by Robyn Merkel-Walsh, MA, CCC-SLP

This is a repost from Ages and Stages, with permission from the author.

OROFACIAL MYOFUNCTIONAL DISORDERS (OMDS) VS. PEDIATRIC FEEDING DISORDERS: WHAT’S THE BUZZ ABOUT?

Commentary by Robyn Merkel-Walsh, MA, CCC-SLP in New Jersey, USA

September 2018

Recently, I gave a webinar with the same title as this blog for TalkTools. The purpose of this webinar was to clarify some confusion being discussed on social media. Here, I discuss the topic in a written format.

SO, WHAT IS THE BUZZ ABOUT?

There is constant discussion on social media regarding orofacial myofunctional disorders (OMDs) and scope of practice. Pediatric feeding therapy and orofacial myofunctional therapy (OMT) overlap but require specific training for each skill set. There is confusion and disagreement among professionals regarding scope of practice and treatment, the ages these treatments begin, and who delivers the services. Internationally, OMD and pediatric feeding are delivered in various setting by interdisciplinary teams, but the team leader may vary from country to country. To understand delivery models, we must first understand the similarities and differences between pediatric feeding therapy and orofacial myofunctional therapy and how professionals may find themselves questioning their specific roles with these complex disorders.

 PEDIATRIC FEEDING

It makes sense to start by discussing pediatric feeding and relative disorders because feeding is a function of daily living that starts at birth. In order to understand abnormal development you must understand normal development (Bahr, 2017). There are four modern texts that thoroughly describe infantile reflexes, pre-feeding, and feeding (in chronological order): Pre-Feeding Skills by Morris & Klein (2000); Nobody Ever Taught me (or my Mother) That! Everything from Bottles and Breathing to Healthy Speech Development! by Bahr (2010); A Sensory Motor Approach to Feeding by Overland & Merkel-Walsh (2013), and Feed Your Baby and Toddler Right: Early Eating and Drinking Skills Encourage the Best Development by Bahr (2018). These guide parents and professionals in keeping babies and children on track in feeding. However, when feeding problems arise, it is crucial for parents and professionals to seek a qualified pediatric feeding therapist.

The American Speech Language and Hearing Association (ASHA, 2018a) describes feeding as four stages:

• Oral Preparation Stage – preparing the food or liquid in the oral cavity to form a bolus including: sucking liquids, manipulating soft boluses, and chewing solid food.
• Oral Transit Phase – moving or propelling the bolus posteriorly through the oral cavity.
• Pharyngeal Phase – initiating the swallow and moving the bolus through the pharynx.
• Esophageal Phase – moving the bolus through the cervical and thoracic esophagus and into the stomach via esophageal peristalsis (Logemann, 1998).

It is in the scope of a speech-language pathologist’s (SLP’s) practice to assess and treat all four stages of feeding; however, when we think of feeding across the lifespan, we also look to international board certified lactation consultants (IBCLCs), nurses, occupational and physical therapists as well for their roles in the four stages of feeding. The oral preparatory and transit stages are also targeted by SLPs in orofacial myofunctional therapy (OMT), but according to Holtzman (2018):

The word “feeding” is aptly applied to infants and others unable to feed themselves, including those adults who have serious “feeding” and swallowing issues. This “related” area is not within the scope of orofacial myologists. In fact, it is not even within the scope of practice for many of us SLPs who lack experience and specific training with “feeding.”

While it is true that orofacial myology training is not the same as pediatric feeding training, in 2016 Byeon conducted a study that showed orofacial myofunctional exercise was effective in the rehabilitation of oral phase swallowing function in dysphagia patients by improving orofacial muscle strength and response rate. This, however, was a study done with adult patients in the rehabilitation setting. ASHA (2018b) reminds SLPs that:

Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children. An understanding of adult anatomy and physiology of the swallow may provide a good basis for understanding dysphagia in children; however, additional knowledge and skills specific to pediatric populations are needed. As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be educated and appropriately trained to do so.

Pediatric feeding therapy varies from orofacial myofunctional therapy/orofacial myology. This includes but is not limited to:

• Pediatric feeding therapy can be passive, requiring no volitional execution of motor skills by the client, but rather motor responses that occur with superimposed techniques by the therapist to elicit a response (e.g., stimulating the lateral borders of the tongue to elicit lateralization – Morris & Klein, 2000; Bahr, 2010 & 2018; Overland & Merkel-Walsh, 2013).
• Pediatric feeding therapy is based on normal oral sensory-motor development and task analyses of the pre-feeding skills needed for safe, effective nutritive feeding (Overland & Merkel-Walsh, 2013).
• Pediatric feeding therapy has nutritional targets and considers optimal weight gain and the growth curve.
• Pediatric feeding therapy may involve the oral and pharyngeal stages of swallowing which requires a specific skill set.
• Pediatric feeding therapy can occur from 0-18 years of age to include: breast, bottle, puree, solid, cup, straw, and tube feedings.
• A pediatric feeding team may include a/an: IBCLC, gastroenterologist, endocrinologist, allergist, otolaryngologist, pulmonologist/respiratory therapist, dietician, speech-language pathologist, home health aide, nurse, occupational therapist and/or a physical therapist.

