Three Referrals, Three Different Languages
One referral says "Coryllos type 3." The next says "BTAT 5, shallow latch." A third says "tight frenulum, please evaluate." When every provider on a team uses a different tongue-tie assessment tool, or none at all, each handoff turns into translation work.
The short answer: BTAT, or its picture version TABBY, is the most practical shared language for mixed teams. Hazelbaker adds depth in skilled lactation hands. Coryllos describes anatomy, not function. None of them replaces watching a full feed, checking milk transfer, hearing about maternal pain, and following weight.
At Latched Beginnings in Austin, we regularly receive screening scores from IBCLCs, midwives, nurses, and pediatric clinicians, and we value each one. Here's what each tool measures, what the evidence supports, and how to use a score in a referral.
Is Any Tongue-Tie Assessment Tool Actually Validated?
It depends on what "validated" means. The AAP's 2024 clinical report lists Hazelbaker, BTAT, and several other tools, then states that none has been validated. A systematic review and meta-analysis in Pediatric Dentistry was kinder to BTAT and TABBY, reporting high discriminative accuracy (area under the curve 0.95 across more than 2,000 clinical cases) and a strong correlation with Hazelbaker (r = 0.89), but rated that evidence as very low certainty.
Both can be true. BTAT and TABBY have the most supporting data, but no score tells you whether a release will help a particular dyad feed. That's why the Academy of Breastfeeding Medicine says no tool should be "the sole means of deciding whether a frenotomy is indicated," and the AAO-HNS consensus panel declined to recommend a preferred grading system.
Practice reflects that gap. In a 2025 survey of 286 pediatric dentists, otolaryngologists, and surgeons, fewer than half of those aware of frenulum scoring systems used them regularly. A scoping review of 53 frenotomy studies found Coryllos, an anatomy-only system, behind surgical decisions more often than any other tool, with cut-offs that varied widely.
What BTAT, TABBY, Hazelbaker, and Coryllos Actually Measure
Bristol Tongue Assessment Tool (BTAT)
BTAT scores four items from 0 to 2 (tongue tip appearance, frenulum attachment to the lower gum ridge, lift with the mouth wide, and protrusion) for a total of 0 to 8. A Bristol, UK, team developed it from clinical practice and Hazelbaker, aiming for a tool that's quick to learn and consistent between users.
Tongue-tie and Breastfed Babies (TABBY)
TABBY is the picture version of BTAT: 12 images, the same four items, the same 0 to 8 score. In its development audits, midwives' TABBY and BTAT scores agreed 97.7% of the time, and the authors say clinical staff can use it after short training.
Hazelbaker Assessment Tool for Lingual Frenulum Function
Hazelbaker is the most detailed option: five appearance items and seven function items, including suck-related movements like cupping, peristalsis, and snapback. In one reliability study, two clinicians agreed well on lateralization, lift, and extension but poorly on the four sucking items. It rewards training, which is why it suits IBCLCs.
Coryllos Type 1 to 4
Coryllos describes where the frenulum attaches, from near the tip (type 1) to submucosal (type 4), not how the tongue moves. The AAO-HNS panel didn't reach consensus that it should be preferred, and a meta-analysis of 71 studies found reported tongue-tie prevalence ranged from 2% to 20% depending on the tool, with Coryllos highest. It's anatomy shorthand, not a severity score.
Which Tool Should Your Team Standardize On?
For most mixed teams, we'd suggest one functional screen everyone scores the same way: BTAT for clinicians comfortable with written descriptions, TABBY where visual anchors help. IBCLCs who prefer Hazelbaker can keep it and still report a BTAT or TABBY total. Record a Coryllos type if you like, never on its own.
Pair the tongue screen with a structured feeding assessment; the AAP report suggests LATCH or the Infant Breastfeeding Assessment Tool.
Can nurses and midwives use TABBY? Yes: it was developed with practicing midwives and has served as a standard birth-hospital screen. Our guide for doulas and midwives supporting families through oral tie care covers where birth workers fit in the referral path.
Standardizing may also make care fairer. In a regional Cincinnati study in Breastfeeding Medicine, privately insured newborns were 2.75 times as likely as publicly insured ones to have a frenotomy during the birth stay. After birth hospitals adopted TABBY as a standard screen, the payer gap and the gap between non-Hispanic White and non-Hispanic Black infants were no longer statistically significant.
What Score Means "Refer," and Why Scores Disagree
BTAT and TABBY share suggested bands: 8 is normal, 6 or 7 is borderline (wait and see, with positioning and attachment support), and 5 or below suggests impaired tongue function that may or may not affect feeding. Even in the TABBY audits, choosing babies for frenotomy required a separate breastfeeding assessment.
