Tongue Ties, Lip Ties, and Cheek Ties

April 3, 2018

I have been seeing a lot of babies with tongue ties (ankyloglossia) coming through our local early intervention evaluation clinic lately because of the effect it has on breastfeeding. As a graduate student, I was taught that tongue-ties usually do not affect speech, so when I saw that there was a continuing education class by Robyn Merkel-Walsh (and co-author Lori Overland) on Tethered Oral Tissue (TOTs) addressing the impact of tongue and lip ties on feeding and speech coming to a town near me, I knew I had to attend. Here are the highlights of the course (written with permission and editing from Robyn Merkel-Walsh MA, CCC-SLP/COM®):

What are tongue, lip, and cheek ties?

  • A tongue-tie occurs when the piece of tissue that connects the tongue to the floor of the mouth (called the lingual frenum or frenulum) is either too short or too tight and therefore restricts normal tongue movement to some degree. (Mayo Clinic, 2016) Tongue-tie can also be the result of the frenulum being in an atypical location.
  • A lip tie occurs when the piece of tissue that connects the lip to the gum (called the labial frenum or frenulum) is attached too close to the teeth or extends beyond the teeth into the hard palate. This restricts movement of the lip and affects the appearance of the face. The vast majority of people with a lip tie also have a tongue tie.
  • A third type of tie, known as a buccal tie, occurs when the tissue between the cheek and gums (buccal frena or frenula) is too thick or too tight. This restricts the ability of the cheeks to be used for feeding and speech.

What issues are caused by tongue, lip, and cheek ties?

  • All stages of feeding may be affected by TOTs across the lifespan including breastfeeding, bottle feeding, spoon use, eating solids, cup drinking, and straw use.
  • Speech sound production can be affected by ties. Research is emerging. Depending on the location and severity of the tie(s), every consonant in the English language has the potential to be impacted, though some sounds are more typical than others such as /s/ or /z/ (Marchesan, 2004). Older children who have been in speech therapy for many years, without fully correcting their sound production, may have tongue, lip, or cheek ties that are preventing them from progressing any further.
  • Tongue-ties are associated with sleep-disordered breathing, which can range from snoring to obstructive sleep apnea. (Guilleminault, Huseni, and Lo, 2016). Obstructive sleep apnea in infants has been associated with sudden infant death syndrome (SIDS). Follow the link to learn about the potential implications of sleep-disordered breathing in children.
  • Reflux in babies is a red-flag for a tongue-tie. The improper sucking pattern causes the baby to swallow air (aerophagia), leading to reflux. (Siegel, 2016)
  • The resting posture of the tongue should be inside the mouth, behind the top front teeth, with the mouth closed. This allows breathing through the nose, where the air can be filtered. When the tongue is restricted, it can cause open mouth posture/mouth breathing, which doesn’t allow the nasal turbinates to do their job. This results in the potential for more bacteria and viruses to enter the body, leading to the potential for illness.
  • Appropriate lingual resting posture is a natural palatal expander (quoted from Linda D’Onofrio, SLP). A restricted tongue that does not assume typical resting posture can cause the palate to become vaulted and narrow which leads to differential dental eruption. This is described in detail in the book by Hanson & Mason text entitled Orofacial Myology (2004).  This cycle increases the chance of orthodontia as the child gets older.

What is the role of the speech-language pathologist (SLP) in the treatment of ties?

  • The American Speech-Language Hearing Association (ASHA) states in the OMD Practice Portal that SLPs cannot “formally” diagnose a tongue, lip, or cheek tie or decide if surgery is warranted; however many SLPs find that the surgeons rely on them to help make this decision based on functional issues. The role of the SLP with TOTs includes: 1) the assessment of structure and description of suspected anomalies associated with TOTs (ex. note the location of the frena or tightness thereof) and 2) the diagnosis and treatment of the functional impact of TOTs on feeding and speech. This evaluation and descriptive report can be helpful to a physician or dentist in making the diagnosis and determining if there is a need for frenectomy (the procedure that releases TOTs).
  • SLPs can design and carry out a pre-operative program to acclimate the client and family to the oral sensory-motor treatment before surgery. Proper implementation before the surgery and immediately following it can reduce the chance of reattachment and scarring.
  • SLPs can design and carry out a post-operative program for neuromuscular re-education of the mouth for feeding and speech after surgery. Clients with a history of ties may use compensatory movements for feeding and eating that they will need to overcome.
  • This is detailed in Functional Assessment and Remediation of Tethered Oral Tissue which was co-authored by Merkel-Walsh & Overland.

