Children sleep most children when obstructive sleep apnoea. They have difficulty breathing through their nose. Allergic rhinitis is the most commonly cited disease, followed by hypertrophy of the tonsils and adenoids. Whether overweight or not, often the tonsils and adenoids in children with sleep disorder breathing are found to be enlarged. Clinically, it is recognized that enlargement of these tissues is often associated with frequent oral breathing. Many of these children , when diagnosed with sleep apnea, will present at an ear nose and throat. They will have their tonsils and adenoids removed. But, we have to bear in mind, if you have the tonsils and adenoids removed of a child. We have to restore nasal breathing. Otherwise, persistence of mouth breathing, post tonsillectomy and adenoidectomy, plays a role in the progressive worsening of the AHI index. According to Dr. Christian Guilleminault, no evidence of mouth breathing during sleep is a minimum of 44 percent of sleep time and a maximum of 100%. From our perspective, evidence of mouth breathing is any time that the child or adult is breathing through an open mouth during sleep. According to Dr. Christian Guilleminault, if nasal breathing is not restored despite the short-term improvements after adenoidtonsillectomy, continued use of the oral breathing route may be associated with abnormal impacts on airway growth and possibly blunted neuromuscular responsiveness of airway tissues. Another factor that we need to look at, in terms of children’s sleep, is teeth agenesis. When teeth are absent or are extracted early in life , during their growth, this can lead to bone retraction and affect the facial growth. Children with missing teeth or children with extraction of teeth; it can affect the development of the jaws. The jaws are narrow. The jaws are set back. If there’s not enough room for the tongue in the mouth, the tongue then is going to encroach into the airway. In an adult, a good-sized airway is the size of your thumb. It’s about a half an inch or one point two centimeters. When the mouth is small and the tongue is falling back into the throat, the area of the airway is infringed. With a reduced diameter of airway, this will increase the negative pressure during inspiration. leading and contributing to both hypopneas and apneas. In this paper, 257 people aged between 14 to 30 years of age, who had extraction of their wisdom teeth. Patients had flow limitation between 50 to 90 percent of total sleep time. In other words, the extraction of teeth causes a compromise to their airway. With a more narrow airway, there’s a restriction to their breathing. The average AHI is seven and a half events per hour in this group of people. Teeth agenesis and obstructive sleep apnea; This paper is looking at 41 subjects and they had flow limitation for 50% of total sleep time. Their average. AHI was 7.3 and tooth agenesis is a common disorder. It’s between 10 to 20 percent of the studied population. More common is one tooth missing but in 10% of cases, there are two teeth missing. In the children recognized in this paper with sleep disorder breathing, they had at least two missing teeth. But as infants , they were crying and labelled as having colic. They had sleep disruption and they had difficulty feeding. Their Mallampati score was quite high of three or four and they had a high narrow palate associated with a narrow maxilla. High narrow palate and narrow maxilla means that there’s not enough room for the tongue in the roof of the mouth. Rapid maxillary expansion, Llghtwire appliances, functional appliances, is a fundamental requirement if we are to help prevent obstructive sleep apnea later in life. Another point in relation to tooth agenesis , is that dentists can recognize this early on in the child’s life . If a child presents with tooth agenesis, there is a strong likelihood that, as this child progresses into adulthood, they’ve got an increased risk of obstructive sleep apnoea. So, instead of waiting for this adult to be diagnosed as having obstructive sleep apnea when they are 40 years of age, dentists are in a position to be able to advise and also to do something about it in terms of development of the jaws. Prematurity is also associated with muscle hypertonia. In this paper, they investigated 400 premature infants, 292 indicated progressive development of obstructive breathing during sleep. Full-term children, of course, are also at risk, especially when they mouth breathe. Another point to take into consideration is the muscle activity limitations which are easily recognisable at birth. What I talk about here is a short anterior frenulum which leads to abnormal feeding behavior and speech development. In this paper, by Dr. Christian Guilleminault, all children in the study, with untreated short frenulum had sleep disorder breathing and all had a narrow high palate. If the tongue is tied to the floor of the mouth, the tongue is not able to raise to be in the correct resting posture in the roof of the mouth. We need the tongue as a scaffold to the jaws. The pressures exerted by the tongue, by being in the roof of the mouth, helped to direct the jaws forward. As the jaws develop forward the airway is expanded. Children with a short anterior frenulum, they also have difficulty breastfeeding. The importance of breastfeeding is not just about correct nutrition. The importance of breastfeeding is also to exercise the muscles of the face. It takes work for the baby to extrapolate milk from the breast. In doing so, it is giving the muscles of the face a workout and this helps to develop good muscle tone. Breastfeeding causes manipulation of the muscles necessary for craniofacial growth. According to Dr. Christian Guilleminault, who coined the phrase “obstructive sleep apnea”, any defect in nasal breathing will affect many fundamental functions during early development and would lead to sleep disorder breathing. He goes on to say that the case against mouth breathing is growing and given its negative consequences, we feel that restoration of the nasal breathing route as early as possible is critical. Treatment of pediatric obstructive sleep apnea and sleep disorder breathing means restoration of continuous nasal breathing both during wakefulness and sleep. The interesting point here is that Dr. Guilleminault was not just advocating