D-Restricted Ltd:®
Baby Tongue Tie Practitioner Hinckley Leicestershire
07910608179
D-Restricted Ltd:®
Tongue-Tie
Ankyloglossia (tongue-tie)
“Ankyloglossia is a congenital anomaly characterised by an abnormally short lingual frenulum; the tip of the tongue can not be protruded beyond the lower incisor teeth. It varies in degree, from a mild form from which the tongue is bound only by a thin mucous membrane, to a severe form in which the tongue is completely fused to the floor of the mouth. Breastfeeding difficulties may arise as a result of the inability to suck effectively, causing sore nipples and poor infant weight gain”
(NICE interventional procedures guidance 2005 www.nice.org.uk/guidance/ipg149/chapter/1-guidance?print=true )
Frenulotomy
“A procedure for excising a frenulum; such as the excision of the lingual frenum from its attachment to the mucoperiosteal covering the alveolar process to correct ankyloglossia.”
(Mosby’s Medical Dictionary 5th edition, Elsevier, 2009)
Some pictures of frenulums and post procedure wounds can be seen here: GALLERY
What is a Tongue-Tie?
Tongue tie is a problem that occurs in babies who have a tight piece of skin between the underside of their tongue and the floor of their mouth.
The medical name for tongue tie is ankyloglossia, and the piece of skin joining the tongue to the base of the mouth is called the lingual frenulum.
It can sometimes affect the baby's feeding, making it hard for them to attach properly to their mother's breast. Tongue tie is a birth defect that affects 3-10% of newborn babies. It is more common in boys than girls.
Normally, the tongue is loosely attached to the base of the mouth with a piece of skin called the lingual frenulum. In babies with tongue tie, this piece of skin is unusually short and tight, restricting the tongues movement.
This prevents the baby from feeding properly and also causes problems for the breastfeeding parent.
To breastfeed successfully, the baby needs to latch on to both breast tissue and nipple, and the baby's tongue needs to cover the lower gum so the nipple is protected from damage.
Infants with a restrictive tongue tie are not able to open their mouths wide enough to latch on to their breastfeeding parent's breast, or form a seal on a teat/dummy/pacifier properly.
Breastfed infants tend to slide off the breast and chomp on the nipple with their gums. This is very painful and the breastfeeding parent's nipples can become sore, with ulcers and bleeding. Some babies frequently feed but inefficiently and get tired, but they soon become hungry and want to feed again.
In some cases, these feeding difficulties mean the baby fails to gain much weight.
(http://www.nhs.uk/conditions/tongue-tie/pages/introduction.aspx)
Some further details on a Tongue tie restriction, can be found here: TONGUE TIE
How may a restrictive tongue-tie affect our feeding experience?
The presence of a tongue tie may not affect your baby at all, however some babies may have restricted tongue movement that may not allow your baby to feed properly.
Affects on Breastfeeding Your baby may:
-
Have difficulty getting attached to your breast deeply enough
-
Have difficulty staying attached
-
Feed for prolonged periods
-
Be unsettled and not satisfied
-
Make clicking noises when feeding
-
Suffer with excess wind, colic or reflux
-
May dribble milk when feeding from the breast
-
May choke when feeding
A breastfeeding parent may have:
-
Sore nipples
-
Squashed nipples
-
Blocked ducts
-
Mastitis
-
Low milk supply
Some breastfeeding parents and babies may have some of the above symptoms and problems while others may have them all. Some of the issues may be related to the way your baby is feeding and not the tongue tie. This may be improved by optimising your technique.
Bottle-feeding Your baby with tongue-tie may:-
•Find it difficult to attach to the teat
•Take a long time to feed or feed very quickly
•Drink only small amounts with frequent winding (paced feeding)
•Dribble a lot of milk during feeds
•May not be able to keep a dummy in
•Make clicking noises
•Suffer from excess wind, colic and reflux
Oral Cleanliness/Dental hygiene
When your baby starts to eat solids
Eating food may be a problem as the tongue is important in moving food around the mouth and in swallowing.
When your child starts to talk
Your child's ability to talk is influenced by a variety of factors. Theories may consider a tongue tie may be one of these factors as the movement of the tongue aids in the formation of letters and sounds.
If your child does develop a speech problem they may be referred to a speech and language therapist. If the tongue appears to be causing limited tongue function at this time then the Tongue tie can be cut with the support and expertise of a surgeon or dentist.
The Assessment Process
A tongue function examination will take place to assess both the appearance, and all 7 areas of tongue motility. I will discuss what I am doing/looking for during the assessment and use a scoring tool to help interpret the results.
Your child must be under 12 months old and be fit and well for the procedure to be undertaken.
If your child is unwell, has a fever, currently taking antibiotics for another condition, has any cardiac or liver problems, any blood clotting disorders or blood borne infections the procedure may not proceed. An alternative appointment may be offered at a later date if appropriate. Please discuss medical conditions with D.Warren prior to booking your appointment.
The assessment is short, non-invasive and should not cause any discomfort. An observation of a feed may show me your baby's feeding behaviours, but does not show me what is happening inside your babies mouth, so is not necessary for a functional assessment.
