Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT.

Background: Tongue-tie can be diagnosed in 3-11% of babies, with some studies reporting almost universal breastfeeding difficulties, and others reporting very few feeding difficulties that relate to the tongue-tie itself, instead noting that incorrect positioning and attachment are the primary reasons behind the observed breastfeeding difficulties and not the tongue-tie itself. The only existing trials of frenotomy are small and underpowered and/or include only very short-term or subjective outcomes. Objective: To investigate whether frenotomy is clinically and cost-effective to promote continuation of breastfeeding at 3 months in infants with breastfeeding difficulties diagnosed with tongue-tie. Design: A multicentre, unblinded, randomised, parallel group controlled trial. Setting: Twelve infant feeding services in the UK. Participants: Infants aged up to 10 weeks referred to an infant feeding service (by a parent, midwife or other breastfeeding support service) with breastfeeding difficulties and judged to have tongue-tie. Interventions: Infants were randomly allocated to frenotomy with standard breastfeeding support or standard breastfeeding support without frenotomy. Main outcome measures: Primary outcome was any breastmilk feeding at 3 months according to maternal self-report. Secondary outcomes included mother's pain, exclusive breastmilk feeding, exclusive direct breastfeeding, frenotomy, adverse events, maternal anxiety and depression, maternal and infant NHS health-care resource use, cost-effectiveness, and any breastmilk feeding at 6 months of age. Results: Between March 2019 and November 2020, 169 infants were randomised, 80 to the frenotomy with breastfeeding support arm and 89 to the breastfeeding support arm from a planned sample size of 870 infants. The trial was stopped in the context of the COVID-19 pandemic due to withdrawal of breastfeeding support services, slow recruitment and crossover between arms. In the frenotomy with breastfeeding support arm 74/80 infants (93%) received their allocated intervention, compared to 23/89 (26%) in the breastfeeding support arm. Primary outcome data were available for 163/169 infants (96%). There was no evidence of a difference between the arms in the rate of breastmilk feeding at 3 months, which was high in both groups (67/76, 88% vs. 75/87, 86%; adjusted risk ratio 1.02, 95% confidence interval 0.90 to 1.16). Adverse events were reported for three infants after surgery [bleeding (n = 1), salivary duct damage (n = 1), accidental cut to the tongue and salivary duct damage (n = 1)]. Cost-effectiveness could not be determined with the information available. Limitations: The statistical power of the analysis was extremely limited due to not achieving the target sample size and the high proportion of infants in the breastfeeding support arm who underwent frenotomy. Conclusions: This trial does not provide sufficient information to assess whether frenotomy in addition to breastfeeding support improves breastfeeding rates in infants diagnosed with tongue-tie. Future work: There is a clear lack of equipoise in the UK concerning the use of frenotomy, however, the effectiveness and cost-effectiveness of the procedure still need to be established. Other study designs will need to be considered to address this objective. Trial registration: This trial is registered as ISRCTN 10268851. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme (project number 16/143/01) and will be published in full in Health Technology Assessment; Vol. 27, No. 11. See the NIHR Journals Library website for further project information. The funder had no role in study design or data collection, analysis and interpretation. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Many mothers and babies experience difficulties in establishing breastfeeding. In some babies it is thought that their difficulties may be linked to a condition called tongue-tie, in which a piece of skin tightly joins the middle part of the underside of the tongue to the base of the baby's mouth. This can be treated by an operation to divide the tight part/skin in the middle of the underneath of the tongue. We planned to carry out a trial of 870 babies to find out whether an operation together with breastfeeding support helps more mothers and babies with tongue-tie to continue breastfeeding until the baby is 3 months old compared to breastfeeding support on its own and whether the costs were different between the two groups of mothers and babies. We were only able to recruit 169 babies as the trial was stopped because of slow recruitment, changes to services in the COVID-19 pandemic and a high proportion of the babies in the breastfeeding support group going on to have an operation. There were no differences in the rate of breastfeeding at 3 months between the babies in the group who had an operation straightaway and those in the group that had breastfeeding support alone, or had an operation later. More than four in every five babies in both groups were still breastmilk feeding at 3 months. Three babies who had an operation, around 1 in 50 babies, had a complication of the operation (bleeding, scarring or a cut to the tube that makes saliva). Because of the small size of the study, we cannot say whether an operation to divide a tongue-tie along with breastfeeding support helps babies with tongue-tie and breastfeeding difficulties or has different costs. We will need to try different types of research to answer the question.

