ADHD, Baby Reflux and Tongue Tie: Is there a link?

Is there a link between baby reflux, tongue-tie and ADHD? Quite possibly. Let me tell you about it.

One of the risks of not treating reflux properly, and by this, I mean addressing the underlying cause, is that as your child grows, their risk of developing other more serious conditions increases over time. These include (not limited to):

• Small Intestine Bacterial Overgrowth (SIBO)
• Nutritional Deficiencies
• Obesity and all the associated challenges that go with that
• being diagnosed with behavioural problems and neurodiversities such as ADHD, and being possibly misdiagnosed with ADHD when it is behaviours that are ADHD-like.

This blog focuses on ADHD-like behaviours as one outcome. 

AM I SAYING THAT REFLUX CAUSES ADHD? NO.

What I am saying is that reflux and ADHD-like behaviours have common underlying causes. Understanding this now, while your baby is a baby, gives you an incredible opportunity to take informed action to minimise the risk of an ADHD (mis)diagnosis and other behavioural problems later in life, along with a lot more.

This is a big statement, and to support it, I need to explain a number of elements that come together.

Importantly, I am not saying that 100% of people with ADHD had reflux in infancy, nor am I saying that unresolved reflux in infancy causes ADHD.

I AM saying that unresolved reflux increases the risk of an ADHD misdiagnosis later, and through action now, you can reduce that risk.

True ADHD is a neurodevelopmental condition, which, as far as the literature goes, is present from birth. However, many children are diagnosed with ADHD that may not have been present since birth, and this article is about avoiding incorrect diagnoses later in childhood by doing everything we can in the earliest stages.

For the remainder of this article, the term "ADHD" refers to those individuals who have received a "diagnosis" of ADHD. Actually, it may be a misdiagnosis due to the factors I outline below. This is all about those who present with ADHD-like behaviours and observations and so receive a diagnosis, and in truth, it may not be true that ADHD was present since birth, but rather something that has developed over their life.

The common underlying causes that I’m going to explore here are not the only “causes” of ADHD and do not refer to true ADHD present from birth.

ADHD - A BRIEF INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a neurodiverse disorder which is expressed through behaviour. The behaviour is categorised by either “Inattentive Type”, “Hyperactive Type”, or “Combination Type”.

The most common way of diagnosing ADHD is through observation of behaviours, often coupled with some objective testing. It is not a blood test that gives definitive results.

Most comments I get are that ADHD is something people are born with. Perhaps that is true. However, what if children are diagnosed with ADHD due to their behaviours and inability to focus due to severe sleep deprivation? I believe there may be a lot of misdiagnosis going on, which this article is really about.

I don’t like to put everything down to genetics and walk away because the world of epigenetics (the environment in which genes live, which determines how they express themselves) is showing to be of far more importance - like 80%!) “Unlike genetic changes, epigenetic changes are reversible and do not change your DNA sequence, but they can change how your body reads a DNA sequence.” - CDC, 2020

Two of the underlying common causes of reflux and ADHD (and other behavioural issues for children outside of this) are more about the environment than the underlying gene, mouth breathing and disordered sleep, which go hand in hand.

What this means is that we (as parents and carers) have a massive opportunity to influence how the genes are expressed, to influence the outcome. If it were just genetics, this would not be an option. And it is.

MOUTH BREATHING: A COMMON SYMPTOM IN REFLUX, SILENT REFLUX & MISDIAGNOSED ADHD

Mouth breathing happens when someone holds their lips in an open posture. Breathing is an involuntary action – the diaphragm pulls downwards, forcing the lungs to expand, which draws air in. This air is drawn in through any opening – nose or mouth.

This means when the lips are apart, we inhale air through our mouth, even if some is being inhaled through the nose, too.

When air is inhaled through the mouth rather than the nose, there is 18% less oxygen provided to the brain. This means that during sleeping hours, the brain receives a different oxygen loading. It does not enter the deepest phase of sleep (regardless of how long the sleep duration is), meaning the individual cannot fully process the emotional load of the day.

