Considerations . .
The person holding legal parental rights will be asked to sign to say they have read and agree to the Privacy Notice-prior to any personal details being sought.
This is found here, or by clicking on 'Privacy Notice' tab.
Please take time to read the information below, and the "Associated Risks" prior to your appointment. By doing so, you are able to make an informed choice enabling time to ask more detailed questions.
To the appointment please bring with you your Child's Red Health Book, hand mitts and a blanket or towel to swaddle your baby during the procedure. The infant's GP details are also required (name and address).
During the procedure an adult will be required to hold the baby's head securely.
Full consent must be signed for prior to the tongue tie procedure taking place, and this must be signed by the legal primary caregiver.
I will forward a letter to your GP with minimal personal data on. I also like to document in your Child's Red Health Record (CRHC) for your records too
A parent will be expected to breast or bottle feed straight after the procedure to help stem any blood loss and allow for further assessment-in my presence.
Opportunity for questions is welcome throughout the appointment.
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 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 your appointment confirmation.
If your child is 6-12 months old; discussion prior to your appointment is necessary by seeing me in person or a photograph of the oral cavity before the appointment is recommended to address opposing teeth. You may wish to consider administering paracetamol 20-30 minutes before the procedure. Body-therapy is likely to be recommended and both adults may be needed to assist.
Tongue tie division is NOT an "instant-fix"
NOR a "stand-alone" treatment.
•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 crainial-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 the above treatments can divide the tongue, they are recommended as a combination treatment to help ensure your baby learns how to use the newly freed tongue muscle correctly.
•Local breastfeeding support groups are a good source of additional support and usually free of charge, a list of local groups is found at local children's centres, breastfeeding charities (NCT, ABM, LLLi are a few examples), some are directly attached to postnatal wards or are council funded. However, as the divider, I remain the accountable practitioner for any aftercare intervention so if you are unsure please contact me too.
•Parents may see an improvement following division, but even with additional infant feeding support the full benefits may not be seen for a while; combination therapies may help the process. If you believe your infant is not responding as quickly as he/she should be please do not hesitate to get in touch so that we can rectify any concerns efficiently.
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.
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
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.
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.
You will be given tongue tie division post-procedure/aftercare information at your appointment for you to take home.
Post-Division Follow-up Support:
Following your division, I will contact you a few days after the procedure, and continue to offer regular contact until you have met your feeding goals and you feel ready to be discharged from my services. I also offer ongoing support appointments which are private 1:1 slots, Please book via the Bookings tab above to see availability and to secure your appointment.
I also manage my 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)
Associated Risks to the tongue tie procedure
Any known risks will be explained on the day of assessment, and although this is not an exhaustive list; it will be disclosed to enable the parent to make an informed decision. These include:
Most babies do not show signs of pain following the tongue tie division procedure. A few may be 'miserable' for a few days. On rare occasions your baby may particularly unsettled and possibly not feed. Pain relief can be prescribed if this is the case, and in those over 8 weeks old paracetamol may be considered. Whilst this is stressful for you and baby at the time it shouldn't last too long and is considered temporary. For those babies, it may take up to 48 hours for your baby to settle, you are encouraged to contact me, monitor nappy output/signs of dehydration, and if breastfeeding: protect your supply through expressing. At your division appointment you will be given an 'aftercare' sheet, some calming measures for you to try are listed there. Most babies have no issues with pain following the frenulotomy but from experience a few do, but some babies do sleep through the procedure and your infant's response unfortunately can not be predicted.
Other Oral Structures
There is an associated risk that within the vacinity of the mouth I may divide something other than frenulum. Rest assured, I have not done this before, but as the scissors are blunt-ended and curved, they do not have the capacity to do anything sinister-and treatment would be controlling any blood loss.
Research indicates that one baby in a thousand babies will bleed for longer than expected. The bleeding normally settles with wound compression with no further treatment required or long term effects on your baby. Excess and or prolonged bleeding is rare (1:400), and your practitioner is skilled and equipped for such events. Please remain calm and allow your practitioner to contribute to stemming the blood loss. If there is excessive blood loss I may use compression or a specialist dressings to stem it. The Current bleeding guidance will be adhered to as per the Association of Tongue Tie Practitioners guidelines, and can be accessed here:
There have been reported cases of bleeding which has occurred some time after tongue tie division, usually on the same day when the baby has returned home. If this occurs, the bleeding is usually very light and is triggered by strenuous crying (resulting in the tongue lifting and disturbing the wound) or when the wound is disturbed during feeding, particularly if caught by a bottle teat, dummy, or the tip of a nipple shield (1:300).
