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Belle Verdiglione Features
Alison Hazelbaker, Ph.D., IBCLC, Columbus, Ohio, USA
Photo:  Belle Verdiglione

Tongue-tie and “lip-tie” are terms tripping off many a tongue today. Alison Hazelbaker examines what parents need to know if they suspect their baby may have a tie.

Recently, my second grandson and seventh grandchild was born. One of the first things I did as his grandmother, after the magical first hours slid by, was to check his tongue function. I was looking for a tongue-tie because tongue-tie runs in my family. I was tongue-tied and my two sons were tongue-tied. Luckily, only one out of seven grandchildren has had the condition. My new grandson does not, nor does he have any feeding problems.

A diagnosis of tongue-tie has become increasingly popular in the United States and elsewhere. This is partly a backlash against earlier failure to look for and properly and promptly treat this relatively common congenital anomaly. Unfortunately, the power of social media and the manipulation of parental emotion have caused an increase in diagnosis of the condition, well beyond its actual incidence.

We define tongue-tie as tissue (the frenulum) connecting the underside of the tongue to the floor of the mouth when this tissue compromises tongue mobility. It is a mild congenital anomaly that can cause infant feeding issues. It is NOT true that tongue-tie is the cause of most breastfeeding problems.

The reality is that there are many different causes of breastfeeding issues, most of which are easily remedied. One of the most prevalent causes is simple positioning and latch-on mismanagement. Babies are born to breastfeed. During birth, their reflexes help them to be born, and these same reflexes help them to crawl to the breast and self-attach. Unfortunately, mothers and babies are not given the support they need in certain birth settings to allow this dance between them to unfold naturally.

Helping a mother and baby into a more relaxed, laid back, feeding position can often resolve breastfeeding issues. Tiny adjustments to other positions can often make all the difference too. When improved breastfeeding management does not solve the problem, another cause may be at play. It takes a knowledgeable support person to sort through the possibilities with the parents. Sometimes, breastfeeding challenges have more significant causes, for example torticollis* can mimic tongue-tie and undermine breastfeeding. It is not uncommon for torticollis to be mistaken for a posterior tongue-tie.

Posterior tongue-tie

Some health care providers claim that as many as 50% of babies have a tongue-tie, most possessing a posterior tie. Please keep in mind that properly performed scientific research has identified true tongue-tie in only 5% of babies and posterior tie in only 30% of that 5%.1

Dr. David Todd, a researcher and neonatologist in Australia, did a three-year study in which he found that 70% of truly tied babies had an anterior tie (one in which the lingual frenulum was attached closer to the tip of the tongue). Only 30% had a posterior tie (one in which the lingual frenulum was attached closer to the base of the tongue). Clearly, the diagnosis of posterior tie has become far too common.

Please keep in mind that properly performed scientific research has identified true tongue-tie in only 5% of babies and posterior tie in only 30% of that 5%.1

Part of the problem is the lack of appropriate screening for the condition. There is only one screening tool for tongue-tie that has been proven through scientific research to accurately identify tongue-tie in babies. This screening tool, the Assessment Tool for Lingual Frenulum Function©™ (ATLFF), was developed over a three-year period in the 1990s and is reproduced below.2 

The ATLFF©™ evaluates seven different functional aspects of your baby’s tongue movement, and five appearance aspects. In this way, it has the power to determine if your baby is truly tongue-tied or if your baby has a different cause of tongue-function problems, such as torticollis. This assessment tool is the standard against which all other tongue-tie assessment tools will have to be measured (those are the methodological rules). It is available in several different languages and is currently being translated into Polish and Estonian.

Simply looking under the baby’s tongue or pressing back against the baby’s tongue base will not render an accurate diagnosis.3 Before allowing a health care practitioner to screen your baby, ask how he or she performs an assessment. You always have the right to seek out another health care provider.

You may have heard that behind every anterior tie is a posterior tie. This statement is confusing. Babies do not have two kinds of tongue-tie. The professional who first made this statement meant that treating a tongue-tie by simply nicking the front of the lingual frenulum with a pair of scissors was not enough to restore optimal tongue movement. The practitioner performing the surgery needs to cut far enough back for full restoration. For some babies, this may mean that a diamond-shaped wound will be created near the tongue base, for others, stopping just before the diamond shaped wound occurs is enough. There is currently no scientific evidence that creating the larger diamond-shaped wound is superior to the simple, less deep frenotomy/frenectomy. However, we know that just snipping the very front of the lingual frenulum does not work and the procedure will need to be repeated.

