Breathing and Babies: What Parents Need to Know

00:01Hi, everyone. Welcome to Baby Steps Nutrition, a podcast that focuses on nutrition, health, and wellness for families of children of all ages and stages. I'm your host, Argavan N., a pediatric dietitian and mom of two young children. My goal is to bring you impactful information that you can apply every day in a simplified, practical form to make life easier.

00:33Now, let's get into today's conversation. Today, I'm excited to chat with Dr. Lim, the founder and principal dentist at Sparkle Dental. She has advanced training in dental sleep medicine and oral facial myofunctional therapy. And she's the author of Breathe, Sleep, Thrive, which I'm holding a copy in my hand right now.

00:58Dr. Lim is passionate about helping parents understand airway health, something that is often overlooked or brushed off with. They'll grow out of it. But as she explains, many kids actually grow into these issues. Let's welcome Dr. Lim to the show. Hi, Dr. Lim. Thank you so much for being here. Hi, Garavan. Thank you so much for having me as well. It is my pleasure.

01:22Let's take it all the way back to what led you to even want to focus your career on sleep medicine and airway development. Yeah, I've been a general dentist for 26 years. And I first became involved in snoring and sleep apnea through my husband's snoring. So that was around over 12 years ago, I think. And it was just driving me very crazy. I wasn't able to get a decent night's sleep. And so one night in frustration, I decided I was going to Google up dental appliances.

01:50I was aware that you could get lower jaw repositioning devices that people could wear during sleep that would help open up their airway and help them breathe and be quieter. And I decided I was going to learn more to help other spouses in the same boat. And so that's when I became one of dentists, Australia's first dentist to qualify in this area and become involved in offering these dental appliances for adults with snoring and obstructive sleep apnea.

02:15But I also started to question, you know, a lot of people that have these issues, it's not just the sound, it affects their health and their energy levels. It's linked to increased risk of diseases. And we're treating a jaw problem with these appliances. So how come we can't grow jaws better in the first place? And that's why I've become involved with early interceptive orthodontics and really addressing the underlying problems that contribute to poor jaw development, which is oral dysfunction and ensuring that the muscles work well during sucking, swallowing and breathing and chewing so that the muscles will grow well, the jaws will grow well in the earliest years of life.

02:53Yeah. And it is amazing how common snoring is, but as we know, it is not normal. I mean, there is even this term called sleep divorce, meaning couples who live together have chosen to sleep in separate rooms because snoring has become such a common problem and it is affecting the other party sleep. Yeah, absolutely. Yeah. I'm one of those couples. Yes. Yeah.

03:17It's just actually much better quality of sleep to be able to do that. Yeah. And a lot of what you talk about, Dr. Lim, is bridging dentistry with sleep health. And so when did you first realize, I know you talked about with your husband, but we see now a lot of kids, if we were to observe them during sleep, they sleep with their mouth open or even at resting state, there's a gap between their upper and lower lip.

03:41Yeah. Because, you know, a lot of healthcare is really focused on obstructive sleep apnea, even though, you know, 85% of people that have obstructive sleep apnea have been underdiagnosed. We're really mainly diagnosing and looking for those end stage problems. But what I think people don't recognize is obstructive sleep apnea is not something you suddenly get with old age or weight gain. It's a developmental problem that has its origins from infancy and how we're using our mouth muscles and how we're breathing and our jaws are growing from those earliest years of life.

04:15And one of the very first signs that we're going down this downward slope of problems is mouth breathing or open mouth breathing during as young as infancy. And so as a dietitian who initially has started out working in pediatrics and having worked with feeding specialists and occupational therapists, speech therapists, oftentimes there's a lot of kids with early feeding challenges, which now we know is a lot of it is tied to airway development.

04:46Can you talk to us about those early months and how those can affect and shape lifelong habits? Yeah, so the first year of life is the most rapid window of jaw development and form follows function. And so it's the oerofacial muscles that actually stimulate the jaw development. So how they are working actually influences how the jaw structures will grow in a very big way because of that important trajectory of growth.

