Tongue-Tie Politics of Breastfeeding

Photo: Bronwyn and Ruby by Lisa Trocchi

Tongue-tie, lip-tie, ‘tethered oral tissues’ (or ‘TOTs’) are terms tripping off many a health professional’s tongue today. If you are a breastfeeding advocate in the lactation field, or a mother struggling to breastfeed and searching for support or solutions, the popular discussion of these anomalies will likely not have escaped your attention.

A tongue-tie exists when the tissue (frenulum) connecting the underside of the tongue to the floor of the mouth compromises tongue mobility. Restoring optimal tongue movement may be achieved by performing surgery that involves either cutting with scissors or lasering the lingual frenulum or the upper lip frenulum (the tissue connecting the inside of the lip with the gum). You can get your buccals done while you are at it [I predict these will be fashionable in 2018]. While tongue-tie is a mild anomaly that may cause feeding issues, it is not the cause of the majority of breastfeeding challenges. There are very often breastfeeding solutions to breastfeeding problems.

Mothers report improvements in breastfeeding following surgical procedures on their babies to release ties, believing that this is what saved breastfeeding, and without which breastfeeding would not have been possible. Some mothers report no improvement to breastfeeding following surgical procedures, and others say that things have become still worse, and that breastfeeding is no longer possible as a result. I am not going to speculate on whether, when or to what degree tongues need releasing. I am sceptical about the rapidly growing numbers of apparently faulty babies.

To date, there exists a paucity of reliable evidence regarding the diagnosis and the treatment or otherwise of tongue-ties upon which to make fully informed decisions, either as a health professional or a parent.

‘A kind of pseudo-science prevails concerning this topic, where poor research methodologies are ignored or not comprehended by prominent and authoritative advocates of deep-tissue incisions, where the need for theoretical frames are derided, where articles are thrown around the internet as proof without any credible analysis of the data, that is, without critical thought about how that data is interpreted.

Worst of all, a poisoned, divisive discourse dominates, with advocates of deep-tissue frenectomies unashamedly questioning the competence or experience of those health professionals who are more cautious …  Lactation consultants … who are sceptical about the value of these deep cuts fear to speak out. Being labelled incompetent by colleagues or by parent groups online† … Our tongues have been tied. A disturbing and anti-intellectual group has taken hold in the field of breastfeeding support.’ Professor Pamela Douglas

For more than 99% of our existence as a species, all human infants have obtained their main nutrition through breastfeeding and as mammals we have an evolutionary history of lactation that is even more ancient. (Stuart-Macadam, Introduction to Biocultural Perspectives Walter de Gruyter, Inc. New York).

‘Unfortunately, the power of social media and the manipulation of parental emotion have caused an increase in diagnosis [of tongue-tie], well beyond its actual incidence.’ Alison Hazelbaker

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The Politics of Breastfeeding

The tongue-tie controversy really is a new chapter in the politics of breastfeeding. I’ve been re-reading Gabrielle Palmer’s books, The Politics of Breastfeeding and Why the Politics of Breastfeeding Matter, in which the author describes how a thirst for profit systematically undermines a mother’s confidence in her ability to breastfeed and challenges our complacency about how we feed our children, encouraging us to reappraise the whole subject.

There are some striking parallels between the promotion of artificial baby milk and of tongue-tie release. These are just a few that spring to mind.

  • How in the last century, it’s a sad fact that the more contact mothers have had with health workers the less they have breastfed. (I’m not saying health workers should stop trying, this is just an observation.)
  • How it is often easier, and more lucrative, to work out a stopgap way of alleviating a problem than it is to discover why it occurred in the first place.
  • Our reliance these days on technological solutions and how women in industrialised countries crave instructions as a direct measure of their lack of confidence.
  • How very often mistakes become sanctified because they are in print.
  • How the medical profession strives to be neutral, yet manages to ignore the integration of commercial interests with medical issues.
  • The confusion between philanthropy and vested interest and how many are so caught up in the whirlwind of career progress and profit seeking that they seem unable to review the damage they do.

Informed choice is the mantra of western society and is seen as a right, but few parents are fully informed.