Babies do not have two kinds of tongue-tie.

Tongue-tie treatment

Treatment for tongue-tie falls into two categories: frenotomy, which consists of cutting into the lingual frenulum with sterile scissors to free up the tongue, and frenectomy, which consists of removing the lingual frenulum by using laser, scalpel, or electrocautery. All of the scientific literature on tongue-tie treatment for breastfed babies is based on simple frenotomy using sterile scissors. Not one of these studies shows any significant risks of the procedure when performed by trained hands. Minimal bleeding may occur: extensive bleeding occurs in less than 1% of babies.

That leads us to talk about the need for proper training. In the USA, there exists no requirement for training to either assess or treat tongue-tied babies. Any health care professional who works with babies is allowed to assess a baby for tongue-tie. Any practitioner who is allowed to perform minor surgery can perform tongue-tie surgery. We must rely on the ethical behavior of practitioners to get training on their own from a formal or informal training program. Please be aware that most physicians are NOT trained to perform frenotomy/frenectomy.

Two formal training programs currently exist: one in the UK and one in Boston in the USA. Other informal trainings have sprung up everywhere; many practitioners learn from another who has more experience. This means there is no standardized approach and no guarantee that the practitioner has met a minimum standard of competence. Please be sure to ask a practitioner to whom you have been referred what kind of training he or she has, how many procedures he or she has performed, and what kind of results he or she has achieved. If he or she performs laser frenectomy, ask if he or she is certified through the Academy of Laser Dentistry.

There is no scientific evidence that proves that laser frenectomy is superior to scissors frenotomy in tongue-tied babies. Before laser became widely available, most tongue-tied babies received scissors frenotomy with excellent results. Currently, most tongue-tied babies throughout the world receive scissors frenotomy.

There are many types of lasers, each suited for different uses. Diode lasers, in particular, leave a larger area of damaged tissue even in the hands of an experienced laser surgeon because they use a hot tip to burn the tissue rather than the laser beam to vaporize the tissue. CO2 laser is the laser of preference when working with the smaller mouth size of an infant.4

Because the lingual frenulum is a connective tissue band containing certain types of fibers that do not stretch with use and is designed to stabilize the tongue in the mouth, it will not change over time or with exercise. If your baby is truly tongue-tied, the only remedy is to cut into the frenulum or remove the tissue. Problems may arise if this tissue is left intact including: speech delay, speech articulation problems, postural stability problems, airway development problems, development of sleep disordered breathing, sleep apnea, malocclusion of the upper and lower teeth, teeth cleaning issues, and swallowing of air, gas, and bloating.2 On the other hand, cutting a lingual frenulum that does not need to be cut may create other problems. Many practitioners have seen excessive scar tissue formation in babies who had a frenotomy/frenectomy and did not need the procedure. This is based on observation and more research is required before we can determine what long-term problems may arise when babies receive a frenotomy/frenectomy when they don’t need it.

Many parents worry about the aftercare “stretching” exercises that are commonly recommended post surgery. It is never appropriate to rub the wound to “break down the scar tissue” or to prevent excessive scar tissue formation. Wound healing science shows that rubbing the wound itself will cause excessive scar tissue to form contributing to the phenomenon of “reattachment.”5 Gentle movements of the tongue in the direction the tongue would normally move during breastfeeding and tongue play suffice. You can ensure your baby performs these movements with some simple strategies that work with the baby’s normal reflexes:

  1. Tickle the baby’s lips in the middle with the tip of your finger. The baby should stick out his or her tongue in response. Alternately, you can tickle the tip of your baby’s tongue to get tongue extrusion.
  2. Rub your baby’s lower gumline with your finger pad from the center of the gum backwards while maintaining gentle contact with the gumline itself. Your baby’s tongue will follow your finger. Repeat this motion three or four times, then switch to the other side.
  3. Allow your baby to suck on your finger. Keep your finger pad up on the hard palate. This encourages your baby’s tongue to create a central groove or gutter and encourages peristalsis (the wave motion) and lifting of the tongue.

