Decrease Tongue Protrusion and Improve Oral-motor Strength

Tongue protrusion is very closely associated with Down Syndrome and is regularly cited as a feature of the condition. It has been traditionally stated that this is due to the presence of an enlarged tongue, however current thinking favors a combination of physical and developmental factors, specific to each individual.

Tongue movement should be considered within the context of the whole body. All parts of the body are connected and factors affecting normal motor development in one area may also influence the mouth. In order to develop movement and skills, we must have a stable trunk. Without that stability, our function is affected. Think of a young baby – their body movements are uncontrolled and random, but become more organized as they learn to control various parts of the body. Once trunk stability is established, body parts such as arms, legs, head, etc. can develop more refined movement. For example, before a child can reach and grasp a toy, they must develop control over the shoulder and trunk.

Similarly, oral stability depends on neck and shoulder stability, which is dependent on trunk and pelvis stability. A stable jaw is necessary for the development of controlled tongue and lip movements and as the range of tongue movement develops, children develop a sense of their tongue’s natural resting-place in the mouth (e.g. in the middle).

It is important to remember that not every child with Down Syndrome protrudes their tongue but also, that it is a normal part of early development. It may become exaggerated or persist due to one or many of the following factors:

• Children with Down Syndrome have a weak suckle as infants and learn to control the flow of liquid by protruding their tongue.
• Individuals with Down Syndrome have a smaller, higher arched hard palate which means that the tongue is contained in a smaller than average space.
• There is lower than average tone in the muscles of the tongue. This makes it appear larger because it is floppier. 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-coordinating the necessary movements to control the tongue.
• 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 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.

• 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.
• 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.
• Tongue protrusion may develop due to airway compromise such as large adenoids or tonsils, which are common in individuals with Down Syndrome.
• 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.
• Many children with Down Syndrome have delayed motor development and therefore may not have the stable base from which oral-motor skills can develop.
• 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 equalize 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. 

In my own experience of working with children with Down Syndrome, tongue protrusion has generally been a transient phase, often associated with periods of teething or throat infections. Cases that have persisted have been a reflection of a more significantly reduced overall body tone and consequently, more significantly delayed oral-motor development. These children have also demonstrated more delayed eating and drinking skills, which is reflected in reluctance to transition from smooth to lumpy foods and delayed biting and chewing skills. Biting and chewing relies on graded jaw movements and the ability to move the tongue in a variety of directions. In encouraging a child to experience biting and chewing safely, both areas can be developed at the child’s own pace.

From an oral-motor viewpoint, there are a number of areas that can be focused on. While the primary focus is on improving oral-motor skills, there will be a knock-on effect in relation to feeding and speech development. Be aware of your child’s level of development and consult with your speech & language therapist, physiotherapist and occupational therapist, to ensure you select an appropriate starting point. To minimize tongue protrusion, your child needs to develop some or all of the following:

• Stable, central base (i.e. control over the trunk, head, etc.)
• Increased oral/facial muscle tone
• Increased oral sensitivity
• Improved lip movements
• Improved jaw movements
• Improved tongue movements. 

As you can see, tongue protrusion may occur for a number of reasons. Many children with Down Syndrome may simply be exhibiting a generalized delay in their development, of which tongue protrusion is one feature. It is important therefore, that a full assessment is carried out, to ensure that the correct remediation path is chosen. It would be inappropriate to focus on skills that the child is unable to achieve. In normal development, these oral motor patterns are generally established by the age of 24 months, but your child may have a developmental delay and difficulties with low tone, so starting any activities at this age may be inappropriate. Every child presents a different picture; therefore every therapy plan should be tailor-made. It is essential that you consult with a speech and language therapist, occupational therapist and physiotherapist to get an overall picture of your child’s physical, sensory and oral-motor development and discuss the value of working on this area. These are the professionals qualified to guide you through the process.

Without the possibility of meeting therapists, you could try some of the suggestions below. Eliminate any medical reasons (e.g. enlarged adenoids/tonsils, teething, throat/respiratory infections, etc.). Select one or two exercises to try, but be aware that doing them all at the same time could be harmful. Adults can often become overenthusiastic and if the child is unable to co-operate with the exercises, they may become resistant to any form of intervention in the longer term. It is vital therefore that you are aware of your child’s strengths and difficulties and give them lots of praise for any attempt that they make. They may require many opportunities to practice and will need you to demonstrate it clearly, in a way that they will understand. Observe your child and take note of the times their tongue protrudes, what they are doing at the time, how long it persists, if they correct it themselves, etc.