Whom should parents contact if they suspect that their child has a tongue, lip, or cheek tie?

  • The first step is a functional assessment. Too often releases are performed without this and it makes post-operative care more difficult. Functional assessments are conducted by IBCLCs, SLPs, OTs, and RDHs depending on the age of the patient and the symptoms presented. There is not a TOTs leader but rather a TOTs team. The Ankyloglossia Bodyworkers is a good referral source as are the IAOM and TalkTools® (see below).
  • Once a functional assessment is conducted, the patient/parents of the patient should seek a referral to an otolaryngologist (ENT), oral surgeon, or dentist with expertise in TOTs to make the diagnosis and perform the revision if it is deemed necessary. Organizations such as the International Consortium Of Oral Ankylofrenula Professionals (ICAP) and the International Affiliation of Tongue-tie Professionals (IATP) have lists of providers.
  • The age of the patient and what is being affected (e.g. speech, breastfeeding, dental eruption, fascial restriction etc.) by TOTs determines which other professionals should be consulted. In addition to the aforementioned professionals, TOTs impacts the whole body; therefore, chiropractors and physical therapists can assist with patient care. Craniosacral therapy and TummyTime® are often used with TOTs patients.

Other facts about ties:

  • Babies born prematurely are at higher risk of tongue, lip, and cheek ties because there is less time for the tissue to detach.
  • In earlier generations, babies had their tongues clipped before leaving the hospital. The procedure hadn’t yet been perfected, and breastfeeding became less popular as more women entered the workforce. As a result, the practice fell out of favor. As breastfeeding has increased in recent years, the identification of tongue and lip ties has been on the rise. (Ghaheri, 2014)
  • Well-meaning doctors often test for tongue-tie by having the child stick out his/her tongue, assuming that if the tongue can protrude, it isn’t restricted; however, this misses all of the functional postures required for feeding and speaking.
  • Frena tissue is collagen-based. It cannot be stretched. No amount of stretching will “fix” TOTs, but pre- and post-op therapy can assist with function.
  • Brazil now has a Frenum Inspection Law based on the correlation of SIDS and ankyloglossia in their country. All babies must be inspected for tongue-tie before leaving the hospital and if diagnosed, will have a revision. (Martinelli, Marchesan, and Berretin-Felix, 2012)

To learn more about tethered oral tissues, check out these links:


Compiled from information from the TalkTools workshop: Functional Assessment and Remediation of Tethered Oral Tissues (TOTs), authored by Robyn Merkel-Walsh and Lori Overland, as presented by Robyn Merkel-Walsh, MA, CCC-SLP.

Sibling Play

January 13, 2018

I recently came across this video from a few years ago of my own kids, and it got me thinking about all of the skills infants and toddlers can learn by playing with their older siblings.

My then four and a half year old son thought he was teaching his 10-month-old sister the words “above” and “below.” But he was really doing so much more than that. As a Speech-Language Pathologist, I was so excited to see my daughter exhibiting joint attention (two people aware that they are both attending to the same object or activity for a social purpose, such as when a child points to an airplane and then looks to his mother to make sure she sees that he is pointing and what he is pointing to.) Not only is she engaged with her brother in this simple game, but she also looks over at me (behind the camera), as if to say “Do you see this awesome game we’re playing?”

