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Clinical Pathways

Child Health
Tongue Tie Management

Background

Tongue tie or ankyloglossia is a congenital anomaly occurring in approximately 0.2%-10% of the population and is characterised by a short frenulum or a highly attached genioglossus muscle restricting tongue movements. Only 25% - 50% of babies with ankyloglossia will have feeding problems related to their tongue tie. 

The definition of tongue tie is not standardised and there is wide variation of opinion regarding its clinical significance and optimal management. International data supports a target rate for tongue tie release surgery between 2% - 5%.

Equity information:

Maori babies are significantly less likely than non-Maori babies to have been exclusively breastfed by three months. Poor breast feeding rates in Maori babies is likely to reflect reduced access to lactation support. Rural locality and being from a lower socioeconomic demographic, are likely contributors to reduced access to lactation support for Maori.

Assessment

  1. Clinical Features

    • Clinical features of tongue tie may include
      • inability to protrude the tongue more than 1 to 2mm past the lower central incisors
      • for infants too young to voluntarily protrude the tongue, a frenulum that prevents placement of the examiner' s fingers between the underside of the tongue and mandibular alveolus is considered abnormally restrictive
      • abnormally short frenulum, inserting at or near the tip of the tongue
      • difficulty lifting the tongue to the upper dental alveolus
      • impaired side to side movement of the tongue
    • Mother may have symptoms and signs that include:
      • nipple damage/nipple pain
      • low milk supply
      • plugged ducts
      • mastitis
      • breast pain/caused by nipple compression 
    • N.B. It is important for the mother and baby to be examined together as both may have contributing anatomy variations leading to the presenting issue.

  2. Infants 48 hours to < 3 months

     

Management

    • Plunket- any age baby especially those who live rurally, struggle to get to hospital or are otherwise "hard to reach".
    • Hospital midwives- 0-6 weeks.
    • Bethlehem Birthing Centre- 0-6 weeks.
    • Contacts:
      • Plunket: Karen Palmer, 027 243 7897
      • Whakatane: Aani Sherwin, 07 306 0999 ext 4302, 027 550 7014
      • Tauranga: Raewyn Sherratt or Kelly Van der Westhuizen, 027 771 1759
      • Bethlehem Birthing Centre: shauna@birthingcentre.co.nz 021 508 368, 07 570 6106

  2. If infant > 3 months, frenotomy not indicted

  3. If non-significant BTAT > 4, no action

  4. If significant BTAT 0-4 +, refer for frenotomy

    • A significant tongue tie is one that interferes with breastfeeding BTAT 0-4:
      • sore/cracked nipples
      • low milk supply
      • mastitis (recurrent)
      • difficulty attaching to the breast or they cannot seem to stay attached for a full feed
      • failure to thrive
    • Consultation with a lactation specialist (International Board Certified Lactation Consultant) may help the child compensate for problems related to tongue tie thereby avoiding surgery.
    • Please refer to either Whakatane or Tauranga LC. Babies born at Bethlehem Birthing Centre can have review with LC at BBC until 6 weeks of age.
    • In WBOP any age baby especially babies in rural areas, hard to reach families and those unable to access the hospital for an appointment can be referred to Plunket LC - 027 243 7897.
      • Refer to Māmā Maia for initial assessment via bpac eref (breastfeeding support). Ph 027 5541120
      • Contacts:
        • Whakatane: Aani Sherwin, 07 306 0999 ext 4302, 027 550 7014
        • Tauranga: Raewyn Sherratt or Kelly Van der Westhuizen, 027 771 1759
      • If complicated Tongue Tie paeditrician can refer to paediatric surgery of Maxillofacial Surgeon. 

  5. If dysmorphic features or co-morbidities, refer to paediatricians

Information

  • This pathway was adapted from the Waikato DHB version on Map of Medicine and developed in collaboration with:

    Name Position

    Dr Vivienne Hobbs

    Consultant Paediatrician

    Dr Alison James

    GP Liaison, BOPDHB

    Karen Palmer

    Community Lactation Services Co-ordinator, Plunket

    Shauna Walters

    Bethlehem Birthing Centre

    Raewyn Sherratt

    Lactation Consultant, BOPDHB

    Aani Sherwin

    Lactation Consultant, Whakatane, BOPDHB

    Kelly Van der Westhuizen

    Lactation Consultant, BOPDHB

    Dr Jillian Caisley

    GP, WBOPPHO

    Dr Varsha Gandhi

    Senior Registrar, Paediatrics, BOPDHB

    Dr Jeremy Armishaw

    Consultant Paediatrician, BOPDHB

    Dr Josh Agnew

    Consultant Paediatrician, BOPDHB

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.