Tongue-Tie: A complex issue requiring careful assessment

Tongue-Tie: A complex issue requiring careful assessment

ByLondon Speech and Feeding

Tongue-tie, or ankyloglossia, is a condition where the lingual frenulum, the thin piece of tissue that connects the underside of the tongue to the floor of the mouth, is too short or tight. Tongue-tie is quite common in babies and is often not detected after birth. Tongue-tie can lead to a difficult start with breast feeding as it makes it very difficult for the baby to latch effectively.

In my clinical experience as a feeding therapist, I have seen many babies who were not able to latch well due to the frenulum being tight. In many cases an experienced feeding speech therapist/lactation consultant can really make a difference and help a new mum to latch the baby even though the tongue is tethered to the floor of the baby’s mouth. In some cases the frenulum can be divided and once this has been done, in some cases, feeding improves immediately or soon after the division. But this is not always the case. I have seen several babies who have had as many as four tongue-tie divisions and feeding was still difficult.

It is important to say that while tongue-tie can sometimes impact speech and feeding, it’s important to note that it’s not always the root cause of these difficulties. In recent years, there has been a surge of interest in tongue-tie division surgeries, with some cases being unnecessary. It’s crucial to understand the complexities of tongue-tie and the role of speech therapy in addressing related challenges.

The impact of tongue-tie on speech and feeding

When tongue-tie is severe, it can interfere with the tongue’s ability to move freely, affecting speech production and swallowing. Some common speech and feeding difficulties associated with tongue-tie include:

  • Feeding difficulties: Challenges with sucking, chewing, and swallowing.
  • Drooling: Excessive drooling due to difficulty controlling saliva.
  • Speech problems: Difficulty producing certain sounds, such as /l/, /r/, /t/, /s/ and /d/.

The importance of comprehensive assessment

Before considering any surgical intervention for tongue-tie, it’s essential to undergo a thorough evaluation by a qualified speech-language therapist (SLT). An SLT can assess the severity of the tongue-tie, its impact on speech and feeding, and determine if surgery is necessary.

  • Functional assessment: The SLT will assess the tongue’s range of motion, its impact on speech sounds, and the child’s overall oral motor skills.
  • Feeding evaluation: The SLT will observe the child’s feeding patterns and identify any difficulties related to tongue-tie.
  • Differential diagnosis: The SLT will rule out other potential causes of speech and feeding difficulties, such as apraxia of speech, dysarthria, or sensory processing disorders.

The role of speech therapy

Even in cases where tongue-tie is present, speech therapy can often be highly effective in addressing speech and feeding difficulties. Here’s how speech therapy can help:

  • Articulation therapy: Targeting specific speech sounds that may be affected by tongue-tie.
  • Childhood Apraxia of Speech (CAS): if the diagnosis by the SLT has shown that in fact the child has motor planning difficulties then there are very specific and effective treatment programmes that help with this and can make a real difference over time.
  • Feeding therapy: Strategies to improve swallowing, chewing, and oral-motor skills.
  • Sensory integration: Addressing underlying sensory processing issues that may contribute to feeding difficulties.

London Speech and Feeding Case Study: The importance of comprehensive assessment

One of my clients was initially diagnosed with tongue-tie and recommended for surgery at the age of eight years old. His speech had been perceived by parents and teachers as ‘mumbled and unclear’.

However, after a thorough evaluation, I was able to determine that the child’s primary issue was apraxia of speech, a neurological disorder that affects motor planning for speech. Parents decided to wait with surgery and trust my judgment and we proceeded with weekly intensive speech therapy to address motor planning difficulties around tricky sounds and words. I am delighted to say that the child’s speech has improved significantly, demonstrating the importance of comprehensive assessment and individualised treatment. He is no longer seen as a candidate for an operation, which would have been traumatic for him at his age and, as it turned out, entirely unnecessary.

Below is a short video clip of my working on the /l/ sound with this child.

Using the Gingo Puppet from GingoTalk

Conclusion

Tongue-tie is a complex issue that requires careful evaluation and individualised treatment. While surgery may certainly be necessary in some cases, it’s essential to consider the potential benefits and risks. Speech therapy can be a highly effective approach for addressing speech and feeding difficulties associated with tongue-tie, even in cases where surgery is still required. By working with a qualified speech-language therapist, parents can ensure that their child receives the best possible care and support.

Please feel free to contact me.

Sonja McGeachie

Early Intervention Speech and Language Therapist

Feeding and Dysphagia (Swallowing) Specialist The London Speech and Feeding Practice

The London Speech and Feeding Practice

Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

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Speech prompts and strategies I use in Speech Sound Therapy
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Speech prompts and strategies I use in Speech Sound Therapy

ByLondon Speech and Feeding

This particular student has a mild motor planning difficulty and six weeks ago he came to me with a very strong lisp. In addition to the lisp he is struggling to produce a number of sounds, SH and L on its own and all the clusters (FL/BL/KL/PL) but also CH together with some vowel difficulties.

The prompts are a mix partially from the DTTC (Dynamic Temporal and Tactile Cueing) model by Dr Edythe Strand as well as phonological models I have learned over the years, and some of them are my own.

Visual/picture prompts and Images

Here I use the ‘Flat Tyre’ Sound, to offer as an image for a new S sound and the ‘Tick Tock’ Sound for a new image of the T sound. Both cards are from the Bjorem Speech Sound Deck, which I love and use almost daily.

Gestural Cues

I like to use all the ‘cued articulation’ hand cues by Jane Passy for consonants and fricatives. Here we use our fingers and hand to illustrate what our tongue does, and we also show whether a sound is voiced or voiceless. When I use one finger it is voiceless (k/f/s/p) and when I use two fingers for the same cue it means that the voice needs to be turned on: (g/v/z/b/n/m). For vowels I like to use Pam Marshalla’s cue system.

Simultaneous production

We say the word together.

Direct imitation

I say the word and my student copies me directly.

Imitation after a delay

I say the word and then after a little wait my student says the word.

Spontaneous production

My student has now learned to say the word by him/herself.

Offering feedback

It sounds like… I just heard… I didn’t hear the first sound there? Can you try again?

Letting the student reflect

By just shaking my head or by looking quizzical so that my student realises something didn’t quite go right.

Postitive reinforcement

‘Yes that was it, do it again, nice one…’

Cognitive reframing

This is a technique where we identify different semantic cues and metaphors or imagery cues, so instead of teaching or focusing on a sound we try out viewing each syllable from a different point of view.

For example: ‘yellow’. I have had great success with this one: we start with just saying ‘yeah yeah yeah’. I might make a little joke and say something like ‘imagine your mum says tidy your bedroom, what do you say or what do you think?’ Answer: ‘yeah yeah yeah’. Then we practice ‘low’ together, I might blow some bubbles high and low and we talk about ‘low’. And then we put ‘Yeah’ and ‘Low’ together and now we have YELLOW!! It might at first still sound a bit odd, like ‘yea-low’ but we soon shape that up and have the real word.

Each student is different and having a great rapport is crucial to our success.

Then a little game break after some 7–10 or so repetitions and always trying to finish on a positive note.

What game breaks do I use:

Very quick ones! Students can post something, place a counter in a game, take out a Jenga block from the tower, pop in a counter for ‘connect 4’, stick a sword into the Pop the Pirate barrel or add a couple of Lego blocks to something they are building.

I hope this is helpful, please contact me for any questions.

Sonja McGeachie

Early Intervention Speech and Language Therapist

Feeding and Dysphagia (Swallowing) Specialist The London Speech and Feeding Practice

The London Speech and Feeding Practice

Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

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