SLP & LC Karrie Page Answers my Questions about Tongue & Lip Ties for May is Speech and Hearing Month
I’ve talked a little bit on the blog about Liam’s tongue and lip tie surgeries. He suffered with reflux and gas and seemed uncomfortable most of the time as a newborn. I noticed that he couldn’t stick his tongue out very far and when he did, it created a heart shape. His frenum or frenulum (the soft tissue that connects the underside of the tongue to the bottom of the mouth) was attached right to the very tip of his tongue. He had a shallow latch when nursing and has been slow to gain weight. Although his latch didn’t bother me, I wondered if it contributed to some of his tummy troubles. We still haven’t sorted out if he is a little guy because of difficulty feeding, his heart condition, or if that’s just the way he is.
I was referred to Karrie Page. Karrie wasn’t my lactation consultant, but she chatted with me on the phone, answered about a million questions, and gave us the name of another LC who was closer to our area of the province. Karrie is a Speech-Language Pathologist (SLP) who works with adults in stroke rehab, like me. She is also a Lactation Educator (LE), Certified Breastfeeding Specialist (CBS) and Certified Orofacial Myologist (COM). She owns Tip of the Tongue Orofacial Myofunctional Therapy and Lactation Consulting, a private clinic in Red Deer, Alberta, that focuses on educating, empowering, and supporting clients with myofunctional therapy, speech therapy, breastfeeding and tongue and lip ties. I know first hand that she brings quality and compassionate care to central Alberta for all things speech, feeding, breathing, and sleep!
I am so excited to talk to Karrie today about tongue and lip ties. She is an absolute wealth of information, such an advocate for the SLP profession, and was a great support for me with my tongue and lip tied baby.
You’re an SLP who works with adults and then pursued lactation consulting. What drew you into lactation education?
Babies what else 🥰. Honestly, I have never felt as vulnerable as I did when I first became a mom. I was so overwhelmed and so unprepared. I encountered all the struggles with breastfeeding my first son. This is where my passion for helping mamas started. I love that I am in a profession where I can help new mamas be educated, prepared and empowered to start off successfully with their journey with their baby.
As an SLP I recognized that I could help positively impact these client’s growth and development in all aspects - speech, breathing, sleep and orofacial development.
My work as a speech pathologist began with helping clients who have had a stroke. I love learning about how the brain can heal and change (neuroplasticity) and helping clients through their rehabilitation. I then was fortunate enough to cross paths with an amazing orthodontist, Dr. Ivan Hucal, who introduced me to the world of myofunctional therapy. I immediately saw the connection between the behavioural therapy that is involved with myofunctional therapy and neuroplasticity. As an SLP I recognized that I could help positively impact these client’s growth and development in all aspects- speech, breathing, sleep and orofacial development. As my knowledge and experience developed over the initial 15 years of my practice, I realized that if I could become involved with these clients earlier, as babies, I could have an even larger positive impact on their development. I began to see the impact early intervention could have on potentially preventing speech concerns and negative facial growth.
You started your own business- Tip of the Tongue Orofacial Myofunctional Therapy and Lactation Consulting. Can you explain what orofacial myofunctional therapy is?
Myofunctional therapy focuses on improving the rest posture of the tongue, jaw and lips to maximize oral development and functions of breathing, speech, chewing and swallowing. Where your tongue rests, is where it will begin to speak from. So as an SLP, I know that correcting oral rest posture first, will create the foundation or “home base” for all speech sound production.
How do all of these things- speech pathology, lactation consulting and myofunctional therapy work together?
Talking, eating, swallowing and orofacial growth all involve the oral cavity- the tongue, jaw, teeth and lips. How your mouth develops, where your tongue and lips rest will determine how you produce your speech sounds, the clarity of your speech, how your muscles work for chewing and swallowing and ultimately how your face will grow and develop.
It is so rewarding as a therapist to know we can be part of the solution, guiding positive growth and development versus waiting to intervene only after concerns arise. I cringe when I hear moms say “I only wish I knew then….” I much prefer “I am so thankful we learned this now.”
