Tongue tie surgery (frenotomy) is the new tonsillectomy. It’s a surgery that is necessary for certain narrow indications but has become extremely popular to treat conditions that don’t need treatment.

Even members of the Academy of Breastfeeding Medicine have been forced to conclude that it is often poorly done, often wrongly done and harms babies.

Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey was published in International Breastfeeding Journal earlier this year.

Tongue tie surgery has exploded in frequency and purported indications in the early 21st Century. As the authors explain:

In the past 10–15 years, there has been increased concern about ankyloglossia and its effect on infant breastfeeding. This has been associated with increased performance of frenotomy. Physicians and other healthcare professionals with expertise in breastfeeding have voiced concerns about complications related to the performance of infant frenotomy…

Only members of the Academy of Breastfeeding Medicine were surveyed about their professional experience.

What did they find from this small group?

Seventy-eight (37%) respondents reported caring for an infant with a complication, 100/211 (47%) reported caring for an infant with a misdiagnosis, 130/211 (62%) reported caring for an infant with a complication or a misdiagnosis with 81/211 (38%) of respondents reporting not caring for an infant with a complication or a misdiagnosis. Seventy-four (56%) of respondents who classified themselves as a breastfeeding medicine specialist reported caring for infants with complications or misdiagnoses compared to 58 (44%) who did not report being a breastfeeding specialist. There were no differences in location of practice, years in practice, gender of provider, or clinical time caring for breastfeeding patients between those who reported caring for a patient with a complication or misdiagnosis and those who did not.

The results are startling:

More than 80% of the ABM physicians surveyed had cared for babies who had major misdiagnoses. And the misdiagnoses were not subtle or subjective. Fully 42% of those babies were cut unnecessarily when neuromuscular dysfunction — not tongue tie — was the source of breastfeeding difficulties. A further 12% had major anatomic anomalies (cleft palate, Pierre Robin Syndrome, retrognathia) indicating that the diagnosis of tongue tie was made by someone who didn’t actually examine the baby or had no idea what normal infant anatomy looks like.

These misdiagnoses are not trivial issues because tongue tie surgery can have significant complications. In addition to babies who experience bleeding requiring medical attention, infection and abscess, ABM members reported that over 25% of complications involved oral aversion. Think about that for a minute: babies who were forced to undergo mouth surgery — simply so they could breastfeed instead of consuming pumped breastmilk or formula — experienced so much pain that they stopped eating altogether! Breastfeeding became NOT the close bonding experience promised by lactation consultants, but agony for the baby.

Further analysis revealed that the incidence of oral aversion was highest in babies subjected to more expensive forms of surgery:

Historically, frenotomy has been performed with scissors with use of the laser increasing… The pediatric ENT consensus statement concluded that there is “insufficient evidence to support claims that one technique of frenotomy, such as laser, is superior to other techniques”. We found that use of the laser/bovie/electrosurgery was significantly associated with oral aversion/feeding refusal as a frenotomy complication.

The authors conclude:

Infant frenotomy can have associated complications and misdiagnoses, some of which are associated with location and method of frenotomy. Recommendations for avoiding complications and misdiagnoses include the following. Physicians and dentists need to work closely with lactation professionals to optimize breastfeeding support and to evaluate for other causes of breastfeeding problems before referral for or performance of frenotomy. Physicians and dentists need to be able to engage in an informed discussion and shared decision making about ankyloglossia, its effects on breastfeeding, the frenotomy procedure and its possible complications before referral for or performance of frenotomy…

What should parents take away from this study:

1. Tongue tie is often misdiagnosed
2. Tongue tie surgery can cause severe pain for babies
3. Tongue tie surgery is almost never “necessary” because pumped breastmilk or infant formula can treat the problem without surgery and without pain for babies
4. Tongue tie surgery should not be done without a second opinion
5. Parents should be very wary about consenting to tongue tie surgery if a second opinion raises questions about the need for surgery.

It is important to note that this study is merely a survey of breastfeeding professionals, not a study of babies. The actual incidence of misdiagnoses and complications may be different from what the study implies. It is valuable nonetheless because even members of the Academy of Breastfeeding Medicine — the professionals most committed to promoting breastfeeding — are acknowledging major misdiagnoses and serious complications of a surgery that is more common than ever.

Is attachment parenting ”best”?

It’s critical to interrogate the dominant philosophy of contemporary parenting to understand whether it is truly the best way to parent children or merely a reflection of unexamined beliefs about the role of women, market culture and subconscious racism and classism.

The ‘good’ attached mother: An analysis of postmaternal and postracial thinking in birth and breastfeeding policy in neoliberal Britain by Patricia Hamilton is a fascinating effort to understand. In her paper Hamilton goes beyond the misogynist religious injunctions of the last century that inspired attachment parenting to market driven, racism inflected beliefs of the 21st Century.

