Tongue-tie and frenulotomy

Most people have a piece of tissue joining the underside of the tongue to the floor of their mouth, called the lingual frenulum. If this piece of tissue is short, thick or extends to the tip of the tongue and causes restriction to tongue movement, it is called a tongue-tie or ankyloglossia.

Research suggests that about 1 in 10 babies may be born with a tongue-tie. It is more common for boys than girls and it can run in families, so your baby may have a relative who had a tongue-tie. Some tongue-ties are easily seen and identified by a health professional during a routine check, others are less obvious and are identified as a result of difficulties with feeding.

Some babies with a tongue-tie experience breastfeeding difficulties caused by the restricted movement of the tongue. This can be divided by one of the Frenulotomy Specialist Midwives (FSM). If your baby has a frenulum that is not causing any feeding difficulties, then frenotomy is not required. This is why babies are not routinely checked for tongue-tie at the newborn examination.

To breastfeed successfully, the baby needs to latch on to both the breast tissue and nipple and their tongue needs to cover the lower gum so the nipple is protected from damage.

Babies with a restrictive tongue-tie may not be able to open their mouth’s wide enough to take a deep latch of breast tissue properly. This may cause them to slide off the breast and ‘chew’ on the nipple with their gums and they may not successfully remove milk from the breast.

It is essential to seek breastfeeding support from a midwife, maternity support worker, breastfeeding counsellor, health visitor or nursery nurse for advice on good positioning and attachment.

If you are breastfeeding, your baby may:

• Have difficulty latching on to and/or staying latched to your breast
• Be feeding for a long time (over 60 mins) every feed
• Be unsettled and seem hungry after feeds
• Have significant weight loss or slow weight gain
• Suffer with wind or colic
• Have reflux (vomiting after feeds)

If the tongue-tie is affecting breastfeeding, you may have:

• Sore, cracked nipples
• Misshapen nipples after feeding
• Lumps in your breast (indicating blocked ducts)
• Pain, swelling and/or redness of the breast and possibly flu-like symptoms (mastitis)
• A low or decreasing milk supply
• Breasts that do not feel emptied after feeding

These problems may be due to the way your baby is feeding and not just because a tongue-tie is present. It is essential that an experienced breastfeeding support worker observes your positioning, attachment and a whole breastfeed to ensure good attachment. You can contact your midwife, health visitor or local breastfeeding counsellor for feeding support or see leaflet GHPI1575 ‘Breastfeeding support, expressing your breastmilk, cup and syringe feeding your baby’ for details.

If your baby is breast feeding and has a tongue-tie it may be causing feeding problems and you may be referred to a tongue-tie practitioner at Gloucestershire Royal or Cheltenham General Hospitals. The Frenulotomy Specialist Midwife (FSM) has had specialist training in tongue-tie assessment and separation. The person referring your baby to the FSM will ask you some questions about your baby’s feeding and refer you to one of the clinics. You will be asked to take your baby’s red book with you. It will also be helpful if your baby is hungry so they feed after the procedure.

At the clinic the FSM will assess your baby and discuss the following with you:

• The way your baby’s tongue moves
• The way your baby is feeding
• Treatment options

You will be given all the information in order that you can make an informed decision. Please ask any questions that you may have.

You can then:

• Agree for your baby to have their tongue-tie separated at that same appointment
• Decide not to have your baby’s tongue-tie separated

In either case, we will give you information about how you can get support in your area with feeding your baby.

Part of the tongue-tie may separate on its own. This can be in childhood or when they are adults. Often tongue-ties stretch as babies get older.

The procedure to separate tongue-tie is called frenulotomy and is classed as a minor surgical procedure. It takes a few minutes from start to finish. There are some minor risks but evidence shows that it is a safe procedure and once completed it is likely that your baby will improve their feeding technique.

Evidence suggests that frenulotomy may help to improve breast feeding but there is no evidence to suggest the same for bottle feeding. Therefore, frenulotomy is not usually carried out for bottle-fed babies. Your midwife or health visitor can contact the Infant Feeding Team if you wish to discuss this further.

