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Tongue Tie

Checked: 26-09-2023 by Vicky Ryan Next Review: 26-09-2025

Overview

Tongue-tie (ankyloglossia) can restrict the tongue movement and affect feeding in some breastfed babies. If suspected, timely assessment by a trained professional is required to assess for any effect on feeding and ensure breastfeeding is established.

There is considerable overlap of symptoms with other conditions, but symptoms can include nipple pain/trauma, mastitis, low milk supply, difficulty latching, frequent or very lengthy feeds, clicking noises during feeds, colic/wind/reflux, and poor weight gain. If optimising positioning and attachment has not helped, and tongue-tie is suspected, refer for a formal assessment to determine if division is needed - see below.

The TABBY Assessment Tool is a helpful, easy to use, pictorial guide developed in Bristol which consists of 12 images demonstrating appearance of the infant tongue, its attachment to the gum and the limits of tongue mobility.

It is scored from 0 to a maximum of 8:

8 indicates normal tongue function
6 or 7 is considered borderline
5 or below suggests an impairment of tongue function

This can be useful when trying to decide if tongue-tie could be the cause of the feeding difficulties. It is also included as part of the Tongue Tie Referral form.

Breastfed babies aged <12 weeks (corrected)

Breastfed babies <12 weeks (corrected) with persistent problems not resolved by breastfeeding support and thought to be related to tongue tie can be referred for assessment and management at tongue tie clinics run by both UHBW and NBT.

Exclusions for the midwifery run service are:

If the tongue is thick and vascular
There are aberrant structures beneath the tongue
There is a family history of coagulation disorders

UHBW:

For clinics at St Michael’s and Weston General Hospital, refer using this form and send by email to tonguetiereferrals@uhbw.nhs.uk

NBT:

For clinics at Southmead and Cossham, refer by email to infantfeedingteam@nbt.nhs.uk (form in development and Remedy will be updated when this is available).

Babies and Children who do not meet criteria

The following groups of Babies and children do not meet criteria for referral:

Babies and children who are 13 weeks or older (corrected)
Babies excluded from midwifery care for medical reasons
Bottle fed babies (any age) - see advice in section below.

Babies and children in these groups or others who do not meet the criteria in the Tongue-Tie Division Criteria Based Access Policy cannot be referred.

If the patient in question is clinically exceptional, an EFR application would be required before referral can proceed.

Lip Tie

The surgical correction of lip tie (at any age), where the lip is connected too tightly to the upper gum, is not routinely commissioned. If there is clinical exceptionality an EFR application would be required in this instance.

Bottle Fed Babies

Babies who are bottlefed are less likely to benefit from a tongue tie procedure and there is limited evidence to support this approach. Bottle fed babies therefore do not meet the criteria for tongue tie division as stated in the Tongue-Tie Division Criteria Based Access Policy.

There are options for babies that struggle to feed from bottles with tongue tie e.g. different styled teats. Teat and bottle feeding advice can be found here: http://www.babies.co.uk/feeding/a/the-right-bottle-and-teat/.

The Infant Feeding Specialist teams are also able accept referrals for bottle fed babies for assessment and support with feeding difficulties – see the Breastfeeding Support page for referral info.

The NHS bottle feeding advice page and the start4life guide to bottle-feeding booklet also have advice on bottle feeding. The booklet includes a link on the back page to sign up for free emails, videos and texts from the Start4Life Information Service for Parents throughout pregnancy and as their baby grows at www.nhs.uk/start4life.

There is also a local Facebook Group, Bristol Feeding Friends, for local informal peer support.

Resources

Patient information: Tongue-tie - NHS (www.nhs.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.