Ankyloglossia (tongue-tie) in a breastfed infant may interfere with effective breastfeeding and cause maternal nipple pain and trauma. It has been identified as a risk for premature breastfeeding cessation. This guideline outlines assessment and management of babies born with suspected or confirmed tongue-tie.

To optimise breastfeeding support through effective assessment and management of tongue-tie in babies.

EMR: Electronic medical record (Bossnet)

HATLFF: Hazelbaker Assessment Tool for Lingual Frenulum Function

Tongue-tie (ankyloglossia): a congenital condition in which the lingual frenulum is abnormally short, tight or thick, and may restrict mobility of the tongue.

Tongue -tie is defined primarily by functional limitation rather than by appearance. If the frenulum restricts tongue movements required for effective feeding, it may be defined as a tongue-tie. On the other hand, a frenulum that appears short and tight may not restrict tongue movement and therefore is not a tongue-tie.

Whilst there is currently no consenus on classification of tongue-ties, they are broadly classified as anterior or posterior. This guideline is primarily related to management of anterior tongue-ties.

Frenotomy: Division of the lingual frenulum by sterile scissors or laser.

Following thorough assessment of breastfeeding and ensuring correct positioning and attachment, signs that a baby may have a tongue-tie include:

• Nipple pain and trauma

• Misshapen nipples after breastfeeding

• A compression or stripe mark on the nipples after breastfeeding

• Frequent loss of suction while feeding

• Clicking sounds while feeding

• Prolonged length of feeds

• Lack of satiety after feeds

• Poor weight gains

• The baby's tongue cannot extend beyond the baby's lips

• The baby's tongue cannot be moved sideways or there is poor tongue lift

• The baby's tongue tip may be notched or heart-shaped

• The baby's tongue may look flat or square instead of pointed when the tongue is extended.

Contraindications for surgical frenotomy may include oral malformations such as cleft palate, Pierre Robin Sequence, bleeding disorders, neuromuscular conditions and Vitamin K deficiency.

• The lingual frenulum is a normal structure. Tongue- tie exists only if the frenulum is so short or tight that it restricts functional movement of the tongue.

• There are varying degrees of tongue-tie and not all require frenotomy.

• Tongue-tie may lead to inefficient milk removal and subsequently low milk supply.

• Management is determined on a case by case basis taking into consideration anatomical appearance, any functional restriction of tongue movements and breastfeeding assessment.

• Where there are no feeding problems, frenotomy is not indicated

• If tongue-tie is suspected as the cause of breastfeeding problems, early frenotomy within the first few weeks of life appears to be associated with better breastfeeding outcomes.

• There is limited evidence on the effect tongue-tie may have on speech development and there is no existing method for predicting potential speech difficulties in babies with tongue-tie.

• Although tongue-tie primarily affects breastfeeding, occasionally a bottle-fed baby with a severe tongue-tie may require frenotomy for feeding difficulties.

• Clinicians should avoid using the term 'tongue-tie' until a definitive diagnosis has been made on the basis of skilled breastfeeding and oral assessment. The term 'prominent frenulum' is suggested as an alternative when explaining initial examination findings to parents.

Posterior tongue-tie / Laser release of tongue-ties/ referral to other providers

Laser release of tongue-ties are not performed at Grampians Health and management of posterior tongue-tie and laser release are not within the scope of the guideline. If a posterior tongue-tie is suspected, the baby may be referred to a lactation consultant, paediatrician, a paediatric dentist or a paediatric surgeon for further assessment. The Breastfeeding Service at Grampians Health Ballarat maintains a list of healthcare practitioners who provide surgical and/or laser tongue tie release.

Parents should be advised that Grampians Health does not specifically endorse the practices of these providers. Parents should discuss all options offered for management of tongue-tie with other providers and seek alternative opinions if they feel uncomfortable with treatment offered.

