Episode 207: Breathe, Sleep, Thrive with Dr. Shereen Lim

Hi and welcome to episode 207 of the Untethered podcast. Today we have Dr. Sherene Lim joining us. Dr. Sherene Lim is a Perth based dentist with a postgraduate Diploma in Dental Sleep Medicine from the University of Western Australia. She's been involved in the team management of snoring and obstructive sleep apnea for over a decade. Dr. Lim is dedicated to promoting airway health from infancy as an alternative approach to minimize the development of these problems and is the author of the book Breathe Sleep Thrive. Discover how airway health can unlock your child's greater health, learning and potential. Her work in private practice is restricted to tongue tie management from infancy to adulthood, early interceptive orthodontics and myofunctional therapy. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I hi. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Shereen, welcome to the podcast.

Thanks so much for having me, Halle.

Well, and thank you for sending me your new book, Breathe Sleep Thrive. I love how the COVID feels too, it's so soft. But I wanted to ask, really what prompted writing this book?

Yeah, so I've been involved with adults the management of adult snoring and obstructive sleep apnea for about 12 years now and what I could really sense was that many of these patients that have developed these problems, it is a jaw underlying J problem of poor craniofacial development and when the jaws don't grow well, our airway doesn't develop well. And so we're really providing a band aid solution for nighttime symptoms when we provide these old appliances. So I started to question how come we don't develop jaws well in the first place? In dental school we're taught that you can actually do early interceptive orthodontics from the age of seven to eight and trying to refer to orthodontists that weren't quite on board with this idea. And so that's when I decided I was going to learn early orthodontics myself and be able to offer it to my own children. But I also needed a way to tell parents why we were going to do something differently. Why were we going to do it? In our practice, we might have referred their children for orthodontics, and they've been told to watch and wait and have teeth out and try to correct the problem by alleviating crowding with those teeth removed. But why is it that we're going to do something differently this time? So it's a big conversation to have during a very quick dental appointment, and I wanted to be able to put the dots together a lot better for parents.

That's so helpful, I think, like you said, putting the dots together for parents, kind of connecting those dots and painting a picture that parents are going to understand. So when you say early orthodontics, you know, what age is that for you?

Yeah, well, when I first started, it was at age 7 to 8. So that's when I was trying to tell people. Because even then, when you refer to an orthodontist, a lot of orthodontists are telling patients, just wait till your child's older. We can do it more efficiently at age 12, when 90% of the jaw growth is done. But what I now recognize is that jaw growth peaks in the first six years of life. So 60% of jaw development is done by that age. So the earlier we can get in, usually the better, because when the jaws aren't growing well, it means that we're not going to be breathing as well as we can. And some children, they're having a lot of problems with their sleep and behavioral concerns, and they're not functioning to their full potential. I don't think it's necessary to wait. So technically, expansion can be done as early as two years when children are starting to have all their baby teeth through. But my comfort level over the last few years has. Has got lower to about three to four years of age. So I'm seeing children as young as that.

I love that. I get very excited when I talk to practitioners who are, you know, and doctors who are working with these younger children, because it's like you said, you, you notice that the jaws are really, it's forming in the first six years of life, and there's a lot that can and should be changed. Maybe, you know, in terms of getting growth on track and addressing some of these symptoms that you mentioned. We see so many of the children, you know, even in my own practice and caseload where they, they're really struggling. And like you mentioned, their sleep is not great and their behaviors are not great. And that's on top of all the speech, language, feeding, other myo and you know, occupational therapy, motor issues that they're coming to us for. And parents are always surprised when we ask, you know, how does your child sleep? Well, are you okay? They stay in bed all night, but are you sure they're getting quality sleep? Is their mouth closed? Where is their tongue? Do you hear them breathing? Are they snoring? We start to ask these questions and so often parents are like, how is this relevant to my child's speech, language, feeding evaluation or OT eval? And we're like, oh, it's all so relevant and interconnected. So you had mentioned these symptoms can be problematic. Obviously not obviously, but I know in our line of work we always say don't ignore the snore and snore is a big problem. But I like to highlight even just audible noisy breathing. Is that something that you discuss with your families?