Back in the 1950s, doctors persuaded mothers that artificial feeding was ‘scientific’. They added mystique by presenting gobbledygook to impress. Breastfeeding failure became accepted as a common flaw in women’s bodies, and now tongue-tie is becoming accepted as a common problem in infants’ mouths. Effective distribution of promotion by a universal means of communication creates a market. Where are mothers able to find consistent and impartial information? On Facebook?

hammer-1629587__340And it is fascinating to follow the social media discourse on the topic: the conjectures of some enthusiasts who believe that air swallowed because of tongue or lip-tie leads to leaky gut, food intolerances, nut allergy, and other digestive problems. ‘Restless foetus’, bed wetting, constipation, late crawling, worn out adrenal glands, mouth breathing, sleep disturbances, spinal deformity, ADHD, webbed fingers syndrome, and conjunctivitis have been blamed on tied tongues. A new device on sale for training babies’ tongues lists a connection between tongue-tie and leukaemia in its marketing promotion. There’s a growing number of claims cited in chat groups for what tongue-tie release can cure, including, but not limited to, umbilical hernia, mouth breathing, craniosynostosis, motion sickness, hating the car seat and nappy changes. It can even prevent SIDS…

Adults too are benefiting from having their tongues released to cure headache and neck tension, balance, vision, erectile dysfunction, tight pelvic floor and stress incontinence. Some hypothesise that releasing a tie can shorten the menstrual cycle and shrink nodules in the thyroid through some connection with pituitary function. Perhaps tongue-tie is at the root of all hormonal problems? (I’ll keep an eye out!) One woman wrote that after the procedure, not only was her posture improved but her breasts were perkier too. What next? Perhaps a connection between tongue-tie and autism? Indeed, such a connection has already been made, I missed that one … Schizophrenia even!

I recently heard a lactation consultant relate how she had seen flyers from a provider of tongue-tie surgical procedures handed out to pregnant women at a mother and baby fair.

‘If advertising simply provided information, it would be hard to object. But a lot of advertising makes us feel we need something that previously we didn’t need.’ Richard Layard

Discussing artificial baby milks, Palmer notes that in spite of the lack of evidence that the ingredients are essential or even safe, no company has ever put a label on the tin that reads:

‘This product is as yet unproven to be completely safe, thank you for letting us use your baby as a guinea pig.’

She rightly judges controlled experimentation on babies to be unethical.

Since publishing my initial version of this post in January 2017, in addition to the ever-growing list of conjectures above, there has been a proliferation of opportunities for ‘education’: conferences, symposia, and ‘master’ classes at which advocates of these surgeries sell their promotion and encourage professionals to further their beliefs. ‘Generous’ donations are being publicly presented by providers of laser surgery, a percentage per procedure carried out, to perinatal mental health charities who support mothers with postpartum depression to show how much they care for these vulnerable new mothers. The opportunities don’t stop there. For just $30 you can now join a Facebook program, a mama circle, for support on your tie ‘journey’.

Homeopathic remedies now exist specifically to help with the emotional and physical trauma involved in tongue-tie surgery, some of them come with an endorsement from lactation consultants. Whatever will be be next? Perhaps laser dentists teaming up with TOT enthusiast health professional referrers? [Sure enough, that has happened.] Or, as one GP wryly suggested a new formula milk designed for babies with ties? And there is now a ‘magical Minbie teat’ being marketed at mothers with tongue-tied babies. Tell me again how there is no bandwagon?

Do the benefits of surgical procedure outweigh the risks? And what actually are those risks?

Is it right to recommend release without full, impartial information, for which we need to know that a procedure is safe AND effective in doing what it is supposed to do?

When professionals carrying out tongue-tie surgery are doing procedures with the intention of improving breastfeeding and breastfeeding does not improve, how can a mother fail not to feel undermined and anxious?

As a mother who cares about babies and wants mothers to breastfeed, and as someone who has no financial interest in whether they do or not, I cannot ignore the stories I hear, the ones about babies suffering from oral aversion following (often repeated) tongue-tie release surgeries, stories of botched procedures, wounded babies and harsh aftercare, and those with excessive bleeding.

