Tongue Tie

Key Messages

Some babies are born with the condition tongue tie, which has the medical name ankyloglossia. The fold of skin under the tongue that connects to the tongue to the bottom of the mouth is shorter or thicker than usual, and this restricts the movement of the tongue. The condition may be mild, or it can be severe, with the tongue joined to the bottom of the mouth.

It happens in 1 to 10% of babies but in most cases, it does not cause any problems.

Most referrals to the tongue tie service are made by CMWs and HVs in the community. We would not expect patients to be directed to primary care by other healthcare professionals specifically for a referral for tongue tie. The aim of the document is to provide guidance to primary care on the assessment and referral criteria for tongue tie if the need arises.

Please note pre-referral criteria are applicable in this referral.

Key pre-referral criteria summary:

Referrals will be returned to referrer if:

  • Bristol Tongue Assessment Tool (BTAT) score 7 or more.

Refer babies with a BTAT score of 6 or less to ENT tongue tie clinic.

Out of Scope:

Children over 12 months or adults with tongue tie affecting speech or eating may be referred to age-appropriate ENT services without a BTAT score


Signs and Symptoms

Tongue tie may cause problems with breastfeeding, such as difficulties attaching or staying attached to the breast, and the mother suffering sore nipples. If the baby isn’t feeding efficiently, he or she may not gain weight at the normal rate.

Other problems reported very rarely are speech difficulties, dental problems and difficulty licking. There is very minimal evidence in the medical literature that tongue tie causes these problems.


If tongue tie is identified but there are no feeding concerns and baby is gaining weight at the expected rate:

If there are feeding concerns

  • Use the Bristol Tongue Assessment Tool (BTAT)
a. Tongue tip appearanceHeart shapedSlight cleft/notchedRounded
b. Attachment of frenulum to lower gum ridgeAttached at top of gum ridgeAttached to inner aspect of gumAttached to floor of mouth
c. Lift of tongue with mouth wide (crying)Minimal tongue liftEdges only to mid-mouthFull tongue lift to mid-mouth
d. Protrusion of tongueTip stays behind gumTip over gumTip can extend over lower lip
Total score (add all a-d domains above)__/8

If the score is 7 or 8:


Referral Criteria

Refer babies with a BTAT score of 6 or less to ENT tongue tie clinic.

Referrals will be returned to referrer if:

  • Bristol Tongue Assessment Tool (BTAT) score 7 or more

Referral Instructions

e-Referral Service Selection

Specialty: Children’s & Adolescent Services

Clinic Type: ENT

Service: DRSS-Western-ENT (Children)-Devon ICB-15N

Referral Forms

DRSS referral form

Supporting Information

Patient Information

Tongue Tie – patient information leaflet (PHNT)


NICE guidance (IPG149): Division of ankyloglossia (tongue-tie) for breastfeeding

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2023


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