Yeah, definitely. There's a whole spectrum of breathing disturbances. And you know, a lot of healthcare focuses on obstructive sleep apnea, which is the most severe end of the problem. But the problem with that is it's characterized by 10 second pauses in breathing. And if you don't get a certain number, if you don't get one per hour of sleep if you're a child, or five per hour of sleep if you're an adult, you won't meet that threshold for diagnosis. But that doesn't even include people that have nine second obstructions or eight second obstructions. Or sometimes, particularly in children, they just work so hard, their sympathetic nervous systems are really intact and there's a stress response all night long to when airflow is being obstructed, they're, they have a fight or flight response. They might grind their teeth or toss and turn and all these things just to help keep their airway open. And so they compensate. And they may not get drops in oxygenation, but it's very disturbed sleep. And it can be linked to all these poor, fragmented, unrestorative sleep and behavioral concerns and concerns with their concentration and attention. And really the problem with healthcare is focusing on these extremes, but really the problems actually originate when mouth breathing begins. The very first sign of problems is mouth breathing. And when we breathe through our mouth, we're going to have more instability of our airway during sleep.

Yes. I love the highlight of mouth breathing because I think that at least in the United States, it's so normalized. You watch TV or you look at ads of people, you know, modeling clothing or whatever, and the mouth is always at least lightly parted with these big lips. And sometimes it's even more, you know, open. But I think it's just the brain doesn't even recognize that the lips apart is not a normal posture. And so it, you know, we have these conversations with parents or adult patients sometimes, and, you know, it's like they have to kind of sit switch. They have to turn on this switch to go, oh, that, that snoring that seems so cute. And, you know, TV shows and movies and that, you know, those lips apart that seem so sexy in an ad, none of that is okay. But it's become so commercialized and normalized that our brains don't even recognize it. And then obviously, beyond that, there's a lot of health signs, symptoms, issues that follow mouth breathing in terms of that early expansion that you were referencing before and now, you know, the sleep disorder breathing, mouth breathing. For those who may not be familiar, what is the relationship between, let's say a baby is mouth breathing or a toddler's mouth breathing? And we're noticing that their jaws are not developing as they should be. Like, what is for a parent who may not know, what is that connection?

Yeah, well, one of the key influences on palate development early in childhood is having good tongue to palate suction. So that tongue needs to be in contact with the palate, and it actually sculpts the palate during that stage. Those early years is when that palate is most moldable, and it's even molded in utero. So we need to have good suction, including during breastfeeding. So that tongue is sometimes called nature's breastfeeding is sometimes called nature's palate expander. So for good effective transfer of milk, we need that tongue suctioning to the roof of the mouth. And as it drops, it creates a vacuum. And so that's how milk is extracted most efficiently. And so that's constant action of the tongue suctioning against the roof of the mouth. It's actually promoting good palate development, but it actually promotes good tongue tone as well, because that tongue should suction to the palate to during rest. And so when we breathe optimally through our nose with our lips closed and our tongue suctioned up, that is actually going to provide the proper stimulus for palate development. And if we open our mouth when we're breathing and our tongue sits low, there's nothing to counteract the Inward pressures of the lips and cheeks. And so then we get the distortion of the palate. And so when we see a baby that has their mouth open, it's ideal if we can try to close their mouth, especially during sleep, so that they can develop that nasal breathing. If they leave their mouth open, they will become mouth breathers.

Yeah, it's one of those topics that we touch on quite a bit. And I am very passionate about educating new parents and other providers about the importance of when a baby is born, they should have a closed mouth posture. Now, granted, does a baby maybe have some clearing to do after they've just left the womb? Yes, that's, you know, in all fairness. Absolutely. But we are seeing these babies, you know, who are born with open mouth postures. Their lips are a little bit more tented, it's a little bit higher in the middle of the upper lip. Sometimes, like you're saying that tongue is low on the floor of the mouth and they've already, they're already presenting with these high narrow palates. And it really makes for challenging breast feeding and, or bottle feeding. And we noticed that it's. These babies really struggle sometimes to create that, that sucks, follow breathe, that, you know, that pattern plus that proper lingual suction on, you know, the mother's nipple or the bottle nipple to draw the milk and then a whole host of other things, you know, sometimes follow suit. So it's definitely one of those things that I think is becoming discussed a bit more, but it's still not very well understood along amongst a lot of new moms and even providers out there. So I, I appreciate this discussion because I think this is, it starts there. And if the earlier we can intervene, you know, the better off this child is going to be down the road. We can start to shake the jaw and work on tongue position and that nasal breathing and everything, you know, from infancy and, or toddlerhood. So I love that you really, you know, you highlight the early intervention piece. But also, we can't do a lot of, I think, molding or not molding, but early orthodontia until maybe closer to two or maybe even three, depending. But there's still other things that we can definitely address at birth and before two years of age. Thank you for highlighting that.

