The Note That Arrives Before the Family Does
You've just watched a full feed. The latch kept slipping, you heard clicking, and the nipple came out creased. The pre- and post-feed weights barely moved. Now you're wondering how to word the write-up, what to include, and whether you can even name what you suspect. Good tongue-tie referral documentation answers all three.
The short version: record what you observed and measured, in your own scope's language, and ask for an evaluation rather than a procedure. A clear note gives the evaluator a baseline, spares the family from retelling a hard story, and supports whatever their plan asks for later.
At Latched Beginnings in Austin, we review referral notes before a consultation, and the strongest ones shape the whole visit. Here's what makes a note useful, and how to write one without stepping outside your scope.
Can I Write "Tongue-Tie" in My Notes?
Usually, yes, as the concern you're referring for, not as a diagnosis. IBLCE's advisory opinion on assessment, diagnosis, and referral frames the IBCLC's role as assess, document, and refer, with diagnosis left to those separately qualified. Its own worked example describes the baby's trouble using the tongue to transfer milk, explains that some babies have this because of a tongue-tie, and offers a list of providers who diagnose and treat it.
The same logic works across professions. Lactation consultants and counselors describe feeding function. Chiropractors chart their own findings, like limited neck rotation, and the feeding concern behind the referral, keeping in mind that a release doesn't treat torticollis. Doulas don't assess, so they record what the parent reports. Pediatric clinicians can diagnose ankyloglossia, but the evaluator still needs the feeding picture. When unsure, check with your board or certifying body. A few swaps help:
- Instead of "baby has a tongue-tie," try "limited tongue elevation and extension during feeding; referred for evaluation of possible oral restriction."
- Instead of "needs a release," try "requesting evaluation of oral function; family aware a release may or may not be recommended."
- Instead of "tie is causing the head tilt," try "right rotation limited, prefers left breast, ongoing latch pain."
What Should a Strong Referral Note Include?
Aim for one page the evaluator can read in two minutes, reason for referral first. For a framework on the observation itself, see our functional tongue-tie assessment guide for IBCLCs.
The Reason, Your Question, and What You Told the Family
Write one sentence on why you're referring and what you want answered, such as "Is tongue function limiting milk transfer?" Note that you framed the visit as an evaluation. Our guide on what to tell families before a tongue-tie referral covers that conversation.
Weights, Diapers, and Transfer, With Dates
Include birth weight, lowest weight, and latest weight, each dated, with the scale used, plus daily wet and dirty diapers. If you did pre- and post-feed weights, give both numbers and the feed length, plus supplement volumes.
Pain and Nipple Changes Over Time
Record a 0 to 10 pain score at latch and mid-feed, nipple shape after feeds, and any cracks, blanching, or bleeding. A dated timeline beats a single score, because pain that persists despite latch help says more than one hard day.
What's Been Tried, for How Long, and What Changed
List latch and positioning work, nipple shields, pumping plans, bodywork, and supplementation, with start dates and results. "Laid-back positioning for 10 days, pain from 8 to 6" says far more than "tried positioning," and it documents the conservative care many plans want to see.
Screening Score, History, and Family Goals
If you used the Bristol Tongue Assessment Tool (BTAT) or TABBY, give the total, item scores, and the baby's state when scored. Add prematurity or NICU time, birth events, head-turn preference, low tone, jaw or palate differences, and the family's feeding goals.
What Do Insurers Look For in the Chart?
It depends on the plan, so treat these as examples, not rules. Elevance Health's guideline CG-SURG-122 calls infant lingual frenotomy medically necessary with a feeding difficulty such as poor latch or nipple pain, a TABBY or BTAT score of 5 or below, difficulty persisting despite lactation or speech-language support, and no documented contraindication like hypotonia or craniofacial anomalies.
Other policies are broader. Aetna's bulletin covers frenotomy when newborn feeding difficulties exist, with no scoring tool named. Washington State's Health Care Authority covers lingual frenotomy for breastfeeding when symptoms haven't improved with lactation support, other causes have been evaluated and treated, and a primary care provider performs or refers the procedure. It adds that lactation support isn't limited to lactation consultants.
