Self-Assessment Checklist that may identify compromised growth, development, and function

Age group: 3 Years – 5 Years Old

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Key Signs and Symptoms that You can Assess

If you have answered Yes to multiple items below, we would encourage you to schedule a comprehensive airway, tongue, and lip assessment for your loved one at Little Bird Pediatric Dentistry by calling 905-876-2473 (BIRD) or visit our website (www.littlebirddental.ca) for further information.

*For specific findings, click on “” to see a picture example and the reasoning (or why) behind.

*For specific findings, click on to see a picture example and the reasoning (or why) behind.

While Child is Awake

Mouth open/lips apart (when not talking, playing, etc.) most of the day or routinely throughout the day

3-5 year old awake mouth openWhy: At rest (when not eating or speaking, etc.), our mouths should be closed with lips sealed. If mouths are open routinely, it increases the tendency to mouth breathe. Learn more about the importance of nasal breathing.

Difficulty breathing through nose and/or avoidance of breathing through nose

Dry, cracked lips, and/or regularly licking lips

Frequent ear infections, strep throat, and/or tonsillitis

Frequent infectionsWhy: Following 6 months of age, anatomical changes take place (maturational descent of the epiglottis) alongside baby’s transition into developing a coordinated adult breathing/swallowing pattern.Possible causes for continued frequent infections may stem from mouth breathing, which lacks any filtration, thereby causing potential for inflammation and insult to the tonsils and adenoids. This may lead to an increase in size of the tonsils and adenoids (furthering airway compromise) and/or infection.Another possible cause is if the child has a restricted/tethered tongue (tie) with/without a compromised swallowing pattern known as a tongue thrust swallow. This swallowing pattern may not allow for necessary protection of the Eustachian tube when opening/draining with each swallow, and as such predisposes the child to developing ear infections.

Surgical removal of tonsils and/or adenoids

Speech difficulties (mumbling, lisp, and/or hard to understand)

Falls asleep inappropriately during the day

Regularly has bags (dark circles) under eyes and/or complains of sore eyes

Why: Bags or dark circles under eyes are due to venous pooling, and is a sign that a child is not attaining a necessary length of quality (deep) sleep. This may be found in association with open mouth posture (mouth breathing while sleeping), snoring and/or heavy breathing (aka. breathing disordered sleep). Please see sleeping section below for further signs and symptoms that you can assess.

Crowding of teeth (no spaces) and/or anterior open bite (space between front teeth when back teeth are touching)

Primary teeth anterior open bite

Child with all their baby (primary) teeth, demonstrating an anterior open bite (space between upper and lower front teeth, when back teeth are together)

Why: If a child’s tongue rest posture and function are optimized along with lips sealed and nasal breathing, their palate (roof of mouth) will likely develop to be flat and wide, allowing for adequate space for teeth to erupt (without crowding). However, if one of these elements is not followed (i.e. tongue resting low in the mouth, compromised tongue thrust swallow, open mouth tendency and/or mouth breathing), the palate (roof of mouth) will likely develop to be narrow, high arched (can fit a thumb up) without adequate space for teeth to erupt, resulting in crowding.The same compromised elements may also lead to the presentation of an anterior open bite (as seen in the picture), where there is a space between the front upper and lower teeth.

Forward head posture (center of ear lobe in front of middle of shoulder)

Regular neck pain, stiffness, tension, and/or spasms

Suffers from frequent headaches and/or migraines

Hyperactivity throughout the day and/or limited attention span (difficulty concentrating/focusing, etc.)

Why: Although there are various possibilities for hyperactivity, one must understand that this is a common feature of children whom are over-tired, and may be showing signs of breathing disordered sleep (i.e. mouth breathing, snoring, obstructive sleep apnea, etc.). Young children are not able to comprehend being over-tired, and instead may demonstrate hyperactivity and an inability to focus or concentrate. Older children, teenagers and adults differ, as they are able to understand when they are tired and act accordingly. For example, think of when you drive late at night and are feeling tired. In order to stay awake, you might turn the volume up on the radio, roll down the windows and/or move around.

This is precisely what younger children are doing when they are overtired, but many times do not know how to stop.

Highly spirited (poor emotional regulation)

While Child is Sleeping

Mouth open/lips apart and/or drool on pillow (regularly)

Toddler sleeping mouth openWhy: When sleeping our mouths should be closed with lips sealed, guaranteeing that we are breathing through our noses. Learn more about the importance of nasal breathing.

If mouths are open (whether due to muscle memory, tongues trained to be down, tongue and/or lip tie, nose obstruction, etc.), it increases the likelihood of mouth breathing. Mouth breathing, snoring and/or heavy breathing are all possible audible signs of a compromised airway. In order to achieve optimized growth, development and sleep, the lips must be sealed at rest with the tongue up against the roof of the mouth (aka. palate).

