Post- Frenulotomy wound careAWM (Active Wound Management)

Katherine Fisher BSc, MSc, IBCLC Lactation Consultant,Team Leader Tongue Tie Clinic.

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• Mid-line anomaly-incomplete apoptosis at 7 weeks gestation.

• 2:1 incidence in males.• 1:7 babies will have frenular tissue that may or may

not cause restriction in tongue mobility.• Familial tendency for incidence.• Increased incidence-Folic acid prophylaxis/more

effective diagnosis?• Early 1941 study reported an incidence of 4 babies in

1000.

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Aetiology and Incidence

Frenular tissue or Tongue–tie?

• All babies will have a degree of frenular tissue.

• A frenulum only becomes a Tongue-tie when it restricts tongue mobility, and as a consequence may or may not cause difficulties with breastfeeding.

• Careful assessment always required, and treatment offered only on clinical indication.

• Risks of frenulotomy include; Pain, bleeding, recurrence and late scarring.

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Difficulties caused by Tongue-tie

• Slow weight gain/ weight stasis.• Rapid weight gain.• Nipple pain/ trauma, bacterial /fungal infection.• Fractured/prolonged feeds.• Aerophagia.• Sub-optimal milk transfer unsettled baby.• Up/down regulation of maternal milk supply.

• Tongue –tie severity should not graded on visual assessment of the position of the frenulum alone.

• Grading -severe, moderate, mild, relates only to restrictions in tongue mobility.

• Various Tongue-tie Assessment Tools include;

• Hazlebaker: HATLEFF assessment of lingual frenulum function.

• BTAT: Bristol Tongue tie assessment tool, for appearance and function.

• Ingram 2015: TAP Tongue-tie assessment protocol.

• Ingram 2015: TAP • Griffiths: Thin, medium, and thick.• Kotlow: Type 1, 2, 3,4

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Tongue-tie variants - anterior

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• Often difficult to see.• Palpable sub-lingual/sub-mucousal

band of tissue.• Digital pressure on the frenular tissue

usually demonstrates a ‘short’ tongue of 4-6mm

• Babies need approximately 16mm of tongue to protrude persistently over the alveolar ridge.

• Kotlow: ‘With a finger, run it underneath the tongue from side to side. The feeling of a tie can be described as a fence, speed bump or ridge in the bottom of the mouth. A normally developed mouth floor will fee smooth. Any kind of a bump has the potential to cause problems’.

Posterior Tongue tie

Maxillary or upper lip tie.

• Little evidence for treating maxillary tie in babies.

• Diastema? divides gum tissue, suspected potential to cause dental issues.

• Potential to reduce eversion of the top lip during feeding.

• I am only aware of one paediatric dentist in the uk, who treats with laser.

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The procedure

• Direct division, using a Brodie director.

• No GA• Topical and pre-emptive

analgesia for babies over 8 weeks old.

• Haemostasis readily achieved by breastfeeding alone.

• Extremely important to attain an adequate sub-lingual romboid of 6-10mms.

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Pre and post-frenulotomy analgesia

Age appropriate pre-emptive and post surgical analgesia;

Paracetamol suppositories or suspension.

Sucrose solution or sachets.

Topical Lidocaine gel or liquid.

BREAST MILK !

Adequate isolation of posterior frenular tissue prior to division, using a Brodie grooved director.

1) The Brodie grooved director , isolates only the tissue for division and places it under tension.

2) The director lifts the tongue clear of the salivary ducts.

3) The director protects the genioglossis muscle and sub-lingual blood vessels.

Achieving an adequate sub-lingual rhomboid, a complete frenulotomy

Complete Frenulotomy;Sub-lingual rhomboid visible,Fascia excised, vertical genioglossus muscle may be visible.

Incomplete Frenulotomy,residual frenular tissue remains in Situe.This procedure is unlikely to improve tongue mobility or Breastfeeding.

Post –frenulotomy after-care

• Pre-procedure talk includes benefits, risks, and alternatives to Frenulotomy.

• After-care sheet on discharge.

• Telephone support for parents and referrers.

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Normal wound sloughing, infection is not an evidenced, risk of Frenulotomy.

Support for AWM

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AWM is controversial and poorly understood in the UK.No published evidence yet, our practice is based on anecdote, understanding of oral wound healing, and extensive clinical experience. Shin & Bordeaux 2012 post frenulotomy treatment with wound massage 90% had an improved appearance.

Melissa Cole: less than 3% recurrence rate in her practice.Tongue lifts, and finger tip massage on the incision site, rolling pin massage on floor of the mouth and whole of the site.