Perform these gentle movements several times per day when your baby is most receptive. Of course, breastfeeding itself generates appropriate movement to assist with proper wound healing. Any exercises should not cause your baby to cry: aftercare therapy should be part of playtime and be fun.

tongue-tie-and-lip-tie

Kathy Grossman

Frenotomy/frenectomy alone will not necessarily address the entire breastfeeding problem. Babies may have breastfeeding issues in addition to tongue-tie. Parents need to work with a professional who is knowledgeable in breastfeeding management post-surgical correction of the tongue-tie for best results and to properly address any other problems the baby may be experiencing. (For instance, if the mother’s milk supply has dwindled due to ineffective stimulation and drainage of milk from the breasts, then the correction of the tie will not in itself address the domino effects of lactation failure that may already have occurred.)

“Lip-tie”

You may have heard or read online that upper “lip-tie” is a common cause of breastfeeding problems. In 93.3% of babies the upper lip frenulum (the tissue connecting the inside of the lip with the gum) looks exactly like those currently considered “lip-tie.”7 The upper lip frenulum, unlike the lingual frenulum, changes over time with growth and development. This frenulum gets smaller, thinner, and will insert higher up on the gumline as the teeth erupt.8,9 By the time a child has permanent teeth, the upper lip frenulum looks nothing at all like it did during infancy.

Can a prominent upper lip frenulum ever cause a breastfeeding problem? We don’t know for sure. It might, but it might not. We don’t have a proper way to assess the upper lip frenulum to determine if it is abnormal. We certainly have no scientific studies that show that cutting the upper lip frenulum resolves breastfeeding problems.

We certainly have no scientific studies that show that cutting the upper lip frenulum resolves breastfeeding problems.

Claims made about “lip-tie” causing dental caries are false. Breast milk does not pool in the mouth nor does it cause cavities.10 There is also no absolute proof that a prominent upper lip frenulum causes a separation between the upper central teeth, known as a diastema. Diastema can be hereditary and is not the cause of any functional problems. It is a sign of beauty in some cultures; in others, orthodontia is used to close the gap for cosmetic purposes alone.

Any claim that all tongue-tied babies also have an upper “lip-tie” is absolutely NOT true. The lingual frenulum and the upper lip frenulum develop at different times during embryonic and fetal life under different influences and processes. The lingual frenulum and the upper lip frenulum should be assessed and treated as separate issues. Functionally, the tongue and the lips link via reflex. When the tongue moves backward in the mouth, the lips move inward and vice versa. A baby who has a retracted tongue, either due to tongue-tie or to torticollis, will often have tense lips. Once the tongue position is corrected, the lips resume their normal position and function.

At breast, the upper lip need only evert (turn outward), rather than flange, despite claims to the contrary. Only the bottom lip flanges during breastfeeding. Do not be misled by claims that both lips flange for proper lip seal at the breast.

Only the bottom lip flanges during breastfeeding. Do not be misled by claims that both lips flange for proper lip seal at the breast.

The lingual frenulum has few blood vessels and pain receptors. Cutting into it without anesthesia causes little discomfort for the baby. The upper lip frenulum has an extensive blood supply and many pain receptors. Cutting into it without anesthesia may generate pain for the baby.

Surgery is invasive. Cutting the lingual frenulum or maxillary frenulum (for “lip-tie”) on a baby who does not need this procedure is considered highly unethical and professionally irresponsible.6 Babies are vulnerable and deserve our protection.

Because the vast majority of babies possess a prominent upper lip frenulum that will grow and change over time, a wait and see approach is valid. Unless it can definitively be proven that the upper lip frenulum is so tight that it truly prevents the upper lip from everting during breastfeeding causing breastfeeding problems, the lingual frenulum should be evaluated and treated first, as needed. Once the tongue position and function have normalized, the upper lip can be reassessed and treated, as needed. Many practitioners have found that treating the lingual frenulum usually resolves the upper lip issues.11

Babies are vulnerable and deserve our protection.

The Internet

tongue-tie-diagnosis

Christina Simantiri

As a parent, you are in a unique position to make decisions for your baby. If you are having breastfeeding problems, seek skilled care from practitioners and counselors who are well informed in breastfeeding management. While an LLL Leader may refer a mother to a specialist if she suspects a problem, diagnosis is outside a Leader’s remit. Seek out information from sources that are well supported by scientific research. 