If frenotomy is required:

• Sterile frenotomy scissors

• A small piece of sterile gauze

• Examination gloves

• Examination light

• Firm surface

• Oral sucrose solution or expressed breastmilk

Assessment of Tongue-tie

A detailed clinical assessment is necessary to determine the presence of and degree of tongue-tie and exclude other possible causes of breastfeeding problems. Assessment should include maternal and infant history, oral examination and breastfeeding assessment. This must be made by an experienced lactation consultant or doctor and should include all of the following;

1. Identification of maternal factors

• Parity and previous breastfeeding experience

• Nipple and areola size, shape, elasticity and whether flat or inverted

• Presence of nipple pain or trauma

• Plans for continued breastfeeding

2. Family history

• History of parent or sibling with tongue-tie

• History of bleeding disorders in the family

3. Identification of infant factors which may be associated with feeding problems.

• Gestation at birth and current age of baby

• Congenital abnormalities and other medical issues

• Birth history, including maternal analgesia and anaesthesia

• Time to first skin contact and first feed

• Hydration, output, weight loss

4. Visual and digital assessment

• Use the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) to assess lingual function and appearance (see Appendix 1)

• Examine the baby's mouth for any other oral abnormality such as cleft palate, high arched palate.

• Refer to speech pathologist and/or medical practitioner for specialist assessment of any other oral abnormalities identified.

5. Feeding assessment

• A full breastfeeding history and assessment must be completed to identify if feeding problems are due to poor technique or other factors. (Refer to Assessment of Breastfeeding in the Breastfeeding the Healthy Term Newborn guideline CPP0443).

• Assessment and correction of any positioning and attachment issues must be made before any decision is made regarding frenotomy.

• Ensure treatment of any nipple pain and trauma.

Documentation of assessment

The e-form MR135.3 Tongue tie assessment and release is completed in the baby's EMR following assessment, including any recommendations and management.

Decision regarding the need for frenotomy

Following assessment, discuss with baby's parents the recommended management as follows:

HATLFF function score 11 or above with appearance score 10 or above and NO breastfeeding problems

• Frenotomy is not indicated

• Advise mother to seek help promptly if breastfeeding problems develop - ensure she is aware of breastfeeding support service contact details

HATLFF function score 11 or above with appearance score 10 or above WITH breastfeeding problems

• Assess and manage breastfeeding problems

• Offer conservative management

• Frenotomy may be recommended if problems persist despite skilled assistance

HATLFF function score less than 11 with appearance score less than 8 and NO breastfeeding problems

• Frenotomy is not indicated

• Arrange follow-up appointment at Breastfeeding Clinic at 2-3 weeks of age for breastfeeding assessment

• Frenotomy may be recommended following review if indications develop

HATLFF score - function score less than 11 with appearance score less than 8 WITH breastfeeding problems

• Assess and manage breastfeeding problems

• Frenotomy may be recommended if parents' consent

• Offer conservative management if parents do not consent to frenotomy

 Conservative / expectant management

There is limited evidence about the effectiveness of non-surgical management for tongue-tie. A 'wait and see' approach is often appropriate as many early breastfeeding problems may be overcome with skilled support, without the need for frenotomy. Conservative strategies which may be useful include:

• Positioning and attachment modifications

• Use of nipple shields

• Expressing and topping up or exclusively bottle-feeding expressed breastmilk (EBM)

• Supplementation at the breast using a supply line

If conservative management is the preferred option in the newborn period, follow up at Breastfeeding Clinic should be offered within 2 weeks to re-assess and frenotomy offered if indicated.

Frenotomy can be performed at Paediatrics Ballarat up to around 6-8 weeks of age. A referral is required; this can be arranged through the Breastfeeding Support Service following assessment.

Parent request for frenotomy

Shared, informed decision making between clinicians and parents must take into account the parents preferences and values. The assessment outcome, risks and benefits of each option should be discussed. Parents who request frenotomy without a clear indication should be referred to a Paediatrician for further discussion.

In the absence of current problems, there is no evidence to support frenotomy to prevent possible future feeding or speech problems.

Parent Information

Provide parents with a copy of Tongue-tie: information for families from the Royal Women's Hospital - see Appendix 2.

Speech Pathology Australia also provides information for parents - see Appendix 3

Frenotomy Procedure

The procedure may be performed in babies up to 3-4 months of age depending on individual practitioner preference, without anaesthesia with little discomfort to the infant.

