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 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.
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.
- 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 types of feeding are affected by ties – breastfeeding, bottle feeding, spoon use, eating solids, cup drinking, and straw use.
- Speech sound production can be affected by ties. Depending on the location and severity of the tie(s), every consonant in the English language has the potential to be impacted. 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. 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.
- 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 breathing, which allows more bacteria and viruses to enter the body, leading to the potential for illness.
- A correct resting posture of the tongue allows the hard palate to spread. A restricted tongue that does not sit in this posture causes the palate not to spread, increasing the chance of orthodontia as the child gets older.
What is the role of the speech-language pathologist (SLP) in the treatment of ties?
- SLPs cannot formally diagnose a tongue, lip, or cheek tie. However, an SLP can evaluate the appearance and structure of the oral mechanism, as well as its functioning for feeding and speech. This evaluation can be helpful to a physician or dentist in making the diagnosis and determining if there is a need for revision (the procedure that corrects the tie).
- SLPs can design and carry out a preoperative 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 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.
Whom should parents contact if they suspect that their child has a tongue, lip, or cheek tie?
- Look for a physician or dentist with expertise in tongue and lip ties to make the diagnosis and perform the revision if it is determined necessary.
- The age of the child and what is being affected (e.g. speech, breastfeeding, tooth development) by the tie will help determine which other professionals, such as a speech-language pathologist, dental hygienist, occupational therapist, physical therapist, craniosacral therapist, or lactation consultant can best address the issue.
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.
- Well-meaning doctors often test for tongue tie by having the child stick out his/her tongue, assuming that if the tongue can stick out, it isn’t restricted. However, this misses all of the motor skills required for feeding and speaking. This is not the right way to diagnose a tongue tie.
- Frenulum tissue (the tissue that is tied) is collagen-based. It cannot be stretched. No amount of stretching will fix a tongue tie.
- A study of babies who had died from SIDS found that the majority had lip and tongue ties, which makes sense given the relationship of tongue ties to sleep disordered breathing. Brazil now has a Frenum Inspection Law. All babies must be inspected for tongue tie before leaving the hospital and be revised if a tie is found.
- In bottle-fed infants with ties, feeding problems may not show up until the child begins eating with a spoon or drinking from a cup.
- It is not normal for a baby or child to bite the straw or cup. If the baby or child must bite the straw or cup in order to drink, it is because there is an underlying oral motor deficit that should be assessed by a professional.
- Hard swallows are not normal and are an indication of an underlying oral motor deficit that should be assessed by a professional.
Compiled from information from the TalkTools workshop: Functional Assessment and Remediation of Tethered Oral Tissues (TOTs), as presented by Robyn Merkel-Walsh, MA, CCC-SLP