Hi TalkTools,

I have a question about the straw hierarchy. I have a 5 year old with severe phonological processing disorder and recently repaired posterior tongue tie. I have started the straw hierarchy with her. She is on straw #3 and able to take in a single sip and multiple, consecutive sips, but seems to take too big of a water bolus which causes her to pause before swallowing to make a suckling motion to manage it in her mouth before swallowing it. Any suggestions? Thank you.

Jody

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Hi Jody,

I am thinking based on what you are saying that she is demonstrating a reverse swallow. I am gathering that you are saying that this is what you are seeing on multiple swallows and not single sips. If she is not doing it on single sips I would try to stay there for an extended period of time to get her used to swallowing in the correct way and then build up to multiple sips. Your client can demonstrate tongue protrusion with the first 4 straws but cannot move to #5 without tongue retraction. I hope this helps. Please let me know if you have other questions.

Thanks,

Liz

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Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 11 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.

Hi,

I work for a not for profit helping connect families to community resources. I just attended an appointment with a mother and 3 month old infant with Down Syndrome at the child's Family Physician's office. When the mother made the statement that she feels like her child is choking on its tongue and asked if this would change, the doctor told the mother that persons with DS have larger tongues and hopefully as her child grows his mouth would grow. 

​***This is just not true. Low muscle tone may make the tongue appear to be enlarged but tongues of people with a diagnosis of DS are not larger than the typical population. If this child is choking it may be secondary to low muscle tone, the insertion of the tongue, or inability to coordinate suck, swallow and breath. Starting a muscle based program from birth will make a difference. Feel free to look at the resources on the TalkTools website, particularly the DS feeding class, at this point.***​

The mother also raised a question about her child's head shape and if it would change (there has been a referral for a helmet consult and a request for referral for PT that the PCP does not want to make until after the helmet consult). The PCP told the mother that it may or may not change and the PCP associated the child's head shape with the child's diagnosis of DS. How can I better educate this mother about this? I am beside myself. Is there not information that states otherwise?

​***I am not an expert in head shape...however some babies with DS do have some asymmetry or a flat back of the head. I have had a number of babies on my caseload that have successfully worn helmets.***​

Lisa

Lori Overland, MS, CCC-SLP, C/NDT

Hi,

 

I am a physical therapist working in Early Intervention in NJ. I have a 12 month child that I suspect has an undiagnosed syndrome. She has very low muscle throughout. Her cognitive level is about 6 months. She cannot sit unsupported. She can imitate a play action. She is making very few sounds. Frequently sticks out her tongue, open mouth posture. She can only eat pureed foods. I called for a speech assessment and was told by the Speech Therapist that there is no evidence that Oral Motor Therapy can help her speech at this age. Is that true?

Thank you for your help!

 

Tal

Dear Tal, 

Thank you for your question.  My name is Monica Purdy and I am a speech and language pathologist that also specializes in oral placement therapy and feeding. There is a lot of research on oral motor and the effectiveness and evidenced based information. If you visit this page on the TalkTools website you will find articles that you can print off and give to the speech therapist. Many speech therapists assume when someone mentions "oral motor" that they are referring to exercises such as "tongue wagging" (moving the tongue from side to side outside of the mouth), puffing the cheeks, and/or elevating the tongue to the nose or chin (again outside of the mouth). These activities do not have any support and are not related to speech or feeding and should not be used. However as you know being a physical therapist you can address muscle function by working on stability, dissociation, grading, precision and endurance in order to help a client with feeding and speech intelligibility. At TalkTools we do this by using kinesthetic feedback or tactile cues to help a client achieve these skills. Many times we work on feeding because it is a precursor to speech and we can prevent speech sound distortions from occurring if we address the muscles in feeding.   

I hope this helps, if you have any further questions please do not hesitate to contact me. 

Monica Purdy, M.A., CCC-SLP

Hello!

 

I have a 13 month old with Down syndrome who has a significant tongue thrust swallow pattern and tongue protrusion. Her tongue is ALWAYS out of her mouth, far. Almost as if she is intentionally pushing it all the way out. She retracts her tongue when I place a straw in the corner of her mouth, place a puff on her molar ridge (and will maintain tongue lateralization for a short period), and when I place the elephant jiggler in her mouth. As soon as she attempts to control the puff with her tongue or swallow, her tongue pushes forward again. I can prompt her to retract her tongue at rest but it comes right back out. What else can I do? I only get to see her one time per month at this point. Mom sits in on sessions and carries over at home. Pediatrician and ENT have no concerns about size of tonsils; I have not observed them myself yet.

 

Aubrie

Hi Aubrie,

It sounds like you have been working really hard with this patient to address the tongue retraction.  Everything you are already doing sounds great.  I would add bubble blowing, horn blowing and chewing on the back molars (with cubes of food if able, z-vibe and the bite tubes). All of this will encourage tongue retraction in the mouth. The more you can work on the retraction the better.  

I hope this helps.

Please let me know if you have any other questions.

Thanks,

Elizabeth J. Smithson, M.S.P., CCC-SLP 

Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 10 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.

Dear Sir/Madam,

 

I am a speech and language therapist working in the UK. I had the TalkTools training a couple of years back.I assessed a child last week taking over from another therapist who has just left. This child was advised to drink thick and thin fluids from a thick straw (McDonald's thickness). The child can drink thin fluids easily from straw #7 but has not had any success with straw #8. I observed the child with the thick fluid from a thick straw and they managed really well. When drinking from a cup with no straw there was still notable tongue protrusion. I am not quite sure where to move this child on? Should we move to straw #8 (thin fluids) and continue with thick fluids from a thicker straw? Should you be continuing on the straw hierarchy until there is efficient tongue retraction when drinking from an open cup? I would appreciate some guidance.

 

Best wishes,

 

Melissa

Hi Melissa, 

I would continue on the next straw if she is drinking at ease with tongue retraction as you said. I would want to use the straws for all drinking attempts and minimize the use of the cup. I would work on activities that promote tongue retraction before working on the cup. This will reinforce the motor plan.  I would then make sure to place the cup under her tongue and prevent her from using her tongue as her lower lip.  If this is not working you may want to remove the cup for a short time and work only with the straw and then revisit the cup.  Giving the child a break and only reinforcing the tongue retraction may help.

It is possible for a child to continue demonstrating tongue protrusion with cup drinking after the straw protocol but I would consider that atypical.

Keep me posted and let me know if you have any other questions.

Thanks,

Elizabeth Smithson, MSP, CCC-SLP

Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 10 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.