What is occupational therapy?
Occupational therapy is the only profession that helps people across the lifespan to do the things they want and need to do through the therapeutic use of daily activities (occupations). Occupational therapy practitioners enable people of all ages to live life to its fullest by helping them promote health, and prevent—or live better with—injury, illness, or disability.
The broad definition of OT enables all OT’s to be the specific practitioner they want to be with post-grad training, or more generalists working in various settings. At B.WELL OT, Co., we focus on infants and children engaging in the “occupations” of (mostly) feeding and playing. We do this with therapeutic handling, therapeutic activities, environmental modification, activity analysis, neuromuscular re-education, sensory integration, myofascial release, and other bodywork methods.
What is a tongue-tie?
Tongue-Tie (ankyloglossia) is caused by a tight or short lingual frenulum (the fascia that anchors the tongue to the floor of the mouth). The frenulum normally thins and recedes before birth. Where this doesn’t happen, the frenulum may restrict tongue mobility. Tongue tie often runs in families and is thought to be more common in boys than girls. There is an association between high or unusual palates and tongue tie, because restricted tongue movement can affect the shape of the palate.
The terms “tongue tie” (TT) and “ankyloglossia” are used synonymously to represent a condition where movement of the tongue is assessed as being limited. This limitation is usually attributed to the lingual frenulum “tethering” the tongue, with the frenulum itself often being called a “tongue tie.” However, it is generally agreed ankyloglossia is not a purely anatomical or appearance‐based diagnosis, and that limitation of tongue movement is crucial to the diagnosis and in the decision to proceed to frenotomy (Suter and Bornstein, 2009; Puapornpong et al., 2014; Chinnadurai et al., 2015; Francis et al., 2015; Walsh and Tunkel, 2017). As yet no clear anatomical variables have been identified that have direct correlation with limitation of specific tongue movements, or improvement in any objective outcome measures following frenotomy. Consequently, major controversy still exists around when and how the frenulum is determined to be limiting movement, and when that limitation is sufficient to warrant surgical intervention.
From “What is a tongue tie? Defining the anatomy of the in‐situ lingual frenulum” by Nikki Mills Seth M. Pransky Donna T. Geddes Seyed Ali Mirjalili
This is why B.WELL OT, Co. does a full functional assessment of general behaviors, resting mouth posture, body alignment, muscle tone, presence of tension, as well as noting parent’s symptoms, baby’s symptoms, and finally—evaluating the tongue and lips to determine if there is restriction in function.
Symptoms associated with tongue-ties
Breast and Bottle Feeding
Breastfeeding parent experiences pain while baby nurses.
Symptoms seen in infant:
difficulty latching / poor or shallow latch
clicking when sucking
ineffective milk transfer / poor weight gain
failure to thrive
irritability or fussiness at the breast
cannot sustain latch / pops on and off frequently
dependent on nipple shield
cannot hold pacifier in mouth (may be able to use a Mam pacifier, though this is a further sign of dysfunction)
fatigues or quickly falls asleep when feeding
frequent cluster feeds or feeding more than the norm
chewing / gumming nipple
dimple of cheeks while sucking
absent lip flange
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:
gassiness; fussiness; “colicky baby.”
treatment for gastroesophogeal reflux disease, yet to be confirmed via testing. new research is showing more risks for babies <6 months.
fatigue, resulting in falling asleep at the breast.
discomfort for both baby and mother, resulting in shorter feedings.
need for more frequent feedings around 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.
to see an ultrasound video of how babies optimally breastfeed, click here.
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
Via Melanie Potock, MA, CCC-SLP
What is an upper-lip tie?
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.
Symptoms associated with upper lip-ties
The impact of the upper lip-tie can vary according to its classification. 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. Baby may also have difficulty fully opening their mouth due to an overactive obicularis oris (muscle surrounding the mouth) that is restricted by the lip tie.
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 breastfeeding – 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 breastfeed 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
Spoon Feeding
Inability to clean the spoon with the top lip
Inadequate caloric intake due to inefficiency and fatigue
Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications
Finger Feeding
Inability to manipulate food with top lip for biting, chewing and swallowing
Possible development of picky, hesitant or selective eating because eating certain foods are challenging
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
Early dental decay on upper teeth where milk residue and food is often trapped
Significant gap between front teeth
Periodontal disease in adulthood
Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.
Via Melanie Potock, MA, CCC-SLP