In addition, pediatric feeding therapy is different in that it focuses on:

• Medical considerations (e.g., nasogastric tube, tracheostomy, etc.) and complex medical complications (neonatal intensive care unit stay, traumatic brain injury, etc.).
• Learning adaptive strategies to compensate for oral sensory-motor deficits or delays/disorders in pre-feeding skills.
• Collaborating with a gastroenterologist and/or dietician to establish calorie targets, safe textures, and diet expansion.
• Working with occupational and physical therapists for optimum posture, alignment, and sensory regulation to maximize progress in feeding sessions.
• Coordinating with IBCLCs to transition infants from breast to bottle and pureed to solid foods.
• Coordinating with a medical team for cardiac and respiratory concerns.

 OROFACIAL MYOFUNCTIONAL THERAPY/OROFACIAL MYOLOGY

At the time of this blog, the American Speech-Language Hearing Association (ASHA) is working on the practice portal for Orofacial Myofunctional Disorders (OMDs). The public portal (ASHA, 2018c) for OMDs suggests that OMDs can cause issues with eating, drinking, and speaking and that allergies, large tonsils and adenoids, detrimental oral habits, and genetics are causes of OMDs. The SLP can help patients learn to change how they use their tongues. According to the ASHA portal, treatment may include paying close attention to tongue and mouth movements; knowing where the tongue and mouth muscles are when at rest, speaking, and eating; saying sounds more clearly; and changing chewing and swallowing. Lehman (2016), a registered dental hygienist, warns that orofacial myofunctional therapy is not just about a tongue thrust, but rather a tongue thrust is a sign and symptom of an underlying problem. This supports ASHA’s position that progress may be difficult if the underlying structural issues impacting the airway are not addressed (ASHA, 2018c).

Historically, the International Association of Orofacial Myology (IAOM) has been a leader in the training, certification, and publication of diagnosis and treatment information on OMDs. Two important publications outline the history of the IAOM. These are Dr. Marvin Hanson’s and Dr. Robert Mason’s book entitled Orofacial Myology International Perspectives (Hanson & Mason, 2003) and International Association of Orofacial History: Origin-Background-Contributors (Stevens-Mills, 2011). These content-rich publications explain how the fields of dentistry and speech-language pathology merged to diagnosis and remediate disorders of the orofacial complex. The IAOM certifies dentists, medical doctors, orthodontists, speech-language pathologists (SLPs), and registered dental hygienists (RDHs) as Certified Orofacial Myologists (COM-TM). The SLP has the unique skill set that they can be trained in both pediatric feeding and OMT.

Image description: Venn Diagram

The IAOM Certification process challenges the participant with in-depth investigation into the etiologies, symptoms, treatment variances, and supportive research related to Orofacial Myofunctional Disorders. The process enhances their breadth of clinical knowledge that cannot be obtained through a single course method (IAOM, 2018).According to the IAOM’s website:

In addition to the IAOM, there are organizations such as The Academy of Orofacial Myofunctional Therapy (AOMT, 2018), TalkTools, and The International Consortium of Ankyloglossia Professionals (ICAP) that provide various types of professionals training in OMD; however, there is often controversy as to scope of practice in the various professions. According to the IAOM, only three professions have OMD written into their scopes of practice: RDH, SLP, and dentists.

Orofacial Myofunctional Therapy (OMT) varies from pediatric feeding therapy. This includes but is not limited to:

• OMT is active and often requires volitional execution of a motor plan by the client, such as practicing lingual oral resting posture (Merkel-Walsh, 2011).
• OMT requires the patient to know the “why” of the program and the patient has to “work” at their goals (Holtzman, 2018).
• OMT is based on abnormal structure, tone, oral resting posture, habits and swallowing patterns (AOMT, 2018).
• While early signs of OMD can be recognized in infants and toddlers, OMT start time varies in the literature from as early as 4 years and as old age 8 years (Holtzman, 2018).
• An OMD team may include a/an: pediatrician, physician, speech-language pathologist, RDH-COM (TM), SLP-COM (TM), dentist, orthodontist, allergist, otolaryngologist, sleep specialist, bodyworker (e.g., osteopath, chiropractor, licensed massage therapist, physical therapist, occupational therapist, etc.) and/or oral maxillofacial surgeon.