A video demonstrating how this is achieved is found here:
The Tongue-Tie Procedure (frenulotomy)
Your baby will be swaddled and whilst an adult holds the baby’s head still, an excision will be made between the salivary glands and the tongue to release the tongue from the floor of the mouth. The practitioner will ensure that there is nil further frenulum that may cause further issues and further snips may be necessary to ensure this. Full consent must be signed for prior to the tongue tie procedure taking place, and this must be signed by the legal primary caregiver. If your child is 3-12 months old; you may wish to consider administering paracetamol 20-30 minutes before the procedure.
A single-use sterile disposable curved blunt-ended scissor, designed especially for the procedure will be used. Following this some gauze will be pressed onto the site to stem any blood loss. The baby will then be handed back to a parent who will be sitting comfortably and prepared to feed the baby. This also helps stem any bleeding but in addition also enables the baby to begin learning how to utilise the newly freed muscle (tongue).
Once bleeding is stemmed, a post tongue tie procedure feeding assessment is done. Although an immediate improvement is possible, full advantage cannot be assumed for some time. Further support from local breastfeeding support groups alongside my suggestions is strongly advised, and other additional support may also be advised.
Assessment and consent must be completed prior to the procedure, and appropriately signed. Copies can be sent to the parents on request.
A parent will be requested to breast or bottle feed straight after the procedure to help stem any blood loss and allow for further assessment in my presence, sucking is also thought to provide comfort for your infant too.
You will be given tongue tie division post-procedure/aftercare information at your appointment for you to take home. I will forward a letter to your GP with minimal personal data on through Royal Mail post. I also like to document in your Child's Red Health Record (CRHC) for your records too.
Post-Division Follow-Up Support
Following your division, I will contact you a few days after the procedure and offer contact for 6 weeks. I call this "IBCLC in my pocket!" and allows you the opportunity to ask me any questions, queries, concerns at any point during that 6 week period; after which you are both discharged from my services.
I also offer ongoing support appointments which are private 1:1 slots, Please book via the 'Book Online' tab above to see availability and to secure your appointment.
Local breastfeeding support groups are a good source of additional support and usually free of charge, a list of local groups is found at many local children's centres or through your local health visiting team. Breastfeeding charities (NCT, ABM, LLLi are a few examples) are an additional option and some are directly attached to postnatal wards or are council funded. Some are listed in the 'Lactation Support' tab above.
However, as the tongue-tie release provider, I remain the accountable practitioner for any aftercare intervention so if you are unsure please contact me too.
I also manage a facebook page, which is a closed safe space to get information, support and ask questions. It houses lots of evidence and articles too (see the 'announcements' section within).
At Home
The best advice following tongue tie division is to feed to demand (cue/responsive feeding) as often as necessary-this is applicable for both breast and bottle fed infants. Babymoons are often advised and allows for undisturbed time between breastfeeding mother and baby to re-learn how to latch with the newly freed tongue muscle, recognise feeding cues and allows for calm, unpressurised time between mother and child. Skin-on-skin time can not be emphasized enough.
Please be wary of anything entering your babies mouth following the tongue tie procedure, such as dummies/pacifiers, bottle teats or fingers for a few days. Whilst this is not forbidden caution should be taken as 'knocking' the affected area may reinstate bleeding and could be sore. This includes any teething remedies-we do not know how these will react on an open wound, in-particular the powder form.
Skin-to skin time and tummy-time is strongly recommended to enable your infant to get comfort and pleasure being with a parent as well as both supply and structural alignment benefits this entails.
In the beginning your baby may take a step backwards with breastfeeding. This is rare and there is no way of predicting it, but it usually depends on the circumstances and interventions that have been used prior to the frenectomy. Eg keeps tongue lifted, can’t latch or unsettled; seen as pain.
Please refer to the tongue tie division post procedure information sheet given at your appointment.
'Bodywork therapy' is strongly recommended for all infants, especially those who have/had a tongue tie restriction. Babies that have been born with interventions (induction, epidural, narcotic use in labour, breech or transverse presentation, c section or instrumental deliveries) will find this therapy particularly useful.
https://www.tonguetie.org.uk/manual-therapy-and-infant-feeding/
Blog | D-Restricted Ltd (tongue-tie.info)
Your local breastfeeding support group should be a great support too at this time, and can support mothers with achieving a wide gape for a successful latch as well as peer support within the group. Private follow-up/support is also available and online bookable-please refer to the 'Bookings' tab above, and I am also in contact with you at least once per week to follow your progress and address any issues early.
© DIANA WARREN IBCLC, RGN
Tongue-Function Exercises
Please be reassured that I DO NOT advocate disruptive wound management techniques. You may come across these being discussed online, YouTube and even tongue-tie Facebook groups. Sometimes they are given different names to make the process sound gentle, such as 'wound massage' 'tongue lifts' or 'sweeping under the tongue'. Please be mindful of this. Ultimately these involve touching the wound in some form which I (& many other UK based practitioners) do not suggest that you do.
