SLP'S Role in Post-Frenectomy Care for Children Who Present with Feeding Challenges
Ankyloglossia is not a newly discovered condition, and about 3% of infants are born with a tongue-tie (Amir, James, & Donath, 2006), though new research suggests this number may be higher, after 32.54% of 1,715 infants were found to have posterior tongue-tie after a specialized maneuver for inspection (Martinelli, Marchesan & Berretin-Felix, 2018). Ankyloglossia is an embryological piece of tissue present at birth that restricts the tongue's range of motion. Tongue-tie can also affect the way a child eats, speaks and swallows (Mayo Clinic, 2016; IATP, 2016). The role of the speech-language pathologist is important in children who present with ankyloglossia due to the possible impact on feeding skills.
There are implications that ankyloglossia may impact breast feeding, and bolus motility. The American Academy of Pediatrics has taken the stance that ankyloglossia should be considered in cases of problematic breastfeeding (Coryllos, Genna, & Salloum, 2004). In a clinical study, lactation consultations, otolaryngologists, speech pathologists and pediatricians were surveyed on their beliefs regarding the impact of ankyloglossia on feeding. Sixty nine percent of lactation consultants, but a minority of physician respondents, believe tongue-tie is frequently associated with oral feeding problems (Messner & Lalakea, 2000). In another study in 2012 showed that 80.4% of mothers strongly believed frenectomy benefited their child's ability to breastfeed, and 82.9% of mothers were able to initiate/resume breastfeeding after the procedure was performed (Steehler, Steehler & Harley, 2012).
There are studies that indicate lactation counseling and consulting is critical with breastfeeding challenges of tongue-tied infants (AABM, 2016; Genna, 2002); however, not all cases of ankyloglossia are identified in the breastfeeding year(s). SLP’s roles are sometimes dismissed, especially when physicians imply that an International Board Certified Lactation Consultant® (IBCLC®) should be the primary specialist performing pre/post up care with ankyloglossia patients (Ghaheri, 2017). While this may be appropriate for breastfeeding, physicians must also consider that some children are experiencing feeding challenges with bottle, spoon, cup, straw and solid feedings. In a recent ASHA Leader Blog, Melanie Potock described specific complications of feeding with ankyloglossia including: oral sensitivity secondary to limited stimulation/mobility of tongue, gagging and subsequent vomiting when food gets stuck on tongue and excessive use of the lower lip (Potock, 2015).
Here is an example of how TOTs may impact breastfeeding:
(click here to see this chart larger)
While the literature mainly focuses on breastfeeding, ankyloglossia teams including lactation consultants, registered dental hygienists, speech-language pathologists, occupational therapists and oral surgeons are reporting clinical evidence that feeding issues are evident (Siegel, Calasuma, Emanuel, Fabbie, Watson-Genna, Merkel-Walsh & Overland, 2017). Since not all cases of ankyloglossia are diagnosed in infancy, SLPs may meet toddlers and older children who have feeding challenges stemming from a lingual restriction and a thorough assessment of structure and function is needed followed by pre and post-operative neuromuscular re-education (Merkel-Walsh & Overland, 2018).
Examples of how TOTs impacts solid feedings are as follows:
(click here to see this chart larger)
Frenectomy experts such as Dr. Ghaheri (2017) and Dr. Kotlow (2006) have long discussed the importance of post-surgical aftercare. Recently, a study involving 101 cases of tongue-tie revealed that with the surgical technique of frenectomy, the patients had improved lingual mobility when reinforced with rehabilitation exercises (Ferres-Amat, Pastor-Vera, Ferres-Amat, Mareque-Bueno, Prats-Armengol & Ferres-Padro, 2016). Stretches both before and after surgery are needed to establish muscle movement and the placement of the tongue (Pine, 2018).
