Episode 177: How to Stop Infant and Toddler Thumbsucking

Hi and welcome to episode 177 of the Untethered Podcast. Today it's your host, Hallie Balkan, and I am bringing you an episode on oral habits, especially as they relate to the infant and toddler population. So what do I mean? Well, we're going to be diving into how do we get an infant or toddler to stop sucking their thumb? Or do we? What is the best solution? Who do we go to and in order to address this issue? And how do we know if it's even a problem? Right, so let's dive in.

Quick disclaimer. All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan.

Hi.

I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses.

Let's get started. All right, so on today's episode I want to dive into the topic of oral habits. And we will be bringing you more on this topic going forward so that you can hear from different area experts on the topic of oral habits. But let's first discuss whether you're a parent or a professional listening and you are not familiar with the term oral habits or what an oral habit is. Essentially it's a behavior that involves either your tongue, your lips, the roof of your mouth, teeth, gums, right, those oral structures. And with this we see things like thumb sucking, finger sucking, maybe blanket or clothing sucking, you know, maybe chewing on or sucking on your clothing. Sometimes we see that in our toddlers there may be tongue sucking. Sometimes we see that use of pacifiers or soothers. Sucking on the lip, licking the lip or around the lips, mouth breathing, nail biting, right. Even chewing on foreign objects. Anytime a non food item enters the mouth for the purpose of chewing or sucking, remember it's a non food item. We call this an oral habit. Now the one thing we want to remember is that infants do mouth objects, toys, things in their environment that may be non food items. This is a part of exploration. We may start to see this early on in infancy and carry out through a lot of infancy. And this is Typical. We, this is how infants explore their world. So we're not talking about that mouthing of toys that may happen for a minute or two here and there. As children explore their environment and learn about the environment around them, we are talking about an oral habit. And I'm going to dive into how we know whether or not it's a habit and if it's problematic. Okay, so when we assess an oral habit, for example, we look at three main things. Let's use thumb sucking as an example as that is when of the topics that we focused on for this episode. And we look at frequency, intensity and duration. So how frequently does that thumb sucking happen? Is it just like a few minutes here or there, or is it throughout the day, always before bed for at least, you know, 10, 20, 30, 40 plus minutes? You know, how long is it going on? That's the duration. Right? So I said frequency, intensity and duration. So frequency, how often, duration, for how long each time it does occur and then intensity with what intensity, what force are they engaging in that thumb sucking or that oral habit? Are they like intensely, like sucking really hard? So if you try to pull a pacifier out of their mouth or pull the thumb out of their mouth, not that we're going around doing that, but if you did, are they really holding onto it? Are they biting down? Are they sucking really hard? What intensity are they using in prolonging that oral habit? Okay, so if this is an oral habit that occurs frequently with that high intensity and for a long period of time, then we want to consider an assessment. Now, who do we go to? If we're talking about infants and toddlers, the correct provider would be a speech language pathologist or an occupational therapist trained in pediatric feeding. Okay. Sensory oral, motor feeding. Ideally, we want this individual to also have training in orofacial myofunctional disorders. Airway tethered oral tissues. Right. Because this oral habit is probably telling us there is more going on. Now, the reason why I suggest a pediatric feeding therapist that has these additional trainings skill sets is because when a child between birth to 4 years of age presents with an oral habit, it's more than just an airway issue. We don't typically just see, oh, you know, their jaw is in the wrong place and so they're sucking their thumb. No, we actually see it impact how they chew, how they swallow, and sometimes it can even impact speech. Right. Then we start to see it impact sleep, which can impact language development, which can impact the central nervous system, which can impact their sensory responses. Okay, so that SLP or OT becomes extremely necessary in these cases. And unfortunately we're seeing a lot of these kids be referred to traditional myofunctional therapists who are not trained in how to work with infants and toddlers. Infants and toddlers. A therapeutic approach, right. For neuromuscular reeducation is what we call it in regards to teaching them how to