Thanks for posting this link, Ellen.

The problem with a simple tool for identifying tongue tie is that there 
are different degrees of tongue tie, and many different tongue motions 
that can be impacted.  I have found that the most obvious tongue ties 
(the Coryllos type 1 or Griffiths 100%) are not always problematic, 
whereas the type 3 and 4 (25% and 0% Griffiths) can cause more 
difficulties with simultaneous tongue elevation and extension, and can 
cause more tongue retraction and posterior elevation during sucking, 
which is baad for nipples and infant intake.

Some of the movement one needs to assess:
 extension over the lip with the tongue held out flat WITH the mouth 
open.  Many infants who are tongue tied can get the tongue tip over the 
gum when the mouth is closed, but retract it as they open.  Some infants 
can extend the tongue if they roll the tied tip under the body of the 
tongue, but this is a sign that treatment is necessary.

lateralization of the tongue tip to the corners of the lip without 
twisting of the body of the tongue.  Compensatory movement is to twist 
the tongue upward (caudally) on the side opposite the direction of 
tongue tip movement.  This is a sign that the baby cannot lateralize 
properly.  Lateralization is important for handling solids and oral hygeine.

elevation of the tongue tip to the palate with the mouth open, with the 
body of the tongue pointing straight up.  Curling back of the anterior 
tongue is a sign that elevation is restricted, and lack of ability to 
touch the palate means that there is restriction.  Elevation is one of 
the most important movement for breastfeeding, because what goes up must 
come down, and the drop of the posterior tongue is what pulls milk out 
of the breast.  The more posterior depression, the more milk moved.  
Obviously if the tongue can't elevate, there's nowhere to drop it.

grooving - longitudinal grooving of the tongue should be crisp and 
symmetrical.  Alison calls this cupping in the ATLFF, but most 
occupational therapists call cupping the lifting of the anterior tongue 
to stabilize the teat in the mouth. 

cupping - at least 25% of the length of the tongue should be able to 
cup, or there might be a posterior (tpe 3 or 4) tongue tie.  WHen you 
get good at observing this, you can see a little line of flexure on the 
tongue that shows you where the frenulum attaches underneathe.  If that 
line is too far forward, then baby needs treatment.

The ATLFF is valuable because it started us looking at parameters of 
tongue function.  As with any tool, it will be refined with time and 
further study.  I used the ATLFF initially, but as I've observed more 
and more tongue tied infants, I've started making decisions about which 
babies to refer for evaluation based on how severe movement restrictions 
are, how dangerous for breastfeeding baby's compensations are, and how 
much progress we make with management alterations.

You'll find some photos and further information on the above at
http://www.jabfp.org/cgi/content/full/18/1/1

Catherine Watson Genna, IBCLC  NYC (and working on contributing to this 
issue)

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