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.


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


Car Talk

June 4, 2013

With the summer upon us, many families will be traveling, yielding potentially many hours in a car or on a plane during which you will need to occupy your child. Below are a few ideas for entertaining your child, and at the same time, fostering his language development.

Play category games. These games help your child to better organize the meanings of words and how words relate to each other in his mind. They are also helpful for working on turn taking. Here are some ideas of categories in which you can take turns naming members.

  • colors
  • vehicles
  • foods
  • fruits
  • vegetables
  • clothes
  • Disney characters
  • super heroes
  • things with wheels (You can talk about how this is not necessarily the same as vehicles. Boats are vehicles without wheels. Suitcases can have wheels but aren’t vehicles.)

You can make the games slightly more complex by adding an extra feature to the category.

  • foods that are green
  • Disney characters that aren’t people
  • vehicles that don’t go on land

For kids who are a little older, you can make the task harder by making it an alphabet game. Take turns naming category members beginning with each letter of the alphabet. For example, if the category were foods, the first person could say “apple,” the second person could say “bagel,” and so on.

For preschoolers on up, you can take turns trying to come up with as many words as you can think of that start with a particular letter. For young children who aren’t yet reading and spelling, this requires the use of phonics (letter-sound associations) and phonological skills. For example, if the letter is M, your child has to recognize that M says /m/ and then think of words that begin with that sound. If your child is in speech therapy and is working on saying a particular sound correctly, this can be a great carryover activity.

There are also plenty of free printable games available on the web that are perfect for the car. Travel bingo and backseat scavenger hunts, in which your child looks out the window to find specific things, utilize attention and memory skills. This vehicle graphing activity is an easy way to work on early math skills. Once the graph is completed, you can talk about quantity concepts like more, less, most, and least.

As you can see, none of these games require you to bring a lot of extra stuff on your trip, but they can help fill what seem like endless hours in the car. What games do you and your family like to play in the car? Leave a comment to let us know!

backseat kid

Picture It

April 29, 2013

If your child is like most, she loves to see herself in pictures. Why not take advantage of this and use it as an opportunity to help develop her language skills? Of course, sources for pictures to look at and work with are numerous. You may have them tucked neatly into a baby book or scrapbook, or perhaps, they’re all uploaded to Facebook. You may have them accessible on a tablet, in which case your child can touch and scroll through them herself. Wherever they are, and however you choose to share them with your child, there are plenty of skills you can target through this simple activity.

  • Pointing – You can work on the actual act of using the index finger to point to things. This does not come naturally to some children, especially those with language delays. Simply model pointing yourself as you name what you are pointing out.
  • Referring to self – As your child points to pictures of herself, encourage her to use words like I and me, as well as her name. “There I am,” or, “It’s me.”
  • Combining words – You can model this for your child by describing a picture in two to three words. “Suzy’s hat,” or, “Johnny in wagon.”
  • Using verbs – Often, children who are language delayed develop a large vocabulary of nouns to label things, but they are short on verbs to describe actions. You can ask your child what she was doing in the picture. If she has trouble coming up with a sentence with a verb, you can model a sentence like, “Jenny was dancing,” or, “Kelly was swimming in the pool.”

If you’re really ambitious, you can take current pictures of your child and create an album or slideshow of her doing specific activities, wearing specific items of clothing, or holding specific objects you might want to talk about. For example, you might take pictures of her playing dress up and then talk about a silly hat or big sunglasses. Or, you can take pictures of her throwing and kicking a ball and then talk about those verbs. The possibilities are truly endless.

How has talking about pictures of himself or herself helped your child?

Toddler with sunglasses

Learning Language Through Natural Routines: A Walk in the Neighborhood

April 15, 2013

Now that spring is here, it’s a great time to go on an outside adventure with your child. Point to and label everything you see, feel, and hear, as you take a walk through the neighborhood. Below are some ideas that will help to build your child’s vocabulary. These activities are appropriate for young children with and without language delays.

toddler walking

  • Encourage your child to look for animals that are different sizes. This will help him learn the concepts big and little
  • If you hear a plane, point it out to your child, and say, “I see the plane. I hear the plane.” Encourage your child to repeat the word plane.
  • Talk about the weather: “It feels hot today, ” or “I see a lot of clouds in the sky. Maybe it’s going to rain.”
  • Help your child understand and respond to questions that begin with where. Ask, “Where is the red car?’ or, “Where is the stop sign?” If your child does not respond, you can point out the object, and say, “There it is.” If he points correctly, you can say, “Yes, it’s straight ahead,” or “Yes, it’s in the driveway.”
  • Talk about the words fast and slow. You might comment, “That car is going fast.” Ask your child to run fast or walk slowly.
  • Help your child understand the preposition over by asking him to jump over the cracks in the sidewalk.

Remember, young children need to hear literally several thousand words per day in order to become proficient communicators. By commenting on the things you and your child see, even if you don’t ask your child to say anything in response, your are providing good language input.

What other words and concepts can you think of to talk about as you take a walk with your child? Leave a comment with your thoughts.


Learning Language through Natural Routines: Brushing Teeth

March 5, 2013

What’s more routine than something you do with your child at least once a day? In this article, you’ll find a few strategies to support language development while brushing your child’s teeth.

Pre-linguistic/Play Skills – Your child will use objects in appropriate play or self-care.

At toothbrushing time, bring a doll or stuffed animal into the bathroom. Let your child watch you pretend to brush the doll’s teeth. Then give the toothbrush to your child and see if he will pretend to brush the doll’s teeth. You can prompt by saying, “You brush baby’s teeth.” If he doesn’t respond to the verbal prompt, you can provide hand-over-hand assistance.

Receptive Language – Your child will follow two-step related commands.

At the beginning of the routine, give your child the instruction, “Get the toothpaste and open it.” If he is not able to follow the two-step command, give one part at at time. Tell your child to, “Get the toothpaste.” After he has completed that part, tell your child to, “Open the toothpaste.”  As always, you can provide a physical prompt by providing hand-over-hand assistance, if needed. Another two-step command you can give your child during this routine is, “Close the toothpaste and put it away.”

Expressive Language – Your child will use word combinations.

(This task assumes that your child already regularly uses single words without prompting.)

Allow your child the chance to brush his teeth either before or after you do it. Ask, “Whose turn is it first?” You are looking for a phrase like, “My turn,” “Daddy do,” or some other two-word combination appropriate to the situation. If your child responds with only one word, model a two-word phrase for him to repeat. If you need to use the words me or my when modeling the phrase to refer to your child, be sure to point to your child as you say it, so he will not think you are correcting whose turn it is. After the first person has had a turn, ask, “Now whose turn is it?” Model the desired phrase as needed.Toothbrushing

By adding any of these strategies to your toothbrushing routine, you’ll give your child extra practice with his developing language without having to invest a lot of extra time. The next article in this series will give you suggestions to foster language development during walks around your neighborhood.