Symptoms of Tongue-Tied (Short Frenulum, Ankyloglossia)

Recently I had a friend whose baby was diagnosed with being tongue-tied, also known as ankyloglossia and short frenulum. I wish that her baby boy had been diagnosed sooner, but it took over a month. Although that seems long to me since I work with small babies, I know that some people go even longer before having an answer to their child's feeding and language problems.

My friend's son had poor feeding problems from the beginning and didn't learn how to breastfeed. That should have been the first clue of a problem, because Mom had already successfully breastfed her older son for a year. She said when she attempted to breastfeed him, it hurt really bad, even after she tried to put his lips on the right part of her areola. I only wish she could have gotten together with a lactation consultant (LC) because I think it would have been diagnosed then, but she didn't go to a LC. So, Mom switched her son to a bottle, but not just one bottle, she went through 5 different types of bottles and nipples before she found the "right" one. Even then, he only drank an ounce or two of formula at a time and it took over 20 minutes just for that small amount. He had poor suction on the nipple of his bottle and pacifiers, which lets us know his tongue wasn't working very efficiently. Somehow he was slowly gaining weight and not losing, yet the quality of life was chaotic for Mom because she was practically feeding him most of his waking hours.

After talking to her sister-in-law over the phone who lived far away, but who happens to be a pediatric nurse, my friend realized what it was- ankyloglossia. She was asked to look to see if he could stick his tongue out over the gumline, and he couldn't. She was asked if the tip of his tongue looks like the bottom of a heart because of the skin under the tongue bounding the tongue down, and guess what, it did have a heart shape. My friend was advised to take this information back to her pediatrician, so she did. Once the doctor got a better look, she realized that other symptoms were present. They included: high palate, gags easily, and sometimes has trouble swallowing liquid (would just hold it in the oral cavity). Also noted was that he had tight neck muscles, maybe because he was using every head/neck muscle he had just to drink from a bottle. My friend's son was also diagnosed with GERD (reflux), so I think that the feeding problems were blamed on that, but once the medicine didn't fix everything, it was obvious there was more going on than reflux.
He then got his frenulum (skin under the tongue) clipped. Feeding problems got immediately better, and he has gained weight at a higher rate now. He doesn't even need to do any oral-motor exercises, he just figured it out after a couple of feedings, and he can even drink from more than one type of bottle. So, not only were mealtime problems resolved so were any possible future speech problems! And even better, parents can sleep more at night with less frequent wakings for a feeding!

Every once in a while, I am the one that notices ankyloglossia, but usually it has been identified by the hospital staff, pediatrician, or lactation consultant long before the child was sent to me for a feeding disorder. Sometimes when I catch it, there are other problems as well including delayed gross-motor skills, poor sleeping, and irritability...of course if I couldn't eat and sleep well, I would be grumpy too! So, don't assume that just because no one has ever diagnosed your baby with being tongue-tied that he doesn't have it. If you notice the above-mentioned symptoms, please call your child's physician and have them do a detailed oral exam!

Improving Balance Through Simple Play

I used to work in a therapy clinic and before that a hospital. One of the positives to those facilities, was LOTS of equipment including swings, rocker boards, balance beams, balls of various sizes, rock walls, air mattresses, trampolines, and more! It is so much easier to help children work on their balance with all of this equipment. The downside is that the child doesn't have this equipment at home, and at the most the child is getting 1-3 hours of weekly therapy in the clinic. So, what about all of those waking hours spent in play at home with no equipment? How can the family help the child improve on his balance skills? Well, going to the park, restaurant playgrounds, and mall play areas are great ideas, but those locations are limited also...you can't live there after all. You also can't live at the facilities that have gymnastics, dance, and karate lessons.

