Posted by Casey Roy on
The 2018 ASHA Convention was held last week in Boston, MA. The TalkTools team had such an amazing time meeting new people, catching up with old friends, and most importantly - teaching about Oral Placement Therapy.
This year at ASHA, we celebrated the launch of our newest book, Functional Assessment and Remediation of TOTs (Tethered Oral Tissues), co-authored by Robyn Merkel-Walsh, MA, CCC-SLP and Lori Overland, MS, CCC-SLP, C/NDT, CLC.
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-SLP & Lori Overland, MS, CCC-SLP, C/NDT, CLC
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).
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).
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.
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.
Posted by Deborah Grauzam on
The Oral Motor Institute has recently published a new monograph by TalkTools® Instructors Robyn Merkel-Walsh MA, CCC-SLP and Lori L. Overland MS, CCC-SLP/NDT-C.
"SELF-LIMITED DIETS IN CHILDREN WITH A DIAGNOSIS OF AUTISM SPECTRUM DISORDERS"
ABSTRACT
The CDC (2014) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. They also indicate that in “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Children with ASD often present with comorbid feeding issues. Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of all published, peer-reviewed research relating to feeding problems and autism. Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with autism (Korschun & Edwards, 2013).
Researchers are exploring the possible causes of ASD, but thus far there are many theories regarding this complex disorder, ranging from genetics to autoimmune dysregulation (Merkel-Walsh, 2012). There is also debate regarding methods of treatment for children with autism. Applied Behavioral Analysis (ABA) has the most empirical research to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Autism Speaks, 2014). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health. (Iovannone, Dunlap, Huber, & Kincaid , 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD.
PURPOSE
This article explores 1) the sensory-motor system as it relates to feeding, 2) the importance of a thorough assessment; 3) biomedical treatment approaches for children with ASD, 4) Applied Behavioral Analysis (ABA) and its’ relevance when treating sensory-motor based feeding disorders in children with ASD.
METHOD
Numerous texts, journal articles, print articles, internet articles and clinical presentations were reviewed in order to collect information on the etiology, treatment and outcomes of feeding therapy for self-limited diets with children on the autism spectrum, who have comorbid feeding issues. The authors explored current research in speech - language pathology, biomedical and holistic medicine, nutrition, and Applied Behavioral Analysis (ABA). The authors also looked at case studies and the factors that may have influenced the diets of three children with ASD, who seemingly had behavioral issues, but when assessed presented with structural, medical and /or sensory-motor issues.
RESULTS
The authors found that self-limited diets are often not purely behavioral in nature, and there is a future need for more peer reviewed research on this topic.
[...]
Read the full monograph here.
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Robyn Merkel-Walsh, MA, CCC-SLP has specialized for over 21 years in Oral Placement and myofunctional disorders in children. She is employed by the Ridgefield Board of Education, runs a private practice in Ridgefield, NJ, is the board chair of the Oral Motor Institute, and is a member of the TalkTools® speakers bureau.
Meet her in Washington, DC May 14, 2016, in Syracuse, NY June 4, 2016, in Minneapolis, MN July 8-10, 2016. See our full Event Calendar here.
Lori Overland, MS, CCC-SLP is a speech and language pathologist with more than 35 years of professional experience. She specializes in dealing with the unique needs of infants, toddlers, pre-schoolers and school-aged children with oral sensory-motor, feeding and oral placement/speech disorders. In addition to her private practice, Lori is a member of the TalkTools® speakers bureau.
Posted by Deborah Grauzam on
Follow the link below to read 5 of 2014's best blog posts on feeding. Topics range from "stepping away from the Sippy Cup" to the "Medical Side of Pediatric Feeding."
Pediatric Feeding Tops the Charts: Five Top Blog Posts from 2014
Interested in learning more about Feeding Therapy? Keep an eye on our workshop schedule for one of Lori Overland's "Feeding Therapy: A Sensory Motor Approach" classes or watch it on-demand here. This informative course will walk you through therapeutic techniques that you can use the next day. Enabling your clients to tolerate sensory feedback from temperatures, textures, and tastes. 
Posted by Deborah Grauzam on
A Sensory-Motor Approach to Feeding, Lori Overland, M.S., CCC/SLP
In this paper published by ASHA Perspectives on Swallowing and Swallowing Disorders (Dysphagia), Lori explores the oral phase of feeding and how SLP's can help child develop motor plans for safe nutritive feedings.
What other parts of this paper do you think are important in a Sensory-Motor Approach to Feeding?
