Margaret,
        There is an assessment tool for lingual frenulum *function* that was
developed by Alison Hazelbaker, IBCLC.  The crux of the assessment is that the
ability of the infant to use to tongue is even more important than the
appearance of the tongue.  The essential tongue skills that can be inhibited
by a tight frenulum are:
Elevation and extension of the tongue (these need to be simultaneous, and be
able to be sustained in order for the tongue to milk the breast)  Inability to
sustain these movements results in recoil of the tongue- often snapping the
tip against moms nipple like a rubber band (ouch) and making a clicking noise.

Configuration or longitudinal grooving (cupping) of the tongue to stabilize
the teat in the mouth and handle the bolus of milk.  WIth a poor cup the
infant chokes and gags as milk slips into the pharynx before he is ready to
swallow.

Peristalsis of the tongue to milk the teat- when a frenulum is short, the
peristaltic wave will not originate in the anterior tongue, or will be weak.
The infant compensates by using more jaw compression, which causes mom deep
breast and nipple pain.

Those are the big three for sucking.  Alison's ATLFF tool also checks
transverse tongue movements, anterior spread, and appearance factors.  I have
found it to be invaluable.  If you are interested, email me privately and I
can give you ordering info.
        In practice, when there is suspicion of a suck problem, I evaluate
tongue function, first by observing a feed then by digital exam.  If function
is only moderately impaired and mom's nipples are not damaged, I try
management changes first- positions which facilitate tongue-breast contact and
increase stability and gravitational assist to tongue extension.  If these
fail we refer to an oral surgeon or ENT.  (There are many other resources,
these are the people who are willing and able to assess and treat infants in
my area.)  For those infants who cannot latch or cannot latch without pain or
damage to mom, I encourage seeing the surgeon immediately.
        Some infants take time after surgery to achieve optimal tongue
function.  Some benefit from some type of suck rehab.  Others do fine
immediately or with the tincture of time.
Catherine Watson Genna, IBCLC  NYC  [log in to unmask]