Ankyloglossia (Tongue Tie) — Detailed Feeding History — Clinical Pathway: Primary Care, Outpatient Specialty Care

Infants with Ankyloglossia (Tongue-Tie) Clinical Pathway — Outpatient Specialty Care and Primary Care

Detailed Feeding History/Observation

If any of the following indicators are not appropriate or typical for infant’s age, consider referral with a lactation consultant and/or speech-language pathologist.

Breastfeeding
  • Frequency, number of feeds/breast emptying at breast/chest in 24 hrs
  • Longest interval between feedings/emptying per 24 hrs
  • One breast or both breasts per feeding
  • See or hear baby swallow
  • Any supplementation of expressed human milk
  • Access to a breast pump
Bottle feeding
  • Frequency, length, amount per feed and in 24 hrs
  • Longest interval between feedings per 24 hr period
  • Bottle type, nipple type and size
  • Assess positioning
Elimination
  • # wet diapers/urine output in 24 hrs
  • # stool diapers per 24 hrs

Breast/Chestfeeding Observation

Observation of feeding can help assess infants’ skill and stamina related to oral feeding. Many breast/chestfeeding problems can be effectively managed by skilled lactation support. By modifying the latch and position and with the temporary use of nipple shields and expressed breast milk for supplementation when necessary, many breastfeeding and lactation challenges can be improved upon if not resolved.

Position
  • Parent comfortable
  • Infant with head/shoulder/hip alignment
  • Infant close to parent (tummy to tummy)
  • Infant at level of breast
Latch
  • Wide open mouth
  • Latched deeply on to breast
  • Upper and lower lips flanged
  • Maintains latch throughout feeding
  • No audible clicking
  • No loss of milk
Milk transfer
Parental comfort
  • Parent denies pain throughout feeding
  • Nipple looks round without creasing or pinched appearance
Use of lactation aids
  • Nipple shield
  • Supplemental Nursing System

Lactating Parent Assessment

Assessing/protecting milk production is essential to future outcomes of breast/chestfeeding.
At each visit, providers should assess production and intervene as needed.

History
  • Prior lactation experience
  • Lactation risk factors for delayed lactation or inadequate milk production
    • Infertility
    • PCOS
    • Thyroid dysfunction
    • Hypertension
    • Diabetes
    • Surgeries, traumas or piercings of chest, breast, or nipples
    • Lactating parent medications
    • Hormonal contraception
Physical Assessment
(may be reported)
  • Abnormal breast tissue
    • Hypoplasia or missing breast tissue
  • Abnormal nipple exam
    • Inverted, flat
  • Damage to nipples related to breastfeeding
    • Compression stripes, white pallor, scabbing
  • Incomplete breast drainage
  • Breast engorgement, lumps, clogs
  • Severe unrelenting pain during or after feedings
  • Inability to let down because of pain

Milk Production Assessment and Interventions

  • Perceived or actual low milk production is one of the most common reasons given for discontinuing breastfeeding.
  • Modifiable factors should be addressed: parental anxiety and mental health issues, comfort and relaxation for the lactating parent, frequency and effectiveness of milk removal, and any underlying medical conditions.
Infant Signs and Symptoms of Low Parental
Milk Production		 Interventions for Inadequate Milk Production
  • Dehydration
  • Atypical feeding patterns for age
  • Inadequate weight gain
  • Inadequate number of wet diapers and/or stools
  • Supplementation with formula and/or frozen milk not by parental choice
  • Breast/chest feed and/or pump a minimum of 8x per day
  • Initiate pumping whenever infant is receiving a bottle supplementation (of formula or human milk)
  • Ensure parent has access to a high-quality breast pump
  • Referral to a lactation consultant