Tongue Tie and IBCLC assessment

Midwife's Notes - 1 November 2024 I conducted this consultation in the family's home, where I met with the mother, Sarah, and the baby, Leo, for a detailed assessment regarding feeding difficulties. Dr. Hannah Green, the referring paediatrician, was also present via video call to provide additional context. The primary concern identified was Leo's inability to latch effectively, leading to significant discomfort for Sarah during breastfeeding. Sarah's pregnancy was uneventful, but labour was prolonged, lasting over 24 hours, culminating in an emergency C-section due to fetal distress. Leo's newborn physical examination was normal, though he was noted to have a slightly recessed chin. His birth weight was 3.5 kg (50th centile), and his current weight is 3.2 kg (10th centile), indicating a significant drop and failure to thrive. From birth, Leo struggled with latching, often slipping off the breast and producing clicking sounds. He currently feeds for only 5-7 minutes per session, every 1.5 to 2 hours, which is insufficient. Sarah reports severe nipple pain, describing it as a 'sharp, burning sensation' after each feed. She has not sought input from other feeding professionals prior to this consultation. The primary difficulties are poor latch, short feeding duration, and maternal pain. Sarah has been attempting to pump to maintain her milk supply using a Medela Swing single electric pump. She pumps 3-4 times a day, with each session lasting approximately 15-20 minutes, yielding around 30-40ml per session. Leo is currently supplemented with 60ml of Hipp Organic Combiotic formula per feed, given via a Philips Avent Natural bottle, after every attempted breastfeed. The reason for this assessment was Sarah's distress over the persistent feeding issues and Leo's weight loss. She hopes for a definitive diagnosis and effective intervention to enable successful, pain-free breastfeeding and improve Leo's weight gain. During my assessment, I observed that Leo presented with a tight neck and shoulders, favouring his left side, which impacted his ability to achieve a symmetrical latch. His body was often stiff and arched during feeding attempts, making it difficult for him to relax into a feeding position. On oral examination, I noted a high, arched palate and a short frenulum that restricted tongue elevation and extension. There was evident tension in his masseter and temporalis muscles. His facial structure appeared symmetrical, but his tongue exhibited a heart-shaped appearance on elevation, with limited lateral movement and inability to protrude past the lower lip margin. The suck reflex was present but disorganised, and his tongue showed difficulty cupping around the nipple. I explained to Sarah that a tongue tie is a condition where the frenulum, the piece of skin connecting the underside of the tongue to the floor of the mouth, is unusually short or tight, restricting the tongue's movement. I clarified how the tongue is crucial for creating a vacuum and compressing the nipple effectively during feeding, and how a restricted tongue can lead to poor latch, inefficient milk transfer, and maternal pain. I discussed the evidence linking birth experiences, body tension, and cranial nerve function to feeding difficulties, emphasising that these factors can collectively impact feeding experience and positioning. I detailed how the frenulum's restriction was impeding Leo's ability to achieve an optimal suck. We discussed the risks and benefits of tongue tie division. I explained that risks include minor bleeding, infection, and potential reattachment, though these are rare. Benefits include improved latch, reduced maternal pain, increased milk transfer, and better weight gain for Leo. I emphasised that while division often improves tongue coordination and strength, ongoing feeding support would still be necessary to establish optimal feeding patterns. Given the significant feeding difficulties and Leo's weight loss, I indicated that division was advisable. Sarah opted to proceed. Prior to the procedure, I guided her through some gentle stretches for Leo's neck and jaw to optimise his body alignment. The division was performed immediately. Following the division, Leo was immediately offered the breast. He latched more deeply and effectively, feeding for 15 minutes with improved milk transfer, and Sarah reported significantly less pain. I discussed expectations for the coming days, including continued improvement in feeding, and potential fussiness as Leo adjusts. I provided Sarah with detailed aftercare instructions for the wound site and a set of oral exercises to encourage full tongue mobility. We reviewed various feeding positions and comfort techniques. We arranged a follow-up consultation in one week to assess Leo's feeding progress and weight gain, and I provided contact details for ongoing support should any concerns arise before then.