It’s a scene from a Normal Rockwell painting. You see your child playing quietly with a favorite toy, and you are filled with love for your sweet, kind, precious toddler. You bend down to kiss them on the cheek and…you are completely repulsed by their nauseatingly bad breath.

What did this kid do, eat from the dog food dish? How can your innocent angel have such a hellish odor coming from their tiny mouth? And what can you do about it?

Rest assured, you are not alone. Bad breath (halitosis) is common among toddlers, but there is no single reason for this. Halitosis can be caused by lots of different problems.

Oral Causes of Halitosis

The human mouth is basically a petri dish full of bacteria. Most experts think that the foul odor of halitosis is caused by products of bacterial metabolism like sulfur, volatile fatty acids, and other chemicals like the appropriately named putrescine and cadaverine.

The prime source of these bacteria is the tongue, especially tongues that are heavily coated. These germs are also found between the teeth and gums (periodontal area).

What to Do

Brushing or scraping the tongue, particularly the back half of the tongue, has been shown to help reduce halitosis in adults, though no studies on toddlers have been done. But this is certainly a risk-free treatment you can try at home.

Mouthwashes, especially those that contain zinc, have also been shown to reduce halitosis in adults. But again, no studies have been done on toddlers, who may not be able to swish and spit a mouthwash.

Nasal Causes of Halitosis

Chronic sinusitis has been shown to be a common cause of bad breath in toddlers. These children almost always have other signs or symptoms like a runny nose, cough, nasal obstruction, or facial pain.

In addition, a foreign object stuck up the nose, such as a bead or piece of food, is common in this age group, and can result in breath odor. When this is the case, the child usually also has foul-smelling, and often green, discharge from the nose. In these instances, the odor is remarkable, and gets worse quickly.

What to Do

If you suspect your child has sinusitis and it is fairly recent in onset, then you can try to wait it out. Many sinus infections are caused by viruses. Having your child drink lots of water and blowing their nose may help. But if you’ve tried these methods without benefit, then see your child’s doctor. Sometimes an antibiotic is necessary to resolve chronic sinusitis.

If you suspect a foreign object in your child’s nose, then call your pediatrician. By the time it gets to the point of foul-smelling breath and green discharge, the object is now probably surrounded by swollen nasal tissue and it may be difficult to extract at home. Your child’s doctor may be able to remove it in the office or refer you elsewhere.

GI Causes of Halitosis

Gastrointestinal causes of halitosis in toddlers are not as common as the other causes, but need to be considered when other GI complaints are present.

If your child has chronic bad breath and also has abdominal pain, nausea, vomiting, or heartburn, then gastroesophageal reflux disease (GERD) is a possible source. In this condition, stomach acid will reflux or travel up the esophagus, often into the throat or mouth, and in some cases out the mouth. Parents may be more familiar with GERD as an infant problem, but it can occur in the toddler years.

Infection with Helicobacter pylori, bacteria that can infect the stomach and cause a multitude of symptoms, is another disease that can cause bad breath. Usually, this occurs in combination with other obvious GI complaints like abdominal pain, nausea, vomiting, or burping. H. pylori infection is more common in older children and adults, but can sometimes be found in toddlers.

What to Do

These issues are obviously best treated by a doctor. Medications are the mainstay of treatment for these problems, but your child may need further testing first to determine if GERD or H. pylori is the cause of the problem.

If your child has frequent or chronic GI symptoms along with bad breath, talk to your pediatrician.

Other Causes of Halitosis

Children with mouth breathing while sleeping have a higher incidence of halitosis than children without mouth breathing.

Mouth breathing can dry the oral mucosa, leading to a decrease in the flow of saliva, which results in a release of the foul-smelling compounds in the mouth mentioned above. There are many reasons why children are mouth breathers, ranging from allergy-induced nasal congestion to large adenoids blocking the child’s airway.

What to Do

If your child is a mouth breather, seek help from your doctor. Because there are many causes of mouth breathing during sleep, some of which are medically significant, a pediatric healthcare provider should evaluate these cases.