The person holding legal parental rights will be asked to sign to say they have read and agree to the Privacy Notice, Terms & Conditions, and COVID-19 disclaimer-these can be read in advance of your appointment by clicking on any of the links below, or you may choose to read them during your consultation/appointment.
Additional 'Considerations' are found on the drop-down menu subpages or the following links:
Please take time to read all of the information provided 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)
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.
© DIANA WARREN IBCLC, RGN