Exploring Airway Health and Speech Therapy Connections with Dr. Shereen Lim - Ep. 92
This podcast is one you won’t want to miss. My guest is Dr. Shereen Lim, a dentist who specializes in airway health. Dr Lim has written a book called Breath, Sleep, Thrive: Discover how airway health can unlock your child’s greater health, learning, and potential.
In this interview we cover a lot of ground, from the value of breastfeeding for jaw development, to the effect of tongue ties on posture, and so much more!
--- Useful Links ---
Breathe, Sleep, Thrive: Discover how airway health can unlock your child’s greater health, learning, and potential.
myomunchee.com
Mallampati score
Music: Simple Gifts performed by Ted Yoder, used with permission
Transcript
Denise:
Welcome to the Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I'm Denise Stratton, a pediatric speech-language pathologist of 30-plus years. I'm closer to the end of my career than the beginning and along the way I've worked long and hard to become a better therapist. Join me as we explore the many topics that fall under our umbrellas as SLPs. I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Hello, welcome to another Speech Umbrella podcast. We are in for a real treat today. My guest is Dr Shereen Lim, a dentist who specializes in promoting airway health. Shereen is a wealth of information, a deep well. As I was reading her book, I was connecting dots all over the place about my clients. I'm going to read her bio now and then we'll jump into the interview, because I have a boatload of questions. We're all going to learn so much today. Dr Shereen Lim is a Perth-based dentist with a postgraduate diploma in dental sleep medicine from the University of Western Australia. She has been involved in the team management of snoring and obstructive sleep apnea for over a decade. Dr Lim is dedicated to promoting airway health for infancy as an alternative approach to minimize the development of these problems and their consequences and, as 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 time management from infancy to adulthood, early interceptive orthodontics and myofunctional therapy. Welcome, Shereen. Thank you so much for joining me on the speech umbrella. As I was reading your book, I couldn't help but think of an early childhood dental experience of mine and how, if my dentist had known what you know, maybe I would have got a palate expander, maybe I wouldn't have had to have eight teeth removed in one visit, because my parents lived an hour from doctors and so had to all be done at once, and it was kind of traumatic because they didn't give me enough gauze and I was bleeding all over the place on the way home, anyway. And now I have these retainers I put in at night, not my favorite thing, but I thought, wow, what if I didn't have to wear retainers every night? Wouldn't that be awesome? But you know, my outcome was good. I didn't have health or speech or behavioral issues. I was in speech therapy for R. I have a bit of an over jet, not bad. I was orthodontia when I was an adult, but for many kids, you know, the outcome is not as good as mine, and they have these airway issues, and so that's what we're going to dive into today. I've got some questions that I want to ask you on. Some of them are a little bit more general, and then we're going to take a really deep dive. But let's find out, how did you get started in managing snoring and obstructive sleep apnea?
Shereen Lim:
My interest in snoring and obstructive sleep apnea was prompted by my husband's snoring and the frustration of the disturbance it was creating in my sleep, and so that's what prompted me to learn more about dental devices that could actually be worn overnight to hold the lower jaw forward and open up the airway. And so I became one of Australia's first dentists to obtain a qualification in this area and become involved in the team management of adult snoring and obstructive sleep apnea. And so what I soon realized is that snoring is not just a noise. It can actually create some serious health risk and impact people's quality of life, and we're looking at this craniofacial problem or a problem of poor jaw development. I wondered how come we don't intervene and do orthodontic interventions and modify jaw development when children are still growing. And so in dental school we're taught you can modify jaw development through early intercept of orthodontic appliances. The reality is many of us we referred to orthodontist, and the traditional age is not to do anything until age 12. Watch and wait, like you said, take out teeth down the line and then straighten them with braces. But I became familiar with the research to suggest that if we can widen palates it can actually improve breathing and sleep. So I wanted to know how come we don't do that and I decided I was gonna learn more about this as well. So I did a lot of training in early intercept of orthodontics and started to become more involved in that, and I met Dr. Christian in 2014, pioneer of obstructive sleep apnea. Told him that your work has really inspired me to learn more about early intercept of orthodontics and he said if you're doing palate expansion, you're too late, and I had no idea what that meant at the time. But it was rabbit hole of learning to find out that the jaw development is very modifiable by how the muscles are working in the earliest years of the life how we suck, swallow, breathe and chew. These all influence our jaw development. And that's how I became involved with promotion of the mechanical benefits of breastfeeding, tongue-tie release and my functional therapy to actually really help promote good jaw development and good muscle function.
