Identifying tongue tie: Does that tell us who will have breastfeeding problems?

If you’ve spent much time discussing tongue ties with other medical professionals, then you probably already know it’s a controversial topic. And if you’ve spent much time around breastfeeding parents (either as a professional or a parent yourself), you probably know that it is sometimes difficult, painful, and emotionally-loaded for the breastfeeder.

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So what’s an SLP to do when working on feeding with breastfeeding infants who might have tethered oral tissues??! (Freeze! Step one is to make friends with a lactation consultant.) This study from Schlatter et al., which follows more than 700 breastfeeding dyads might give you a little guidance. Using structured assessment tools, they evaluated every infant’s tongue appearance and function and interviewed each mother to determine if there were any breastfeeding problems. Dyads who demonstrated both impaired infant tongue function and breastfeeding problems were referred for a frenotomy (or, “…if their parents actively opted for the procedure”). Then the interview was repeated two weeks later to see if breastfeeding had improved.

The authors used three assessments that are open access (!!!). Hazelbaker’s Assessment Tool for Lingual Frenulum Function (HATLFF), the LATCH Assessment Tool, and the Bristol Breastfeeding Assessment Tool. The full article has great details on how these assessments were used to determine frenotomy referrals and how maternal interviews were carried out (along with a very readable summary of similar research that has come before this study).

So what did they learn?

  1. Infants with a tongue tie were more likely to have breastfeeding problems, but it’s not quite so cut and dry as that might sound. 55% of the babies with tongue tie had breastfeeding problems, whereas 42% of babies without a tongue tie had breastfeeding problems (significantly less than those with tongue tie).

  2. In infants with tongue tie, the overall tongue function subscore on the ATLFF and the item measuring tongue peristalsis were the best way to predict which dyads would have more frequent breastfeeding problems.

  3. Looking across all dyads, tongue tielow birthweight (under 2500g), birth before 37 weeks gestation, and lack of prior breastfeeding experience increased the odds of breastfeeding problems.

  4. The majority of moms do report an improvement in breastfeeding post-frenotomy.

Here’s what this means for your practice: identifying a tongue tie may increase the odds of breastfeeding problems in some infants, but there's more to investigate. Looking at medical history, discussing breastfeeding history, and comprehensive feeding assessment are essential to decision-making. And when you are checking for tongue tie, tongue function is much more relevant than the appearance of the frenulum. 

Schlatter, S.-M., Schupp, W., Jörg‐Elard, O., Sabine, H., Kunze, M., Stavropoulou, D., Hentschel, R. (2019). The role of tongue‐tie in breastfeeding problems—A prospective observational study. Acta Paediatrica. doi: 10.1111/apa.14924.

Oral feeding success: What does that mean for future development?

Let’s say you’re working in a NICU: how well are you able predict which preemies will have difficulty with oral feeding? Or which ones will have impaired global development long after discharge? Or maybe you’re an early intervention SLP. How do you decide who needs services after discharge from the NICU and who might benefit from a wait-and-see approach? This study of extremely low gestational age (ELGA, meaning born before 28 weeks gestation) can help build our sense of who might need extra or earlier support.

Researchers collected data from the charts of ELGA infants, tracking which factors were related to feeding difficulties while still in the NICU, as well as cognitive, language, and motor skills during follow-up visits at 8 months and 20 months corrected age. For this study, infants with feeding difficulties meant no oral feeding by 35 weeks gestational age or inability to consume at least 100ml/kg/day by 38 weeks (aka, not meeting standard nutritional needs by mouth). Let’s break down what they found out by time period:

In the NICU: 59% of the ELGA infants in this study had feeding difficulties. These infants were more likely to have comorbidities that we associate with the sickest preemies (bronchopulmonary dysplasia, hypotension, retinopathy of prematurity, etc.) Other factors associated with feeding difficulties* included longer use of mechanical ventilation, steroid treatment, significant GI issues, and a late start to oral feeding trials. If you’re spending your days feeding NICU babies (and fielding the tricky question of “How soon do you think they will learn to eat so we can take them home?”), keeping these risk factors in mind might help you determine needed treatment frequency or to help parents understand how difficult it really can be for ELGA infants to master oral feeding.
 
At eight months corrected age:  The babies who had feeding difficulties in the NICU were more likely to have lower cognitive and motor skills than the preemies who had a smoother oral feeding course. Additionally, the later an infant started oral feeding attempts, the more likely they were to have poor cognitive or motor outcomes.

