Problem-Solving: Twelve-Month-old with apparent tongue tie and poor chewing

Question:

I have a 12-month-old that just came in for an evaluation. Lactation consultant at birth reported tie. Mother reported pain while breastfeeding and inadequate suction. She decided not to have the tie cut. Fast forward to 12 months. They just started to introduce chewables about 1 month ago. I see lingual lateralization with emerging munching–it is inconsistent. He does not drink from a straw. He drinks water and whole milk from a spout. He coughs inconsistently when he drinks and it appears, he is not sipping then swallowing but holding liquid in his mouth—-does anyone have experience with tongue tie impacting the peristalsis movement of the tongue for drinking? Mother reported that during his time drinking from a bottle he did not ever cough.

I got a look at his tongue–it appears to be a posterior tie; however, it is hard for me to tell if this is truly what is impacting him. If peristalsis is impacted could that mean decreased laryngeal elevation? Besides recommendation to a dentist and ENT should I recommend a MBS?

Any input would be greatly appreciated!

 

Answer:

Tongue tie is indeed a controversial topic, not only for SLPs but also for our large ENT group, who do not even agree amongst themselves.

I was fortunate as a young pediatric SLP to take an 8-week NDT course (Neuro Developmental Treatment) that was primarily for OTs and Pts and focused on the kinesiology, motor-control and dynamic interrelated components of movement that produce the gross motor, fine motor and oral-motor synergies that underlie functional skills. It also taught us about compensatory motor patterns that can be created by muscular/structural restrictions to movement. It opened a while new world to me about the motor mapping and structural-muscular relationships that are the underpinnings for swallowing and feeding. That perspective has so enhanced my work in dysphagia over many years, and continues to do so, both related to theory, components of movement required, evolution of feeding/swallowing and looking at treatment of feeding/swallowing from a sensory-motor learning perspective.

My clinical experience across the pediatric age groups from neonates through teenagers strongly suggests that truly-tethered oral tissues can change those synergies and create the need for maladaptive/compensatory behaviors with feeding, adversely affecting breastfeeding, bottle-feeding, spoon-feeding, mastication of solids, cup-drinking, and straw drinking.

Amber, I wonder if the 12-month-old you described, who it sounds like was otherwise normally developing, may be having trouble with using the tongue tip and lateral borders of the tongue to move food to the molar ridge and keep it there for chewing and to manage liquid.

Depending on the location of a posterior tongue tie, it may create difficulty accessing the lateral borders of the tongue to assist with bolus control and transport. This can lead to compensations of humping of the back of the tongue or restricted tongue retraction that can adversely affect the swallow. Contraction of the lateral borders of the tongue is required for tongue retraction which is part of the swallow pathway that, yes, as you suggested, could indeed adversely affect pharyngeal peristalsis. There can be pooling of liquid on the surface of the tongue (flattened instead of having a central groove due to restricted “lift of the blade by tethering), creating the need to hold the bolus to avert spilling across the tongue blade into the lateral sulci. If there is a true posterior tongue tie, the muscle coordination with spoon feeding is likely also being affected, though may not be as readily obvious if he can “eat from a spoon.” Compensations during eating can result, including, for example, avoiding/refusing solids, multiple swallows to clear a bolus, ineffective suction with a straw, hard swallows to facilitate bolus transport, overstuffing to ”move food”, swallowing foods not fully masticated, or pocketing due to the inability to transport a bolus properly. Progression to more difficult solids such as meat will be challenging due to lack of disassociation of tongue and jaw movements because a munching pattern is all that is available.

A swallow study, interpreted thoughtfully specific to components of movement along the swallow pathway, can objectify the compensations adversely affecting function. I recently saw an otherwise normally developing 5-year-old referred for a swallow study due to “not chewing”. She had altered articulation (suspicious for tethered oral tissues based on its presentation), refusal of solids, poor cup and straw drinking. Her clinical examination, own history provided through my gentle questions and obvious restrictions in oral motor movements suggested upper lip, anterior tongue and posterior tongue ties. The subsequent instrumental assessment as requested by the MD suggested restrictions in movement that created many of the differences I described above. She was seen by a local pediatric dentist well known of specializing in this area of pediatric practice and had multiple releases. Much relearning was required with her community SLP to support learning of new oral-motor maps and synergies for functional skills. Just one example from many. That does not suggest that all such feeding problems use as examples above are due to ties, but we need to thoughtfully complete a through differential with each infant or child or adolescent, and continue asking questions both during sessions and after, with each other.

My Pediatric PTs colleagues love talking about tethered oral tissues, since they bring such clear understanding of motor synergies and structural-muscular relationships that adversely affect function. Sometimes they say it can affect function quite obviously and at other times, in a more subtle way that alters quality of movement, and affects motor learning going forward, affecting future skills. Might this be applicable to eating and drinking, as it evolves and progresses through motor learning and experience? My thought is yes.

I hope this is helpful.

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