I like to teach parents simple ways to help a child improve his balance skills that doesn't require any equipment at all; just their bodies and items they already have around the home. Some simple ideas for babies and young toddlers include:

-Lap play: have the child sit on your lap while facing you, and as you sing and talk to him, bounce him gently up/down and side-to-side to help elicit equilibrium reactions in which the arms come out to the side and the head comes back to the middle. I sing songs such as "The Noble Duke of York", "Rock, Rock, Rock Your Boat", "Getty Up Horsie", and make up songs that don't even exist. Initially, place your hands on the child's trunk (belly/back), then as he improves, lower your hands toward his hips. Be sure to watch the facial reactions in order to know if you can make it harder or should slow down.

-Animal walks: toddlers love to play pretend such as getting on all fours on the floor and pretending to be a cow or puppy. They also like to slither on their bellies as if they were a snake. My two favorite animal imitations are donkey kicks (get on all fours and kick the legs behing you) and bear crawl (similar to a dog, but straighten the legs so that the bottom is pointed in the air, if you are into Yoga it is the "Downward. Dog" pose). Try these or make up some animal imitations.

-Dance: Hold the older baby or toddler in your arms while you sway side-to-side, spin both ways, or jump up and down. Even lean over to see if the child can handle his head being upside down.

-Jumping on the bed: hold the child if he can't jump yet and help him jump. Then after awhile, place him on the floor and see if he can stand longer on his own. Often, the proprioceptive input from jumping helps with "body in space" awareness". If the child can independently stand and jump, then make the game harder such as squatting to jump like a frog or bunny, or add singing or music, especially a song about jumping. For an older toddler, have them jump down from a stool or over the stool as if they are Jack Be Nimble jumping of the candlestick!

I have many more ideas...the sky is the limit! I just listed a few to let you know that you don't need lots of expensive equipment to work on balance skills in between therapy visits. Well, time to go join my husband and daughter playing "Five Little Monkeys Jumping On the Bed".

Fostering A Young Child's Imagination

I have to hand it to my husband because for someone without any education what so ever in child development, he does an excellent job of fostering our two children's imagination. It is not uncommon for him to bring home toys or items for him and the kids to play with. He tends to buy the fun imaginative toys and I tend to buy the fun craft projects and gross-motor toys; my only rule is no hand-held electronic devices until the kids are older. I also limit computer time and electronic toys of any type. The key word is limit, not eliminate.

My favorite story about him and my daughter playing imaginatevely is how he bought her a Peter Pan costume and him a Captain Hook outfit that included the eye patch, hat, hooked hand, and sword. He did this back when she was four years old and they had watched the Disney (R) Peter Pan movie numerous times. She then started wanting to act out scenes with her Dad. Of course he is thinking "How can you really act out the scenes without the proper gear?". I stood back and watched them play. It was amazing to watch. She quoted lines from the movie here and there, but mostly just played the part. He would toss her in the air onto our king-sized bed to pretend like she was shot out of the cannon. Then she walked across the bed as if it were the plank. They also had sword fights with foam swords. She sometimes switched roles and was Tiger Lily. To top it off, she insisted at bedtime everynight for at least 3 months that him or I read the Peter Pan story to her. From an occupational therapist's point of view it was nice to see the motor planning, coordination, and problem-solving during the whole play period.

Really, this is huge, because so often the children I work with that have developmental disabilities have difficulties with play. Not only is the reciprocal interaction difficult, but also not perseverating on how things must go. Often the play skills of the kids I work with is initially guided by the adults. It then hopefully progresses to the children initiating the ideas and expanding the amount of time they can play one activity. Because I work with infants and toddlers I don't see this often, but sometimes right around the time the child turns 3 years old it starts to emerge. It is times like that I wish I still worked with children of all ages such as when I worked in a therapy clinic.

Sometimes I work with children who are functioning age-appropriate or above normal in the area of cognition. Maybe I am working with them in OT due to feeding problems or orthopedic impairments of the upper extremities such as a brachial plexus injury. When I do work with these kids, once they are two years old I can get them to do amazing things all in the name of imagination. For example, if I can get a 30-month old boy with a nerve injury to his arm to pretend that the exercise ball is a horse and that he is a cowboy, then I can get him to do some great stretches, strengthening, and balance exercises without him ever realizing it. If his favorite character is Spider Man, then we can jump, wheelbarrow walk, and go through obstacle courses while he pretends to be Spider Man. The possibilities are endless.

