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

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Provider Resources

Related Pathway

Malnutrition, Outpatient

Definition of Ankyloglossia
- Tongue is limited in range of movement and subsequent function, due to presence of restrictive sublingual frenulum

Infants < 6 mos with Suspected Tongue-Tie or Restriction
Impacting Feeding, Weight Gain

Exclusions
Prominent Labial Frenulum

Primary Care Team Assessment

History and Physical Exam
Detailed Feeding History, Observation
Milk Production Assessment, Interventions
Physical exam features of Tongue Restriction
- Band of tissue that tethers tongue to floor of mouth
- Limited tongue mobility (extension, elevation, and lateralization)
- Tongue may be notched or heart-shaped

Restrictive Lingual Frenulum
- with abnormal assessment
  and definitive impact on feeding

Unclear Restrictive Lingual Frenulum
- and feeding is impacted

Expedited ENT Referral
Discussion with ENT or medical/dental provider

Consider Lactation Consult
- Milk production concerns
- Difficulty with latch
- Breast or nipple pain/trauma

Continue to monitor growth
Support breast/chestfeeding
Re-evaluate feeding at routine visits

Consider Lactation Consult
- Milk production concerns
- Difficulty with latch
- Breast or nipple pain/trauma
Consider speech (SLP) consult
- Difficulty with bottle feeding

Post procedure follow-up with PCP
- Monitor weight
- Continue lactation and/or SLP referral for resolution of any continued feeding challenges

Restrictive
Lingual Frenulum
with impact on feeding identified

No Restrictive Lingual Frenulum but continued feeding difficulties

Expedited ENT Referral

Consider other causes
Monitor feeding and nutrition
SLP may refer to interdisciplinary feeding team if concerns appear more complex

Posted: February 2022
Revised: May 2024

Authors:
- M. Devine, RN;
- M. Kawan, MD;
- R. Lessen, IBCLC;
- E. Scott, OTR/L;
- J. Liberati, CRNP;
- M. Brodnik, CRNP;
- D. Kaminski, MD;
- S. Galbally, CCC-SLP;
- J. McDonald, DO;
- A. Buzi, MD

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Primary Care and Outpatient Specialty Care Clinical Pathway for the Care of Infants with Ankyloglossia (Tongue-Tie)

Evidence