Typically speaking, Facebook groups do not meet scientific criteria. If an information page does not provide sound scientific information with references, then consider the information to be opinion.

Stay away from pages wherein mothers and practitioners are diagnosing tongue-tie and “lip-tie” from pictures or simple descriptions. Tongue-tie is a functional problem and should be assessed using the functional criteria by a professional who has experience identifying these problems and who can make an accurate differential diagnosis.

Stay away from pages wherein mothers and practitioners are diagnosing tongue-tie and “lip-tie” from pictures or simple descriptions.

Anyone who uses scare tactics to goad parents into having their child treated has not done a good job of providing unbiased, evidence-based, and balanced information. Ultimately, it is the parents’ right and responsibility to make the decision to have a tongue-tie or “lip-tie” treated.

As a mother, I was certain that having my sons’ tongue-tie corrected to assist with breastfeeding was a good call. I do not regret those decisions. I made my decisions based on sound, scientific evidence about the risks vs. the benefits. As a health care provider, I would not hesitate to send one of my patients for a frenotomy/frenectomy performed by an experienced surgeon if the baby were truly tongue-tied. I cannot say that I have the same confidence for what is called maxillary or upper “lip-tie.” The scientific evidence does not support routine performance for upper lip revision for breastfeeding issues at this point in time.

As guardians of our babies, all parents and health care providers need to be sure that the benefits of any surgical procedure outweigh its risks. Our vulnerable babies depend on us to do so.

References
  1. Todd, D.A. & Hogan, M.J. (2015). Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes. Breastfeeding Review, 23(1): 11-6.
  2. Hazelbaker, A.K. (2010). Tongue-tie: morphogenesis, impact, assessment and treatment. Columbus: Aidan and Eva Press.
  3. Greenhalgh, T. (2014). How to read a paper, 5th ed. Oxford: John Wiley and Sons, Ltd.
  4. Kaplan, M., Hazelbaker, A. & Vitruk, P. (2015). Infant frenectomy with 10,600 nm dental CO2 laser. WAGD Newsletter, April: 10-12.
  5. Darby, I. A., et al. (2014). Fibroblasts and myofibroblasts in wound healing. Clinical, Cosmetic and Investigational Dermatology, 7:301-311.
  6. Edge, R.S. & Groves, J.R. (2006). Ethics of Health Care, 3rd ed. Clifton Park: Thomson Delmar Learning.
  7. Flinck, A., Paludan, A.,  Matsson, L., Holm, A.K. & Axelsson, I. (1994). Oral findings in a group of newborn Swedish children. Int J Paediatr, 4(2):67-73.
  8. Boutsi, E.A. (2014). The maxillary labial frenum. J Cranio Max Dis, 3:1-2.
  9. Nagavini, N.B. & Umashankara, K. V. (2014). Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis, 3:5-10.
  10. Erikson, P. R. & Mazhari, E. (1999). Investigation of the role of human breast milk in caries development. American Academy of Pediatric Dentistry21(2): 86-90.
  11. Personal communication: Dr. Yvonne Le Fort, Hillary Myers, Dr. Val Finigan.
  12. ADDITIONAL REFERENCES

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Infant Trauma

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LASER

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Maxillary Frenum and Lip “tie”

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We live in a time in which we spend many of our waking hours sitting. We sit to work, eat, to be entertained. All this sitting has led to poor posture, which leads to muscular imbalance in our lower body. These muscular imbalances, in turn, cause our babies to adopt positions while they are inside growing that create tension in their necks. This condition, called “acquired soft tissue torticollis,” can mimic tongue-tie and undermine breastfeeding. If your baby shows a head-turning preference to one side over the other, has neck tension, flattening on the back of the head, one eye or ear that looks higher, larger or farther forward than the other and/or feels like he is biting you during breastfeeding, torticollis might be the cause. Torticollis responds to a multi-pronged treatment approach.

