Question & Answer - Oral Sensory-Motor, Myofunctional, Vocal Tract, & Airway Information
What should every parent know about teething and drooling?
Interview with Diane Bahr (DB) by Dr. Teresa Signorelli (TS) of Kids A to Z with Dr. T (May, 2015)
The following is the summary of a radio interview with Diane Bahr by Dr. Teresa Signorelli of Kids A to Z with Dr. T. You may listen to the actual interview by clicking on the “radio interview” link in the previous sentence. This interview is a continuation of discussions begun in October, November, and February about good feeding and mouth development.
In this interview, we discuss a little more information from the book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (pp. 115-121). This book was written as a resource for both parents and professionals (e.g., speech-language pathologists, occupational therapists, orofacial myofunctional therapists, lactation consultants, pediatricians, dentists, nurses, early interventionists, and others). It contains many detailed checklists and practical techniques that parents and others can use to keep kids “on track” in feeding, speech, and mouth development (beginning at birth).
TS: Would you tell us who you are and what you do?
DB: I’m a speech-language pathologist, specifically trained in feeding and oral sensory-motor treatment, with over 30 years of experience. I’ve authored two books Oral Motor Assessment and Treatment: Ages and Stages and Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. I’ve taught undergraduate, graduate, continuing education, and parent education courses. I’m also the co-owner of Ages and Stages®, LLC (Resources for Feeding, Speech, and Mouth Function) where our mission is to provide the best possible feeding, speech, and mouth development information for families and professionals. Our goal is to prevent feeding, speech, and mouth development problems when possible by helping parents keep their children “on track” developmentally.
TS: What is the most common concern you find parents have about teething and drooling?
DB: With regard to teething, parents usually want to know if it’s safe to give their children solid foods if they don’t have teeth. With regard to drooling, parents usually want to know how much drooling is too much.
TS: What are parents often surprised to learn regarding teething and drooling?
DB: Children drool when they are developing gross motor or whole-body movement skills (e.g., crawling and walking), fine motor skills (e.g., using their hands, eyes, and, mouths), as well as while teething from birth to 30-months.
Teething occurs as children chew on appropriate toys and foods. If a child is not getting enough chewing experience, teeth may come in late, in an irregular sequence, or improperly formed.
Profuse drooling is never typical. When parents see drooling during the development of motor skills and tooth emergence, it should be just a “dribble.” If the child’s shirt is constantly wet, that is atypical drooling.
TS: Do you have a theory about why teething and drooling are seen together other than the fact that they both occur in the mouth?
DB: Teething involves mouth movement which is a form of fine motor function. Therefore, teething movements (which occur with increasing food textures and appropriate mouth toys) elicit drooling. This is similar to what happens during the learning of other fine and gross motor skills.
TS: In your book you have a chart on teething and drooling from 1 month of age to 24 months of age. Can you tell us about this developmental process?
DB: Babies go through a developmental teething process mostly during the first two years of life, and drooling/dribbling is often part of this process. While I have a detailed chart and description of these processes in my book, here is a brief summary. At one-month of age, babies rarely drool because little saliva is produced. Between 2 and 5-months of age, parents may see some drooling as the baby is mouthing hands, fingers, or an appropriate toy. Teeth usually begin to erupt between 5 and 9-months of age, particularly if the child uses appropriate mouth toys and has appropriate feeding experiences. As we know, some drooling occurs with teething and the development of motor skills (e.g., rolling, sitting, crawling, babbling, hand use, etc.). The primary (or baby) teeth will usually erupt in a specific sequence between 5 and 30 months of age. The sequence is listed in my book, but parents can also find this information on the Internet. I suggest that parents record their children’s tooth emergence using a chart to see if their children are “on track” because tooth and jaw development go hand-in-hand. Jaw and airway development also go hand-in-hand. Everything in the mouth, facial, and cranial areas is connected.
TS: You said that drooling during tooth emergence should be a dribble (not profuse). Can you explain this further?
DB: Yes, profuse or excessive drooling is never typical. The drooling that is seen during motor development and teething should be more of a periodic “dribble” than a stream of saliva. If a child has a constant stream of saliva, something else may be going on, and the parents will need to look into this. One concern about significant saliva loss is hydration. And, we know that children need appropriate hydration for good brain and body function. By the way, children seem to need 2/3’s of their weight in ounces of non-caffeinated, non-sugar fluids each day to remain adequately hydrated. So, a 36-pound child needs 24 ounces of water per day.
TS: How are feeding, mouthing, and teething related?
DB: Mouthing, biting, and chewing on safe and appropriate mouth toys and foods seem to be crucial to the emergence of teeth. We see many children today who go through prolonged periods of sucking on pacifiers and thumbs without appropriate mouthing, biting, and chewing experiences. We are also seeing many child whose teeth do not seem to be emerging on time and in the proper sequence. In my experience, children need to bite and chew on toys and appropriate foods in order to get teeth. We talked about appropriate food texture introduction in our first two interviews. We spoke about the appropriate use of mouth toys in our last interview.