properly chew, swallow, maybe speak if you're working with an slp. And that's a goal, you know, correct oral rest, posture, breathing, it's, it, it's very different than a traditional myofunctional therapy program. And I'm sharing this because I get phone calls all the time from parents saying, oh, I need a myofunctional therapist. We say, okay, what is your child's date of birth and the B. And it's a baby, it's an infant, it's a child. But you know, under the age of one or it's a toddler, you must have at minimum the cognitive level of a four year old child to participate in a traditional orofacial myofunctional therapy program. That said, we can absolutely take and adapt what we do in a traditional MYO program to a younger child. Okay. And we're going to get more into how to eliminate that thumb sucking in a moment. But I want to make this very clear. When we are doing traditional myo, that's an active activity, that's an active type of therapy. When we are working on these same goals in a younger population or in a population that has developmental delays or cognitive delays, we need to consider that child in front of us. This becomes a passive therapeutic approach and falls under the scope of pediatric feeding. There is an overlap in what we are addressing. Yes, you need additional training. Yes, you need to further your skill set to fully grasp what to address in that therapy. However it is, it falls under pediatric feeding, it is billed under pediatric feeding, and only SLPs, OTs and arguably PTs who are trained can provide that service and bill for that service. Okay? So I just want to make that very clear as we've been receiving a lot of parents who've been given the runaround, their children have supposedly received a myofunctional therapy program. Very little if anything, has been improved. In fact, in some cases, things have been heightened and worsened. And so we want to make sure that a child is being sent to the correct provider and that there are not individuals who are misrepresenting their abilities, their skills. And I say this with love, but please know, please do your research and Please note that a traditional myofunctional therapist that is not an SLP or OT or in very few cases, pt. Those providers are not trained in how to work with children before between the ages of birth to four. And they should be referring out if they do encounter you and. Or your child. Okay. All right. So going back to the oral habits, one common reason, and I want to explain this, you understand where I'm coming from when I explain how we go about treating the thumb sucking in this population, this age group. One common reason that thumb sucking occurs is to fill a void, avoid. When the tongue lives on the floor of the mouth instead of up on the palate, up in the roof of our mouth. Okay. When a evaluation and treatment is warranted. Right. We note that it's to address oral rest, posture. But also for a lot of these children, it's not just that their tongue is not living on the roof of their mouth. They're not elevating their tongue at all, which is that. Which ties back into feeding development, speech development, the ability to get restful sleep at night and continue to develop. Because we know that there's a lot of. There's a lot that goes on when a child is sleeping. The brain repairs itself, the body rests and restores. We need that restorative sleep and we don't get it if we are not getting deep sleep throughout the night. Right. It's not always about quantity. Right. Quality of sleep is more critical than quantity. But nobody's really focused on that. Everybody focuses on, oh, you know, infants need X number of hours per night at this age. A toddler needs this many hours at night for this age. Why is nobody talking about the quality of their sleep? Okay, like I got a. Not I. One of my therapists in my practice got a five and a half year old child recently who's on three medications, two for ADHD and one for. For when it's an antidepressant depressant. Has this child ever had a sleep study? Nope. Has this child ever had anybody ask them about sleep before they met us? Nope. Has anybody ever looked in the kid's mouth? Nope. This is a problem, right? This is a problem. This could have been prevented had this child been referred to the right provider at a younger age and actually was sent to us for one thing, was assessed for another. And we are going down that airway, Mayo Tots, World Realm roller coaster, if you will, with this child now. And the parent and the parents kind of go like, whoa, this all makes so much sense. Yes. It makes so much sense. But we need to be providing these children with the correct providers, providing these parents with the correct providers. Okay? Now, the other thing I will tell you is children who are not treated. You know, there's a lot of literature that says that, like, oh, you know, one in five children still suck their thumb. Actually, the research out there demonstrates that