Hall and Renfrew rightly describe the literature with relation to ankyloglossia as containing “little high quality objective evidence”; they also describe the difficulties in study methodology in this setting with particular reference to concealing the diagnosis from parents in control studies.¹ With regards to intervention, they note that “…frenulotomy in the newborn is a low risk minor procedure, performed without anaesthetic” and that “…significant venous bleeding could occur if technique is not meticulous but we found no reports of serious adverse events”.

Ankyloglossia intervention in the outpatient setting has been performed for over 20 years in Edinburgh without anaesthetic. We recently reviewed 28 months of patients (February 2002–June 2004) who underwent the procedure to assess the complication and success rates. We fully acknowledge that our study was neither controlled nor had objective measures of outcome; nevertheless, it is the only study we know of to specifically investigate the safety of outpatient intervention in this country.

Patients were identified from outpatient correspondence to general practitioners if they were initially referred for consideration of ankyloglossia as a cause of feeding difficulties. If appropriate the tongue tie was divided in the clinic by one of two consultant paediatric surgeons using the following method:

The baby is firmly swaddled in a blanket and held (by an experienced nurse) across the examination couch with his head towards the surgeon. The baby’s head is steadied by the nurse who can also assist in pulling down the chin with her thumb to encourage the mouth to open. The surgeon’s left index finger elevates the tongue placing the frenulum under tension. The transparent part of the frenulum is divided with iris scissors. Care must be taken to avoid cutting into the thicker posterior part of the frenulum which carries the blood supply. Bleeding should be minimal or nonexistent. The baby is fed by the mother in another room and checked again by the surgeon before leaving the clinic.

The mothers of the study patients were telephoned to complete a brief telephone questionnaire relating to possible complications and some subjective indicators of success after a minimum 14 day period. Forty four (of a possible 51 study patients) were successfully contacted.

The mean age of infants on the day of tongue tie division was 49 days (SD 41, mean 38, mode 38) with the youngest infant being 3 days old and the oldest 202 days old. The study group consisted of 25 males (57%) and 19 females (43%).

The type of feeding before the procedure was documented and included all types of feeding attempted by the mother until the date of tongue tie division. Forty mothers were at least partly breast feeding, four infants were exclusively formula fed. Of the 40 breast fed infants, 35 (88%) had problems latching on. Thirty three (83%) of the mothers had sore nipples and 15 (38%) had mastitis. Thirty five (80%) of the 44 mothers noted an improvement in the ease of feeding after the procedure, with 28 (64%) also noting an improvement in the time taken for a feed. Three of the four formula fed infants were improved in both these areas.

With regard to the complication rate (table 1), any pain or bleeding after leaving the clinic was considered significant as well as any episodes of infection, any need to seek medical advice, and any repeat procedure required to release the tongue tie. The mean time of leaving the clinic after the procedure was 29 minutes (SD 21 minutes), with the shortest wait 0 minutes and the longest wait 120 minutes in an infant whose mother was awaiting delivery of a breast pump from stores. Excluding this infant, the longest wait was 60 minutes.

One infant had bleeding after leaving the clinic. The bleeding was minimal and self limiting. The baby did not require any further medical attention and had left the clinic 15 minutes after the procedure.

One infant was reported as being in pain after the procedure and was given a single dose of paracetamol with good effect. There were no incidents of infection and no requirement for further medical advice after the procedure. Two patients required a repeat procedure which was performed in the same way on a separate day. Both repeat procedures were successful.

This study shows that frenotomy in outpatients is both effective in releasing tongue tie and safe in terms of potential complications (9% overall complication rate). We suggest that the consideration of ankyloglossia is important in the differential diagnosis of an infant with difficulties feeding or a mother having pain breast feeding. If diagnosed in either of these situations, the ankyloglossia can be easily treated in the outpatient clinic setting with a low complication rate. We would recommend the mother be encouraged to remain in clinic for a minimum of 30 minutes after the procedure during which time a test feed can be performed. Routine outpatient follow up is not required.