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 the COVID-19 disclaimer at the beginning of the appointment.
These can be read in advance by clicking on any of the links below.
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 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.
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 'Infant Feeding Support' tab above.
However, as the divider, 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)
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.
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.
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 a muscle, and occasionally I may suggest some tongue - function exercises to help address any weak areas of the tongue. 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 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 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 (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.
Tongue tie division is NOT an "instant-fix"
NOR a "stand-alone" treatment.
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, 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.
© DIANA WARREN IBCLC, RGN