INFANT TONGUE-TIE SERVICE INFORMATION FOR PARENTS
TONGUE-TIE
Tongue-tie which is a congenital anomaly characterised by abnormally restricted band of tissue under the tongue which may cause feeding difficulties (NICE, 2020).
Types of tongue-tie:
ANTERIOR OR POSTERIOR TONGUE-TIE
PLEASE NOTE: Not all babies who have tongue-tie develop feeding difficulties. Majority of feeding problems can be resolved by getting support and correct positioning and attachment techniques. Tongue-tie release procedure or “Frenulotomy” should only be considered in an event that despite effort to improve feeding has still been difficult.
Symptoms of tongue-tie on Breastfeeding:
*Mothers - may experience pain, sore/crack nipples, painful breastfeeding, low milk supply, oversupply, recurring mastitis, frequent blocked ducts, possible susceptibility to nipple thrush due to nipple trauma.
*Babies – may have poor latch quality/shallow latch, slipping on and off the breast, clicking noises during feed, reflux symptoms such as wind/colic, frustration, posseting, head rocking, arching back. Others may have slow/poor weight gain or fast weight gain, weight lost, very frequent or constant feeds that baby appears unsatisfied.
Symptoms of tongue-tie on Bottle feeding:
*Babies- may have clicking noises, poor seal in the bottle, lots of dribbling/spillage, very long feed, slow weight gain, frustration, reflux symptoms/wind/colic.
FRENULOTOMY - is a small procedure on releasing the baby’s tight frenulum “tongue-tie”
BENEFIT: to help improve baby’s tongue movement as an opportunity to improve the latch on feeding.
OUTCOME/EXPECTATION: It is important to understand that frenulotomy is not a full guarantee of solving all the feeding problems. Continuous support and establishing feeding are necessary. Most mothers reported good outcome, while others experienced that the feeding take some time to improve, but few have reported little or no improvement following the procedure.
Consideration: Baby had Vitamin K at birth, healthy baby without underlying complex medical issues like bleeding disorder. Frenulotomy can be done on babies who are less than 6 months of age without requiring anaesthetic. Babies who are over 8 weeks old can be given infant paracetamol/calpol before the procedure. It is also ideal that baby is hungry before the division.
Alternatives:
Some parents wish to avoid frenulotomy such as considering the following:
1. Waiting for growth – most babies, as they get bigger, the mouth and tongue also get bigger which may additionally improve the issues on feeding
2. Manual therapies like baby massage, or cranio-osteopathy. Some mothers feel that their baby feeds better after trying these and may not need a tongue-tie division if feeding is improving well.
3. Mix feeding- whether expressing breastmilk or supplementing with formula as per maternal choice.
RISKS:
Frenulotomy is a low risk and usually very quick procedure that most babies tolerate well. However, it is important for parents to understand its benefit and risks before requesting and consenting for the procedure. There is very little nerve ending in the tongue-tie tissue that the procedure itself won't cause pain but more of a temporary discomfort from the instrument or wound after the procedure.
RISKS
1. Pain/discomfort and minimal bleed - manageable by feeding immediately after procedure and calming techniques. Prolong bleed & infection are very rare, thus requiring emergency care is highly unlikely. The practitioner is well trained to handle this situation and rest assured that your baby’s safety will be prioritised.
2. Low risk or about 4% risk of tight re-attachment of the scar tissue as the wound heals. Some babies may develop tongue movement restrictions due to tight scar tissue as a result of wound healing. The feeding difficulties may develop again, although most babies will continue to feed better. It is important that mother seeks feeding support. There are very few babies who may need a second division only if absolutely necessary with parent’s informed choice.
3. Small risk of oral aversion – although most babies will feed normally, it is common that some babies may have temporary fussiness at least 24-48 hours post procedure. Mother can offer feeding responsively, and provide calming techniques such as skin to skin, cuddles, music, baby bath etc
Please Note: you may notice white/yellowish colour under the tongue few days post division. This is not a sign of infection but a normal wound healing. This should turn pink/red again in 1-2weeks.
AFTER CARE:
1. If you are Breastfeeding, continue to breastfeed responsively or offer the breast every 2-3 hours to exercise the tongue well after the procedure. The action of frequent breastfeeding may help strengthen the tongue muscle which may reduce the risk of tight scar tissue. If you are bottle feeding, there is anecdotal claims of some professionals that this may increase the risk of tight re-attachment. However, the possible benefit of frenulotomy may outweigh the risk in terms of infant feeding improvement.
2. In an event of the rare occurrence of prolong or sudden bleeding which is not managing by feeding or sucking – with clean gauze or muslin, apply firm pressure under your baby’s tongue for 5 minutes ensuring clear airway, and call 999 or go to your nearest A&E. Please refer to ATP bleeding management leaflet.
3. Tongue Exercises
a. Baby sucking on the parent’s clean index finger to encourage tongue extension. Playing and talking to your baby may also encourage this as your baby will stick out his/her tongue frequently. Other ways of gentle tongue exercises will be demonstrated to you and videos will be provided for reference.
VIDEOS FOR TONGUE EXERCISES POST-FRENULOTOMY
b. Avoid dummies if possible, encourage frequent breastfeeding.
c. Wound massage under the tongue (OPTIONAL as we lack further evidence for its effectiveness, please do this with caution as discussed).
* Benefit – some practitioners believe that by doing wound massage, it reduces the risk of tight scarring of the tissue by disrupting the wound.
* Risks of wound massage – while some practitioners believe that the risks of wound massage may cause pain, bleeding, infection, aversion and possible tight re-attachment of the wound. If you choose to do this; the guide as follows:
- Ensure that you have a short fingernail and you wash your hands thoroughly with soap and water especially the fingertips before doing the massage. You may apply dentinox/bonjela (teething gel) under your baby's tongue where the wound is and wait for at least 5 mins before you do the massage to reduce discomfort. This will also be demonstrated to you:
a. First week: Do a firm gentle massage - applying a firm pressure using the index finger under the baby's tongue in a circular motion for 6 seconds at least 2x a day
b. On the second week: Do a stretching massage - applying an up and down massage using the index finger under baby's tongue for 6 seconds at least 2x a day. The stretching massage can be done for further 2-3 weeks.
Feed your baby immediately after the wound massage if you decided to do this exercise.
4. Follow-up Support
RESOURCES:
· NHS on Ankyloglossia 2020
· NICE guidelines 2020
· ATP information 2021
· UNICEF 2019
· KCH 2018
Last Updated: June 2021