Parenting today is defined by a growing list of ever more specific decisions and duties, often made in the early years of child-rearing. Increasingly individualised, these choices, which include infant feeding options and sleeping positions, have taken on tremendous significance in neoliberal society, a socio-political context defined by market logic…

A new parenting paradigm, attachment parenting (AP), has emerged to guide child- rearing choices and has grown in influence with the entrenchment of neoliberalism. In this paper, I examine the correspondence between attachment parenting … and parenting-related policies advanced by the neoliberal state. This process is illuminated by examining motherhood through the perspective of black women, revealing the raced, gendered and classed dimensions of ‘good’ parenting that neoliberal ideology seeks to disguise.

This is a novel lens. Instead of examining the impact of attachment parenting on the children of those who promulgated its tenets — Western, white, middle and upper class — Hamilton asks us to evaluate the philosophy by its impact on non-Western, non-white poor women. This, she believes, will tell us more about the true purpose of the philosophy.

Hamilton looks specifically at birth and breastfeeding policy in Britain. The state has been very active in aggressively promoting both midwifery and compulsory breastfeeding regardless of what women actually want. According to the logic of AP that’s what’s best for babies. But Hamilton suggest that babies have nothing to do it. Birth and breastfeeding policy are driven by what is good for the neoliberal state.

Consider, for example, midwifery care.

[C]linical practice director, Mark Baker’s … is quoted in The Guardian: ‘Surgical interventions can be very costly, so midwifery-led care is value for money while putting the mother in control and delivering healthy babies’

Baker’s analysis communicates three points: first, it points to cost-cutting as a primary motivation … Second, it suggests that saving money and the promotion of (neoliberal) maternal autonomy and child health are goals with equal value … Finally, the attention to maternal autonomy contributes to the celebration of self-governance central to neoliberal citizenship… Baker’s explanation demonstrates the twin duties performed by the neoliberal state – the cutting of welfare spending is accompanied by an investment in ‘health-related technologies, programs, and healthcare and public healthcare arrangements that aim to produce new kinds of citizens’…

Simply put, the state has identified a way to save money by exerting control over women’s bodies and then pretending that this is what’s best for babies and mothers.

[S]uch programs and technologies contribute to an ideal of ‘good’ motherhood that prioritises a narrowed definition of choice that supports some women and excludes others.

But that’s apparently acceptable when those who are supported are Western, white and relatively well off while those who are excluded are women of color and underprivileged women. Those who are most likely to be harmed come from groups with higher maternal mortality rates and therefore most in need of obstetric, not midwifery, care.

The desire to save money through the bodies of women is even more explicit in breastfeeding promotion. There is an entire subset of the breastfeeding literature that repeatedly calculates the purported savings to entire economies of Western countries if only they could force more women to breastfeed.

It is well known that breastfeeding is social patterned with wealthier white women more likely to breastfeed than women who suffer from racism and economic inequities.

However, despite this recognition, rather than developing policies that address socio-economic inequality, the state’s intense focus on breastfeeding has led to the construction of an idealised version of motherhood that equates breastfeeding with ‘good’ mothering…

For black mothers then, their capacity to feed their infants ‘correctly’ is a measure not just of ‘good’ motherhood but also an indication of deservingness; practices that limit black women’s use of state resources draw attention away from whether they are and ought to be citizens in the first place …

Black women’s “failure” to breastfeed can therefore be constructed as a failure to save the state money, a fraught proposition for women already stereotyped as undeserving.

Hamilton welcomes increased government support for midwifery care and breastfeeding promotion if it increases women’s available choices. But it actually narrows them by foreclosing other choices that women might prefer.

The government has disguised its promotion for midwifery and breastfeeding as what the country can do for babies and mothers — when the reality is that the aggressive promotion of both unmedicated vaginal birth and breastfeeding is what women can do for their country.

That’s much easier to understand when we look at the impact of the philosophy on those it harms.

Attachment parenting has become the dominant parenting philosophy in Western countries in the early 21st Century. The ostensible reason is because it’s good for babies, making them more securely attached, happier and ultimately more productive citizens.

That has been the justification for government promotion of policies that are based on AP recommendations. Such policies include the bias toward midwifery care in most industrialized countries, efforts to reduce birth interventions, C-section targets, aggressive breastfeeding promotion, rooming in during postpartum hospital stays, and baby-wearing.

But what if attachment parenting isn’t about what’s good for babies? What if it’s about what’s good for the State? Or perhaps it’s about what’s good for social conservatives?

How can we tell?