In addition, orofacial myofunctional therapy is different from feeding therapy in that it focuses on:

• Volitional imitation of oral postures such as “tongue to the SMILE spot” (Merkel-Walsh, 2011).
• Practicing oral resting posture and the lingual palatal seal.
• Drilling articulation and oral placements of lingual alveolar phonemes ensuring that not only acoustics are correct but the phonetic placements are correct as well (Merkel-Walsh & Overland, 2018).
• Targeting oral habits such as thumb sucking and mouth breathing (e.g., Sandra Holtzman’s online Unplugging the Thumb, n.d.).
• Working on respiratory control with the dentist, otolaryngologist (ENT), or other appropriate medical professionals when the airway is not patent.
• Developing self-awareness of saliva management.
• Coordinating with dentists and orthodontists regarding appliances and management (e.g., Myobrace, Advanced Lightwire Functional appliance, other palatal expanders, etc.).
• Providing active wound management and neuromuscular re-education for patients pre- and post-frenectomy.
• Coordinating with the medical team to rule out and or treat sleep disordered breathing (Archambault, 2018).

A COMPARISON

Just because there is a variation between pediatric feeding and OMT, it does not mean there is not an overlap in diagnosis and in treatment. Many SLPs who have interest and specialized training in pediatric feeding also have training in OMDs and vice versa; however, this is not always the case. The similarities and differences between pediatric feeding and OMT can be confusing to the consumer at times. For example, therapy that is recommended for pre- and post- frenectomy is often considered OMT, but when it is with an infant or toddler, the term may be contraindicated based on the target age group for OMT. Merkel-Walsh and Overland (2018) call pre- and post-operative therapy with infants and toddlers “neuromuscular re-education” and describe the importance of a multidisciplinary team.

Most seasoned clinicians who are trained in these therapy methods know we can recognize the early signs and symptoms of OMDs in babies, toddlers, and individuals with complex diagnoses, but the treatment varies based on the volitional control of the patient. Obviously an infant cannot self-monitor oral resting posture; however, a well-trained therapist can assist in improving mouth posture in patients who do not have volitional control. This varies in a teenage patient, where the orofacial myologist teaches the patient how to position the mouth at rest and assigns homework for self-monitoring. In both age groups the SLP will be working with the medical team to determine the underlying causes of open mouth posture to rule out structural concerns such as adenoidal hypertrophy.

While SLPs and OTs can work with feeding across the lifespan, only therapists who have been specifically trained to work with the infant population should do so, and related fields who are only trained in OMT should not attempt to transfer a skill set meant for older patients onto infants.

Confusion occurs because pediatric feeding and OMT often target some similar goals such as improving:

• Range of motion of the jaw, lips, cheeks, and tongue
• Lip closure
• Oral transit time
• Mastication
• Bolus mobility
• Lingual protrusion, retraction, lateralization, and elevation
• Tongue tip dissociation to the incisive papilla
• Lingual palatal seal
• Labial seal on a straw or cup

SLPs may be encouraging and manipulating the placement of a bolus using massage, myofascial release, pre-feeding activities, oral tools, strengthening exercises, and/or oral sensory-motor cues to facilitate progress. RDH’s working on OMT will target many similar goals but will not target the feeding components because it is not within their scope of practice. OTs may be doing the feeding component and not the speech piece as defined by their scope of practice. It is up to professionals to rely on their professional associations to define scope of practice, as well as their state’s licensing board to define what is allowed within their state. For example, SLP’s can learn about their scope from The American Speech-Language-Hearing Association (ASHA, 2016b).

It is also important to note that taking a class on a topic to learn information does not necessarily mean it is ethical to practice that method. Inter-professional training helps us understand how varied professionals can assist us with patient care, but we may not be able to practice what is learned in a particular course if we do not have the license to do so. For example, many IBCLC’s and RDH’s have taken courses with TalkTools on the management of tethered oral tissues. Pediatric feeding, speech, and OMT are covered in this course; therefore, these professionals should not utilize exercises for articulation with their patients when it is not within scope. Likewise, SLPs can take courses on global sensory-motor dysfunction to better understand these issues but should still be referring to OT and PT when appropriate. The overlap of pediatric feeding and OMT can be demonstrated in this graphic created by Billings, D’Onofrio, Gatto, and Merkel-Walsh in 2017 (Merkel-Walsh, 2018).