At the end of your appointment, I talk you through what to do in this event and I provide you with the Association of Tongue Tie Practitioners 'Aftercare after frenulotomy' sheet, who have worked closely with a surgical Neonatal Consultant to provide guidance for further bleeding. I recommend these are kept with your child at all times until the wound is completely healed (approximately 2 weeks).
Of 10,000 babies who were followed up post procedure by a local practitioner; only one had an infection that needed treating with antibiotics, and continued to breastfeed through this experience. Infection is associated with a fever/high temperature with a wound that is not healing ; if you feel that the wound is infected, please see your GP to consider oral antibiotics and review. I am happy to review the wound/view any pictures you can send me as occasionally infection is assumed when it is not. However, I can not diagnose a wound infection based on a picture.
Nursing Strike/ Feeding Aversion
Occasionally, post procedure, a baby may refuse to feed. I believe this may be because the wound site itself is inflamed (inflammation is 1 of 4 stages of the wound healing process) and maybe uncomfortable. If this happens with your baby there are ways to help your baby feed. The main point to remember is that this is a temporary phase and the most important thing is that your baby gets nutrition and calories until your baby is ready to feed again. Please contact me if you feel this is happening so I can support you.
Reformation (sometimes phrased Reattachment/Regrowth)
In some babies the frenulum may reform . You may notice changes in the way your baby feeds perhaps similar to your previous experience. A further frenulotomy may be considered. Current research indicates that around 1-4% of initial divisions can reform. It is also thought there could be hidden frenulum which is brought forward with improved tongue movement, or scar formation (or a combination of both elements).
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' is strongly recommended for all infants, especially those with a tongue tie. 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.
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..
Optimum Improvement Time
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.
Infant feeding support groups are an invaluable source in these circumstances, alongside body-therapy (https://www.tonguetie.org.uk/manual-therapy-and-infant-feeding/). You are also more than welcome to contact me by phone, text, email or see me for a follow-up review.
Vitamin K helps the blood to clot and prevents serious bleeding. In newborns, 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, or additional consent if your infant has not received it, which may include discussions with your primary care-provider.
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 independant 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, you will be asked to sign the disclaimer on the consent form to state that you have been made aware of the risks involved.
Terms and Conditions
1. Vitamin K has been administered via injection at birth by your midwife, or if taken orally both doses have been administered and the course is complete.
*In the event parents do not wish for Vitamin K administration, or oral course is incomplete, additional consent is required to proceed.
2. A parent or legal Guardian has to be present for the appointment.
3. Payment is due at the end of the appointment and delay in paying may result in further actions.
*If division is declined, the outstanding balance is for one hour of 'Infant Feeding' support.
**Should a personal insurance plan be incurring the cost, it is parental responsibility to ensure the procedure is covered in their "Terms and Conditions". Payment for the appointment is still due at the appointment time from the parent(s) to myself, and then would be claimed from the insurance provider to the claiming parent.
4. The practitioner reserves the right to decline the procedure at any point.
5. Consent to control any excessive blood loss, which may require the use of specialist dressings/techniques or attendance to local Children's Emergency Department.
6. The parent or legal guardian must declare any allergies of the infant and breastfeeding parent.
7. Any appointment where the attendees do not attend without prior arrangement with the practitioner will lose their deposit payment as per the cancellation policy.
8. If you need to cancel your appointment at any point please do so in advance as I often receive last minute referrals who can utilise your appointment.
9. The parent/legal guardian must declare any medications the infant is receiving.
10. D.Warren may choose to contact your healthcare provider(s) should there be a any concern for you or your family's health or welfare, this may include your GP or your Health visitor. For example a safeguarding concern, abuse, neglect or medical concern (this list is not exhaustive). Similarly, D. Warren may be legally required to share the documentation held with professional authorities or insurance companies (in reference to your child's care), I also give permission for this to be shared where appropriate.