If we recognize that tongue has a key role in developing the palate, there comes a point where we actually need to do expansion to allow the space for that tongue to do all its job as well. And so I, I do think that we must not overlook the importance of palate Expansion to restore normal oral function as well. So it's a really continuous cycle of dysfunction and poor development. So the earlier we can break it by correcting both the structure and the function, the more early we get things developing and on track.

Absolutely. And so with the role of palate expansion beyond what you described, in terms of how it helps breathing and or sleep, what I'm hearing, and from what my understanding too, is that tongue up helps support, assuming that we have space for the tongue and the palate, whether palatal expansion is underway or has happened, that really guides the tongue up to the palate. The nose then becomes our primary source of air intake. And, you know, we're expelling air through the nose as well. And that is going to then in turn improve our sleep, improve health, improve, you know, what else are you seeing? Or is that the discussion that you're ultimately having with families?

I see a lot of children come in for speech problems. Sometimes they've had speech therapy for many years or. And then I come and it's usually going to be a problem with both jaw development and tongue function as well. And so what I've noticed, I usually will always address the palate first because I feel it's the most quickest and reliable way to make a difference. Because when the mouth is not growing well and the muscles aren't working well, there will be some suboptimal sleep. And so with the palate expansion, I feel that's the quickest thing. A lot of parents will notice straight away that their child is less restless, less teeth grinding, and, you know, able to cope better during the day. So those are the things that change. But even with the speech, what I've started to do is document videos of children speaking before, at initial consult and after expansion without doing any therapy or addressing the tongue. And what I'm noticing is that a lot of children, they move their mouth less, they make their sounds more with their tongue, and you don't see their mouth working as much. So I'm really fascinated by and interested in the connection between palette expansion and speech.

I was, I would love to see some research or some conversations around this because we, you know, as a speech pathologist, that's one of the things that really threw me into the myofunctional therapy space and into the airway and taught space. I was like, these kids with these severe speech sound disorders, they, they've been in years of therapy. Some of them were coming to me for my evals after I got trained, and I'm like, I'm the seventh speech. Speech with all. Can't even talk speech pathologist that this child is being. And they're only 13. They've been in 11 years of speech. This is absurd. You know, and I primarily, before getting into Maya, was really only working with infants, toddlers, you know, and preschool age. And even then we were hitting walls. And I'm going, this shouldn't be this hard. I'm teaching the child where to put their tongue. I'm teaching them how to say the sound. They understand it. They can do it maybe in isolation and just making the sound or attaching another sound to it or maybe even a single word. But when we start to build on phrases and sentences and have conversation, it's. It's not carrying over. And, you know, and this really opened my eyes to that whole conversation of they're compensating and they don't have the space to make contact, whether it's with the lingual borders of the tongue, you know, the tongue's borders with the palate for certain sounds, or it's being able to retract the tongue. They don't have enough space to do that. Sometimes there's tether oral tissues at play. That may also be impacting it as well. And it's. Yeah. I mean, I love this conversation. I would love to learn. You know, I'd love to see some research around it.

I agree. Because when I started telling people this is what the parents said. Speech pathologists are like, that's not such a thing. You know, so that's why I start taking videos of children, just so that it's really, really clear. Yes. This is occurring the whole way they produce the speech sound is different. The way they use their muscles when we have more room for the tongue to fit.

Yeah, yeah. And that's the whole thing, too, is I don't remember in grad school being taught to assess for compensations and. Or to figure out what's preventing the child from making the sound. It was more about, okay, they can't make it. Here's how we teach them to make it. And I remember coming out of grad school and being like, what do I do?

I don't know what to do.

And I would just. Just go through my articulation test and mark all the errors and start working on those sounds in therapy. And then I'd hit my head against the wall because we were hitting a wall and their progress.

And.

