How Do You Know When it’s a Language Delay Versus a Disorder?

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Editor’s Note: This is an excerpt from a blog post that originally appeared on Special Education Guide. 

How do you know when it’s a language delay versus a disorder?

Unfortunately, there is not always a straightforward answer to this question. A language delay is just that—a delay in acquisition of language skills compared to one’s chronological and cognitive/intellectual age-peers. A young child with a language delay may exhibit a slower onset of a language skill, rate of progression through the acquisition process, sequence in which the language skills are learned, or all of the above.

However, there is a subset of children who continue to demonstrate persistent difficulties acquiring and using language skills below chronological age expectations (by preschool or school age) that cannot be explained by other factors (for example, low nonverbal intelligence, sensory impairments or autism spectrum disorder) and may be identified as having a specific language impairment (language disorder).

In contrast to a delay or a disorder is a language difference. With a language difference, communication behaviors meet the norms of the primary speech community but do not meet the norms of Standard English. This difference can exist whether the person in question is a child from a different country or simply from a different neighborhood in the same city.

So, what are some options for addressing language delays and disorders?

Intervention for a delay may take on several forms:

  • Indirect treatment and monitoring
    • Provide activities for parents and caregivers to engage in with the child, such as book-sharing and parent-child interaction groups.
    • Check in with the family periodically to monitor language development.
  • Direct intervention, including techniques such as:
    • Expansions—repeating the child’s utterance and adding grammatical and semantic detail.
    • Recasts—changing the mode or voice of the child’s original utterance (for example, declarative to interrogative).
    • Build-ups and breakdowns—the child’s utterance is expanded (built up) and then broken down into grammatical components (break down) and then built up again into its expanded form.

Intervention for a language disorder is child specific and based on that child’s current level of language functioning, profile of strengths and weaknesses, and functioning in related areas, including hearing, cognitive level and speech production skills. The overall goal of intervention is to stimulate language development and teach skills to enhance communication and access academic content. The developmental appropriateness and potential effectiveness on communication and academic and social success should be considered when developing treatment goals.

 

Aruna Hari Prasad, MA, CCC-SLP, is ASHA associate director of school services.  ahariprasad@asha.org

10 Early Signs and Symptoms of Childhood Apraxia of Speech

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I was a practicing speech-language pathologist for five years before my daughter was born. I worked primarily at the elementary and middle-school levels. I took professional development workshops on childhood apraxia of speech (CAS) and treated it successfully in three kiddos from my caseload. Perhaps that’s why I was bewildered, angry and utterly devastated when I missed those very signs in my own child.

I hadn’t yet worked in early intervention, so I missed what seem like obvious signs to me now that I specialize in the disorder. I urge all SLPs to learn more about CAS, because the disorder requires a specialized approach different from other commonly used treatments for speech and language delays.

In addition, ASHA denotes that the qualified professional to diagnose CAS is an SLP with specialized knowledge in motor learning theory and skills with differential diagnosis in childhood motor speech disorder, not a neurologist or other medical practitioner. It’s important to know the signs, but also to refer your client to a qualified SLP for differential diagnosis if you suspect childhood apraxia of speech.

Here are 10 early signs and symptoms of childhood apraxia of speech:

  • Limited babbling, or variation within babbling
  • Limited phonetic diversity
  • Inconsistent errors
  • Increased errors or difficulty with longer or more complex syllable and word shapes
  • Omissions, particularly in word initial syllable shapes
  • Vowel errors/distortions
  • Excessive, equal stress
  • Loss of previously produced words
  • More difficulty with volitional versus automatic speech responses
  • Predominant use of simple syllable shapes

Other non-speech “soft signs” that may be present include:

  • Impaired volitional oral movements (oral apraxia)
    • Difficulty with volitional “smiling” “kissing” “puckering”
  • Delays with fine/gross motor skills
  • Feeding difficulties that include choking and/or poor manipulation of food
  • General awkwardness or clumsiness

These are early signs, but many overlap with other phonologic and language delays, so it’s important to keep in mind that differential diagnosis is critical, as over-diagnosis of CAS remains problematic. It’s still a relatively rare disorder; however, there are resources that can help if you suspect it.