nasal breathing during sleep, he’s also advocating nasal breathing during wakefulness. In fact, restoration of nasal breathing during wake and sleep may be the only valid “complete” correction of pediatric sleep disorder breathing. The impact of poor sleep in a child will affect a number of things. Most notably is academic performance and also behaviour. Mouth breathers show cognitive impairment as well as attention deficit hyperactivity disorder, memory concentration, attention, learning disability, low perception and sensorimotor integration. It has been shown that children with excessive daytime sleepiness, appear to have almost ten times the risk of learning difficulties. These kids, they’re sitting in school, their mouths are open and they’re having a poor night’s sleep. When they awake in the morning, they don’t have the ability to focus. They don’t have the ability to concentrate. When I went through primary school, which is junior school, I was a pretty good student. I was a mouth breather all the way through because of having asthma. I had asthma and the inflammation of the lung. As we know, your lungs and your nose are a unified airway. So, if you have asthma, which is inflammation of the lungs, you’re more likely to have rhinitis, which is stuffiness of the nose. So stuffiness of the nose is going to cause nasal breathing to we replaced by mouth breathing. I breathed through an open mouth for many many years. Probably from about 1975 to 1976 right until 1998. I was a good student when I was in junior school but it fell apart when I got into secondary school. Because of the constant fatigue, because of poor sleep, I was not able to focus and I was losing interest academically. I would have been labeled as a poor student. After a number of years, I started to put in a lot of drive and effort into my studies but I noticed for me the amount of effort that I had to do was doubled out of my peers. If you don’t have focus, if you don’t have good energy, if you don’t have good concentration, it takes a lot of work to learn material. I drove myself through university, but I could have done it a lot easier. We have hundreds and thousands of children, 50% of the studied population, they are persistently mouth-breathing. Very few health care professionals are advocating these children to nasal breathe. These children, they’re often labeled as stupid. These kids are not stupid Many of these children have poor sleep. When we are working with children, we have to inform parents of the risk that mouth-breathing imposes. academically on their child. No parent wants their child to do less well academically. Performing well in school, performing well in high school, performing well in university, will give that child the confidence and the ability to reach their full potential. Students with learning disabilities have a higher prevalence of pharyngeal tonsil hypertrophy and paletine tonsil hypertrophy. They have enlarged adenoids. They’ve inflamed tonsils and this is impacting their breathing during sleep. So that it’s no coincidence a child who is not breathing well during sleep, they’re not going to have a good night’s sleep. They don’t achieve a deep sleep. They’ve got a restless sleep. They’re waking up tired. If you’re waking up tired, you’re more likely to be irritable. It will affect your behaviour. It will affect your mood. It will affect your concentration and it will affect your ability to focus. So it’s not a surprise that these kids can have up to ten times the risk of learning difficulties. This study here concluded that children With adenotonsillar hypertrophy have more learning difficulties when compared to children without such hypertrophy. In another paper, the cognitive function in children with varying severity of sleep disorder breathing and control children with no history of sleep disorder breathing. They looked at a hundred and thirty seven children, seventy five of which were male aged between seven and twelve years of age. The researchers found that there was a lower general intellectual ability in all children with sleep disorder breathing regardless of severity, for example, even if the child is snoring. So children don’t need to be stopping breathing during sleep to have a lower general intellectual ability. Any child who is snoring is not breathing well. Any child who is not breathing well is not getting a deep sleep and if they are not getting a deep sleep their concentration in school will be impacted. Higher rates of impairment were also noted on measures of executive and academic functioning in children with sleep disorder breathing. ADHD Sleep disturbances, poor school performance, and hyperactivity are all mental complication seen in many children related to their nasal allergies. Now we know that rhinitis affects ten to thirty percent of the Western population. For example, in the United States it affects up to sixty million individuals. We also know that the prevalence of learning difficulties, autism, ADHD and children with behavioral issues, is one in ten of the United States population. In this paper, forty percent of children who suffer from sleep disorder breathing develop a ADD, ADHD and/or a learning disability. That’s four and ten children. As a result, the impact sleep is having on their behaviour. Another paper statistically , if a child snores by the age of 8 and if it’s untreated, there is an 80% chance that the child will have a permanent 20% reduction in their mental capacity. Additionally, if a child is diagnosed with sleep disorder breathing in the first five years of life and untreated, they are 60% more likely to require special needs education by the age of eight. Doctors treating ADD and ADHD rarely consider nasal obstruction as a cause, and are unaware that the condition is likely reversible without the need for medications and psychological therapy. From my personal experience, there are two options that we have if a child presents with enlarged adenoids and tonsils. I will give you an example. My daughter, when she was six months of age; a pediatric dentist was here in Ireland with us and she was looking into the roof of my child’s mouth. My child showed a very narrow maxilla and a very high upper palate. She was born that way. So, there’s no doubt that genetics play in influence. When the child was 2 or 3 years of age, especially