Tongue tie referral form

Assessment +/- division of tongue tie in a breastfed baby

Paediatric ENT service provided by Infant Feeding Specialist Midwife team

Outpatient clinics located at St Michaels and Weston General Hospitals. Infants must be <12 weeks of age at time of referral, with persistent breastfeeding problems, suspected to be caused by ankyloglossia (tongue tie)*.

Complete form on screen (or scan) and email as PDF attachment to: ubh-tr.tonguetieUHBristol@nhs.net

Date of referral: Click here to enter a date Age of child at referral: Click here to enter text	Current inpatient at St Michaels? No ☐ Definitely going home without being seen ☐ Yes: do not use this form - please call 25164 to refer
Child's name: Click here to enter name Trust/NHS number: Click here to enter text D.O.B: Click here to enter a date Sex: F ☐ M ☐ GP practice: Click here to enter text Vit K: IM ☐ Oral ☐ Declined ☐ N/K ☐	Parent / carers name: Click here to enter name Contact details Click here to enter text (phone no. essential):
First line of address: Click here to enter text Area: Click here eg. Bristol / Weston / N Somerset NB: An appointment in either Bristol or Weston will be offered based on availability, and parent / carer preference where possible
Who has observed and assessed a full feed, and when?* Click here to enter name, role, date TABBY/BTAT score: Click here to enter text	Referrer Name: Click here to enter text Profession: Click here to enter text Location: Click here to enter text Contact no.: Click here to enter text UHBW ‘Tongue tie’ leaflet provided via: hardcopy ☐ maternity app ☐ online: foi.avon.nhs.uk ☐
Potential tongue tie previously assessed by member of specialist midwife team? Y ☐ N ☐ N/K ☐
Feeding History (select all that apply)	Presenting Problem (select all that apply)
Exclusively breastfeeding: ☐	Sore / damaged nipples:	☐
Mix feeding / topping up breastfeeds#: ☐ with: EBM ☐ Formula milk ☐ via: Bottle ☐ Cup ☐ Other ☐	Sliding off breast / shallow latch:	☐
Clicking:	☐
Excessive weight loss:	☐
EBM only - no feeds at breast# ☐	Slow weight gain / static weight:	☐
Formula (bottle) due to CCG Policy we are only able feeding only to accept referrals for breastfed babies	Unsettled / frustrated baby / breast refusal:	☐
Additional comments: #please state reason here Click here to enter text	Short frequent feeds:	☐
Prolonged feeds:	☐
Engorgement / mastitis:	☐
Possible issues with milk supply:	☐

*It is vital that positioning and attachment are thoroughly supported and assessed by an appropriately trained supporter prior to referral for tongue tie assessment / division, and also afterwards. If feeding is going well there is no need to refer.

Appointment / referral queries: Tel ENT 0117 3421611 Clinical infant feeding specialist queries: Tel 0117 3425164