Snoring with mouth open (more than 3x/week)

Gasp/stop breathing

Regular teeth grinding and/or wears a night guard

Frequent awakenings, regular nightmares, and/or night terrors (more than 1/week)

3-5 year old night terrorsWhy: Amongst a list of possible causes that includes stress, etc. Regular nightmares or night terrors may also be an indication that the child’s sympathetic nervous system (fight or flight) is being activated causing a macro (large) arousal (that will awaken the child) in attempt to re-establish and maintain their airway (breathing). We must remember that the number one goal of our bodies is to keep us alive – keep us breathing; therefore if there is any airway compromise while asleep, our bodies will be triggered to awaken. If this is occurring on a regular basis, your child may not be achieving consistent deep sleep with full muscle relaxation (parasympathetic nervous system – rest and digest activation) that is necessary for their optimized growth and development.

Restless sleep (always moving around and/or restless legs/arms)

Sweating heavily while sleeping (pajamas and/or sheets regularly damp)

Current or history of regular bedwetting

Why: Amongst a list of possible causes, bedwetting may also be an indication that the child’s sympathetic nervous system (fight or flight) is being activated causing a macro (large) arousal (that will awaken the child) in attempt to re-establish and maintain their airway (breathing). We must remember that the number one goal of our bodies is to keep us alive – keep us breathing; therefore if there is any airway compromise while asleep, our bodies will be triggered to awaken.

If this is occurring on a regular basis, your child may not be achieving consistent deep sleep with full muscle relaxation (parasympathetic nervous system – rest and digest activation) that is necessary for their optimized growth and development.

While Child is Feeding (Current or History of Challenges)

a) Breastfeeding and/or Bottle Feeding Challenges

E.g. poor/shallow latch, gumming, reflux symptoms, poor weight gain, etc.

b) Mom’s Breastfeeding Challenges (as applicable)

E.g. cracked/creased nipples, pain with latch or with nursing, poor/incomplete breast drainage, etc.

c) Eating and Drinking Signs/Symptoms

Picky eater (avoidance of crunchy/fibrous foods and/or specific food textures)

Smacking sounds when chewing/swallowing (mouth open when chewing)

Difficulty swallowing (e.g. tongue thrust swallow, pushing food out of mouth, sensitive gag, etc.)

Difficulty drinking from an open cup

Gags easily

Poor/slow weight gain and/or failure to thrive

Why: There are many possible reasons for picky eating, however one that must not be overlooked is if the child has a mouth-breathing (open mouth) tendency, commonly seen in conjunction with a restricted/tethered tongue (tie) and/or compromised tongue thrust swallowing pattern.

In this case, the child will tend to prefer a soft food diet that does not require much chewing as it is very challenging to breathe and eat with our mouths (humans are designed to breathe through our noses and eat with our mouths). Recall the last time you were sick with a congested nose, your diet too, likely consisted of soups, eggs, and soft foods.

Another possibility is if the child’s diet following 6 months was limited to soft foods that did not require the use of their muscles for chewing, they may develop a preference towards these foods.

picky eater 4 year oldchild 5 years old picky eater

     *For families with current feeding challenges (breast/bottle/solids), we would encourage you to seek assistance from either your local lactation consultant or occupational therapist (OT)

Primary teeth anterior open bite

Child with all their baby (primary) teeth, demonstrating an anterior open bite (space between upper and lower front teeth, when back teeth are together)

Why: If a child’s tongue rest posture and function are optimized along with lips sealed and nasal breathing, their palate (roof of mouth) will likely develop to be flat and wide, allowing for adequate space for teeth to erupt (without crowding). However, if one of these elements is not followed (i.e. tongue resting low in the mouth, compromised tongue thrust swallow, open mouth tendency and/or mouth breathing), the palate (roof of mouth) will likely develop to be narrow, high arched (can fit a thumb up) without adequate space for teeth to erupt, resulting in crowding.

The same compromised elements may also lead to the presentation of an anterior open bite (as seen in the picture), where there is a space between the front upper and lower teeth.

Why: Teeth grinding, restless sleep and/or sweating heavily can all be possible indications that the child’s sympathetic nervous system (fight or flight) is being activated causing micro (small) arousals (that typically do not awake the child) in attempt to maintain their airway (breathing). If this is occurring, your child may not be achieving consistent deep sleep with full muscle relaxation (parasympathetic nervous system – rest and digest activation) that is necessary for their optimized growth and development.

Primary teeth grinding

Upper baby teeth of child with generalized tooth grinding, showing even/flat wear across all upper teeth

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