One population of children with age-appropriate cognition that I sometimes see a "not so good" imagination in is kids with feeding problems. Not the mechanical or motor problem feeding delays, but the behavioral and sensory-based feeding problems. Some of the time this is due to the overly structured environment they live in along with being constantly told what to do; maybe this is the etiology of the feeding problem- they can control food and mealtime even when they can control nothing else. Before I make anyone mad, I emphasize "sometimes", mainly because sensory-based feeding problems have many reasons for arising. I am focusing in on when it is truly a child with behavioral based feeding issues. For example, if a 2.5 year old child is somewhat robotic in that he can label colors, animal names, and facts that only a 5 or 6 year old would know, but can't play with his kitchen play set or with another child interactively, then imaginative play is delayed. And the reason is not because he is not intelligent enough. I can peg these kids quite early on in the evaluation process because usually the parents are trying to answers questions for the kid and guiding them to follow my directions with multiple cues. If the child doesn't perform, the parent either becomes frustrated, demands the child do it again, or tells me "I know he can do this".

Some thoughts on promoting imagination during play:

- offer toys that can be played with in more than one way such as cars, blocks, dress up clothes, and balls. Not that toys that can only be played with one way are bad, they just may not promote the imagination as much.

- follow your child's lead instead of having them join your play all of the time. For example, if your child has a limited repertoire of play and insists on playing with trains on the tracks, not expect him to play dress-up with an animal costume. Instead, change the train tracks, change the location of the train table, or push the trains around the room including over the chairs, under the table, and through the hallways while making "choo-choo" sounds. Expand upon their interests which is much more likely to help them be creative.

- encourage simple artwork such as finger paints, water sticks, chalk, and crayons. Do this with blank paper as opposed to a coloring book

- set up obstacle courses and pretend like you are in the jungle or some other place, and name all of the furniture after what you would see in the jungle. When crawling between the back of two chairs with a sheet draped over it, pretend as if that is the dangling greenery from the jungle trees.

Well, that is enough ideas for now. I am off to go play cops and robbers in the backyard with my two little ones!

Understanding Social Cues

Today is Easter. Yesterday, our subdivision had an Easter party and mini-carnival in the nieghborhood park. Not only do I love these type of events because they are fun, but I enjoy watching children play. I think it is fun to watch the kids during the Easter egg hunt. And this year a little excitement was added when a baby rabbit jumped across the park, then 10 minutes later the mama rabbit jumped out too. The kids were squealing ecstaticly as they watched and chased the rabbit. Of course the kids were also happy to participate in the games such as the bean bag toss, "fishing", sack races, and the cake walk.

It was at the cake walk that I was in such a state of analyzation while I observed my son. At first, he was watching the other kids (including big sister) walk around the course of numbers as he sat in his stroller. Then they stopped and if their number was called out, they won a cake or other treats. Eventually, he repeatedly said "walk, walk", so I let him out of the stroller. My gut was that this 21 month old is going to run all around aimlessly. But he didn't. I was pleasantly surprised when he went over and joined the school-aged children at the cake walk. He even went the correct direction and walked about the same distance from the numbered markers as the other kids. What impressed me the most, is when the music stopped he looked around and noticed the other kids stopped at a marker. So he stopped and he stood there for about 2-3 minutes just like the others did. When the music began again, he participated again. I was in such awe that I didn't have to teach him how to participate; he just took social cues and used them correctly. I have 6 year old clients with developmental delays or autism spectrum disorders that don't know how to do this. It always amazes me how effortlessly a typically developing child learns to perform such skills. Maybe because I was an occupational therapist for 9 years before I had my first child, but I am always flabbergasted that such things don't have to be taught. This makes me appreciate the littile kids that I work with even more, because they have to work soooo HARD for every new skill they learn. And for many reasons, social skills are one of the last things to come along. Language and motor skills are often the focus of therapy initially. Later on, emotional, behavioral, and cognitive skills are addressed. But it takes all of these skills combined to have decent social skills. Whether it be reciprocating during conversation, imitating the action of peers, or not blurting out something inappropriate, social skills do not come easy to many young (and older) kids with disabilities.

