Global Perspectives on Tongue-Tie Assessment of One to Ten Year-Old Children in Speech-Language Pathology

Abstract

Purpose: Speech-language pathologists (SLPs) are essential in evaluating tongue structure and function. Due to limited psychometrically validated assessment tools, evidence-based practitioners often rely on clinical expertise to inform their assessment and clinical decision-making. This study aimed to explore how SLPs assess tongue structure and function in children aged 1 to 10 years suspected of having a tongue-tie by examining global practice patterns. Methods: A total of 194 practicing, English-speaking SLPs participated in a global online survey. The survey gathered information on participant demographics, classification tools used, and methods for assessing tongue structure and function, oral motor function and speech production in children with suspected tongue-tie. Results: Participants reported using various measures, including case history, oral examination, and clinical assessment. These measures encompassed evaluation of tongue structure, oral motor tasks and functional measures, including observation of speech, feeding, and swallowing. Notably, 40% of participants indicated they did not use any published assessment tool. While over 90% of participants evaluated feeding skills through parent questionnaires, only 55% observed feeding during mealtimes. Additionally, SLPs in the United States reported using different classification tools for tongue-tie compared to their counterparts in Australia, the United Kingdom and other countries. Conclusion: There is a global trend of limited use of published tongue-tie assessment tools in clinical practice. Most clinicians rely on various measures to evaluate tongue structure and function in children with suspected tongue-tie. These findings highlight the need for a specialized assessment tool that is designed and validated for evaluating tongue structure and function in children beyond infancy.

INTRODUCTION

Speech-language pathologists (SLPs) play a pivotal role in infant feeding and swallowing to ensure optimal health and well-being in children and promote mealtime participation. Scope of practice guidelines emphasize SLPs’ key involvement in assessing, diagnosing, and managing various aspects of feeding, eating, drinking, saliva control, and swallowing over the lifespan (SPA, 2022; ASHA, 2016).

Ankyloglossia, commonly known as tongue-tie (TT) is characterized by a functional restriction of tongue movement from a restricted lingual frenulum (Australian Dental Association (ADA), 2000; Fernando, 1998). Prevalence rates for TT vary, ranging from 0.1% to 32.5% depending on age and diagnostic criteria (Hill, Lee & Pados, 2020; Maya-Enero et al., 2021; Suter & Bornstein, 2009). An increase in surgical interventions globally over the past two decades correlates with increased breastfeeding rates and heightened awareness of TT (Chinnadurai et al., 2015; Kapoor et al., 2018; Walsh et al., 2017). While most of the literature on TT focuses on infants, untreated TT in children over 1 year of age has been associated with speech sound production difficulties, feeding challenges, orthodontic issues, sleep and breathing disturbances and impairments to activities like licking ice-cream on a cone and kissing (Chinnadurai et al., 2015; Walsh & Benoit, 2019; Yoon et al., 2017).

The definition of ankyloglossia or TT refers to both structure and function, and it is imperative to assess both aspects thoroughly. Therefore, comprehensive case history and thorough assessment of oral structure and function conducted by qualified professionals, including SLPs, are recommended for evaluating TT (Messner & Lalakea, 2002). Various published assessment tools, including classification systems and comprehensive assessment protocols (see Appendix A and Appendix B), are available to guide clinical assessment, measuring a broad spectrum of tongue structures and functions. Despite the functional definition of TT emphasizing a restriction in tongue mobility due to a short or restricted frenulum (ADA, 2020), commonly used classification systems often evaluate TT severity based on a single structural or functional measure, lacking comprehensive diagnostic capabilities and psychometric data (Kotlow, 1999; Garcia Pola et al., 2020; Ruffoli et al., 2005; Yoon et al., 2017). Comprehensive TT assessment protocols, such as the Lingual Frenulum Protocol, offer a more inclusive evaluation, encompassing both structural and functional aspects (Marchesan, 2012). However, psychometric information for the English version of the LFP is unavailable and validation was conducted with children and adults over 7 years of age in Portuguese (Marchesan, 2012). A systematic review by Suter and Bornstein (2009) highlighted the need for universally accepted diagnostic criteria and measures for TT assessment.

