Bifid Uvula and Tongue Tie: What Matters?
Bifid uvula and tongue-tie
A bifid uvula may be noticed during an examination of a baby’s mouth, sometimes alongside a suspected tongue-tie. These are different anatomical findings: a bifid uvula concerns the soft palate, while tongue-tie concerns the lingual frenulum beneath the tongue.
The distinction matters because feeding difficulties can have more than one cause. A restrictive lingual frenulum may contribute to feeding difficulties in some babies, while a bifid uvula may be an isolated anatomical variation or a sign that the palate needs further assessment. Neither finding alone establishes the cause of a feeding problem or whether a procedure is appropriate (LeFort et al., 2021; Thomas et al., 2024).
The oral structures should be considered together during the same assessment. If an anatomical variation is identified, its significance needs to be understood before proceeding with frenulotomy. Where a bifid uvula raises concern about a possible submucous cleft palate, appropriate specialist advice should be sought before tongue-tie division is considered.
What is a bifid uvula?
The uvula is the small, soft structure that hangs from the back of the soft palate. A bifid uvula is split, or appears forked, at its tip. The division may be subtle or more readily visible. A uvula may also have a notched appearance, where there is an indentation at its tip without a complete division.
A bifid uvula is an anatomical variation, and its reported prevalence varies between populations. Feka et al. (2019) examined the prevalence of bifid uvula in primary school children in Geneva and reported a prevalence of 0.42% in their study population. Cambridge University Hospitals NHS Foundation Trust reports that around 2% of people have an isolated bifid uvula without other health concerns (Cambridge University Hospitals NHS Foundation Trust, 2023).
These figures illustrate why prevalence estimates should be considered in the context of the population studied. An isolated bifid uvula does not automatically indicate a cleft palate or a functional problem. However, it can be a clinical sign of a submucous cleft palate, so the wider palatal examination and any associated symptoms are important (Feka et al., 2019; Reiter et al., 2011).
A notched appearance should also be considered in the context of the whole examination rather than interpreted in isolation. The appearance of the uvula alone cannot establish whether the underlying palatal muscles are structurally or functionally affected.
When might a cleft palate be present?
A submucous cleft palate is a difference in the structure of the palate in which the mucosal covering may remain intact while the underlying palatal muscles have not developed or joined in the usual way. The palate can therefore look relatively normal despite differences in its structure and function (Calnan, 1954; Reiter et al., 2011).
The traditional clinical signs associated with submucous cleft palate are:
A bifid uvula.
A translucent or bluish midline area in the soft palate, sometimes called zona pellucida.
A notch at the back of the hard palate.
These signs are often described as Calnan’s triad (Calnan, 1954). Not every individual with a submucous cleft palate has all three signs, and some cases can be difficult to identify from appearance alone (Reiter et al., 2011; ten Dam et al., 2013).
This is why a bifid uvula should neither be treated as a diagnosis in itself nor dismissed without considering the wider clinical picture. An apparently intact palate does not necessarily exclude a submucous cleft.
A specialist assessment may consider the shape and movement of the soft palate, the appearance of the hard palate, feeding history and any other features that suggest impaired palatal function. Further investigation may be indicated depending on the findings.
For more information, see my article Submucosal cleft palate and feeding issues in infants.
CLAPA also provides information about cleft lip and palate and NHS cleft services.
Does an isolated bifid uvula affect feeding?
An isolated bifid uvula would not usually be expected to cause feeding difficulties by itself. Cambridge University Hospitals NHS Foundation Trust explains that many babies with a bifid uvula have no other health concerns and feed well. The concern arises when the finding is associated with a submucous cleft palate or another difference affecting palatal function (Cambridge University Hospitals NHS Foundation Trust, 2023).
The soft palate contributes to separating the mouth from the nasal cavity during swallowing. If the palate cannot close effectively, milk may pass into the nose during feeding. Other concerns can include prolonged feeds, tiring during feeds and difficulty maintaining effective feeding. These symptoms are not proof of a submucous cleft palate, but they warrant assessment when considered alongside the anatomical findings (Cambridge University Hospitals NHS Foundation Trust, 2023; Reiter et al., 2011).
