Post Pediatrician Visit Update (tongue-tie / mouth breathing)

As such things often are, Michael's pediatrician visit was oddly anti-climactic. I think I tend to build doctor visits up in my head as Super-Important-Life-Altering-Decision meetings when often they are pretty routine. Our pediatrician was -completely- uninterested in the tongue-tie. She had been educated that clipping a tongue-tie rarely fixes speech problems and didn't want to give it further thought.

I've been thinking about why the tongue-tie bothers me even though I know that Michael can produce 4/6 alveolar sounds. It bugs me that he cannot stick his tongue out horizontally and cannot lift his tongue up on command. If it isn't the tongue-tie restricting that movement I want to know what is. Is it weakness? If so, what is the origin of the weakness? Can habitual mouth breathing result in low enough tone to impact tongue strength? Our pediatrician was uninterested. She said, some people can curl their tongue up. Some can't. Perhaps Michael just can't lift his tongue. I have to say, I was unsatisfied.

She was, however concerned about the mouth breathing. After examining him, she declared his tonsils of normal size. She can't see his adenoids though and wants him to see an ENT to get an opinion about the tonsils/adenoids/sinuses. She said I could ask the ENT about the tongue-tie if I wanted another opinion.

Her bet however, based upon my husband's history of needing allergy shots as a child and Michael's history of eczema, is allergies. She referred us to an allergist and wants him to take Flonase at night and Claritin in the morning. The receptionist for the allergist told me that they always allocate time for skin testing even when scheduling an initial appointment so I need to pull him off the Claritin 5 days before the appointment just in case the doctor decides he needs skin testing.

Hmm. Skin testing my 4 year old. That sounds... interesting. Other than educating him before hand, bringing something distracting to watch on the iPad, and some super special treat for when he's done does anyone have any suggestions for what to expect or how to handle it?

Presumably, when we figure out why Michael can't breathe through his nose and address the underlying issue the mouth breathing will cease. Perhaps some improved tongue strength and mobility will follow? It'll be two weeks or more before we get through the specialist appointments and begin to get some answers (I hope). I sure do hate waiting.

The Weekly Review: Week 54

Crafty SLP Idea of the Week

Katie at The Red Kitchen made 26 beanbags out of old t-shirts (one for each letter of the alphabet). She stitched the capital letter on the front of each beanbag and the matching lowercase letter on the back. They are adorable and you should definitely follow the link to her tutorial if you're interested.

If you made some for the consonant sounds you could play a ton of games with them. Kids could toss them back and forth and say the sound each time they catch the bag. They could toss them in a bucket or through a hoop. They could play hot potato with them. You could use them for practicing the sounds in isolation, or have older kids think of a word that contains the sound.

Ava this Week

Ava's been bitten by the I'll-do-it-myself bug. Every time I try to help her with something only to have her firmly and often rudely reject my assistance, I have to take a deep breath and remind myself that this is a good thing. She's becoming more independent. Letting her do things herself improves her self-help skills. It would all be easier if she said it sweetly, with a pleasant smile and managed to do it just as quickly as if I were helping. Is that too much to ask?

Weekly Michael

The littles were playing in the backyard together by themselves (oh, the joy) the other day. The back door opened with a boom and Michael came running inside looking for me with quite the sense of urgency. I mentally prepared myself for some kind of minor disaster. Instead, he just had a question. "Mama, is sod a word?"

We've been having fun with rhyming and playing games with word endings, so we have been having lots of discussions of what is and what is not a word. So I wasn't completely surprised by the question. I told him "yes" and launched into a somewhat long-winded discussion of what sod is. As soon as I finished, he rushed back outside shouting to his sister, "Sod is a word, but it doesn't mean jump!"

I was left wondering what exactly their discussion had been about before Michael came in to request my expert opinion.

Ava's and Michael's Weekly Home Therapy Notes

The children have enjoyed the change of pace provided by the magnet cards and switcheroo game, and we met my goal of slowing down to focus on quality over quantity. I think next week we'll go back to drill fueled by bribery though and focus on some intense practice again.

It explains some things... (Calling for tongue-tie experts)

So here's the situation. Earlier this week I took the children to the dentist. She informed me that Michael has a mild-moderate tongue-tie. My mental response: Umm what? Are you sure? How on earth could I have possibly missed that!!! Did you make that determination based upon physical examination or behaviors?

I wasn't present for his examination because they accidentally scheduled the children at the same time and I was busy with Ava keeping her very overloaded sensory system calmed down just enough to get a little cleaning in through holding her in my lap, trying to simultaneously cover her ears and hold her hands, and singing soothing songs. But that's another story and I digress.

I knew Michael can't raise his tongue on command and that he can't stick it out very well. When you ask him to stick his tongue out he can get it out, but it curls down and sticks to the outside of his lower lip. He cannot stick it out forward at all. He can't raise it at all. I had always assumed that that was part of the same motor-planning spectrum that I've become so familiar with in Ava - or possibly a weakness issue. Well, look at where assumptions get you.

When we got home, I grabbed a clean cloth and pried up his tongue. Sure enough, you can't get it up very far and his lingual frenulum extends pretty far towards the tip of his tongue. On top of that, the lingual frenulum doesn't stretch at all and therefore even with some gentle manual pulling you can't get a lot of distance between the tongue and the bottom of his mouth. On top of that, he cannot get any upward curl of the tip of his tongue at all.

Let's summarize. Michael does appear to have a mild-moderate physical tongue tie. He has speech problems with /f, v, s, z, and th/. He produces all of those sounds as an interdental /s/ that is produced auditorily as a nice sharp /s/ sound. So, his /s/ sounds sound fine but are produced "incorrectly" and his /th/ sounds are produced with proper placement but sound like an /s/. He can, however, produce /t, d, and l/ just fine and those involve alveolar placement.

So here's my question for anyone out there who wants to chime in with an opinion. Given that he can produce /t, d, and l/ is it likely that the tongue-tie is the issue with the other speech errors? If there is no functional consequence of the tongue-tie I'm reluctant to have it clipped. However, if it is likely that the tongue-tie is impacting his speech errors, even in part, getting it clipped seems like an option to consider.

I already have a pediatrician appointment set up for Friday to discuss Michael's chronic mouth-breathing and nasal congestion and I intend to get her opinion about the tongue-tie issue then. However, she's not a speech-path so her opinion on whether it is effecting his speech isn't going to be an expert one. She's more the person to offer information and pros and cons on the procedure itself.

Thoughts and opinions from SLPs with some experience with tongue-tie? Please. :-) I tried to get some pictures for reference, but it was tricky. I had to try to manipulate his tongue with my left hand while taking the picture one-handed with my right. I apologize for the picture quality.

The first picture is what he does if you just instruct him to stick his tongue out.

The second picture is what he can do if you model sticking the tongue straight out without letting it curl downward.

The third is his attempt to curl his tongue up. He tilts his entire head backward and tries to push it up with his bottom lip and bottom jaw.

The fourth picture is my attempt to get an actual picture of his lingual frenulum.