The overarching goal of the current study was to investigate how SLPs assess tongue structure and function in children from 1 to 10 years of age with suspected TT. By exploring practice patterns globally, we aimed to:

• Explore case history items utilized by SLPs in assessing TT.
• Evaluate classification systems used by SLPs to categorize the appearance and severity of TT.
• Identify tools and methodologies employed by SLPs to measure tongue structure.
• Examine oral motor tasks recommended or prescribed by SLPs as part of TT assessment and management.
• Identify tools and methodologies that are used to assess functional outcomes and efficacy of different assessments of tongue function in children with TT, including speech production.

Materials and Methods

Ethical clearance was secured from the Curtin University Human Research Ethics Committee (HREC2020-0301) before initiating this study. This research employed an online, descriptive, cross-sectional survey aimed at English-speaking SLPs globally, to explore the clinical assessment practices for 1 to 10 year-old children with suspected TT.

Participants

The target group comprised SLPs proficient in English from any country. Recruitment efforts were made through Speech Pathology Australia (SPA), Speech-Language and Audiology Canada, as well as various professional interest groups with international membership via social media.

Materials

An online survey was generated using Qualtrics software, Version 13 (Qualtrics, 2013). Survey questions were formulated based on outcomes from a literature review of assessment tools and insights from other relevant online surveys (Brinkmann et al., 2004; Richmond, 2019). A total of 15 questions explored participants’ utilization of published assessments and the specific structural and functional measures they employed.

Table 1. Online survey questions: speech-language pathologist participant demographics and assessment use for assessing children with suspected tongue-tie.

provides an overview of the survey questions. In instances where respondents selected the ‘other’ option within a multiple-choice question, they were encouraged to provide a detailed description.

Procedure

Before the survey launch, two speech-language pathologists (SLPs) with expertise in survey research reviewed the survey meticulously. Their feedback focused on assessing the survey’s structure, clarity, and content. This preliminary review was crucial for refining the instrument and ensuring that it effectively captured the intended information. The online survey was accessible for a duration of 8 weeks, spanning July to September 2020. An information flyer containing a reusable survey link was disseminated through professional organizations and social media channels. Essential participant information and details regarding informed consent were featured on the first landing page of the survey. Participants indicated their informed consent by selecting ‘yes’ to commence the survey.

Analysis

Data were extracted from Qualtrics into Microsoft Excel and were used to compute response frequencies for multiple-choice questions and rank-order options for questions requiring ranking.

Content analysis was applied to free text responses under the ‘other’ option for all questions, as well as additional comments provided after the survey following the methodology outlined by O’Cathain and Thomas (2004).

RESULTS

A total of 255 participants from 20 countries consented to participate in the study, 206 respondents answered questions beyond the initial demographic section, and 147 completed the entire survey.

Table 2. Online survey: speech-language pathologist respondent and attrition rates by question.

lists a summary of respondents by question.

Participant details, such as nationality, workplaces and years of experience are detailed in

Table 3. Demographic characteristics of participants) by nationality, workplace context and years of experience.

. The average duration of experience was 12.3 years (SD = 9.1).

Participants reported the frequency with which they assess clients aged 1 to 10 years with TT and whether they typically serve as the initial point of contact for evaluating children in this age range. Responses are documented in

Table 4. Frequency of assessment and initial contact role in tongue-tie evaluation for children aged 1 to 10 years (N = 206).

.

Participants were asked to report on the average duration of a typical assessment for a child aged 1 to 10 years with TT, with most reporting it takes less than 15 minutes (Figure 1).

Respondents were prompted to select all applicable options regarding the sources from which they have received referrals to assess children within this age range for TT. Examples of other practitioners from which SLPs received referrals included lactation consultants, paediatricians, bodyworkers (e.g., osteopaths, chiropractors) and neonatologists. Additionally, they were asked to identify the professionals to whom they refer 1 to 10 year-old children with TT.

Table 5. Sources of referrals to and from speech-language pathologists by participants when assessing children aged 1 to 10 years with suspected tongue-tie (N = 206).

provides a comprehensive overview of the sources of referral to SLP services and the recipients of referral from SLPs in this context.

Case History

Participants were requested to discern the case history questions that offered the utmost insights, prioritizing them during the assessment (

Table 6. Participant prioritization of case history questions in tongue-tie assessment (N = 147).

).

