My issue with doing this procedure would be similar to any other surgical 
procedure. The reason my ped doesn't do them, and refers out to an ENT 
practice, who actually DOES them (had a baby taken care of last week)is 
that she, my Ped, says, "I'm not a surgeon and don't do surgical 
procedures." (FTR, she also doesn't do circs for the same reason. Let's 
not open that can of worms. :) ) 

I would be concerned about the vein, that in some babies does lie VERY 
close to the Frenulum. Severe bleeding could occur, with a very small slip 
of the scalpel or scissors and I know the docs I work with will often do 
the procedure in the hospital, if they are concerned with either a bleed 
issue or a situation where sometimes the frenulum is thick, and might need 
more than a simple snip. I would be concerned with proper sterile field 
precautions, and of course, the fact, that I would not be able to use 
viscous Xylocaine (prescription medication) to numb the fren,(some babies 
seem to feel little or no pain, while others cry quite heartily, although 
they are all given Tylenol AND Xylocaine before the procedure)  as well as 
not be able to treat the mom or baby with antibiotics, if any infection 
occurs. (Very often the ENTs I work with will indeed prescibe something 
like Diclox, as the mother's nipples are often quite damaged, and it is 
almost a given that there is some nasty bacteria in the cracks, which will 
impair healing, increase inflamation and increase pain. If we notice the 
fren right away (not usually the case as about 99% of the tight frens seen 
by LCs were "missed" in the hospital, and often by the doctor at the first 
or even second visit, and were only noticed when the pain for mom was 
severe she called me, or one of my collegues.) Of course, my concern also 
lies with maybe losing my practice, and maybe my home may be the result of 
a bleed, an infection, being charged with practicing medicine without a 
license, or other situations. I'd rather let the doctors deal with this. 

It is very frustrating to see situations where the doctors simply will NOT 
treat the fren, or, in the original case presented, refuse to even admit 
it is present. I, too, have heard doctors say, "Oh, we never do that any 
more. We don't have to anymore." What has changed? Babies certainly don't 
have fewer instances of tight Frenulums, I think the "Oh, she can always 
just use a bottle and pump, or 'keep trying'." is a "much more simple" 
solution, in some's eyes. But, unless we are all given CLINICAL training 
and have the facilities to provide a sterile field, are allowed to 
prescribe drugs, like Xylocaine and antibiotics (or even codeine or 
Vicodin to these mothers who are often in excruciating pain) the safety 
for both ourselves and our clients does require an MD, a DO,a DDS or a NP 
to provide the actual surgical procedure.

What I have found very helpful for my clients is for me to give them a 
letter (type written, with a copy for me, WITH a reference to the newer 
study which showed the superiority of clipping on breastfeeding success) 
(perhaps one of the other LCs could help out here, I have the reference to 
the study in an other place) for her to bring with her to the ENT and the 
Ped. I also call the ENT's office, quickly tell them what my findings 
were, and that I know the doctor might be willing to help, and then type 
up my report and fax it to the doctors, stat. I have found that this 
approach is VERY succesful in getting the procedure done, usually very 
soon, and of course, I include in my report the pain the mother is in 
(adding that, if it is true, there is "no excessive complaining noted, 
despite the severe pain this woman appears to be in" doctors seem to, for 
some reason, really respond to this. *sigh* I also include that I will do 
a follow up, with at least 2 weight checks in the next week, to make sure 
that the latch IS being adjusted, the wound on the mother and baby are 
healing and that the baby is transfering milk and gaining well. Having a 
good repoire with a good ENT is really key, in this respect. I also 
include that I did refer the mother to this partcular EMT or Ped Dentist, 
if true, which, of couse, is also helpful. 

Anything to get the procedure done, help the baby latch, insure good milk 
transfer, and get the mother as comfortable as possible breastfeeding.

I would be happy to post the letter I faxed last week, (the mother has 
given me permission, and I would not use the doctor's name) for which the 
doctor agreed to clip and did so. In this case,  the receptionist sceduled 
the procedure a week hence. I was then informed that doc hadn't received 
the fax yet, when we made sure that was done, he called and rescheduled 
for the next morning. 

Although this is a pretty frustating situation, there are trained 
professionals who will do the procedure. They have the training, the 
equipment, the medications, and, of course, the malpractice insurance.

Good luck to all,

Mary Jozwiak IBCLC, RLC
Private Practice

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