Treatment of tongue tie

Deputy Health and Disability Commissioner Meenal Duggal today released a report finding a lactation consultant in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for care provided to a five-day old baby.

The lactation consultant, who was also a registered midwife, assessed the mother and baby and diagnosed the baby with a tongue tie. She recommended a frenotomy to release the tongue tie and provided the parents with information about the procedure. A frenotomy involves lifting the tongue and cutting the thin piece of skin under the tongue (the frenulum) with scissors. The lactation consultant did not advise the parents of the non-surgical alternatives to a frenotomy.

When the parents advised the lactation consultant that their baby had not received a vitamin K injection at birth, she did not explain that there is a risk of significant blood loss following a frenotomy when vitamin K has not yet been administered. This occurs because vitamin K helps to clot the blood and prevent serious bleeding.

After the lactation consultant performed the frenotomy there was some bleeding at the site which she controlled via compression with sterile gauze. Before leaving the lactation consultant told the parents to call her if the bleeding started again. Later that afternoon the bleeding started again but the mother controlled it with compression and sterile gauze.

At 6.30pm the bleeding started again and the parents were unable to control it. When the father contacted the lactation consultant she told him to use compression on the site and to call an ambulance if the bleeding continued. The parents were able to stop the bleeding at this time, but at 8pm the bleeding started again and they were unable to control it. They called an ambulance but were unable to contact the lactation consultant. When ambulance staff arrived the baby was transferred to hospital and received a vitamin K injection. The bleeding stopped at midnight.

Ms Duggal considered that the lactation consultant failed to provide services with reasonable skill and care. Ms Duggal was critical of the lactation consultant’s decision to perform a frenotomy given the baby had not had a vitamin K injection, and of her failure to review the baby in person or refer him to hospital after the father’s call.

Ms Duggal was also critical that the lactation consultant failed to offer the parents a non-surgical alternative to a frenotomy, and that she did not advise them that there was an increased risk of significant bleeding for babies who have not received a vitamin K injection. This meant the parents were unable to make an informed choice, or give informed consent to the frenotomy on behalf of their baby.

Ms Duggal recommended the lactation consultant provide a letter of apology to the baby’s parents.The Midwifery Council undertook a competency review of the lactation consultant’s performance of frenotomies, and made specific recommendations regarding her practice.

In response to a complaint regarding the treatment of tongue tie earlier this year, Ms Duggal recommended that the Ministry of Health consider formulating a consensus position on frenotomies, and consider developing guidelines for the diagnosis and performance of frenotomies by midwives. The Ministry of Health accepted this recommendation and is making progress with a working group to address the issue. Ms Duggal said this was a positive step towards having better information available for parents to make informed decisions.

https://www.hdc.org.nz/decisions/search-decisions/2018/16hdc01563/