The three most important case history items were feeding history/current issues, medical history, and breastfeeding history. The three least important case history items were aesthetic concerns, fluency, and social/emotional impacts of TT.

Assessment Tools

Table 7. Assessment or classification systems used by participants when assessing children aged one to 10 years with tongue-tie by country (n = 147).

lists the reported frequency of utilization of published assessment tools, encompassing classification systems, comprehensive assessment protocols, and various instruments. Participants could select all that applied. Interestingly, of the top two assessment tools by geographical region, all countries selected ‘None’ as one of the top two. In the US, the majority of participants utilize the Merkel-Walsh and Overland (2016) Tethered Oral Tie screening tool (17%), whilst in Australia the second most frequently used assessment is the ATLFF (Hazelbaker, 1999), and of other counties, the Kotlow (1999) and Quick Tongue Tie (Yoon et al., 2017) were the second most frequently reported. A subset of participants (8%) also indicated the use of alternative tools, such as the Nuffield assessment (Williams & Stephens, 2004), resources from Pamela Marshalla (Marshalla Speech & Language, 2024), and the Beckman Oral Motor Evaluation Protocol (Beckman, 1986).

Measures of Tongue Structure

The use of measures of tongue structure is outlined in

Table 8. Measures of Tongue Structure Tools Used by Participants to Assess Children Aged One to 10 Years of Age with Tongue-Tie by Country (N= 147).

. Ninety percent of participants reported assessing tongue tip appearance in both elevated (n = 133) and protruded tongue positions (n = 132). The other most reported measures included lingual frenulum appearance (n = 128) and measuring lingual frenulum length (n = 110). When analysed by geographical region, the top three items reported by participants from the United States (n = 418), Australia (n = 221), United Kingdom (n = 29) and other countries combined (n = 62) were ‘tongue tip appearance when elevated’, ‘tongue tip appearance when protruded’, and ‘lingual frenulum appearance.’

Oral Motor Tasks

A summary of assessments of oral motor tasks as reported by participants by geographical area is provided in Table 9. Other measures included suction of the tongue onto the palate (n = 8), dissociation of tongue and jaw movements (n = 3), tremors (n = 1), coordination (n = 1), tongue tip sweep of teeth (n = 1) and licking of hard palate front to back (n = 1). Three participants noted difficulty eliciting oral motor tasks due to the age of their clients. There was significant overlap of oral motor tasks by country, with all countries reporting ‘tongue tip elevation (when mouth is opened as wide as possible)’ as the top item assessed in the United States (n = 72), Australia (n = 40), United Kingdom (n = 7) and other countries combined (n = 13). The full distribution of tasks by country is outlined in Table 9.

Assessment of Speech Production

The utilization of measures related to speech production is outlined in

Table 10. Assessments of speech production used by participants when assessing children aged one to 10 years with tongue-tie by country (N = 144).

. Other measures included tongue placement during speech, tongue and jaw movement during speech, phonetic inventory, articulation of vowels, fluency, placement analysis, compensations, and syllable structures which were reported by one participant for each of these items. Participants from the United States, Australia and the United Kingdom all reported the same top three assessment tasks for assessing speech production, including assessing intelligibility, articulation of alveolar and palatal- alveolar sounds, and assessment of phonological processes. The third item reported by the other countries was ‘percentage phonemes/consonants correct’ instead of assessment of phonological processes.

Assessment of Tongue Function

Table 11. Functional assessment of tongue function used by participants when assessing children aged one to 10 years with tongue-tie by country (N = 142).

outlines measures of functional assessments of tongue function. Ninety percent of participants reported providing a parent questionnaire or screening questions regarding eating and swallowing issues (n = 132), observation of oral cavity hygiene (n = 103), and observations of cup drinking (n = 95) and straw drinking (n = 85). Other measures included breastfeeding-related measures (n=4), volitional wet swallow (n=2), facial muscle activation while drinking (n=1), time taken to orally break down foods (n=1), and where food is broken down in the mouth (n=1). Participants from all countries reported the same top two assessment tasks for assessing tongue function, including, parent questionnaire or screening questions about eating and swallowing issues, observation of oral cavity and hygiene, and cup drinking.

