"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


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.


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


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).


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.

#ASHA17 American Speech–Language–Hearing Association ankyloglossia ASHA convention ASHA poster Lori Overland Oral Placement Therapy Robyn Merkel-Walsh tethered oral tissue Tethering of Oral Tissues tongue tie TOT TOTs

← Older Post Newer Post →

Leave a comment

Please note, comments must be approved before they are published