 

Assessment Tool for Lingual Frenulum Function (ATLFF)™

© Alison K. Hazelbaker, PhD, IBCLC, FILCA, 1993, 2009, 2012, 2016

Function Item score:       _______

 

Appearance Item score:             _______

 

Combined Score:           _______ / _______  

Mother’s Name:
Baby’s name: Baby’s age:
Date of assessment:

FUNCTION ITEMS

Lateralization Cupping of tongue
2 Complete 2 Entire edge with a firm cup
1 Body of tongue but not tongue tip 1 Side edges only OR moderate cup
0 None 0 Poor OR no cup
Lift of tongue Peristalsis
2 Tip to mid-mouth 2 Complete anterior to posterior
1 Only edges to mid- mouth 1 Partial OR originating posterior to tongue tip
0 Tip stays at alveolar ridge OR tip rises only to

mid-mouth with jaw closure AND/OR mid-tongue

dimples

0 None OR Reverse peristalsis (tongue-thrust)
Extension of tongue Snap back
2 Tip over lower lip 2 None
1 Tip over lower gum only 1 Periodic
0 Neither of the above OR anterior or mid-tongue

humps AND/OR dimples

0 Frequent OR with each suck
Spread of anterior tongue
2 Complete
1 Moderate OR partial
0 Little OR none

APPEARANCE ITEMS

Appearance of tongue when lifted Elasticity of frenulum
2 Round OR square 2 Very elastic (excellent)
1 Slight cleft in tip apparent 1 Moderately elastic
0 Heart shaped 0 Little OR no elasticity
Length of lingual frenulum when tongue lifted Attachment of lingual frenulum to tongue
2 More than 1 cm OR absent frenulum 2 Posterior to the juncture between the body and blade of the tongue
1 1 cm 1 In front of the juncture between the body and the blade of the tongue
0 Less than 1 cm 0 At the tip with or without notching
Attachment of lingual frenulum to inferior alveolar ridge
2 Attached to floor of mouth
1 Attached to the backside of the inferior alveolus
0 Attached to ridge of inferior alveolus
ASSESSMENT    
14   = Perfect Function score regardless of Appearance Item score. Surgical treatment not recommended.

11   = Acceptable Function score only if Appearance Item score is 10.

<11 = Function Score indicates function impaired. Frenotomy should be considered if management fails. Frenotomy necessary if Appearance Item score is < 8.

tongue-tie-and-lip-tieAlison Hazelbaker, PhD, IBCLC, FILCA, CST, RCST, long-time La Leche League Leader and International Board Certified Lactation Consultant, maintains a private practice in Columbus, Ohio, USA, where she provides free screening of babies for tongue-tie. During her Master’s degree program, she developed the Assessment Tool for Lingual Frenulum Function©™ and performed the first prospective study on the impact of tongue-tie on breastfeeding. She authored Tongue-tie: Morphogenesis, Impact, Assessment and Treatment and is currently writing a primer for parents on tongue-tie. Alison mothered five children through breastfeeding and has eight grandchildren.

 


Comments

  1. I must say I disagree with many of Allison’s statements.

    I have had the unfortunate task of treating many of her clients after they have followed her recommendations to a ‘T’ to no or very little improvement and then be scolded by her or one of her associates as to how ‘they did it wrong’. We went in for a frenotomy and perhaps an ÚLT revision and the look on the faces of both mom and baby says it all. They are relaxed, painfree and happy for the first time.

    I have never used her assessment tool. Her tool was created in 1990! That is 26 YEARS ago. The babies we see now are very different from the babies of 26 years ago. Why? Because 26 years ago is before big pharma started stuffing the pre-natal vitamin with folic acid to help prevent Spina Bifida. It’s not FOLIC ACID that prevents Spina Bífida, it’s FOLATE. Folic acid is synthetic FOLATE and is not synthesized by 50% of the population. Folic acid is attributed to midline defects, TT, PTT and ULTs being 3 of the midline defects showing up in DROVES. The %s stated in this article are of ALL babies born. If we were to look at ‘Newborns and moms seeking help due to problems’ as a cohort, the stats would change dramatically.

    I have my own fail proof tool; listening to and watching the mom and the baby. It’s amazing how much they know and how much they want to tell us if we just listen.

    Asking a mom and baby to nurse un-productively or inefficiently 10 times a day for more then a couple of days is, in my opinion, very unprofessional.

    I have met clients of Allison’s who tried for 6 weeks or MORE. That is over 300 feeds that were painful, unproductive and or inefficient. That is NOT ok.