I do not deny there may in some instances be a connection between tethered oral tissues and effective breastfeeding. What I am doing is to recommend caution and ask for a more rigorous and a more open dialogue between professionals and between mothers over what the evidence reveals with regard to these surgical procedures.

Babies and their mothers are vulnerable, their protection is paramount, even if saying so has cost me a lot of friends as well as my job.

My tongue won’t be tied.

† I have been banned from a few tongue-tie groups I have participated in on Facebook and know others have been ejected too. One health professional was told in a mothers’  group to refrain from using the words ‘cut’ or ‘surgery’ and that they were ‘moving away’ from such language to talking about ‘revision’ instead …

Worth reading

Why the Politics of Breastfeeding Matter (Pinter & Martin Why It Matters Book 6)

March 2017: from the Australian Breastfeeding Association’s professional journal, Breastfeeding Review 2017; 25(1): 9-15, a paper reflecting upon the oral tie phenomenon by Renee Kam, Lois Wattis, and Pamela Douglas, which includes the serious methodological shortcomings of a number of recent and popularly cited studies.

My post reflecting on this and the lack of credibility.

Cochrane Review 11 March 2017. Frenotomy for tongue-tie in newborn infants ‘The small number of trials along with methodological shortcomings limits the certainty of these findings.’ ‘No consistent positive effect on infant breastfeeding.’

July 2017 Australian Dental Association expresses its concerns: Frenotomy in newborns: HAS INCREASED AWARENESS LED TO UNNECESSARY TREATMENT?

July 2017 Dental Council NZ expresses its concerns

Put those lasers away:

Take a look at what the Australian Dental Association Queensland president has to say this month (September 2017) about the surgical management of tongue ties in the breastfed infant. And again in December 2017.

And on lip frenula:

Santa Maria, C., Aby, J., Trong, M. T., Thakur, Y., Rea, S., & Messner, A. (2017). The Superior Labial Frenulum in Newborns: What Is Normal? Global Pediatric Health4, 2333794X17718896. http://doi.org/10.1177/2333794X17718896

Al-Najjim, A., & Sen, P. (2014). Are upper labial frenectomies in children aged 11 and under appropriate? Is it time to change practice and agree guidelines? Faculty Dental Journal, 5(1), 14–17. doi:10.1308/204268514×13859766312557

The prevalence of a midline diastema reduces with age from 98% of 6-year-olds, 49% of 11-year-olds to 7% of teenagers and therefore the majority of diastemata will tend to close spontaneously during teenage years without any intervention.

Read my other posts on ties here.

I do not make any money at all by publishing posts on this WordPress.

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27 thoughts on “Tongue-Tie Politics of Breastfeeding

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  1. The emotional instability in mothers with whom I meet following failure of an oral revision to reinstate a successful breastfeeding relationship is very concerning. These mothers and their babies in just a few weeks following childbirth, have been introduced to nipple shields, sns, babies with oral aversion, just to name a few issues. Are these situations now pushing some mothers into post natal depresion? My first task, when I meet a mother in this situation, is more often than not, to suggest some “time out” for both mother and infant. Resurrecting breastfeeding under these circumstances is a challenge, to say the least. And where are the individuals who got the mother started on this roller coaster? Usually checking their bank balance. Yes, there are genuine instances, and yes, the results are evident in “back to breast” success. We need direction for this dilemma urgently.

