Ankyloglossia

Template

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ExamChoose one

FeedingChoose one

PlanChoose one

ConsentChoose any

ProcedureChoose any

Follow-upChoose one

Follow-up reasonChoose anyJoins the line above

Counseling

A small white or yellow patch under the tongue is normal healing over the next week. Stretching exercises are not needed. Recommended supportive care with an emphasis on frequent feeds and continued lactation support. Return precautions given including bleeding that does not stop with gentle pressure, poor feeding, fever, fewer wet diapers, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Many latch problems improve with lactation support, and frenotomy remains an option if they do not. Posterior and lip ties are normal structures and are not a reason for surgery. Recommended supportive care with an emphasis on frequent feeds and the lactation plan. Return precautions given including poor feeding, painful feeding that is not improving, fewer wet diapers, poor weight gain, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

A tongue-tie that is not causing feeding problems does not need treatment, and frenotomy does not prevent future speech or sleep problems. Recommended supportive care with an emphasis on continued lactation support. Return precautions given including painful or difficult feeding, poor weight gain, fewer wet diapers, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Ankyloglossia
• Restrictive anterior lingual frenulum limiting tongue movement
• Breastfeeding difficulty not improved with lactation support
• Frenotomy performed
• Consent signed after discussing benefits, risks (bleeding, infection, pain), and alternatives (watchful waiting or specialist referral)
• Confirmed vitamin K given at birth
• Pain control with sucrose or breastfeeding offered
• Time-out performed
• Frenulum exposed with a tongue guard and divided with scissors until released; hemostasis with gentle pressure; tolerated without complication; fed immediately afterward
• Follow up in 1 week to recheck feeding and weight

A small white or yellow patch under the tongue is normal healing over the next week. Stretching exercises are not needed. Recommended supportive care with an emphasis on frequent feeds and continued lactation support. Return precautions given including bleeding that does not stop with gentle pressure, poor feeding, fever, fewer wet diapers, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Restrictive vs not
Symptomatic: not improved with lactation support
Frenotomy, lactation first, ENT, none
Consent; vitamin K time-out
No stretching exercises

Return precautions in the template

bleeding that does not stop with gentle pressurepoor feedingfeverfewer wet diapers

Sources

Thomas J et al; AAP Section on Breastfeeding. Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report. Pediatrics…