Initiating intervention in babies can ultimately help to change the way their orofacial growth occurs. We can be part of the team to help identify early red flags of concerns and intervene with timely education and interventions to possibly prevent future concerns. Early intervention truly can prevent abnormal facial growth and set these kids up for proper speech sound development, proper closed lip nasal breathing rest posture and restful sleep which we know impacts all areas of physical and cognitive growth. It is so rewarding as a therapist to know we can be part of the solution, guiding positive growth and development versus waiting to intervene only after concerns arise. I cringe when I hear moms say “I only wish I knew then….” I much prefer “I am so thankful we learned this now.”
One of your areas of special interest is in tethered oral tissues (tongue and lip ties). Liam had both tongue and lip ties. So what is a tongue tie? And what’s the big deal?
“Ankyloglossia” or tongue tie means that the individual has restricted tongue mobility due to the presence of restrictive tissue between the underneath of the tongue and the floor of the mouth. It is a congenital anomaly that a baby is born with.
If the tongue is restricted… functional activities such as speech, chewing, swallowing and rest posture are negatively impacted.
Typically, it is characterized by an abnormally short, thick lingual frenulum which affects the movement of tongue. Tongue tie includes a spectrum of restriction, therefore some tongue ties are the classic to the tip very visible tongue ties and others are less obvious and including webbing beneath the mucosa that might be barely perceptible without touching it. This is why it is so important to have a hands on assessment. In order for the tongue to function well, it needs to be free to move in both a horizontal (forward and back) and vertical (up and down) direction. If the tongue is restricted in one or both of these movements, functional activities such as speech, chewing, swallowing and rest posture are negatively impacted.
What are some signs to look for to identify a tongue tie in a baby or child?
This is where things become a bit complex. The following are red flags that your child *may* have a tongue tie, but these symptoms can also be caused by concerns other than a tongue tie. This is why it is so important to have a comprehensive assessment by a speech pathologist trained in tethered oral tissues and orofacial development.
Some common symptoms as outlined by Dr. Baxter at the Alabama Tongue Tie Center are:
Some common symptoms in infants are:
Shallow latch
Difficulty bottle feeding
Difficulty holding a pacifier in
Slow or poor weight gain
Reflux or spitting up often
Excessive gassiness or fussiness “colic”
Prolonged feeding time on the breast or the bottle
Milk dribbling out of the sides of the mouth when eating
Clicking or smacking noise when eating
High arched palate
Snoring
Common symptoms in mom:
Painful nursing
Bleeding, blistered, cracked, creased nipples
Incomplete breast drainage
Infected nipples, mastitis, thrush
Can’t nurse without a nipple shield
Some common symptoms in children:
Trouble with speech sounds
Imprecise or “mumbling” speech clarity
Slow eater
“picky” eater especially with textures such as meat, mashed potatoes
Choking or gagging on liquids or solid foods
Spitting out food or packing cheeks
Crooked, crowded teeth or highly arched palate
Restless sleep (moving while sleeping, kicking)
Snoring
Night time teeth grinding
Open mouth rest posture (day and/or night)
Hyperactivity or inattention
I wasn’t sure where to turn when I suspected that my baby had a tongue tie, and I’m a Speech Pathologist! What do you recommend parents do if they suspect their baby or child has a tongue or lip tie?
Seek out a speech language pathologist who has extensive training in tethered oral tissues. They can do a functional assessment to look at how the potential restricted lip and/or tongue range of motion is impacting the functions of breathing, rest posture, speaking, chewing and or swallowing. Together with the therapist you will decide if a consultation for a release is indicated.
I was lucky to be able to continue to breastfeed. Is it always possible to breastfeed a baby with ties or tie revisions?
Possibly. When we look at breastfeeding we are looking at a dyad- a mom and baby together. So how they work together will determine the success of breastfeeding. There are many things on both the mom side and the baby side that need to be evaluated to determine what can help make breastfeeding more successful. For example, if a mom has a very robust milk supply, baby sometimes doesn’t have to work very hard to transfer milk. On the other hand, if mom has flat or inverted nipples the anatomy alone can make it very difficult for the baby to latch. Certain positions can also make latching easier or more difficult if the baby has a tongue tie. This is why a thorough lactation assessment is needed to evaluate all of the contributing factors and to trial less invasive strategies prior to a tongue tie release being recommended.
