Blood clotting disorders and Tongue-tie division

Tongue-tie, also known as ankyloglossia, describes a lingual frenulum that restricts tongue movement. However, identifying a restrictive frenulum does not, in itself, establish that surgical division is necessary. Assessment needs to consider the infant’s oral function, feeding difficulties, clinical history and whether the potential benefits of division outweigh the risks for that individual baby (NICE, 2005).

One important part of pre-procedure assessment is identifying any known or suspected condition that could affect blood clotting. Some conditions interfere with the body’s ability to stop bleeding, while others increase the tendency for blood clots to develop within blood vessels. These are different clinical issues, and the distinction matters when considering the suitability, setting and timing of a surgical procedure.

Although many bleeding and clotting disorders are uncommon, a relevant family history or previously undiagnosed condition may not be apparent from an infant’s general appearance. A baby may appear well and have no history of previous surgery or significant injury, yet still have an inherited bleeding disorder. Conversely, a family history of thrombophilia does not automatically mean that an infant has the condition or that tongue-tie division is necessarily contraindicated.

This article explores the differences between bleeding disorders and thrombophilia, the information that may be relevant before tongue-tie division, and circumstances in which further assessment or specialist advice may be needed.

Understanding the two sides of blood clotting

Blood clotting, or haemostasis, is a complex process involving blood vessels, platelets and clotting proteins known as coagulation factors. These work together to limit blood loss when a blood vessel is injured. If the process is impaired, bleeding may be prolonged or excessive. If the balance is disrupted in the opposite direction, abnormal clots may form within the circulation (NHS, n.d.-a; NHS, n.d.-b).

Bleeding disorders include conditions such as haemophilia A, haemophilia B, von Willebrand disease, certain clotting-factor deficiencies and platelet disorders. Their severity varies considerably. Some cause relatively mild symptoms, whereas others can result in serious bleeding following an injury, operation or other invasive procedure (NHS, n.d.-a; NHS, n.d.-c).

Thrombophilia describes an increased tendency to develop abnormal blood clots. It can be inherited or acquired, and examples include factor V Leiden, the prothrombin gene variant G20210A, deficiencies of antithrombin, protein C or protein S, and antiphospholipid syndrome (NHS, n.d.-b).

Thrombosis occurs when a blood clot develops within a blood vessel. If part of a clot breaks away and travels through the circulation before lodging elsewhere, it is called an embolus. A pulmonary embolism occurs when a clot blocks a blood vessel in the lungs and can be life-threatening (NHS, n.d.-b). These are important consequences of thrombophilia to understand, but they should not be confused with established complications of a particular procedure.

The presence of thrombophilia does not, by itself, establish that a particular procedure is contraindicated or that an embolism is likely to occur following it. Equally, it should not be treated as irrelevant when an individual infant’s medical history raises concerns. The significance of a diagnosis depends on the particular condition, the infant’s circumstances and the clinical assessment.

It is also important to distinguish factor V deficiency from factor V Leiden. Factor V deficiency is a rare bleeding disorder in which insufficient factor V is available for normal clot formation. Factor V Leiden is an inherited genetic variant associated with an increased tendency to develop abnormal blood clots. Despite the similar names, they have different implications for assessment (NHS, n.d.-b; UKHCDO, n.d.).

Which conditions may affect the decision to divide?

The following table provides an overview of conditions that may be relevant to a pre-procedure history. It is not an exhaustive diagnostic list, and it should not be used as a stand-alone decision tool. A diagnosis does not have the same implications for every infant, and the significance of a condition depends on its type, severity and clinical context.