Studies in humanized mice and convalescent humans yield a SARS-CoV-2 antibody cocktail.

Neutralizing antibodies have become an important tool in treating infectious diseases. Recently, two separate approaches yielded successful antibody treatments for Ebola-one from genetically humanized mice and the other from a human survivor. Here, we describe parallel efforts using both humanized mice and convalescent patients to generate antibodies against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein, which yielded a large collection of fully human antibodies that were characterized for binding, neutralization, and three-dimensional structure. On the basis of these criteria, we selected pairs of highly potent individual antibodies that simultaneously bind the receptor binding domain of the spike protein, thereby providing ideal partners for a therapeutic antibody cocktail that aims to decrease the potential for virus escape mutants that might arise in response to selective pressure from a single-antibody treatment.

Online story comprehension among children with ADHD: which core deficits are involved?

Children with ADHD have difficulty understanding causal connections and goal plans within stories. This study examined mediators of group differences in story narrations between children ages 7-9 with and without ADHD, including as potential mediators both the core deficits of ADHD (i.e., inattention, disinhibition, planning/working memory) as well measures of phonological processing and verbal skills. Forty-nine children with ADHD and 67 non-referred children narrated a wordless book and completed tasks assessing the core deficits of ADHD, phonological processing, and verbal skills. Results revealed that, although no shorter than those of non-referred children, the narratives of children with ADHD contained fewer elements relating to the story's causal structure and goal plan. Deficits in sustained attention accounted for the most variance in these differences. Results have implications for understanding and ameliorating the academic problems experienced by children with ADHD.

Difficulties in comprehending causal relations among children with ADHD: the role of cognitive engagement.

The present study examined whether time spent in long looks (i.e., >or=15 s), an index of cognitive engagement, would account for differences between children with attention deficit hyperactivity disorder (ADHD) and comparison children in understanding causal relations. Children viewed two televised stories, once in the presence of toys and once in their absence. Dependent variables were visual attention and questions tapping factual information and causal relations. Comparison children answered significantly more causal relations questions than did the children with ADHD, but only in the toys-present condition. Four lines of evidence revealed that the difficulties children with ADHD had in answering causal relations questions in the toys-present condition could be linked specifically to this group's decreased time spent in long looks.

On-line story representation in boys with attention deficit hyperactivity disorder.

Children with attention deficit hyperactivity disorder (ADHD) face an increased risk of poor achievement in school. Thus, knowledge of the cognitive processing abilities of children with ADHD is critical to understanding and improving their academic performance. Although many studies have focused on the specific nature of the attention deficit experienced by children with ADHD, few have examined higher order cognitive processing such as comprehension of stories. The present study examined the processes of encoding story information, building a story representation, and modifying a story representation in boys with ADHD and nonreferred boys. Boys were asked to narrate a story from a picture book twice. Boys with ADHD showed deficits in representing goals and goal plans in their narrations, as compared to nonreferred boys. Boys with ADHD also committed more errors than nonreferred boys, but did correct certain types of errors on their second telling. Implications are discussed in terms of future research needed to identify the cognitive deficits that account for these narrative deficits.

Comprehension of televised stories in boys with attention deficit/hyperactivity disorder and nonreferred boys.

Two studies compared comprehension of televised stories by 7- to 12-year-old boys with attention deficit/hyperactivity disorder (ADHD) and nonreferred comparison boys. Boys watched one show with toys present and one with toys absent. Visual attention was continuously recorded, and recall was tested after each show. Across studies, visual attention was high with toys absent but decreased sharply with toys present for boys with ADHD. Groups showed similar levels of cued recall of discrete units of information regardless of differences in attention. When recall tasks and television story structure required knowledge of relations among events, the reduced attention of boys with ADHD interfered with recall. Although visual attention of comparison boys also decreased to some extent with toys present, there was no such decrement in recall. Implications of the difficulties children with ADHD have in integrated story comprehension are discussed.