05:16Now, in the earliest of years of life, we can have feeding problems like you will know that one of the most common issues is gassiness in babies. Yes, yes. And so this could often be related to poor sucking and swallowing or the intake of air. And many times, you know, we're not taught as parents how to know when a child is breastfeeding or feeding correctly. If there's no pain or there's good weight gain, you know, we seem to think that everything is OK.

05:46I certainly did when my two children were young as well. But if there is gulping or intake of air or spillage or difficulties with staying latched coming on and off and all these things introducing air intake that can lead to reflux-like symptoms and this gassiness or difficulties being settled, needing to be held upright, arching during feeds.

06:12All these issues, they can actually be related to poor function of the muscles. And then the other thing that you will mention is cluster feeding. When babies seem to need to feed frequently, that can sometimes be related to poor drainage or inefficient latch mechanics. So it can tire out a child. They're not able to feed as efficiently. So they may actually be feeding more frequently than is normal.

06:38So there's all these issues, you know, poor supply that can be related to poor drainage or efficiency, all these issues that we don't often think of. How is the mouth working? And we can sometimes do solutions like give babies anti-reflux formulas or, you know, reflux medications and different things, but they don't really address the underlying issue, which means that the muscles don't get the chance to work properly.

07:10And they don't set up the foundation for good speech and chewing down the track. And then the jaw structures don't grow as well as they could be. Yeah. And you touched upon something really important when you said weight gain, because that is the number one thing that even as a healthcare professional, I was trained to look at. If the child is gaining weight, most likely the issue is not a major one, but a lot of the times, as you know, you will talk to parents and feeding is so frustrating.

07:39It either takes too long or it's clustered, as you said, or it's so frequent. And then there's a lot of issues related to that, where it's, you know, gassiness or colic or, you know, spitting up and all of the things that we hear that are so common among babies, especially those from new families. So if you had to sort of pick the top early signs that parents should look for that this is not normal, what would you say those are?

08:08Yeah, there's a lot of compensation patterns that occur, but really with a latch, if a parent wants to breastfeed, but they're not able to, yeah, definitely just checking how the mouth is working, working with a lactation consultant, IBCLC, and looking for someone that actually understands the mechanics and what optimal function looks like.

08:34That's not going to just tick off the weight gain and tick off, you know, the no pain, because a lot of parents will describe, they're being told their baby is feeding properly, but it's very frustrating. Baby's coming on and off all the time, or it's pinching, it's not comfortable, or yeah, there is that intake of air and they're very unsettled. It's taking too long or too quick. Their baby's falling asleep very easily.

08:58And they're some of the most common problems that we encounter. Which as a new parent, right, we know we question things all the time, we're exhausted, we're frustrated. And the biggest help is support from trusted healthcare professionals. So sometimes it could be that the pediatrician may say, the baby is fine, this is not a big issue, and that they will outgrow it.

09:23But if you do suspect something is going on, and as you mentioned, a lactation consultant, and that's a great place to start. And maybe down the road, it might warrant working with a feeding specialist. But first place to start is that latch, whether it's for bottle or breastfeeding. Yes, and really understanding tongue ties are a very common contributor to these issues. And not all of us get training in that area.

09:50You know, we are dentists or considered oral physicians of the mouth. We get trained nothing on tongue tie in our training programs. And we don't even really get taught about the tongue and what the functions and what optimal movement looks like. And same thing with lactation consultants and speech pathologists. Just many of us are working in this field and dealing with those common problems, but we don't actually get the fundamental training in tongue tie. And so, and what are the compensations?

10:18What is ideal? And so sometimes it's quite common for me to see families that have gone to multiple professionals. Yeah. And they're getting told, oh, this is not a problem. Babies will grow out of it. But I think something like you will know is that parents should trust their own intuition if they don't feel that they're getting listened to or that guidance that is helping them to recognize, yes, not every healthcare professional is trained in this area.

10:48And to keep looking because they may get different conflicting opinions. That would be a normal thing. And I always like to look through parenting forums to see what are some of the commonly asked questions. And one of those that comes up a lot is tongue tie. And I know there's different procedures that some can say it's controversial, but can you tell us what tongue tie is? And then we can talk about poor jaw development and how that contributes to feeding difficulty.