Years of Experience and Assessment Tool Used

A chi-square test of independence was conducted to examine the relationship between years of experience and the type of assessment tool used. The data were categorized into five experience ranges: 0 – 5 years, 6 – 10 years, 11 – 15 years, 16 – 20 years, and >21 years. The assessment tools included Hazelbaker’s (1993) HATLFF, Quick Tongue Tie Assessment Tool (QTT), Kotlow’s (1999), Coryllos’ (2004) classification, Fernando’s (1998) Tongue Assessment Protocol (TAP), Marchesan’s (2012) Lingual Frenulum Protocol, Merkel-Walsh and Overland’s (2016) Tethered Oral Tie screening tool, and “None.”

The chi-square test indicated that there was no significant association between years of experience and the type of assessment tool used, χ²(20, N = 100) = 10.50, p = .953. This result suggests that the choice of assessment tool does not significantly depend on the years of experience of the practitioners.

Table 12. Assessment tool usage by years of clinical experience (N = 218).

outlines the frequency of assessment tool usage by years of experience.

DISCUSSION

The current study aimed to investigate how SLPs assess tongue structure and function in children aged 1 to 10 years with a suspected TT, and explored a range of items, including case history items, classification systems, tools and methodologies to measure tongue structure, oral motor tasks and functional outcomes and efficacy of different assessments of tongue function in children with TT, including speech production, amongst clinicians globally.

Key Measures

The results demonstrated extensive utilization of measures across all assessment areas. Between 63% to 91% of participants assessed tongue elevation, protrusion, lateral movements, retraction, licking of lips, tongue resting position and touching of molars with tongue tip. Eighty-seven percent of survey participants assessed articulation of alveolar (tongue-tip to superior alveolar ridge) and palatal-alveolar (mid-tongue approximation with hard palate) speech sounds, whilst 79% assessed intelligibility, and 54% assessed phonological processes. There was limited reported assessment of rate (26%) and voice (11%) during the assessment of TT. Feeding history and current issues (65%), medical history (54%) and breastfeeding history (56%) were rated in the top three case history priorities by participants. Interestingly, over 90% of respondents reported investigating feeding issues through parent questionnaires or screening questions; 54% to 66% of participants reported direct observation of eating and drinking during oral trials with various textures, cups/straws and mealtimes.

The widespread assessment of feeding issues reported by participants supports Chinnadurai et al.’s (2015) recommendations for more research into the impacts of TT on feeding and swallowing. Management of feeding and swallowing difficulties in children is within the scope of practice for SLPs in Australia and the United States, however, we are aware of no studies that reported on the confidence and competence of SLPs in making differential diagnoses for children with TT (SPA, 2012). Recruitment targeted interest groups related to pediatric dysphagia, but the survey did not ask participants to indicate their skills in this practice area. Participants outside of this practice area may account for the reduced use of direct observation measures compared to case history questions, and the lack of use of published feeding and swallowing assessment tools. Alternatively, participants may use case history questions for all participants but did not report using observational measures as they only use these when the case history warrants further investigation.

There was limited indication that participants used objective measures or validated tools to assess tongue structure, oral motor skills or feeding skills. Only 23% measured ‘Maxillary Incisive Papillae at Room of Mouth’ (MOTTIP), and only 16% used the Quick Tongue-Tie (QTT) tool, which is a specialised instrument used to measure free-tongue measurement, lingual frenulum length, tongue protrusion and/or tongue elevation. This may be due to a lack of awareness, use of estimation or anatomical reference points instead of objective measurement, intolerance of measurement procedures by younger children, or lack of fit of tools to the needs of clinicians. For example, clinical assessment tools such as the Test of Masticating and Swallowing Solids (TOMASS) were developed for healthy adults from 20 to 80 years of age, and were later modified and a normative database was established for 638 children from 4 to18 years of age in two commercially available crackers in four countries, and then for 2 to 4 year-old children in Australia (Huckabee et al., 2018; Frank et al., 2019; Porter et al., 2024). The TOMASS was not identified or may not have been widely adopted for clinical use at the time of survey completion.

The results from this survey do not specifically indicate which of the measures selected were considered primary diagnostic indicators for TT and which were part of routine, comprehensive or exclusionary assessment procedures. Several participants commented that diagnosis of TT is typically not the focus of clinical assessment and that the measures they reported using were part of a routine comprehensive assessment of a child’s speech, language, and swallowing skills. This reflects comments by Walsh and Tunkel (2017) that simplistic TT diagnostic frameworks do not reflect the complexities of speech and feeding mechanisms and tongue development, and thus do not explain the subsequent variability in presentation and treatment outcomes for children with TT.