Sometimes to work on client's social skills, I meet clients and their parents within the community such as at McDonald's (R) playground and parks. These places seem to always have other children present which makes it the perfect location to work on social skills. Sometimes, I have clients that progress to reading the cues of the other kids, but so often we are working on the basics such as waiting in line at the slide, not pushing or hitting other kids, and playing near other children. I do think however with repetition that many children eventually learn these skills, especially when imitation is a focus in individual therapy sessions. Those who do not catch on naturally over time may benefit from a social-motor group at a local therapy or psychology clinic. At first, the parents and therapist are exerting a lot of energy for the kids to play together. Over time, it is nice to see how the adults can back-off because the kids are improving...yeah!

CLASS: community living assistance services and supports

If it weren't for the recent healthcare reform bill, many Americans would shrug their shoulders if you asked them if they knew what the commnity living assistance services and supports (CLASS) program was. In fact, some of them still don't know what it is, mainly because the healthcare reform bill is over 2300 pages long, so who could expect them to understand every single detail?!? But this post will not get into my positive and/or negative thoughts on the bill. I am just motivated to blog on the CLASS program.

Although it is a federal program that provides long term care for mentally and/or physically disabled Americans, each state varies a bit in how they handle enrollment and other details. Information on the criteria for who qualifies can be found on this government link:
http://www.retiredamericans.org/ht/a/GetDocumentAction/i/12355 and http://www.kff.org/healthreform/upload/7996.pdf

What is consistent across state lines is that it helps with the long term needs of the individual. It may include payment for adapted feeding equipment, respite, physical/occupational therapy treatments, wheelchair and accessories, and modifications to a home/apt. By keeping the individual with special needs as independent as possible, it is believed to help in numerous ways, and possibly save the taxpayers money because the individual is overall healthier and less dependent upon caregivers. I have had the honor of providing therapy services to young adults with cerebral palsy in which CLASS paid for it. The only thing that seemed to be a bit burdensome is when I ordered adapted feeding equipment or computerized assistive technology, it took many months for the paperwork to be processed and items to be purchased. But hey, at least it got paid for eventually, and these young adults wouldn't have had the money to pay for it on their own otherwise.

I presently work as an occupational therapist with infants and toddlers, and at times am doing case management (social work) with families too. One of the things I encourage families with children with developmental disabilities (cerebral palsy, down syndrome, CHARGE, etc) to do is sign up for the CLASS program. They can sign up on the waiting list for more than one company that sponsors it, but once they're application is being processed they can only go with one facility. I say to go with the first place that calls you, or at least in my area. One place I know off of the top of my head that offers the programs is MHMRA. In the state that I live in sometimes it is 5 or more years before the child's application gets processed and they begin the CLASS program. Some states are quicker, probably depends on funds and populations...not sure. It seems so weird to rush these parents of babies into signing up for various programs when they have barely grasped the reality that their baby will have a permanent disability. But if they wait to sign up for it when they need it, then they'll be disappointed of the waiting period. There are numerous other programs that I encourage people to sign up for, but I think every state is so different in what they offer. I encourage parents to find a case manager if they don't already have one. They can really help you navigate the world of special needs programs. And it looks like after the healthcare reform bill is in effect, there will be changes to the present programs as well as new additional ones.

Defying Gravity...Carnivals Should Be Fun!