11:16Yeah, tongue tie is really the attachment that joins the undersurface of the tongue to the floor of the mouth. And sometimes it can be abnormally tight or short and restrict normal movement. And so they can be very variable in presentation. Some will be more all the way to the tip of the tongue and they're quite obvious to identify. And some are considered more hidden or sometimes called posterior tongue tie, which means that they are not as obvious visually.

11:47You almost have to lift the tongue up to see it and feel it. When they impact the elevation of the mid-tongue, that'll interfere with normal sucking, swallowing and breathing. So for efficient transfer of milk, we need this tongue to be able to suction to the roof of the mouth. And when it drops, it creates a vacuum. And that's how milk is efficiently transferred or removed from the breast.

12:13And so when that is shortened, children will develop other compensations or they're unable to suck properly. And that's when they take in air. And so it's very under-recognized. But yeah, that is what tongue tie is. It's variable in presentation. There's lots of compensations that people can have. But at the end of the day, we want to try not to use other muscles such as our jaw.

12:38And we don't want to overuse the muscles or perioral muscles, the lips and the cheeks. Because when we overuse those muscles and our tongue doesn't work correctly, those compensations, they don't allow us to use our tongue properly the way that it's designed to, to develop the palate. So breastfeeding is sometimes called nature's palate expander. That suction or that continual lifting of the tongue during an optimal latch, it actually helps to broaden the palate.

13:10And it requires a complex coordination of all the muscles and the jaw going backwards and forwards. So it really properly develops the jaws forward and wide. So we really want the tongue to work well for that jaw development as well as for breathing. Because the ideal posture for the tongue to rest during sleep is going to be up. And if there is a restriction or we haven't used our tongue properly, it'll ultimately play out down the line in terms of sleep-disturbed breathing.

13:42Because when the tongue is resting low during sleep, when everything is more floppy, we're relaxed, we're lying on our backs, that tongue is more likely to create some sort of obstruction of normal airflow. And that can lead to snoring and those other problems as well. And someone who's a chronic mouth breather, how does that impact the facial growth?

14:09When we breathe through our mouth, we have lower overall muscle tone. So we have our mouth open and the tongue is more likely to sit low. And so that will lead to a more downward and vertical direction of growth. That tongue is not providing the proper stimulus to grow the jaw wide. So we're likely to have a more narrow jaw.

14:34And so when our jaw structures don't grow well, we actually want them to develop well because those jaw structures form the outer borders of our airway. It's actually the palate or the root of the mouth is the floor of the nose and it's the housing for the tongue. And when the jaw structures develop forward, it actually allows more space for the throat. When they're not developed well or more backwards, it kind of pinches the throat.

15:01So that's why we really want to promote good jaw development for healthy breathing down the track. And something you talk about, Dr. Lim, is sleep quality and behavioral issues in children. How are those two linked? Behavioral issues? Well, there's a lot of research to support that snoring or even mouth breathing is linked to increased risk of behavioral and learning difficulties in children.

15:29Because when we breathe through our mouth and have our mouth open, if you've ever tried to breathe a snore with your mouth closed and with your mouth open, you'll actually see that it's easier to snore with your mouth open. And so that snoring is actually a sign that the airflow is not as smooth. And so it's going to create more disturbances in our breathing and sleep is going to be more unrestorative.

15:59And when we don't get that deep sleep, it's really important, especially in young children where 90% of the adult size brain is attained by the age of three years. So they have a really high need for sleep, restorative sleep, for memory consolidation and development of that brain. And so when we don't get that right, that is how we're going to have those issues from that sleep fragmentation.

16:27And there's also research to link obstructive breathing, including snoring, to deficits in gray matter when we look at MRIs of children. As a dietitian who's worked with kids who've been diagnosed or suspected to have ADHD, one of the questions I always ask is, how is the sleep quality? And a lot of the times it might be that the parent has to go check on the child when they're sleeping to check for those things that you mentioned.

16:56And is the child a mouth breather? Are they constantly twisting and turning while they sleep? Are they snoring, right? Some of the telltale signs that they're not getting a restful sleep. They're asleep, they're in their bed for an X number of hours, but they're not getting that restful sleep that they need and that oxygen to the brain. For sure, because when a child is not getting good sleep or they're sleepy, it's not like an adult who may be more lethargic.

