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Children's Health

Wide Opening Mouth



Hello, My 4 years old daughter opens her mouth very wide about 20 times a day. When I ask her to close it, she she tries to close it under duress, what looks unnatural. Throw doctor didn`t see any tonsils enlargement. I read about some tics, children may have it. She had DTaP and Polio shots last month and then she started to do it often. I wonder if it can be a side effect. She used to do it when she was about 1.5 ~ 2 years old and then she stopped. I really worry about it, because she does it very often and around other kids and adults, like she doesn`t control it. Any advice what I should do or check??

Thank you,


I am sure that is a concerning behavior! Since your daughter did have the behavior previously, it is very unlikely that it is a consequence of her immunizations. A tic disorder, if that is in fact what it is, is not listed in any of the Immunizations and Vaccines literature from the American Academy of Pediatrics or the Centers for Disease Control and Prevention vaccines page as a known sequela.

A sudden appearance or worsening of tic disorders may follow a streptococcal infection, whether it is the typical strep throat or strep infections of the skin, with those being most common in girls around the perineal area and perianal area. It is a condition known as a PANDA, Pediatric Neuropsychiatric Disorder Associated with group A Streptococcus. If a strep culture or strep antibody titer reveals a recent strep infection, treatment with penicillin, or another drug that is effective against streptococci if your child is allergic to penicillin, often brings marked improvement.

There is no diagnostic test for tics per se. Instead, the doctor needs to attempt to decide if it is a habit or a simple tic, a compulsion or a complex tic, or possibly a seizure. Her evaluation should include a detailed medical and developmental history, a child interview, and a complete physical exam with a detailed neurological evaluation. Family history of tic and seizure disorders and a review of current stresses and strains in the child's and family's life are also needed.

There are both medication and psychological therapies available, but most specialists do not treat tics agressively. They also do not recommend that parents, teachers, and others bring a lot of attention to the habit or tic. This may actually increase child anxiety and reinforce the tic or habit as an outlet for anxiety.

A good way to proceed would be to start with her regular doctor and see if a referral is a good idea to either a pediatric neurologist or a pediatric behavioral and developmental specialist.

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Response by:

Mary M Gottesman, PhD, RN, CPNP, FAAN Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University