Liam’s ties were surgically corrected via diode laser by a dentist who specializes in these procedures when he was two months old. What are the treatment options?
A tongue tie release can be completed by scissors or laser (diode or C02 laser). The skill and experience of the provider is more important than the tool.
Liam, minutes after surgery. We weren’t able to go into the procedure with him. We were told that babies are swaddled and wear eye protection for the diode laser surgery. Babies are not sedated. The procedure takes minutes, and we were told it is much less painful than circumcision. There was some bleeding, and the dentist wanted him to nurse right away, both to help with the bleeding and ensure that the procedure was successful in getting a better latch.
What happens during a tie release or frenectomy?
Just because you normalize the structure, doesn’t mean you normalize the function.
Just because you normalize the structure, doesn’t mean you normalize the function. You must do pre and post release education and therapy to retrain the tongue’s function movements and to maximize recovery from the release. This is why it is important to work with a speech pathologist BEFORE the release. Our goal is to both ensure the release is required but also to prepare the client for release and ensure optimal timing for the release based on the individual’s readiness.
Who do you recommend for tongue tie procedures?
I think the best advice is to interview the release provider to truly learn their knowledge and skill in this specialty area. Families do have a choice of providers. Find out not just how many releases they have done, what type of training they have had, but also what kind of education and support they provide to the family, what follow up they provide and what other professionals they recommend the family consult with before considering a release.
Too many times I have had desperate calls from moms who have just had their baby in for a “snip” with no education or support with just the hope that the release will “cure” the feeding concerns.
Typically, the person doing the release is skilled in their specialty, the surgical procedure, but not in the lactation support and problem solving the other issues around function and feeding. Too many times I have had desperate calls from moms who have just had their baby in for a “snip” with no education or support with just the hope that the release will “cure” the feeding concerns. Well educated providers are knowledgeable in knowing that the release itself is not always a “cure all” and that often there is pre and post therapy that needs to be done to ensure proper healing and function. Informed providers will be able to discuss the latest research, their recent training and best practices for releases. Providers need to provide follow up checks to see how things are going with wound healing and with feeding. Without a follow up they truly do not know the success of their procedures.
Are there potential long term side effects to tongue ties that are not dealt with?
Tongue tie release is not recommend just based on what we see visually. This is why it is so important to have a hands-on assessment so that the therapist can look, feel and evaluate the function of the tongue with regard to oral rest posture, speech breathing, sleep and feeding (breastfeeding, bottle feeding and solid food). A release is only recommended when there are clear functional limitations from the tongue restriction. There can be long term consequences from a tongue tie such as abnormal facial growth, sleep disordered breathing, persistent speech articulation errors and difficulty with chewing and swallowing.
What resources do you recommend for parents of children with tongue ties?
The following websites are evidence based and have great resources for parents
The Breathe Institute https://www.thebreatheinstitute.com
Dr. Bobby Ghaheri https://www.drghaheri.com/
Dr. Richard Baxter www.tonguetieal.com
An update on Liam: We didn’t see a drastic improvement after his tongue and lip tie revisions. We had to stretch his wounds six times a day for six weeks to prevent them from healing too closed. He hated it. We hated it. He had a follow-up appointment with the dentist one week after his surgery. She suggested that we weren’t completing the stretches hard enough so we tried to do them more aggressively. We also followed up with our lactation consultant, as well as local OT and SLP. Unfortunately, Liam’s reflux and gas didn’t improve until he seemed to outgrow them, and he still has a shallow latch. However, he stopped making a clicking sound when nursing, he stopped snoring, and his palate (the top of the mouth) went from high and arched to a more normal shape. I suspect that his tongue tie has reattached somewhat, despite the stretches. It has been frustrating, and I’ve questioned whether we should have gone ahead with it in the first place, but after everything, I am glad we did. I’m hopeful that it will prevent future feeding, speech, breathing, and sleeping problems for him. And I’m thankful for the support and knowledge that Karrie has provided to us along the way.
Thank you so much Karrie! I really appreciate you taking the time to answer my questions and share your knowledge. Karrie is located in Red Deer, Alberta. You can contact her by phone at 403-391-1413 or www.tipofthetongue.ca.