This lack of deep sleep builds up over a long period of time, sort of like chronic deep sleep deprivation, and presents itself as a behavioural challenge. What is happening in these children is that the inability of the brain to process the emotional load of the day builds up over time until, eventually, their capacity to control and process emotions reaches its limit. Suddenly, they “explode” behaviourally.

Symptoms of Sleep Disordered Breathing include:

• Mouth breathing
• Snoring
• Apnoea (trying to inhale air while not being able to)
• Gasping
• Laboured breathing
• Excessive sweating
• Restless sleep
• Leg kicking
• Hyperextension of the neck 

In fact, all of the above symptoms and behaviours occur with mouth breathing. And so, for me, it seems sensible to investigate mouth breathing some more.

A lot of infants with reflux, silent reflux, colic, CMPA and other food allergies hold an open mouth posture at rest. This is mouth breathing.

And while their sleep patterns and requirements are different during infancy, mouth breathing is the point of focus that we should look at. While it may not cause direct issues in infancy, it can have a longer-term impact.

WHAT CAUSES MOUTH-BREATHING?

Infants are not born knowing how to breathe through their mouths; it is a skill that is learned around four months or later. When they cry, they inhale through their mouths. However, if you’ve ever witnessed a young baby with a stuffy nose, you want to tell them to “open your mouth” to breathe, except they simply haven’t developed the skill to coordinate like this.

The normal human (and mammalian) way of breathing is nasal breathing. Mouth breathing is a survival adaptation. A skill that we learn to survive.

One reason that mouth breathing is developed as a survival skill is when the nasal airway becomes blocked; this can happen during a cold, with which we are most familiar. However, it can also happen in response to a number of other issues:

REFLUX CAN CAUSE MOUTH BREATHING THROUGH DIFFERENT PATHWAYS:

1. The production of mucous blocks the nasal passages and requires the baby to adapt to breathing through their mouth for survival. Think of hay fever: when the body detects pollen, interprets it as a pathogen, and produces mucous, it wraps it up and removes it from the body through sneezing and coughing. This mucous can build up rather quickly for an infant, blocking their nasal passages and requiring them to learn how to breathe through their mouth for survival. The reflux causative factors for this are:

a) The regurgitation of stomach acid into the oesophagus, throat or nasal passages causes these structures to produce mucous to protect itself.

b) Baby has an allergy, which results in the production of mucous from the same tissues as above. This allergy could be a food allergy such as dairy (CMPA), soy or any other food in fact! Or an                        environmental allergy such as a response to dust, pollen or other airborne factors.

2. Receded chin or Retrognathia: this is named as a medical condition where the lower jaw sides behind the upper jaw, resulting in an overbite. In severe cases, it is simply impossible for a baby to have their lips meet and touch, and so they become mouth breathers simply because of the passive act of breathing as described above. However, having a receded chin (retrognathia) is not just a “clinical condition” or unchangeable if someone has Pierre-Robin Syndrome. We need to look further. When we understand the anatomical features of the face, mouth, and jaw, we start to see that this posture can be developed as a response to a number of things, including:

a) Tongue-tie (ankyloglossia): the tongue is a massive structure which is attached to the lower jawbone (mandible). If there is a restriction present, then this can pull the lower jaw backwards, preventing the lower jaw from being in its proper forward position.

b) Trauma to the face can cause the displacement of the lower jaw. This is a “floating” bone; it is held in place only by muscles and ligaments, unlike the hip, for example, which is a neatly fitting ball-and-socket joint. Therefore, any sort of trauma, or indeed unwanted tension in the muscles of the mouth and face, can cause this jaw to be out of proper alignment. These can be simple muscular tension or as a result of other actions; for example, the use of forceps and ventose during birth can misalign a baby’s head, as indeed can the gentle hands of anyone assisting the baby in the birthing process.

HOW TO REDUCE MOUTH BREATHING IN BABIES WITH REFLUX AND ALLERGIES

For all of the four elements identified above in connection with reflux, we can figure out what is going on for each child, specifically, and then address it appropriately. By addressing the underlying cause of reflux in each case, we resolve the reflux AND reduce the chances and occurrence of mouth breathing.

Hence, the vital part of getting the right solution for each baby and to address reflux as early as possible.

