Tagged "ankyloglossia"


IAOM Convention 2018: OMD in Children with Down Syndrome, OPT for OMD & Feeding with Tongue Tie

Posted by Casey Roy on

TalkTools Instructors Robyn Merkel-Walsh, MA, CCC-SLP and Lori Overland, MS, CCC-SLP, C/NDT, CLC headed to Charlotte last weekend to present at the International Association of Orofacial Myology 2018 Convention.

The IAOM's mission is to "improve the health of the public by advancing the art and science of orofacial myology." Robyn is on track to become an IAOM Certified Orofacial Myologist - she has recently passed the written IAOM exam with the highest score of anyone taking the exam.

At this year's IAOM convention, Robyn and Lori presented 3 posters:

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"Functional Assessment of Feeding Challenges in Children with Ankyloglossia"

Posted by Deborah Grauzam on

This poster was presented at the 2017 annual American Speech-Language & Hearing Association, Saturday, November 11, 11 a.m.-12:30 p.m.

"Functional Assessment of Feeding Challenges in Children with Ankyloglossia"

Authors: Robyn Merkel-Walsh, MA, CCC-SLPLori Overland, MS, CCC-SLP, C/NDT, CLC

TalkTools | TOTs poster

Click here to view the full poster

Introduction:

Presentation explores 1) current classification systems for ankyloglossia; 2) functional assessment of ankyloglossia; 3) oral sensory-motor feeding challenges associated with ankyloglossia and 4) implications for treatment.

Discussion:

Ankyloglossia is not a newly discovered condition, and about 3% of infants are born with a tongue-tie (Amir, James, & Donath, 2006). The International Association of Tongue-Tie Professionals (IATP) adds that tongue-tie is an embryological remnant of tissue in the mid-line between the under-surface of the tongue and the floor of the mouth that restricts normal tongue movement (IATP, 2016). Three terms are being used synonymously to identify this condition: 1) Ankyloglossia 2) Tongue-Tie and 3) Tethering of Oral Tissues (TOTS). Tethering of Oral Tissues (TOTS) is a fairly new term that was coined by Kevin Boyd, DDS at the International Association of Tongue-tie Professionals at their annual conference in Quebec, Montreal Canada in October of 2014. TOTS as a term is more inclusive of tissue restriction of the tongue, lips and buccal frena (Boyd, 2014). The terms do not seem to be committed to one field of specialty, but the ICD10 coding system introduced in October 2015 is still only using one label for this condition, ankyloglossia (ASHA, 2015).

Over the past few years, this topic has been more frequently discussed in the fields of lactation, speech pathology, oral surgery, orofacial myology and otolaryngology. In a clinical study, lactation consultations, otolaryngologists, speech pathologists and pediatricians were surveyed on their beliefs regarding the impact of ankyloglossia on feeding. 69 percent of lactation consultants, but a minority of physician respondents, believe tongue-tie is frequently associated with oral feeding problems (Messner & Lalakea, 2000).

TalkTools | TOTs pictures

There have been several professionals who have published tongue-tie classification tools such as: Alison Hazelbaker, Lawrence Kotlow and Carmen Fernando. The International Affiliation of Tongue-Tie Professionals (IATP) cautions that classification can never substitute for assessment because classification develops categories based on broad, general criteria whereas assessment uses specific, detailed criteria for the purpose of accuracy and thoroughness (IATP, 2016). Researchers are collecting evidence on the histological characteristics of the frenulum (de Castro Martinelli, Marchesan, Gusmao, de Castro Rodrigues & Berretin-Felix, 2014); however, many professionals cannot agree on a classification system or diagnostic protocol to uniformly label the anomaly.

Despite these classifications systems, there does not seem to be a comprehensive assessment protocol to date that specifically task analyzes function for all stages of feeding skills. The Lingual Frenulum Protocol for Infants provides quick functional assessments for infants who breast and/or bottle feed. The Lingual Frenulum Protocol provides a general functional assessment of feeding and speech skills. These tools assist in determining whether or not a frenulum release is warranted, but do give clinical implications for treatment (Martinelli, Marchesan & Berretin-Felix, 2012).

TalkTools | TOTs diagram

Functional assessment of ankyloglossia considers not only the structure, but the impact on lingual range of motion specifically for the pre-feeding skills required for all stages of feeding. Range of motion observations should include: lip closure as it relates to cup drinking and spoon feeding; lip protrusion as it relates to the breast, bottle and spoon; lip rounding as it relates to straw drinking; lingual retraction as it relates to oral transport of a
liquid or bolus; intraoral lateralization as it relates to chewing; and transporting a bolus and tongue tip elevation as it relates to swallowing (Overland & Merkel-Walsh, 2013). Assessment strategies will be dependent on the age of the child, cognitive ability and motor planning ability.