So is a primary-care referral required? Not always for the evaluation, and families can often book directly. But some plans want the pediatrician involved, and the AAP's clinical report describes frenotomy by the medical home or a provider it refers to. Copy the pediatrician either way, and have families check their plan.
Should You Attach Photos or Video?
Only if they show function. A short clip of a feed showing the latch, swallowing, and any clicking can help. A still photo of the frenulum mostly shows appearance, which doesn't tell anyone how the baby feeds.
Get written consent first, spelling out what you'll record, why, and who will see it. IBLCE's Code of Professional Conduct requires IBCLCs to get advance written consent before photographing or recording a client and child. Label files with the baby's age and date, skip texts and social messages, and use a secure portal, or let the family share files through the evaluator's intake.
When the Note Should Point Somewhere Else First
Not every feeding problem is a tongue problem, and a good note can say so. If the story fits oversupply, positioning, a sleepy newborn, or a baby recovering from a hard birth, your note may end with a plan and a recheck date instead. The AAP recommends a complete breastfeeding assessment, with other causes evaluated and treated, before any procedure.
Some findings belong with the pediatrician today: fewer than about 6 wet diapers a day after day 5, poor weight gain, fever, breathing trouble, blue color, unusual sleepiness, or blood. A parent with a fever or breast lump should call their OB or midwife promptly. Chart that you sent them, and why.
Partnering With Latched Beginnings in Austin
You already do the hard part: noticing that something is off and putting it into words the next provider can use. Dr. Kacie Culotta, DMD, is the only dentist in Austin who holds both a laser certification for tongue-tie releases and a lactation counselor certification, so she reads your note through both lenses.
Your weights, pain scores, and trial history become the baseline for an evaluation that includes watching a feed and assessing function, not just appearance. Not every baby we see needs a release. With the family's permission, we share what we found, what we recommended, and the aftercare plan, as we describe in closing the loop with referring providers. Our patient referral forms make the handoff simple.
Frequently Asked Questions
Does tongue-tie referral documentation need a TABBY or BTAT score?
Not always, but it helps when you've used a tool, because at least one large insurer's guideline asks for a TABBY or BTAT score of 5 or below. Both tools run from 0 to 8. The AAP notes that none of the common scoring tools has been validated, so record who scored it and when.
What should tongue-tie referral documentation look like if I'm a doula?
Keep it to what the parent told you and what you noticed, dated, plus what you suggested, since doulas support families but don't assess or diagnose. For example: "Day 6, parent reports 45-minute feeds and cracked nipples; suggested IBCLC visit and pediatrician check." Give the family a copy.
How long should a family try lactation support before I refer?
There's no single cutoff, so document each change with dates and let the trend guide you. The AAP notes most nipple pain peaks around day 3 and eases to mild within 7 to 10 days, so pain persisting well past that is worth flagging. Poor weight gain shouldn't wait.
Can I send my notes straight to the tongue-tie provider?
Yes, with the family's consent, and it's easiest to get that consent at intake, before you ever need it. IBLCE's code asks IBCLCs to get consent before a consultation to share clinical information with the care team, and HIPAA permits covered providers to share for treatment.
What if the evaluation finds no tie after I referred?
That's a useful answer, not a wasted referral, because a referral asks a question and "no release needed" is one of the valid answers. The AAP report notes fewer than 50% of infants with physical findings of ankyloglossia had breastfeeding trouble, and your data still guides the next step.
Should I write "posterior tongue-tie" in my referral?
Describe what the tongue does instead, because function translates between offices more reliably than labels that different providers use differently. The AAP calls posterior ankyloglossia a poorly defined term, so "tongue lifts less than halfway to the palate with mouth wide" is clearer.
Where can I send a tongue-tie referral in Austin?
Latched Beginnings is at 1701 Simond Ave, Suite 107A, in Austin's Mueller area, and you can reach our team at (512) 814-7480. Dr. Kacie sees families from Austin, East Austin, North Austin, Round Rock, Cedar Park, Pflugerville, Leander, and Georgetown.
Call to Action
If you care for babies and families in the Austin area, we'd love to make your next handoff easier. Send your tongue-tie referral documentation with our referral forms, reach out to coordinate care for a family we share, or ask about provider coaching for your team.
