Division of ankyloglossia (tongue-tie) for breastfeeding

# Guidance
Current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support the use of the procedure provided that normal arrangements are in place for consent, audit and clinical governance.
Division of ankyloglossia (tongue-tie) for breastfeeding should only be performed by registered healthcare professionals who are properly trained.
Publication of further controlled trials on the effect of the procedure on successful long-term breastfeeding will be useful.# The procedure

# Indications
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.
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.

# Outline of the procedure
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.

# Efficacy
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).
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.
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.

# Safety
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.
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.
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.

# Other comments
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.
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.# Further information
The Institute has developed a clinical guideline on postnatal care. The Health Development Agency has also published a systematic review on breastfeeding.
Andrew DillonChief ExecutiveDecember 2005

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedure overview of division of ankyloglossia (tongue-tie) for breastfeeding', February 2005.

# Information for patients
NICE has produced information on this procedure for patients and carers. It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
It has been incorporated into the NICE pathway on postnatal care, along with other related guidance and products.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2005. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
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