How do you interpret the BTAT (Bristol Tongue Assessment Tool) table for tongue tie diagnosis?

How to Interpret the BTAT (Bristol Tongue Assessment Tool) for Tongue-Tie

The Bristol Tongue Assessment Tool (BTAT) is a simple, validated clinical assessment tool that provides an objective score to determine the severity of tongue-tie in infants, with scores of 4 or below typically indicating the need for frenotomy after appropriate breastfeeding assessment.

Understanding the BTAT Components

The BTAT evaluates four key elements of tongue appearance and function, with each element scored from 0-2:

1. Tongue Appearance (0-2 points)

   • 2: Round or square
   • 1: Slight cleft in tip
   • 0: Heart-shaped or notched

2. Frenulum Attachment to Lower Gum Ridge (0-2 points)

   • 2: Attached to floor of mouth
   • 1: Attached to mid-lower gum
   • 0: Attached at top of gum ridge

3. Lift of Tongue with Mouth Wide (0-2 points)

   • 2: Edges to mid-mouth
   • 1: Edges only to mid-way
   • 0: Minimal tongue lift

4. Protrusion of Tongue (0-2 points)

   • 2: Tip over lower lip
   • 1: Tip to lower lip
   • 0: Tip stays behind lower gum

Scoring Interpretation

The BTAT provides a total score ranging from 0-8:

• Score 8: Normal tongue function
• Score 6-7: Borderline tongue function
• Score 5 or below: Impaired tongue function
• Score 4 or below: Typically indicates need for frenotomy (after breastfeeding assessment) 1

Clinical Application

When using the BTAT:

1. Perform in well-lit conditions with the infant calm and mouth wide open
2. Assess all four components systematically
3. Calculate the total score to determine severity
4. Document findings using the standardized scoring system
5. Combine with breastfeeding assessment before making treatment decisions

TABBY Tool - Picture Version of BTAT

The Tongue-tie and Breastfed Babies (TABBY) assessment tool is a picture version of the BTAT that consists of 12 images showing:

• Appearance of infant tongue
• Attachment to the gum
• Limits of tongue mobility

The TABBY has shown 97.7% agreement with BTAT scores in clinical audits, making it a reliable visual alternative 1.

Clinical Decision Making

When interpreting BTAT scores:

• Scores of 4 or below: Consider frenotomy after appropriate breastfeeding assessment
• Scores of 5: Borderline cases requiring careful clinical judgment and breastfeeding assessment
• Scores of 6-8: Typically do not require surgical intervention

Important Considerations

• The BTAT should be used as part of a comprehensive assessment that includes evaluation of breastfeeding difficulties
• Maternal nipple pain and feeding difficulties should be documented alongside the BTAT score
• The tool has good internal reliability (Cronbach's α=0.708) and good correlation between different assessors (ICC=0.760) 2
• BTAT shows strong correlation (0.89) with the more complex Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) 2

Common Pitfalls to Avoid

1. Relying solely on the BTAT score without assessing breastfeeding difficulties
2. Inconsistent technique when examining different components
3. Failure to document baseline scores before intervention
4. Not reassessing after frenotomy to document improvement
5. Overlooking other causes of feeding difficulties beyond tongue-tie

The BTAT provides an objective measure that can help standardize assessment of tongue-tie severity and inform clinical decision-making regarding the need for frenotomy in infants experiencing breastfeeding difficulties.