I suggest we should interrogate the individual tenets of attachment parenting by asking three questions:

Who profits? Who’s harmed? Who avoids responsibility?

C-section Targets

Consider the C-section target rate of 10-15%. There’s never been ANY scientific evidence for such a low target rate. Indeed the best scientific evidence thus far, produced by Atul Gawande, Neel Shah and their colleagues, indicates a MINIMUM C-section rate of 19% in order to ensure low maternal and neonatal mortality. So why do so many countries promote a C-section rate incompatible with safety?

Who profits from low C-section rates?

In most industrialized countries the government pays for C-sections. Even in the US, which lacks national health insurance, the government pays for a substantial proportion of C-sections through its provision of Medicaid. Therefore, the government profits when C-section rates are held artificially low.

Who is harmed?

Babies and mothers are harmed. Some babies sustain permanent brain injuries because of C-section targets. Some babies and mothers die. Groups of ethnic minorities or low socio-economic status (or both) suffer more than most since they are often more likely to experience complications that are best treated by C-sections.

Moreover any women who want maternal request C-sections suffer through labors they did not want to endure.

Who avoids responsibility?

Artificially low C-section targets allow governments to avoid responsibility for providing high quality medical care. Instead of acknowledging they are withholding needed medical care from vulnerable populations they can deny the harm they cause by pretending — in line with AP philosophy — that reducing C-section rates improve infant outcomes.

Breastfeeding

Consider aggressive breastfeeding promotion. The government has a myriad of initiatives to pressure women into breastfeeding as if how a woman uses her breasts is any of the governments’ business. But according to the tenets of AP breastfeeding improves bonding which leads to happier, more productive people who are supposedly healthier (and therefore cheaper to care for).

Who profits from aggressive breastfeeding promotion?

In most industrialized countries the government is the leading purchaser of infant formula. Forcing women to breastfeed is pure profit; the government pays nothing and the mother pays all the costs — and there are many. Breastfeeding is not free; for many women it is the difference between a steady income and no job at all.

Breastfeeding rates are socially patterned. Wealthier, white women are most likely to breastfeed and poor women and women of color have far lower breastfeeding rates. Therefore, while breastfeeding promotion appears to affect the entire population equally, it is those women who are most likely to need government support who are impacted.

Who is harmed?

Ironically the greatest harm is done to the very children who are supposed to benefit. Exclusive breastfeeding — leading to dehydration, hyperbilirubinemia and starvation — has become the leading risk for newborn hospital readmission.

Women are also harmed by aggressive breastfeeding policies that can compromise their mental and physical health. Moreover women are harmed by any policy that considers their time worthless as breastfeeding policy does.

Who avoids responsibility?

Promoting breastfeeding allows government to avoid responsibility for providing infant nutrition. Instead of acknowledging that they are saving money by foisting the costs of nutrition onto mothers, they can deny the harm they cause by pretending — in line with AP philosophy — that increasing breastfeeding rates improve infant outcomes.

Baby Wearing

There is zero scientific evidence to support baby wearing. It is a recommendation that was fabricated specifically to make it impossible for mothers to work. But wait! Didn’t Native American mothers carry their babies everywhere? They did but — in direct contrast to skin-to-skin — they used cradleboards.

According to Wikipedia:

Cradleboards were used during periods when the infant’s mother had to travel or otherwise be mobile for work … The cradleboard could be carried on the mother’s back … The cradleboard can also be stood up against a large tree or rock if the infant is small, or hung from a pole (as inside an Iroquois longhouse), or even hung from a sturdy tree branch…

So Native American mothers carried their babies everywhere for the same reason other indigenous mothers did: so they could work, NOT so they could avoid work.

Who profits from baby wearing?

Social conservative can benefit when they can disguise misogyny as “better for babies.”

Who is harmed?

Mothers are harmed by efforts to keep them immured within the home, especially when they are pressured to do by fabricated claims that their children will be damaged if they don’t stay in physical contact continuously.

Who avoids responsibility?

In this country AP helps the government avoid responsibility for mandating adequate maternity leave and providing high quality daycare. AP implies that women shouldn’t work so governments musn’t help women manage the inherent contradictions between providing nurturing care as a mother and taking one’s place in the market economy. Either they must stay home with their children (as social conservatives want) or they must devote themselves to their jobs (the imperative of a market economy).

Asking the same three questions is a good exercise to apply to any tenet of AP. You might be surprised by what you find.

The bottom line is that while Attachment Parenting is promoted as better for babies, it is often better only for governments or social conservatives.

Do the purported benefits of breastfeeding really exist or are they merely artifacts of wealth, health and privilege. A new paper dramatically demonstrates what happens to the benefits of breastfeeding when you take confounding variables into account.

