Why is there clicking when my baby is breastfeeding?

Clicking is a common issue mamas have when their baby's are breastfeeding. During breastfeeding the middle portion of the tongue lifts up and creates a vacuum with the palate. When the seal of the vacuum/suction is broken, we get the clicking sound.

Why is my baby clicking when they are breastfeeding and what can I do to help?

We know the reason behind the audible sound of clicking– loss of suction/vacuum by the tongue losing its seal. But what's even more important is why the baby is losing suction! And like most things, this requires teamwork. The one person I always recommend is an airway and tie savvy IBCLC. I recommend IBCLCs because they have the most training in breastfeeding and are capable of supporting a wider variety of needs. If they can't help you, they also tend to have an awesome network of people they trust that can.

So below are a list of reasons why baby may have clicking and who to see based on your child:

• Poor latch and clicking: If you have painful or sore nipples, your baby has milk coming out the side of the mouth, your baby chomps/chews instead of sucks, it takes a long time to feed, they pop on and off, you have a forceful letdown or your milk supply is “low” then an IBCLC is your gold standard for assistance. An IBCLC specializes in lactation and breastfeeding. They can help you with positioning your baby and you for the most support and comfort. IBCLCs can make sure the baby is latched well, in a position that is comfortable for both mom and baby, and able to transfer milk as well as do weighted feeds which are awesome if you're also concerned about weight gain and if baby is getting enough on the breast. They also help with milk transfer, supply, expression, clogged ducts and calming the baby to breastfeed.

• Torticollis and/or plagiocephaly and clicking: torticollis is where the child's neck tilts to one side and looks to the other as if they are looking at the sky. You may notice your baby only likes to look in one direction. Plagiocephaly often comes with torticollis and is when a baby gets a “flat spot” on their head. I want you to take a second and tilt your right ear to your right shoulder and look to the left and try to swallow. It is anything but easy. If your baby can't easily turn their head to neutral, you notice a flat spot or your baby nurses better on one breast, or one breast is painful or baby pops off or clicks more while nursing, I highly recommend a bodyworker (more info down below).

• Facial, jaw and skeletal asymmetries and tension with clicking: First off, these can be super subtle and everyone is a little asymmetrical, even models! We aren't chasing perfect symmetry. Instead we are looking if the baby can turn and tilt their head in both directions or if we can move their hips in all directions. Or sometimes we look at our cute babies and think that one eye looks a little bigger than the other or the chin is tilted to the side. These changes are often a result of where the baby was in utero (always pushing on one spot, “nestled in,” breech, etc) or birth (fast birth, long birth, asynclitic birth, “stalled” birth, cesarean, forceps, vacuum) as well as the position you put your baby in now.

Tension and asymmetry can also show up as “really strong babies” who are able to lift their head up super early or frequently arch back or they are constantly popping off the breast and flailing around. We may look in their mouth and feel tension or tightness at the floor of the mouth which is preventing the tongue from movinf. It can also do the opposite and be the “lazy baby” or “floppy baby” that struggles to nurse because they are too tired. We may see them flop around but for them it requires more strength for them to nurse because they have to work harder to get the same amount of milk. Your baby isn't lazy, they just need extra support. And that support is through a bodyworker.

It also takes muscle strength, mobility and coordination of the mouth and body working together to efficiently and effectively create the vacuum. There's a saying that “what's happening in the body is happening in the mouth.” This is because if there is tension throughout the body, there will be a natural pull and compensation that we will as in the mouth. This is another reason bodywork is so helpful because it can help with that coordination and strength so your baby is hitting their oral and motor milestones!

• Oral Motor Dysfunction: I'll admit this is NOT my area of expertise which is why I prefer to always work with an SLP or OT trained in myofunctional therapy and oral motor dysfunction. A lot of people immediately jump to tongue ties, but there's other areas where the suction can be lost to cause the clicking sound. As a chiro, I don’t have training in feeding concerns and proper swallowing mechanics- that lies with the SLPs and OTs. But, just a few instances of oral motor dysfunction are when the cheeks are overworking and you might see their little cheeks moving in and out as the nurse. Or maybe they are chomping down and you see their jaw moving rapidly up and down trying to pull the muscle out with pure strength instead of the vacuum. Or maybe you see your child has a really tight chin and can’t open their mouth wide. Or maybe the tongue needs more strength and endurance, but has range of motion. And sometimes the jaw is working to create a suction rather than the tongue. The possibilities are endless. That's why it's important to connect with a provider who is also an infant feeding specialist (SLP or OT with extra training) and an IBCLC to make sure you are treating the cause and that the baby is physically prepared if they do need a release.

• Tongue tie and clicking: If the mid-tongue is restricted (previously referred to as a posterior tongue tie), then it can not properly lift to create the seal needed to prevent the clicking. If you think your baby has a tongue tie, I highly recommend first reaching out to an SLP trained in oral motor dysfunction and myofunctional therapy first. They will have preferred providers who they have worked with that they trust to perform a frenectomy or frenotomy (“release”). Although plenty of people market themselves as being tie savvy, you will want someone trusted by others in the airway and tie community.

• Premature birth, low birth weight, developmental delays, family history of Ehlers-Danlos Syndrome or hypermobility: early breastfeeding is driven by reflexes and the coordination of suck-swallow-breath which is learned around 34-46 weeks inutero. If your baby was premature, it's important you work with an SLP or OT trained in feeding therapy to help improve that coordination. If your baby also arches a lot or is a “floppy or lazy baby” it's important to work with a provider who understands pediatric motor development (PT or chiro) who can help support your child through developmental milestones which will also support feeding milestones.

• Structural abnormality and airway protection: okay, I'm going to preface that this is not the “norm” so please take a deep breath before reading this. It is NOT meant to scare you as it is to remind you that there is more to clicking than tongue ties as there are occasionally more complex issues that cause clicking. But google is a scary place so before you jump down that hole and freak yourself out, please ask for help from a qualified professional. If your baby has chronic congestion that you can't seem to clear with saline rinses, they constantly gurgle or it sounds like they have a hoarse cough or sounding voice, or if they constantly turn their neck and it looks like they are looking up at the sky, a pediatric SLP trained in feeding and the appropriate referral to ENT or GI depending on other signs and symptoms.

Will clicking stop on its own?

Oftentimes we hear the audible clicking sound disappear around 4.5-6 months of age. Unfortunately this doesn't mean that the baby is suddenly free of their oral motor dysfunction. While the sound itself disappears, it's usually because the baby has built up enough compensations that we no longer hear it. Around that same time the baby also gains a lot more midline strength and they can use that development to mask the oral dysfunction. You can think of it as the baby creating their own “band-aid” but not actually fixing the root cause.

Will clicking improve or go away on its own with a tongue tie release? How about a lip tie?

If the baby ONLY has a tongue tie and no sign of oral motor dysfunction, torticollis, plagiocephaly, asymmetries, muscular tension, muscular compensation, nervous system dysregulation (constant fight or flight or the “lazy baby”), reflux then a frenectomy (tongue tie release) may be the magical key that stops the clicking and discomfort you're having. And for those families, it truly does feel magical. But for many that isn't their reality.

For others it takes a little bit of time as the baby develops strength, coordination and endurance for the new tongue range of motion. It takes time for the tongue to relearn how to move and stabilize. I know when I broke my arm it took me about 6 weeks to regain strength and it can take this long for many babies to fully restore function as well.

Unfortunately many babies need more TLC than that because compensation and functional issues don't magically disappear. That compensation can go back as early as 13-16 weeks inutero when we first see babies sucking and swallowing. Even if they are “only” a few weeks old, those movement patterns have already been learned and need to be corrected. The reason I highlighted the different providers is because for many babies, clicking needs exercises before feeding, suck training, bodywork and developmentally appropriate strength.

As for the lip tie revision, that will not correct the clicking sound. If your baby is unable to widen their lips, open their mouth or phalnge their upper lip, it may help with that. It may also help any smacking sound you hear, but it won’t help clicking as that is the loss of suction by the mid-tongue.

My baby seems uncomfortable. Should I stop breastfeeding and switch to bottle feeding if they are clicking?

I don't often like to make absolutes, but I will say you most likely shouldn't stop breastfeeding if clicking or gassiness or aerophagia are your main concerns. Especially if you want to breastfeed! I personally would exhaust all other options before stopping. The main reason being that it may not make a difference! There's a reason your child is clicking and switching to a bottle doesn't correct the WHY. Oftentimes these kids are later diagnosed with “reflux” and given medication when they should have been given speech therapy, OT, and bodywork!

<<Side note: Just as moms who want to breastfeed can continue to do so, if you don't want to breastfeed, please give yourself permission to stop. If you are mentally or physically exhausted or you don't want to breastfeed, you are also allowed to listen to and respect your body's requests. You can switch to bottle feed your baby. You are still an awesome mom. I would simply recommend you still reach out to the providers to get to the root cause while switching.>>

Your Support Team for Clicking with Breastfeeding

• IBCLC: I recommend finding your state or local tongue tie group on Facebook to find a tie savvy IBCLC who will know when and who to refer to if you need additional support. They will also be able to address any pain, discomfort and positioning you may need help with.

• Bodyworker: Unpopular opinion-the best bodyworker is the one you have access to who is trained in pediatrics and oral/airway health. This may be a pediatric chiropractor, PT, OT, massage therapist trained in craniosacral therapy or craniosacral fascial therapy (CFT). I honestly don't believe one credential is superior to the other as much as the knowledge the provider has sought out. Ask your IBCLC or local tongue tie group for recommendations and utilize who is available and who you feel comfortable with.

• SLP or OT trained in feeding therapy and myofunctional therapy: I love recommending myofunctional therapy for adults but when it comes to little people, they can't “do myo” because it requires them to actively participate in therapy. For peds, I love an SLP trained in myo AND feeding therapy/oral motor dysfunction because they are able to look at the baby through multiple lens to see what they need the most.

• Release provider: I would highly recommend using the release provider recommended by your other parts of your team as they are the trusted providers in your area. This could be an ENT, pediatric dentist or periodontist depending on your area and who has the most knowledge around ties.

Digestion, Constipation, and Tongue Ties

Have you ever wondered if your chronic constipation or the little bits of food that are in your stool could be related to a tongue tie? 

Or maybe you have wondered why you have “done everything” and still get constipated?

If you're a “why” and “how” person that loves knowledge, get your Nerd goggles on and get ready to take a deep dive in because info dumping is my love language. If you prefer quick info without details, I got your back. Just head to the bolded TLDR sections below.

We're first going to break down the basics on eating from start to finish and where tongue ties play a role in digestion and constipation.

Step 1: Chewing and Tongue Ties

Digestion begins in our mouths. When we first put food in our mouth, our body's job is to start the digestive process with both digestive juices and breaking down food. We chew on one side of our mouth in a rotary fashion, pushing the food from side to the other with our tongue. In an ideal world, we chew each bite 32-40 times before swallowing. 

The chewing process helps take larger food and turns it into much smaller and softer food. It basically turns food into mush. This mush is called a bolus. Chewing also helps your body produce more saliva so you don't have to depend on water to help you swallow. If you are used to chugging water while eating, it may be because you aren't chewing enough or your body isn't creating enough saliva to help turn your food into that bolus.

Oftentimes, with a tongue tie we aren't able to lateralize the tongue allowing for the rotary chewing mentioned above. That means we can't easily move the tongue from side-to-side and we become dependent on chomping our food rather than using that rotary movement to grind. This requires a lot more energy and for many with a tongue tie, they naturally gravitate towards soft foods or end up not chewing food well enough.

One way to visualize this is using a mortar and pestle with something as soft as basil. Normally we take the pestle and we grind the basil within the mortar. This helps break down the basil by crushing and grinding. In the case of a tie, we're basically stabbing it up and not able to fully break it down or grind it. If we do end up pulverizing the basil, it takes a lot more time and energy!  When this happens, chewing also becomes a lot more cumbersome and takes a lot more energy. Oftentimes, people are only chewing six to eight times before gulping the partially chewed food down because if they chew the full 32x they feel exhausted afterward.

Finally, chewing releases digestive enzymes to further break down our food. The two main enzymes are amylase and lipase.  Amylase helps break down complex carbohydrates into sugars so they're more easily digestible. Lipase helps break down fats and fatty acids. Additionally, there's lysozyme, which breaks down the cell walls of bacteria. These enzymes help break down food, so the nutrients are more easily absorbed and can help with preventing bacteria from entering the GI tract (especially helpful in GERD, bowel disorders, constipation and diarrhea). Since digestion starts with the physical breakdown of food, when we aren't properly chewing, this increases our risk for constipation as the other parts of the digestive system were not designed to break down large chunks of food. 

TLDR: How do tongue ties affect chewing? Tongue ties limit how much people chew, causing large bits of undigested food in stool and decreasing digestive enzymes needed to break down food for absorption.

Step 2: Swallowing and Tongue Ties

When we're ready to swallow that bolus of food, the anterior parts of the tongue naturally move to gather the bolus onto the tongue so it's securely against the hard palate (roof of the mouth). This movement is what keeps us from having food shoot out the sides of our mouths when we swallow. 

Next, there's an elevation and retraction of the soft palate. This movement helps block air from the nose from going down while also blocking liquids from going up and out the nose.

At the same time, there's relaxation of the upper esophageal sphincter. You can think of sphincters as automatic control valves that open and close to either create movement or prevent the movement of something from one area to another. In this case, the upper esophageal sphincter stops air from entering the esophagus (where food should go) during eating and also prevents food from going into the larynx and trachea (aka “windpipe” or where air should go) while breathing. For the swallowing of liquid and food, our bodies naturally close off the larynx and contract the pharynx to block food from entering the respiratory system.

This closure and contraction is deeply intertwined with the tongue! You see, our tongue muscles are attached to the front aspect of the hyoid.  On the back side of that hyoid is our epiglottis... the epiglottis is in charge of closing off the larynx to prevent food from entering the respiratory system and also preventing air from entering the digestive system.  This is often why people with tongue ties complain they always choke on food or water and often experience reflux. Their tongue isn't able to freely move which limits the strength and timing of the epiglottis. When the tongue isn't able to move freely, it can prevent the closure of the larynx and let air and/or food go where it shouldn't…which causes chronic choking or aerophagia/swallowing air which can lead to reflux.

TLDR: How do tongue ties affect swallowing? Tongue ties limit or delay the movement of the tongue which makes it easier for air to be swallowed or shoot out the nose and also easier to choke on food and water. 

Step 3 & 5: Peristaltic Movement and Tongue Ties

Peristalsis is the involuntary contraction and relaxation of the esophagus and intestinal tract in a wave-like movement that pushes food through the system. I'm including this as steps 3 and 5 because it occurs in the esophagus and intestines with the stomach in between. 

This peristaltic movement starts with the tongue. When we swallow a bolus of food the front of the tongue acts like a wave or piston and pushes the food down towards the pharynx and this wave-like motion continues through the esophagus. 

Fun fact: Both the posterior aspect of the tongue and the esophagus are innervated by the Vagus nerve. The Vagus nerve is largely recognized as being part of the Autonomic Nervous System and responds to stress. When we are in a relaxed and flowing state, we are said to be in a parasympathetic state allowing for both rest and digestion. When we are in a stress response, we are in a sympathetic state where the body is prepared to fight, flight or freeze. Vagus nerve stimulation is frequently activated in the back of the throat and tongue. When there's a tongue tie, it makes it harder for the first wave-like motion of the tongue to be started and this can delay the parasympathetic response for rest and digestion and decreases peristalsis. This decrease in peristalsis is a fancy way of saying that food stays in the intestinal tract for too long. Ideally food takes 1-3 days to fully pass through the system. If you are seeing food you ate 3+ days ago coming out in your poop, this is a sign that you are not chewing well enough and you have slow transit constipation because your food is in your system longer than it should be.

Once food has reached the intestines, the main focus is on nutrient absorption. The food should have been broken down by the digestive enzymes in the mouth and stomach. The small intestine is where 90% of nutrients and minerals should be absorbed. The goal of the large intestines are to absorb electrolytes and water, absorb vitamins and minerals as well as use that peristaltic movement to propel feces towards the rectum for it to be removed. 

More than half the dry weight of poop is bacteria. If we think back to peristalsis, if our body is in a sympathetic state (fight or flight), one of two opposites typically happens. First, we can have diarrhea. This is when the body has acknowledged a stressor and basically said, "we don't have time for this" and it pushes the food through quickly so it doesn't have to use energy to break down and digest the food. The other extreme is constipation. In the case of chronic stress, the body never fully relaxes or rests so peristalsis decreases causing constipation. That means your body is absorbing more bacteria than we would like which can cause more digestive problems. 

TLDR: How do tongue ties affect digestion/peristalsis? Tongue ties cause increased nervous system dysregulation and decreased peristalsis making the digestive process go from “rest and digest” to “fight or flight” and can slow down digestion causing constipation.

Step 4: The stomach

The stomach is an interesting organ because it's basically a balloon with two openings instead of one. Just like a balloon, our stomach can only handle a certain quantity inside it. If you are taking in too much air (see step 1) or your peristalsis is slowed (see steps 3&5) your risk of reflux is increased. There's an equally nerdy, information-packed blog dedicated to reflux so it's attached here.

TLDR: How do tongue ties affect the stomach? If you are taking in too much air (see swallowing above and reflux article attached above), your stomach is unable to support the increase in pressure and you are more likely to have reflux.

Step 6: The pelvic floor and bowel movements and tongue ties

Have you ever heard of the TMJ/jaw and pelvic floor connection? There's another action-packed blog on that connection here. But to summarize:

TLDR: How do tongue ties affect the pelvic floor? People with tongue ties often have upregulated nervous systems and tension. When we clench the jaw we also instinctively clench the pelvic floor muscles which can cause constipation.

The foundation to all steps: nervous system regulation and tongue ties

I mentioned this earlier with the Vagus nerve and peristalsis but it is important enough to have its own section. More and more research is highlighting that tongue ties cause open mouth breathing and can lead to sleep apnea or sleep disordered breathing. Open mouth breathing means that people aren't breathing through their noses. Nasal breathing is important because it filters air thereby decreasing risk of infection, it warms the air before it reaches your lungs, decreases dry mouth and activates the parasympathetic nervous system, causing a rest and digest or calming sensation through the body. Oftentimes people with tongue ties struggle to get a full breath or feel like they can't fully exhale because of their tongue ties. Once released, they feel like they can fully and freely breathe for the first time ever. 

Sleep disordered breathing is a beast of its own because it can cause ADHD-like symptoms where kids often act wired and adults are chronically fatigued despite labs “being normal”. One way to look at this is to imagine you are attacked by a bear, your body doesn't care if you need to poop…it only cares if you escape from the bear. So it turns to the sympathetic state or “fight and flight” to help you escape rather than allowing you to “rest and digest” in the parasympathetic state. If your body is under stress from sleep apnea or chronic sleep deprivation, it will slow the bowels to account for the stress. When this happens, we often see bedwetting or “waking to pee” along with chronic constipation because the body doesn't know when to release the appropriate hormones. 

TLDR: How does a tongue tie afgext the nervous system? Tongue ties increase your risk for sleep apnea and open mouth breathing which both increase the sympathetic nervous system or “fight and flight” and decrease the parasympathetic or “rest and digest system” which causes constipation  

Now, because you know I hate leaving you without actionable steps, watch out for the follow up on how to support and improve constipation while you still have a tongue tie.

It's a bird, It's a plane, It's reflux...or is it?

Reflux, like Superman, is a bit of a mystery to most. Where did it come from? What makes it stronger? Most importantly, what is reflux's kryptonite? Unfortunately, in our case, reflux isn't the hero but the villain. 

The first step to figuring out reflux's kryptonite is a surprising one to many. It's figuring out if it is *actually* reflux! And that looks like a job for Moms.

You may be thinking, "What do you mean...ACTUALLY reflux? What else could it be?" We all know that Superman is really Clark Kent, but what many don't don't know is that reflux is *often* aerophagia. 

Aerophagia

Aero-what, you ask? Aerophagia is a fancy way of saying “swallowed air”. The thing is, every single one of us swallows SOME air. The stomach is a muscle and can grow and expand...up to a certain amount.  In the case of aerophagia, the stomach fills with too much air rather than (or in addition to) food.

To a certain extent, our body is made to handle this pressure. But the time comes that the pressure is just too much. You can think of it like filling an untied balloon. If you add air, it'll grow and expand to the size it's supposed to be without issue. When it comes to aerophagia, take that same balloon but, this time, overfill it with air. The pressure becomes too much and when you go to tie the balloon the extra air will likely shoot up and out. Luckily, just like balloons,our bodies have an opening that can let that excess air out in the form of regurgitation, vomit, spit up, hiccups, burps, and farts. The opening at the top is called the lower esophageal sphincter and it keeps our stomach contents in the stomach. In the case of aerophagia, the excess air can sometimes be mistaken for reflux and overtime can actually cause reflux. 

Now, before you take a deep dive into this, I need you to know it's a lot. If you want a warm and fuzzy, feel-good story on reflux, this isn't it. If you're tired of your baby's constant reflux and are determined to find answers, this is for you. As you move forward please know that some of it may pertain to your little one while some of it may be irrelevant. Each person is unique so it's important to figure out what works for them individually.

What does aerophagia look like? Aka Does my baby have reflux?

Aeropagia looks a lot like reflux. These babies often present with colic-like symptoms, including crying and discomfort with feeding. Oftentimes, babies will have a bloated stomach, abdominal distension, cry while eating, and have excessive burps, belches, hiccups, spit ups and farts. We're not talking about the occasional spit up here or there, but rather the, "I hate taking my baby in the car because I have to clean the spit up off the walls" or "I'm tired of doing the laundry because of the towels we use for cleaning up vomit." Almost all babies under the age of 3 months will spit up a little bit here and there if they overeat or are stressed…a small amount of spit up is normal! If it's not a regular occurrence, don't worry about it. If it's a daily occurrence, forceful or causes more distress, this is when it becomes an issue we need to look out for.

Aerophagia babies can also be seen through observation as they frequently arch their back and look like the letter "c". If they sit in a car seat, their head may be twisted or looking up at the sky. When/if they sleep, you'll notice their head tilted up with their jaw pointed upwards. Or maybe you've said they are "really strong for their age" and lift their heads up from birth or roll over before 4 months old.  But here's the catch, that strength is actually a sign of tension. Newborns aren't supposed to be able to lift their heads or roll. It's actually developmentally inappropriate for a 6 week old to roll over.

Aerophagia vs reflux...how do I know if my baby has reflux or aerophagia?

One of the big giveaways to reflux vs aerophagia is the smell. If the baby's spit-up smells rancid or acidic, then it is more likely to be true reflux. If it doesn't smell a lot, then it is more likely to be aerophagia because the milk isn't settling and mixing with the gastric juices and acid.

We can also look at the history of the baby while eating, both bottle and breast. If there's a history of tongue ties, painful latch (mom clenching her jaw or curling her toes in pain or resisting the urge to squeeze baby's head because of pain) these can be signs of a poor latch which can let air in. Also, clicking while drinking, nursing forever (or taking only short breaks), poor seal around the nipple of bottle or breast (corners of the mouth should be fully sealed around nipple), fussiness during or after feeding are considered a latch issue which can cause the aerophagia.

We can also tell based on some symptoms. By definition, reflux is stomach acid or bile irritating the lining. Reflux typically worsens the more it happens and one of the easiest ways to know this is by listening to your little one's cry. As horrible as it is for you to listen to, if your baby's cry becomes more raspy and gurgling, then they most likely have reflux. If your little one is always hiccuping, burping or yawning or would make a grown man blush with their farts, this is a sign of aerophagia and excess gas rather than reflux.. 

Another way is through a bit of trial and error. If your little one has been taking proton pump inhibitors and hasn't improved, there's a good chance they actually have aerophagia. Or if the baby developed a cough without improvement while taking PPI, this may indicate aerophagia or aerophagia-induced reflux.

What causes reflux and aerophagia and how can I help my baby?

This part is probably the most important because once you find out the why(s), you can help your baby a whole lot faster. Now here's the tricky part…oftentimes there isn't ONE cause but a collection of things that once added together, are too much for the body to handle. 

Overtime as the different components of aerophagia add up, more symptoms can occur. True reflux, where acid is being regurgitated, can be caused by aerophagia. Chronic aerophagia can also lead to increased constipation and stress which can add to the risk of reflux. Unfortunately all of these stressors can change how the body handles that pressure and the symptoms get worse rather than better. This is because there's an increase in pressure on the lower esophageal sphincter that overcomes the strength/tone of the sphincter and leads to the sphincter being open longer (aka that balloon is losing all of its air rather than just the excess air). As the body becomes more stressed, it also becomes more sensitive to inflammation, irritation and distension which can cause more reflux.

As doom and gloom as that last paragraph sounds, I want you to know there is also hope. So I want you to look at a few reasons why babies may experience aerophagia and how to best support them based on what you are seeing:

1. Tongue and lip ties:  The things mentioned below are not exclusive to a tongue and lip tie but common with them which is why I listed them underneath.

• Poor latch: an Improper latch does not mean a baby is tongue tied as there are many causes for a poor latch. But if you frequently see your baby nursing from the bottle or breast and the edges of their mouth form a “v-shape” with open gaps rather than “c-shaped” lips gathering the entire nipple, this can be a sign of limited tongue mobility. If your baby can't open their mouth wide (lips stay mostly closed or pursed together) or close their mouth, pops on and off the breast, you experience nipple pain in between feeds, your nipple is a different shape/color after feeding, you hear them gulping milk or gasping for air during feeding or they are chugging and noisey while at the breast, there's milk pouring out the sides of their mouth or you feel like your baby feeds ALL of the time or for extended periods (or short periods but frequently), you frequently have mastitis or clogged ducts or your baby has a white coat on the top of their tongue, all of these are a sign of breastfeeding dysfunction. It's best to connect with both an IBCLC trained in oral ties AND a speech pathologist trained in feeding therapy and myofunctional therapy to get to the root cause.

• Open mouth breathing or tongue on floor of mouth: When you look at your baby their mouth should be closed unless they are actively using it to communicate or eat. If you look at your baby while they are playing, doing tummy time, sleeping or in the car seat and you see their mouth is open or their tongue is on the floor of the mouth, this is a sign that needs to be looked at by a speech therapist trained in myofunctional therapy to assess tongue function, bodyworker trained in oral ties (this can be an OT, PT, DC, CFT/Gillespie, CST, osteopath) If the bodyworker or SLP cannot make improvements, then a referral to pediatric ENT is warranted to ensure they are able to breathe through their nose.

• Excessive crying, sighing and hiccuping: Excessive crying can be a sign of nervous system dysfunction which can further increase the risk of reflux and aerophagia. If you find your baby is frequently distressed or sighing and hiccuping, I recommend a speech pathologist trained in myofunctional therapy and a bodyworker trained in diaphragm release for infants (OT, PT, DC, CFT/Gillespie, CST, osteopath, PRI-trained provider)

• Cranial dysfunction: You may be wondering what I mean by this but if you have noticed that your beautiful little baby is a little asymmetrical (one eye bigger or wider than the other, one ear further away from the head, one nostril smaller than the other, jaw tilted to one side) this can be a sign of cranial dysfunction. Cranial dysfunction can influence how both the muscles and nerves of the tongue, face and airway work which can be addressed by a chiropractor trained in cranial work or an osteopath. 

• Torticollis and plagiocephaly: Take a deep breath in and focus on your throat. How do you feel? Now, tilt your head to one side and look up. How does it feel? When our little ones have torticollis (head preference to one side) or plagiocephaly (flattening of one side), it can make it more difficult to breath freely so they are more likely to take in excess air. This is where a PT, OT, and chiro trained in motor development comes in handy.

• Posture while feeding: There's a breastfeeding saying of “nose to nipple” which helps the baby slightly look up to open the mouth to latch. This is helpful because it helps open the airway. If you find your baby's chin is tucked to their chest, it will be harder for them to swallow. It’s also important to support the baby so that their butt, shoulders and the middle of their ear are relatively aligned. This may require lots of pillows but it helps support the baby so they can eat in a more relaxed and comfortable way. If you notice any discomfort or struggle to get a comfortable position while feeding, find an IBCLC trained in ties. If you are “doing everything right” and the baby still has symptoms, reach out to a speech therapist or OT trained in myofunctional therapy for evaluation.

• Sleep disordered breathing and sleep apnea: This goes hand and hand with open mouth breathing, but if you notice your baby thrashes or jolts in their sleep, seems excessively tired or wired compared to kids their age, snores or breathes loudly in their sleep, they may have SDB. My first recommendation is again a SLP trained in myofunctional therapy and they can make the appropriate referral to a pediatric ENT or airway focused dentist based on how your baby is presenting.

• Excessive gag reflex: All newborns should have a gag reflex BUT it should not be activated if you gently slide your finger or nipple into their mouth. They should be able to take your finger into their mouth without gagging. If they can't this is something that should be addressed by an OT, Chiro, SLP, PT, or myofunctional therapist trained in oral assessment and treatment.

2. Improper bottle feeding

• Shaking formula/bottle too much: This sounds pretty straight forward but when making a bottle, make sure you gently mix the formula and stir the breastmilk to ensure the heat is consistent. Shaking the bottle too much can increase aerophagia so make sure you are gently swirling the bottle to limit the addition of air into the milk.

• Wrong nipple on bottle: Some kids do really well with a premi nippe or the newborn nipple because it has a slower flow. Other kids that struggle with ties may require a greater flow because they don't have the muscle control to appropriately suck. You can limit this by trying different nipples and bottles. There is not a magic bottle that works for everyone so it will take time to figure out what works for your little one. 

• Posture while feeding: see above

3. Secondhand smoke 

4. Genetic predisposition to connective tissue disorder:

   As the lower esophageal sphincter is a muscle, if you have a connective tissue disorder like Ehlers Danlos or hypermobility, it is common for the sphincter to also be hypermobile and have a delayed closure and decreased endurance so the risk of aerophagia and reflux are increased. While we can't change the connective tissue and muscle, we can make sure all developmental milestones are met and pediatric physical therapists or chiropractors trained in motor development like DNS are helpful to help ensure optimal motor development.

5. Nervous system dysregulation:

   I'm not going to lie, I wish this one wasn't part of aerophagia or reflux. Unfortunately, both acute and chronic stress can alter the lower esophageal sphincter. When the body is under stress, emotionally and/or physically, it naturally decreases vagal tone which makes the body hypersensitive to inflammation, irritation and distension. Stress also decreases the nerve function to the intestines, making it more susceptible to dysbiosis, food allergies, cellular damage to GI tract, and constipation which can all increase the risk of reflux. The best way to support a baby's nervous system is through co-regulation. In the newborn age, this means taking care of your emotional and mental needs, skin-to-skin and all of the snuggles you can give. If you notice that you are struggling to regulate, this is also a time to lean into any community you have and ask for help with dishes, laundry, meals, etc. 

6. Neurodivergence:

   Studies have shown that Neurodivergent people (autistic, ADHD, Sensory processing disorder) are more likely to have reflux and/or aerophagia. This is likely attributed to two things that are common in the ND community, sleep issues and open mouth breathing. If this sounds like your little one, the two best recommendations I can give are a speech pathologist trained in myofunctional therapy or a sensory based OT (DIR floortime, Ayers Sensory,etc).

7. Premature birth → aerophagia and reflux are both common in kids that are born prematurely because of:

• Decreased sphincter control: at the time of birth the lower esophageal sphincter hasn't fully developed and premature babies have lower resting tone compared to non-premature babies. If your baby requires a NG tube, this can also alter the sphincter and make it more likely to stay open allowing more air and acid into the esophagus.

• Low vagal tone: low vagal tone is similar to nervous system dysregulation but can also be caused by stress, congenital or acquired neurological conditions, birth trauma, tongue dysfunction not properly activating the vagus nerve, cranial and cervical dysfunction not allowing optimal conductance of the nerves.

• Decreased tongue strength and endurance: just as every other muscle of the body has low tone, so do the muscles of the tongue and airway. In fact, we can see babies on ultrasound doing a coordinated suck-swallow-breathe pattern arrive 32 weeks with improved function after 34 weeks.  Babies that born before 32-34 weeks are more likely to have a decreased suck-swallow-breathe pattern and are more likely to take in air.

8. Inability to breathe through the nose:

   This can be from structural limitations like a deviated septum (up to 20% of newborns may have one), small nasal passages (see cranial dysfunction above), or nasal congestion (see environmental factors below). If your baby is not able to breathe through their nose, a pediatric ENT is the first person to reach out to. There are over-the-counter medications that may be recommended like Xclear nasal spray or olbas nasal spray or it may require more extensive care based on how your baby presents.

9. Environmental factors influencing respiration:

   This can be anything from mold exposure to allergies (environmental and food) and asthma. Oftentimes when someone is congested or struggling to get enough oxygen due to these things, they will naturally swallow air as they are taking big gasps trying to get oxygen rather than normal slow breaths. If you suspect this of your child, I'd recommend first doing a 3 week trial of dairy and gluten removal. If it persists or your baby presents with a rash, eczema or increased congestion, finding an allergist and/or functional medicine provider can be very helpful. If your baby has red or black poops, a pediatric gastroenteritis and allergist should be on the top of your list for people to see.

10. Anatomical anomalies of esophagus, lower esophageal sphincter and abdomen (hernia):

    This one definitely requires the help of a gastroenterology or pediatrician. But if you notice a bulge in your baby's belly or around the belly button, it can be a sign of a hernia and should be monitored by your pediatrician. If your baby was previously feeding okay and is now projectile or forcefully vomiting or can't keep anything down, please head to the ER as this is a sign of pyloric stenosis which needs to be treated right away.

Alright, if you've made it this far, take a deep breath in and a long exhale. I know having a baby that is struggling with reflux or aerophagia can feel overwhelming and exhausting. You are not alone and there is support out there to help you find your little one's kryptonite for their reflux.