Tongue Tie and IBCLC Assessment

Summarise consultation Consultation held virtually via video call on 1 November 2024 with Mrs. Sarah Davies and her 3-week-old infant, Leo. The primary reason for the consultation was concerns regarding Leo's feeding difficulties, specifically poor latch and clicking noises during breastfeeding, and associated maternal nipple pain. Ms. Davies' partner, Mr. John Davies, was also present during the consultation. Pregnancy, labour and birth history Mrs. Davies' pregnancy was uncomplicated. Labour was induced at 40+5 weeks due to reduced fetal movements, resulting in a spontaneous vaginal delivery. No immediate concerns were noted at birth. Newborn examination was unremarkable. Birth weight was 3.5 kg (50th centile). Current weight is 3.8 kg (40th centile), indicating appropriate weight gain but still below birth centile, suggesting potential feeding inefficiencies. Feeding History and assessment Leo initiated breastfeeding shortly after birth but has consistently struggled with latching. Mrs. Davies reports prolonged feeding sessions (45-60 minutes) every 1.5-2 hours, with frequent clicking sounds and poor milk transfer indicators. Mrs. Davies experiences significant nipple pain and occasional blanching. A community midwife previously observed a feed and suggested potential tongue tie, recommending this consultation. No bottle feeding has been introduced. No other professionals have been involved. Reason for consultation Mrs. Davies sought assessment for Leo's feeding difficulties, hoping for a clearer understanding of the cause and practical solutions to improve breastfeeding comfort and efficiency, ultimately aiming for exclusive breastfeeding. Tongue tie assessment and findings Body movement: Leo demonstrated good overall body tone and movement. No significant asymmetries observed. Positioning: When brought to the breast, Leo displayed some head retraction and difficulty maintaining a deep latch. His mouth opening was sometimes shallow. Oral and facial examination: Palate was high-arched. No cleft noted. Mandibular movement appeared restricted slightly. Lip assessment revealed good flanging of the upper lip, but the lower lip tended to tuck inwards. Tongue function: During suckling observation, the tongue elevation was limited, and the tongue did not protrude past the lower gum line. The lateral margins of the tongue did not cup the breast effectively. A 'heart-shaped' appearance of the tongue tip was noted when elevated. Tongue appearance: A visible tight anterior frenulum was noted, extending to the tip of the tongue, tethering it to the floor of the mouth. Information and advice discussed Detailed explanation of normal tongue function in breastfeeding was provided. The potential impact of restricted tongue movement on latch, milk transfer, and maternal comfort was discussed. Visual aids were used to explain the anatomy of a tongue tie and its classification. What is a tongue tie? A tongue tie, or ankyloglossia, is a condition where an unusually short, thick, or tight band of tissue (lingual frenulum) tethers the bottom of the tongue's tip to the floor of the mouth. This restriction can impair the tongue's ability to move freely, elevate, and protrude, which is crucial for an effective latch and efficient milk extraction during breastfeeding. Risks and benefits of division Risks: Potential for minor bleeding, temporary discomfort, infection (rare), and possibility of frenulum reattachment (also rare). These risks are generally low, especially when performed by an experienced practitioner. Benefits: Improved latch, reduced maternal nipple pain, more efficient milk transfer, better weight gain for the infant, and potential reduction in symptoms like clicking and reflux. Plan Given the clinical presentation, observed feeding difficulties, and the clear physical finding of an anterior tongue tie impacting feeding, a frenotomy (division of the frenulum) is indicated. Mrs. Davies was provided with information regarding a local specialist who performs the procedure. She was given the choice to proceed with the division. Preparation for division involves ensuring the baby is fed shortly before the procedure to allow for post-procedure feeding. The timing of division is recommended as soon as possible to alleviate current feeding issues. Post-division, immediate skin-to-skin and feeding at the breast will be encouraged, with careful observation of the latch and milk transfer. Ongoing advice Aftercare guidance: Instructions were provided for gentle wound care and monitoring for signs of infection. Gentle tongue exercises to encourage mobility were demonstrated. Expectations: Parents were advised that while improvement is often immediate, it can take several days or weeks for the baby to fully adapt to the new tongue mobility and for feeding to become consistently comfortable and efficient. Persistence and continued support are key. Feeding support offered: Referral to a local breastfeeding support group and provision of contact details for ongoing IBCLC support were given. Follow-up consultation in one week was scheduled to reassess feeding. Ongoing care or support arrangements: Parents encouraged to contact the IBCLC directly with any concerns or for further support.