You can tap the below resources to learn more about childhood apraxia of speech.

 

Laura Smith, MA, CCC-SLP, is a school-based and private clinician in the Denver metro area specializing in childhood apraxia of speech. She’s CASANA-certified for advanced training and clinical expertise in Childhood Apraxia of Speech and often speaks at conferences and consults for school districts or other professionals. Like her on Facebook, follow her on Pinterest, or visit her website at SLPMommyofApraxia.comlauraslpmommy@gmail.com

 

 

 

 

 

Interprofessional Pre-screening Shortens the Wait for Autism Diagnoses

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Editor’s Note: In recognition of Autism Awareness Month, we have several posts addressing autism-related issues throughout April. The screening program described here is one of several ASD initiatives at Wichita State University; another that eases children’s visits to the dentist is explored in this month’s April ASHA Leader issue.

 

Recently, I became passionate about expediting identification and diagnosis for young children who show signs and symptoms of autism spectrum disorder (ASD). This desire was fueled by a research project I conducted with Douglas F. Parham and Jagadeesh Rajagopalan; the results revealed that pediatricians and family physicians have not been screening young children for ASD as recommended by the American Academy of Pediatrics (regularly conducting ASD-specific screenings for children two times prior to their second birthday) in Kansas, Iowa and Oklahoma.

Based on these results, I determined that one way I could help advance the identification of these young children would be to develop an authentic interprofessional education opportunity for students in the allied-health and education programs at my university: Wichita State University in Kansas. In the spring of 2012, WSU students, faculty and community professionals agreed to form the Wichita State University-Community Partners: Autism Interdisciplinary Diagnostic Team (AIDT).

The team aims to:

  1. Educate undergraduate and graduate students to better recognize the characteristics of ASD and to be able to participate in screening, assessment and referral of children who demonstrate early signs.
  2. Provide a highly needed service to children and families throughout south-central Kansas.

Since the initiation of this team, faculty, clinical educators and students from eight departments—communication sciences and disorders (audiology and speech-language pathology), early childhood unified special education, clinical psychology, physical therapy, dental hygiene, physician assistant, nursing and public health—have participated. Additionally, the University of Kansas School of Medicine–Wichita (represented by a developmental pediatrician and an advanced practice registered nurse) has been a valued partner and referral source.

Faculty and clinical educators recruit and select students to participate in our screening program. Student participants must enroll in a field-based experience and/or an appropriate class within their respective programs. All stakeholders then do a one-day training prior to the start of each semester on identifying the characteristics of ASD, to screen, to participate in the assessment process and to identify appropriate referrals for children and families. The educators agree to participate in at least four diagnostic sessions each semester, ensuring that students from various professions have multiple opportunities to work together, while observing interprofessional collaboration among university and community professionals.

The partnering developmental pediatrician and the advanced practice registered nurse refer children and families to the screening program based on the “red flag” characteristics parents report on the pediatrician’s developmental history form. The program’s coordinator (that’s me) contacts the family via phone to gather additional developmental information, and then the team meets to discuss that information and other relevant documents.

The team conducts the evaluation over two days. The first day, we assess the child’s communication, play and cognitive abilities, using selected tools and strategies based on the child’s strengths and needs. The second day, we administer the Autism Diagnostic Observation Schedule-2 and the Childhood Autism Rating Scale-Second Edition, Standard Version, to provide the developmental pediatrician with diagnosis-relevant information. We also conduct hearing, motor and oral health screenings. The team then meets to discuss the aggregated assessment results, which, in addition to appropriate recommendations and resources, are shared with the family.

We schedule an appointment for the child and family with the developmental pediatrician approximately one week following our assessment. Someone from our team accompanies the family to the appointment to act as a liaison and assist with the examination.