Today my family of four along with my sister-in-law went to the carnival. Within the "kiddy" section, there were simple rides like the carousel but there were some more gravity-defying rides as well. My husband enjoyed riding the rides with my 6 year old daughter while my 21-month old son stayed in the stroller and I took pictures of everyone. But I did manage to get on one ride with my daughter, and boy was it fun! It was a ride that went in a circlular pattern while the kids/adults layed two people to an "airplane". While on our airplane, we were lying on our bellies and strapped in from behind. Not only did the ride go in a forward circular pattern, but it also went up/down making you feel as if you were "losing your stomach". Now, I grabbed my little one's hand, because I was thinking she may freak out. But I was wrong, she squealed with laughter. She had so much fun! And she should have. Once kids are of a certain age, they should think it is so much fun to move in various ways against gravity. It is not uncommon to see a toddler trying to be upside down off a couch or jumping off of furniture!

There are five directions to move within space: up/down, forward/backward, circles (rotary and axial), upside down, and sideways. Swinging on a swingset back and forth is a simple way to move, whereas riding the carnival ride today as described above was more complicated because it combined movements. When we move in these various directions, vestibular receptors in the inner ear are stimulated. The vestibular system can be a tricky sense. When a person has an ear infection or vertigo, this system can go haywire and throw the person's balance off. It is quite scary to feel off balance. That is why some kids with vestibular disorders don't like carnival rides. In fact, some would probably whether do anything but get on that ride!

If you have a child who doesn't like to play at the park on the swings, slides, or climbing devices, it is possible that he has difficulties with vestibular processing. If the child also has a gross motor delay or falls often, this should be discussed with the child's physician. Physical or occupational therapy services may be necessary to help the child. It may seem trivial when the child is only 2 years old, but if the problem is not corrected, the child ends up being a grade schooler who can't ride a bike or roller skate with his peers. He may also be the type who is clumsy, making him be the last one chosen to play games during school recess such as for soccer or dodge ball. If you suspect that your child has problems with vestibular processing, it is definately worth checking out.

Some other signs of the problem could include: low muscle tone, delayed development with two handed activities, clingy to parent when should be playing with peers (especially at birthday parties), fatigues easily, scared to sit in chair or on potty due to dangling feet, short attention span, and delayed eye-hand coordination. Those were all symptoms of kids who are over-responsive to vestibular input or who have sensory based motor disorders. Kids who are under-responsive are more lethargic and passive. Kids who are sensory seekers are described as the energizer bunnies and can never seem to get enough movement unless they are asleep. Some of these kids are even known to tire out the family's energetic dog! They tend to jump from high surfaces, fidget, and spin around. All of this over activity needs to be directed, especially if the child has a language or fine-motor delay. These children may or may not have a sensory processing disorder (SPD, AKA sensory integration dysfuncton), but should be checked out by a therapist. I don't think that every child with the above-mentioned symptoms necessarily has a vestibular disorder, there could be other things going on including neurological deficits, other disabilities, or environmental factors. An example of an environmental factor is lack of or decreased stimulation such as being at home all day with a mom who is on bedrest and can't help the child get the necessary exercise he needs, so he overly seeks out movement such as jumping off of high surfaces. This is the case where it is well worth it to pay extra for a young babysitter to come over to play or to invest in a mini-trampoline for the living room. So, not every referral to a therapist will mean the child needs intervention, but maybe at least some ideas can be generated for helping the child.

Understanding Baby's Signals

By no means am I the baby whisperer, but I'd like to think that I am pretty good at reading cues babies give off to let us know their needs. For example, sucking on their fingers indicates that they are hungry whereas having irregular breathing can indicate they are drowsy. I think that this is important for new parents to understand, especially when it comes to understanding why the baby is crying. Afterall, not every tear shed from the baby means they neeed a bottle!

Instead of re-writing every signal babies tend to give off, I am providing links to a couple of sites that do a good job of explaining this already



http://www.sense-ablebaby.com/Our_Baby.html#Infant_Sleep_&_Wake_States

http://www.uihealthcare.com/depts/maternitycenter/newborninfo/signals.html