about 33% of the population sucks their thumb. And so we're talking about adults who suck their thumb, many in private. And you would never even know that. Maybe a friend of yours does that. Why? Why does this happen? Right? Why is there this ongoing need to put a thumb in your mouth? Well, let's look at dentition, right? Let's look at airway. Let's look at where the jaw sits. Now, again, I'm not a dentist. I've said this in other episodes. I'm not an orthodontist. I don't move teeth for a living. But I can look at a mouth and observe and determine if the jaws appear to be aligned, if the max level, the upper jaw, sits too far back compared to the lower jaw. Like, maybe the lower jaw sits in front of it. Maybe it's the opposite. Maybe the upper jaw is in the right place in the lower jaw is sitting too far back. One of the things that we have noted in a lot of our birth, you know, through four kiddos who suck their thumb, is they're using their thumb as what we call a mandibular advancement device. They're basically taking that thumb. If you put your thumb in your mouth right now and you suck on it or just put it in there, then put your thumb up in your palate, it's going to naturally push your lower jaw forward even a couple millimeters. That's all that's needed. Sometimes when that happens, that opens the airway more. Okay, and go back to the last episode I just talked about how when we grow our jaws forward, laterally, right? We're seeing the airway increase in size. The airway increases in size. Let's say a child who is having lower quality of sleep because they can't breathe properly through their nose. Maybe they're snoring, maybe their tongue's falling back when they sleep and blocking their airway. Who knows? There could be a whole host of things going on there. Could be enlarged adenoids or tonsils. Right. Or high neuro pallets. All kinds of different things going on here. What we do know is that airway is compromised and they have resistance, right? There is resistance to air flow when they're sleeping. That resistance reduces the airflow when breathing during sleep and that in turn can impact cognitive development. We've seen that children with obstructive sleep apnea, as I, I believe I previously talked about this, especially when touching on like ADHD. I believe it's 16 points lower, like 10 to 16 points depending on the research article. IQ is 10 to 16 points lower than same age peers that do not have obstructive sleep apnea. So we are seeing the toll that a low quality of sleep has on the developing brain. Right. So we absolutely need to be having these conversations and addressing it. So. Okay, great. Holly, this is all wonderful. You've talked about this. What do we do now? Find that provider for an assessment. If you want somebody, you can always reach out to me. If you're not sure where to go. Allie Balkan on Instagram, you can also go to pediatricfeedingtherapist.com those providers are all SLPs or OTS who have been vetted in terms of their at least having the SLP or OT credential. And they have taken the feed the peds course which goes over this teaches them along with pediatric feeding and a whole host of other things. It's a 40.5 hour course and we're, we take a deep dive in two of the modules that I personally teach on tethered oral tissues and airway as it relates to orofacial myofunctional disorders and all this fun stuff and how to work on that. With the birth to four, arguably five population, some kids are not ready until they're a little older. So I want you to know that not everybody's thumb sucking just stops or magically disappears as is sometimes suggested. We need to pay attention to these oral habits as they can become very detrimental to oral facial growth over time. We commonly, as I was alluding to before, observe really unfavorable, if you will, changes to our lower jaw or mandible and to our maxilla, our upper jaw, to the hard palate, to the dental occlusion. Right. So sometimes, you know, taking that thumb out, you can do thumb sucking elimination programs. Do you have to? That's. That depends who you talk to as to their opinion on the matter. The other thing I want to mention is that, you know, we see a lot of like open bites or overbites, right. Shifting of teeth. Sometimes there's skin problems. Sometimes the skin on the actual thumb itself is being sucked on or skin around the lips or the lips themselves become chapped, right. Or cal they develop calluses. Sometimes we see Speech problems. There could be social issues surrounding the thumb sucking and, and so on and so forth. Especially as they get older, especially as they enter kindergarten. Their children are not always kind these days. Right. So it's something to pay attention to for sure. But if we treat the habit by figuring out the root cause, what void is this thumb in the mouth filling, what void is this oral habit filling, Then we can treat them and get them back on track. And by treating treating the root cause, the