| Individual condition | Hereditary or acquired? | Associated risk | |---|---|---| | Haemophilia A (factor VIII deficiency) | Usually inherited; acquired cases are rare | Prolonged or serious bleeding | | Haemophilia B (factor IX deficiency) | Usually inherited; acquired cases are rare | Prolonged or serious bleeding | | Von Willebrand disease | Usually inherited; acquired forms also occur | Impaired platelet adhesion and clot formation, potentially causing prolonged bleeding | | Fibrinogen disorders (factor I) | Usually inherited; acquired abnormalities can occur | May cause bleeding, thrombosis or both, depending on the disorder | | Prothrombin deficiency (factor II) | Usually inherited; acquired deficiency can occur | Bleeding due to impaired clot formation | | Factor V deficiency | Usually inherited; acquired deficiency can occur | Bleeding | | Factor VII deficiency | Usually inherited; acquired deficiency can occur | Bleeding of variable severity | | Factor X deficiency | Usually inherited; acquired deficiency can occur | Bleeding | | Factor XI deficiency | Usually inherited; acquired deficiency can occur | Bleeding risk varies and may be more apparent following procedures involving mucosal tissue | | Factor XIII deficiency | Usually inherited; acquired deficiency can occur | Potentially serious bleeding; routine screening coagulation tests may be normal | | Inherited platelet-function disorders | Usually inherited | Impaired primary haemostasis and potentially prolonged mucosal or wound bleeding | | Thrombocytopenia | Acquired or inherited | A reduced platelet count may increase bleeding risk, depending on the cause and severity | | Vitamin K deficiency bleeding (VKDB) | Acquired | Reduced activity of vitamin K-dependent clotting factors, potentially causing serious bleeding | | Liver disease affecting coagulation | Acquired, inherited or associated with other conditions | May cause bleeding abnormalities and, in some circumstances, increased thrombosis risk | | Disseminated intravascular coagulation (DIC) | Acquired | Abnormal clot formation and potentially serious bleeding | | Factor V Leiden | Inherited | Increased tendency to develop abnormal blood clots; not the same as factor V deficiency | | Prothrombin gene variant G20210A | Inherited | Increased tendency to develop abnormal blood clots | | Antithrombin deficiency | Usually inherited; acquired reductions also occur | Increased tendency to develop abnormal blood clots | | Protein C deficiency | Usually inherited; acquired deficiency can occur | Increased tendency to develop abnormal blood clots | | Protein S deficiency | Usually inherited; acquired deficiency can occur | Increased tendency to develop abnormal blood clots | | Antiphospholipid syndrome (APS) | Acquired autoimmune condition | Increased tendency to develop thrombosis; pregnancy complications may also occur | | Alpha- or beta-thalassaemia | Inherited | Primarily affects haemoglobin production and oxygen transport; it is not a primary coagulation disorder |

The conditions listed above vary considerably in their severity and clinical implications, and this table is intended to provide general information rather than determine an infant’s suitability for surgery. Where an infant has a known or suspected bleeding disorder, thrombophilia or another condition that may affect haemostasis, the practitioner should seek advice from the healthcare professional accountable for the infant’s relevant medical care before making a decision about tongue-tie division. Where the implications remain uncertain or further assessment is needed, referral to an appropriate medical or specialist service should be arranged. Neither the condition’s name alone nor this table should be used as a substitute for individual clinical assessment.

The distinction between bleeding disorders and thrombophilia remains important. A condition associated with abnormal clot formation does not necessarily cause excessive bleeding, while a condition that impairs haemostasis may create a direct concern when an incision is made. Some disorders, including certain fibrinogen abnormalities and liver-related coagulation disturbances, can involve both bleeding and thrombosis.

What the family history can reveal

A family history can provide important information when assessing an infant before a surgical procedure. Asking whether close relatives have been diagnosed with a bleeding disorder, experienced unexplained excessive bleeding, or developed blood clots at an unusually young age may identify a reason for further assessment.

Relevant questions include whether anyone in the family has haemophilia, von Willebrand disease, a known clotting-factor deficiency, an inherited platelet disorder or a diagnosed thrombophilia. A history of unexplained bleeding after surgery, dental treatment or childbirth may also be relevant, particularly if the bleeding was prolonged or required additional treatment (NHS, n.d.-a; NHS, n.d.-c).

A family history of thrombosis may be significant where a close relative has a confirmed inherited thrombophilia or experienced an unexplained blood clot at a young age. However, a relative having had a blood clot does not establish that the infant has an inherited condition. Blood clots can occur for several reasons, and the circumstances surrounding the event matter.

The inheritance pattern also needs to be understood. Haemophilia A and haemophilia B are usually X-linked conditions. A mother who carries an affected gene may pass it to her children. Sons who inherit the affected gene are more likely to have haemophilia, while daughters who inherit it are often carriers, although some have bleeding symptoms themselves. A father with haemophilia passes his affected X chromosome to his daughters, but not to his sons, because sons inherit their father’s Y chromosome (NHS, n.d.-a).

Other inherited bleeding disorders and thrombophilias follow different inheritance patterns. Some may affect children of any sex, and some require a child to inherit an altered gene from both biological parents before the condition develops in its more severe form. It is therefore important not to assume that a condition will follow a particular side of the family or affect only boys.