If a baby has a bifid uvula but is feeding comfortably, transferring milk effectively and growing as expected, this is reassuring. It does not, however, remove the need to follow the advice of the relevant cleft or paediatric team about whether monitoring or further assessment is appropriate.
The key distinction is between the appearance of the uvula and the function of the palate. An isolated anatomical variation is not the same as a palate that cannot perform its usual role.
Feeding difficulties associated with tongue-tie
Tongue-tie, clinically termed ankyloglossia, concerns the lingual frenulum beneath the tongue. The frenulum is a normal anatomical structure, and its appearance varies considerably between babies. It becomes clinically relevant when restriction of tongue movement affects function (Messner et al., 2020; Thomas et al., 2024).
Where tongue-tie is functionally significant, assessment may identify restricted tongue elevation or extension alongside feeding difficulties. During breastfeeding, these may include difficulty maintaining attachment, ineffective milk transfer or persistent nipple pain and trauma. With bottle feeding, the assessment may consider the baby’s seal around the teat, tongue and jaw movements, milk loss, feeding efficiency and coordination.
These signs are not unique to tongue-tie. Clicking, prolonged feeds, milk leakage and unsettled behaviour can have several explanations. A visible frenulum or a single feeding symptom should not be used alone to diagnose a restrictive tongue-tie or determine whether frenulotomy is indicated (Messner et al., 2020; Thomas et al., 2024).
The evidence base for frenulotomy has historically focused more heavily on breastfeeding outcomes, particularly maternal nipple pain, than on bottle-feeding outcomes. A Cochrane review found that frenotomy may reduce maternal nipple pain in the short term, but evidence for consistent improvement in infant feeding outcomes was limited by the quality and size of the included studies (O’Shea et al., 2017). Decisions about treatment therefore need to be based on an individual assessment rather than the presence of a frenulum alone.
For more information, see:
My article Infant Oral Anatomy: Structure, Function and Feeding explains how the tongue, palate, lips, cheeks and jaw work together during feeding, and why anatomy needs to be considered alongside function.
Feeding difficulties associated with cleft palate
Feeding difficulties associated with a submucous cleft palate have a different potential explanation from those associated with tongue-tie. Where palatal muscle function is affected, a baby may have difficulty achieving the separation between the mouth and nose needed for effective feeding.
Possible signs include milk passing through the nose, tiring during feeds and prolonged feeds. The significance of these symptoms depends on the individual baby’s examination and overall feeding assessment. They should not automatically be attributed to tongue-tie simply because a lingual frenulum is visible (Cambridge University Hospitals NHS Foundation Trust, 2023; Reiter et al., 2011).
Some babies with a cleft palate need specialist feeding equipment. Certain specialist bottles can help deliver milk when a baby cannot generate the suction required with a conventional bottle. These bottles may have soft, squeezable reservoirs or other features designed for particular feeding needs. The appropriate system and feeding technique should be demonstrated and advised upon by the specialist cleft team (Cambridge University Hospitals NHS Foundation Trust, 2023).
These specialist bottles are used for particular feeding needs associated with cleft palate or palatal dysfunction. They are not required simply because a baby has an isolated bifid uvula, and they are not a treatment for tongue-tie. Families should not have to determine which equipment is appropriate without specialist advice.
Where a baby has suspected or confirmed palatal dysfunction, the feeding plan should be developed with the relevant specialist team. This allows the baby’s anatomy, feeding ability, growth and wider needs to be considered together.
When an anatomical variation changes the plan
A bifid uvula identified during an oral assessment warrants consideration of the wider palatal anatomy, including whether a submucous cleft palate may be present. The tongue, lingual frenulum, palate and other oral structures should be considered together during the same assessment, rather than treating a suspected tongue-tie as an isolated finding.
Where an anatomical variation is identified, its significance needs to be considered before proceeding with frenulotomy. If a submucous cleft palate is suspected, appropriate specialist advice should be sought and the potential implications for feeding and palatal function clarified before tongue-tie division is considered.