TalkTools | TOTs table

Conclusion:

In summary, the assessment of ankyloglossia should not be limited to appearance alone. Oral motor skills including pre-feeding and feeding should be task analyzed. Since there is conflicting views on whether or not ankyloglossia should be surgically corrected, assessment must clearly consider the functional impact of the tongue-tie on feeding challenges (AABM, 2016; Ferres-Amat, Pastor-Vera, Ferres-Amat, Mareque-Bueno, Prats-Armengol & Ferres-Padro, 2016; Francis, Chinnadurai, Morad, Epstein, Kohanim, Krishnaswami, Sathe & McPheeters, 2015; Kummer, 2016; Merdad & Mascarenhas, 2010;
Sethi, Smith, Kortequee, Ward & Clarke, 2013).

References:

American Academy of Breastfeeding Medicine (AABM). (2016). Protocol # 11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from: http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf

Amir, L.H., James, J.P. & Donath, S.M. (2006). Reliability of the Hazelbaker assessment tool for lingual frenulum function. International Breastfeeding Journal, 1(3).

American Speech-Language-Hearing Association (2015). ICD-10-CM Diagnosis Codes for Audiology and Speech-Language Pathology Preparing for Implementation. Retrieved from: http://www.asha.org/Practice/reimbursement/coding/ICD-10/

Boyd, K. (2014). Impact of tongue-tie over a lifetime: an anthropological perspective. Presentation at the IATP 2nd World Summit. Montreal, Quebec.

de Castro Martinelli, R.L., Marchesan, I.Q., Gusmao, R.J., de Castro Rodrigues, A. & Berretin-Felix, G. (2014). Histological characteristics of altered human lingual frenulum. International Journal of Pediatrics and Child Health, 2, 5-9.

Ferres-Amat, E., Pastor-Vera, T., Ferres-Amat, E., Mareque-Bueno, J., Prats-Armengol, J. & Ferres-Padro, E. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Journal of Oral Medicine and Pathology, 1:21 (1):39-47

Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., Krishnaswami, S., Sathe, N.A. & McPheeters, M.L. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie. Comparative Effectiveness Reviews, No. 149. Agency for Healthcare Research and Quality. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK299120/.

International Affiliation of Tongue-Tie Professionals (2016). Classification. Retrieved from: http://tonguetieprofessionals.org/about/assessment/classification/

Kummer, A. (2016). To clip or not to clip? That’s the question. Presented at the annual convention of The American Speech-Language-Hearing Association. Philadelphia, PA.

Martinelli, R.L., Marchesan, I.Q., & Berretin-Felix, G. (2012). Lingual Frenulum Protocol with Scores for Infants. International Journal of Orofacial Myology, 38, 104-113.

Merdad, H. & Mascarenhas, A.K. (2010). Ankyloglossia may cause breastfeeding, tongue mobility, and speech difficulties, with inconclusive results on treatment choices. Journal of Evidence-Based Dental Practice, 10(3):152-3.

Messner, A.H. & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, 54(2):123-31.

Overland, L. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.

Sethi N., Smith D., Kortequee S., Ward V.M. & Clarke S. (2013). Benefits of frenulotomy in infants with ankyloglossia. International Journal of Pediatric Otorhinolaryngology, 77(5): 762-5.

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Tongue Ties and Speech Sound Disorders: What Are We Overlooking?

Posted by Deborah Grauzam on

“The conversation for tongue tie in the speech pathology community is growing louder among some groups of speech-language pathologists (SLPs) (ASHA Leader, 2015). An ASHA literature search has suggested a correlation between tongue ties and difficulty producing lingual alveolar phonemes (Merkel-Walsh & Jahn, 2014). Furthermore, Eschler, Klein, and Overby (2010) indicated that SLPs’ diagnostic criteria, treatment, goals, and discharge criteria for ankyloglossia differ depending on comorbid behavior (i.e., SSDs or feeding/swallowing difficulty).

Recently, there is a rise in the identification of posterior tongue ties in infants who are having trouble feeding and toddlers/adolescents who are exhibiting continuous speech sound errors despite years of speech-language pathology services. Posterior ankyloglossia is characterized by a thickened frenulum (Type III) or a submucosal frenulum visualized as a flat, broad mound absent of any typical protruding frenular tissue, and restricts movement at base of tongue (Type IV) (Kutlow, 2011).”

Meaux, A., Savage, M., & Gonsoulin, C. presented the poster “Tongue Ties and Speech Sound Disorders: What Are We Overlooking?” at the 2016 Annual ASHA Convention, November 17-19 in Philadelphia, PA.

