2 The procedure

2.1 Indications

2.1.1 Ankyloglossia, also known as tongue-tie, is a congenital anomaly characterised by an abnormally short lingual frenulum, which may restrict mobility of the tongue. It varies from a mild form in which the tongue is bound only by a thin mucous membrane, to a severe form in which the tongue is completely fused to the floor of the mouth. Breastfeeding difficulties may arise, such as problems with latching (getting the mother and baby appropriately positioned to breastfeed successfully), sore nipples and poor infant weight gain.

2.1.2 Many tongue-ties are asymptomatic and cause no problems. Some babies with tongue-tie have breastfeeding difficulties. Conservative management includes breastfeeding advice, and careful assessment is important to determine whether the frenulum is interfering with feeding and whether its division is appropriate. Some practitioners believe that if division is required, this should be undertaken as early as possible. This may enable the mother to continue to breastfeed, rather than having to feed artificially.

2.2 Outline of the procedure

2.2.1 In early infancy, division of the tongue-tie is usually performed without anaesthesia, although local anaesthetic is sometimes used. The baby's head is stabilised, and sharp, blunt-ended scissors are used to divide the lingual frenulum. There should be little or no blood loss and feeding may be resumed immediately. After the early months of life, general anaesthesia is usually required.

2.3 Efficacy

2.3.1 One randomised controlled trial compared division of tongue-tie with 48 hours of intensive support from a lactation consultant. Mothers reported that 95% (19/20) of babies had improved breastfeeding 48 hours after tongue-tie division, compared with 5% (1/20) of babies in the control group (p < 0.001).

2.3.2 In one case series of 215 babies, 80% (173/215) of mothers reported improved breastfeeding 24 hours after the procedure. In another case series of 123 babies, 100% (70/70) of mothers reported improved latch after the procedure, and the 53 mothers with nipple pain noted significant improvement immediately after the procedure. In a third case series, 100% (36/36) of babies were reported to have normal tongue motion at 3 months. For more details, refer to the Sources of evidence.

2.3.3 There were conflicting opinions among the Specialist Advisors and some stated that it is difficult to be certain whether any perceived improvement in breastfeeding is due to division of the tongue-tie.

2.4 Safety

2.4.1 Few adverse effects were reported. One case series reported that, after the procedure, 2% (4/215) of babies had an ulcer under the tongue for more than 48 hours. Two studies, including a total of 159 babies, stated that there were no complications.

2.4.2 Two studies reported that 8% (3/36) and 18% (39/215) of babies slept through the procedure. For more details, refer to the Sources of evidence.

2.4.3 The Specialist Advisors stated that adverse effects were likely to be rare. Potential adverse events include bleeding, infection, ulceration, pain, damage to the tongue and submandibular ducts, and recurrence of the tongue-tie.

2.5 Other comments

2.5.1 It was recognised that breastfeeding is a complex interaction between mother and child, and that many factors can affect the ability to feed. Skilled breastfeeding support is an integral part of the management of breastfeeding difficulties.

2.5.2 Public consultation highlighted that this procedure may also be relevant for bottle feeding, but it was noted that this was not included in the scope or in the literature search for this guidance.