Tuesday, May 15, 2012

Feeding and Tongue Protrusion?

Feeding your kids is something a lot of parents take for granted.  Once the MD gives you the 'thumbs up' to present 'solids,' you think nothing more of it.  If you're like me, you worry about the possible allergic reaction, or initial choking/gagging, but you never give much thought to their tongue.  I certainly never did.  Then you have a child with DS and, suddenly, you find yourself looking at feeding in a whole new way.

I had read that babies/children with Down Syndrome (DS) often have a protruding tongue (so far, this doesn't seem to be the case with Josiah).  Tongue protrusion may be exacerbated by any of the following factors:

1.  Babies with DS have a weak suck and learn to control the flow of liquid by protruding their tongue.

2.  Individuals with Down Syndrome have a smaller, higher arched hard palate which means that the tongue is contained in a smaller than average space.  The first time the MD came to see Josiah (which was in the hospital), he almost immediately stuck his finger in Josiah's mouth.  He quickly proclaimed, "Yup!  He has an extremely high palate."

3.  There is lower than average tone in the muscles of the tongue. This makes it appear larger because it is floppier (Josiah's tongue doesn't seem to be larger; floppier, yes). Tongue movement depends on the actions of a variety of muscles in the mouth and it plays a role in swallowing, breathing, chewing and speaking. Individuals with Down Syndrome have difficulty with producing and co-ordinating the necessary movements to control the tongue.  Josiah's PT has commented, at times, that Josiah's tongue 'is all over the place'.

4.  During normal development, the tongue grows at a different rate to other parts of the face such as the jaw, which in the early years, normally results in the tongue having a high, forward position in the mouth. This, combined with a smaller oral space and low tone in the tongue, may result in the tongue protruding.

5.  The muscles of the tongue constantly correct and readjust the tongue’s position in the mouth, based on the sensory feedback it receives. Many children with Down Syndrome have difficulty receiving and integrating sensory information and may not develop these skills as quickly or completely. Consequently, they may not be aware that their tongue is protruding.

6.  Tongue protrusion may also result from an inability to move the jaw separately from the tongue. This is a skill that develops over time and is dependent on jaw stability. Without this stability the tongue protrudes as the jaw lowers.

7.  Tongue protrusion may develop due to airway compromise such as large adenoids or tonsils, which are common in individuals with Down Syndrome.

8.  The ability to self-correct a protruding tongue requires some degree of insight and motivation to change. Depending on a child’s age and developmental level, this self-monitoring may not develop fully, or may develop much later.

9.  Many children with Down Syndrome have delayed motor development and therefore may not have the stable base from which oral-motor skills can develop.

10.  Upper respiratory tract infections, which block the child’s nose, may cause them to breathe through their mouth rather than their nose. In mouth-breathing the jaw lowers and the tongue is no longer contained within the mouth. These infections may develop as a result of middle ear infections, which are common to individuals with Down Syndrome. This develops due to a dysfunction of the Eustachian tube, which is located at the back of the throat and is connected to the middle ear (its function is to equalise air pressure on both sides of the eardrum). If there is low tone in the muscles surrounding the entrance to the tube, fast-flowing fluid may enter the middle ear, causing an infection over time.

Knowing that tongue protrusion may be an issue, I decided to video record a recent feeding.  In the video, Josiah was eating rice cereal (which is relatively new to him).  I don't see evidence of tongue protrusion.  I do think there is some tongue thrusting (common with all babies).  I'll delve into tongue thrusting next time :)

I will show this to the feeding specialist (who comes tomorrow).  Meanwhile, enjoy the video & tell me what you think.....  

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