In addition to the social communication skills my daughter was showing off, Nicole Winningham, an Infant Toddler Developmental Specialist and owner of Partnering with Parents, noted many other developmental milestones on display in this short clip:

  • Standing up (gross motor)
  • Shifting weight (gross motor)
  • Object permanence (cognitive)
  • Attending to an activity (cognitive)
  • Imitation (personal-social)
  • Index finger isolation (fine motor)

You can see from the video above how many skills are practiced in less than 30 seconds of sibling play. Kids with developmental delays need many hours of active engagement each week to help them catch up to their peers. Infants and toddlers learn best through natural routines. With support from a qualified provider like a Speech-Language Pathologist, Occupational Therapist, Physical Therapist, or Infant Toddler Developmental Specialist, parents can learn how to help their children using strategies embedded in everyday routines, like playing with their big brothers and sisters.

Big brother and little sister

What if your child does not have an older sibling (or a typically developing sibling)? Joining a playgroup, going to kids’ play places like baby gym or the park, or spending a few hours a week in a childcare setting can all be great ways to give your child the opportunity to benefit from social interactions with role model peers.


Early Detection of Autism Spectrum Disorder

November 17, 2016

Autism Spectrum Disorder (ASD) is a complex neurological condition, which affects an individual’s communication skills, social interactions, and cognitive functioning. In the U.S., only 20% of people with ASD are diagnosed before age 3, with most diagnoses not occurring until age 4-5.

According to the Autism Society of the United States, early intervention (beginning before age 3) can reduce the cost of care over a person’s lifetime by 67%. All states have early intervention programs. In Florida, the Early Steps program serves families of infants and toddlers with developmental disabilities and delays up until a child’s third birthday. Because early intervention services end at age 3 in most states, early diagnosis is necessary to access those services and achieve better outcomes.

Parents are often encouraged by well-meaning friends, relatives, and even physicians, to take a “wait and see” approach when it comes to communication disorders, with the rationale that the child is just a late talker and will grow out of it. While some children really are just late talkers, it is not normal for a child not to talk until age 3 or 4, and the opportunity for early intervention is lost, in the event something more significant than being a late talker is going on.

Below are some milestones to be aware of. If your child has not met these milestones, that it is a red flag for Autism Spectrum Disorder and/or a language delay.

By your child’s first birthday, s/he should be:

  • Babbling (strings of consonants and vowels)
  • Pointing to things (both to ask for them and just to show them to you)
  • Following your point
  • Responding to his/her name


By your child’s second birthday, s/he should be:

  • Using at least 50 words spontaneously (without you saying the word first)
  • Beginning to meaningfully combine two words and not just using memorized phrases like “thank you” or “here ya go”


The loss of words in a child 18 months or older is an additional red flag for ASD.

Some of the social behaviors that are absent or delayed in children with ASD can go unrecognized if you’re unsure of what to look for. Autism Navigator is a great resource to view side-by-side videos of young children at risk for ASD and typically developing peers. The ASD Video Glossary on this site can be especially helpful in figuring out if what you see your child doing is a sign of ASD or typical behavior.

A diagnosis of Autism Spectrum Disorder is hard for any parent to hear, but children are not helped by taking a “wait and see” approach. If you suspect that your child has any kind of developmental delay, you should contact your state’s early intervention program as early as possible to give your child the chance at the best possible outcomes.

hanen-program-logoSharon Ascher, M.A., CCC-SLP

Speech-Language Pathologist

Certified to Provide: More Than Words® – The Hanen Program® for Parents of Children with Autism Spectrum Disorder or Social Communication Difficulties

How Many Words Does Your Child Say?

April 9, 2015

When you take your toddler to a well-child check-up at the pediatrician s/he will certainly ask you how many words your child says. The developmental milestone that they are looking at is your child’s spontaneous use of words. These are words your child says not in imitation. If your child points to a dog and says “dog,” that is spontaneous. If you ask your child, “What’s that?” and he says “ball,” that is spontaneous. If your child repeats a word s/he overhears or says a word when you tell him or her to say it, then it’s imitated.