Resolving reflux at the root cause in the infancy days massively reduces the risk of ADHD later in life. And before you ask, there is no evidence to support the connection between reflux and ADHD. However, everything else in this article, as I have built it, IS evidence-based and published in peer-reviewed journals.

No one else understands reflux as I do, and so the system is not looking to prevent ADHD; rather, they are still focused on “fixing it”. Personally, I prefer to prevent where possible.

If you want the hundreds of articles available to read more about ADHD, mouth breathing and sleep relationships, there are many, many search engines prepared to help you right now!

To understand what is the underlying cause of your baby’s reflux right now, take a look at our online workshop.

To learn more about how you can encourage the proper use of the tongue through oral play and facial massage without waiting for an appointment with someone else, start with the new “It’s All About The Tongue” mini course.

“Children with sleep disturbances or ADHD should be assessed for the presence of mouth breathing, as early identification and correction of mouth breathing may help to prevent unnecessary exposure to the medication.” (3)

If you found this blog helpful in any way, please let us know (email here), and feel free to share it so more families can be made aware of the importance of supporting infants as early as possible to allow them to be as healthy and happy as possible.

How can I help?

If you think your baby has a tongue tie and this is what may be causing their reflux, the best place to start is the Oral Play Guide.  This mini-course is for you if your baby is having difficulty feeding and/ or has a confirmed tongue tie.

If you are unsure of the underlying cause of your baby's reflux, then my Reflux Free Baby Workshop will help you identify it. This can be done by reading all the symptoms your baby has, grouping them into patterns and using this pattern analysis to figure out the underlying cause. By doing this, you can take specific action to address the specific cause in your baby.

Use the box below to get your free Baby Reflux Symptoms Tracker so you can really start to see what is going on for your baby, regardless of diagnosis, reflux, silent reflux, colic or allergies.

The course is suitable for both bottle-feeding and breastfed babies who are suffering from baby reflux.

Head to the links below for suggested reading:

• Tongue Tie and Reflux: The Intolerable Injustice to Infants
• Is Reflux Genetic?
• What Doctors Won't Tell You About Baby Reflux and Colic

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REFERENCES

_{(1) Sano M, Sano S, Oka N, Yoshino K, Kato T. Increased oxygen load in the prefrontal cortex from mouth breathing: a vector-based near-infrared spectroscopy study. Neuroreport. 2013;24(17):935-940. doi:10.1097/WNR.0000000000000008 [Link]}

_{(2) Trosman I, Trosman SJ. Cognitive and Behavioral Consequences of Sleep Disordered Breathing in Children. Med Sci (Basel). 2017;5(4):30. Published 2017 Dec 1. doi:10.3390/medsci5040030 [link]}

_{(3) Kalaskar R, Bhaje P, Kalaskar A, Faye A. Sleep Difficulties and Symptoms of Attention-deficit Hyperactivity Disorder in Children with Mouth Breathing. Int J Clin Pediatr Dent. 2021;14(5):604-609. doi:10.5005/jp-journals-10005-1987 [Link]}

_{Further Reading:}

_{Knight FLC, Dimitriou D. Poor Sleep Has Negative Implications for Children With and Without ADHD, but in Different Ways. Behav Sleep Med. 2019 Jul-Aug;17(4):423-436. doi: 10.1080/15402002.2017.1395335. Epub 2017 Nov 14. PMID: 29072500. [Link]}

_{Govardhan C, Murdock J, Norouz-Knutsen L, Valcu-Pinkerton S, Zaghi S. Lingual and Maxillary Labial Frenuloplasty with Myofunctional Therapy as a Treatment for Mouth Breathing and Snoring. Case Rep Otolaryngol. 2019;2019:3408053. Published 2019 Mar 10. doi:10.1155/2019/3408053 [Link]}

_{Torre C, Guilleminault C. Establishment of nasal breathing should be the ultimate goal to secure adequate craniofacial and airway development in children. J Pediatr (Rio J). 2018 Mar-Apr;94(2):101-103. doi: 10.1016/j.jped.2017.08.002. Epub 2017 Aug 30. PMID: 28859912. [Link]}