Frenotomy may only be performed by a Lactation Consultant or Medical Officer trained in the procedure.

If the frenulum is very thick, release by a lactation consultant is inappropriate: the baby should be referred to a medical officer experienced in frenotomy or paediatric surgeon.

If a blood vessel is visible, the frenulum should only be released where there is appropriate equipment to ensure haemostasis. Referral to a paediatric surgeon is required.

 Vitamin K administration

• Tongue-tie should be delayed until 24 hours after baby has received intramuscular Vitamin K (Phytomenadione) or 24 hours after the baby has completed 2 oral doses of Vitamin K.

• If parents have chosen not to administer Vitamin K, recommend that this should occur before frenotomy is performed.

• If there is a family history of significant bleeding disorders, such as haemophilia, refer for surgical opinion.

Consent

Informed verbal consent must be obtained from a parent/caregiver prior to the procedure. Document verbal consent on the Tongue-tie Assessment and Management e-form MR 135.3

Points to discuss

• Rationale for the procedure, alternative options

• Risk of bleeding and infection

• No guarantee that frenotomy will solve breastfeeding problems

• How the procedure is performed

• Possible need for repeat procedure

• Requirement for administration of Vitamin K (as above)

• Family history of bleeding disorders (as above)

• Follow up care

Procedure:

1. The procedure is explained to the parents, who may choose to be present if they wish.

2. The baby needs to be awake, but not distressed. The procedure is preferably performed immediately prior to a feed so the baby can be comforted at the breast immediately afterwards and to prevent vomiting of a recent feed.

3. Give the baby oral sucrose 0.5-1ml - refer to CPG0156 Neonatal eHandbook

4. The baby is placed supine on a firm, secure surface under an examination light. (e.g. baby resuscitation cot, consulting room bed).

5. An assistant raises the baby's arms and holds the elbows close to the baby's ears, securely but gently restraining the head and arms. Alternatively, the baby is wrapped securely, and its body and head gently restrained by the assistant. Slight extension of the head can assist mouth opening and exposure of the frenulum. The chin can also be stabilised by the assistant's finger or a third person if necessary.

6. The clinician performing the procedure lifts the tongue with gloved finger and thumb on either side of the frenulum to clearly expose it.

7. Using sterile scissors, the frenulum is released by approximately 2 to 3 mm at its thinnest portion, between the tongue and the alveolar ridge, into the sulcus just proximal to the genioglossus muscle.

8. Care is taken not to incise any vascular tissue, the base of the tongue, the genioglossus muscle, or the gingival mucosa.

9. The clinician wraps a small piece of gauze around the index finger and presses gently but firmly down on the floor of the mouth for 20-30 seconds to complete the release (blunt dissection).

10. There should be minimal blood loss, i.e., no more than a drop or two, collected on the sterile gauze.

11. The initial cut is assessed for effectiveness and if necessary, another small cut is made.

12. The frenulum is assessed again after a second cut.

13. The mouth is inspected for bleeding before the baby is comforted and offered the breast.

14. Re-assessment of nipple pain and infant attachment should occur post release.

15. Following a breastfeed, the mouth is examined again to ensure there is no bleeding and to assess the effectiveness of the release.

16. No specific post procedure care is required. Occasionally a small white, diamond shaped wound may be seen under the tongue; explain to the parents that this is normal and should heal within two weeks of the release.

Documentation

Document all assessment findings, recommendations, verbal consent and procedure on MR135.3 Tongue-tie assessment and release or in the baby's inpatient progress notes or applicable outpatient documentation.

Document the procedure in the baby's green child health record - medical procedures section (behind the growth charts)

Record procedure in frenotomy database on Breastfeeding 'S' drive

Follow up

Clinical follow up after frenotomy is important particularly if there have been significant breastfeeding problems. Follow up may be by phone, Telehealth or in person.

Follow up assessment should include:

• Effectiveness of frenotomy procedure

• Oral assessment

• Documentation of any adverse events following the procedure

• Breastfeeding assessment