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    1. I just read this post from start to finish. While I cannot explain the phenomenon of tethered oral tissues and the “supposed” relief of breastfeeding issues with frenulectomies, I can certainly speak to the subject. I received an invitation (from a local LLL) in 2012 to attend a four day conference on “Ankyloglossia” (tongue-ties). There were to be ENTs, pediatric dentists, speech therapists, occupational therapists, etc., speaking at this official conference. I quickly discarded my invitation, thinking, “there’s no way I’m going to waste my time or my designated education money on such a small part of my scope of practice.” Well, I realize today that it may have been the best education that I could have received. I am a registered nurse certified in Inpatient Obstetrics, Newborn Nursing, IBCLC, and an Advanced Nurse Lactation Consultant (ANLC). I tell you this not to be a glory hound, but rather to help you understand the full circle that I have come and how I have arrived here today. I have been assessing newborns for 24 years now and I can assure everyone that no nurse, doctor, nurse practitioner, or Lactation consultant are “trained” in identifying a tongue tie, much less classifying the extent. As a matter of fact, I’m very leary of physicians that will perform frenulectomies, and the parents should be, too. There are just a few that I’ve come across that know how to truly release a tongue-tie, whether they are using scissors OR laser. Those three physicians have been specially trained outside of their regular training and have some reason to embrace assisting dyads reach their goals. The tool that they are using pales when compared to the surgeon behind the tool. I can honestly say that around 20% of the infants that I evaluate go to a specialist (that I have seen do thorough releases) and have frenulectomies. It should always be a team approach, which works very well in securing prolonged breastfeeding. I could read the wive’s tales and take a gander at why we are seeing more today than a century ago, but my opinion wouldn’t matter. More research and evidence needs to be published. I’m happy to say that I am one that is stepping up and doing the work that is required to prove the evidence that this procedure, with limited risks, just may be worth the time after all. There are multiple reasons that I will send a neonate or an infant for the procedure. It should be known that I always evaluate a situation from a breastfeeding standpoint, first. It may just be some tweaking of the latch/ positioning. Some reasons that I may refer neonate/infants would be maternal PAIN ((not soreness) with feedings, excessive neonatal weight loss, failure to thrive, inability to stay in the growth chart (the WHO chart), “popping on and off constantly”, unable to maintain suction at the breast, excessive fussiness, which would more than likely be diagnosed as “colic” or @acid reflux.” Just a reminder…ALL babies have acid reflux. They just need time to let the lowers esophageal sphincter, (LES) muscle become more mature.👍 A side note…I find in my practice that most babies gave an in intolerance to dairy during the first 4 to 12 months of their life. Phew! Rant over! Please feel free to message for more information!

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  2. Thank you for being brave enough to take a stand for mothers and babies. I think we have only just seen the tip of the iceburg in how the massive overdiagnosis of tongue has hurt babies, eroded mothers confidence, and wasted a lot of time and money taking advantage of distraught parents desperate desire to breastfeed sucessfully. I honestly wonder if the lactation community as we know it will survive the backlash that will be coming as doctors and parents learn to stay far away from the psuedoscience that it has been promoting.

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  3. As a retired IBCLC and also retired LLL leader, I believe this article is well done and is a balanced view of the tongue-tie issue. I agree with the need of a cautious approach and the critical importance of positional fit between mother and baby. This is despite the fact that tongue-tie runs in my family (my father, me, 2 of 3 daughters, 2 of 3 grandchildren). It was the reason I quit breastfeeding with my first child. The nipple pain from my baby’s tongue-tie was excruciating, noticed immediately with our first breastfeed. I did not know that my baby had a tongue-tie at that time but suspected it. I relactated and tried again to breastfeed a month or two after I had quit breastfeeding. There was no pain. Why? Not sure of the whys but assumed that something significant had changed–tie broken or mouth area just larger. With my second baby I never experienced any pain. So I recognize in a personal way that nipple pain is an indicator of a problem. My third baby I had significant pain for 18 months but refused to quit. I understand the wish for a quick fix because the pain can be almost intolerable. With my third baby I continued to breastfeed because I understood the importance of position, the need to keep the breast as stable as possible, of nursing often-sometimes every 15 minutes for a few minutes at a time. Do I wish this scenario on other mothers? No, I am glad there are remedies such as revision for moms and babies who are in this situation. Yet any invasive procedure comes with risks, particular if a mother is not well-grounded in the importance of positioning and of nursing often (a very hungry baby can really do damage to sore nipple tissue). I realized the situation with my 3rd baby lasted longer because she unlike her sisters had a different jaw structure. One day, after all her teeth came in, I suddenly noticed that her bottom teeth overlapped her top teeth, something very different from her siblings. My personal experience showed me that there can be more than one problem that needs to be addressed. Yet some problems do not have a quick fix. One can view my determination to keep breastfeeding despite the pain as having a martyr syndrome. But I believe that breastfeeding was very important to me not only because I knew from quitting breastfeeding with my first baby how emotionally upsetting it was; but also I had the education that had convinced me of the vital nature of breastfeeding to my babies’ health and my own health. I have many questions regarding tongue-tie and I think that mother’s need to understand any medical procedure or intervention comes with the risk of adverse effects. Your article speaks to me because of my personal experience and my many years trying to help moms with breastfeeding problems. One of your key points regarding positional fit between mother and baby and over diagnosis of tongue tie has been my impression for the past few years. I really appreciate this well written article!

