Author Name:
National Institute of Child Health

Biography:

Division of ankyloglossia (tongue-tie) for breastfeeding

About this information
The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. One of NICE’s roles is to produce guidance (recommendations) on whether interventional procedures are safe enough and work well enough to be used routinely in the NHS in England, Wales and Scotland.

This information describes the guidance that NICE has issued on a procedure to help babies with a condition known as ankyloglossia or tongue-tie to breastfeed. It is not a complete description of what is involved in the procedure – your baby’s healthcare team should describe it in detail.

NICE has looked at whether division of tongue-tie is safe enough and works well enough for it to be used routinely to help babies with tongue-tie to breastfeed.
To produce this guidance, NICE has:

• looked at the results of studies on the safety of the procedure and
  how well it works
• asked experts for their opinions
• asked the views of the organisations that speak for the healthcare
  professionals and for the babies and parents who will be affected
  by this guidance.

This guidance is part of NICE’s work on ‘interventional procedures’ (see ‘Further information’).

About the procedure
Some babies are born with the condition tongue-tie, which has the medical name ankyloglossia. The fold of skin under the tongue that connects to the tongue to the bottom of the mouth is shorter than usual, and this restricts the movement of the tongue. The condition may be mild, or it can be severe, with the tongue joined to the bottom of the mouth.

Tongue-tie can cause problems with breastfeeding, such as problems ‘latching on’ (getting in the right position to feed efficiently) and sore nipples. If the baby isn’t feeding efficiently, he or she may not gain weight at the normal rate. The procedure NICE has looked at involves cutting through the fold of skin using sharp, blunt-ended scissors. For a very young baby, this is usually done without an anaesthetic or using a local anaesthetic. The baby should be able to feed straight after having the procedure.
A general anaesthetic is usually used for babies more than a few months old.

How well the procedure works
What the studies said
One study compared what happened in babies who had the tonguetie procedure with babies whose mother had 48 hours of intensive support from a breastfeeding specialist. Nearly all the mothers of babies who had the procedure said that breastfeeding had improved 24 hours afterwards (it improved in 19 out of 20 babies). As a comparison, only 1 mother out of 20 who had support from the breastfeeding specialist said that breastfeeding improved afterwards. In one study that followed what happened in 215 babies who had the tongue-tie procedure, 173 mothers said breastfeeding improved
afterwards. In another study, all 70 mothers said that their babies could latch on better after having the procedure. And the 53 mothers who had felt nipple pain said that this improved after their babies had the procedure. In a third study, all 36 babies in the study who had the tongue-tie procedure could move their tongues normally 3 months later.
What the experts said
The experts did not agree about how well the tongue-tie procedure worked. Some said that it was difficult to tell whether the improvement in breastfeeding happened as a result of the procedure.

Risks and possible problems with the procedure
What the studies said
The studies did not report many problems after the tongue-tie procedure. In one study, 4 out of 215 babies had an ulcer under their tongue that lasted more than 48 hours. Two studies that included a total of 159 babies found no problems after the procedure.
In one study, 3 out of 36 babies slept through the procedure, and 39 out of 215 babies slept through it in another study.
What the experts said
The experts said that problems were likely to be very rare. The following were possible, though: bleeding, infection, ulcers, pain, and damage to the tongue and surrounding area. It was also possible that the tongue-tie might return.

What has NICE decided?
NICE has considered the evidence on division of tongue-tie. It has recommended that when healthcare professionals use this procedure for babies with tongue-tie they should be sure that:

• the parents or carers understand what is involved and agree (consent) to the treatment, and
• the results of the procedure are monitored.

The procedure should be carried out by registered healthcare professionals who have been trained to do it. NICE has also said that it would be helpful to see the results from
studies looking at the effects of the procedure on long-term breastfeeding.
Other comments from NICE
Many factors influence breastfeeding, and support from someone with specialist knowledge is very important. The procedure may also be used to help with bottle feeding, but the NICE guidance does not cover this.

What the decision means for you
You may have been offered the tongue-tie procedure for your baby. NICE has decided that the procedure is safe enough and appears to work well enough for use in the NHS. Nonetheless, you should understand the benefits and risks of the procedure before you agree to it. A healthcare professional should discuss the benefits and risks with you. Some of these may be described above.

Further information
You have the right to be fully informed and to share in decisionmaking about the treatment you receive. You may want to discuss this guidance with the doctors and nurses looking after your baby. The NICE website (www.nice.org.uk) has further information about NICE, the Interventional Procedures Programme and the full guidance
on division of ankyloglossia (tongue-tie) for breastfeeding that has been issued to the NHS. The evidence that NICE considered in developing this guidance is also available from the NICE website. NICE is developing a clinical guideline on postnatal care, and
information on the progress of the guideline can be found at
www.nice.org.uk/page.aspx?o=guidelines.inprogress.postnatalcare  
A report called ‘Breastfeeding for longer – what works?’ is also available from the NICE website (www.publichealth.nice.org.uk/page.aspx?o=502749).
If you have access to the internet, you can find more information on breastfeeding on the NHS Direct website (www.nhsdirect.nhs.uk). You can also phone NHS Direct on 0845 46 47.