Since the introduction of the AIDT, 133 students, clinical educators, faculty and community professionals across 10 disciplines have come together via this individualized education program field-based experience. Our students and professionals have assessed 24 young children who present with characteristics of ASD, and approximately 85 percent of these children have received a confirming medical diagnosis.

Participants and families alike gain from this experience. Students learn from, with and among others who are committed to interprofessional practice. Families voice their appreciation for receiving diagnostic information from multiple disciplines all at once, so they don’t have to run from place to place to receive it.

Mostly, they value how quickly the AIDT’s work enables them to get their child needed help.

 

Trisha Self, PhD, CCC-SLP, is an associate professor in the Department of Communication Sciences and Disorders at Wichita State University and coordinator of the school’s Community Partners: Autism Interdisciplinary Diagnostic Team. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 10, Issues in Higher Education.
Trisha.Self@wichita.edu 

Top 10 Lessons I Learned from Loving Kids with Autism

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Editor’s Note: Today is World Autism Awareness Day, so we have a special post to celebrate the wonders that people with this unique perspective bring to the world. Read more about autism in this month’s April ASHA Leader issue devoted to the topic, which includes articles on the importance of helping people with ASD predict what happens next and how to measure clients’ progress in social skills groups.

 

If you’ve had the good fortune of loving kids with autism, you’ve probably encountered a few unexpected lessons in life.  In honor of National Autism Awareness Month and to express my gratitude for what my friends with autism spectrum disorder have taught me, I’d like to share my Top 10:

#10. In a world of too many gadgets and gizmos, a spinning top is pretty cool.

#9. Echolalia keeps my “over 40” brain sharp. I’ve learned to repeat, repeat, repeat.

#8. Parents with patience are the best teachers.

#7. Consistency is so comforting.

#6. Random objects can bring one kid a lot of joy. I’ve learned to appreciate road maps, bathroom signs and every single state’s license plates, to name just a few.

#5. Sometimes, carrying a favorite toy all day long just makes everything go better.

#4. Flapping really does feel good.

#3. The world needs more quirky.

#2. The first spontaneous “hug” is the best one of all.

And the #1 lesson I learned from my clients with autism?

#1. Love is when you take the time to know someone who sees the world differently than you.

 

What lessons have you learned from loving kids with autism? I’d love to know. Let’s start a list here to celebrate and raise awareness of all that the world can learn from these extraordinary, beautiful people.

 

Melanie Potock, MA, CCC-SLPtreats children, birth to teens, who have difficulty eating. She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids, and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Potock’s two-day course on pediatric feeding is offered for ASHA CEUs.  Melanie@mymunchbug.com  

 

 

A Voice Lift? Is It Really Necessary?

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It’s an image-driven world in which we live. Instagram, Facebook, SnapChat, Twitter and YouTube launch llamas and two-toned dresses into stardom. We are also definitely not interested in showing our age. Botox and cosmetic surgeries work wonders for our outward appearance. But what is a person to expect as the larynx ages? Is a voice lift out of the plausible realm?

Some presbyphonia is present in many clients I see. As the male vocal folds lose mass, they bow outward and voice quality becomes breathy and high-pitched. The voice becomes lower in pitch as the female ages. This happens because muscle fibers do not regenerate as quickly when we get older, so the vocal folds begin to atrophy. The lamina propria (second layer of the vocal folds) is not as flexible and fibers tend to break down.

Three subsystems of the voice need to be in balance to have a fully functioning mechanism: breath, sound and resonance. When we age, lung tissues lose elasticity and rib-cage cartilages begin to ossify. Ossification also affects cartilages of the larynx. This is not always bad, as vocal scientist Ingo Titze suggests, because this hardening can help stabilize the voice box as it anchors the acrobatic muscles for speech or singing. A thoughtful article by Claudia Friedlander discusses this in further detail, as does this post from Gray Matter Therapy.