But then at twenty months corrected age? Feeding difficulties in NICU no longer helped researchers predict who would demonstrate deficits in development, though authors say that this may have been impacted by a drop in follow-up rates at the 20 month visits.

So if you’re either serving infants post-NICU discharge or deciding which infants to refer to the full gamut of therapy services when they leave your facility, this study can help shape your practice. ELGA infants with feeding difficulties are likely to require early intervention, particularly in their first year. But that doesn’t mean that the ELGA infants without feeding difficulties are home free since prematurity plays a significant role in development. If “which of these babies is most at risk” is a question that keeps popping up for you, check out our growing collection of reviews on prematurity.

*If you’re a NICU SLP, be sure to check out the full text of the article for specifics on which factors (especially those related to GI function) the researchers included in their analysis. Not only can it help inform your treatment, but could be handy to pass on to your neonatologists if you’re advocating for more appropriate referrals on your unit!

 

Patra, K. & Greene, M.M. (2019). Impact of feeding difficulties in the NICU on neurodevelopmental outcomes at 8 and 20 months corrected age in extremely low gestational age infants. Journal of Perinatology. doi: 10.1038/s41372-019-0428-4.

How stable is an early ASD diagnosis?

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Turns out, pretty stable. While available diagnostic tools may not be the best for very early diagnoses (<12 months), this study on over 1000 toddlers sampled from the general population found a diagnosis of ASD made at 18 months by a clinician with expertise in ASD was more stable than diagnoses of language delay or typical development. 84% of children who received an early diagnosis of ASD still qualified for that diagnosis at 3–4 years of age. Other relevant takeaways include:

  • The most common diagnostic transition: ASD at first visit to ASD features at last visit (i.e., children no longer met full criteria for ASD on DSM-V, but still had some characteristics of ASD)

  • Only 1.8% of toddlers went from an initial diagnosis of ASD to typical development

  • ASD was missed in almost 1/4 of first evaluations; many of these later-diagnosed children (~43%) were initially suspected to have a language delay instead

We still need more research to figure out the best treatments and courses of action, so the intervention piece is still business-as-usual; but for now we can trust that early diagnosis of ASD is not only possible, it’s pretty reliable.

 

Pierce, K., Gazestani, V. H., Bacon, E., Carter Barnes, C., Cha, D., Nalabolu, S., …, & Courchesne, E. (2019). Evaluation of the diagnostic stability of the early autism spectrum disorder phenotype in the general population starting at 12 months. JAMA Pediatrics. doi:10.1001/ jamapediatrics.2019.0624.

Red flags for CAS in young children

Childhood apraxia of speech is a complicated disorder that can be difficult to identify, due to its huge variability in presentation and similarities with phonologically-based speech sound disorder. The task is even more challenging when working with very young children with limited vocalizations. But what if there were specific red flags to look for in young children, similar to those we use for suspected autism or hearing impairment?

Overby et al. reviewed hours of home video footage of infants and toddlers to determine if there are clinical red flags that are reliably associated with a later diagnosis of CAS or speech sound disorder. Turns out, the speech characteristics of young children who later receive a diagnosis of CAS are markedly different from those of typically developing children. Between birth and 24 months, the following atypicalities were observed in children with a later diagnosis of CAS: 

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  • Limited vocalizations with few “speech-like” sounds

  • Lack of a speech-like consonant by 12 months

  • Limited consonant repertoire

    • specifically, < 3 consonants at 8–16 months and/or < 5 consonants at 17–24 months

  • Lack of velar productions and favoring of bilabials

  • Favoring stops & nasals

  • Limited syllable structures

    • productions between 13–18 months were largely vowels, lacking CV or CVC structures

As an early interventionist, being aware of these red flags may help to tease out language versus speech difficulties and provide appropriate interventions at a younger age. Infants and toddlers with a later diagnosis of speech sound disorder showed a similar, but less severe profile, and the results did not quite reach significance. However, it is important to be aware of this pattern so that we can provide all children with the most optimal early intervention services.

 

Overby, M.S., Caspari, S.S., & Schreiber, J. (2019). Volubility, consonant emergence, and syllabic structure in infants and toddlers later diagnosed with childhood apraxia of speech, speech sound disorder, and typical development: A retrospective video analysis. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2019_JSLHR-S-18-0046.

A quick course on cerebral palsy

Join me in my rabbit hole for a moment, SLP friends. Bring coffee. Last month, Developmental Medicine & Child Neurology had a whole issue on cerebral palsy (CP).