View the full poster here

Authors: Ashley Meaux, PhD, CCC-SLP, Meghan Savage, PhD, CCC-SLP, & Courtney Gonsoulin, MA, CCC-SLP

TalkTools | Tongue Ties and Speech Sound Disorders

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Breastfeeding Improvement Following Tongue-Tie and Lip-Tie Release: A Prospective Cohort Study

Posted by Deborah Grauzam on

Bobak A. Ghaheri, MD; Melissa Cole, IBCLC; Sarah C. Fausel, BA; Maria Chuop, BS; Jess C. Mace, MPH, CCRP This article was published in The Laryngoscope, 00:000–000, 2016.

Objectives/Hypothesis

Numerous symptoms may arise that prevent mother-infant dyads from maintaining desired breastfeeding intervals. Investigations into treatments that positively influence breastfeeding outcomes allow for improved patient counseling for treatment decisions to optimize breastfeeding quality. This investigation aimed to determine the impact of surgical tongue-tie/lip-tie release on breastfeeding impairment.

Study Design

Prospective, cohort study from June 2014 to April 2015 in a private practice setting.

Methods

Study participants consisted of breastfeeding mother–infant (0–12 weeks of age) dyads with untreated ankyloglossia and/or tethered maxillary labial frenula who completed preoperative, 1 week, and 1 month postoperative surveys consisting of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), visual analog scale (VAS) for nipple pain severity, and the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R). Breastmilk intake was measured preoperatively and 1 week postoperatively.

Results

A total of 237 dyads were enrolled after self-electing laser lingual frenotomy and/or maxillary labial frenectomy. Isolated posterior tongue-tie was identified in 78% of infants. Significant postoperative improvements were reported between mean preoperative scores compared to 1 week and 1 month scores of the BSES-SF (F(2) 5 212.3; P < .001), the I-GERQ-R (F(2) 5 85.3; P < .001), and VAS pain scale (F(2) 5 259.8; P < .001). Average breastmilk intake improved 155% from 3.0 (2.9) to 4.9 (4.5) mL/min (P < .001).

Conclusions

Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes. Improvements occur early (1 week postoperatively) and continue to improve through 1 month postoperatively. Improvements were demonstrated in both infants with classic anterior tongue-tie and less obvious posterior tongue-tie. This study identifies a previously under-recognized patient population that may benefit from surgical intervention if abnormal breastfeeding symptoms exist.

Key Words

Breastfeeding, ankyloglossia, patient outcome assessment, outcome assessment (healthcare), visual analog scale, gastroesophageal reflux.

Level of Evidence

2c

Introduction

The rate of breastfeeding in the United States has been rising over the last 20 years with the increased emphasis on improved health outcomes in breastfed children and the recent impetus for hospitals to meet care standards established by the Baby Friendly Hospital Initiative. Previous research has demonstrated increased breastfeeding failure rate in mothers who intended to breastfeed in the hospital setting. The causes of breastfeeding cessation are multifactorial and include poor weight gain necessitating supplementation, poor latch, maternal nipple pain, and structural restrictions like ankyloglossia.

Ankyloglossia (either classic anterior tongue-tie or submucosal restriction) and a tethered superior labial frenum (upper lip-tie) cause altered latch and sucking mechanics. The suckling process is complex and multi-factorial, and dysfunction may cause diverse signs and symptoms in the breastfeeding dyad. Latch difficulties and suboptimal sucking mechanics may result in inefficient milk transfer, poor weight gain, low milk supply, nipple pain and trauma.

Recently, the Agency for Healthcare Research and Quality (AHRQ) evaluated the existing body of evidence regarding lingual frenotomy and maxillary labial frenectomy, concluding that the strength of outcomes-based evidence supporting those procedures was “generally low to insufficient.” The insufficient research quality is largely due to the lack of randomized controlled trials. Previous studies have examined the impact of lingual frenotomy on maternal pain, improvement in latch quality, and improvement of breastfeeding complaints. Some breastfeeding specialists have documented an improvement in maternal self-efficacy; this improvement in self-efficacy is an established predictor for continued breastfeeding. In children with reflux symptomatology, clinical improvement has been suggested following frenotomy. Due to the complex and multifactorial nature of infant reflux, and because of the lack of published studies trying to determine correlation between tongue-tie and reflux symptoms, further investigation is warranted.

To better elucidate treatment outcomes surrounding these procedures and to help address the AHRQ determination for higher level evidence, we designed a prospective cohort study aimed to test four hypotheses regarding tongue-tie/lip-tie release: 1) Surgical release will improve maternal breastfeeding self-efficacy. 2) Surgical release will improve maternal nipple pain. 3) The procedure will improve milk transfer rates following tongue-tie/lip-tie release. 4) The procedure will improve infant gastroesophageal reflux symptoms.

Read the full article here.

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