Following the assessment and discussion the FSM will ask you to sign a consent form before the procedure is carried out.

Your baby will be placed in a cot or on a bed and wrapped in a towel, with a hand gently placed on either side of their head to keep them still. A special pair of blunt-ended, curved scissors will be used to cut the tongue-tie.

You will be able to stay with your baby during the procedure or if you wish you can temporarily leave the room while the frenulotomy is carried out. The FSM will support you with breastfeeding immediately after the procedure.

No. It is not appropriate to give a local anaesthetic because:

• the frenulum has very little blood or nerve supply
• giving a local anaesthetic using a needle is likely to be as uncomfortable as dividing the tongue-tie itself
• giving anaesthesia prolongs the procedure.
• numbing the mouth can affect the baby’s ability to feed following the procedure

It is best for your baby to feed straight after the procedure as this will comfort them, stop any bleeding and also help to prevent the frenulum from healing over again.

At first your baby’s mouth will not look unusual in any way. The following day, or the day after that, you may notice a small, white or bright yellow/orange colour blister on the underside of your baby’s tongue. As far as is known, this is painless and it does not stop your baby feeding. The size of the wound will reduce and then disappear over the following 7 to 14 days.

Will my baby cry?

Some babies sleep through the procedure. However, most babies cry, but no more than during a nappy change. Babies often cry because they do not like being held still and in this case because someone is holding their mouth open, they often cry even before the tongue-tie is divided.

Some parents have said that their baby seemed unsettled after the procedure, some older babies can be unsettled for 24 to 48 hours after frenulotomy but feeding and cuddling in skin-to-skin contact should help with this. Some babies may need pain relief.

For babies under 8 weeks old you will need to discuss pain relief with your GP because, although liquid paracetamol is safe, your GP will need to work out the dose based on your baby’s weight.

For babies over 8 weeks: Paracetamol medicine (e.g. Calpol®) can be given without a prescription (always read the label and do not exceed the recommended dose).

Is there a risk of infection?

Research shows that the risk of infection is very small. Sterile scissors, gloves and swabs are always used during the procedure. The mouth is not a sterile area but is clean and quick to heal. Also, breastmilk has been found to naturally contain antibodies to fight infection.

It is best to avoid possible sources of infection, such as dummies, teats or nipple shields) until the frenulum has healed, which usually takes a few days.

If you must use bottle/teats/nipple shield please make sure that you follow the correct sterilisation method to reduce the chance of infection.

Wash your hands before feeding your baby.

If your baby’s wound looks swollen, red and inflamed or if your baby develops a high temperature, does not want to feed, is sleepy or irritable please make an urgent appointment with your GP.

Out of surgery hours please contact NHS 111 for advice.

If you have any concerns about the wound healing and infection, please contact your GP.

Will my baby’s mouth bleed?

A small amount of blood loss is expected, however heavy bleeding following the procedure is rare. To reduce the risk of bleeding from the procedure your baby will need to have had Vitamin K by injection or oral drops following birth. If your baby has had oral Vitamin K drops parents or midwife must have seen the baby swallow the drops with the dose after birth and a dose at 7 days old. If there is heavy bleeding, the FSM will press a piece of sterile gauze against the cut and apply pressure until the bleeding stops. Before you leave the clinic, the tongue-tie practitioner will make sure that there is no bleeding from the wound.

If your baby vomits after the procedure, you may notice some pinkness or blood streaks in the milk/vomit. You may also notice your baby’s stools are brown following the procedure. This is due to the small amount of blood swallowed with the first feed after the procedure.

What if there is bleeding from the wound when I am at home with my baby?

This is very rare, but if it does happen try to calm and feed your baby for 5 minutes, this should stop any oozing. If your baby will not feed, press the wound site for at least 5 full minutes with a clean gauze swab or clean muslin, the bleeding should stop.

