Home Health Care Tip Back That Tongue! The Posterior Tongue Tie and Feeding Challenges

Tip Back That Tongue! The Posterior Tongue Tie and Feeding Challenges

by Melanie Potock MA
written by

In a March 2015 post titled Just Flip the Lip, we explored how the band of tissue or “frenum” that attaches the upper lip to gum tissue can affect feeding development if the frenum is too restrictive. Today, we’ll focus on the lingual frenal attachment that is the easiest to miss: The posterior tongue tie (sometimes referred to as a submucosal tongue tie), a form of ankyloglossia.

Consider that the normal lingual frenum inserts at about midline, just under the tongue and down to the floor of the mouth allowing free range of movement and oral motor skill development. While many pediatric professionals are familiar with a tongue-tie when the frenum attaches closer to the tongue tip (where it’s visible when the tip is gently lifted), the posterior tongue tie requires a specific technique to view. According to Bobby Ghaheri, an ENT surgeon who specializes in treating ankyloglossia, whether anterior or posterior terminology is used, the focus should be on function. As he describes in this article, many anterior ties also include a posterior restriction and releasing just the thin membrane is not always adequate for full tongue function necessary for feeding. The frenum, if visible at all, may appear short and thick, but is often buried in the in the mucosal covering of the tongue.

As a pediatric feeding therapist, I gently lift up the tip of every child’s tongue during the oral examination. But, if I suspect a posterior tongue tie, my next step is to follow the procedure noted in this video by Dr. Ghaheri. This gives me enough information to ask the family to consult further with their pediatrician or primary care provider and a then a pediatric ENT, pediatric dentist or oral surgeon, who may also use specific instruments to better view the attachment. I feel my role as an SLP is to screen, not diagnose.

There are clues that indicate that a posterior tongue tie may be present before following the procedure noted above. The following are just some of the more common indicators of possible restriction of the lingual frenum impacting feeding development:

Appearance
  • Square, heart shaped or indented tip of tongue at rest and/or upon attempted protrusion—this is often indicative of anterior tongue ties, but as noted by Dr. Ghareri, the posterior restriction my still be present.
  • Dimpled tongue on dorsal surface, especially during movement.
Breast and Bottle Feeding
  • Difficulty latching and/or slow feeding.
  • Mother experiences pain while baby nurses.
  • In addition, as seen with upper lip ties, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
Spoon and Finger Feeding
  • Retraction of tongue upon presentation of the spoon.
  • Inadequate caloric intake due to inefficiency and fatigue.
  • Tactile oral sensitivity secondary to limited stimulation/mobility of tongue.
  • Over-use of lips, especially lower lip.
  • Difficulty progressing from “munching” to a more lateral, mature chewing pattern.
  • Tongue restriction may influence swallowing patterns and cause compensatory motor movements, which may lead to additional complications, such as “sucking back” the bolus in order to propel it to be swallowed.
  • Possible development of picky, hesitant or selective eating because eating certain foods are challenging.
  • Gagging and subsequent vomiting when food gets “stuck” on tongue.
  • Secondary behaviors to avoid discomfort that are thus protective in nature, such as refusing to sit at the table or being able to eat only when distracted.
Oral Hygiene, Dental and Other Issues Related to Feeding
  • Dental decay in childhood and adulthood because the tongue cannot clean the teeth and spread saliva.
  • Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.
  • Open bite.
  • Snoring.
  • Drooling.
  • Messy eating.
  • Requiring frequent sips of liquid to wash down bolus.

On sharing my findings with a child’s caregivers and primary care physician, a pediatric dentist, oral surgeon or ENT will determine next steps for the frenectomy. Linda Murzyn-Dantzer at Children’s Hospital Colorado shared her insight on the use of laser treatment for frenectomies. She noted that the laser can be used safely in a clinic setting, eliminating the need for treatment under sedation or general anesthesia. The laser itself provides some analgesia and often there is minimal need for other anesthetics, which may not be well-tolerated and may compete for other cell receptors and influence oxygen levels.

The laser can help to control bleeding and stitches may not be required. The laser offers precision when cutting tissue, and if the patient moves even slightly, the controls allow the beam to be stopped almost instantly. Traditional surgical techniques are also an option and used in a variety of situations, but Dr. Murzyn-Dantzer chooses the use of a laser over electrocautery techniques that may overheat or burn tissue, affecting cell layers beneath the targeted tissue and causing post-operative discomfort and increased healing time.

 

Melanie Potock, MA, CCC-SLP, treats 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!” mymunchbug.com/contact-us/ 

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14 comments

Mia May 26, 2015 - 5:48 pm

Thank you for your article. I am a SLP and my daughter (who is now 1) was born with a posterior tongue tie. We had difficulty with bringing my milk supply in, even with round the clock feedings. We had her tongue tie lasered at 8 weeks old, but it was a stressful decision to make as I had never even heard of a posterior tongue tie!