TS: What should parents do if they suspect their child is drooling too much?
DB: Parents need to work with their child’s pediatrician to understand why the child is drooling. There are four areas that need to be considered.
TS: So tell us about the first area parents and pediatricians should consider with regard to excessive drooling.
DB: The first area to consider is nose breathing. If a child is not breathing easily, clearly, and consistently through his or her nose, then the parent needs to look into this.
When a child cannot breathe through the nose, he or she must breathe through the mouth. Mouth breathing is very unhealthy because nose breathing helps with the warming, filtering, and processing of the air for use by the body. There is a specific chemical called nitric oxide that is only produced during nose breathing which is needed for the body’s metabolic processes.
Mouth breathing often results from a child’s inability to breathe through the nose. This may be due to a small nasal area that is difficult to clear, allergies, enlarged adenoids, or anything that may be impeding the upper airway. These problems are usually treated by a pediatric ear, nose, and throat doctor, also known as an otolaryngologist. In my opinion, it is important for parents to continually pursue problems that block a child’s nose breathing. It is not OK for children to have blocked upper airways.
Mouth breathing also leads to a low jaw and tongue resting position where it is easy for saliva to pool in the mouth. When saliva pools or collects in the mouth, we often see drooling. As we discussed in our last interview, a low jaw and tongue resting position is a problem for adequate jaw development.
Mouth breathing can also change the way children perceive sensation in the mouth. Just open your mouth and breathe for a minute. What does this do to your sensation in the mouth?
TS: So, tell us about oral or mouth sensation problems and how to address them.
DB: If saliva is pooling in the child’s mouth, the child may not feel it and therefore not swallow it. Oral or mouth awareness can be explored with a child during tooth brushing. How does the child respond to tooth brushing? Does the child seem to want firmer than usual brushing? Does the child resist tooth brushing? This will give the parents a sense of whether the child needs added oral sensation to feel what is in the mouth or is overly sensitive to what is in the mouth.
In my experience, oral sensation can be improved or typified through the use of oral massage. There is a systematic oral massage in my book. However, I will send a copy of the oral massage to parents and professionals who contact me.
Here is a brief summary of oral massage. Systematic oral massage should be enjoyable for the parent and the child, and it is best if done 3 times per day during a routine like tooth brushing. I usually have parents learn and practice the massage on their own mouths first. Then I have the parents do the oral massage in front of the child. Children need to see that the oral massage can be part of a daily routine. Older children can take turns doing the oral massage with the parent. While oral massage may sound a little strange in our culture, many cultures use massage for a variety of health reasons.
The massage usually begins in an area on the child’s body where he or she readily accepts touch. For many children, this may be the arms, legs, or back. I like to begin on the arms to get the child used to my touch. I use firm but gentle on-off presses, moving up the arms to the shoulders. Then I move to the child’s face (when the child is ready) where I use firm but gentle rotary massage strokes on the cheeks and around the lips. If the child does not like the rotary strokes, I use firm but gentle on-off presses. I make this into a game that the parent and child can do at home. The whole idea is to have the child ready to accept touch within the mouth.
Once the child is ready for massage inside of the mouth, the parent can use a gloved finger or a small soft brush (if the child has teeth) to massage the tongue, the teeth and gums, the inner cheeks, and the outside edge of the palate (or roof of the mouth) working from the front of the mouth to the back. Parents need to know how to properly massage a child’s mouth because this is a very vulnerable area of the body. Oral massage can be easily added to the child’s tooth brushing routine, and older children can be taught to appropriately brush/massage the insides of their own mouths.
TS: What is the third area that parents and pediatricians need to look at when a child drools?
DB: A third area to consider when a child drools is jaw closure. If a child has an open mouth posture, the parent and pediatrician need to discuss whether this is caused by a possible airway blockage (as we previously discussed) and/or if this is caused by a jaw problem. There could be a jaw alignment problem that can be addressed by a pediatric orofacial myofunctional therapist or oral sensory-motor specialist in conjunction with a pediatric dentist or orthodontist. We discussed these jaw problems in our last interview.
The child may also have a jaw weakness. The mandible or lower jaw bone is heavy, and the child must hold this bone up against the constant force of gravity in order to keep the mouth closed at rest. If the child’s jaw elevator muscles (which raise the jaw) don’t have adequate strength, the child most likely won’t be able to keep the mouth closed at rest.
I treat this by using systematic jaw work. In my book, I called this “Jaws-Ercise.” Systematic jaw work should be fun and enjoyable for the child. It can be done with babies beginning at birth if needed. Once children can use appropriate mouth toys and eat appropriately textured foods, jaw work can be facilitated using those toys and foods.
Basically, we want the child to chew on appropriate toys and foods at each back molar area 12 to 15 times for 3 sets at least daily. Orofacial myofunctional therapists may want the child chewing on toys and foods on both back molar surfaces simultaneously for 20 repetitions.
Jaw work can be done while parents and children are sitting and looking at books together. It is used to help strengthen the jaw elevator muscles which raise the jaw against gravity. I encourage parents to be good role models for their children by doing the jaw work along with them. Chewing while looking at books can also improve attention, focus, and concentration.
