Question & Answer - Oral Sensory-Motor, Myofunctional, Vocal Tract, & Airway Information
How do you keep your child's mouth in shape from birth? The Scoop on Pacifier-Use, Thumb-Sucking, and Mouth Toys.
Interview with Diane Bahr (DB) by Dr. Teresa Signorelli (TS) of Kids A to Z with Dr. T (February, 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 and November of 2014 about 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. 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 oral sensory-motor and feeding therapy, 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 and professionals keep children “on track” developmentally.
TS: What is the most common concern you find parents have about mouth development?
DB: With so many older children wearing braces, having palatal expanders, and being diagnosed with sleep apnea, parents want to know what they can do from an early age to help their children develop the best possible mouth and airway structures.
TS: What are parents often surprised to learn regarding mouth development?
DB: A significant amount of mouth and airway development occurs in the first year of life when the structures are growing rapidly. As we discussed in previous interviews, mouth and airway development are interconnected because they share common structures such as the hard palate (roof of the mouth). Parents can help make a difference in how their children’s mouths and airways develop by the feeding processes they use and the mouth play they encourage.
TS: Let’s talk about the process of mouth development? Can you begin by telling us something about the hand-mouth connection?
DB: In Chapter 4 of my book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development, I talk about the hand-mouth connection. Hands and mouths work and develop together from birth.
This begins with the hand and mouth reflexes with which babies are born. These are the palmomental, Babkin, and grasp responses. When you touch a baby’s palm, the mentalis muscle is activated, which helps the baby’s lower lip evert for the latch. When you press the base of the baby’s palm, “the baby’s mouth opens, eyes close, and head moves forward” which helps with feeding. When you place your finger into a baby’s palm, the baby grasps the finger. This grasp tightens when the baby sucks. A baby’s hand-mouth connection can often be seen on ultrasound while the baby is still in utero (e.g., thumb, hand, and foot suckling).
TS: You talk in your book about the development of mouthing. Can you tell us something about that?
DB: Babies go through a developmental mouthing process during the first two years of life. I’m going to talk mainly about the first year because this is information many parents don’t get to hear.
There is a period of generalized mouthing from birth until around 5-months of age. During this period, babies suck on their fists, fingers, and thumbs mostly near the front of their mouths. Around 3-months of age, babies gain increased control over the mouthing process. This is a time when parents can help a baby hold an appropriate mouth toy to the mouth. The baby will suck and bite on the toy.
By 5 to 6-months of age babies develop even more oral control and begin the process of discriminative mouthing. At this age, a baby needs appropriate mouth toys that the baby can explore throughout the mouth, not just in the front of the mouth. This helps a baby develop sensory discrimination within the mouth that he or she will ultimately use for food manipulation and speech. Many parents don’t know about the discriminative mouthing process, and many mouth toy manufacturers do not provide appropriate mouth toys for this process.
TS: You mentioned “discriminative mouthing” and that many toy manufacturers do not provide appropriate mouthing toys. Would you tell us what you mean by “discriminative mouthing” and what appropriate mouth toys might look like?
DB: Discriminative mouthing is when a baby uses the mouth like a “third hand” to explore hands, fingers, and mouth toys. The toys need to be large enough so the baby won’t swallow or choke on them but small enough so the baby can move the toy safely throughout the mouth. These toys are often triangular in shape or have protuberances that the baby can move all around the mouth.
For young babies, I like ARK’s Baby Grabber, Debra Beckman’s Tri-Chews, and the Chewy-Q from Chewy Tubes. These items are made in the USA from FDA approved materials. I provide information in my book on where to purchase them. However, parents can look for toys with the qualities we discussed.
TS: How are mouthing and teething related?
DB: Mouthing is an important part of the teething process. Mouthing, biting, and chewing on safe and appropriate mouth toys and foods seem to be crucial to the emergence of teeth. The primary teeth emerge mostly during the first 2-years of life. We see many children today who go through prolonged periods of sucking on pacifiers and thumbs without appropriate mouthing, biting, and chewing experiences. We also see 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.
TS: There a number of common mouth development problems. Let’s talk about what they are and what parents can do about them. Let’s start with the problem of having a high-narrow palate or roof of the mouth.
DB: As we discussed in our previous interviews, high-narrow palates (roofs of the mouth) usually cause the child’s nasal and sinus areas to become smaller than usual. This makes the child’s upper airway smaller and more difficult to clear which may contribute to unhealthy mouth breathing, allergies, sinus problems, and sleep apnea. High narrow palates usually result from low resting tongue postures (where the tongue sits in the bottom of the mouth instead of resting within the hard palate area). Therefore, it is important for a baby to have time throughout the day and night for the tongue to rest properly within the mouth with the mouth closed at rest (without a pacifier or thumb).
