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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:
- Provide support with breast/bottle feeding
- Provide parent information leaflet
- Reassure
If there are feeding concerns
- Use the Bristol Tongue Assessment Tool (BTAT)
| 0 | 1 | 2 | ||
| a. Tongue tip appearance | Heart shaped | Slight cleft/notched | Rounded | |
| b. Attachment of frenulum to lower gum ridge | Attached at top of gum ridge | Attached to inner aspect of gum | Attached to floor of mouth | |
| c. Lift of tongue with mouth wide (crying) | Minimal tongue lift | Edges only to mid-mouth | Full tongue lift to mid-mouth | |
| d. Protrusion of tongue | Tip stays behind gum | Tip over gum | Tip can extend over lower lip | |
| Total score (add all a-d domains above) | __/8 |
If the score is 7 or 8:
- Provide support with breast/bottle feeding
- Provide parent information leaflet
- Reassure
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 Form
Patient Information
Tongue Tie – patient information leaflet (PHNT)
Evidence
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
