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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