if she had a head cold, I would notice that she stopped breathing during her sleep. Every time that she stopped breathing she would move position in the bed. Now, it wasn’t happening all that often, but I was noticing that there was an impairment to her breathing. I took the best advice that I could at a time and I was advised that she needed to have her adenoids and her tonsils removed. I presented her to our local ear, nose, and throat and we had the surgery done. Following surgery there was no mention of the importance of nasal breathing. There was no breathing rehabilitation. Despite the fact of the papers coming from Dr. Christian Guilleminault that the relapse rate is very high and that sleep disorder breathing would return frequently within 3 years of the operation. If I was to do it again, I would have embarked on a totally different route. I would have brought her to a functional dentist first. To help develop the maxilla, to help develop the mandible, to help make room for the airway and then to restore nasal .breathing This way there’s less trauma involved with the child. Now granted it may not always be working 100% but we now have seen patients that parents were reluctant to bring their children to ENT. So, we advised an maxillary expansion. We advised on development of the jaws, we advised development of the airway, and restoration of nasal breathing. The adenoids shrank . The tonsils shrank. It happened frequently within 12 weeks. I would say to a parent or a healthcare professional, give parents an option. Any child who is presenting with narrow jaws, with setback jaws and with adenoids have an airway problem. Something has to be done with it. Otherwise their sleep, their academics, their behaviour, and lifelong health can be affected. The two options are; number one is maxillary expansion, development of the jaws, restoration of nasal breathing. If that doesn’t work, the second option is available which is adenoidectomy tonsillectomy. Post operation we would encourage the parents to bring their child for functional orthodontics and restoration of nasal breathing. This paper here. It was very interesting because we had a group of asthmatic children who were also mouth breathing . We not only Investigated asthma, but also what was investigated was their sleep. We have to bear in mind that asthma is a condition. It’s not just about asthma. It’s not just about asthma for children and it’s not just about asthma for adults. When one has asthma, there is inflammation in the lower airways. But more recently, it has been recognized that the lower airways and the upper airways are linked. It’s a unified airway. Since 2014, researchers have recognized that if there’s inflamation in the lower airways, it can travel up to the upper airways. Which is the nose, the nasal cavity and if there’s inflammation in the nose and the nasal cavity, it can travel down to the lower airways. An individual with asthma has an increased tendency to have nasal stuffiness. With increased nasal stuffiness, the likelihood is that we breathe through an open mouth. With mouth breathing, we also have increased agitation, and we also have poor sleep. So when we have a child presenting with asthma or an adult presenting with asthma, we need to consider their breathing patterns. Mouth breathing, fast breathing and upper chest breathing is going to adversely impact sleep. These individuals are a much higher risk of sleep disorder breathing. They’re waking up tired. They’re more likely to snore, to have obstructive sleep apnea, to have hypopneas. The child then in school, they’re going in tired and cannot concentrate. If you cannot concentrate, it is normal that you could feel frustrated . If you’re feeling frustrated then you can exhibit behavioral difficulties. When we are looking at asthma, we need to consider the wider range of effects here. The increased anxiety in this group of individuals. The increased sleep problems in this group of individuals and of course the asthma problems. It is a condition that feeds in on itself. Mouth breathing, that’s feeding back into constriction of the airways. Constriction of the airways with increased inflammation contributing to nasal stuffiness. Increased nasal stuffiness which reinforces mouth breathing. Mouth breathing which then in turn increases the risk of sleep problems by one point eight times and will increase risk of sleep that in turn is feeling back into anxiety . The mouth breathing also feeding into anxiety because we’re not using our diaphragm as effectively or more likely to be fast breathing using the upper chest. Diaphragmatic breathing is really important for maintaining stability of the mind. If we’re using upper chest, we are in that fight-or-flight response and when we are in that fight-or-flight response, we breathe faster. Faster breathing, in turn, will feed back into asthma. Any healthcare professional , who is working with asthma; Please consider the impact that breathing pattern disorders is having on your patient’s asthma. Don’t just rely on medication. Of course, there is a wonderful role of medication and treatment of asthma but there is also a wonderful role of simple strategies that you can give to your patients. Breathing through the nose. Slow breathing using the diaphragm. We can help reduce asthma symptoms, especially in those asthmatics who have poor asthma control. I was one of them. For 20 years, I was visiting doctors departments. I presented at emergency departments. I was a constant mouth breather. I had constant nasal stuffiness. My sleep was affected. My concentration was affected and it wreaked havoc on my life. I heard about the importance of nasal breathing in 1998 by reading a newspaper article. I did the nose and blocking technique. I switched to nasal breathing and it made a tremendous difference to my quality of life. We have a half a million individuals in Ireland with asthma. 5.6 million the United Kingdom , 20 million in the United States. How many of these are taught the importance of functional breathing using the nose, slow breathing. How many are gave the tools to effectively help their own asthma? It’s not just about medication. We also need to look at breathing. It’s not just about asthma. We also need to improve their sleep and their anxiety. We can do that by simple strategies to change breathing patterns.