Consent - Division of Tongue Tie

CONSENT INFORMATION – PATIENT COPY

DIVISION OF TONGUE TIE

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having a Division of tongue tie. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.

What is “Tongue tie”?

 Tongue-tie (ankyloglossia) is a congenital condition in which the lingual frenulum is abnormally short and may therefore restrict mobility of the tongue tip. The lingual frenulum is a normal structure that is present in all babies. If it is short and restricts the movement and function of the tongue, it is called tongue-tie. Not all tongue-ties require release - the division of the lingual frenulum - and these may be considered a normal variant unless there are clearly identified feeding problems.

What is “division of tongue tie”?

Division of tongue tie is the division of the band of tissue tethering the tongue.

Why divide tongue ties?

Tongue-tie can interfere with a baby's ability to suckle efficiently at the breast. This may lead to nipple pain and trauma, poor breast milk intake and a decrease in milk supply over time.

 What are the symptoms?

The good news is that lots of babies with tongue-tie experience no problems at all, either with feeding or speech. However, some babies will have problems with breastfeeding because they won't be able to use their tongue to massage their mother's nipple and areola. If they can't stick their tongue out beyond their lower gum they won't get enough milk. Any of the following can be symptoms of tongue-tie:
(1) failure to latch on
(2) slipping off the breast while feeding
(3) Sore nipples, mastitis and/or blocked ducts
(4) continuous feeding
(5) colic
(6) slow weight gain

Remember, a baby with tongue-tie may not have all of the above symptoms and some babies will have these symptoms, but not have a tongue-tie.

How are tongue-ties divided?

Dividing your baby's tongue-tie does not require a general anesthetic, providing they are less than 8 months of age. It only takes a minute or so, though it may well seem longer. A trained health professional will simply wrap your baby up with a towel, divide the tongue-tie with sterile scissors and bring him back to you quickly so that you can feed him.

Does it hurt?

Logically, dividing a tongue tie ought to hurt. However, a significant number of small babies (about 1 in 6) are asleep when their tongue tie is divided and remain asleep during the procedure!

Older babies do not like being wrapped up so they usually cry out, and it can sometimes be quite difficult to know whether dividing their tongue-tie is actually painful, as they are already complaining at being wrapped up.

Following division, the baby is promptly unwrapped and returned for feeding. Although some babies will cry for up to 60 seconds, the average is just 15 seconds (and some just stay asleep).

So, for some babies division does not hurt and for the rest it does not hurt very much at all.

What about the wound?

A few drops of blood are normal, but this always stops quickly and is never a problem. The inside of the mouth heals much faster than most of the rest of the body because the lining of the mouth is being worn away and renewed all the time. This happens even quicker in babies, so there is no need for any form of wound management, the baby just needs to be fed. Often there is a white patch under the tongue which takes 24 - 48 hours to heal. This does not seem to cause the baby any discomfort.

The Future

If the baby is breastfeeding or bottle feeding well, then the tongue-tie does not need to be divided. Most tongue-ties in newborn babies are thin, but those remaining in 3-year-olds are mostly thick. So, the thin ones must either have been divided by the lower teeth as they come through, or they are accidentally torn by a parent putting a teaspoon of food under, rather than over, the tongue, or the infant thrusts a toy into their own mouth, which they will all do.

Although some babies can breast- or bottle feed well, they may have problems coping with lumpy food. They may not be able to transfer food from the front to the back of the mouth or chew properly. These infants will be helped by tongue-tie division, at any age.

A few tongue-ties do persist and may cause speech or other problems, but this will not be really apparent until the child is at least 3 years old. If there is a problem, the tongue-tie can be divided under a very short General Anesthetic. Most children with a tongue-tie and a speech problem improve following division.

General Risks of having the procedure:

These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.

What are the risks of the procedure?

While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require readmission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
This complication is extremely rare.
(b) Infection. Persistent bad breath, worsening mouth discomfort or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above
(c) Pain. Mild mouth pain is common during the first few days after surgery, requiring regular pain killers.
(d) Damage to sublingual gland, which sits beneath the tongue. This may cause a cyst to form. This may need further surgery.
(e) Injury to the teeth, lips, gums or tongue.
(f) Burns from the equipment used to seal of bleeding areas during the operation.
(g) Rarely, tongue tie may come back due to growth of scar tissue. This may need further surgery.

Consent Acknowledgement:

* The doctor has explained my medical condition and the proposed surgical procedure.
* I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options.
* My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood / blood product transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements,

I REQUEST TO HAVE THE PROCEDURE.

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date…………………



INFORMED CONSENT: DIVISION OF TONGUE TIE


Patient Identification Label to be affixed here






A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter present.Yes_____________No___________

B. CONDITION AND PROCEDURE
The doctor has explained that I have the following condition:
(Doctor to document in patient’s own words)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Division of tongue tie” for more

C.ANAESTHETIC

Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE

While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may occur either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require readmission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
This complication is extremely rare.
(b) Infection. Persistent bad breath, worsening mouth discomfort or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above
(c) Pain. Mild mouth pain is common during the first few days after surgery, requiring regular pain killers.
(d) Damage to sublingual gland, which sits beneath the tongue. This may cause a cyst to form. This may need further surgery.
(e) Injury to the teeth, lips, gums or tongue.
(f) Burns from the equipment used to seal of bleeding areas during the operation.
(g) Rarely, tongue tie may come back due to growth of scar tissue. This may need further surgery.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND

The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur.
The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
(Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT

I acknowledge that:
* The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
* The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
* I have been given a Patient Information Sheet on Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
* I understand that the procedure may include a blood transfusion.
* I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
* The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
* I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).
* I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,

I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
I have explained
* The patient ‘s condition
* Need for treatment
* The procedure and the risks
* Relevant treatment options and their risks
* Likely consequences if those risks occur
* The significant risks and problems specific to this patient

I have given the Patient/ Guardian an opportunity to:
* Ask questions about any of the above matters
* Raise any other concerns, which I have answered as fully as possible.

I am of the opinion that the Patient/ Substitute Decision Maker understood the above information.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………



Patients Initials ______________