The paper is To what extent does confounding explain the association between breastfeeding duration and cognitive development up to age 14? Findings from the UK Millennium Cohort Study by Peyrera-Ellis et al.

The authors start with the assumption that breastfeeding improves children’s cognition but acknowledge what critics (including me) repeatedly argue:

A systematic review found that on average breastfed infants scored 3.44 points higher in standardised intelligence tests than their non-breastfed peers, however, a causal relationship is still debated. It is argued that improved cognitive outcomes could be explained by other characteristics of the women who breastfeed their babies, principally socioeconomic position (SEP) and maternal intelligence.

The authors provide one of the best illustrations I ever seen of the many confounding variables that impact breastfeeding research.

It shows that maternal characteristics have important effects on cognition and ALSO have important effects on breastfeeding duration. Therefore any research that seeks to quantify the impact breastfeeding has on child cognition MUST take them into account or the results will be invalid.

This authors looked at data from 7,855 singletons born in 2000–2002 and followed up to age 14 years within the UK Millennium Cohort Study. What did they authors find?

A picture — or in this case two pictures — is worth a thousand words.

This is the impact of breastfeeding on standardized cognitive verbal scores:

This is the impact of breastfeeding on standardized cognitive spatial scores:

These charts illustrate four points:

1. The purported impact of breastfeeding on cognition steadily melts away as ever more adjustments are made for confounding variables

The top set of measurements depict the uncorrected data. If you were to only look at that you might think that breastfeeding has a significant impact on cognition

But when you read the charts from top to bottom as successive corrections are made for confounding variables in models 1-4, you can see that the magnitude of the effect drops dramatically until it is less than 0.03 standard deviations meaning that the difference is very small.

How do the authors spin the result that impact of breastfeeding is actually small?

Adjustment for SEP explained approximately half of the initially observed associations. Further adjustment for maternal cognitive measures failed to completely remove the remaining associations at ages 7, 11 and 14. The fully-adjusted coefficients where there is evidence of an effect of breastfeeding on verbal cognitive scores varied between 0.08 (age 7; <2 months vs never breastfed) to 0.26 SD (age 14; ≥12 months vs never breastfed). For spatial scores, the coefficients varied between 0.08 (age 7; <2 months vs never breastfed) to 0.19 SD (ages 7 and 11; 4 to <6 months vs never breastfed). This suggests that while the association in this population is not completely due to confounding, the effect of breastfeeding on cognitive development is modest in this population.

2. The remaining small impact of breastfeeding on cognition may simply reflect residual confounding.

In their illustration of confounding variables the authors include paternal cognitive score but acknowledge that they could not adjust for it because they did not have that information.

We also considered the possibility that the remaining associations were explained by residual confounding produced by unmeasured confounders, such as paternal measures of cognitive ability or broader measures of maternal cognitive ability. This was assessed through the calculation of the E-values. In order to explain the aforementioned associations, any unmeasured confounder should be associated with both BF duration and cognitive scores with coefficients of at least 0.39 (to fully explain a coefficient of 0.10) or 0.68 (to fully explain a coefficient of 0.26). Therefore, while there is room for the associations to be further explained, it is unlikely that all the observed associations could be explained in full by additional adjustment.

But you don’t have to reduce the coefficient to zero in order for the impact to be nearly non-existent and paternal cognitive score as well as broader measures of maternal cognitive ability may account for most of the differences that the authors found.

3. If breastfeeding really leads to improvements in cognitive outcomes, we would expect there to be a dose-response relationship but that’s not what the charts show. There appears to be little relationship between the duration of breastfeeding and its purported impact.

4. The fact that the impact of breastfeeding appears to increase over childhood raises further questions and they recognize it.

The association at age 14 seems to be stronger than at other ages. The outcome was measured with a different instrument at age 14, which may contribute to the observed differences. However, these results seem to be in line with those of Kanazawa, who showed that the effect of BF on intelligence increased as children got older in the 1958 British Birth cohort… [T]hese findings could be due to chance or (less likely) to residual confounding and should be revisited in future studies.

The results suggests that it is another factor which could have a cumulative impact like socio-economic status (allowing access to successive better educational institutions for example), not breastfeeding, is responsible.

The authors conclude with the same assumption with which they started:

…[T]he role of breastfeeding on the child’s cognitive scores should not be underestimated. While a small increase in cognitive outcomes may not be clinically meaningful at the individual level, it has the potential to be influential at the population level…

The irony is that the role of breastfeeding on children’s cognitive development has been repeatedly over-estimated and, as the authors acknowledge is not clinically meaningful and therefore not a reason for an individual woman to choose to breastfeed.