Tongue ‘scissors’ surgery in babies to be examined; new guidelines as minister warns of ‘unnecessary focus on condition’

Surgery on babies with a frenulum will be examined more closely after some healthcare workers reported an increase in controversial procedures.

Assistant Health Minister Dr. Ayesha Verrall says some children need minor surgery, but warns that there may also be “unnecessary attention to the condition,” with anecdotal reports of possibly unnecessary procedures.

The Health Ministry has released the first national guidelines on braces, amid a lengthy debate about how best to treat a condition that affects 5 to 10 percent of babies.

Tongue tied (ankyloglossia) is when the small piece of tissue, called a frenulum, that connects the tongue to the base of the mouth is short or tight, which can prevent the tongue from moving properly.

In many cases, breastfeeding will be possible without surgery, but about 2 to 5 percent of all babies have a frenulum that can cause problems latching on.

Symptoms, such as painful breastfeeding and restless baby, may have other causes, and it may take time for mother and baby to learn to breastfeed.

That has led to concern that some babies may unnecessarily undergo minor surgery, when the tongue is lifted and the frenulum is cut with sterile scissors.

“In some babies with a tongue lock, the tissue needs to be cut to allow more movement. However, this is not necessary for everyone,” Verrall said.

“So far there has been no national council related to frenulum, and there may also be an unnecessary focus on the condition, which can delay the management of other feeding-related problems in babies.

“Now that we have [the guidelines], people can audit your practice against them. It could help people make clearer decisions about which babies really need surgery; Although it is a simple surgery, we prefer to avoid it for those who do not need it. “

Verrall said changes had been called for, and some healthcare workers reported an increase in the number of surgeries. Other problems included a lack of clear and consistent information for parents and uneven access to treatment.

The new guidelines were drafted with the help of experts from the Pediatric Society, the Midwifery Council and College, the Dental Association, the College of Physicians, Plunket, and the Association of Lactation Consultants.

If a problem is suspected, a breastfeeding evaluation will be conducted, where the healthcare professional talks with the parents about their baby’s feeding history, observes how the baby is breastfeeding, and adjusts the technique if necessary.

A scoring tool is used to determine the degree of frenulum, and written consent must be obtained prior to a frenotomy, including an explanation of treatment options and risks, and the baby must have received vitamin K beforehand.

Frenotomy can be performed by a midwife or GP, but complicated cases should be referred to a specialist, such as a dental surgeon or pediatrician. A midwife or lactation consultant should observe breastfeeding as soon as possible afterward, with follow-up support.

Most of the research papers found significant improvements in 80 to 90 percent of cases after minor surgery, the guidelines note, but “there are conflicting opinions among healthcare professionals and some say it’s hard to be sure if any perceived improvement in lactation is due to split tongue tie. “

Rare but serious complications include infections, ulcers, and pain. Being too quick to blame breastfeeding problems with the frenulum can delay the diagnosis of underlying medical conditions.

The ministry says it is difficult to know the number of tongue holding scissors made, because not all treatment is done within DHBs and there was no obligation to provide data.

“While the surgery is minor, it is not risk-free. With the new guidance, parents can rest assured that regardless of who is treating their baby or where they live, all healthcare professionals follow the same advice for refer, evaluate and treat the condition. “Verrall said.

“The expectation in the guidelines is clear: clinicians should audit their practice for frenulum. This is a form of surgery that needs the same approach. [as other procedures]. “

Tongue tie

• About 2 to 5 percent of babies have a frenulum that can cause problems with breastfeeding or, in severe cases, with bottle feeding.

• If a breastfeeding evaluation suggests that the frenulum is causing problems, a release (also called frenulum scissors, frenulum split, or frenotomy) may be recommended.

• This involves lifting the tongue and cutting the tissue that connects the tongue to the base of the mouth, with a pair of sterile scissors. There should be little bleeding.

Source: National guidelines of the Ministry of Health.