I have a Q & A on my website that explains jaw work with and without food in detail. The question was on a slightly different topic, but the jaw work is basically the same. Here is the question from my site: “I am working with a 3-year old boy who is dependent on purees…. What steps would you take to help him learn to chew foods?"
TS: So, now we know about the importance of nose breathing, oral massage, and jaw work, what is the fourth factor for parents and pediatricians to consider with regard to drooling?
DB: The fourth factor is swallowing. Depending on whose research you read, we swallow between 1000 and 2000 times per day when we are awake outside of meals or snacks. I suggest that parents observe their child’s swallow. This can be seen by watching the child’s voice box (also called the larynx) rise. The larynx should rise for each swallow.
We are talking about swallows outside of the meal or snack setting. If a child is not swallowing every 30 to 60 seconds when the mouth is at rest, this could be a reason for saliva pooling or collecting within the mouth. Parents can work on a child’s swallowing tempo by setting aside a time when the child can practice taking sips of liquid from an appropriate cup or straw every 30 to 60 seconds. Again, I encourage the parent to do this along with the child. We want these activities to be part of daily life. We also want them to be enjoyable for the parents and the child.
TS: Are there professionals who treat children with drooling problems, and who are they?
DB: Yes, some speech-language pathologists, occupational therapists, oral sensory-motor specialists, and orofacial myofunctional therapists work specifically with children who drool. In addition to my information on the resolution of drooling, Pam Marshalla has a book on drooling. You can find this book on the Marshalla Speech and Language website.
TS: You have a wonderful website and networking program for families and related professionals called “Ages and Stages” that provides resources for feeding, speech, and mouth function. Would you talk to us about this?
DB: As previously mentioned, our mission is to provide the best possible feeding, speech, and mouth development information for families and professionals. We do this through blogs, Q & A’s, and other formats. Our goal is to prevent feeding, speech, and mouth development problems when possible by helping parents keep their children “on track” developmentally through the application of evidence-based information. As a speech-language pathologist, I have worked with many children who have disabilities, but I noticed that parents of typically developing children also needed the information we have (as oral sensory-motor and feeding specialists) to keep their kids “on track.” Our website is where we offer free parent-professional book guides in addition to a lot of other free information.
TS: You also have a number of publications and host trainings. Would you tell us about these projects too and how to access them?
DB: In addition to my two books, I have written a number of journal and popular articles for parents, families, and professionals. These are listed on my website.
I have recently published an E-course on the topic of newborn and infant mouth development entitled Everything You Need to Know about a Baby’s Mouth for Good Feeding, Speech, and Mouth Development. The course is particularly useful for new parents, because it talks about avoiding many of the pitfalls that occur during the first year of life.
While the course was originally developed as a continuing education course for professionals, it’s presented in such a way that parents and care providers can understand and benefit from it. Information on all of my projects can be found on my website.
TS: Finally, as we close our show, would you list your top “Five Fabulous Facts for Families” about teething and drooling?
DB: As I have said in previous interviews, I am providing you with educational information based on my years of experience as a clinician. I am not providing medical advice. So, here are five ideas I would like you to take with you:
-Always talk with your pediatrician about the methods and techniques you are using with your child. Your pediatrician is a partner in your child-rearing process. Speaking with your child’s pediatrician can be particularly important if your child’s teeth are not emerging properly or if your child’s drooling is related to an airway issue. Your pediatrician can guide you to a pediatric dentist or otolaryngologist.
-If possible, begin tracking and guiding your child’s mouth development from birth. Track your child’s tooth development using a chart, and keep an eye on the amount of drooling your child is doing from birth to 30 months. A child should not be drooling once teething is finished.
-If your child is drooling profusely, consider the following four factors. Does your child have easy, clear, and consistent nasal breathing? If not, you may need to work with a pediatric otolaryngologist. Does your child have adequate sensation within the mouth? If not, you may need to do some systematic oral massage as part of your child’s tooth brushing routine. Does your child have a closed mouth at rest? If not, consider whether your child has the ability to keep the jaw closed against gravity. You may need to consider doing some systematic jaw work to strengthen the muscles that close the jaw. Does your child swallow every 30 to 60 seconds outside of meals and snacks? If not, you may need to help your child practice his or her swallowing tempo while taking appropriate sips from a cup or straw.
-If drooling is a significant problem for your child, see the appropriate specialist. This could be a speech-language pathologist, an occupational therapist, an oral sensory-motor specialist, or an orofacial myofunctional therapist who works with this problem.
-On my website, I have a websites and companies resource list with a section on mouth structure and function where you can find many resources about mouth and airway development. We are also working on a networking directory to help you find appropriate professionals in your area. In addition, you are always welcome to contact me directly with your questions at firstname.lastname@example.org.
Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development. Arlington, TX: Sensory World.
Permission granted by Dr. Teresa Signorelli of Kids A to Z with Dr. T for printing this summary of the radio interview with Diane Bahr.