It’s helpful to think about our voices and how they differ because of gender. The female voice is affected by androgens, estrogen and progesterone. Wendy D. LeBorgne and Marci Rosenberg report in their book, “The Vocal Athlete,” that during menopause, low levels of estrogen cause the once thick mucosal membrane of the vocal folds to lose mass and flexibility. Progesterone has been shown to help shed cells off the vocal fold mucus membranes. Prior to menstruation, secretions and mucus on the vocal folds thicken, the larynx dries out, the voice becomes less agile and range may be affected. Hemorrhage risk and swelling is great at this time because capillaries change how they transport blood. Robert Sataloff has said in a NATS Chat recently, that the vocal fold swelling is protein-bound and cannot be shed by diuretics.

All of this happens because hormones are running rampant. A cure? Possibly regulation by birth-control medications, because they balance out those hormones. As menopause hits, hormones tend to disappear, and with them the qualities that made the voice sound female in the first place. Vocal folds thicken, epithelium atrophies, vocal fold nerve connections demyelinate. This might explain why vibrato slows as well.

What about the men? They start off with high-pitched voices, but when change occurs at puberty, pitch lowers with the presence of androgens. Booming male voices are the result of increased blood flow to the voice box. As with women, male hormones decrease with age, so power and tone go with them.

Presbylaryngis is an age-related voice issue caused by nature taking its course, but that doesn’t mean it can’t adversely affect quality of life. Voice pathologists do their best to rehabilitate with vocal function exercises and other treatment techniques. Sataloff says that 80 percent of the time this is sufficient. A surgical option is injection laryngoplasty, often coined the “voice lift.” The procedure consists of fat grafting, injectables or implants, and its necessity is controversial. Do people really need a rejuvenated voice? With an increase in hearing loss as we age, I can see why it’s popular.

 

Read about behavioral voice lifts. 

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech treatment in her private practice, a tempo Voice Center, LLC, and lectures on the singing voice to area choirs and students. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. Knickerbocker blogs on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.

Want to Work in Acute Care Pediatrics? 5 Traits for Success

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It’s hard to believe I’ve been an SLP for 38 years! For most of that time, I’ve worked in an acute-care pediatric setting. I’m employed at the Florida Hospital for Children in Orlando, where I provide pediatric/neonatal swallowing and feeding services for multiple acute-care services, including neonatal intensive care, pediatric intensive care, newborn nursery, general pediatrics, oncology, epilepsy, ears, nose and throat, gastrointestinal, congenital heart surgery, plastics, and extracorporeal membrane oxygenation. Thinking on my feet, but carefully considering both the evidence base and interdisciplinary perspectives, is a must every day.

Sometimes people ask me: What are you passionate about? What drives you?

I am passionate about the neonatal intensive care unit and our tiny patients. Being a part of this wonderful team and fostering the parent-infant relationship through supporting safe and successful feeding continues to fill my heart with joy after all these years. I am a lifelong learner and am passionate about creating opportunities to learn from physicians, nurses, respiratory therapists, my rehab colleagues and the families I serve.

Are you interested in working with these tiny and fragile patients? If so, here are some questions to ask yourself:

  1. Do you like to solve a puzzle? Problem-solving is essential in acute care! Critically thinking about a patient’s medical history and co-morbidities, then looking at the data and making sense of the information is key. Is the infant/child safe to feed? If so, what is the best approach? How can the child best communicate? What is interfering?
  2. Are you passionate about evidence-based practice? Physicians want to know why you are recommending what you are and what evidence there is to back it up. Sometimes the highest level of evidence is our clinical experience and wisdom. But we need to be aware of what hard evidence exists and bring it to the physicians.
  3. Do you work best in a team setting? Looking at the critically ill child works best in the context of multiple perspectives. Physician specialists, bedside nursing, respiratory therapists, dieticians and our rehab colleagues bring information that helps us make better clinical decisions. Through team interactions, we jointly problem-solve.
  4. Do change and unpredictability give you a buzz? Some days we need rollerskates! The day can change quickly with new consults, children being discharged, and changes in the patients we are treating. Being ready for change and staying focused are key to riding the wave.
  5. Are you well-grounded in normal and atypical development? This knowledge allows us to problem-solve and recognize what symptoms deserve our focus. Experience in birth-to-3 is invaluable for preparing to become a pediatric acute-care SLP.

