Ankyloglossia (commonly known as tongue tie) is defined by the National Institute for Health and Care Excellence (NICE, 2005) as ‘a congenital anomaly characterised by an abnormally short lingual frenulum: the tip of the tongue cannot be protruded beyond the lower incisor teeth’. It is suggested that infants with a tongue tie are susceptible to difficulties with feeding, particularly those who are breastfed (NICE, 2005). Infants with a tongue tie may also suffer from other functional problems with speech and dentition (Kale et al, 2019). A lack of a universal assessment method means that it is difficult to fully determine the incidence of the condition; however, it is thought to affect up to 11% of neonates (Illing, 2019) with varying degrees of severity and clinical impact. Male infants are more commonly affected than female infants (Brookes and Bowley, 2014).
However, it is important to recognise that a diagnosis of tongue tie does not necessarily correlate with breastfeeding difficulties, as approximately 50% of infants with a tongue tie will be able to successfully breastfeed, particularly if provided with effective and ongoing lactation support in the neonatal period (NICE, 2005; Association of Tongue Tie Practitioners (ATTP), 2020). For those infants who have a severely restricted frenulum, feeding can be profoundly impacted, leading to a poor latch, ineffective milk transfer, insufficient weight gain, unsettled infants and maternal nipple pain (Webb et al, 2013; Burrows and Lanlehin; 2015; Illing, 2019). Without the appropriate intervention, many women may cease breastfeeding earlier than they had anticipated. Healthcare professionals (particularly midwives, health visitors and neonatal nurses) play a crucial role in supporting lactation (Royal College of Midwives, 2018; Nursing and Midwifery Council, 2019) and, as it is advocated that division of the frenulum is effective in the early neonatal period (NICE, 2005; Sharma and Jayaraj, 2015), it seems logical to support those professionals to train in this important area.
NICE (2005) and the ATTP (2020) suggest that tongue tie practitioners should be registered healthcare professionals who are experienced in lactation support and recognise that the role of tongue tie division should fall within the practitioners' usual sphere of practice. Therefore, it is essential that the selection of appropriate candidates for a training course is robust and thorough. With many NHS hospital trusts now offering tongue tie services, it is vital that practitioners are appropriately trained and imperative that training is robust and standardised (Burrows and Lanlehin, 2015).
Frenulotomy (division of the lingual frenulum also known as frenotomy, frenuplasty and lingual frenectomy) is a safe and effective procedure (NICE, 2005; Webb et al, 2013) and is, therefore, supported by NICE as a procedure to help rectify some of the problems associated with a tongue tie, particularly for those infants who are struggling to establish breastfeeding. There is evidence that maternal satisfaction with breastfeeding can improve as a result of the procedure (Muldoon et al, 2017, Emmerson, 2018; Illing, 2019) and some evidence that division may lead to increased duration of breastfeeding (Webb et al, 2013, Muldoon et al, 2017; Emmerson, 2018). Furthermore, mothers reported less nipple pain from breastfeeding post-procedure (Dollberg et al, 2006; Burrows and Lanlehin, 2015; Muldoon et al, 2017; Illing, 2019). Emmerson (2018) does suggest that frenulotomy does not solve all breastfeeding difficulties and emphasises the importance of ongoing lactation support for women after the procedure.
Frenulotomy has minimal risk of complications post procedure (NICE, 2005; Webb et al; 2013; Brookes and Bowley, 2014). Potential complications can include excessive bleeding, infection, damage to the musculature of the tongue, ulcers developing under the tongue and a requirement for a revision following scarring or incomplete division (Webb et al, 2013; Ganesan et al, 2019). It is essential that healthcare practitioners are trained to manage these situations, should they arise.
Currently, access to tongue tie services for assessment and treatment is determined by where the mother chooses to give birth and where she and her baby are registered with a GP, as this dictates what services are commissioned for the population where they live (NHS England, 2013). There is also evidence of a lack of trained staff to undertake the frenulotomy procedure, adding to the issues with access to services (HealthWatch Suffolk, 2018). A report by Fox et al (2016) found that tongue tie service provision varies across NHS trusts and a need for access to skilled assessment and treatment. They asserted that this would lead to the prevention of under- and over-diagnosis but would also need to be coupled with appropriate and timely breastfeeding support for women.
The University of Wolverhampton offer an accredited training course that attempts to address these issues by educating healthcare professionals in the assessment of ankyloglossia, treatment in the form of frenulotomy and through supporting women with infant feeding.
