Tongue Tie: Management

Tongue-tie (ankyloglossia) is a congenital condition in which the lingual frenulum is abnormally short and may therefore restrict mobility of the tongue tip (Lalakea and Messner 2003).

• Indications baby has a tongue-tie

• Signs

• Assessment

• Procedure

• References

Indications that a baby could have a significant tongue-tie include:

• Nipple pain and damage

• Misshapen nipple after breastfeeding

• A compression/ stripe mark on the nipple after breastfeeding

• The baby often loses suction while feeding and sucks air

• The baby's mouth makes a clicking sound while feeding

• The baby fails to gain weight

Signs of a symptomatic tongue-tie:

• Tongue can't poke out past the lips

• Tongue tip can't touch the roof of the mouth

• Tongue can't be moved sideways

• Tongue tip may look flat or square, instead of pointy, when the tongue is extended

• Tongue tip may be notched or heart-shaped

Assessment

Accreditation guideline

Procedure

• If the lactation consultant recommends release and the frenulum is visualised to be a thin membrane, consider release (Lalakea and Messner 2003).

• The parents should give written informed consent prior to the release.

• An appropriately credentialed staff member should perform tongue-tie release (see Guidelines).

• If the frenulum is thickened and release considered appropriate, the infant should be referred to a paediatric surgeon.

• A complete history should be taken prior to physical assessment to exclude other causes of breastfeeding difficulties.

• The mouth should be carefully inspected to exclude any other oral pathology, e.g. cleft palate.

• Using the Hazelbaker Assessment Tool for Lingual Frenulum Function, score the appearance and function of the infant's tongue.

• In early infancy (up to four months), the procedure may be performed without anaesthesia with little discomfort to the infant. The infant is placed supine with the elbows held flexed securely close to the face. The tongue is lifted gently with gloved finger and thumb so as to expose the frenulum. With 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. Care is taken not to incise any vascular tissue (the base of the tongue, the genioglossus muscle, or the gingival mucosa). There should be minimal blood loss, i.e. no more than a drop or two, collected on sterile gauze. (Ballard JL, Auer CE, and Khoury JC)

• The infant may be returned to the mother for feeding. Re-assessment of nipple pain and infant latch should occur post release.

• No specific aftercare is required.

References

• Ballard J L, Auer C E, Khoury J C, Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad, Pediatrics 2002, 110 (5): e63

• Better Health Channel http://www.betterhealth.vic.gov.au
  

• Hogan M, Westcott C, Griffiths D M, A randomised controlled trial of division of tongue-tie in infants with feeding problems, Archives of Disease in Childhood 2004, 89 (Suppl 1): A5

• Lalakea M L, Messner A H, Ankyloglossia: does it matter? Pediatric Clinics of North America, 2003, 50: 381-97.

• Academy of Breastfeeding Medicine Clinical protocol #11: Guidelines for the evaluated management of neonatal ankyloglossia and its complications in the breastfeeding dyad http://www.bfmed.org
  

• UNICEF UK Baby Friendly initiative, Helping a baby with tongue tie http://www.babyfriendly.org.uk/items/item_detail.asp?item=441