The ASHA Scope of Practice informs us that SLP’s role includes conducting a comprehensive assessment, including clinical and instrumental evaluation; identifying normal and abnormal swallowing anatomy and physiology; and identifying signs of possible or potential disorders in the upper aerodigestive tract (ASHA, 2016). The SLP’s scope also includes orofacial myofunctional disorders including oral anomalies (e.g., cleft lip/palate, dental malocclusion, macroglossia, oral-motor dysfunction, etc. (ASHA, 2016). This certainly includes ankyloglossia. Merkel-Walsh & Overland (2017) discussed that the SLP’s role in the assessment and treatment of ankyloglossia, considers not only the structure, but the impact on function in regards to feeding and speech. Assessment should consider pre-feeding and feeding skills that are impacted by the lingual restriction (Boshart, 2015; Merkel-Walsh & Overland, 2018). These noted deficits then become targeted goals of a pre/post-operative program to support the necessary oral motor skills for a safe and effective, nutritive feeding (Bahr, 2010; Morris & Klein, 2000; Overland & Merkel-Walsh 2013).
In conclusion the SLP’s role in feeding disorders that are subsequent to ankyloglossia are not clearly defined in level one research studies (Merdad & Mascarenhas, 2013); however clinical evidence and emergent studies are evolving. The ASHA Scope of Practice defines the SLP’s role in structural anomalies, oral motor and feeding deficits which are observed in ankyloglossia. SLPs must advocate for their role in providing services for those children who present with feeding challenges secondary to ankyloglossia that are beyond the stage of breastfeeding. Pre- and post- op neuromuscular re-education is critical for positive prognosis post-frenectomy.
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
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.
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).
Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development! Arlington, TX: Sensory World.
Boshart, C. (2015). Demystifying the Tongue Tie. Ellijay, GA: Speech Dynamics.
Coryllos, E., Genna, C.W. & Salloum, A.C. (2004). Congenital tongue-tie and its impact on breastfeeding. American Academy of Pediatrics. Retrieved from: https://www2.aap.org/breastfeeding/files/pdf/BBM-8-27%20Newsletter.pdf
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
Genna, C.W. (2002). Tongue tie and breastfeeding. Leaven, 38(2): 27-29.
Ghaheri, B. (2017). Aftercare. Retrieved from: http://www.drghaheri.com/aftercare/.
International Affiliation of Tongue-Tie Professionals (2016). Classification. Retrieved from: http://tonguetieprofessionals.org/about/assessment/classification/
Kotlow, L. (2006). Preventive Pediatric Dental Care. Retrieved from: https://www.kiddsteeth.com/assets/pdfs/articles/Maxillary%20Frenectomy2006adobenews.pdf
Martinelli,R., Marchesan, I. & Berretin-Felix,G. (2018). Posterior lingual frenulum in infants: occurrence and maneuver for visual inspection. Revista CEFAC, 20(4):478-483.
Mayo Clinic (2016). Diseases and conditions: tongue-tie (Ankyloglossia). Retrieved from: http://www.mayoclinic.org/diseases-conditions/tongue-tie/basics/definition/CON-20035410
Merdad H. & Mascarenhas, A.K. (2013). 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.
Merkel-Walsh, R. & Overland, L.L. (2018). The Functional Assessment and Remediation of Tethered oral Tissues. Charleston, SC: TalkTools.
Merkel-Walsh , R. & Overland L. (2017) Functional assessment of feeding challenges in children with a diagnosis of ankyloglossia. Poster presentation at The American Speech and Hearing Association, Los Angeles, CA.
Messner, A.H. & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolayryngology, 54(2):123-31.
Morris, S. & Klein, M. (2000). Pre-feeding skills (2nd Ed). San Antonio TX: Therapy Skill Builders.
Overland, L. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.
Pine, P. (2018). Please Release Me: The Tethered Oral Tissue Puzzle. NY, NY: MiniBuk.
Potock, M. (2015). Tip back that tongue! The posterior tongue tie and feeding challenges. The Asha Leader Blog. Retrieved From: https://blog.asha.org/2015/05/26/tip-back-that-tongue/
Siegel,S., Calasuma,N., Emanuel, M., Fabbie,P. , Watson-Genna,C., Merkel-Walsh, R. & Overland, L. (2017). Connecting the Dots in TOTs. Oral Presentation, NY, NY.
Steehler, M.W., Steehler, M.K. & Harley, E.H.(2012). A retrospective review of frenectomy in infants with feeding difficulties. Int J Pediatr Otohingolaryngeal, 76(9):1236-40.