Greater Manchester EUR Policy Statement on: Surgical management of Ankyloglossia (tongue tie) GM Ref: GM050 Version: 2.0 (16 September 2020) Commissioning Statement Surgical management of Ankyloglossia (tongue tie) Policy This policy applies to children before their 18th Birthday. Exclusions (Alternative Frenuloplasty is commissioned for babies with fusion of the tongue to the floor of the commissioning mouth. arrangements apply) Treatment/procedures undertaken as part of an externally funded trial or as a part of locally agreed contracts / or pathways of care are excluded from this policy, i.e. locally agreed pathways take precedent over this policy (the EUR Team should be informed of any local pathway for this exclusion to take effect). Policy Frenectomy for infants with feeding problems Inclusion Division of the frenulum should only be conducted when: Criteria The infant is under 3 months of age at the time of referral AND There are perceived breastfeeding difficulties AND Mother and baby have been have been assessed by a health visitor or midwife with specialist expertise in breast feeding who have confirmed tongue tie as the likely cause of the problem NOTE: Frenectomy to address the above should be performed as an outpatient procedure or within a suitable community service. Onward referral to Tier 2 or Secondary care If referral is to a tier 2 or secondary care provider then all of the points above should apply AND An assessment of the degree of ankyloglossia should have been carried out by an appropriately trained clinician (usually midwife or health visitor) using the Hazelbaker Assessment Tool (see Appendix 3) which gives a score of less than or equal to 11 If a bottle fed infant has feeding issues related to tongue tie, then an Individual Funding Request application should be made – if the infant is failing to thrive, this must be marked URGENT. Funding Mechanisms: Breast fed infants: Monitored approval: Referrals may be made in line with the criteria without seeking funding. NOTE: May be the subject of contract challenges and/or audit of cases against commissioned criteria. Bottle Fed Infants: Individual funding request (exceptional case) approval: Requests must be submitted with all relevant supporting evidence. If the infant is failing to thrive, this must be marked URGENT. GM Tongue Tie Policy v2.0 FINAL Page 2 of 23 Frenectomy for older children with speech problems In rare cases a tight frenulum may lead to speech problems. Where this is suspected the child should be assessed by speech and language services to ensure that there is no other underlying diagnosis that is interfering with the child’s language development. In the case of these older children an application for exceptionality is required prior to referral for frenectomy. The application should include: A written assessment from a speech and language therapist stating that they believe the tongue tie to be a significant contributor to the speech problem(s). A score of the degree of tongue tie using the Kotlow Classification of tongue tie (ankyloglossia) If the referral is from a specialist service the tongue range of motion ratio can be given instead. Funding Mechanism: Individual funding request (exceptional case) approval: Requests must be submitted with all relevant supporting evidence. Tongue tie and folic acid In the development of this policy a search was carried out to find evidence linking tongue tie and folic acid. Most of the information found was anecdotal and there was no strong evidence for an association between tongue tie and the use of folic acid before or during pregnancy. This policy supports the use of folic acid in line with the Scientific Advisory Committee on Nutrition (SACN): Update on folic acid (Published: 12 July 2017) (this is summarised at the end of Appendix 1 for ease of referral). Clinical Clinicians can submit an Individual Funding Request (IFR) outside of this guidance if Exceptionality they feel there is a good case for exceptionality. More information on determining clinical exceptionality can be found in the Greater Manchester (GM) Effective Use of Resources (EUR) Operational Policy. Link to GM EUR Operational Policy GM Tongue Tie Policy v2.0 FINAL Page 3 of 23 Contents Commissioning Statement .................................................................................................................... 2 Policy Statement................................................................................................................................... 5 Equality & Equity Statement .................................................................................................................. 5 Governance Arrangements ................................................................................................................... 5 Aims and Objectives ............................................................................................................................. 5 Rationale behind the policy statement ................................................................................................... 6 Treatment / Procedure .......................................................................................................................... 6 Epidemiology and Need ........................................................................................................................ 6 Adherence to NICE Guidance ............................................................................................................... 6 Audit Requirements .............................................................................................................................. 7 Date of Review ..................................................................................................................................... 7 Glossary ............................................................................................................................................... 7 References ........................................................................................................................................... 7 Governance Approvals ......................................................................................................................... 8 Appendix 1 – Evidence Review ............................................................................................................. 9 Appendix 2 – Clinical Coding – ICD10/OPCS4 .................................................................................... 19 Appendix 3 – Hazelbaker Assessment Tool for Lingual Frenulum Function .......................................... 20 Appendix 4 – Version History .............................................................................................................. 22 GM Tongue Tie Policy v2.0 FINAL Page 4 of 23 Policy Statement The GM Effective Use of Resources (EUR) Policy Team, in conjunction with the GM EUR Steering Group, have developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission treatments/procedures in accordance with the criteria outlined in this document. In creating this policy the GM EUR Steering Group has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). Equality & Equity Statement CCGs have a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act 2012. CCG s are committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its functions, CCGs will have due regard to the different needs of protected characteristic groups, in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act 1998. This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the GM EUR Policy Team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. The Equality Act 2010 states that we must treat disabled people as more equal than any other protected characteristic group. This is because their ‘starting point’ is considered to be further back than any other group. This will be reflected in CCGs evidencing taking ‘due regard’ for fair access to healthcare information, services and premises. An Equality Impact Assessment has been carried out on the policy. For more information about the Equality Impact Assessment, please contact [email protected]