If after 5 minutes the bleeding has not stopped, use a fresh clean dry muslin or gauze swab (do not use cotton wool) and apply pressure to the wound site again, for another 5 minutes. Hold the muslin or gauze at all times and do not leave it in your baby’s mouth.

If after feeding or applying pressure the bleeding does not stop, or if at any time you are concerned about your baby’s wellbeing, we advise you to go to your local Emergency Department (ED). Keep constant pressure under your baby’s tongue, using a clean cloth until the bleeding has stopped or you have arrived in the ED.

When you arrive at ED, give staff the letter you will have been given by the tongue-tie practitioner. This letter may have been put in your baby’s Red Book.

Some babies may feed differently after the procedure as the tongue is able to move more freely. If your baby is unable to latch on and breastfeed, try giving some of your expressed milk from a clean, sterilised cup (see leaflet GHPI1575 Breastfeeding support, expressing your breastmilk, cup and syringe feeding your baby’) and keep offering your baby breastfeeds. Skin to skin contact for a long period of time may help.

Some babies take time to relearn how to feed with more tongue movement; they may be unsettled and fussy with feeding for a day or two. You may also find that you need to adjust positioning and attachment.

If your nipples were sore before the procedure, it may take time for them to heal. In some cases there is no improvement in feeding. Please do access the ongoing help you need, the support options are listed in leaflet GHPI1575 ‘Breastfeeding support, expressing your breastmilk, cup and syringe feeding your baby’.

Ways to calm your baby:

• Cuddles, skin to skin contact
• Feeding often will comfort your baby. It also means your baby is getting lots of practice at moving their more mobile tongue and any breast milk will also help with the healing
• Singing and rocking
• Using a sling
• Bathing together
• Baby massage techniques
• Allowing you baby to suck on your clean finger before latching or offering some expressed breastmilk on a clean finger

If you need help with breastfeeding, you can contact your midwife, health visitor or one of the local breastfeeding support groups listed in leaflet GHPI1575 ‘Breastfeeding support, expressing your breastmilk, cup and syringe feeding your baby’.

National breastfeeding support helplines are also listed.

If you continue to having feeding difficulties your midwife or health visitor can refer you to the infant feeding specialist midwife.

It is rare but scar tissue can form in about 4 out of every 100 babies which may restrict your baby’s feeding. If you notice significant feeding difficulties 2 to 3 weeks after the procedure, please contact your midwife or health visitor who will refer you to the infant feeding specialist midwife.

It is important to feed your baby at least every 3 hours for the first few days following the procedure. This will keep your baby’s tongue moving frequently and reduce the risk of scar tissue forming.

Currently, there is no evidence that invasive wound massage or stretching is effective. However, with clean fingers and short nails, there are some gentle fun exercises that you may wish to do to 4 or 5 times a day to encourage your baby to move their tongue in addition to frequent feeding:

• Stick your tongue out for your baby to copy
• Run your fingers along your baby’s gums to encourage sideways movements
• Encourage sucking on your clean finger and attempt a ‘tug of war game’

The FSM may contact you 4 to 6 weeks after your baby’s tongue-tie has been separated. You will be asked if there has been an improvement in your baby’s feeding.

This information is used for audit and to learn ways of improving our service. If you do not wish to be contacted, please let us know during the appointment.

If you have any concerns following the separation of your baby’s tongue-tie please contact:

Infant Feeding Team

Maternity Ward

The Women’s Centre, Gloucestershire Royal Hospital

Tel: 0300 422 5519 (24 hours)

Tel: 0300 422 5520 (24 hours)

Gloucester Birth Unit

Tel: 0300 422 5523 (24 hours)

Cheltenham Birth Centre

Tel: 0300 422 2325 (24 hours)

Stroud Maternity Unit

Tel: 0300 421 8018 (24 hours)

Breast feeding support groups are experienced at supporting mothers with babies who have had tongue-tie separation.

Please see leaflet GHPI1575 ‘Breastfeeding support, expressing your breastmilk, cup and syringe feeding your baby’ for details.