It is a closed mouth at rest with the tongue resting in the palate area that helps to maintain the hard palate’s shape. Breastfeeding is also a nice natural way to help maintain the hard palate’s shape because the breast is drawn deeply into the baby’s mouth to fill the palate area while the baby is feeding. Unfortunately, bottle feeding does not provide the same benefit. Additionally, I have a jaw activity in my book that parents can do with their babies from birth that may help maintain the palate’s shape and assist with the growth of the lower jaw.
TS: Yes, so I understand there can be problems with mouth development that result in overbites, underbites, or other issues. What can you tell us about that?
DB: In my experience, babies who suck excessively without other mouth experiences can have over growth of the upper jaw (leading to an overbite or overjet) and limited growth of the lower jaw (leading to a weak chin and limited airway development). The lower jaw seems to require the biting and chewing experiences we discussed previously to grow forward, which then helps the airway area behind the jaw to develop properly. And, these issues can become very apparent by one-year of age, if not before.
Overbites (top front teeth too far in front of bottom teeth), overjets (top jaw too far in front of bottom jaw), and open bites (opening between the top and bottom teeth) usually result from some form a of a tongue thrust swallow. Tongue thrust swallow may also be referred to as reverse swallow or exaggerated tongue protrusion. This is an unsophisticated form of the swallow where the tongue moves forward in the mouth (often against the front teeth) to begin the swallow, instead of the tongue tip rising up to the ridge behind the top front teeth to initiate or start the swallow.
Underbites (bottom teeth and jaw protrude in front of top teeth and jaw), cross-bites (where the top and bottom teeth cross each other and do not fit together properly), and closed-bites (where teeth meet edge to edge) usually result from jaw development problems in my experience. Typically, when the top and bottom jaws come together, the top teeth are supposed to be slightly in front of the bottom teeth with the molars meeting properly in the back of the mouth, like a lid fitting onto a container (as described by my colleague Marge Foran who is an orofacial myofunctional therapist).
In Chapter 8 of my book, I discuss appropriate mouth development from birth to adolescence. I also talk about the specific mouth development problems we have just discussed and who to see if a child has these issues.
TS: So we’ve discussed some of the problems with mouth development. What can parents do to prevent or resolve these issues? Who are the right professionals with whom to consult?
DB: Parents can help prevent problems by tracking their children’s mouth development from birth and using appropriate feeding and mouth development activities with their children. As you know from our previous interviews, this is one reason I wrote my parent-professional book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. I want parents to have the information we as therapists have about feeding, speech, and mouth development.
However, if parents have not had the opportunity to encourage good mouth development from birth, I suggest they take a look at their child’s mouth development and get appropriate help if needed. As I mentioned before, I have mouth development information (from birth to adolescence) in Chapter 8 of my book.
Now, I don’t want parents to look at the information in Chapter 8 and feel guilty if their children have any of the mouth development problems we’ve discussed. You can’t prevent something you don’t know about as a parent. So, my book is an information book to help parents and their children move forward in the process of mouth development.
There are many specialists available to help parents and children with this process when problems arise. Oral sensory-motor specialists and orofacial myofunctional therapists usually work in conjunction with orthodontists, dentists, oral surgeons, and otolaryngologists (i.e., ear, nose, and throat doctors) to help resolve many of the mouth development issues we have discussed. As an oral sensory-motor specialist, I specialize in jaw and feeding work. If the jaw isn’t working properly, the lips and tongue cannot work properly. Orofacial myofunctional therapists specialize in correcting the resting tongue position and the swallow. There are also dentists who specialize in orthotropic work and functional jaw orthopedics. You can find information about these specialists in Chapter 9 of my book.
TS: Let’s talk about pacifiers and thumb-sucking. Pacifiers are popular with parents to sooth children. Children may also suck their thumbs for a similar purpose. What do you see as appropriate pacifier use versus overuse?
DB: In Chapter 4 of my book, I provide parents with guidelines for appropriate pacifier use and thumb-sucking. As you said, sucking can be very soothing for a young baby.
