Tongue Tie and IBCLC Assessment

Midwife Note - 1 November 2024 Consultation took place at the patient's home with Mrs. Sarah Johnson and her 3-week-old infant, Baby Amelia. The primary concern discussed was difficulties with breastfeeding and suspected tongue tie. Pregnancy, Labour And Birth History Mrs. Johnson experienced an uncomplicated pregnancy. Labour commenced spontaneously at 39 weeks + 2 days and progressed without intervention, resulting in a vaginal birth. There were no noted issues or concerns during labour or birth. NIPE findings were normal. Baby Amelia's birth weight was 3.5 kg (50th centile), and her current weight is 3.8 kg (55th centile). Feeding History And Assessment At birth, Baby Amelia latched well for the first 24 hours. Currently, she struggles to latch deeply, often slips off the breast, and feeding sessions are prolonged, lasting up to 45 minutes, occurring every 1.5-2 hours. Mrs. Johnson reports significant nipple pain and blanching after feeds. She has previously sought advice from a lactation consultant who suggested a possible tongue tie. Mrs. Johnson is using a Medela Swing single pump, pumping 3-4 times a day for 15 minutes, yielding approximately 30-40ml per session. When bottle feeding expressed milk, she uses a Dr. Brown's bottle, giving 60ml per feed. She is currently exclusively providing breast milk. Reason For Consultation The specific reason for this consultation is to assess Baby Amelia for tongue tie and explore options for improving breastfeeding. Mrs. Johnson hopes that an assessment and potential intervention will alleviate her nipple pain and enable a more efficient and comfortable feeding experience for both herself and Amelia. Tongue Tie Assessment And Findings On examination, Baby Amelia presented with some generalised body tension, particularly in the neck and shoulders. Her body position during feeding attempts showed a tendency to arch her back. Oral examination revealed a tight superior labial frenum and a visible posterior tongue tie. The tongue appeared heart-shaped when elevated, and its elevation was restricted. Palpation showed tightness in the floor of mouth musculature. Facial symmetry was noted, and no other anomalies were observed. Tongue function was impaired, with limited lateralisation and extension beyond the lower lip. Information And Advice Discussed What Is A Tongue Tie? Information was provided regarding the anatomy and function of the tongue during feeding, explaining how an unrestricted tongue is crucial for a deep latch and effective milk transfer. The concept of tongue tie (ankyloglossia) was discussed, highlighting how a tight frenulum can restrict tongue movement and impact feeding efficiency. We reviewed relevant evidence linking birth experience, body tension, cranial nerve function, and feeding challenges. The discussion also covered how the frenulum's attachment can impede tongue mobility, affecting suck, swallow, and breathe coordination. Risks And Benefits Of Division The risks and benefits of tongue tie division were discussed in detail with Mrs. Johnson. Potential risks highlighted included minor bleeding, low risk of infection, reattachment of the frenulum (though less common with proper aftercare), and a very rare risk of damage to surrounding oral structures. The benefits discussed included potential improvement in latch, reduction in nipple pain, and enhanced milk transfer. Realistic expectations regarding improved tongue coordination and strength post-division were also addressed, noting that some babies might still require ongoing support. Plan Based on the assessment findings and Mrs. Johnson's concerns, division of both the superior labial frenum and the posterior tongue tie was indicated and offered as an option. Mrs. Johnson opted to proceed with the division. Preparation for division included ensuring Baby Amelia had fed recently to be calm and content. The division was performed immediately after the discussion. Post-division, Baby Amelia latched onto the breast, demonstrating an immediate improvement in latch depth and Mrs. Johnson reported reduced pain. Ongoing Advice Expectations for healing and recovery were discussed, advising that the wound site would heal quickly. Detailed aftercare advice included gentle stretching exercises for the lip and tongue to prevent reattachment, to be performed 3-4 times daily for 2-3 weeks. Comprehensive feeding support was provided, including demonstration and practice of optimal breastfeeding positioning (e.g., laid-back feeding, biological nurturing) and attachment techniques to encourage a deep, asymmetric latch. Advice on pumping included ensuring correct flange size and maintaining pumping frequency to protect milk supply. Bottle feeding advice emphasised paced bottle feeding techniques to mimic breastfeeding flow and avoid overfeeding. Specific body, facial, and oral exercises were demonstrated to release residual tension and promote optimal oral motor function. Ongoing care and support included a follow-up appointment in one week to assess healing and feeding progress, with a recommendation for ongoing lactation consultant support and consideration of a cranial osteopath referral if body tension persists.