A s a speech pathologist forover 24 years, I have seenmany patients with vari-

ous diagnoses. Since my practice special-izes in oral motor and feeding disorders, Imeet many patients who have been strug-gling with speech and feeding issues forsome time, often with limited progress.Most concerning is the pediatric referrals,with frantic, sleep deprived parents whoare doing everything possible to help theirinfant stay hydrated and thriving. Toooften a simple symptom was missed, atongue-tie.

Take, for example, my former patientMolly (name has been changed for pri-vacy). Molly’s mother emailed my officebecause her 18-month-old daughter was

still using a bottle, would barely eat pureedfoods, gagged and choked on solids andcould not drink from a straw or cup. Every-one thought Molly was just being stubbornor picky, but not Molly’s mom. Aftermonths of concern, the pediatrician gave areferral for a feeding evaluation. As soonas I read the case history forms, I immedi-ately knew that a tongue-tie assessmentwas needed.

When I got the full story, feeding issuesstarted at birth. Molly’s mother was notsuccessful at breastfeeding. She had a greatdeal of pain and Molly was losing weight.Mom was very disappointed and frustratedas she wanted to breastfeed, but did notwant Molly to be under nourished. She hadseen a lactation consultant (IBCLC) that

suggested tongue-tie, but the pediatriciandid not feel it was an issue. The plan wasto pump breast milk and use a bottle. Bottlefeedings were not great either. Molly wasalways “colicky” and spit up often. Refluxmedication was prescribed, but it did notreally help. It was a constant struggle.Molly did not like pureed foods when in-troduced and when Gerber Puffs and Chee-rios were started, Molly’s mom stated thatit was like she had no idea what to do withthem. They would just sit in her mouth, orshe would pocket them like a chipmunk.Eventually Molly would scream and cry ateach meal, and PediaSure was her mainsource of nutrition.

When I assessed Molly, I found that thelactation consultant was right; she clearly

By Robyn Merkel-Walsh MA, CCC-SLP

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Tongue-TieWhat Ever!one Needs to Know

had a tongue-tie, but it was not the typemost people are used to seeing. Most peo-ple are used to an “anterior” tongue-tie thatcauses the tongue to be heart shaped and isattached to the tongue tip.

Molly’s issue was different. It was notattached to the tongue tip, but rather it wasa short, thick band of fiber located posteri-orly, behind the salivary duct. This isknown as a posterior tie, and often missedby medical professionals. Why is this hap-pening? It is happening mainly because thetraining of Tethered Oral Tissues (TOTs)occurs on a post-graduate level and issought by the professional voluntarily. Dr.Anthony Jahn, a well-respected New Jer-sey/New York City-based otolaryngologistclaims, “You can’t see what you don’tknow,” and this is very true of TOTS.

Molly came for pre-operative sessionsso help prepare her for a frenectomy, andthen came for therapy for 6 months afterthe surgery. She learned to eat purees,solids and drink through a straw and cup.She is now a happy and thriving pre-schooler who eats a variety of foods and nolonger has reflux symptoms. A seeminglysimple problem was clearly overlooked,and this happens too often in my practice.

What Is A Tongue-Tie?Most people use the term “tongue-

tied” when they do not know what tosay, but tongue-tie is an actual medicaldiagnosis that can impact the waypeople eat and/or speak. Anky-loglossia is the medical term fora tongue-tie. It is a restrictionof the frenulum located under

the tongue. A frenulum is supposed to belike a stretchy band that helps thetongue’s movement, but sometimes peo-ple are born with an abnormal or re-stricted frenulum. The lingual frenulumis one of seven frena in the mouth. Fourbuccal frena (upper and lower), twolabial frena (upper and lower) and onelingual frenulum exist, and any one ofthem can be “tied” or restricted. This iscalled Tethered Oral Tissue or TOTs.Lip-tie is often corrected when a personhas a gap between the two front teeth.

How Does Tongue-Tie or TOTs Cause Problems?

So, what are the symptoms? Ininfancy, the first sign is breast-feeding difficulty such as mater-nal pain and failure to thrive(gain weight). This, however, isonly one issue that can be im-pacted by TOTs as symptoms cancross the life span. As babiesgrow, they may seem to havepicky eating habits, just likeMolly. They may also seem tohave developmental speechproblems, like a lisp, but the rootof the problem is structural.

TOTs does not just impact babies andyoung children. I see patients in my of-fice across the lifespan. Signs and symp-toms of TOTs also include: reflux/aerodigestive issues, orthodontic issues,sleep apnea and TMJ. TOTs may causetightness of the head and neck, which re-sults in pain and discomfort. The redflags of TOTs are: feeding difficulties;speech clarity issues; orthodontic prob-lems; chronic jaw, head or neck pain;and reflux.

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How Is TOTs Treated?For many years, it was commonplace

for newborns to have the tongue-tie“clipped” before being discharged from thehospital. Doctors thought it helped withbreastfeeding. This procedure is known asa frenectomy, which Molly eventually hadas a part of her care. Unfortunately, tongue-tie was also mistakenly clipped, for indi-viduals who stuttered or had speech delays.Perhaps the procedure was done too freely.Then, with the formula feeding surge in the70s, the surgery rate dropped and the baby

was thrown out with the bath water, lead-ing to tongue-tie surgery being some-

what of a taboo. Now that the World Health Or-

ganization (WHO) supports breast-feeding based on important research,tongue-tie is a hot topic, and there is

controversy on when to perform thesurgery and how. TOTs is not a condi-tion that all medical professionals aretrained in, so the surge of frenectomiesmay seem to be a fad to some, TOTsexpert Dr. Bobby Ghaheri argues thatit is more likely due to increased

awareness and genetics that have TOTsidentification on the rise.

Finding HelpTOTS treatment can be complex as

there are many professionals who make upa TOTs team. In the tristate area, parent ad-vocate Krysten Glor created the New Yorkand New Jersey Tongue-Tie Group onFacebook to help parents find the rightproviders. TOTs care involves a team ofprofessionals that provide pre- and post-operative interventions, such as: chiroprac-tors; international board certified lactationconsultants; occupational and/or physicaltherapists; registered dental hygienists;speech-language pathologists; and sur-geons.

If you suspect that you or your child hasTOTs, the first step is speaking to your

physician. There are many organizationsthat can help with a referral to a highlytrained provider and/or therapist, includingAnkyloglossia Bodyworkers; InternationalAssociation of Orofacial Myology; Inter-national Consortium for AnkylofrenulaProfessionals; International Association ofTongue-tie Professionals; and TalkTools.

Patients should schedule their func-tional assessment prior to any surgical pro-cedure and have their therapist of choice ondeck to assist with aftercare.

Robyn Merkel-Walsh is a speech-lan-guage pathologist residing and practic-ing in Bergen County for over twodecades. She is employed by the Ridge-field Board of Education, TalkTools andhas a private practice in Ridgefield. Sheis the author and presenter or many ar-ticles and texts, including The Func-tional Assessment and Remediation ofTethered Oral Tissues (TOTs), co-au-thored with Lori Overland. Robyn hasbeen awarded NJ Top Docs and is theboard chair of the Oral Motor Institute.Robyn can be reached atrobynslp95@aol.com.

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