Yeah, it's. We really, you know, and we were looking at it from an oral motor and structural standpoint. But very differently than we look at it from a myofunctional and orofacial myofunctional standpoint where, you know, that, that same topic that you mentioned, is there enough room for the tongue to fit in the palate as is right now? And if not, okay, now we, you know, we need to make a referral and I'm one who likes to do a myo eval from the get go because I like to know the baseline is, and I think that can be very helpful for patients. But then we'll often refer to an expansion provider to, you know, address the palate. And once we have enough space, space for the tongue, then we will start to work on whatever goals remain at that point, whatever deficits we need to address. Because in my opinion, addressing something before the tongue has enough space, we're teaching compensations and we're going to have to just undo those later. So, you know, we do what we can do. We make do with the space that we have sometimes. But I really like to have at least, you know, maybe it's not the perfect amount of space, but it's enough space to get started. And I think it's interesting that you said that you are seeing change, changes before and after expansion with absolutely no other interventions like to. That's just, that's fascinating to me. I love hearing that.

Absolutely. Hallie. Because when people come to me with a speech concern, it's usually because someone has identified a tongue tie. But, you know, that's not the first thing I'm going to jump into. I want to correct that space first. And a lot of people say, oh, there's no research that tongue tie and speech problems are connected, but it's just the fact that the tongue actually needs to elevate the roof of the mouth when you have speech sounds. And the problem with these compensations when children are using all their other muscles to do their speech is that tongue is not developing its proper tone. And that tongue needs to develop its proper tone during childhood in particular, because it's responsible for helping to guide palate development. And it also contains the genioglossus, or the bulk of the tongue is that muscle that helps to keep the airway open. So we need the tongue working and, you know, it's not good enough to promote these compensations and think that's good enough. Thank you.

Thank you for saying that. It's definitely a battle in the speech pathology world because I once put out a post saying something, something along the lines of, you know, we should not be Teaching compensations and speech therapy. We should be basically figuring out why they're compensating. What is the root cause? Let's address that and then let's circle back and see if they still need speech to be addressed. Some parents come to us and they're like, speech, speech, speech. So I'm coming to you for speech. And we're sitting here going, we will get to the speech, but first we have these other things we need to address. We have airway, we have tongue space. Maybe there's a tetheral tissue. But I also like how you really highlight tongue space. Is there enough room for the tongue? Because I am always hesitant to refer to a release provider until we know whether or not the tongue has enough space. Is it that the tongue is mimicking restricted function because it just doesn't have anywhere to go, or is it actually restricted by the tethered? Is there tether tissue below it that's actually restricting it? And I think we can't really answer that until we've expanded the palate sometimes to figure out, you know, if, if enough, there's enough space in the palate. Does the tongue have the ability and the function to go where it needs to go, or is it still appearing restricted? Obviously, I'm not the release provider. I don't get to make those calls. But I think it really kind of begs the question of like, what comes first? Like, what's the chicken and egg here? You know, do we go for the evaluation, get referred to, you know, whether that's with us first or you first, and then that follows with, you know, if they come to us, we send them to the expansion provider, the orthodontist, who then starts with expansion. Then we see if there's enough tongue space. If we still think we might need a tongue tie release, we do some therapy preoperatively, we do the release, we do our post op and then see what functional deficits need to be addressed. Beyond that. I mean, that, in my opinion, is the route that I'm seeing us take more and more. And that is the ideal route. I don't know what your thoughts are on that. And obviously every case is different, but do you have a thought process on like that timeline, the order of events?

Yeah, it's actually a very common question. I see it on various Facebook groups where parents are wanting to know, do we do tongue tie or do we do ENT surgery or pellet expansion? And generally speaking, in a lot of children, I want to start with palate expansion. I have to think what is my ultimate goal. My ultimate goal is tongue to pellet suction for good breathing. And I need to make that space for it to work because we're going to get to do better therapy and achieve better tongue to palate suction. If we do that and it develops the nasal passages, improves nasal airflow and when children can breathe better through their nose, we can actually do better therapy and help them retrain their lip seal and those things as well. So you know, because I do palate expansion and it's pretty quick, I will have finish that between, you know, four to nine weeks for most children. So to me it's a no brainer to get in and do that palate expansion first. And even when children have enlarged adenoids and tonsils, sometimes if there's a wait list to see a ENT surgeon or a wait list to get the surgery booked in and the child's not functioning well, I will just say let's start the palate expansion while we're waiting because often we know that children will need both. And there is now new research by Dr. Audrey Yun and team which has actually shot shown that within six weeks of palate expansion you can actually get reductions in the size of those adenoids and tonsils. So the more we can promote nasal breathing through palate expansion, we can actually reduce some of these symptoms as well and really get to the root of the problems with it. So I do think palate expansion is a lot of the time very central to what we do. And when children have these ongoing speech issues or sleep concerns, let's not overlook that intervention.