This does not mean that a bifid uvula automatically rules out frenulotomy, or that a clinically significant tongue-tie cannot coexist with a palatal variation. The two findings can occur together. It means that the anatomical findings must be understood in context, and any concerns affecting the safety or appropriateness of the procedure need to be addressed first (Calnan, 1954; Reiter et al., 2011; Messner et al., 2020).
The feeding assessment remains important throughout this process. Difficulties associated with restricted tongue movement and those associated with impaired palatal function may overlap, but they are not interchangeable. Identifying the structures involved helps guide appropriate feeding support, referral and decisions about whether frenulotomy is indicated.
Who should families contact?
If a bifid uvula or a notched uvula is identified, families can contact their GP or paediatric team to discuss assessment and referral. ENT services and specialist cleft teams can also advise about palatal differences. Families and clinicians do not need to be certain that a submucous cleft palate is present before asking for specialist guidance.
If the clinician or family is unsure whether the finding is significant, contacting the local specialist cleft service to ask for advice is a reasonable next step. Specialist cleft teams across the UK assess palatal differences and can advise on the appropriate referral route (CLAPA, n.d.).
If feeding is difficult, it is important to seek feeding support as well as investigating the anatomical finding. An IBCLC or other suitably qualified infant-feeding professional can assess feeding function and identify when referral to paediatric, ENT or cleft services may be appropriate.
Where there is repeated milk regurgitation through the nose, significant feeding fatigue, faltering growth or other concerns about swallowing, timely clinical assessment is particularly important. Coughing, choking, colour changes or breathing difficulties during feeds also warrant prompt clinical attention.
A baby with a bifid uvula who is feeding well may need a different plan from a baby who has feeding difficulties or other signs of palatal dysfunction. The appropriate pathway depends on the individual findings and advice from the relevant clinical team.
References
Calnan, J. (1954) ‘Submucous cleft palate’, British Journal of Plastic Surgery, 6(4), pp. 264–282. https://doi.org/10.1016/S0007-1226(53)80060-3
Cambridge University Hospitals NHS Foundation Trust (2023) Bifid uvula and submucous cleft palate. Patient information leaflet, approved 4 October 2023. Available at: https://www.cuh.nhs.uk/patient-information/bifid-uvula-and-submucous-cleft-palate/
CLAPA (n.d.) About NHS cleft services. Available at: https://clapa.com/what-is-cleft-lip-palate/about-nhs-cleft-services/
CLAPA (n.d.) What is cleft lip and palate? Available at: https://clapa.com/what-is-cleft-lip-palate/
Feka, P., Banon, J., Leuchter, I. and La Scala, G.C. (2019) ‘Prevalence of bifid uvula in primary school children’, International Journal of Pediatric Otorhinolaryngology, 116, pp. 88–91. https://doi.org/10.1016/j.ijporl.2018.10.026
Messner, A.H. et al. (2020) ‘Clinical Consensus Statement: Ankyloglossia in Children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. https://doi.org/10.1177/0194599820915457
O’Shea, J.E. et al. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. https://doi.org/10.1002/14651858.CD011065.pub2
Reiter, R., Brosch, S., Wefel, H., Schlömer, G. and Haase, S. (2011) ‘The submucous cleft palate: diagnosis and therapy’, International Journal of Pediatric Otorhinolaryngology, 75(1), pp. 85–88. https://doi.org/10.1016/j.ijporl.2010.10.015
ten Dam, E., van der Heijden, P., Korsten-Meijer, A.G.W., Goorhuis-Brouwer, S.M. and van der Laan, B.F.A.M. (2013) ‘Age of diagnosis and evaluation of consequences of submucous cleft palate’, International Journal of Pediatric Otorhinolaryngology, 77(6), pp. 1019–1024. https://doi.org/10.1016/j.ijporl.2013.03.036
Thomas, J. et al. (2024) ‘Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report’, Pediatrics, 154(2), e2024067605. https://doi.org/10.1542/peds.2024-067605
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