A negative family history cannot exclude every inherited disorder. Relatives may have mild symptoms that were never investigated, a condition may have arisen through a new genetic change, or the family may not know the relevant medical history. Family history is one part of assessment, not a substitute for clinical judgement.

Recognising possible warning signs in the mother or baby

The absence of a diagnosed condition does not always mean that there is no relevant history. A practitioner should remain alert to information that could indicate an underlying bleeding disorder or another medical concern.

In an infant, potentially relevant features include unusual or extensive bruising, bleeding that appears disproportionate to an injury, prolonged bleeding after a heel-prick blood test or another procedure, blood in the urine or stool, or a known history of unexplained bleeding. These signs do not establish a diagnosis, but they may warrant medical assessment before an elective procedure is considered (NHS, n.d.-a; NHS, n.d.-c).

A history of significant bleeding in the birthing parent may also be relevant, particularly if it was unexplained or disproportionate to the circumstances. Examples include excessive bleeding after childbirth, persistent bleeding after dental treatment or surgery, frequent nosebleeds, easy bruising or unusually heavy menstrual bleeding. These symptoms have multiple possible causes, and they should not be used in isolation to diagnose a bleeding disorder.

Likewise, a history of thrombosis, recurrent pregnancy loss or a confirmed thrombophilia may justify clarification of the diagnosis and its relevance to the infant. Recurrent pregnancy loss can be associated with antiphospholipid syndrome, but it is not proof that a parent or infant has a particular clotting disorder (NHS, n.d.-b).

If an infant has unexplained bleeding, significant bruising, blood in the stool or urine, or other concerning symptoms, the priority is medical assessment rather than proceeding with an elective frenulotomy. Acute or substantial bleeding requires urgent assessment. The purpose of recognising warning signs is not to diagnose a condition in the clinic, but to identify when the available information is insufficient to make a safe decision.

The practical pre-procedure history

A structured history helps ensure that relevant information is considered consistently. The questions should be proportionate to the infant’s circumstances and include any known diagnosis, medication, previous bleeding and relevant family history.

Before tongue-tie division, it is useful to establish whether the infant has a diagnosed bleeding disorder, thrombophilia, liver condition or other illness that could affect haemostasis; whether there has been unusual bleeding or bruising; whether the infant has previously undergone a procedure; and whether a close relative has a confirmed inherited bleeding or clotting disorder.

The vitamin K history is particularly important. The practitioner should establish whether vitamin K was offered and administered, whether the course was completed where oral prophylaxis was chosen, and whether there are any concerns about possible vitamin K deficiency bleeding. The absence of obvious symptoms does not establish that an infant has no bleeding risk.

The history should also identify medicines or treatments that may affect coagulation, any known abnormal blood-test results and any advice previously provided by a paediatrician, haematologist or other specialist. If a diagnosis is reported by the family, it may be necessary to clarify the precise condition rather than relying on a broad description such as “a clotting problem”.

A routine history cannot identify every disorder, and normal examination findings do not exclude all bleeding conditions. Equally, not every infant requires a full panel of coagulation tests. The decision to investigate should be guided by the history, examination, known diagnoses and relevant clinical guidance. Where a concern cannot be resolved within the practitioner’s competence or available service, the appropriate next step is to seek medical or specialist advice rather than make assumptions.

What maternal screening and genetics can tell us

Families may understandably assume that routine antenatal blood tests would have identified a blood disorder that could affect a baby’s suitability for surgery. However, routine antenatal screening does not test every pregnant person for all inherited bleeding disorders or thrombophilias.

In England, antenatal screening is offered for sickle cell and thalassaemia and other relevant haemoglobin disorders through the NHS screening programme. These are inherited blood disorders that affect haemoglobin and the blood’s ability to carry oxygen; they are not the same as the coagulation-factor deficiencies associated with conditions such as haemophilia (NHS, n.d.-d; NHS England, 2024).

There is no universal antenatal screening programme that identifies every case of haemophilia, von Willebrand disease, factor deficiency, platelet-function disorder or inherited thrombophilia. Testing may be offered when there is a relevant family history, previous diagnosis, clinical concern or another indication. The absence of a diagnosis during pregnancy therefore cannot be interpreted as proof that every possible inherited bleeding or clotting disorder has been excluded (NHS, n.d.-a; NHS, n.d.-b).

