Ankyloglossia and infant feeding — formative SAQs

SAQ 1 — The two-week-old with poor weight gain and a painful latch (10 marks, 15 minutes)

A two-week-old exclusively breastfed infant is reviewed because feeds last over an hour, the baby clicks and repeatedly comes off the breast, and he has regained none of his birth weight. His mother has cracked, bleeding nipples and a tender, engorged right breast. On oral examination there is a short, tight frenulum attaching near the tongue tip, and the tongue cannot elevate past the lower gum or form a cup. [2]

a) Define ankyloglossia and classify this tie by position and function, naming two validated functional assessment tools. (3 marks) [9] [11]

b) Outline your immediate management of the feeding failure, including how you would secure the infant's intake and protect the mother's milk supply. (3 marks) [10]

c) State the conservative-first principle, and give the indication for frenotomy in this infant after a trial of support. Summarise the evidence (Cochrane and at least one randomised trial) for frenotomy. (3 marks) [1] [5]

d) Name two procedural complications of frenotomy and one mimic that must be excluded before any division. (1 mark) [12]

SAQ 2 — The six-week-old whose mother wants the tie snipped (10 marks, 15 minutes)

A six-week-old infant is brought by a mother who has read online that the baby is tongue-tied and wants it snipped today. Feeds are settling well with positioning advice from a lactation consultant, the latch is painless and effective, and the infant is gaining weight along the ninth centile. Oral examination shows a mild anterior frenulum with full tongue protrusion, elevation onto the palate, cupping and lateralisation, a normal uvula and an intact palate. [10]

a) State the key principle that governs whether a tongue-tie is treated, and explain why this infant does not meet the indication for frenotomy. (3 marks) [9] [12]

b) Outline the counselling you would give this mother, addressing the overdiagnosis pitfall and the role of skilled lactation support. (3 marks) [10]

c) Describe how your assessment and decision would change if the mother instead reported a painful clicking latch, a compression stripe across the nipple and poor weight gain despite good positioning. (3 marks) [2] [6]

d) Give the safety-net advice and the follow-up arrangements for this dyad. (1 mark) [10]