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  4. You talk about botched procedures and then earlier criticise people for calling others incompetent.

    If people are incompetent, we should be calling them out on it. Tongue tie is an epidemic. Something is causing the rise in it and we should be working out what and fixing it, not denying it exists. Anyone who has suffered through tongue tie will only feel anger reading your article.

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  5. Thank you for writing this I’ve been ruminating on the treatment my child received for a long time and have felt unable to express clearly what had bothered me so much but I’m taking this post as a platform as there’s not many places it’s possible to share my experience.

    My baby had a posterior tongue tie that was unsuccessfully treated by a cautious NHS team. I didn’t find improvement so used an ibclc who gave me positioning advice but said she would not snip further. This cost me £30 per hour.

    After months I was still unhappy and went to a much lauded private provider in West Yorks. The snip was done with the minimum of assessment and off we went. There was some difference but mainly my little one was angry and hurting. The wound tried to heal together and the provider said I needed to go back to have it checked. At this second appointment it was ripped open again with a finger. Then I was instructed to continue hurting my child so the provider could see that I was “lifting” the tongue properly to prevent reattachment. I felt so unsupported and treated with contempt because I hadn’t wanted to make my child suffer. The manner of the two women was not what I expected, having heard so much positive feed back online. I kept in touch with them asking for help constantly but my requests for information on what to do next were repeatedly ignored and I was told to continue osteopath work. I didn’t get any more breastfeeding support from them and I never received follow ups from them, only when I instigated contact myself did I get a response.

    I questioned myself a lot. What had I done wrong to them so that I felt so unsupported? I am still feeding my child now but that tongue never became what they said it should. The division was an improvement and luckily I have some background in peer support and a family set up that supports our breastfeeding journey but I still feel anger towards that provider for failing to support me adequately and putting my child through a traumatic experience. I wonder if there are others who have felt this way but been shy to come forward due to all the positive praise heaped on this provider in online groups?

    I do hope I’ve articulated this clearly, it’s a very emotional journey and I’ve struggled to pin point my negativity but I guess I really wanted to share how badly they made me feel. Thanks for the opportunity.

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    1. I too have had a negative experience with a West York’s company, which is inundated with praise – could we be talking about the same two women? There was a severe lack of information given after minimum assessment. We are still in limbo, not knowing what to do and without our questions being answered……..

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  6. Wow. Talk about missing the forest for the trees.

    What about listening to the hundreds of moms whose babies are diagnosed with restricted oral motion, who find relief after a simple low-risk procedure (that any pediatrician could do in-office if he just would learn how), and listen to them describe their own infancies as they realize they too have a tie and this is why their mother reported bleeding and difficulties nursing them, or their own colic and orthodontics as a baby and child, or their husband’s mouth-breathing and sleep apnea… If you listen for a minute to the stories of a tied baby’s family you’d realize that this issue goes back at least three generations; it’s just finally getting enough press to be fixed now rather than ignored and given a bottle in infancy, braces in middle school, and cpap in adulthood. Why not instead say “what are the causes for such a high incidence? Is anything in our environment perhaps contributing to this? Does our population in the US have a predisposition to it? Slme possible factors are the MTFHR mutation, plastics impairing methylation, foods enriched with folic acid, iodine deficiencies, lack of dietary fat-soluble vitamins, and there are more.