The training course
Prior to 2013, there was, and remains, a lack of formal educational programmes available across the UK for the management of tongue tie, which includes training for division of the frenulum. Others that did exist at that time were informally organised and not academically recognised by a higher educational institution and therefore did not carry any academic credits. There was, and still is, an increasing demand for more professionals to be trained in tongue tie division (Wakelin et al, 2017), allowing them to provide treatment in their own NHS trust or local area to serve their local population and as such applications are received from midwives, nurses, health visitors, doctors and dentists. NICE (2005) recognised that the person delivering a tongue tie service and undertaking frenulotomies must be appropriately trained and be a registered healthcare professional. In response to this need, and with an additional need to establish tongue tie and frenulotomy services in their own area, the specialist midwife for infant feeding at The Dudley Group NHS Foundation Trust at the time approached the University of Wolverhampton in 2012 for support to develop a course. The initial intention of the course was to educate midwives in the clinical skills of assessment of tongue function, diagnosis of ankyloglossia and to perform frenulotomy. In response to the request, the head of continuing professional development at the university agreed that a collaborative approach between the university and the NHS trust to develop, internally validate, accredit and deliver a short course would be beneficial to the needs of the local population. Patient safety and quality of care are global requirements at the forefront of policy agendas in healthcare (Gallen et al, 2019) and it was imperative that this agenda was the foundation for the development of the course.
The initial planning stages of the course included a brief outline of the content, the method of delivery and the assessment strategy. It was agreed that the course should be at postgraduate level and firmly embedded in clinical practice because of the nature of the skills required to carry out assessment and treatment. The University of Wolverhampton already provided continuing professional development programmes at this level for midwives (newborn and infant physical examination and sexual health courses) and had the expertise within the teaching team to deliver this programme at masters' level (Level 7). The emphasis of a master's level programme was to enable the midwife to manage complex problems in the clinical environment and to give them the confidence to deliver care by demonstrating advanced levels of problem-solving and clinical expertise in midwifery (Walker and Spendlove, 2018). Being able to autonomously make decisions about infants with a tongue tie, their assessment and treatment are fundamental qualities of tongue tie practitioners. There is also a need for these professionals to create business cases, work closely with management structures and collaborate with other members of the multidisciplinary team in order to establish a service or make changes to existing services for the benefit of mothers and babies. While Ridgers et al (2009) advocate the appropriateness of tongue tie services being overseen by a medical consultant, the purpose of the proposed programme was to enable tongue tie practitioners to be autonomous and independent of medical services.
Midwifery could already be considered an advanced role, as midwives are the lead professional in pregnancy and childbirth and because of their autonomous decision-making (Homeyard, 2014). Contemporary midwifery practice recognises the need for midwives to undertake further education and training to advance their knowledge and clinical skills further in some areas of practice (Begley et al, 2007). Marshall (2010) advises advancing clinical skills to meet the demands of providers and service users of maternity services, suggesting a range of advanced skills including breech delivery, ventouse delivery, perineal repair and external cephalic version. Frenulotomy can be added to this list of advanced skills, as it is not something that would normally be part of a midwife's pre-registration education or midwifery role. The contribution of advanced practice roles in health services include rapid access to care and seamless patient flow across the service (O'Connor et al, 2018). While the skills to perform frenulotomy are important and were a core component of the planned training course, it was the provision of services to women and their babies that was seen as a key element of the programme.
The original concept of the course was one full face-to-face study day followed by a placement in the frenulotomy clinic at the The Dudley Group NHS Foundation Trust. The writing of the module framework and practice assessment document was created collaboratively by the specialist midwife for infant feeding at the NHS trust, the course leader and the head of continuing professional development at the University of Wolverhampton, making use of the existing framework for clinical assessment within continuous professional development at the university, which was based on the work of Eruat (1994) and the NICE (2005) division of ankyloglossia (tongue-tie) for breastfeeding guidelines. Originally, a total of five key clinical competencies were devised, along with the requirement for students to complete a minimum of 20–25 frenulotomies under supervision of a named supervisor (a tongue tie practitioner). The course was successfully validated by the university in May 2013, with the first cohort of eight midwives commencing in September of that year. Recruitment was kept to a small number because of the advanced nature of frenulotomy and, at this stage in the development of the programme, there were only four recognised practice supervisors in the clinical setting who were able to supervise the students.
As recruitment numbers increased, a change was required relating to the clinical practice element of the course. Applicants can now state if they are able to be supervised in their own employment setting, rather than relying solely on The Dudley Group NHS Foundation Trust. This has created additional capacity and greater access for students across the UK. Other changes have included moving from one full face-to-face study day at the university's Walsall campus to two online study days, which also assists in improving access for students across the UK, and expanding the entry criteria to include a wider range of healthcare professionals.
Analysis
Since commencement of the programme in 2013, there has been a steady increase in the numbers of healthcare professionals applying to undertake the course, with 50 students on the latest iteration (Figure 1). The pass rate for the course overall is 90%. Although the success of the course can be measured by the increased popularity and the overall pass rate, the most important measure of success is the impact the training has had on clinical practice and ultimately the services provided to families.