Image Description: Venn Diagram

CONCLUSION

Pediatric feeding therapy and orofacial myofunctional therapy may overlap; however, each requires a very specific skill set in training and each have very different aspects which make them unique. Both pediatric feeding and OMT involve an interdisciplinary team which ranges from physicians to bodyworkers and crosses the lifespan starting with IBCLC’s all the way up to orofacial myologists with specialized training in tongue thrust, airway dysfunction, and orthodontia. SLPs are unique in that they have both pediatric feeding and OMT within their scope of practice while other fields may have one or the other. Proper training in both skill sets are needed to diagnose and treat, and while overlap may occur, it is important not to transfer the methods used for older patients onto babies and toddlers. It is up to each professional when treating these patients, to ensure the safety of the patient and the ethics of the provider to ensure a proper plan of care, which may mean providing appropriate referrals to the professional with the experience and proper professional scope.

REFERENCES

Academy of Orofacial Myofunctional Therapy. (2018) Retrieved from: https://aomtinfo.org/

American Speech-Language-Hearing Association. (2018a). Pediatric dysphagia: Feeding and swallowing. Retrieved from: https://www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia/

American Speech-Language-Hearing Association. (2018b). Pediatric dysphagia: Roles and responsibilities. Retrieved from: https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965§ion=Roles_and_Responsibilities

American Speech-Language-Hearing Association. (2018c). Orofacial myofunctional disorders. Retrieved from: https://www.asha.org/public/speech/disorders/Orofacial-Myofunctional-Disorders/%C2%A0

American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.

Archambault, N. (2018). Healthy breathing round the clock. The ASHA Leader, 23, 48-54.

Bahr, D. (2018). Feed your baby and toddler right: Early eating and drinking skills encourage the best development. Arlington, TX: Future Horizons.

Bahr, D. (2017). Best practices in pediatric feeding, motor speech, and mouth development. Live Presentation. Clifton, NJ.

Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development! Arlington, TX: Sensory World.

Byeon, H. (2016). Effect of orofacial myofunctional exercise on the improvement of dysphagia patients’ orofacial muscle strength and diadochokinetic rate. Journal of Physical Therapy Science, 28(9), 2611–2614.

Hanson, M.L., & Mason, R.M. (2003). Orofacial Myology International Perspectives. Springfield, IL: Charles C. Thomas Publisher Ltd.

Holtzman, S. (n.d.) Unplugging the thumb. Retrieved from: http://www.orofacialmyology.com/unpluggingthethumb/ForTherapist.html

Holtzman, S. (2018). What age is appropriate for OM treatment? Orofacial Myology News. Retrieved from: http://orofacialmyology.online/wp-content/uploads/2018/06/2018-may-orofacial-myology-online-news.pdf

International Association of Orofacial Myology. (2018). Certified orofacial myologist. Retrieved from: http://iaom.com/certification/

Lehman, A. (2013). Orofacial myology: It’s not just tongue thrust therapy. Dentistry IQ. Retrieved from: https://www.dentistryiq.com/articles/2016/09/myofunctional-therapy-it-s-not-tongue-thrust-therapy.html

Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. Austin, TX: Pro-Ed.

Merkel-Walsh, R. (2018). Orofacial myofunctional disorder or pediatric feeding disorder – What is the buzz about? Webinar presentation. TalkTools.

Merkel-Walsh, R., & Overland, L. (2018). The functional assessment and remediation of tethered oral tissue. Charleston, SC: TalkTools.

Merkel-Walsh, R. (2011) Systematic intervention for lingual elevation (SMILE). Charleston, SC: TalkTools.

Morris, S.E., & Klein, M.D. (2000). Pre-feeding skills (2^nd ed). San Antonio TX: Therapy Skill Builders.

Overland, L., & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.

Stevens-Mills, C. (2011). International association of orofacial history: Origin-background-contributors. International Journal of Orofacial Myology, 37, 5-25.

About the Author

Robyn Merkel Walsh, MA, CCC-SLP has specialized for over 24 years in Oral Placement Therapy, orofacial myofunctional disorders, and feeding disorders. She is employed by the Ridgefield Board of Education, runs a private practice in Ridgefield, NJ, is the board chair of the Oral Motor Institute, and is a member of the TalkTools® speakers’ bureau. She teaches tethered oral tissues, autism, and tongue thrust courses in addition to multiple webinars on topics including but not limited to lisps, oral structure, orofacial myofunctional disorder, as well as feeding and clinical parameters for Autism Spectrum Disorder. Robyn has been invited to speak on Oral Placement Disorders by Conversations in Speech, Bergen County Region V, the IAOM, The Apraxia Network, AAPPSPA, and the MOSAIC Foundation. Robyn has received specialized training in Oral Placement Disorders, feeding, apraxia, Applied Behavioral Analysis, autism, cranio-facial anomalies, Beckman Techniques, and PROMPT and is on track to become an IAOM Certified Orofacial Myologist. Robyn is the co-author of the texts A Sensory-Motor Approach to Feeding and Functional Assessment and Remediation of Tethered Oral Tissues (TOTs). She has also written numerous articles and publications for magazines, ASHA publications, and state and national conventions.