Do the traits above sound like you? If you are thinking about moving into acute-care pediatrics, stay tuned for more to guide you on your journey!

 

Catherine S. Shaker, MS, CCC-SLP, BCS-S, works in acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. She offers seminars on a variety of neonatal/pediatric swallowing/feeding topics across the country. Follow her at www.Shaker4SwallowingandFeeding.com or email her at pediatricseminars@gmail.com.

 

An SLPA Eases a School SLP’s Load

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With only two years in the profession as a certified speech-language pathologist, I started in the schools not knowing  if the workload is overwhelming or just the norm. The 2013-2014 school year was my clinical fellowship experience. I excitedly trudged my way through the paperwork system, found my footing as a therapist and emerged with nothing but wind in my sails.

Yet wind always ebbs and flows. By December of 2014, I realized the overwhelming paperwork leading to canceled sessions was more than what my colleagues were experiencing. I spoke up at our quarterly staff meeting and made it clear I needed some help. I was done sacrificing students’ treatment time for paperwork. With only three speech-language pathology assistants in the district, I didn’t expect much, to be honest. The request was more for my sanity, so that if someone found me under a stack of Individualized Education Programs, there was a story to tell.

To my great surprise, on the first day back after winter break, I read a delightful email from one of the SLPAs reporting she would be with me every Friday till the end of the year. Yay!!

I then immediately started realizing all the things that come along with having an SLPA. I share my (small) office space, walk her through my goals for each student, supervise her with students and sign off on all the paperwork. I almost regretted my decision to ask for the help. But no, no…It was worth it, right?

Then came the self-doubt, all my insecurities crept in. How unorganized I can be with materials, how behind I get with Medicaid billing, how I feel like no one could handle the kids like I do. No, no, it will be fine, I reassured myself. And it was.

My new SLPA arrived on her first Friday. We got right to work going over the day’s schedule, reviewing goals and discussing student’s current skills. Within 35 minutes, she looked through my materials, set up her lessons and was ready for the day. She’s been an SLPA longer than I’ve been an SLP, so it was just another Friday for her. There I was, nervous and excited and she was just wondering where the staff lounge was. Funny how things work out.

I spent that first Friday observing from my desk while writing six IEPs for next Monday’s meetings and finishing an evaluation report, all before noon. None of my kids missed their sessions. If anything, treatment stayed more focused because their SLP wasn’t a crazed lady partially pondering when she was going to do paperwork versus how well they said their /s/ and /z/.

Having an SLPA, even just once a week, makes all the difference with the rest of my sessions. I plan my week out, factoring in the time I know I’ll have on Fridays. Time I spend doing evaluations, writing up extended school year data, monitoring progress for Response to Intervention, collaborating with my classroom teachers and making phone calls home. There are many things that get swept to the side when you have mandatory deadlines always approaching. Having an SLPA has already helped in ways I can’t put to words.

I didn’t realize just how stressed I was until my SLPA swooped in saved my sanity. We’re still working out kinks in the schedule and treatment details, but the benefits far outweigh any of these. If we both continue to coordinate and communicate the session progress, I know I’ll see exciting growth in those students during the final push to the end of the school year.

 

Katie Millican, MEd, CCC-SLP, is an SLP for the Matanuska-Susitna Borough (Alaska) School district. She graduated from the University of West Georgia with her bachelor’s and master’s of education degrees. Her interest in technology leads her to integrate it into day-to-day sessions. She enjoys connecting with her blog readers (SLP_Echo) through all things social media: Twitter, Instagram and Google +.