    Frenectomies don’t have to be expensive. If pediatricians would just learn to do them in office, life would be much easier for everyone– meanwhile, let’s research causes! (See Dr Gehari’s work)

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    1. From Pamela Douglas’s marvellous essay (quoted from in my article): “Now, the internet buzzes with arcane theories about the rise of ‘these new midline defects’, including the conviction that tongue-tie is related to methylenetetrahydrofolate reductase (MTHFR) genetic mutations or pregnancy supplements. But if we apply the lens of evolutionary medicine, the idea that posterior tongue-tie and upper lip-tie have sprung up as widespread new congenital abnormalities in the last decade in the developed world just doesn’t make sense. Homo sapiens has been remarkably morphologically stable over many thousand years.” https://griffithreview.com/…/tongues-tied-about-tongue…/ and see http://www.genetics.edu.au/Professionals/mthfr-dna-test

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  7. Barbara, Dr. Weston A Price’s work photo-documenting the astounding change in the oral structure of aborigines and tribal peoples after just one generation eating the Western diet stands as proof that some structures are highly reactive to changes in nutrition. Price points to narrowing in the mouth / jaw / teeth, and also to the hips become more narrow, making childbirth difficult, and to a lengthening of the skeletal structure, so that people are taller. It is ironic that this describes the ideal of female beauty Hollywood parades for us today: tall, thin hipped and with an overbite.

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    1. ‘Photo-documenting’? But where is the evidence? Those measurements are easy enough to document scientifically but they haven’t been have they? Overbite? Sorry, I’m not buying it.

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  8. Assaulted as infants, indeed. I was one of those vulnerable mothers pressured into revising my baby’s lip frenulum. He has nerve damage, developed oral aversion and landed in hospital on tube feeds. And yes, it was a preferred provider. I found out after the procedure that his upper lip frenulum was normal and should have been left alone. This barbaric practice of lasering horrific wounds into an infant’s mouth needs to stop.

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    1. I am hearing similar reports from others and seeing photos of mutilated mouths too. There is little to regulate this practice as well as no science to support it. Many lactation consultants and mothers are afraid to speak out.

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  9. Hilary Jacobson, I just inadvertantly removed your latest comment in trying to respond to it. You wrote:
    “Hi Barbara, the photo documents were gathered in the early 1900s by Price who traveled the world investigating what happened to the facial structures of indigenous peoples after one or two generations on a western diet. Have you every looked into Price’s work? It’s easily findable online.”

    Would that be the same man sometimes dubbed ‘the patron saint of crank dentistry’?

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  10. There is an independent clinic in Yorkshire where mums are sold many Osteo sessions alongside repeated snips on scar tissue, with little improvement in feeding. I have heard one of the IBCLC’s controls the Tongue Tie UK Facebook page and edits out any negative comments they receive about their service. It’s really hard to know who all the ‘experts’ are and do the best for your baby. We ended up seeing a private provider and were very happy, our NHS wait was too long.

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    1. We had a very bad experience in Yorkshire. Not sure if the same clinic! Very difficult to go off FB and other recommendations. Word of mouth is better. Ended up getting fantastic help in Kendal .

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  11. Interesting to read that both the Australian Dental Association and the Dental Council NZ are expressing their concerns about unnecessary treatments. Follow the links at the bottom of the post added 12 July 2017.

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  12. Gabrielle Palmer wrote: “To protect all babies, impartial, accurate information without commercial bias, must be available, and false information stopped. The Code provides the framework for this essential health measure and it applies universally.”

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  13. Since first writing this post in January, I’ve been listening to mothers and health professionals about what is happening and witnessing evidence of horrific injuries inflicted on infants. Do we have to wait until a baby dies before this is stopped?

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    1. I am really glad, Sara, that you overcame your breastfeeding difficulties. Many women go on to succeed at breastfeeding both with and without having this surgery. What concerns me is that there is no scientific evidence to back up the efficacy of the intervention. I will never say ‘never’, but want to see more than subjective evidence. There are a lot of babies suffering painful interventions and often repeatedly for whom this is not a quick fix.

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