So a low score earns a referral when it sits beside a feeding problem that persists despite skilled support: ongoing pain or nipple damage, poor transfer on a weighed feed, or slow gain. A borderline score in a comfortable, thriving dyad usually isn't a referral on its own. A normal score with painful feeds points elsewhere, such as positioning, oversupply, birth-related tension, or prematurity. And a release won't treat reflux, torticollis, or allergy.
Whatever the score, send dehydration signs (fewer than about 6 wet diapers a day after day 5), poor weight gain, breathing trouble, blue color, or unusual sleepiness to the pediatrician promptly.
Why do two careful providers score the same baby differently? Lift is judged with the mouth wide, and a drowsy, just-fed baby moves differently than a hungry one. Suck items are hard to score consistently, and technique and experience matter. Scoring a few babies side by side as a team is a simple way to calibrate.
How to Document a Score in Your Referral
A score helps most when the next clinician knows how it was obtained. Include:
- The tool, total, and item scores (for example, BTAT 5: tip 1, attachment 1, lift 1, protrusion 2)
- Baby's age and state at scoring (hungry, crying, drowsy, just fed)
- Feed observations: latch, swallowing, clicking, and any test weights
- Maternal pain and nipple shape after feeds
- Weight trajectory and diaper output
- What's been tried, for how long, and your question for us
Documentation can matter for coverage, too. At least one major insurer's medical policy lists a BTAT or TABBY score of 5 or below, with feeding difficulty that persists despite conservative support, among its frenotomy criteria. For the feed-observation side, see our functional tongue-tie assessment guide for IBCLCs.
Partnering With Latched Beginnings in Austin
You already do the hard part: noticing that something is off and deciding when to bring in another set of eyes. We read your BTAT, TABBY, or Hazelbaker score as valuable context, not a verdict. Dr. Kacie Culotta, DMD, then does her own functional evaluation: she watches a full feed, assesses tongue movement hands-on, and weighs maternal comfort, milk transfer, and growth. Not every evaluation ends in a release, and if her findings differ from your score, we'll tell you why.
Dr. Kacie is the only dentist in Austin who holds both a laser certification for tongue-tie releases and a lactation counselor certification, with more than 10 years of experience helping infants and families. When a release is appropriate, families leave with a customized aftercare plan and scheduled follow-ups. We keep you in the loop about shared patients, because your observations make every evaluation better.
Frequently Asked Questions
Which tongue-tie assessment tool is best for a busy birth hospital?
TABBY is usually the most practical tongue-tie assessment tool for a busy unit because it's picture-based, quick to learn, and scored 0 to 8 like BTAT. Pair it with a structured feeding assessment rather than acting on the number alone.
A parent says their baby has a "type 4" tie. Does that mean the baby needs a release?
No. A Coryllos type describes where the frenulum attaches, not how well the tongue moves or how the baby feeds. Types run from 1 (near the tip) to 4 (submucosal), so the decision rests on a functional feeding assessment, maternal comfort, and weight gain.
Can a doula use a tongue-tie assessment tool?
Doulas generally shouldn't score or diagnose tongue-tie, since clinical assessment falls outside most doula scopes, but they often hear first that feeding hurts. Note the family's concerns and help them reach an IBCLC or pediatric provider within a day or two if feeds are painful or the baby isn't gaining.
Should we rescore after a release?
Yes. BTAT was designed partly to monitor change after a procedure, so rescoring at follow-up with the same tool gives everyone a shared before-and-after on the 0 to 8 scale. Score at a similar baby state, and pair the number with how feeds are going.
Do BTAT and TABBY work for bottle-fed babies?
They describe tongue mobility in any infant, but they were developed in breastfeeding dyads; TABBY's evaluation involved 262 babies with breastfeeding difficulties. For a bottle-fed baby, add a bottle-specific observation of seal, leaking, feed length, and weight gain.
Where can I refer a baby for a tongue-tie evaluation in Austin?
You can refer to Latched Beginnings at 1701 Simond Ave, Suite 107A, in Austin's Mueller area. Dr. Kacie Culotta, DMD, sees families from Austin, East Austin, North Austin, Round Rock, Cedar Park, Pflugerville, Leander, and Georgetown. Send screening scores and feeding notes with the referral, or call (512) 814-7480.
Call to Action
If your team is choosing a tongue-tie assessment tool, or you want a referral partner who reads your scores carefully and answers back, we'd love to connect. You can request our patient referral forms, reach out to coordinate care for a shared patient, or ask about provider coaching for your team. Let's build healthier beginnings together.