Call for Advocacy to Garner Government Support for Evidence-Based Treatments

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Editor’s Note: This post is another viewpoint on the Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Evidence-based practice encompasses evidence from high-level research, expert opinion, patient needs and values, along with the context within which the treatment is conducted. In the field of stuttering, we are fortunate to have strong evidence that the Lidcombe Program is effective. If we have clear evidence that a treatment approach works, it should be made available to the people who need it.

Speech Pathology Australia has made a submission to our [Australia’s] federal government to fund stuttering treatment. I’m sure it will be the first of many submissions, which aim to bridge the evidence-practice gap. However, there appears to have been a misunderstanding about the announcement, so SPA published a clarification on its website stating that “SPA’s submission relates only to the formation of the 2015-2016 federal budget. SPA is not supporting legislation or a policy change to promote one program, service or form of treatment over any other.”

As a founder of the speechBITE evidence-based practice website, I thought long and hard about the effect EBP has on clinical practice, funding sources and, most importantly, the clinical outcomes of the people we serve. There are three key aspects to making EBP a central component of clinical decision-making:

  • Firstly, clinicians need to know about the latest treatment advances.
  • Secondly, patients and clients need to be informed about current best practice options, and be satisfied with their treatment decision.
  • Thirdly, funding agencies need to be confident that they are funding treatments that are based on strong evidence.

How can funding agencies be aware of current best practice and confident in their funding decisions? As a profession we need to be proactive by giving this information to funding agencies and lobbying the government. This is precisely what SPA is doing with its proposal. I applaud SPA for taking this step and promoting evidence-based speech pathology practice at the highest level.

 

Leanne Togher, PhD, SLP, is a professor of communication disorders following traumatic brain injury at The University of Sydney and is Senior National Health and Medical Research Council Fellow of Australia. Togher is the director of the speechBITE evidence-based practice website. She is also an international affiliate of ASHA and Fellow of Speech Pathology Australia. She can be reached at Leanne.togher@sydney.edu.au.

Another View on Speech Pathology Australia’s Stuttering Treatment Proposal

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Editor’s Note: This post is a follow-up to yesterday’s post from Craig Coleman regarding a controversial proposal on stuttering treatment and reimbursement from Speech Pathology Australia. We reached out for responses from Ann Packman and Mark Onlsow, two of the originators of the Lidcombe approach to stuttering treatment—on which the SPA proposal centers. We also reached out to SPA and include a statement here from SPA President Deborah Theodoros.

Response from Ann Packman and Mark Onslow:

During the past two decades the Australian government has invested millions of dollars in research funding to develop an evidence-based treatment for early stuttering. The Lidcombe Program is a result of this funding and is now supported by strong evidence from randomized controlled trials. Those randomized trials include evidence for face-to-face treatment, for treatment using webcam, and for group treatment. The Speech Pathology Australia proposal is for our government to further invest in the health of Australian children who stutter, but in a more direct way by contributing to the cost of their treatment.

We wish to clarify that the Speech Pathology Australia proposal is not for a mandate—a directive—that Australian speech pathologists must use the Lidcombe Program to treat preschool children who stutter. Nor is it a proposal to overturn customary evidence-based reasoning and standardize how Australian preschoolers who stutter in Australia are managed. Nor is there any suggestion that the Australian government would not in the future fund any other evidence-based intervention that is supported by randomized controlled trials. Indeed, if such evidence emerges for the efficacy of another treatment for early stuttering, we would encourage Speech Pathology Australia to approach the Australian government to consider it also for taxpayer-assisted support.

 

Message from Deborah Theodoros, president, SPA:

Speech Pathology Australia is advocating for public funding (Medicare) rebates for early stuttering intervention at a level which is demonstrated to be highly efficacious and supported by the strongest level of evidence. However, SPA is not suggesting any policy or legislation which would restrict interventions to one program over another or would require a speech pathologist to use a specific treatment, intervention or service. SPA continues to strongly support the principle of practice that speech pathologists remain free, and duty-bound, to exercise their clinical decision-making in relation to the interventions they provide to clients.