Where a parent is known to have an inherited condition, genetic counselling or specialist advice may help clarify the likelihood of the infant being affected. The implications depend on the particular condition and its inheritance pattern. A carrier parent may pass on a genetic variant without the child necessarily developing the same condition or degree of severity.

Antiphospholipid syndrome requires a separate distinction. It is an acquired autoimmune condition associated with increased clotting risk, rather than a straightforward inherited thrombophilia. A maternal diagnosis does not, in itself, mean that the infant has APS. The family history should be interpreted in context rather than used to infer an infant diagnosis.

Vitamin K, jaundice and acquired bleeding risk

Vitamin K is essential for the production of several clotting factors. Babies are born with relatively low vitamin K stores, and vitamin K deficiency bleeding can occur if there is insufficient vitamin K for normal clotting. Although uncommon, this can be serious, including in infants who initially appear well (NICE, 2021; NICE, 2026).

The history of vitamin K administration should therefore form part of the pre-procedure assessment. If vitamin K was declined, not administered or an oral course was not completed, this information needs to be considered alongside the infant’s age, health and clinical history. It should not be treated as a diagnosis of vitamin K deficiency, but it may mean that the practitioner cannot assume the usual prophylactic protection has been provided.

Jaundice also warrants careful consideration. Prolonged or unexplained jaundice can sometimes be associated with underlying illness, including conditions that affect the liver or bile flow. Since the liver produces many proteins involved in coagulation, significant liver disease may affect haemostasis. However, jaundice alone does not establish liver disease or a clotting abnormality; its cause and the infant’s overall condition need to be assessed in accordance with relevant clinical guidance (NICE, 2010, updated 2023).

For further information on vitamin K and tongue-tie division, see Vitamin K and Tongue-tie Division.

When to seek specialist advice and how to access it

Medical or specialist advice may be needed when the history identifies a diagnosed bleeding disorder, a suspected significant coagulation abnormality, unexplained bleeding or bruising, or an inherited condition whose implications for the proposed procedure are unclear.

For known or suspected haemophilia, factor deficiency, von Willebrand disease or a significant platelet disorder, advice from a paediatric haematology service or haemophilia centre may be needed to establish whether division is appropriate and what arrangements would be required to manage bleeding. The relevant specialist team can advise on investigations, treatment and the appropriate setting for any procedure (NHS England, 2025; UKHCDO, n.d.).

Where thrombophilia is known or suspected, the decision should reflect the specific diagnosis and the infant’s clinical circumstances. Specialist advice may be appropriate when there is a known significant disorder, a personal history of thrombosis, additional medical complexity or uncertainty about how the condition affects the proposed care. A family history or diagnosis of thrombophilia should not automatically be equated with a contraindication to division, but it should not be dismissed without considering its relevance.

If the practitioner cannot establish whether a reported condition is significant, whether further assessment is required or whether the proposed setting is appropriate, the decision should be deferred while suitable advice is obtained. Where the question falls outside the practitioner’s scope of practice or cannot be resolved within the service, referral to the infant’s GP, paediatrician, haematology service or another appropriate healthcare professional should be considered according to the nature of the concern. This is not the same as automatically excluding every infant with a clotting-related diagnosis from consideration for division.

Where advice establishes that a procedure can be undertaken with appropriate arrangements, the plan should be clear before proceeding. Where the risk cannot be adequately assessed or managed within the available service, referral to a more appropriate setting may be necessary.

Community practice, hospital care and whether division is appropriate

The decision about whether tongue-tie division is appropriate involves more than identifying a frenulum or reviewing one risk factor. It requires consideration of the infant’s feeding function, the expected benefit of intervention, the clinical history, relevant examination findings, the practitioner’s scope of practice and the ability to respond to foreseeable complications.

A known bleeding disorder may require a specialist management plan, access to treatment or a setting with facilities that are not available in a community clinic. In these circumstances, proceeding without the necessary assessment or arrangements would not be appropriate. The precise requirements depend on the condition and the advice of the relevant clinical team.

Thrombophilia needs to be considered differently from a bleeding disorder. An inherited tendency to develop blood clots does not necessarily mean that a brief procedure involving the lingual frenulum is contraindicated, and thrombophilia should not automatically be treated as requiring hospital-based frenulotomy. However, the specific diagnosis, the infant’s medical history and any other risk factors remain relevant to an individual decision.