Yes, absolutely. And that research that Audrey Yoon and team have put out there is I think really promising. I remember posting in a Facebook group, gosh, three and a half years ago when my daughter was four and had her first round of expansion. And all of a sudden within a couple of months I was like, her tonsils have gone from like almost touching, very veiny and healthy looking. She's constantly sick. It's, we're in the middle of cold and flu season in November and you know, the east coast of the United States and her tonsils are within normal limits and she's not mouth breathing anymore. And I was going, huh, has anybody seen this? And you know, the group administrator actually make me, made me take down the post because there's no research to support this. How dare you ask this question. I'm like, this is a group of providers. I'm such, I'm just sharing what I saw in my own child's case and asking if anybody else is seeing this, because I'm curious. And then, you know, so I'm so glad that we now have at least some initial research to support the fact that, you know, breathing through our nose, expanding that airway, getting that tongue up. Yes. We can in fact, reduce inflammation and tissue and surrounding areas. And I have her before and after CBCT scans that show how beautifully clear her sinuses, her adenoids are within normal limits. Tonsils went down, her nasal cavity was just clear. Perceptor, you can actually see her septum, and her before was completely congested. You could just tell all the information and how full her sinuses were. So, you know, I. I get very excited about, about this type of research because I think it's very promising. And we do run into families, too, who just say, I don't want my child to have the ENT surgery. Is there another reason? And so we go. You know, obviously I don't promise anything, but I say, hey, let's look into expansion. Go, let's go have a consult, because that may be an option, and that might help. So, again, love that you brought that up. And so if a parent has a child that is snoring, right. And they're listening to us talk and they're like, okay, okay, so who do I see first? Would you recommend that the expansion provider, the orthodontist or dentist who's doing expansion.

Yeah, it's really difficult because not every dentist or orthodontist is thinking the same. So I do think in general, probably like an airway focused dentist or a myofunctional therapist are good places to start because they will probably be able to have a network and, and decide what is the treatment, what is the order, and have some good contact. So even people like yourselves, I feel, will be able to know, you know, how to guide patients as well. I think any professional that understands myofunctional therapy and the importance of good nasal breathing and the importance of good tongue function, that's usually going to be a good place to start.

Absolutely. And so another topic that I see come up sometimes is we were just talking about the tonsils and the adenoids, and let's say that some actually undergo ENT surgery. I was recently talking to a local ENT local to my private practice in Maryland, and he said, you know, we do see sometimes that there's still mouth breathing, or we do see regrowth of tissues at times as well, probably following continued mouth breathing and upper respiratory illnesses and all those fun things. Do you see a. Like, do You. I mean, I don't know if you can quantify it or not, but do you see children still struggling with mouth breathing and. Or regrowth of those adenoids or tonsil, you know, tissues following removal?