17:27A child may display more signs of overtiredness, which could be very similar to ADHD-like symptoms. And so there's quite a bit of research to suggest that sleep-disturbed breathing is linked to increased risk of ADHD symptoms. And when children have those underlying issues treated, for example, with removal of adenoids and tonsils, there is an improvement or reduction in ADHD symptoms.

17:56So therefore, before medicating children with stimulants, it is really important to check the sleep quality because children may actually need a good night's sleep more than anything. And so what you said, we want to recognize a lot of parents don't know. They think if their child is sleeping through the night and they don't need to check on their child, that that child is a good sleeper. But really, for good breathing during sleep, we want to see children with their mouth closed, breathing through their nose.

18:24They should be silent. We shouldn't hear any breathing because that could be an indication that airflow is not smooth. And, you know, we don't want to see them moving, tossing, turning and sweating or looking like it's effortful to breathe. And so we want to look out for those red flags like snoring, teeth grinding, bedwetting, you know, unexplained awakenings where a child might go into their parents' room in the middle of the night for no apparent reason.

18:52Why are they waking? Could it be a breathing disturbance? Stomach sleeping, neck hyperextended, all those type of clues that parents can pay more attention to, especially if their child is having these ADHD type symptoms. Interesting, you said stomach sleeping and bedwetting, which are often just diagnosed and treated on their own, but often not linked to something like nasal breathing and jaw development.

19:20Yeah, for sure. Stomach sleeping, I usually think of as compensation. So if the tongue is resting lightly suctioned to the roof of the mouth, that is our most stable breathing. It's impossible to mouth breathe and it keeps our throat open. However, when the tongue is sitting more low and it's more floppy or low-toned, it's more likely to have a risk of collapsing into the throat during sleep.

19:48And so being on our stomach is quite protective. It actually stops it from falling back into the throat. And so it helps us keep our airway more open. So usually if a child is stomach sleeping, especially babies who have their bum up in the air, they're children that I would assume, okay, maybe there's a tongue posture issue in that child. So interesting. And a big part of what you do is oral facial myofunctional therapy.

20:15Can you explain to us what that is and how does it retrain the muscles of the tongue, the lips and the face to support better breathing and function? Yeah, so myofunctional therapy is really about tongue exercises and exercising the muscles of the throat and the jaw and the face to help promote good oral rest posture, which is tongue lightly suctioned to the roof of the mouth, lip seal gently without strain at rest or at rest, and to promote better swallowing and continuous nasal breathing.

20:50So the research tells us that when we can develop these muscles well and we can achieve that good oral rest posture, we will actually have better breathing. It promotes nasal breathing. It can actually reduce snoring and obstructive sleep apnea. But it's particularly impactful in children because when our muscles are all working correctly and we are breathing through our nose with our tongue posturing correctly, it actually promotes good jaw development.

21:16So it's more critical to do in children and it can typically be done around age four years old. So going back to myofunctional therapy, it's not just for oral rest posture, but it's actually training children how to chew properly and how their muscles can function even during speech and swallowing as well. And so, yes, it can be done around age four to work with children to promote this awareness of what normal habits are like and to retrain more normal habits as well.

21:50So it's something you do on a daily basis and you practice every day. It's more or less like a workout for your oral and facial muscles. That's right, because anything takes time, you know, over a period. It doesn't happen overnight, especially with kids' rapid growth and development. Yeah, for sure. And for parents who are listening to us, they suspect something's off, but they haven't really been able to address how and where with their pediatrician.

22:16What are some of those questions that they should be asking related to their child's jaw, airway or tongue function? Oh, that's quite a broad question. Yeah, I think in the earliest years of life, we really want to pay attention to good oral function. And so when there are breastfeeding difficulties, things are not going as easy as you feel they could be. Or even when children are bottle fed, babies can be affected if they're taking in a lot of air.

22:45So really, the early feeding problems can be the first warning sign. And then as we discussed, we want to look out for the nasal breathing and some of those other red flags that we mentioned. And then when we move on to chewing and eating, we want to make sure that, yeah, children are able to chew their food and swallow it well and not be overly picky. Some children are more averse to harder foods like meat or they have troubles with chewing and they pocket it or they take a long time to eat it or any speech issues.