Ghahiri: Deep sulci tongue lifts, fingertip massage on the site and horizontal adhesion release.Kotlow: Finger tip massage of the incision and tongue lifting.

Supporting parents with after-care

• KCH TTC study demonstrates that AWM significantly reduces the risk of recurrent Tongue-tie to less than 2%.

• Review with referrer at day 5-7 and day 10-14 post procedure.

• Review feeding/treatment plan issued by Tongue-tie clinic.

• Digital examination to assess function and adhesion recurrence.

• Disrupt adhesion if competent, or support parent with massage technique.

• Refer back to Tongue-tie Clinic if recurrence present.

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One more snip, the experience of our centre.

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• Single Centre, single surgeon prospective study.

• 1937 breastfeeding dyads May 2013-October 2015.

• Recurrence rate less than 2%.

• Please look at our poster.

Positioning baby for AWM

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Note off centre C-shaped deep access to lateral sulci, this ensures that any adverse changes to the frenulotomy site are readily noted on a twice daily basis and appropriate action can be taken by parents or the practitioner.

The Kings AWM method

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• Minimises recurrence

• 6 weeks duration

• Stage 1 massage day 0-7 firm finger tip adhesion disrupting of the wound for 5-6 seconds twice daily, start and finish with lateral checking sweep.

• Review appt day 5-7

• Stage 2 scar smoothing and stretching massage day 7 -42+

• Vertical, scar smoothing and stretching massage using the side of the tip of the index finger.

• Review appointment day 10-14

AWM parental training model showing 6 stages of wound progression

The Kings AWM method cont.

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Tongue tie in situ and sublingual rhomboid.Firm adhesion disrupting finger tip massage commences, for 5-7 seconds twice a day

The Kings AWM method cont.

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Wound sloughing and potential fibrin/adhesion formation.Continue firm finger tip massage to prevent/minimise adhesion

The Kings AWM method cont.

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Wound adhesion renders the rhomboid small and restrictiveAdhesions are usually disruptible during this stage to reattain an adequate sub-lingual rhomboid

Stage 2 AWM scar management

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• Scar management to prevent scar contraction

• Contracted collagen fibres on the left.

• Stretched parallel collagen fibres on the right

• Firm collagen stretching massage using the side of the finger tip assists in achieving a wide, flat, scar.

An effective result of AWM

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Day 1

Day 3-5

Day 10

Its important to continue wound care for 4-6 weeks post surgery

Normal post-frenulotomy wound progression

Preventing Recurrence

Baby F, 4 weeks after Frenulotomy. No AWM

Baby S, 3 years after Frenulotomy. No AWM

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Additional complications

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Recurrent tongue tie following 2 revisions by a midwife, note interruption of salivary ducts.

The LiperTM device

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The LiperTM deviceSpecial design to fit under the tonguePerfect combination of flexibility and softnessBio compatible materialsPerfect surface texture to prevent slipping

TM

The LiperTM device use#1

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TM

Can be used by the surgeon instead of a grooved director.

The LiperTM device use#2

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TM

• Soft appliance

• Intuitive

• Not touching the wound

• Easily accepted by parents

• Better compliance

• Not suitable for all babies

The LiperTM device use#3

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TM

Non Surgical TOT ManagementHome exercises to lift and train the tongue for better function for neonates and older patients

Survey

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TM

• An internal survey was conducted among 41 newborns in ages 2-96 days

• 38 (92.7%) parents reported a significant improvement

• 31 ( 75.6%) parents reported that the device was easy to use

• 30 (73.1%) parents reported that the device is more efficient that using the finger

• In 50% of borderline cases the device actually prevented the need for surgery

• Parents that used the finger stretching but had reattachment preferred the LiperTM-device much more than the finger

Use by the parents

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TM

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TM

Concerns about future oral aversion.

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TM

Katherine Fisher: A single operator observational and retrospective study.

• Study of private practice frenulotomy,1500 patients, 3 year period ending 31.12.2017

• 16 data collection points.

• One examines oral aversion symptoms; gagging, breast refusal, difficulty with eating solids, and aversion to fingers, toys approaching, entering or touching the mouth.

• Early indications so far only 3 parents have reported symptoms of oral aversion.

Future AWM research.

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TM

• Dr Eyal Botzer’s practice, Tel Aviv Israel.

• Lactation Consultant’s Master’s degree awaiting ethics committee approval.

• To examine and provide an evidence base for AWM.

• Phase 1, 2 cohorts one with AWM 3 times a day, and the other without re evaluate after 1 week.

• Evaluation tools to be used LATCH score and LFPI Lingual Frenulum Protocol for Infants.

• Phase 2 use of Liper device and a variety of AWM methods.