Yeah, absolutely. That. That is a large part of the work that I do when parents present with, okay, we've had the adenoids and tonsils out. Yes, there were some improvements in sleep, but my child's still mouth breathing, or they still got teeth grinding or very disturbed sleep, or maybe it got better for a little while and now it's come back all those symptoms. And so what I think is really important is that parents recognize when a child snores or has disturbed breathing. It's a multifactorial problem. It's not just the adenoids and tonsils. There are other risk factors, and we need to kind of address all of them comprehensively to ensure the ultimate goal is that we have a child breathing through their nose where their tongue suctioned to the roof of the mouth. And so what are the most common risk factors? Well, one of the big retrospective studies looking at children that had disturbed breathing after adenoids and tonsils has identified mouth breathing. And when it came to mouth breathing, they also suggested that that narrow high palate, that was one of the risk factors for it. And also tongue tie. So they identified if you have a short lingual frenulum or a tongue tie that actually contributed to mouth breathing. So it's not just the regular ENT things that we think of, like deviated septums. It's really addressing that core structure that comes with a high palate or that tongue. And the other thing that they found that one of the other most common findings in children with persistent sleep disturbed breathing is they called it tongue motor immaturity, or children that have the inability to coordinate their tongue to the end spot, saying N. So there are a lot of children that can't do that. They're thrusting their tongue forward. So we know and can predict that they're the children that are going to have problems after their ENT surgery. So we really need to address both those palate issues and making sure the tongue works well following the surgery. I really would like parents to recognize that treatment doesn't begin and end with the adenoids and tonsil removal. We need to make sure that we are going through all the steps and addressing all the risk factors because during childhood is when we need that good quality sleep and we need to deal with it comprehensively. And in fact, there is some line of thinking or published Hypothesis that the enlarged adenoids and tonsils can be a symptom of nasal disuse or poor nasal breathing. The work is published by Dr. Howard Stupak. He's done experiments looking at airflow, and what he suggested is that the origin of those problems is narrow palate. When we have subclinical under development of the palate and it's linked to narrow nasal passages, we actually have more difficulty breathing through our nose, and we're prone not to using our nose. But when we breathe through our mouth, it causes more turbulent airflow and we breathe harder. We have more efforts to breathe, and this can lead to increased work of breathing. And these increased negative intrathoracic pressures, which allow, you know, when we have those vacuum pressures in the throat, number one, we actually will have pulling and swelling of the tissues, and that can contribute to the enlargement of the adenoids and tonsils. And the other thing that I know can contribute is reflux. So, for instance, that can also be related to those airway and breathing problems. So when we breathe harder and we generate those negative intrathoracic pressures or vacuums, it allows stomach contents to. To come back up, and they may not necessarily cause heartburn, but they may aerosolize into their throat and even hang around our teeth. And this can irritate and enlarge the adenoids and tonsils. So there are a number of reasons why the tonsils and adenoids could be a symptom of poor breathing, and we need to recognize that and try to get to the bottom of it, even when surgeries are required.

Yeah, and I think it's the. What you mentioned about the tongue sitting forward or coming forward and not staying on the spot, the end spot, as you called it. You know, it's another interesting conversation in the speech pathology world because people will say, well, you know, at one point, at what point do we treat a tongue thrust? Whether that thrust is forward or there's like a lateral, you know, lisp quality to the speech, or sometimes speech sound is impacted, sometimes it's not. My own daughter, my older one, her tongue would thrust forward when she made her S sound, her sound, but her it sounded clear as day. It didn't sound like a tongue thrust or like a lisp, but I could see it coming forward. And so we still addressed it. Whereas most people in the speech world will say, oh, if you can't hear anything wrong with it, just let it go, let it be. And. Or if you can hear something wrong, they go, well, what age do we treat it and for some reason, five or six years of age is like the standard answer. And I'm, I'm over here going, well, babies bring their tongues forward to breastfeed and bottle feed. You know that that is a function of the tongue to the lower lip as a support for feeding. But beyond that, when they start to feed on solids, when a spoon goes in their mouth, when a cup comes to their lip, that tongue should be retracting. We should be creating space to pull the bolus in and off of the spoon or the utensil or, you know, to allow the water to come in. We cup our tongue and we can seal it to the top of our mouth and swallow it back. There's that parasolic motion that if the tongue can't seal the top of the mouth, that that motion doesn't happen. The bolus goes everywhere. We have indigestive issues, trouble swallowing all the whole nine yards. But I share all this because I think it's very fascinating that what you're noticing is that tongue, that tongue forward posture, and it is coming forward. These children surrounding even the adenoid and tonsillolectomies, those who may have more success with, with addressing mouth breathing versus those after the procedure, you're noticing those whose tongues are more forward posture are struggling. I think post procedure, did I understand that correctly, that they may be the ones who continue to mouth breathe or who may have recurrent issues?

Yeah. So the inability of that tongue to elevate to the end spot is really demonstrating that the child has no coordination or tone. And that's fine to have that during the daytime because you can just compensate. You can use other muscles. You can work harder using your jaw muscles, using your mouth muscles, using your neck muscles sometimes to move things around. But during sleep, all the muscles are relaxed. So that tongue tone is really important. And if that tongue is not properly toned during sleep, it's going to cause obstruction, base of tongue obstruction into the throat. And so I think it's important to recognize that, you know, children can compensate. Even I've seen children that have tongue tied that can still breastfeed, but it's physically impossible for them to have optimal tongue suction. And it does introduce compensations where they overuse their lips and cheeks. So very, very common that that pattern doesn't allow proper development of the tongue tone. And so from here on, we're going to get altered sucking out of swallowing and just all these compounding problems that occur. And you know, when we have altered swallowing, we have poor Eustachian tube function and these children getting multiple sets of grommets and then those increased pressures of the lips and cheeks, they are actually altering the way that the jaw function, jaw grows. So we get that, you know, closure of the jaw, like no, no spaces between the baby teeth. So we see all these things happen and we just have to be able to better recognize that these things are, they're all interconnected and they have their roots in poor tongue function or that restricted tongue mobility. So it's ultimate problem of compensations is that we're going to get breathing problems. And even when I see adults that have been compensating, well, you know, then what we tend to see is they, they've got this chronic neck tension because they're overusing their neck muscles. And then many of them will then get these referred pains, cervicogenic headaches, which is really referred to from their neck. And so many of them struggle with these type of problems as well. And they see multiple providers getting all sorts of treatment to resolve these headaches. And the quality of life is very poor. But when we look at it and we can see this restricted tongue function, that, that is another common end problem in addition to the sleep and breathing problems. We just need to pay more attention to ensuring proper or function.