23:19Whenever there are speech issues, we want to make sure the tongue is able to function well. There's normal mobility and the jaw structures are going really well. So it's really identifying those areas. Like even ear infections are a really common problem in children. And children are often giving antibiotics. They're taken for surgery for ear tube placement. And some children actually have multiple rounds of surgery to have this.

23:47And I think that we need to start considering could it be a swallowing problem? Because when a child doesn't swallow well, they can't clear their eustachian tubes well. And so these are all red flags that a child's mouth is not working properly. So they're things that we can investigate or look at in terms of root causes. And really when it comes to the jaw structures, our first red flag is going to be when children have no spacing between the baby teeth.

24:14So that is a sign that jaw development is off track because we want to have good spaces between all the baby teeth to allow room for the adult teeth. But things like cross bites, where the jaws don't fit or they lean to one side, there's some sort of asymmetry or under bites or over bites. Things where there's issues with the bite, it doesn't look very well aligned or the top teeth are not fitting over the top of the bottom teeth.

24:40They're the first real obvious signs with jaw development. And nowadays, there's more and more providers that are able to intervene early, especially if a child is having issues with how they're functioning or their sleep and breathing. Because sometimes widening the jaw can be a targeted intervention to help improve the palate and the nasal floor and improve breathing as well.

25:11So there's so many things that there's so many different red flags. And that's why I've written the book Breathe, Sleep, Thrive. It really is about guiding parents from the moment a child is born. What are the red flags with feeding? What are the red flags with the mouth? You know, what are the orthodontic problems that they can have? And just all these other symptoms that can develop down the track because it's such a huge area to cover.

25:38You're right. And I'm actually looking at your book and thinking how your passion and knowledge led to you writing this book. Where can our listeners access your book, your work, or how can they find you? Yeah, recently I have launched a book website called Breathe, Sleep, Thrive, book.com. The book can be found on Amazon. That is the easiest place to find it.

26:04It has the broadest distribution. I have a website, drshereenlim.com.au. In terms of being a new patient, it's really difficult. But we haven't accepted new patients for a while. So my focus right now is just sharing cases, sharing awareness. I'm really active on Facebook the most, Dr. Shereen Lim. But I'm also working on Instagram as well.

26:29And I feel right now, just because of the difficulties or limitations with my own time, the book is what I'm really wanting to promote and share with other people because I believe that a lot of parents have found value and answers for it, as well as healthcare colleagues from various professions. It really can help connect the dots and from different perspectives because I have this sleep background, orthodontic, myofunctional therapy, and I attend a lot of different integrative courses.

27:02So it's really helpful for colleagues to be able to get a bigger picture and see these issues and what are the various pathways that people can take when they see the problems. Yeah. And I think it's such a blessing when great knowledge can be shared with a wider audience because, as we know, not everyone can access services. So those can often be limiting, but putting information out there for everyone to make life a little bit easier and often sometimes even intervening when somebody may need some kind of an intervention is critical.

27:38So thank you so much for the book, the information. As I mentioned, I would love to have you on at some point. We can do an Instagram Live or Facebook Live interview to delve into the book further. Yeah, fantastic. I really appreciate your interest in this area and taking on these type of things in I think that working with these infants is really where we can make the most difference. And so it's really important to spread this knowledge and awareness, and I appreciate the opportunity with you as well.

28:08I'm grateful for all of the knowledge that you put out there, and I've learned so much having interacted with you. All of the things you mentioned, I will be sure to put that in the show notes, including a link to the book so that our audience can access it. Dr. Lim, I want to thank you so much for your time, your passion, your energy, your knowledge, and I look forward to more conversations with you. Fantastic.

28:32Thank you so much. Me too. Bye. Bye. And to our listeners, thank you as always for tuning in. Until next time. Thank you for listening to the Baby Steps Nutrition Podcast with your host, Argavan N. We hope you enjoyed our deep dive into all the tips and tricks you and your family can use to make daily life a little easier. If you enjoyed this episode and you'd like to support the podcast, please leave a rating and review, share with others, and follow us on social media.

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