With regard to pacifier use, there was a study of almost 500 children in the year 2000 that demonstrated a connection between long-term pacifier use and middle ear problems. So, in my book I recommend guidelines for pacifier use based on this study. In my opinion, pacifier use is most appropriate for calming babies from birth to 5 or 6-months of age. A child should also be given the opportunity to self-calm with his or her own hands during this time. A calm child doesn’t need a pacifier, thumb-sucking, or finger/digit sucking. When a child overuses a pacifier, it limits the child’s opportunities for communication (e.g., the development of facial expression, cooing, babbling, etc.) in addition to other appropriate mouth experiences.
By 5 to 6-months of age, the child should be using appropriate mouth toys for teething and discriminative mouthing. This activity can also be soothing and calming, and it can increase attention, focus, and concentration. Adults often chew gum for these purposes. They hopefully don’t suck on pacifiers, thumbs, or digits to calm and organize themselves. I usually recommend that parents provide appropriate mouth toys for their children throughout the day and while they look at books together.
The 5 to 6-month period is also a time when many new feeding experiences are introduced as we discussed in our first interview. The baby learns many new mouth movements with these feeding experiences.
Dr. Harvey Karp is the pediatrician who wrote the book The Happiest Baby on the Block. In his book, he recommends that parents discontinue the pacifier at 4 to 5-months of age. The study of almost 500 children (mentioned previously) recommends parents wean their children from the pacifier between 6 and 10 months of age. It was beyond 10-months of age that a correlation was found between pacifier use and middle ear problems in the study. By the way, I also encourage parents to follow similar guidelines to wean children from thumb and finger/digit sucking. However, thumbs and fingers are attached to the child, so weaning may be a little trickier than weaning from a pacifier.
TS: Now, I understand you have an 8-step process parents can use to help wean children from using a pacifier, sucking their thumbs, or engaging in other sucking behaviors. Would you walk us through that? As you do this, would to tell us tips you have for parents to wean their children from pacifiers and how parents can decrease and eliminate thumb-sucking?
DB: As you mentioned, I have an 8-step process for weaning children from the pacifier, thumb, or other sucking habits in my book. The key is to find appropriate mouth toys to replace the pacifier, thumb, or digits when the timing is right. I usually start early by having parents introduce mouth toys hand-over-hand beginning around 3-months of age. Weaning can be complete in some children by 5 or 6-months of age as suggested by Dr. Karp or even earlier. It can be a quite natural and easy process when the child is ready.
The mouth toys used in the weaning process need to be something enjoyable and appropriate for the baby or child. In Chapter 5 of my book, I have a chart with recommended mouth toys by age. As previously mentioned, I like ARK’s Baby Grabber, Debra Beckman’s Tri-Chews, and the Chewy-Q from Chewy Tubes for young babies. Both ARK and Chewy Tubes have a range of safe and appropriate mouth toys. Their items are made in the USA from FDA approved materials. I provide information about these and other companies in my book.
Another key to the weaning process is to provide positive attention (e.g., a smile and/or kind words like “Look at how much fun you are having with your toy.”) when the child is using an alternative item for mouthing in place of a thumb or pacifier. At first, you praise the child frequently for using new mouth toys. Over time, you praise the child intermittently or occasionally as he or she naturally mouths the appropriate toys you’ve introduced. The child will no longer need constant praise for this process.
When helping children break habits such as thumb or finger/digit sucking, I suggest you ignore the habit but not the child. You can just act as if the child is not participating in the habit. I don’t recommend bringing attention to the habit by saying “Take that out of your mouth.” This can actually reinforce the habit in some children. If you have an older child who has a detrimental oral habit, you may need to work with the child on a specific plan to eliminate the habit.
TS: What are the potential ramifications of pacifier overuse and thumb-sucking?
DB: We call thumb and pacifier sucking detrimental oral habits when they continue beyond infancy because they tend to lead to low tongue resting postures and some form of a tongue thrust swallow, which (as you know) can result in a number of mouth development problems.
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 your list your top “Five Fabulous Facts for Families” to provide safe, healthy, and pleasant mouth development experiences?
DB: As I have said in previous interviews, I am providing you with educational information based on my years of experience and study 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, and you learn from one another as you share information about your child.
-If possible, begin tracking and guiding your child’s mouth development from birth. This could save you from expensive orthodontic and other work later on.
-If you have an older child, take a good look at your child’s mouth and airway development. See the appropriate specialists if needed. The sooner you get treatment, the better.
-Heredity plays a part in your child’s structural development, but it is not a reason to skip needed treatment. If underbites, overbites, or other mouth development problems run in your family and your child seems to be headed in that direction, see an orofacial myofunctional therapist, a pediatric dentist, a pediatric otolaryngologist (i.e., ear, nose, and throat doctor), an oral sensory-motor specialist, or other appropriate professional.
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.