11. Acknowledgement of the following protocols (found in more detail below):
-Cancellation and Refunds Policy
12. The signing parent/guardian must be legally responsible for the infant with full legal/custody rights to the infant's welfare.
13. I/we consent to the handling of my/our infant for the purposes of assessment, examination, and if mutually agreed treatment also.
14. If breastfeeding support is offered during the appointment I/we consent to the possible appropriate touch to aid breastfeeding.
15. I/we are aware that photography for the purposes of medical record keeping is taken of my/our infants mouth both pre and post procedure.
Appointments are held at my home based clinic, in a room used specifically for consultation purposes. I have used rental clinics in the past but found I could not control the noise levels from other activities within the same building, interruptions, nor had any control over its cleanliness. I would hope you agree this space provides a warm and welcoming environment for both you and your child.
Due to this I do ask that if you arrive earlier than ten minutes for your appointment that you kindly wait in your vehicle as the space does not accommodate a waiting area and interruptions to the previous clients appointment are unfair.
'D-Restricted:Specialist Infant Feeding Support' and the venue will not be held liable for any damage or loss to any personal belongings or injury whilst clients are on site. Car parking space is usually available (residential area) but vehicles are left at owners risk. However, vehicles are visible from the clinic room.
There is CCTV cameras in operation to the front and rear of the property which may capture images of yourself, family and vehicle. This is registered with ICO and is destroyed after 30 days.
I will always take complaints about any aspects of my services very seriously, in order to ensure that every patient has only the very best experience at all times.
Complaints can be made in writing to: D.Warren
31 Avondale Road, Barlestone, Nuneaton, Warwickshire CV13 0HX,
or via email: email@example.com,
by the patient's parent/legal caregiver or by an authorised person on their behalf. Complaints should be clear, so that it can be dealt with efficiently.
Each complaint will receive written/email acknowledgment within 48 hours, and I will strive to resolve the complaint within 20 working days. Any delays in this process will be formally communicated to the client with a revised time frame.
If you are unhappy with my response, or feel that I have committed misconduct, you may formally file a claim in the first instance to NMC who are the regulatory body for my profession.
The Care Quality Commission are keen to receive feedback on the services they regulate, although they (CQC), my Professional Indemnity Insurance Provider (Hiscox), the Nursing and Midwifery Council (NMC) and the Association of Tongue Tie Practitioners (ATP) do not directly deal with complaints, they may provide you with additional guidance and are also listed below for your convenience.
Care Quality Commission (CQC) www.cqc.org.uk/contact-us (online form) or email firstname.lastname@example.org.
Feedback directly to the CQC is welcomed directly to
Hiscox Insurance Company Ltd, 1 Great St Helen's, London, EC3A 6HX.
Nursing and Midwifery Council (NMC): http://www.nmc.org.uk/concerns-nurses-midwives/concerns-complaints-referrals/
Association of Tongue Tie Practitioners (ATP): http://www.tongue-tie.org.uk
Information Commisioner's Office (ICO) 0303 1231113 Reference ZA100466
Cancellation and Refund Policy
Sometimes, unavoidable things happen which may mean you would need to cancel or reschedule your appointment, and I understand this.
Should you wish to cancel your appointment at any point, please do so at your earliest convenience. I usually have more than one last minute emergency referral that commonly need to make an urgent appointment; who may appreciate an earlier time slot should one become available. Unfortunately I am unable to refund your initial deposit, unless you were to reschedule this, then can then be transferred, unless less than 4 hours notice is given, in which case your deposit is lost.
If you are running late for your appointment, please call me to discuss, as if you are estimated to arrive 10 minutes later than the scheduled time you may miss your appointment and loose your deposit, please ring me to confirm.
Should I need to cancel I will do so as early as possible and I will do my very best to rearrange your appointment with minimal delay, or refund your deposit so you have the option to choose an alternative provider if necessary.
For Parents who have had a division from an alternative practitioner; in the first instance you are encouraged to discuss your concerns with your original practitioner. Should this not be possible, please contact me directly to discuss your care needs 07910608179.
© DIANA WARREN IBCLC, RGN