Why does my child always have their tongue out?
“My baby sticks their tongue out all the time!”
As a pediatrician this is a common concern I hear from parents of newborns. Sticking your tongue out is better known as tongue protrusion. It is when the tongue sticks out beyond the lip border for all to see. Since tongue protrusion is one of the Characteristics of Down syndrome, new parents often ask,
“Does my child have Down syndrome if they constantly stick out their tongue?”
6 Causes of Tongue Protrusion
Just because it seems as if your child sticks their tongue out “all the time” does not automatically mean your child has Down syndrome. In fact, there are multiple reasons that a child’s tongue could be sticking out. Let’s take a look at the top 6:
1. Normal Reflex
I feel that I must emphasize that tongue protrusion is a completely normal (or as we like to saytypical) finding in infants. It is part of the sucking reflex. It usually disappears with time, around 4-6 months when it is time to spoon feed. In other words, your child could simply be sticking their tongue out, just because they like to stick it out. (Don’t you just love how kids like to keep things interesting?) 
The reason the tongue protrudes, other than as a natural reflex, is that the tongue is or appears large. Several things can give this appearance, a true large tongue, a small mouth, growths/masses around the tongue, muscle tone and mouth breathing. If your pediatrician finds one of these things, they should then try to see if there are other characteristics that fit into a syndrome or diagnosis.
A syndrome means that there is a cluster of characteristics that are found together. Tongue protrusion is a characteristic of Down syndrome, however a person cannot be diagnosed with Down syndrome if they only have tongue protrusion. As you will soon read there are several diagnoses that are associated with tongue protrusion.
2. Macroglossia (large tongue)
Macroglossia is an increase in the amount of tissue in the tongue. This causes the tongue to protrude from the mouth as it simply does not fit in a typical mouth. There are various reasons for a tongue to be large both congenital (born with it) and acquired (develops later). Again this is most likely to be seen with other characteristics that fit a syndrome or diagnosis. Some of the more common reasons are Beckwith-Wiedemann syndrome, acromegaly (increase in growth hormone),congenital hypothyroidism (not enough thyroid hormone), and mucopolysaccharides. There can also be a build up of substances from the body in the tongue such as amyloid or glycogen which is seen in amyloidosis and glycogen storage diseases
The majority of text books and articles think that children with Down syndrome have a large tongue, however, from my experiencee as a medical doctor (and a parent of a child born with Down syndrome I think several of the reasons listed below contribute and it can be considered apseudomacroglossia (appears large but is actually normal size) in most cases.
3. Small Mouth
A small mouth will make a normal size tongue stick out giving the appearance of a large tongue. You can have an overall small mouth which I feel a lot of children with Down syndrome have. One reason a child with Down syndrome can have a small mouth is because they have differences in their palate (the top of the mouth) the most common being a narrow higher arched palate. A small mouth is also seen in DiGeorge syndrome. Another cause of a small mouth is micrognathia which means small lower jaw. When looking at a child you usually see a recession of the lower jaw so that it looks like the chin is sucked back. Pierre Robin is a sequence that occurs with the diagnosis of micrognathia.
4. Hypotonia (poor muscle tone)
We have discussed how hypotonia, low muscle tone, affects every muscle in the body including the tongue. It means that at rest there is little tone in the muscle so it hangs like a wet noodle. (I use that metaphor, because this is often how the tongue appears on a child with low muscle tone.)
If the tongue has no tone it will rest in state that is completely relaxed and likely protrude from the mouth. Just think about what your tongue is doing right now. You are holding it back in your mouth, if you just relax the muscle it takes up a lot more room in your mouth. There are several other syndromes that have hypotonia besides Down syndrome including, Prader-Willi, Rett syndrome, and several others, even benign congenital hypotonia which will resolve on its own.
5. Masses
Masses or growths in and around the tongue can either make it large or push the tongue out. There are cysts that can form in salivary glands or what is known as a thyroglossal duct cyst. Cysts are usually observed and resolve on their own. One of our friends right now is dealing with a possible lymphatic malformation that is causing their baby’s tongue to appear large.
6. Mouth Breathing
Simply being a mouth breather can cause the tongue to protrude. Infants are typically nose breathers so something usually causes them to breathe through their mouth whether it be nasal congestion from a cold or allergies, or large tonsils and adenoids. Babies with Down syndrome can often end up being mouth breathers for all of the above reasons. If the reason is large tonsils and adenoids, a surgery may be in order to have them removed if they are causing other problems such as sleep apnea or chronic ear or sinus infections.
Bonus Reason
Some infants develop a habit of sticking out their tongue that continues after the normal reflex has resolved. They have none of the above characteristics, but continue to have tongue protrusion once they start eating. This should probably be dealt with by a speech therapist to help them break the habit.
So, does my child have Down syndrome if they have their tongue out all the time?
As I’ve discussed, there are multiple reasons for a child to exhibit tongue protrusion (having their tongue out.) Parents of newborns often jump to the conclusion that their child has Down syndrome if they see them sticking their tongue out “all the time.” First, ask yourself if you’re being hypersensitive. Is your child really sticking their tongue “all the time?” Second, tongue protrusion alone will not warrant a Down syndrome diagnosis. Your pediatrician will be looking for a combination of characteristics, and ultimately a Chromosome analysis, before confirming a Down syndrome diagnosis.
As always, if you have any concerns about your child, you should always talk with your child’s pediatrician. While the internet can sometimes be helpful, it is by no means a substitute for your child’s pediatrician. Every child is unique, and what you read online about one person’s child, will not always equally apply to yours. Often times parents could save a lot of unnecessary worry by simply bringing their child in to see their pediatrician when they have a medical concern instead of surfing the web, but I know you aren’t one of those types of parents.
What can you do to help with tongue protrusion?
We are still working on this one ourself. Some of the above can be corrected with surgery such as taking out the tonsils and adenoids, extracting the jaw for Pierre Robin and removing cysts. I will have to say that Noah’s tongue protrusion drives his mama a bit crazy.:-) His is not correctable by surgery but requires the help of a speech therapist. We are just starting out with speech therapy and don’t have many tips yet.
We have been told not to tap or flick the tongue to encourage it to go back in the mouth (I am sure there will be a few of you who have actually been told the opposite). We have been told to encourage him to drink from a straw and make sounds that cause you to close your mouth such as“ba” and “ma”. I really like that last one We have also used the Z-vibe with Noah with is often used to help strengthen oral motor skills.