Why Thumb Sucking Isn't the Problem (And What Is)

How often does the habit occur? How long does it last each time? How much force or effort is involved? Hello, my friends, and welcome back to the Untethered Podcast. I'm your host, Hallie Bulkin. Today we're going to dive into a topic that comes up constantly for parents and professionals alike, and that, my friends, is oral habits, especially in infants and toddlers. Okay, we're going to talk a bit about what oral habits actually are, how to know when they're a problem, who you should see for help, and most importantly, why these habits develop in the first place. Because the question isn't always like, how do we stop the habit? It's often, what is this habit trying to tell us? I want that reframe to be very solidified by the end of our time together today. Okay, so let's get into it. Welcome to the Untethered Podcast.

I am your host, Hallie Bulkin. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner, 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, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture—

tongue up, Lips closed, teeth apart, breathe through your nose.

Let's get started.

So what are oral habits? Let's just start there in case you're brand new to this conversation. Oral habits are behaviors that involve the structures of the mouth, right? So think tongue, lips, palate, teeth, gums, right? Any of those structures. Common oral habits might include thumb or finger sucking, pacifier or soother use, blanket clothing, or, you know, material like fabric sucking. Tongue sucking, lip sucking or licking, mouth breathing, nail biting, chewing on non-food objects like they're constantly going into the mouth to chew on, like a pen cap, or, you know, and I'm not talking about babies who are chewing on or sucking on toys because they're in an exploratory age and it's age-appropriate. I'm talking about beyond that. Okay, so anytime a non-food item repeatedly enters the mouth for sucking or chewing, we consider it an oral habit. Now, I also wanna preface this with, you know, when I just gave that toy example, a baby puts a toy in their mouth, they chew, they suck for a couple seconds, they take it out, they keep exploring. That's one thing. You know, if they're finding their fingers for the first time, the fingers go in, they come out, they don't frequently go back in, fine. But if they're constantly going in, that's what we're talking about here. Okay? That clarifying moment, right? Where infants do mouth objects as part of normal development. That is how they explore their environment. Mouthing toys briefly and occasionally is expected and typical. Okay? So again, just to clarify, we're looking for the, like, when this behavior becomes more of a persistent, repetitive, and purposeful behavior, that's when we know it crosses into that, crosses the line, or crosses into a category of being an oral habit. Okay, so how do we know if an oral habit is a problem? There's 3 things we look at, okay, 3 key factors when we're assessing. 1 is frequency, 2 is duration, and 3 is intensity. So the frequency, how often does the habit occur, right? That's number 1. Number 2, do Duration. How long does it last each time? Number 3, intensity. How much force or effort is involved, right? How intensely are they sucking that thumb? For how long and how often does this happen? You know, frequency, duration, intensity. Okay, let's use thumb sucking as an example because it's quite common. We might ask, like, is the child sucking their thumb occasionally or is it throughout the day? Does it happen only briefly or for really long stretches, like especially before sleep, for example? Is the sucking really gentle or is it intense and it's difficult to like interrupt that behavior, right? When that habit becomes frequent and it happens for long durations and it's with a high intensity, that's when we're like, oh, okay, we need to hit pause for a second and consider a professional evaluation, right? So who should you see? Well, for infants and toddlers, the appropriate providers are either a speech-language pathologist or an occupational therapist that is specifically trained in pediatric feeding and sensory oral motor development. Ideally, this provider also has