oral habit often falls by the wayside. Okay, so what do I mean by that? Well, like we've had a few parents in the past, you know, month or two come to us and say, my child sucking their thumb, how do I get them to stop? It's not as easy as weaning off a pacifier at 6 months of age. Right. You can't just take that passy away cold turkey or slowly wean them on one of those weaning systems. No. We have a child who has a thumb attached to their hand which is attached to their wrist and their arm, their body. Right. We cannot remove the thumb. It is always going to be there. So do we put an appliance around the thumb and like tape the thumb to the wrist and make it so that it's not accessible? Do we put the child in a sleep sack? Do we. You know, there's all different kinds of things. We put yucky tasting stuff on that thumb or finger. There's all kinds of like different things on the market. Right. My thought process on that is they are all band aids and some of them can be harmful. My OT friends do not like braces on the thumb that prevent your thumb from mobilizing. Like why are you casting a thumb that's fully functioning? You're going to cause a problem. Right? We're going to cause an issue if we're not using that, especially weeks on end. Not the best solution. Many kids will lick that bitter tasting stuff right off their finger and continue sucking their thumb. They could care less. Then there is sleep sacks. Well, sleep sacks can be problematic, especially at a certain age because of a baby flips over and gets stuck and can't flip back over because of the sack. Well, that could be problematic. Some sacs that allow the, the body, you know, the arms and legs to be moved around may be okay. But a lot of my PT friends prefer no sleep sack or you know, no swaddle after a certain point or outside certain developmental periods. So, you know, it comes to the age of the child and consulting with a specialist who Understands, you know, movement and airway movement and the need to. Well, really, it comes down to movement. Okay. Because what we always say, what we see on the hips, we see on the lips or vice versa, Meaning what's going on down on the hips at the core is going to impact what's going on in the mouth. What's going on in the mouth is going to impact what happens at the core and on the hips. Okay. We need the stability at the hips in order to have a stable environment at the level of the mouth. Right. We also need to have a jaw in the correct place in an open airway in order to breathe properly, in order to stabilize ourselves. It's kind of this catch 22. Right. So do we just jump into treating the oral habits right before, like, jumping into a feeding program or if the child's like, four on up, a MYO program? Not necessarily. I was actually trained that you do that. You can't get in. You can't start, Maya. Without treating that oral habit and eliminating it first. You're going to be hitting a wall, and, you know, you're wasting everybody's time. Right. So I started on in my journey as a myotherapist with treating the oral habit first, and I was very successful. But what I started to realize, especially in families who were not super on board with the program and the commitment of the program, I was like, you know what? Let's just jump into mayo, see what happens. And, oh, my goodness, lo and behold, a lot of these patients, pediatric patients, right? And this is. This is more traditional myo that I noticed this with, like, five, like, four or five years plus through adulthood, a lot of these patients stopped the oral habit. They stopped sucking their thumb. They stopped biting their nails. They stopped chewing on their tongue or sucking their cheek or, you know, sucking on their shirt. And I was like, huh? Why is that happening? And then it dawned on me. Oh, well, like the thumb, for example, was filling a void. It was up in the palate where the tongue is not currently resting. So it's filling a physiological need. Right. When that tongue is up on the palate, it releases endorphins. It also helps to shape at a young age, helps to shape and then hold the shape of the palate. We say that tongue is like our natural palate expander. And so when we don't have that in place, especially when we put the thumb in and it feels good, the body is going to want to keep repeating that. And so then we get into, like I said, this catch 22 of like, well, we can't just like take the thumb away. They're going to fill it with something else. Right. So the reason why some of the thumb sucking elimination programs work is because if you do them in combination with myofunctional therapy and you're working on getting the tongue up into the palate while you get the thumb out of the mouth, well, okay, you know, those go hand in hand. And now we're, we're now filling that void or replacing the habit with the correct habit with having that tongue rest up in the palate. Okay, hopefully that makes sense. When we do these thumb sucking