 

Ann Packman, PhD, SLP, is associate professor and senior research officer for the Australian Stuttering Research Centre, The University of Sydney. She has more than 30 years’ experience in the area of stuttering as a clinician, teacher and researcher and researches nature and treatment of stuttering. Packman recently served as associate editor for fluency for the American Journal of Speech-Language Pathology and is associate editor for fluency for Language, Speech, and Hearing Services in Schools. Packman is an international affiliate of ASHA. She can be reached at ann.packman@sydney.edu.au.

Mark Onslow, PhD, SLP, is the foundation director of the Australian Stuttering Research Centre, The University of Sydney. He was a principal research fellow of the National Health and Medical Research Council of Australia. Onslow’s research interests are the epidemiology of early stuttering in preschoolers, mental health of those who stutter, measurement of stuttering, and the nature and treatment of stuttering. He is a member of the international Lidcombe Program Trainers Consortium. Onslow is an international affiliate of ASHA. He can be reached at mark.onslow@sydney.edu.au.

Deborah Theodoros, PhD, SLP, national president of Speech Pathology Australia, is also professor and head of the division of speech pathology in the University of Queensland’s School of Health and Rehabilitation Sciences. She is a founder and co-director of the multidisciplinary Telerehabilitation Research Unit in the school and past chair of the Telerehabilitation Special Interest Group of the American Telemedicine Association. She can be reached at president@speechpathologyaustralia.org.au.

 

 

Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

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While many pediatric professionals are familiar with a tongue-tie, the illusive lip-tie hides in plain sight beneath the upper lip. Because I focus on feeding difficulties in children and an upper lip-tie can be a contributing factor if a child has trouble feeding, then I probably encounter more lip-ties than some of my colleagues. Still, I’d like to encourage my fellow SLPs to just flip the lip of every single kiddo whenever assessing the oral cavity. And document what you observe. Help increase general knowledge among professionals on different types of upper lip-ties by raising awareness of how they may impact the developmental process of feeding.

Upper lip-ties refer to the band of tissue or “frenum” that attaches the upper lip to the maxillary gingival tissue (upper gums) at midline. Although most babies should have a frenum that attaches to some degree to the maxillary arch, the degree of restriction varies. So it’s important to flip the lip of every child we evaluate in order to gain a better understanding of the spectrum of restriction – especially if you are an SLP who treats pediatric feeding.

During the feeding evaluation process, consider four things: 1) The mobility of the upper lip for breast, bottle, spoon and finger feeding; 2) How well it functions in the process of latching and maintaining the latch; 3) If the lip provides the necessary stability for efficient and effective suck-swallow-breath coordination; and 4) If the lip is an effective tool for cleaning a spoon, manipulating foods in the mouth and contributing to a mature swallow pattern.

Dentist Lawrence A. Kotlow has created an upper lip-tie classification system to better identify, describe and consider the need for treatment. The tie is classified according to where the frenum connects the lip to the gums, known as “insertion points.” Envision a child with a very big “gummy” smile and the upper gum line exposed. Divide the gums into three zones, as described in this article by Kotlow:

“The soft tissue covering the maxillary bone is divided into 3 zones. The tissue just under the nasal area (zone 1) is called the free gingival area; this tissue is movable. Zone 2 tissue is attached to the bone and has little freedom of movement… Zone 3 extends into the area between the teeth and is known as the interdental papilla. This is where the erupting central incisors will position themselves at around 6 months of age.”