Absolutely, absolutely. And I, you know, I think it's something that it's present early on and if we know what to look for, we know how to assess for it, we know who to refer to if that person's not us or we need a different, you know, provider outside of our scope of practice. It could be a one year old, it could be a five year old. I don't think we should be defaulting and waiting because to me that, that actually gives me a lot more information. It's like a window into their oral function, to their breathing, to their sleep, to their growth and development, you know, beyond just speech and language, which I'm not downplaying, but that's, you know, I think everyone goes, oh, it's fine to wait till they're fine to address a tongue thruster, a lisp. And I'm going, no, no, no, we don't need to have, we're not going to necessarily treat the list right now, but we're going to figure out why it's happening. And when we address that we may not have to treat the lisp. And when I say that, I almost get crucified on social media because they're like, how dare you suggest that something that you might not have to treat a lisp and I'm like, like, how dare you suggest we not look at the root cause. But anyway, so I'm kind of dialing it back to infancy then with, you know, pacifiers and sippy cups and all these different things. Do you have a stance on those? On the use of them or the impact?

Yeah, we pacifiers, they obviously alter the tongue posture. When we want tongue to pellet suction, we're actually now pushing the tongue down and we're reversing the swallow. So we are actually allowing children to have that reverse swallow. And obviously the impacts is going to be related to the intensity, duration and frequency of use. And so a lot of parents might think, oh, I'm just using it for nighttime only. But the problem is infants are sleeping most of the time. So we really need to promote more education that it should really be used very sparingly. Soothe and remove if we have to use it. Yes, it can help parents and help baby maybe get to sleep. But like, as much as possible, we should be removing those pacifiers because it will alter the way that the jaws grow and it will alter the way that the muscles function. And I wish that I had known this when I was a new mother as well, because, you know, we all know, oh, dummies do or pacifiers, they do create orthodontic problems. But we have to also recognize, yes, it alters the whole way that our mouth grows and the whole way our mouth grows will determine how we speak and chew and swallow. And very importantly, the way that our mouths grow and the way that our tongue functions during sleep.

Yeah, and that's why the whole concept of an orthodontic pacifier drives me crazy because sometimes we will use in therapy, we'll use more of the cylindrical shaped one where we can put our finger in to help baby kind of cup the tongue and develop a suck for suck training like the Advent Soothing Pacifier. But the, you know, a lot of these orthodontic ones that are like flat, like the mam pacifier, that's marked orthodontic. And you know, I'm over here going, I'm not an orthodontist, but there's nothing orthodontic about this. So it kind of drives us crazy to see that marketed because I think parents don't know any better.

Absolutely. There's been a class action, successful class action against one of those orthodontic dummy brands. So. And even there is another pacifier. I don't know if you know the one, but it's actually been marketed as Something that requires the tongue to suction and work whilst you're using it. So a lot of people, I see colleagues, they really like it. But then I watch the baby fall asleep with it and it stays in the mouth and it's still lowering the tongue posture. So I think, yeah, there really is no perfect dummy at all. So when possible, if we can try to soothe and remove and really address any underlying issues that may be causing a baby distress. And you know, a lot of babies it is the reflux like symptoms as well. So we also want to make sure that children are not sucking and swallowing air because that is commonly misdiagnosed as reflux. It's such a common issue when children are sucking and swallowing air and getting quite a lot of discomfort and reflux like symptoms, whether it be spit ups or gassiness. So I see a lot of that in practice and a lot of the time that I see it in my patient group, it's because of tongue tie. So we want to address that because once a baby is more settled, they may not necessarily need to rely on it anymore.