    Does her method work? Sometimes it does. Did I believe body work is an integral part of healing and successful breastfeeding? YES. I instruct all parents on TUMMYTIME! and give referrals to body workers.

    I spent 6 months in Columbus, Ohio last year. I did not advertise as an IBCLC but word got out I was there and people sought me out. I was shocked at how many complaints I heard about Allison. I had been so looking forward to meeting her and perhaps spending some time with her.

    Three of her references are prior to 2006. Breastfeeding has changed radically since then.

  2. What a disservice this article is to parents. As a 60 year old maternity nurse who has suffered all my life from the effects of tongue/lip tie this article makes me angry. I had my friend to you last February and have seen a marked improvement in my symptoms and can not wonder how my life would have been had I been diagnosed and corrected as an infant. I know now that two of my sons are tied and 5 out of my 7 grandchildren have varying degrees of severity yet only one has had had her ties released. Shame on you Allison for continuing to discredit the work being done out there on ties or even believing how frequently it is happening. I will just have to put you up there with the pediatricians who refuse to deal with it.

  3. So LLL endorse this content? Beyond disappointing

  4. Much along my thoughts too AA…..

  5. Heidi Croal Says: December 16, 2016 at 3:14 pm

    The best most balanced and sensible article written on the subject! The reply’s above are extremely critical, judgmental and as professionals they should know better to reply in such a derogatory way. Alison’s article is research based and very sound. We as professional do not have to agree, especially when there is very little and only anecdotal evidence and we certainly should not be bashing a highly respected professional who literally wrote the book on tongue tie and started the whole debate. Shame on those above for the way they articulated their opinions. We are all trying to help moms succeed at breastfeeding and should be supporting one another as professionals not like children bashing each others ideas. We can debate professionally and that is what Alison did. I have great respect for you Alison! Thank-you.

  6. Alyssa R.C. Says: January 18, 2017 at 8:47 pm

    Annie VerSteeg,

    Alison’s name is spelled with one L not two. I believe her years of experience at least afford her the respect of spelling her name correctly. Interesting that you “treated” many of her clients after they sought treatment with her unsuccessfully, why would you not contact Alison to consult on these cases if your treatment was so much more successful than hers. For the sake of continuity of care. Only 4-5% of babies are tongue-tied, posterior tie is still only a theory and there is NO research to support upper lip revision in breastfeeding so if you were referring parents for revision congrats on practicing unethically. Dr. Hazelbaker NEVER releases a client from care before resolving the issue, that doesn’t mean that parents don’t discontinue care on their own (AMA so to speak). You were only in Columbus for 6 months, how many of her clients could you really have seen in that time? It sounds like you spent the bulk of your time listening to false accusations about Alison and less time attempting to meet or get to know her on your own. Me thinks you are a master of hyperbole.

    Dr. Hazelbaker’s assessment tool is the ONLY evidenced based tool in existence and is used worldwide. Every other tool that has attempted publishing has failed to measure up to the ATLFF. Perhaps you don’t know how to use it correctly? Diagnosing tongue or lip tie off of appearance or simply watching and listening to mom and baby is not evidenced based and frankly is unethical, unless there is some new research study out there that confirms watching and listening to mom and baby nurse is enough to warrant revision.

    Counseling is an integral part of lactation care. That is something Dr. Hazelbaker stresses in her practice and with a Doctorate in Psychology has quite mastered.

    Unfortunately this community of women is unsupportive of Dr. Hazelbaker and has spent more time criticizing, berating, libeling and outright gossiping about her and has done a fine job of tainting her reputation to no fault of her own. Shame on you for perpetuating the problem.

    As a community of women who should be working to embrace, encourage and support women in this field of work we should do less gossiping and spend more time lifting one another up.

    As far as this article being a resource for parents, what is wrong with encouraging parents to ask questions and do research? Especially when it comes to allowing an inexperienced practitioner to slice into their baby’s tongue or lip with a laser that shouldn’t be used for this kind of treatment in the first place. If the doctor or dentist doesn’t want to be bothered spending extra time answering parents questions and they’re only offering this service to make quick money they shouldn’t be treating babies at all.

  7. […] lengthy article by a La Leche League (LLL) leader and International Board Certified Lactation Consultant (IBCLC), […]

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