Now, consider the insertion points. A Class I lip-tie inserts in Zone I and (unless extremely short and tight) does not inhibit movement of the upper lip and should not interfere with breast or bottle feeding. However, if the lip itself is retracted to the degree that a child cannot flange his upper lip for adequate latching and for maintaining suction, further consideration of this type of lip tie may be necessary. Class II lip-ties have an insertion point in Zone 2, where the tissue is attached to the bone. Kotlow describes the Class III tie as inserting in Zone 3, where “the frenum inserts between the areas where the maxillary central incisors will erupt, just short of attaching into the anterior incisor.”  A Class IV lip-tie “involves the lip-tie wrapping into the hard palate and into the anterior papilla (a small bump located just behind where the central incisor will erupt).”

How might an upper lip-tie impact the developmental process of feeding?

The impact of the upper lip-tie can vary according to its classification and, in my professional experience, the fullness of the upper lip also comes into play. But, in general, consider these key points:

Breastfeeding and Bottle Feeding

  • Breast – Inadequate latch: An infant must flange the lips to create enough suction and adequate seal around the tissue that includes the areola and not just the nipple. It is essential that babies take in enough breast tissue to activate the suckling reflex, stimulating both the touch receptors in the lips and in the posterior oral cavity in order to extract enough milk without fatiguing. When the baby suckles less tissue, painful nursing is also a result. One sign (not always present) is a callus on baby’s upper lip, directly at midline. While not always an indicator of a problem, it’s typically associated with an upper lip-tie. It’s simply a reminder to flip the lip!
  • Bottle – Inadequate Seal: Because bottles and nipple shapes are interchangeable and adaptations can be made, it’s possible to compensate for poor lip seal. However, these compensatory strategies are often introduced because all attempts at breastfeeding became too painful, too frustrating or result in poor weight gain…and the culprit all along was the upper lip-tie. It is then assumed that the baby can only bottle feed. I’ve assessed too many children held by teary-eyed mothers who reported difficulty with breast feeding – and no indication in the chart notes that the child had an upper lip-tie. But, upon oral examination, the lip-tie was indeed present and when observing the child’s feeding skills, the tie was at the very least a contributing factor. Releasing the tie resulted in improved ability to breast feed and progress with solids.
  • In addition, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
    • Gassiness; fussiness; “colicky baby”
    • Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing
    • Fatigue resulting in falling asleep at the breast
    • Discomfort for both baby and mother, resulting in shorter feedings
    • Need for more frequent feedings round the clock
    • Poor coordination of suck, swallow, breathe patterns
    • Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.

Spoon Feeding

  1. Inability to clean the spoon with the top lip
  2. Inadequate caloric intake due to inefficiency and fatigue
  3. Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
  4. Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications

Finger Feeding

  1. Inability to manipulate food with top lip for biting, chewing and swallowing
  2. Possible development of picky, hesitant or selective eating because eating certain foods are challenging
  3. Lip restriction may influence swallowing patterns and using compensatory strategies (e.g. sucking in the cheeks to propel food posteriorly to be swallowed) which may lead to additional complications

Oral Hygiene & Dental Issues

  1. Early dental decay on upper teeth where milk residue and food is often trapped
  2. Significant gap between front teeth
  3. Periodontal disease in adulthood
  4. Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.

After documenting what we observe during the evaluation, clear communication with parents and other professionals will help to determine next steps. In feeding therapy, our role is to provide information for involved parents and professionals (this may include pediatricians, lactation consultants, otolaryngologists, gastroenterologists, oral surgeons and/or pediatric dentists). Our primary role is to determine, document and communicate to what degree the restricted top lip is influencing a child’s difficulty feeding.

For detailed information and additional photos, please read Kotlow’s article, Diagnosing and Understanding the Maxillary Lip-tie as it Relates to Breastfeeding, published in the Journal of Human Lactation in May 2013.

In a future post for ASHA, we’ll discuss tongue-ties (ankyloglossia) and the impact on feeding. Upper-lip ties are frequently associated with tongue-ties, so please remember to look for both during oral examinations.

Have you had an experience with an upper lip-tie impacting the feeding progress of one of your clients? If so, please tell us in the comments below.

 

Melanie Potock, MA, CCC-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs.  She can be reached at Melanie@mymunchbug.com