreastfeeding newborns for at least 6 months as the WHOrecommends [13], and to overcome any breastfeeding dif-ficulties during this attempt, should be the goal of anyhealth care professional. If tethered oral tissues are thecause of these breastfeeding difficulties and a non-surgical approach is uneventful, a frenotomy can be a safeprocedure resulting in significant improvement ofbreastfeeding self-efficacy, nipple pain, and gastroesopha-geal reflux problems, if done cautiously by an experiencedsurgeon.References1. Paul SP, Heaton PA (2021) Letter to the Editor about the articlepublished in Clinical Oral Investigations titled "Effect offrenotomy on breastfeeding and reflux: results from theBRIEF prospective longitudinal cohort study. Clin OralInvestig https://doi.org/10.1007/s00784-021-03973-x.2. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A(2020) Effect of frenotomy on breastfeeding and reflux: resultsfrom the BRIEF prospective longitudinal cohort study. Clin OralInvestig. https://doi.org/10.1007/s00784-020-03665-y3. Singendonk MMJ, Brink AJ, Steutel NF, van Etten-Jamaludin FS,van Wijk MP, Benninga MA, Tabbers MM (2017) Variations indefinitions and outcome measures in gastroesophageal reflux dis-ease: a systematic review. Pediatrics 140:e20164166. https://doi.org/10.1542/peds.2016-41664. O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE,Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborninfants. Cochrane Database Syst Rev 3:CD011065. https://doi.org/10.1002/14651858.CD011065.pub25. Francis DO, Chinnadurai S, Morad A et al (2015) Treatments forankyloglossia and ankyloglossia with concomitant lip-tie [Internet].Report No.:15-EHC011-EF. Agency for Healthcare Research andQuality (US), Rockville6. Solis-Pazmino P, Kim GS, Lincango-Naranjo E, Prokop L, PonceOJ, Truong MT (2020) Major complications after tongue-tie re-lease: a case report and systematic review. Int J PediatrOtorhinolaryngol 138:110356. https://doi.org/10.1016/j.ijporl.2020.1103567. Kim DH, Dickie A, Shih ACH, Graham ME (2020) Delayed hem-orrhage following laser frenotomy leading to hypovolemic shock.Breastfeed Med. https://doi.org/10.1089/bfm.2020.0319 Onlineahead of print8. Opara PI, Gabriel-Job N, Opara KO (2012) Neonates presentingwith severe complications of frenotomy: a case series. J Med CaseRep 6:77. https://doi.org/10.1186/1752-1947-6-779. Heaton PAJ (2021) Division of tongue tie: surgical complications.BMJ 372:n8. https://doi.org/10.1136/bmj.n810. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D,Wheeler BJ (2020) Complications following frenotomy forankyloglossia: a 24-month prospective New Zealand PaediatricSurveillance Unit study. J Paediatr Child Health 56(4):557–562.https://doi.org/10.1111/jpc.1468211. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017)Ankyloglossia as a risk factor for maxillary hypoplasia and softpalate elongation: a functional - morphological study. OrthodCraniofac Res 20(4):237–244. https://doi.org/10.1111/ocr.1220612. Guilleminault C, Huseni S, Lo L (2016) A frequent phenotype forpaediatric sleep apnoea: short lingual frenulum. ERJOpen Res 2(3):00043–02016. https://doi.org/10.1183/23120541.00043-201613. World Health Organization (1989) Protecting, promoting andsupporting breast-feeding: the special role of maternity services: ajoint WHO/UNICEF statement. https://www.who.int/nutrition/publications/infantfeeding/9241561300/en/Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Clin Oral Invest

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Reply to the editor concerning:Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospective longitudinal cohort study

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