Figure 1. Student enrolments per year
The Midlands Tongue Tie Practitioners Network was established in July 2017 to support best practice for NHS midwife and nurse tongue tie practitioners. The group provides strategic leadership for the Midlands Regional Tongue Tie Practitioners Network, whose aim is to improve the health and wellbeing of mothers and infants by enabling excellent practice for infant feeding and relationship building. The group is for any NHS tongue tie practitioner and aims to provide consistency among practitioners. An audit was undertaken in 2020 by the Midlands Tongue Tie Practitioners Network as part of ongoing service evaluation. The audit demonstrated that 74% of the parents felt that having a frenulotomy improved feeding.
‘The midwife assessed my baby and took a full feeding history from me. The score was borderline; therefore, I was given the options to not have the treatment or to have the frenulotomy performed. I decided to go ahead with the procedure, which was performed quickly and efficiently by the tongue tie practitioner. I breastfed my baby immediately following the frenulotomy, the pain was less, and my baby was instantly settled and soothed after some minor distress following the procedure.’
(Mother from audit)
Students on the course have been happy with the education and support they received from the university.
‘I did the tongue tie course at the University of Wolverhampton and did my clinical placement at The Dudley Group NHS Foundation Trust in 2019. On placement I was able to increase my practical skills at my own pace and was able to consolidate my knowledge whilst increasing my confidence and gaining a recognised qualification. They also gave me guidance to set up my own clinic within my NHS trust which I have been facilitating now for a year. It has been extremely successful in enabling mothers to breastfeed their babies after having a frenulotomy and improving tongue function. We have an 82% success rate.’
Student (midwife, tongue tie practitioner and infant feeding coordinator at NHS trust)
The main challenge when establishing the course was the lack of national standards for tongue tie assessment and frenulotomy training. Completion of the University of Wolverhampton course, or any other course, is not a requirement to practice as a tongue-tie practitioner. However, it was felt that a set of standards would support the implementation of evidence based practice and ultimately improve services for women and their babies.
Through discussions with current students, it is becoming apparent that there is an increasing demand for tongue tie services across the UK, with Local Maternity and Neonatal Systems and NHS Clinical Commissioning Groups recognising this need and funding healthcare professionals to attend the university course. This may lead to an increase in NHS commissioned services, which, in turn, will lead to improved access for women and their babies to high-quality, standardised, evidence-based care.
Conclusions
Currently, the only real measure of success for the programme is the pass rate and upward trend in the number of applicants and enrolments each year at the university, which indicates that the course is achieving what it set out to do. Further work needs to be undertaken to really understand the impact that the collaborative approach to training has on outcomes for women and their babies, including breastfeeding rates and access to services. This evaluation work could also be undertaken in a collaborative way by making use of the Midlands Tongue Tie Practitioners Network and others that exist around the UK.
In the future, a set of nationally agreed standards of practice that tongue tie practitioners must meet prior to practising clinically would help to standardise practice and raise the quality of the provision of ankyloglossia assessment and frenulotomies. Ultimately, this would provide quality assurance to women and their families of the standard of care that they can expect to receive. Accompanying national standards, it would be useful to have a nationally agreed practice assessment document for higher education institutes to implement and create consistency for supervisors in practice. In addition, a further advance would be to set up a national register of tongue tie practitioners.
In order to improve access to accredited courses, it would be useful to have additional higher education institutes offering this course in conjunction with local NHS trusts. As a consequence, this may improve access to services for women and their families as more trained professionals would be available to provide the services. The University of Wolverhampton is also planning to provide refresher courses for practitioners who have completed the course but have been unable to practice immediately. This will ensure that they are able to improve their confidence without repeating the course.
Overall, the passion and enthusiasm to continue to develop the collaborative programme and to educate a range of healthcare professionals in order to improve outcomes for women and their babies remains a driving force for both the University of Wolverhampton and The Dudley Group NHS Foundation Trust. The increasing number of applicants for the course is encouraging and provides some assurance that there is still a need to educate more tongue tie practitioners and that there is still a need for more tongue tie services.
Key points
- The University of Wolverhampton are currently the only university in the UK to offer an accredited training course in advanced clinical skills in tongue tie (ankyloglossia) management (including frenulotomy)
- With many NHS hospital trusts now offering tongue tie services, it is vital that practitioners are appropriately trained and imperative that training is robust and standardised
- Joint collaboration between the University of Wolverhampton and The Dudley Group NHS Foundation Trust has been a major factor in the course's success
- Since commencement of the programme in 2013, there has been a steady increase in the numbers of healthcare professionals applying to undertake the course, which has an overall pass rate of 90%
- In the future, a set of nationally agreed standards of practice that tongue tie practitioners must meet prior to practising clinically, would help to standardise practice and raise the quality of the provision of ankyloglossia assessment and frenulotomies
CPD reflective questions
- What are the advantages of an educational programme that is collaboratively delivered?
- How does close supervision in clinical practice develop practitioners' clinical skills?
- How does a robust, evidence-based educational programme improve care of women and babies?
- Can access to services be improved by educating healthcare professionals on how to establish local services?
- Would a nationally agreed set of standards impact on the quality of care provided in tongue tie services?