The available literature on complications following infant tongue-tie release describes concerns including bleeding, feeding difficulties and respiratory or airway events. A systematic review of major complications does not identify embolism as an established complication of frenulotomy (Solis-Pazmino et al., 2020). This should not be interpreted as proof that every theoretical risk is impossible, but it is important not to present embolism as a recognised complication of the procedure without supporting evidence.

The distinction is between the general risks associated with an underlying condition and complications established as associated with the procedure itself. Thrombophilia can be associated with serious thrombotic events, including pulmonary embolism, but this does not establish that an embolism is likely to occur because a tongue-tie division has been performed. The condition nevertheless warrants appropriate consideration when it is part of the infant’s known medical history.

The practitioner should not use this article, or any general list of conditions, as a substitute for an individual assessment. Nor should a diagnosis be treated as an automatic decision either for or against intervention. Where the history raises a concern that cannot be adequately assessed within the service, the appropriate response is to obtain further advice, investigate where indicated or refer to a more suitable setting.

Making decisions that prioritise the baby

A restrictive lingual frenulum may contribute to feeding difficulties, but not every infant with a visible or palpable restriction requires surgical division. A functional assessment helps establish whether tongue movement is affecting feeding and whether division is likely to provide a meaningful benefit. Further information is available in A Guide to Understanding Your Baby’s Oral Function and Infant Oral Anatomy: Structure, Function and Feeding.

When division is being considered, the assessment should include the infant’s clinical history, any relevant family history and factors that could affect bleeding or clotting. Where a known or suspected condition creates uncertainty, it is important to establish whether further assessment or specialist advice is needed before proceeding.

Bleeding disorders and thrombophilia should not be treated as interchangeable. An underlying bleeding disorder may have direct implications for wound haemostasis, while thrombophilia relates to an increased tendency to form abnormal blood clots. Some conditions can involve more complex patterns of both bleeding and thrombosis, so the precise diagnosis matters.

The absence of a known diagnosis does not guarantee that an infant has no underlying disorder, and the presence of a diagnosis does not always dictate a single outcome. The aim is to recognise relevant concerns, understand the limitations of the available information and make an informed decision about whether division is appropriate and, if so, where and under what arrangements it should take place.

A careful history, appropriate clinical judgement and timely medical or specialist input where indicated help ensure that decisions are made in the infant’s best interests, without either overlooking relevant risks or excluding babies from consideration solely because a condition has been named.

References

Haemophilia Society (n.d.) Treatment centres and support for people affected by bleeding disorders. Available at: https://haemophilia.org.uk/

Laffan, M. et al. (2024) ‘Guideline on the diagnosis and management of von Willebrand disease’, British Journal of Haematology. Available at: https://doi.org/10.1111/bjh.19385

National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance IPG149. Available at: https://www.nice.org.uk/guidance/ipg149

National Institute for Health and Care Excellence (NICE) (2010, updated 2023) Jaundice in newborn babies under 28 days. Clinical guideline CG98. Available at: https://www.nice.org.uk/guidance/cg98

National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. Guideline NG194. Available at: https://www.nice.org.uk/guidance/ng194

NHS (n.d.-a) Haemophilia. Available at: https://www.nhs.uk/conditions/haemophilia/

NHS (n.d.-b) Thrombophilia. Available at: https://www.nhs.uk/conditions/thrombophilia/

NHS (n.d.-c) Von Willebrand disease. Available at: https://www.nhs.uk/conditions/von-willebrand-disease/

NHS (n.d.-d) Screening for sickle cell and thalassaemia. Available at: https://www.nhs.uk/pregnancy/your-pregnancy-care/screening-for-sickle-cell-and-thalassaemia/

NHS England (2024) Sickle cell and thalassaemia screening programme. Available at: https://www.gov.uk/government/collections/nhs-sickle-cell-and-thalassaemia-sct-screening-programme

NHS England (2025) Consultation on service specification for haemophilia and related bleeding disorders (adults and children): background information. Available at: https://www.england.nhs.uk/long-read/consultation-on-service-specification-for-haemophilia-and-related-bleeding-disorders-adults-and-children-background-information/

Solis-Pazmino, P. et al. (2020) ‘Major complications after tongue-tie release: A case report and systematic review’, International Journal of Pediatric Otorhinolaryngology, 138, article 110356. Available at: https://doi.org/10.1016/j.ijporl.2020.110356

UK Haemophilia Centre Doctors’ Organisation (UKHCDO) (n.d.) Haemophilia centres and resources. Available at: https://www.ukhcdo.org/