Melanie Potock May 29, 2015 - 10:12 am

Hi Mia, thank you for sharing your story here. It’s very helpful!

Mo May 26, 2015 - 6:37 pm

Honestly, you are probably more trained than the average pediatrician. I am very disappointed in the lack of knowledge in the field (it’s just not in their wheelhouse often). I have taken my baby to two pediatricians and neither seemed particularly knowledgeable. My baby was diagnosed by a dentist that I got from a tongue tie support group list.

Melanie Potock May 29, 2015 - 10:13 am

Hi Mo, I know it can be frustrating. I’m hoping that professionals share this article with each other and we begin to raise awareness across the health care community – and of course, for parents too! Thank you for commenting, it’s very helpful!

JOANNE HEIN, MS, CCC-SLP May 26, 2015 - 8:17 pm

terrific information that is little-known.
thank you!*

Melanie Potock May 29, 2015 - 10:13 am

Thank you Joanne!

Sally SLP May 26, 2015 - 9:31 pm

None of this is research based. ASHA, please!!!!!!!! Stop!!!

Jennifer May 28, 2015 - 1:39 pm

SALLY-100% agree! Please show us some research as our hospital extensively searched and found none.

Melanie Potock May 29, 2015 - 10:18 am

Hi Sally and Jennifer, My apologies for the delayed reply to your comments. ASHA is updating their website and there were some glitches with WP. I’ve responded a few times, but I don’t think they are appearing, so I’m going to try once more, as your concern is something I want to address. First, thank you. Research is very important, as we all know. Because blog posts have a word limit, you may not see the articles in the content, but instead will find them in the links. At the bottom of many of those articles, there will be more resources and journal articles. Here’s one to get your started: http://bit.ly/1ExoiBV I found over 20 on ankyloglossia, tongue restriction as it relates to feeding and frenectomy procedures/recovery/reviews of the literature. Thanks again.

SLP Corner: The Posterior Tongue Tie and Feeding Challenges | PediaStaff Pediatric SLP, OT and PT Blog May 28, 2015 - 1:01 pm

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Ann Kummer June 1, 2015 - 4:44 pm

I am honestly surprised by this blog. It seems to be an advertisement for an ENT who “specializes” in frenulectomies rather than evidence-based information. The readers should know that a recent systematic review by AHRQ concluded that “a small body of evidence suggests that frenotomy may be associated with improvements in breastfeeding as reported by mothers, and potentially in nipple pain. However, with small, inconsistently conducted studies, strength of evidence is low to insufficient….” (See reference below.) I am concerned that many children undergo this procedure needlessly.

Treatments for Ankyloglossia and Ankyloglossia with Concomitant Lip-Tie, Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, May 4, 2015
http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2073

Ann Kummer

Melanie Potock June 2, 2015 - 10:44 am

Hi Ann, Thank you for your comments. Small world, because I was just reading over that same review earlier this week. I want to assure you that I am in no way associated with the ENT mentioned in this article nor intended to advertise anyone’s services. What I was trying to do was raise awareness of the possible impact of posterior tongue ties and feeding. In my 18 years of professional experience in treating children with feeding disorders, approximately 50% of the children on my caseload who appear to have a posterior tongue tie (again, I feel my role is to screen, not diagnose) do not end up having the release done. That’s because the final decision is based on function and progress in feeding. To me, it’s important to consider the whole child. Research is important of course, and one of the most important points that I take away from this review is the section on “Research Gaps”. I’d like to see more information specifically on posterior tongue tie and it’s relationship to a child’s ability to manage solids. This is where I tend to see kids having trouble and in my experience most of those kids were reported by their mothers to be poor breast feeders. But, because these children often end up on my caseload after breastfeeding has been abandoned, I cannot determine if the tie was part of the reason that breastfeeding was so challenging. When I was working in the NICU, I was able to follow these kids closely, but that’s not possible with every client. So, yes – let’s keep up with the research. Let’s continue to tip back the tongue to learn more about all types of ties. Let’s screen and team with professionals (ENTS, Pediatric Dentists, etc.) and parents to determine next steps. Most importantly, let’s document well so that we can review findings over time and offer a review that is specific to posterior tongue ties and feeding challenges from birth and in older years.

Jane Fox June 10, 2015 - 8:24 am

Thanks for the simple information on how to recognize tongue tie. Not knowing what’s happening can be so frustrating, especially when it manifests in problems like difficulty feeding. It’s encouraging that there are solutions out there to help. It can really make life easier for everyone. I hope that more people see your article and can get the help they need.

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