Yeah, we see that a lot too. The aerophagia, swallowing of air and the distress, the discomfort, digestive related issues with all that air in the belly and, and it impacts how they feed too. Not to mention we often see tetheral tissues leading to the aerophagia. And it's, it's tricky because I think a lot of these babies also are diagnosed as having reflux. Some are put on reflux medications which aren't helping, which sometimes further seem to exacerbate the issue and, or just don't help. And it's, it's very stressful for new parents. I feel like it's a lot of, of information to digest and like you had said, like, I wish I had known some of this with my own children, especially my first because she was like my best teaching experience and tool. She taught me all the things sent me down this rabbit hole and for that I'll be forever grateful. Even though it was, it was a struggle. But you know, I always tell parents, you do the best with what you've got. You know, I feel like as a parent and an educator, it's my role and responsibility to share the information and then ultimately the parent gets to decide what they do with it. We always try to encourage parents to, you know, eliminate the pacifier if they're using them at all by 6 months of age at the latest before it really becomes more habitual and baby's like really, really on the move. Dragging something around. You know, we always tell them not to use those little pacifiers with the stuffed animals attached to it because you know, we don't need that hanging out the mouth one, especially once baby's mobile for it all but say cut it off and let them keep the lovey and get rid of the rest. So thank you. Because I think that it's helpful for parents, I think to hear that they're really, you know, there is no that I found pacifier or bottle that really resembles a breast or breastfeeding. And you know, they can be tools and very helpful tools if that's something that a parent needs and or chooses for their child. But you know, I think think there's this constant marketing of trying to accomplish breastfeeding through external tools that you know, are just not, they're not quite the same.

Yeah, for sure. And really, when it comes to pacifier replacements, what do I feel is the optimal. Around the age of 5 to 6 months, get a munchie, BB munchie. Get children chewing. Total opposite of a dummy. We want them closing their mouth and chewing and utilizing their jaw muscles and that sensory input that comes from those type of things. I think yeah, the dummies don't really have a place during the day beyond that six month point.

Absolutely, absolutely. Well, this has been amazing. Is there anything that we have, I feel like we've talked about so many topics. Is there anything we haven't covered that you want to make sure we chat about?

No, I think really what I want parents to recognize is that the, we need to promote airway health. And really that means ensuring that children breathe through their nose from the very beginning. Because when we have good nasal breathing, we're going to have good sleep. And when it comes to the nose, we must not overlook the important structural contribution of the palate. When we have a narrow palate, we're going to have poorer nasal breathing. So I think when we're looking at children that have mouth breathing, in addition to addressing any ENT obstructions, whether it be enlarged adenoids and tonsils, we need to really recognize that we need to develop the jaws well. And when we develop the jaws well, we can get the muscles working well better inside our mouth. Working with the myofunctional therapist as well to promote those normal patterns of nasal breathing and good tongue function.

Yeah, absolutely. Well, thank you, Shereen. This has been amazing. If they want to, you know, if they want to find your book, Breathe, Sleep, Thrive, discover how airway health can unlock your child's greater health Learning and potential by Dr. Shereen Lim. Where can they access the book?

Yeah, Amazon has the widest distribution, but otherwise just Google it because it's available in many online sellers and if you're in Australia, you can reach out to us and we can actually help send you a copy as well.

Perfect. And we will definitely link that for them in your link tree as well in the show notes and everything. So they. They have direct access to the book and yeah. Thank you so much. Thank you so much.

You've been so active in promoting information to professionals as well as through your podcast. So I really appreciate. This is one that I've been looking forward to. So thank you.

Well, thank you and I'm so glad this book is out there. I think the more that we can get this information in the hands of both parents and professionals so that they start to understand everything that you've shared with us, you know, on this episode and the the interconnectedness of everything and the importance of airway health, especially in children and driving, you know, proper orofacial growth. I think that's really the key to really unlocking right. Our children's futures, really. So, so thank you for all of your hard work with the book and for sharing your knowledge with us.

Thank you. Helly.

Thanks for listening to this podcast. If you want to hear more of these Myo Taught Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page at Hallebulkin Biz on Instagram at Hallebulkin. And you can head over to theuntetheredpodcast.com to grab a copy of the show Notes where you can also subscribe to be kept up to date on the latest podcast episodes.