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Our search takes us back to 2017, when a HUGE group of researchers lead by Iona Novak described diagnosis and treatment options based on their systematic review (note: this research team also included SLPs and people with CP/parents of people with CP as authors, so we have the FULL EBP triangle going on here!). Cerebral palsy is a huge umbrella diagnosis; but in general, CP is defined as a non-progressive disorder of posture and movement related to an injury or some problem in the developing brain. It can be diagnosed between 1 and 2 years, and sometimes a provisional diagnosis is given until CP can be confirmed or ruled-out after a period of development, around 5 years. For a diagnosis of CP, a child has to demonstrate motor dysfunction and either abnormal neuroimaging or a risky clinical history (genetics, stroke, maternal health risks, etc.). Table 1 in Novak et al. will give you a thorough overview of identification and diagnosis.

Last month, Msall published a commentary on a recent paper by Boychuck et al., who surveyed international experts on CP to compile a list of red flags clinicians should keep in mind (see Table 3 or read the Msall’s one-page commentary for more information):

  • Children should be referred for evaluation if they demonstrate things like:

    • Holding hands in fists, asymmetry, or head lag after 4 months

    • Tightness in legs between 6–12 months

    • Requiring support to sit after 9 months

    • Hand preference before 12 months

  • Children should be referred for monitoring if they demonstrate:

    • A persistent startle after 6 months

    • Consistent toe-walking or asymmetric walking after 12 months

  • Children should be referred to SLPs any time there are feeding or communication delays or concerns

    • Speyer et al. reported a high prevalence of feeding (53.5%), drooling (44%), and swallowing (50.3%) problems in children with CP.

Thinking about the diagnostic process and transition to treatment, EI SLPs should be pretty well-versed in interacting with parents, but it’s always nice to have a reminder of parent priorities as they begin to plan for their child’s interventions. Byrne et al. conducted focus groups of parents and providers and found that overall, parents of children with CP want:

  • Honesty and directness from providers, with information specific to their child (not just a general prognosis)

  • Explanations of the assessments and tools used to make the diagnosis (including the names of the assessments)

  • Written material (it helps to be able to refer back)

  • Support from providers and assistance in securing services 

In terms of treatment in CP, EI is critical for development. We have to help build those brain connections and take advantage of early neuroplasticity. While CP is a motor disorder (so you will probably need involvement from PT and OT in some capacity), many children with CP have feeding and communication difficulties, so SLPs are likely to be involved on intervention teams. For communication, Novak et al. recommended supporting parent–child interaction, and considering AAC. If feeding is a concern, the team should assess swallowing safety because pneumonia is particularly risky for people with CP. For those of you providing family-centered services in natural environments, you’re already on the right track for service delivery for this population. McCoy et al. measured gross motor outcomes in children with CP, but their message is powerful for all EI providers. The number of therapy visits (including PT, OT, AND Speech) did not predict outcomes, but family-centered services and the focus of sessions (e.g., incorporating overall health and well-being and engaging in structured play activities) did. So keep coaching those parents on how to implement interventions in enjoyable and contextualized settings.

 

Boychuck, Z., Andersen, J., Bussieres, A., Fehlings, D., Kirton, A., Li, P., …, & Majnemer, A. (2019). International expert recommendations of clinical features to prompt referral for diagnostic assessment of cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14252.

Byrne, R., Duncan, A., Pickar, T., Burkhardt, S., Boyd, R., Neel, M. L., & Maitre, N. L. (2019). Comparing parent and provider priorities in discussions of early detection and intervention for infants with and at risk of cerebral palsy. Child: Care, Health, and Development. doi: 10.1111/cch.12707.

McCoy, S. W., Palisano, R., Avery, L., Jeffries, L., Fiss, A. L., Chiarello, L., & Hanna, S. (2019). Physical, occupational, and speech therapy for children with cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14325.

Msall, M. E. (2019). Establishing community pathways for the early recognition of cerebral palsy: Red flags, enablement, and family support. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14314.

Novak, I., Morgan, C., Adde, L., Blackman, J., Boyd, R. N., Hernandez-Brunstrom, J., …, & Badawi, N. (2017). Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment. JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1689.

Speyer, R., Cordier, R., Kim, J., Cocks, N., Michou, E., Wilkes-Gillan, S. (2019). Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: A systematic review and meta-analyses. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14316.