Published Assessment Tools

The most frequently used published assessment tools in this survey were Kotlow’s (1999) classification, the Lingual Frenulum Protocol (LFP), and the Tongue Assessment Protocol (TAP) (Fernando, 1998; Kotlow, 1999; Marchesan, 2012). Forty percent of survey participants reported using no published assessment tool. This reflects trends identified by Richmond (2019) and Marchesan (2012) against using published assessment tools to assess oral motor skills or to diagnose TT. The limited use of published assessment tools in clinical practice may indicate a lack of awareness, or that these tools do not meet clinical requirements for efficient, comprehensive, age- and ability-appropriate tools that allow for baseline measurement of treatment goals (Arvedson et al., 2020).

There were also geographic disparities for classification systems used by participants when evaluating children aged with suspected tongue-tie across different countries. Notably, the Merkel-Walsh and Overland (2016) Tethered Oral Tie screening tool was most frequently used in the United States (17%) compared to other countries. The Hazelbaker (1993) Assessment Tool for Lingual Frenulum Function (ATLFF) was commonly utilized in Australia (21%), whereas the Quick Tongue Tie Assessment Tool (QTT) was prominently used in the United States (11%) and other regions (13%). Some tools, like the Ferres-Amat et al. (2016) classification system, had limited use, with no participants reporting their use in Australia, the United Kingdom, and other regions. The “None” category indicated a significant portion of participants not using any specific tool, especially in Australia (29%) and other regions (30%). Overall, there is considerable variation in the use of tongue- tie assessment tools across different countries.

Concerningly, participants most often reported using assessment tools designed for use with infants up to 12 months of age, including the Assessment Tool of Lingual Frenulum Function (ATLFF), and the Neonatal Tongue Screening Test (12%) (Hazelbaker, 1993; Martinelli, 2015). These tools are not validated for use with children over 1 year of age and do not assess functional activities including speech and mature swallowing. Merkel-Walsh and Overland’s (2016) Tethered Oral Tissues protocol was used by 21% of participants, which is a tool available online, through workshops and in a published book; however, psychometric data have not been reported for this tool.

Participants reported assessing a wider range of structural and functional measures than is included in any published tool. However, without the use of a published protocol, it is unknown how clinicians weigh these factors. Survey results suggest that SLPs prioritize speech and feeding impacts over impairments to structure or non-speech oral motor skills. Therefore, a diverse range of measures are used in clinical practice to assess the impact of TT on tongue structure and function in children aged 1 to 10 years, but with limited use of published assessment measures. The duration of assessment can indeed vary depending on the tool used. Some tools are consistently associated with shorter durations (e.g., Quick Tongue Tie Assessment Tool (Yoon et al., 2017), while others, such as Hazelbaker’s (1993) ATLFF and Fernando’s (1998) TAP are used across a wider range of durations. The “None” category indicates that in many cases, no specific tool was applied, potentially affecting the duration of the assessment. This variability suggests that the choice of assessment tool may impact the time required for an evaluation.

Limitations of the study included recruitment of English-speaking SLPs only, and attrition during survey completion. Non-English speaking SLPs were excluded, including clinicians and researchers from South America and Europe, where clinical awareness of TT is generally considered to be strong.

CONCLUSION

This study aimed to explore the assessment practices of SLPs and their assessment of tongue structure and function in 1 to 10 year-old children with suspected TT. The results revealed widespread use of measures across structural, functional, and feeding assessment areas by participants, as well as geographic disparities. The study highlighted limitations in the use of validated or objective tools, with a low percentage of participants employing specific instruments. The findings also underscored the complexity of diagnosing TT, and the need to include a range of measures from comprehensive case history, oral examinations of tongue structure, oral motor tasks, speech and feeding functions. Of concern, is the use of assessment tools designed for infants up to 12 months of age, suggesting a gap or lack of awareness in age-appropriate tools for older children. This study emphasised the need for more comprehensive, age-appropriate and clinically efficient tools to assess tongue structure and function in the differential diagnosis of TT in older children.