Airway Health Inventorys
Your Child's Airway Health Begins at Birth.
A clinician-developed screening inventory for infants and toddlers, ages 0–3. Complete it. Bring it in. Start the conversation.
AirwayZ
Instrument 1 · Infant & Toddler · Ages 0–3
AirwayZ
Airway Health Inventory
Infant & Toddler
Ages 0–3 · Caregiver Report
Ages 0–3 · Caregiver Report
TreatOrigin Productions, LLC
Child's name
Age
Date
Caregiver
Pediatrician
Dentist
How to complete
For each item, mark the number that best reflects your child's experience over the past several months. Answer based on what you observe. There are no right or wrong responses. This form is designed to be shared with your child's healthcare provider as a starting point for conversation, not as a diagnosis.
Severity scale
0 Not present
1 Mild
2 Mild-moderate
3 Moderate 4 Moderate-pronounced 5 Pronounced
Initial column = today · F/U column = after 3 months of care
3 Moderate 4 Moderate-pronounced 5 Pronounced
Initial column = today · F/U column = after 3 months of care
Feeding & Oral Function
During feeding, does your child... · Severity: 0 (not present) → 5 (pronounced)
| 0 | 1 | 2 | 3 | 4 | 5 | F/U | |
|---|---|---|---|---|---|---|---|
| Compensate by breathing through the mouth rather than the nose during feeding? Nasal breathing during feeding is expected in infants; oral compensation is an early pattern worth noting. | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have difficulty latching or sustaining a latch during nursing or bottle feeding? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Tire easily during feeding, pulling off, pausing frequently, or falling asleep before finishing? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Make clicking, popping, or gulping sounds while nursing or bottle feeding? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Cough, gag, or choke during feeds, even occasionally? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have milk or liquid come out of the nose during feeding? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have wet, gurgly, or rattly-sounding breathing after feeds? A wet or gurgly quality after feeding can indicate residual liquid in the airway. | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have frequent spitting up, acid reflux, or regurgitation beyond typical infant patterns? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Resist textured foods or strongly prefer soft foods beyond 18 months of age? | 0 | 1 |
2 | 3 |
4 | 5 |
| Has your child... | Yes | No | Not sure |
|---|---|---|---|
| Been evaluated for tongue tie (ankyloglossia) or lip tie? Restricted tongue or lip mobility can affect feeding efficiency, oral posture, and nasal breathing patterns. | |||
| Used a pacifier beyond 12 months, or developed a thumb or finger sucking habit? Prolonged oral habits influence palatal shape and tongue resting posture. |
Sleep
Snoring frequency · Mark how often each pattern occurs
| Never | ~1× / week | 2–4× / week | Most nights | Every night | |
|---|---|---|---|---|---|
| Does your child snore or breathe loudly and heavily during sleep? | |||||
| Does your child have labored, difficult, or noisy breathing during sleep? |
While sleeping, does your child... · Severity: 0–5
| 0 | 1 | 2 | 3 | 4 | 5 | F/U | |
|---|---|---|---|---|---|---|---|
| Sleep with their mouth open? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Sweat heavily or seem uncomfortably warm during sleep? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Sleep in unusual positions: neck arched, on hands and knees, sitting upright, or head elevated? These positions can reflect an unconscious effort to keep the airway open during sleep. | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Sleep with their neck hyperextended or head tilted noticeably far back? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Move excessively, thrash, or seem restless throughout the night? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Wake frequently during the night without an obvious cause such as hunger or discomfort? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Startle awake suddenly, or wake with obvious gasping, snorting, or an abrupt intake of breath? This pattern is distinct from general restlessness and may indicate brief airway disruption during sleep. | 0 | 1 |
2 | 3 |
4 | 5 |
While awake, does your child... · Severity: 0–5
| 0 | 1 | 2 | 3 | 4 | 5 | F/U | |
|---|---|---|---|---|---|---|---|
| Have noisy, squeaky, or high-pitched breathing while awake, especially when feeding, crying, or lying down? This pattern, sometimes called stridor, can be associated with structural airway differences that are worth evaluating. | 0 | 1 |
2 | 3 |
4 | 5 |
| Have you ever observed your child... | Yes | No | Not sure |
|---|---|---|---|
| Stop breathing, pause breathing for several seconds, or appear to struggle to breathe during sleep? | |||
| Have interrupted snoring: snoring that cuts off abruptly before resuming? |
| If yes to either above, please describe what you observed, how often, and approximately how long it lasted: |
Daytime & Development
During waking hours, does your child... · Severity: 0–5
