Suspected Ankyloglossia Screening/Referral Note

Patient Information

Patient Name: [Patient name]
DOB: [DOB]
Age: [age in days/weeks]
Date: [Date of service]
Provider: [Provider name and credentials]
Location: [Clinic / Hospital / Telehealth]

Chief Concern & History

[Reason for evaluation in 1–2 sentences; may include brief parent quote] (Use function-first language emphasizing feeding impairment rather than anatomy alone.)

Feeding History: [Current feeding mode: breast / bottle / mixed] [Feeding frequency and average duration per feed] [Reported latch issues: clicking / leaking / frequent unlatching / fatigue / none] [Maternal breastfeeding symptoms: nipple pain severity, visible damage, engorgement] [Infant symptoms during or after feeds: aerophagia, reflux, coughing/choking, sleepiness, irritability] (Summarize as a focused narrative emphasizing feeding mechanics and milk transfer.)

Growth & Hydration Context: [Birth weight] [Current weight with date] [Percent change from birth] [Wet diapers per 24h] [Stools per 24h] [Concerns for dehydration or poor weight gain: yes / no] (If critical data unavailable, document "unknown/not obtained" rather than omitting.)

Relevant Perinatal/Medical Factors: [Prematurity, hypotonia, craniofacial differences, cardiac/pulmonary issues, jaundice, oral thrush, other] (Include only if impacting feeding mechanics.)

Prior Evaluations: [Lactation consultant involvement and dates] [Previous tongue-tie assessments] [Any prior frenotomy and response] [Other specialist input]

Conservative Measures Tried & Response: [Latch/position modifications] [Nipple shield use] [Pumping plan] [Supplementation type/amount/frequency] [Response to these measures] (If conservative measures have not been attempted, explicitly state why.)

Objective

Vitals/Growth: [Weight with date] [Length] [Head circumference] [General appearance: well-appearing / fatigued / signs of dehydration / other]

Oral Exam:

• Anatomy: [Oral mucosa] [Palate integrity/shape] [Tongue resting posture] [Sublingual frenulum: thickness, elasticity, attachment points to tongue and floor of mouth, blanching on elevation, heart-shaped tongue tip present / absent] [Maxillary labial frenulum if clinically relevant]
• Function: [Tongue protrusion extent] [Elevation toward palate] [Lateralization] [Cupping and seal behaviors] [Suck dynamics: rhythm, strength, coordination] [Compensatory movements if present]
• [Exam limitations and reason, if applicable]

Assessment Tool: [Tool name, e.g., HATLFF / BTAT / TABBY] [Score] [Key drivers of score] (Include only if used; score is adjunctive to clinical assessment.)

Feeding Observation: [Feeding type observed: breast / bottle / both / not observed] [Position used] [Latch quality: gape, flange, seal] [Audible swallowing: yes / no] [Milk transfer cues] [Maternal comfort and nipple shape post-feed if applicable] [Infant coordination and endurance] [Overall impression: effective transfer / inefficient transfer suspected / unable to assess] (If feeding not observed, document why and what information was used instead.)

Assessment

[Synthesis statement linking anatomy to function] (Use function-first language. Example phrasing: "Findings consistent with restrictive sublingual frenulum with breastfeeding dysfunction despite lactation support" OR "Sublingual frenulum noted but tongue function appears adequate on exam; feeding difficulty likely multifactorial." If exam was limited, state that restriction cannot be confirmed or excluded. Avoid overstating diagnostic certainty.)

Other Contributors to Feeding Difficulty: [Positioning/latch technique] [Milk supply concerns] [Prematurity/immaturity] [Oral thrush] [Palatal or craniofacial factors] [Reflux/coordination issues] [Other] (Include if applicable based on history or exam.)

Plan

Feeding Support: [Lactation follow-up: with whom and timeframe] [Specific technique modifications] [Supplementation plan if needed: type, amount, route, frequency] [Weight check timing and location]

Referral: [Referral target: ENT / Pediatric dentist / Pediatric surgery / SLP / IBCLC / other] [Explicit referral question] [Urgency: routine / expedited / urgent] [Documentation sent: note, growth curves, lactation notes, feeding videos]

Counseling: [Summary of counseling provided regarding known versus uncertain benefits of frenotomy, non-surgical options, and general procedural risks] [Parent questions and preferences, using direct quotes for key concerns] (Note that definitive procedural consent will be obtained by the specialist if applicable.)

Safety Net / Return Precautions: Seek care urgently for: [poor intake or inability to feed] [decreased wet diapers or no urine ≥8 hours] [lethargy or decreased responsiveness] [respiratory distress or color change during feeds] [worsening jaundice] [any caregiver concern]

Communication: [Who was contacted for referral] [Method: phone / secure message / EMR referral] [Records sent: yes / no] [Care team members notified]

Follow-Up: [Planned follow-up interval and with whom] [Contingency plan if weight gain or feeding does not improve]

Signature: [Provider name, credentials, date/time]