The most accurate way to keep a count of your child’s spontaneous words is to maintain a written list and add to it every time you hear a new word. The chart below can be printed and used to track your child’s early word acquisition. If your child reaches 50 words that s/he uses spontaneously before his or her second birthday, you can stop counting. Children should have a minimum of 50 words in their vocabulary by their second birthday. If your child does not have 50 words by age 2, you should seek a speech-language evaluation from a speech-language pathologist or a developmental evaluation through your state’s early intervention program.

Toddler Word Chart


Simple, but Effective, Communication Strategy

March 24, 2015

This simple strategy is easy to implement at home. At snack time, get down on your child’s level and offer two choices. Hold them about shoulder-width apart and far enough away so that your child cannot grab. Once s/he points to or reaches for the desired object, hold that one up by your face and say the name of it. Pause expectantly, giving your child the opportunity to imitate. After about 5 seconds (you can count in your head), say the name again and pause. Do this once more and then hand the item over whether or not your child has imitated. If your child does imitate (or attempt to imitate) the word, be sure to praise the effort.


Benefits of using this strategy:

  1. By offering a choice, your child has to intentionally communicate a want or need. This is an early step on the way to talking.
  2. By getting down on your child’s level, you get his/her attention and make it easier to watch your face.
  3. Children tend to look at the object they want, so bringing it up by your face while you say its name encourages eye contact and allows your child to watch your mouth as you form the word, so s/he can see how it is said.
  4. By pausing expectantly and waiting, rather than saying, “Say ___,” you are giving your child the opportunity to imitate without any pressure. This is important because many children with delayed language will shut down when pressure is put on them to speak. Please be sure not to tell your child to say the desired word.
  5. By saying the word 3 times, you ensure that s/he has heard the word 3 times in the immediate context of the item, which helps with understanding the meaning of the word.
  6. By giving the item to your child after the third time you have said it, you reduce everyone’s frustration. You, as the parent, do not have all day to wait for your child to say a word before giving a snack. By limiting yourself to saying the word 3 times, you get to move on. Your child also gets to practice being patient.
  7. When this strategy is used consistently, many children get tired of waiting for you to say the word three times, and learn to imitate after the first or second time.


  1. If your child points specifically to what s/he wants, you can skip the step about offering a choice, as your child has already used intentional communication to indicate a want/need. Go straight to holding the desired item up by your face.
  2. Once you’re comfortable with this strategy at snack time, try it out during other routines. (Green shirt or red shirt; play trains or blocks; milk or water)


Let’s Pretend!

November 30, 2014

It’s that time of year again when parents, grandparents, aunts, and uncles go out in search of new toys for their youngest relatives. I’ve written before about tips for choosing toys, always at this time of year it seems. (Top Toys for Toddlers and How To Choose Toys That Encourage Development Through Play). And here I go again.

This year, I’m focusing on toys that encourage symbolic and/or pretend play. Language and play develop along similar paths, so as children’s play becomes more complex, so does their language. The toys below lend themselves to children narrating what they are doing. For some little ones, this will be in complete sentences, while for others, they may just use single words or two-word phrases. Regardless of the complexity, it’s important that children be able to use language to comment about what they are doing, rather than just for labeling pictures and requesting desired items.

Parents and caregivers can support language development by reflecting back what the child says and expanding on it. For example, if your child is playing with a farm set, puts the horse in the barn, and says “Horsie night-night,” you could respond by saying “The horse is going night-night,” or “The horse is going to sleep.”

So here are a few toys that encourage symbolic and/or pretend play. None of them require batteries, which saves you money, saves you from listening to annoying toy sounds, and allows your child to use his or her imagination.