training in orofacial myofunctional disorders, airway and breathing, tethered oral tissues like tongue ties, lip ties. Why? Because in children who are birth to 4 years of age, oral habits are rarely just about the habit. They often impact, or maybe are impacted by, feeding and chewing skills, swallowing patterns, oral rest posture, right? Is your tongue up? Are your lips together? Are we breathing through our nose? Breathing and airway function, sleep quality, speech and language development, sensory regulation, like so many things, right? And this is why pediatric feeding therapists are super essential in this age group. I want to be very clear here. I want to make a very critical, if you will, clarification about myofunctional therapy because this is something that we see causing real harm. And I've said this for the past 5 years, Traditional orofacial myofunctional therapy is an active therapy. It requires a certain level of cognitive development, okay, to have happened, or a certain cognitive level, if you will. Generally, you have to be at least age 4, but arguably closer to age 5 cognitively. Like, not just like, oh, we turned 5 years of age. Like, no, this child needs to be able to follow multi-step directions, the steps, the directions we would expect a 5-year-old to be able to follow. 'Cause even then, sometimes a Myo program could be a little tricky for them. Infants and toddlers do not participate in traditional Myotherapy programs, right? When we work on these similar goals in your younger children, which is possible, we can take Myo and adapt it. Our approach is passive. It's developmentally appropriate and it falls under the scope of a pediatric feeding therapist or pediatric feeding therapy, okay? So only appropriately trained and licensed SLPs and OTs, and in some cases there might be PTs as well that have pediatric feeding expertise, right? Only these professionals should be providing and billing for this type of intervention. I said what I said. That is what is legally and ethically appropriate, and anybody else who's trying to sell a MYO program to young children or for education, it's a money grab. Again, I said what I said. It's unfortunate, but we are seeing many children get referred to providers who are not trained or licensed to to work with this population. And so in some cases, children are receiving inappropriate treatment, and we're actually seeing their symptoms worsen. Sometimes they're just not improving, and it's very expensive in time and finances. Other times, the symptoms actually get worse. So please do your research. Ask about credentials. Ask about experience with infants and toddlers. Ask about— like, when I say credentials, not just like, oh, they say they're certified or trained, but like Are they licensed as an SLP or OT if they're working with your child and your child is under the age of 5? Also, are they licensed as an SLP, OT, PT, RDH, or dentist if they're over the age of 5 and providing myo? Because there's a lot of other people out there doing myo these days who do not have the proper education or licensure to do that either. Fun times out there. And they all will say, oh, myo is the wild, wild west and it's not regulated. Yes, it is. Just because somebody decided to hop on the internet and say it's not regulated and everybody else agreed It is regulated. It's regulated by our state licensure that we all got after going through graduate schools. You know, as SLPs, and I know the OTs as well, we had to go to undergrad and graduate school and take exams and do lots of continuing education. It wasn't just like, oh, I want to work with this population, so let me go take a course and get certified because this person certifies me. No, no. Who's— understand what certifications allow anybody and everybody to get certified because it's inappropriate, it's dangerous, it's unethical. Okay, I'm off my soapbox. All right. It's just unfortunate that 5 years later we're still having this issue, and I feel like it really needs to be highlighted. So there you go. Just do your research. Okay. If a provider is not qualified, they should be referring out. That is what a good provider does. All right. So let's go back to oral habits. Sorry for my soapbox. Sorry, not sorry.