elimination programs, we need to be asking like, is this working long term? Are these kids coming back to redo the program or for a touch up, is it holding? I don't like the concept of a thumb sucking elimination programs. Like a standalone program. We used to offer it. We very rarely do it at this point and we require a myofunctional therapy program first. Now with our birth to four kiddos, this requires a pediatric feeding assessment which focuses on airway, it focuses on oral rest, posture, tetheral tissues. Right. Those are all parts of our feeding assessment. So when I see feeding, I don't want you to think, oh my child feeds fine. They don't have a problem. No, the realm of sensory motor feeding covers all of these areas and these are all areas that are in scope. Right. So we may do a feeding and. Or you know, well, not and or but feeding assessment. That includes looking at tetheral tissues. That includes looking at the orofacial complex. Because that's what we do in a feeding evaluation anyways. Right, we're already doing that. So now we're just adding in. Okay, are they functioning properly for preparing a bolus for sucking and swallowing and maybe they're suck, swallow, breathe, if they're bottle or breastfeeding, you know, how are they using utensils? What are their orofacial muscles do around a straw, you know, looking at all these different things and then, oh, by the way, let's see how they are at rest. Where's the tongue at rest? What are the lips doing? Are they nasal breathing? And how about at night? That's just a piece of our feeding evaluation for birth to four. And that's what we are teaching and feed the peds. And that's what's been missing in the industry, which is why I. Other professions have started to encroach on this space and have been practicing without a license with this population. This is not a population that should be assessed for a myo disorder unless they are an SLP or an OT or potentially, like I said, a PT who has experience with pediatric feeding, which there are PTs out there that do have this experience. So I want to go back, right? Maybe the question is not how do we stop thumb sucking, but rather what void is the thumb sucking filling and how can we treat it in this population right now? Okay, because again, when we treat that underlying issue, when we train the tongue to function properly, right, Maybe the tongue can't lateralize or protrude or retract or elevate. And depending on the age, we also need to know what skills are expected, especially between birth to 3 years of age when a lot of these orofacial skills and movements and you know, range of emotions are not range of motions, but the range of motion expected for different oral tasks are developing. Right? We have to look at the underlying issue and we have to treat the underlying issue. And then like I said before, the oral habits often fix themselves, if you will. They go away on their own and they don't need to be targeted directly. In the rare case that they do still need to be targeted. At least we have primed the pump, right? At least we have trained the child on that infant or toddler on what is expected. We know they can do it even if it has, even if they can't physically do it right now because that thumb is living in the mouth, now we can start to figure out how do we address getting that thumb out because we know they have the skills and we want the skills to carry over. But that's not going to happen with the thumb in the mouth. That is rare though. Typically when the child has the skills and we get that tongue up on the palate, nothing else is needed. So that thumb doesn't find its way in the mouth. So I want to just share that and highlight who to see when it's a problem, how we address it. And with that understanding that like I've always said, we are connected from the tip of our tongue to the tip of our toes. Everything is interconnected and there is always a root cause, underlying reason for what is happening. And we have to be asking what is that and how is it impacting the child? What is the functional impact on this child? Right, Feeding, sleep, speech, attention, behavior. Because yes, even in 2 year olds, and now we're seeing 5 year olds on medications for ADHD, as I mentioned, who have never had a sleep study. Nobody's ever looked in their mouth. But anyways, I digress. We need to be looking at how is the child presenting and what is the root cause. Okay, so hopefully this is enlightening. Hopefully this is helpful. Again, if you have any questions, feel free to reach out to me on Instagram @halliebulcken and if you want somebody in your area properly trained, go to pediatricfeedingtherapist.com or DM me@holly Balkan and Instagram and I would be happy to check with my network and you know, try to find somebody for you in your area who can properly assess. Hope this was helpful and enjoyable. And this is your host Hallie Balkan signing off.

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