| 0 | 1 | 2 | 3 | 4 | 5 | F/U | |
|---|---|---|---|---|---|---|---|
| Breathe through the mouth during waking hours? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have a dry mouth upon waking: lips dry, mouth open at the start of the day? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have frequent ear infections, persistent runny nose, or chronic nasal congestion? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have frequent throat infections, tonsil swelling, or recurring colds? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have allergic symptoms: runny eyes, skin reactions, eczema, or chronic sneezing? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Seem irritable, difficult to soothe, or have difficulty sustaining attention in play or interaction for their age? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have speech that is delayed or difficult for familiar adults to understand? | 0 | 1 |
2 | 3 |
4 | 5 |
|
| Have speech that sounds nasal, hoarse, or consistently congested in quality? | 0 | 1 |
2 | 3 |
4 | 5 |
Development & Medical History · Yes / No / Not sure
| Yes | No | Not sure | |
|---|---|---|---|
| Has your child had difficulty gaining weight despite seemingly adequate feeding, or has a provider noted poor weight gain or failure to thrive? | |||
| Has a physician flagged your child's growth as slower than expected or below their growth curve at any point? | |||
| Has your child had repeated chest infections, bronchiolitis, or pneumonia that a provider has treated or been concerned about? Recurrent lower respiratory infections in infants can be associated with aspiration or airway vulnerability. | |||
| Has a provider ever expressed concern about your child's muscle tone, describing them as floppy, low-toned, or hypotonic? Reduced muscle tone can affect airway stability, particularly during sleep. | |||
| Have your child's tonsils or adenoids been evaluated by a physician or ENT? | |||
| Has your child been evaluated for, or diagnosed with, any chromosomal or connective tissue condition? Including Down syndrome, Ehlers-Danlos syndrome, or similar. These conditions are associated with a higher likelihood of airway-related patterns. | |||
| Does your child have unusually flexible or "double-jointed" joints in the fingers, wrists, or elsewhere? | |||
| Has your child been evaluated for or diagnosed with autism spectrum disorder? | |||
| Was your child born prematurely, or were there significant complications during pregnancy or delivery? | |||
| Is your child regularly exposed to cigarette smoke, vaping, or secondhand smoke in the home or car? Environmental smoke exposure is associated with increased airway inflammation and more pronounced symptoms in infants with airway-related concerns. | |||
| Is there a family history of snoring, sleep apnea, recessed jaw, crowded teeth, or tonsil and adenoid problems? Craniofacial and airway patterns often run in families. A positive family history increases the relevance of other findings on this form. |
For the Clinician
This instrument is part of the AirwayZ Airway Health Inventory, a five-instrument comprehensive screening tool spanning birth through adulthood, developed by Elizabeth Walker, DMD, MSD. It draws from validated content in the Healthy Start / Bergersen Sleep Disordered Breathing Questionnaire, the Pediatric Sleep Questionnaire (Chervin et al., 2000), and the BEARS framework, augmented with orofacial, feeding-aspiration, postural, connective tissue, and systemic domains not captured in standard instruments. Initial and follow-up columns support treatment tracking over time. Composite scoring is intentionally absent. Individual item patterns and clinical judgment should guide next steps. Items with severity 4 or 5, any affirmative response to observed breathing pauses or gasping arousals, and any affirmative witnessed apnea response are recommended as priority discussion points.
A Note for Caregivers
What this inventory is
A starting point for a clinical conversation, not a diagnosis. Many of the patterns this form captures are well understood and, when identified early, are highly addressable. Bringing this completed form to your child's provider is a meaningful and proactive step.
What to do next
Share this with your child's pediatrician, family physician, or a dentist or orthodontist with airway training. If your provider isn't familiar with airway-focused care, an AirwayZ-affiliated clinician may be a helpful resource. Visit airwayz.com to find a provider near you.
About higher severity patterns
Pronounced patterns in any category, especially around breathing during sleep, feeding difficulties, or airway sounds while awake, are worth raising with a provider. These findings are recognized, well-studied, and when addressed, often make a meaningful difference in a child's development, sleep, and quality of life.
Why early identification matters
The first three years represent the most significant window of craniofacial and neurological development. Identifying airway-related patterns in infancy and toddlerhood offers the widest possible opportunity for gentle, effective care, and often the simplest path forward.