All right.

So one of the most common reasons that we actually see these oral habits, like thumb sucking, for example, The reason why we see it develop is to fill a void. When the tongue is not resting up on the palate where it belongs, children often substitute with a thumb, a finger, or a pacifier. Okay, and I'm looking for one of my tongue models to show you guys. If you're watching on YouTube or you see us on social media, possibly, right? That tongue is not resting up on the palate where it belongs, children will substitute with their thumb or a pacifier. And that habit provides sensory input, right? Stability to the jaw and the oral structures. And sometimes it actually even improves the airflow. Wild. This ties directly to feeding development, speech development, jaw growth and development, sleep quality. Okay. And here's the thing, sleep matters a whole lot more than most of us give it credit for, right? It's not just about how many hours a child sleeps, it's about the quality of sleep, the sleep quality, okay? We know that disrupted sleep and airway obstruction can significantly impact cognitive development, right? There is research that shows, and this is not to scare you parents and providers, but we need to be aware of this, right? There's research that shows that children with obstructive sleep apnea can score 10 to 16 IQ points lower than their peers without sleep-disordered breathing. Yet many children who are diagnosed with ADHD or behavioral concerns have never had a sleep evaluation or an oral airway assessment. Make it make sense, right? This is a problem. So I wanna dive into the airway connection a little because in many young children who suck their thumb, that thumb is acting like a mandibular advancement device, right? When the thumb sits in the mouth, I'm gonna show you again if you're watching, it gently brings the lower jaw forward a little bit, even just a few millimeters. That small shift can open our airway and make breathing easier during sleep. Okay, so the habit isn't random, it's compensatory. And if the airway is restricted due to the jaw position, our high palate, maybe enlarged tonsils or adenoids, maybe poor tongue posture— the posture of the tongue is low, maybe forward, right? The body finds a workaround. Our body is very smart. And that workaround, my friends, often becomes an oral habit. Okay? So band-aid solutions don't work, and I wanna dive into what I mean by that because we have so many parents who ask us about like, what about thinner nail polish or sprays? What about a thumb brace or splint? What about taping the thumb? What about sleep sacks or restraints? These approaches may temporarily block access to the habit, but they do not, they don't address the underlying cause. And in some cases, they actually create new problems, especially when they restrict the movement or the sensory input. Okay, if the body still needs to fill the void, it will simply find another way. So what does work? Well, instead of asking how do we stop thumb sucking, what we need to be asking is what is this habit compensating for? Let me say that again. The question is not how do we stop sucking the thumb, how do I get my kid to stop? It's what is the habit that they're compensating for? Like, or what is— why is this habit compensating? And what is it compensating for, right? What is this habit compensating for? When we treat the root cause, air, which could be airway, oral rest posture, feeding mechanics, tongue function, the habit often resolves on its own. Wild, right? The tongue is meant to rest up on the palate. Here's my little mouth model again. We want it up on the palate, okay? When it does that, it releases calming endorphins, it supports the jaw and the palate development, it makes that nice beautiful U-shape that's flatter and not like high and narrow and not super V-shaped, you know, or really, really narrow like I was saying. It helps stabilize our breathing, supports the upper airway, it eliminates the need for substitution. And so that's why standalone thumb sucking elimination programs rarely hold long-term and can be very stressful. To the child, whether they seem stressful or not. It is very, very opposite of what we should be doing when it comes to addressing this with our little ones. When intervention is needed, it should be done in conjunction with therapy that restores proper function. 'Cause here's the thing, if you take that thumb away and you convince them through your psychologically driven program that they should not be sucking their thumb anymore, you have now created a bigger airway issue for them, or they're just gonna find another thing to fill that void, another oral habit that's just not the thumb. Will be something else. Let's not put them into more of an airway crisis and trying to get the thumb out. I know it's not the most attractive thing, it's maybe not the cleanest habit, you know, we don't want our kids moving, walking around, putting their thumb hands everywhere and then putting it in their mouth. I get it, I get it, I do. But the way you do this is very systematic. There is a very systematic way we do this, and my friends, pediatric feeding therapy is the foundation for that. Okay, so for children Birth to 4, the correct starting point is a comprehensive pediatric feeding evaluation, which includes oral structure and function, tethered oral tissues, airway and breathing, oral rest posture, feeding skills like breast, bottle, solids, utensils, wherever they're at in their feeding journey, sleep concerns, right? This is not just about whether a child eats fine or eats enough foods or whatever. Feeding therapy encompasses the entire orofacial system, and this is what we teach inside Feed the Peeds, and this is what's been missing in the industry for far too long. Okay, again, myofunctional therapy might be the next step if they're like at least age 5 cognitively, but if not, pediatric feeding, that is where you start. Okay, because we're really focused on the infants and toddlers here today. The oral habits are not random, they are signals. It's like throwing an SOS sign up, right? When we listen to what that habit is telling us and we treat the underlying cause, that root cause, we can support healthier growth better sleep, improved feeding, and stronger overall development. Okay, we are quite literally connected from the tip of our tongue to the tip of our toes. Nothing happens in isolation in the body. So that's my big PSA for today. If you're unsure where to go next, where to turn, you can reach me at @halliebulkin on Instagram or visit pediatricfeedingtherapist.com to find vetted SLPs and OTs trained in pediatric feeding. You can also go to feedthepeeds.com and hop on the waitlist so you know when we reopen the course. But anyways, thank you so much for being here. I'm done with my soapbox for today. I'll see you guys next time on the Untethered Podcast.

Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers and is for informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider. Thanks for listening to this podcast. If you value in this episode and want to hear more of these Myotots, airway, and feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @halliebulkin on Instagram to get all the latest updates.