Be patient and be prepared to repeat the activity over and over again. It may take time before the skill is achieved. Most of all - make it fun!

Precautions  

• Don’t do all the activities at the same time.
• These activities should not be done at mealtimes as this could lead to aversive behaviors around food.
• These exercises should be dome for short periods of time.
• Talk through what you are doing, each step of the way.
• Ensure you are both positioned in a relaxed, comfortable position.
• Ensure your child is in a stable, supported position.
• Minimize distractions e.g. TV, radio, other people etc.
• Pause to allow time to swallow any saliva that may have accumulated.
• These exercises can be done throughout the day, washing, drying at bathtime, using a towel, sponge, facecloth, etc).
• Don’t attempt this if your child has a cold.
• Stop if your child becomes distressed at any time.

Some oral-motor exercises

• If your child is sensitive around their face, prepare them before you approach their face. Use slow, firm strokes over the hands, arms, shoulders, body and neck with a rough texture (e.g. towel, etc.)
• Using firm strokes/touch with a rough texture (e.g. towel, etc.) start at the sides of the face / forehead / chin and gradually work towards the centre of the face.
• Massage the cheeks using circular movements, particularly around the mouth.
• Use 2 fingers to press the top and bottom lips firmly together. Hold for a couple of minutes and release.
• Stroke firmly downwards on the area between the nose and top lip while using your finger to push the bottom lip upwards.
• Using your thumb and index finger, pull the top lip down, starting under the nose and working towards the top of the lip (without touching the lip itself).
• Do the same for the bottom lip, working from chin to the lip. Support the jaw if necessary.

• Press the lips together by pressing one index finger below the nose and the other below the bottom lip - rotate the fingers towards the lips.
• Gradually introduce stronger flavors at mealtimes:

1. curry,  Chinese sauces, garlic
2. chips: vinegar, garlic, mayonnaise dip, brown sauce, ketchup, etc.
3. tangy or bitter flavor fruits and yoghurts: kiwi, lemon, forest fruits, grapefruit, cranberry, etc.

• Extremes of temperature:

1. ice-cream, ice-pops
2. worm food

• Sensory toys:

1. “Bumble Balls”
2. Teethers that are textured or battery operated for vibrations, etc.

Practical ideas for developing jaw and tongue movements

• When spoon-feeding your child, place the food centrally on the tongue and apply firm downward pressure. This will reduce tongue protrusion that occurs during swallowing.
• As the protrusion reduces, place the food at the sides of the mouth, between the teeth. This will encourage munching and sideward tongue movements.
• To stimulate biting, munching and sideward tongue movements:

1. Initially, do this at times when your child is relaxed.
2. Initially, these activities should not be done at mealtimes.
3. Use items such as tethers (ridged etc.), foods that do not break up, bite and stay firm foods, dried, but not too dry fruits: bananas, peaches, apricots, Liquorices sticks, etc.

• Place the item in the mouth, between the teeth, along the line of the jaw and ensure that it is not placed so as to stretch the lips. Do not place too far back in case your child gags.
• Place on the best side initially, than move to the other side.
• If the child is not munching, pull the item out slightly and gently or press down.
• When you feel your child is confident about their biting skills, introduce food items. Initially use bite-and-dissolve foods (Boudoir biscuits, meringues, Skips/Snax, etc.)
• If the child is not biting off the food, break it off for them while they are biting down on it. Do not force your child to take foods that their mouth is not ready to handle.
• Over time, gradually introduce chewier foods in the same way.

Practical ideas for developing lip movements

• Using a mirror, make “oo” sounds (e.g. a ghost/owl/ monkey/wind etc.) and “ee” sounds (e.g. mouse, E-I-E-I-O, etc.) using exaggerated lip movements. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape).
• Practice kissing. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape). Put on some lip stick or face paint and make kiss marks on a mirror, tissue, paper etc.
• Sucking through a straw. Make a tight lip seal around the straw.
• Blowing bubbles, blowing cotton wool balls across the table, blowing whistles/party blowers, blowing bubbles in water with a straw, etc.