Please see the ATP position statement (2021) on this for a further explanation.
I will provide you with all of the information and suggested advice necessary based on your infant's individual needs following assessment.
The tongue is collection of muscles, and I do suggest some tongue - function exercises to help address any weak areas of the tongue and to keep the tongue as an organ mobile. Rest assured, these exercises do not involve touching the wound at all, as I have concerns for pain, infection, bleeding and disruption of the natural wound healing phases. Examples may include 'tummy-time' or sticking out your own tongue at your little one in the hope that they mimic your behaviour. These sucking skills are evidence based and discussed at your appointment.
(Catherine Watson-Genna (2013) "Supporting Sucking Skills in Breastfeeding Infants" 2nd Edition Jones & Bartlett Publishers, New York).
Optimum Improvement Timeframe
Some of you will notice a difference in feeding behaviours immediately, but others may take several days or weeks depending on influencing factors. The tongue is a muscle and needs to rebuild its strength to correct the "current state" of muscle weakness. There is also likely to be tension in the surrounding oral structures, which will need to relax in order to achieve a wide open gape to feed.
As with any medical procedure, things are not clearly 'black & white' but if you are struggling please contact me so I can support/reassess/re-divide/refer on so that we can rectify any concerns efficiently.
Division of a tongue tie can vary in degree of its effectiveness based on a number of factors, ie babies age, birthing experience or alignment factors. Other treatments may be suggested at your infant’s assessment and may include cranial-osteopathy, babymoons, hand expression (to increase milk supply), speech therapy or treatment for damaged nipples or thrush may need to be sought. These recommendations are not mandatory but are suggestions which may aid your baby-feeding journey. None of these treatments can divide the restrictive frenulum, they are recommended as a combination treatment to help ensure your baby learns how to use the newly freed tongue muscle correctly.
Infant feeding support groups are an invaluable source in these circumstances, alongside body-therapy (Body-therapies). You are also more than welcome to contact me by phone, text, email or see me for a follow-up review.
Tongue tie division is NOT an "instant-fix"
NOR a "stand-alone" treatment.
Vitamin K
Vitamin K helps the blood to clot and prevents serious bleeding. In new-borns, Vitamin K injections can prevent a now rare, but potentially fatal, bleeding disorder called 'Vitamin K Deficiency Bleeding' (VKDB), also known as 'Heamorrhagic Disease of the Newborn' (HDN).
As per my 'Terms and Conditions' to proceed to a division by myself, I prefer that your infant has received vitamin K, if this has not been administered, please contact me BEFORE you book your appointment.
This is usually done at birth via one small injection or oral doses. At least 2 of the 3 oral doses (day 0, 4-7 & day 28) need to have been administered and evidence of Vitamin K administration is done by your midwife and documented in your child's red health book. If you choose injection form, then just one dose, which is usually administered within one hour of birth.
If you originally declined Vitamin K but have since changed your mind in order consider a division, you would need to contact your community midwife, or employ a private independent midwife to source, prescribe and administer it for you. If your infant is over 6 weeks old and has not received Vitamin K, it is unlikely you will be able to source it. In which case, a 'clotting screen' blood test, done in a similar way to the 'heel prick' test will confirm/deny risk factors and may be obtained via your GP on request or privately.
Whilst I respect every parents unique decision to decline Vitamin K, in my home environment clinic, should the unexpected occur, acute intervention is not local.
Should you wish to proceed without Vitamin K cover, please discuss this with me BEFORE you book a consultation with me. You will be asked to sign the disclaimer on the consent form to state that you have been made aware of any additional risks involved, and may mean additional discussions with your primary caregiver prior to the procedure being agreed.
Lip Tie Statement
A lip tie diagnosis and division is a very grey area in UK; Internationally providers may divide alongside a tongue tie release, but current research, inclusive of labial and buccal ties does suggest that isn't necessary.
My understanding is that issues with lip-ties are more dentally related and regular dental visits as normal and routine are suggested. A lingual lip-tie is normal anatomy-everybody has one-and they tend to recede as one grows anyway-particularly when adult teeth come through.
However, should you suspect your little one has one, once you do start weaning onto solid foods: be sure to remove any food debris from either side of the tie as held against the gum or tooth may cause decay.
There is also new research I read recently that suggested that even if a lip tie was divided, unless bone was removed then it would usually reform/reattach anyway as the upper lip has not technically got to move in order to allow for a good nutritional intake. It is also a very vascular area so blood loss is generally higher in comparison to most tongue-tie releases. The best profession to get further info on this is the infant’s dentist or an oral surgeon qualified in this area as they can address or signpost any issues. Some oral surgeons and dental surgeons may consider a division should they agree it is impacting the individual's growth.
It is also worth mentioning that many perceived lip tie problems are actually tongue tie related-and once tongue function reaches optimum motility the symptoms alleviate. Sometimes a lip tie can affect the ‘vacuum draw’ of getting breast into a correct breast feeding position but this does not prevent a successful pain-free breastfeed, can be addressed with correct positioning and attachment techniques, and can be subjective.
You may find these helpful: