The Many Causes of Reflux

Sleepless nights. 

Gas that makes your baby wither in pain.

Constant crying (from both you and the baby) that breaks your heart.

Watching your baby in pain, not knowing how you can help.

Having an infant with reflux can be hard and not knowing what your next steps to help them can be even harder. Let's break down the many causes of reflux. Hopefully you can get your little one to a provider who can help both of you take the next steps forward to helping your little one.

What is infant reflux?

Beyond discomfort, irritability, excessive crying, back arching and breast/bottle refusal, infant reflux is when the lower esophageal sphincter (think of this as a little valve that goes from the esophagus to the stomach) relaxes and opens after swallowing to allow food to move from the esophagus to the stomach. It should remain closed when not actively digesting food. When a baby has reflux, the sphincter stays open and allows normal stomach acid to flow upward.

A lot of babies are given proton pump inhibitors (lansoprazole) and histamine-2 receptor antagonists (ranitidine) to help with the reflux. Unfortunately, research has shown that those medications aren't really effective at reducing GERD symptoms. The reason these medications aren't always effective is because it assumes that reflux is caused by excess acid. In many cases, the acid is actually secondary to the root cause(s) of reflux or it isn't acid at all, but actually excess air that is coming upwards causing the discomfort. That's why it is important to look at ALL of the causes of reflux as there may be more than one!

What is normal infant reflux?

There are two main forms of reflux, those labeled “happy spitters” and those whose parents are tired of cleaning spit up off of walls, car doors and spending countless hours trying to calm their baby. 

Happy spitters are babies that have a little bit of spit up. This usually isn't a lot of spit up and the child seems unphased. Reflux babies typically struggle in their day-to-day activities, find sleep nearly impossible, they may be losing weight or eating all of the time to counteract what they lose in their spit-up. This blog is about the latter. 

What causes of infant reflux?

First, let's look at the NORMAL (not just common, but truly normal) causes of reflux.

Weak LES and reflux

Babies are born with a weak lower esophageal sphincter (LES). Basically the sphincter needs time to strengthen so it can fully close. When a baby is born prematurely, this is even more common. Infants quite literally have half of the pressure as adults and preemies have ⅙ the pressure to help keep the LES closed. {{Nerd facts: A full-term infant has a resting tone of 18mmHg and babies that are born at 35-36 weeks have a pressure of 12mmHg and babies born at 27-28 weeks have a pressure of 3.8mmHg. For comparison, adult pressure is usually closer to 25mmHg.}} This isn't meant to scare you, but to let you know that most of these infants grow out of reflux as they get older.

Next, let's think about how babies lie at rest…they generally have “baby bellies” where their stomachs stick out and they have a slight arch in the low back. As babies grow, their lower esophageal sphincter also grows and changes position. In babies the LES is located just above the diaphragm and by 6 months it moves to be level with the diaphragm. This arched newborn position makes it harder for the LES to function optimally. In infants younger than six months, they typically have a liquid-only diet (breastmilk, formula or combo feeding) and in addition to their weak lower esophageal sphincter, the sphincter sits at a slight angle along that normal baby belly arch. These babies also tend to be happy spitters and improve at 4 months and resolve completely at 6-7.5 months when babies start to go on all-fours and more upright, allowing the sphincter to move into a more neutral position and open/close freely.

Causes of Reflux that Need More Support

Dysbiosis and GI Inflammation

Dysbiosis is a fancy way to say that a child's gut microbiome is altered. This can be from genetics, maternal dysbiosis, premature birth and/or antibiotic use. Gut dysbiosis, food allergies, mold, and parasites can all lead to GI inflammation. This inflammation can cause increased pressure on the LES. The most common food allergy in infants is CMPA, or cow’'s milk protein allergy. For these babies, removing cow's milk and soy from both infant and mother's diet can decrease reflux. For other babies, a probiotic like l. reuteri can be helpful by decreasing dysbiosis and inflammation.  

Visceral Hyperalgesia or Hypersensitivity (includes family history of Neurodivergence, ADHD or Autism)

Have you ever eaten something spoiled and had food poisoning? It starts as uncomfortable vomiting and by the end every ounce of your body is in pain. While this comes from dehydration, it’s also because your body has become hypersensitive to the pain…meaning it registers more pain than normal. Hypersensitivity can also increase in kids that don't sleep well. Either way, some babies feel every small change in body sensation.

The ability to feel pain, pressure and inflammatory changes is called interoception. In neurodivergent people (ADHD, ASD), interoception can be altered with both hyperawareness and decreased awareness. Just as adults feel increased pain with food poisoning, infants can have the same thing happen to them when they have reflux. Their brains experience more pain/awareness related to inflammation and distension in the esophagus and stomach. For these babies, it's important to focus on a whole body approach – decreasing inflammation, increasing comfort/vagal tone and supporting the body as a whole.

Low Vagal Tone or Vagal Reactivity 

You've probably heard about “vagal exercises” for stress in adults. When we think of kids, we often hear “all they do is eat, sleep, pee and poop – what do they have to be stressed about?”. While I get the sentiment, it's important to remember that a lot more goes into infant stress response. When it comes to infants being stressed, it includes body stressors like birth trauma, maternal stress, premature birth, environmental concerns (toxins, allergens), missed naps, sleep disordered breathing and obstructive sleep apnea and even sensory differences. 

It's also a fun fact that the vagus nerve plays an important role in digestion. The vagus nerve supplies part of the transverse colon, helping food move through the digestive tract. If a baby has slow digestion, the vagus nerve is frequently the cause.  This is a two-way street, and gut inflammation can also increase stress on infants.

A few ways to support vagal tone includes massaging (or using a vibration tool) in front of the ear, skin-to-skin contact, singing, babywearing, infant massage and rhythmic movements.

Delayed Milestones, Arching of Back, Hernias, Rectus Abdominis

If we recap the growth and change of development from infancy to 6 months, it's important to highlight the LES moving position to be at the level of the diaphragm. The change in location allows the diaphragm to act as a sling to help support the LES. Any delay or modification in developmental milestones can change the LES. This can be any change from a newborn lifting their head or rolling before 3 months to a baby hating tummy time, a baby frequently arching their back or doing “baby sit-ups” to not being able to hold their feet over the ground when they are on their back. 

If a baby is born with a hernia or noticeable rectus abdominis separation, this may delay the natural changes of pelvic floor and diaphragm development. If one parent is hypermobile, this can also delay milestones and increase reflux as the sphincters are hypermobile. Additionally, if a child is hypermobile they may have delayed milestones because their body needs increased support and stability.

Feeding Support / Tubes

NG-tubes and Orogastric tubes naturally keep the LES open. The breakdown of foods also begins in the mouth with enzymes breaking food down. By skipping this part of digestion, it can cause increased gas as the other parts of digestion have to work harder for normal digestion. For these babies, time is the best thing for your little one as the priority is making sure they are able to take in the nutrition needed.

Surgery

Surgery anywhere in the chest and abdomen can also alter reflux. Whether a child needed cardiopulmonary bypass, congenital heart defects, or abdominal surgery, all of these can alter the pressure in the abdomen and chest. If a baby had surgery and now has reflux, finding a provider who can do scar tissue massage can be helpful to help babies relieve reflux.

Constipation and GI Obstruction

This one is a two-way street, where constipation can increase reflux and reflux can increase constipation. Reflux causes babies to have increased pressure in the chest. Constipation causes babies to have increased pressure in the lower abdomen. The LES lies in between those areas and when either/both of those areas have higher pressure, the LES isn't able to fully close and stay closed. This constant fluctuation and battle between pressures can increase both constipation and reflux. 

It's important to note that if a baby is projectile vomiting (3-4 feet) after eating, losing weight, dehydrated or not having regular bowel movements, the baby needs to be seen by the pediatrician as soon as possible.

Aerophagia: Breathing, Oxygen Support, Excessive Crying 

Babies that need meconium aspiration or oxygen support are more likely to have reflux. Babies that breathe with their mouth open or take in extra air while eating are also more likely to have reflux. The area that we transport air (trachea and larynx) and the area we transport food (esophagus) sit right next to each other (and share a pathway in the nose and mouth area). Sometimes when we take in extra air or breathe with our mouth open the air goes into the stomach rather than the lungs. When this happens, reflux can happen because the pressure is too high because there is too much air in the stomach. This can also happen when a baby cries a lot or has frequent hiccups. 

Aerophagia: Overfeeding, Shaking Formula Too Much, Wrong Bottle/Nipple, Unrealistic Expectations

Aerophagia was mentioned above, but it can increase anytime a baby takes in too much air. If a mother has an over-active letdown, babies may break the seal and take in more air. Happy spitters sometimes take in too much milk at the breast and then spit out what is extra. These babies are generally happy, the spit up looks like milky drool or a little extra spit up, and the milk doesn't smell sour/partially digested. Overfeeding can also occur with unrealistic expectations. This can be from parents misunderstanding baby's cues, unrealistic societal expectations around sleep, and giving too much formula/breastmilk. Most breastfed babies will eat 2-4oz from birth to one because the composition of breastmilk naturally changes to meet the baby's needs. Meanwhile, formula fed babies will increase their intake from 2-3oz at birth to 6-8oz by the age of one. This often leads to breastfed children being overfed because “they must be hungry” for only eating 3oz. On the other hand, formulas that are shaken too much, or using the wrong bottle or nipple for the baby's mouth can lead to increasing air in the stomach.

Tongue tie, Cleft Palate, Cleft Lip, Oral Motor Dysfunction (Suck-Swallow-Breathe Coordination Issue), 

Tongue tied babies may develop increased reflux at 3-4 months of age when more controlled oral-motor coordination is needed for nursing. If a baby has a tongue tie, you may notice that they frequently have their mouth open, or that the corners of their mouth aren't able to fully close on the nipple/bottle. This can prevent the tongue from creating a good seal on the roof of the mouth and allow extra air into the stomach. These babies also frequently have a suck-swallow-breathe pattern that isn't maturing as we expect. In these cases, working with someone trained in infant oral motor work (SLP, OT, PT, DC) will be the best solution to making sure your baby has appropriate oral motor coordination and strength and can help guide you in knowing when your baby is ready for a tongue tie release and do post-operative exercises to help your child continue developing strength. 

Reflux treatment is so much more than acid blocking medications. In order to fully help your child, it's important to look at all aspects of their body, birth, development and emotional regulation. My hope is that this blog either helps guide you to the right provider(s) for your child or gives you the confidence you need to know that time will help.

Why do I (or my child) have Open Mouth Posture?

This is a question I see ALL of the time on Facebook mom groups.

“My child is a mouth breather at night. How can I help them?”

“My child always has their mouth open at rest. What do I need to do?”

Or maybe it's you that breathes through your mouth and you notice “I wake up in the morning with a dry throat and I need help.”

Why should I care about open mouth posture?

First, let's have a quick chat as to why we care about open mouth posture. When we are at rest and the lips are open and the tongue sits low, the muscles of the face and neck lose their general tone. When the mouth stays open during sleep, the tongue tends to drop down and back, causing the jaw to relax backwards and narrow the airway…which is a fancy way of saying it can cause obstructive sleep apnea or sleep disordered breathing (SDB). One study actually showed the number one predictor of SDB in children isn't snoring or daytime fatigue, but breathing with your mouth open! In adults we frequently worry about SDB because it is linked to high blood pressure, heart disease (heart attack or strokes), daytime fatigue, and diabetes. In kids, those risks look more like behavioral concerns (ADHD, sensory seeking, anxiety) and cognitive risks where kids don't excel in school because of their sleep deprivation.

How can I help with open mouth posture?

Now, back to the main topic – What can we do to help with open mouth posture? The answer is anything but easy because it depends! Instead of giving you one way to treat open mouth posture, I’m going to challenge you to look at all aspects of it to make sure you are finding the root cause(s) for long-term success. 

Ear Infections and Teething

If your child was recently sick with an ear infection or they are teething, they may have temporary open mouth posture. This is because the nerve that goes to the jaw actually runs right in front of the ear and when there is pressure in the region of the nerve, it can cause discomfort in other areas. Thankfully this is usually short-lived and will go away after a few days to two weeks. 

ENT Conditions: Nasal Polyps, Swollen Turbinates, Deviated Septum, Enlarged Tonsils & Adenoids

All of these conditions can make it difficult for someone to breathe through their nose. It's like trying to blow through a straw when someone is holding it shut…the air can't make its way through the airway system. The body prioritizes the ability to breathe and in these cases, open mouth breathing is a safety mechanism. It allows a person who can't breathe through the nose (or the area between the nose and upper throat) to continue to breathe. This is where an ENT evaluation is important. They can help you determine if nasal steroid sprays, antihistamines, decongestants or surgery may be the best option for you. If you have enlarged tonsils and adenoids, I highly recommend reading the rest of this blog as swollen tonsils and adenoids is usually a symptom of something else going on -- like allergies, reflux or oral ties. I am NOT saying you shouldn't look into tonsil and adenoid removal as there are times they can be so enlarged that it can cause severe obstructive sleep apnea. If this is the case, the question isn't tonsil and adenoid removal OR expansion and myofunctional therapy, the question is who are the best providers to get your child breathing and sleeping again.

Allergies, Asthma, and Histamine

Allergies, asthma and histamine intolerance can frequently cause open mouth breathing. All of these can increase inflammation of different parts of the airway, making it difficult to transfer air from the mouth to the lungs. Once again this is a protective mechanism and it's important to work with an allergy specialist to help you determine what your allergies are and ways to manage, avoid or eliminate them. 

• Reduce food allergens 

• Track what you respond poorly to

• Even if you aren't allergic, some people notice that they produce more mucus after eating dairy products or artificial sweeteners. I will say this isn't well supported by research, but the number of people who notice improvement when reducing dairy means I at least like to mention it even if it isn't fully supported

• Minimize allergens around the house

• If you are allergic to dust mites or nature (grass, trees, pollen), then dusting, vacuuming and mopping regularly can help. It's important to use a damp cloth or microfiber to trap the dust and remove it from being airborne. 

• Removing clutter, knickknacks, stuffed animals, curtains and blinds can all reduce dust

• Use a HEPA filter - my personal favorite is MedifyAir as they are high quality and less expensive than most others

• Wash bedding in hot water weekly

• It's equally important what you wash your sheets in! It's important to limit sulfates, dyes and fragrances in laundry detergent. Products like Tide, Gain, Febreze and odor eliminators can all cause nasal irritation. Sometimes switching your laundry detergent can help decrease that irritation. Some options you might consider include: Molly's Suds, ECOS, Charlie's Soap, Biokleen, 9 Elements

• Control humidity

• Feel free to laugh at this one if you are in Corpus Christi with 90% humidity. You probably won't be able to get between the generally recommended 30-50% humidity without a full-time dehumidifier (or 4), but it can be helpful to reduce some of the humidity to help with congestion

• If you're up North and in a low humidity climate in the winter where the heater is running and it is super dry, then you might actually need a humidifier! 

Hormones aka Track your Cycle

• Runny noses can often worsen during the luteal phase (~10-15 days before period) thanks to hormones. This leads to increased obstruction and less airflow through the nose. If it is severe, some providers will write a prescription for an anti-cholinergic nasal spray like Atrovent to help decrease the runny nose. It's important to note that it has only been shown to help with runny noses and does not help with congestion, sneezing or postnasal drip. It can also be very drying so it shouldn't be used regularly or even more than once a day.

• If you notice any other symptoms (sleep issues, nightmares, itchiness, PMDD) during the late luteal phase, then I recommend reaching out to myself or a functional medicine provider for 1:1 individualized support.

Reflux

It’s not always GERD or a burning sensation! Postnasal drip without nasal blockage and sneezing can be reflux. Chronic throat clearing, hoarseness, feeling of something in your throat (frequent swallowing), persistent coughing can also be a sign of reflux. Reflux is another one of those things that if you notice these symptoms, I recommend reaching out. 10-40% of people don't respond to proton pump inhibitors because it's non-acid reflux which is treated differently. I could write an additional blog on the causes of reflux and treatment options, but it's important to know that treatment can include anything from diet, breathing, exercise, oral motor, nervous system regulation to supplements to supporting acid production at the right time and digestive support to ensure the body is breaking everything down when it should.

Torticollis and Plagiocephaly

This is an oversimplification, but torticollis and plagiocephaly are both frequently caused by a lack of motion in the neck. The easiest way to explain how torticollis (head tilt) and plagiocephaly (flat spot on the head) can cause open mouth posture is by having you run through a little exercise. First, tilt your head to the left and then look to the right. Check in with how the area on the underside of your jaw/upper throat feels. Frequently you will feel tension in that area and opening your mouth will relax that. Next, keep your head straight but look down as far as you can. We frequently see this in children who have a flat spot or bald spot on the back of their head near their neck, this is also the child that is hard to clean under the chin. This causes a lot of tension in that same area that is relieved when the mouth opens. Finally, tilt your head up and look at the sky and again notice how the area under your jaw feels. In little kids, this may be the child that always looks like they are looking up or the child that flings their head back in order to roll. Frequently this feels like a pulling/tension sensation under the neck. All of these sensations can cause open mouth posture as a way to relieve comfort from a neck that has lost its full range of motion. If you think this is your child, I highly recommend a chiropractor, PT or OT trained in pediatric motor development for a full assessment.

Oral Ties

I hinted to oral ties (tongue ties) when I mentioned oral motor under reflux, but it's important to note that oral ties are one reason a person might have open mouth posture. Using a similar experiment as before, gently pull the area on the underside of your jaw down and back. That's what happens when our tongue isn't able to freely move. At rest and during sleep, your tongue should be gently rested on the roof of the mouth. When someone has a tongue tie, the jaw shifts backwards from the tongue tension and the mouth opens. If you think this might be the cause for you or your child's open mouth posture, I recommend finding a myofunctional therapist and airway focused dentist/ortho in your area to help. They can help make sure there is enough space in your mouth for your tongue to rest on the roof and release the tongue so it has full range of motion.

Low Tone and Hypermobility

If your child has low tone or you have a family history of hypermobility, you may notice open mouth posture. That's because both of these require a greater baseline of stability to remain closed. The best thing you can do for this is to see a myofunctional therapist, chiro, PT or OT trained in pediatrics to help support the strength and coordination needed to have closed mouth posture.

What can we do in the short term to promote nasal breathing?

Nasal sprays for open mouth breathing:

• Intranasal corticosteroid: Not so fun fact, it can take 21 days for new nasal steroids to be effective in nasal tissue. This is important so you can have realistic expectations on whether or not it is helping. In general, it's recommended you try them for 30 days to know if there is a difference

• Antihistamine nasal spray: allergic rhinitis + sneezing, itchy eyes. This is not great for nasal congestion and can be gross tasting so a lot of children will not tolerate this

• Nasal saline: great for kids, keeps nasal passages clear and reduces crusty dry noses

• Xylitol: great to reduce bacteria and may reduce ear infection frequency. This is great because it can be used 2-3x/day

• What about nasal decongestants? Nope. Not without a provider and only short-term because it can cause dependency/addiction. It works fast and effectively when you can't sleep with a cold and can help with nosebleeds but requires further workup!!

Mouth tape for open mouth breathing?

Please consider that question mark bolded, italicized and highlighted because it is important! While mouth tape can prevent open mouth posture, it's important to evaluate the risks. If you have any upper airway restriction or obstruction, mouth taping can limit your ability to breathe. I do NOT recommend mouth taping without specific recommendations from a provider who has tested to make sure you can breathe through your nose.

Herbs for open mouth breathing

I highly recommend working with a provider when it comes to herbs. There are some herbs like quercetin, NAC, butterbur, stinging nettle and supplements like Vitamin D, zinc, omega-3s that can help with allergies and inflammation. HOWEVER, they are not for everyone. For instance, Vitamin D should be checked with other fat soluble vitamins and be given with fats for full absorption. Zinc is great but too much can cause copper deficiency because they compete for absorption. As much as I love quercetin, it should be avoided in people on blood thinners, estrogen dependent breast cancer or kidney disease. It can also cause migraines and brain fog if added too quickly. NAC is wonderful to help with histamine and inflammation but for someone with issues metabolizing sulfur or gut dysbiosis, it can actually cause pain and burning sensation in the GI tract. All of this to say, help through herbs and supplements is possible, but just because something is natural doesn't mean it is harmless. It is important to work without someone who understands side effects, benefits and risks to help you safely navigate adding the, to support sleep.

Essential oils for open mouth breathing

In older children (over 8) and adults, using peppermint, eucalyptus, thyme and rosemary essential oils under the nose can be helpful for opening the airway to make breathing easier. My personal favorite is using Olbas oil on a pillowcase or using the Olbas inhaler before bed. For younger children, some essential oils like peppermint and eucalyptus can have a reciprocal response…meaning that instead of opening the airway it can actually close it. This is why it's important to not immediately lather kids up with Vicks or essential oils before you know what is safe for your specfic child.

Nasal Strips for Open Mouth Breathing

This is another area where we don't have a lot of research to support that nasal strips improve sleep, but we do have a lot of people singing their praises. Nasal strips like Breathe Right help to open the nasal passages. We also have magnetic nasal strips like Intake Breathing and the mute nasal dilator which both open the nasal airway. If you have inflamed turbinates or allergies or a deviated septum, these can be temporary supports that improve sleep quality while you wait for treatment.

Facial Cupping and Acupuncture 

Once again, the research on cupping isn't where I would like for it to be, but quite a few people will say they breathe easier. On the other hand, acupuncture is getting more and more information to suggest it can be helpful with sleep disordered breathing, and can decrease mucosal swelling. If you are looking for support to help open the airway so your mouth can close, acupuncture may be a great option to help.

References

• Lv ZT, Jiang WX, Huang JM, Zhang JM, Chen AM. The Clinical Effect of Acupuncture in the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2016;2016:8792167. doi: 10.1155/2016/8792167. Epub 2016 Apr 4. PMID: 27127530; PMCID: PMC4834396. 

• Albrecht T, Wu S, Baumann I, Plinkert PK, Sertel S. Measurable impact of acupuncture on mucosal swelling of inferior turbinates: a prospective, randomized, controlled study. Acta Otolaryngol. 2015 Feb;135(2):169-76. doi: 10.3109/00016489.2014.973533. PMID: 25578128.

Why Neurodivergent People Struggle with Bowel & Bladder

Full disclaimer, this is probably one of the nerdiest posts I have ever written, but I think it's important for more people to understand. If you're in Neurodivergent support groups, you've probably seen:

“My child refuses to potty train”

“My child won't pee/poop on the toilet”

“They don't tell me when they need to go”

“It's like my child doesn't care if they sit in their pee or poop”

As a pediatric pelvic floor provider, I usually want to shout from the mountain tops and explain that it isn't a won't/doesn't care situation as much as a “I'm struggling to learn a task” and need more or different support. And since I'm a WHY person, I want to take the time to help other people understand why Neurodivergent kids may struggle with bowel and bladder issues.

First, let's talk about how we know when we have to pee. As we move throughout the day, our bladder fills with urine. Once the bladder stretches a certain amount, the bladder sends a signal to the brain. This signal is based on bladder pressure or how much urine is in the bladder.

In newborns and young children the brain isn't fully developed and it simply empties automatically once full…that's why we have diapers. As children get older and their brains mature, this is when we develop the nervous system control that allows for bowel and bladder training.

One part of the brain (the periaqueductal gray or PAG) recognizes that stretch and determines if you are going to ignore it or act on it. This area of the brain also processes threats (fight/flight/freeze), modulates pain (determines if there is or isn't pain), and is in control of breathing, heart rate, supports REM sleep and temperature regulation along with urination. I highlight these other actions of the PAG because a lot of Neurodivergent people will recognize that they (or their children) may process one or more of these other aspects differently…from sensory sensitivities, differences in pain perception (hypersensitive vs hyposensitive), sleep differences to emotional regulation. While more research is needed, we have a few studies that have shown that Autistic people have increased brain volume and density in this area. One thing we frequently talk about is co-regulation and helping children feel safe in their environment based on how their brain processes that information. When it comes to the restroom, if a child is in pain (from constipation or bladder spasms), overwhelmed by sensory information or afraid of what might happen (Will they fall into the toilet? Will the toilet suck them down the drain?), then the body will prioritize the threat over the need to use the restroom. The changes in the PAG and its ability to determine threat and safety is one reason Neurodivergent people process the need for urination/defecation differently.

From the PAG, the sensory relay system next goes to two parts of the brain – the locus coeruleus (LC) and thalamus sensory relay. The LC is in charge of arousal/alertness. The LC is heavily studied around sleep because of the role it plays in alertness…or how the body responds to a stimulus. When it comes to the bladder, the LC is what says “this is important and you need to take action now” or “nope, this is background noise, no need to pay attention” or “you might want to start paying attention to this.” It also is in charge of norepinephrine, which is frequently considered the fight/flight/freeze hormone. The LC quite literally tells you to pay attention. As an adult, if you've ever been so focused on something (hyperfocused or time blindness) that you've forgotten to eat, drink, or pee, it's the LC that prevented those sensations from coming to consciousness. For kids, this is the child that is playing a game and doesn't realize they need to use the restroom because their brain is focused on the game and hasn't prioritized the need to pee/poop. If there is pain or discomfort with urination, the body will also increase its norepinephrine response…which can decrease body awareness, and increase pelvic floor tone. This is where pediatric pelvic floor therapy excels because it can work on decreasing the threat response.

At the same time the LC is doing its job, the sensory signals go to the thalamus on its way to the insula, ACC, PFC. The thalamus is the sensory and motor relay system…every single sensation we feel or movement we do goes through the thalamus. From the thalamus, the information goes to the insula. If you've been in the Neuroaffirming community long, you've probably heard about interoception- or the body's ability to feel bodily sensations…from hunger, thirst, bowel and bladder to a racing heart. The insula is the part of the brain that processes interoception and builds body-sensation vocabulary. It's the part of the brain that says “I feel pressure in my lower abdomen. That means I need to pee.” It's what connects the sensation to what it means. Research has shown reduced activation in the insula in autistic and ADHD children…meaning that they frequently have both decreased sensation (interoception) and decreased connection to meaning. This is highlighted by children who “don't feel the urge to pee/poop” as well as by children that may do the “potty dance” but they don't recognize they need to use the restroom.

From the insula, the bladder sensations move to the anterior cingulate cortex (ACC). The ACC frequently has both a different structure and altered connectivity in ADHD and autistic people. This area of the brain is what processes urgency, motivation and conflict detection. This is seen in the child that doesn't recognize the urge until it's too late…the child that jumps up and shouts, “I need to go NOW!” When it comes to motivation, this is the child that may recognize they need to go, but their brain says, “Nope, this isn't important enough to act on” or the brain says, “I am too busy”. When it comes to Pathological Demand Avoidance (PDA), this is the area of the brain that says, “This is too many demands. We are under attack, and instead of using the restroom, we are going to hold our pee and avoid it at all costs.” A child isn't refusing to use the bathroom, their brain has determined that the bathroom is a threat to their safety and is avoiding it to try and limit threats/demands.

Another part of the brain, the prefrontal cortex, “reads the room” and determines if it is a socially acceptable time to use the restroom.

If you're in a bathroom, then your brain tells your bladder that it is okay to go. If you're not in the bathroom, your brain tells your bladder it needs to wait until you can find a restroom. The bladder continues to fill until you can make it to the restroom.

After the LC and thalamus sensory route, the sensory relay system goes to the Pontine Micturition Center (PMC). The PMC is in charge of finally giving the “go” signal and allowing the bladder to physically go. While it is in charge of supporting bladder filling and preventing leaking, the PMC does NOT decide whether or not this happens…it simply reacts to what the other parts of the brain tells it to do.

Now, let's go back to the beginning for a minute. Remember how the bladder starts the signalling process by reaching a certain pressure? To make it easy, let's look at a 10-year old's bladder. They normally respond when there is ~250mL (~1 cup) inside the bladder. Let's think back to all of the parts of the brain that could over-respond or under-respond and lead to a person not using the restroom or using the restroom too frequently! When urination is delayed, the bladder will naturally start to stretch more and the brain may say, “we don't need to respond at 250mL, let's wait until it's 450mL” and over time that becomes 500mL. The bladder capacity can quite literally double. When this happens, it can cause pain whenever the bladder contracts or whenever they go pee…leading to increased pain/discomfort or decreased safety. This can lead to a cycle where the body has learned it is not safe to pee or poop so kids withhold to keep them safe. This isn't behavioral…it's a safety response!

Now, take a deep breath and let it all out. I know that was a lot. But if there is one key takeaway from this, it's to focus on supporting your child and their brain so you can help them learn their body's signals and brain's safety measures to help them feel safe in the bathroom.

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.