Fisher Price Little People Mini Farm – This one has no batteries. If you choose the Fun Sounds Farm, do yourself a favor and never put the batteries in. If you put the batteries in, your child may learn that a cow says oink or a sheep says moo because the toy does not know which animal figure your child is playing with as s/he puts it on a spot that activates the sound.

little people farm


Tea Set – There are lots of tea sets out there with batteries, but this one doesn’t use any. It’s simple, which will encourage your child’s creativity. Pair this with some dolls or stuffed animals, and your child can host a tea party.

tea set


Doctor Kit – This is a great toy for acting out adult roles, as well as playing with others. Children can take turns being the doctor or the patient. Playing with the doctor’s tools can help desensitize children to them, so they are more comfortable in the doctor’s office.

doctor kit


Cooking Set – Children can play restaurant or house with this set of cookware and food. They don’t even need a play kitchen to make believe they’re cooking like mom or dad.

cooking set


Baby Doll Set – Both feeding and clothing the baby are great for pretend play. Additionally, dressing and undressing the baby require the use of fine motor skills. All kids, not just girls, are likely to enjoy taking care of a pretend baby.

baby doll set


I have intentionally left out toolbox sets. While some children engage in pretend play with hammers and screwdrivers, many children only use them for banging. Since we are looking for higher level play than just banging, I recommend choosing a different play set.

I receive no financial benefit from promoting these toys. I just think they are great toys for young children. All of these toys can be found on Amazon, which is where the links will take you, but the same or similar toys can be found in any toy store. Happy shopping!


Top Ten Uses for Plastic Drink Bottles

July 15, 2014

Many communities have recycling programs for used plastic bottles, but whether yours does or not, you can upcycle your used plastic drink bottles for some fun activities with your kids. Here are my top ten uses for plastic bottles and some skills you can address while you play.

1. Once you have a collection of at least three bottles, you can set them up like bowling pins and have your child roll a ball to knock them down. One or two-liter soda bottles work best for this, but you could use water bottles instead.

  • Talk about the concepts of up and down as you set up and knock down the pins.
  • Work on sequencing: first we put up the pins and then we knocked them down.
  • Practice taking turns.

2. You can fill bottles with a variety of different small objects and then super glue them shut to create sensory bottles. A quick search on Pinterest will reveal hundreds of ideas for what to put in the bottles. Here are a couple of ideas that I like for working on basic concepts. Small Gatorade bottles work well for this because they are sturdy and have a wide openings, but you could use any clear plastic bottle you have.

  • Fill each of several water bottles with items of a different color. Then talk to your toddler about each color and the items that are in the bottles. You can add water to the bottle to make the items float freely.
  • Fill several bottles with items that make different sounds (jingle bells, dry rice, cotton balls). You can talk about loud and quiet.

Orange Sensory Bottle

3. Create a tornado in a bottle by filling it with water and adding a little bit of dish soap. Seal the bottle closed with super glue. Then shake it up to see a tornado.

4. Use a collection of empty and cleaned plastic and cardboard food containers to create a play supermarket.

  • You can name the items for your toddler as he puts them in the basket.
  • Talk about the sizes of the containers. (The soda bottle is bigger than the water bottle.)
  • Engage in pretend play with your child. One of you can be the customer while the other is the cashier, and then switch roles.

5. Put colorful items inside a two-liter bottle, seal it with super glue, and let your crawling baby roll it across the floor.

6. Save the caps from a variety of bottles and let your child sort them by size or color. Not only can you work on the concepts of color and size, but as you sort, you can work on same and different.

7. Your empty plastic bottles can become bath toys as you allow your child to practice pouring water from one bottle into another.

8. Have your child work on his fine motor skills and hand-eye coordination by picking up raisins, Goldfish crackers, or Cheerios one at a time and putting them in an empty and dry water bottle or soda bottle with a small opening. Then let him dump them out and do it again.

9. Use toothpicks or  uncooked rice or beans inside a plastic bottle to make a shaker toy for your toddler. For preschoolers, see if they can copy a rhythm pattern after you.

10. Give your child age-appropriate art materials to create an animal or a vehicle out of a bottle. Again, you can find plenty of such projects on Pinterest. Or you can let your child’s imagination run wild. Your child can work on sequencing by telling the steps to complete the project in the correct order.

Before you throw away your next plastic drink bottle, think about how you could use it instead to play with your child. You’ll be keeping some trash out of the landfill and some money in your wallet as you create some free toys.

Do you have any other ideas for using plastic bottles for play? If so, leave a comment to tell us.