Self-Assessment Checklist that may identify compromised growth, development, and function
Age group: 6 Months – 2 Years Old
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.
While Child is Awake
Mouth open/lips apart at rest (when not babbling, talking, playing) most of the day or routinely throughout the day
Difficulty breathing through nose, regular nasal congestion, and/or avoidance of breathing through nose
Dry, cracked lips and/or regularly licking lips
Frequent ear infections, strep throat, and/or tonsillitis (and/or surgical removal of tonsils and/or adenoids)
Why: 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.
Regularly have bags (dark circles) under eyes
Crowding of teeth (no spaces) and/or anterior open bite (space between front teeth when back teeth are touching)
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.
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)
Why: 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)
Frequent awakenings, nightmares, and/or night terrors (more than 1x/week)
Why: 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.
Sweating heavily while sleeping (pajamas and/or sheets damp)
While Child is Feeding (Current* or History of Challenges)
a) Breastfeeding and Bottle Feeding Signs/Symptoms
Poor latch (e.g. difficulty achieving or maintaining a good latch)
Gumming or chewing of nipple
Frequent clicking sounds, gulping, coughing, gagging, and/or choking
Why: A possible reason for frequent “clicking” could be that the baby has restricted/tethered oral tissues (tongue and/or lip tie). Clicking on the breast (or feeding mechanism) often occurs when the child cannot maintain suction or a good seal (latch) and with each “click”, they are swallowing air. Aerophagia is excessive swallowing of air. When excessive amounts of air reach the child’s stomach, abdominal distension (expansion), burping, vomiting/regurgitation, and excessive gas may result. This can be very uncomfortable, resulting in child’s upset and crying that worsens when laid on their backs. This is why clicking may be found in conjunction with a history of colic.
Note: Although there are other possible reasons for “clicking” and colic, if observed, a caring & comprehensive assessment of the baby is recommended.
© Natalie Cormier with Little Bird
Milk leaks or spills out the side of their mouth while actively feeding
Upper lip folded down (curled inward) and/or lower lip tucked in (curled inwards)
Dried milk residue/coating on back of tongue
Reflux symptoms (e.g. vomiting, regurgitation, frequent spit ups, crying after feeding, etc.)
Swallowing air regularly (increased gassiness, belly discomfort)
Insatiable baby (e.g. feeding every hour, falls asleep quickly when feeding and wakes shortly to feed again)
Poor weight gain, failure to thrive, and/or slows down weight gain
b) Eating and Drinking Signs/Symptoms
Picky eater (e.g. avoidance of crunchy/fibrous foods and/or specific food textures)
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.
Smacking sounds when chewing/swallowing (mouth open when chewing)
Difficulty swallowing (e.g. tongue thrust, pushing food out of mouth, sensitive gag, etc.)
Difficulty drinking from an open cup
c) Mom’s Signs/Symptoms (if applicable)
Creased, cracked, bruised, flattened, blanched, cut, and/or bleeding nipples after nursing
Severe pain when attempting to latch and/or while nursing
Poor or incomplete breast drainage and/or drop in Mom’s milk supply
*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)
Why: Optimized breastfeeding should be comfortable for both Mom and baby. Baby’s tongue should extend above and beyond their lower gum pad, forming a tongue to upper lip seal with Mom’s areola (breast). A possible reason for maternal nursing discomfort or difficulties can be from baby having restricted/tethered oral tissues (tongue and/or lip tie). If present, there is likely to be notable pain for Mom on latch and while nursing, as the baby’s gum pad (which is hard bone covered by a thin layer of soft gum) would be compressing against Mom’s nipple to hold breast in place and get milk to flow.
Why: In order to achieve an optimal latch/seal when nursing, the upper lip needs to be able to evert outwards, similar to “fish lips” allowing for maximal extension of breast tissue into baby’s mouth. If the upper lip is tethered (tied) and curls inward, it may prevent the extension of breast tissue as well as push the tongue backwards. If this occurs, there would be notable pain for mom on latch and while nursing, as the baby’s gum pad (instead of tongue against breast areola) would be compressing the nipple.
Why: Callous or blisters on upper lips may be signs of a restricted lip (tie). As instead of the upper lip being able to evert (fish lips) while nursing, it is curling inward and receiving extensive friction (rubbing).
Dry or cracked lips are a common sign that the baby is having their mouth open and/or mouth breathing. A restricted upper lip (tie) could prevent the baby from being able to close their mouth (lips sealed at rest), resulting in compromised mouth breathing.
Why: If dried milk residue on tongue is regularly noticed, it may be a sign of a restricted tongue (tie) causing altered tongue function. To which the portion of the tongue with the milk residue is unable to contact the roof of the mouth (palate) to be cleansed and cleared in an optimized swallowing pattern.
Why: Reflux symptoms may be caused by possible restricted/tethered oral tissues (tongue and/or lip tie). Tongue and/or lip ties may present with frequent clicking on the breast, difficulty achieving a good latch (seal) and swallowing air (aerophagia) to which during the day is coming out as gas or as vomit/ regurgitation. At night, you may see silent reflux, with the baby waking up in the morning congested. Congestion while sleeping is not always an allergy. Therefore, prior to Mom going on special diets and/or removing dairy (common allergens), it is encouraged to have baby assessed – as if a tie is present and treated appropriately allowing for baby to attain a good latch, symptoms may resolve.