Denise:
Let's talk about why breastfeeding develops the optimal jaw and muscle function, for good airway health, for speech. How does that even work? What are the mechanics of breastfeeding versus bottle?
Shereen Lim:
Yeah so, breastfeeding I mean the first year of life is one of the most rapid windows of jaw development. So what we're doing in the first year of life and how our muscles are working, it's really going to have a great influence on our airway development. And so with breastfeeding it is a more powerful muscle workout than bottle feeding. So with breastfeeding it's sometimes called nature's palate expander, because for a really efficient transfer of milk it relies upon tongue suction, so that tongue elevates and it compresses the very malleable breast tissue up against the palate and so it sculpts that palate quite broadly and then as the tongue drops it creates a vacuum and that's when milk is transferred from the breast. And to get this tongue suction going we need very coordinated jaw movement. So we're really stimulating that lower jaw back and forth. Breastfeeding in general will promote more forward and wide development of our airways, and so it's really foundational to develop those muscles well for good speech, chewing, and swallowing later on in life. In contrast, with the bottle feeding, it doesn't require as much effort. We don't rely on tongue suction. In fact the milk comes out a lot more easily and the teat, it's not as malleable. Like, so it pushes the tongue down, it lowers the tongue, so there's nothing to counteract the inward pressures of the lips and cheeks. And then we get a distortion of the palate, so it becomes more narrow, and so I also think breastfeeding it's really well designed to suck, swallow and breathe. Babies can suck, swallow and breathe at the same time, in contrast to bottle feeding where they can't regulate the flow and they often have to pause to breathe, and sometimes this is where mouth breathing can begin.
Denise:
Well, sometimes you hear a baby bottle feeding gasp as their bottle feeding and you notice that the other day and I was like, huh, I wonder what Shereen was saying about that. So, while we're talking about breathing, what are the signs and symptoms of disturbed sleep breathing in children? What should parents look for?
Shereen Lim:
Well, it's very common for me to ask about a child's sleep and parents are pretty happy if they don't have to wake during the night to attend to their child. Good sleeper. However, what we really want to see when children are sleeping is that they are very still and look very restful and peaceful. They aren't making any sounds and they're breathing with their mouth closed and through their nose. So any signs like mouth breathing, snoring, gasping, restlessness. So the frequent tossing and turning and sweating, teeth grinding, bedwetting, unusual sleep positions like neck hyper extension to open up the airway, or stomach sleeping, which can sometimes be a compensation to keep the tongue from blocking the throat. All these things, unexplained awakening, sometimes that child coming into bed in the middle of the night. Why are they waking? We mustn't overlook our breathing disturbance. They're the main symptoms to look for during the nighttime.
Denise:
Let's talk a little bit about teeth grinding, because I wasn't aware of that until recently, that teeth grinding can be a symptom of airway obstruction or something like that, or of a tongue tie. So why would a child grind their teeth?
Shereen Lim:
Teeth grinding is really one of the strongest red flags that a child may have an underlying breathing disturbance, and so it's thought to be a protective mechanism to help keep the airway open and protect against obstructive sleep apnea or complete collapses of the airway. So in children, when there is a limitation of airflow, their sympathetic nervous systems are more responsive, and so they will react with an arousal from sleep, and what happens is they recruit the muscles during the grinding and that helps open up the airway. So what that means is they're not getting the prolonged collapses of the airway that we see in obstructive sleep apnea, but it actually is very disturbed sleep. It's a state of constant stress and fight or flight response, and it doesn't allow children to enter the deep stages of sleep. So when we have teeth grinding, we must not overlook the contribution of disturbed breathing, and we know that children that have adenoids and tonsils there's been some research that 65% of them will have a reduction in teeth grinding. There's also some research to support widening a palate, palate expansion, which can improve nasal airflow. That can also reduce teeth grinding, and that's something that I see very commonly in my practice. When we do palate expansion, within six weeks there may be an elimination or reduction in teeth grinding. But then we also know that if the tongue is sitting low inside the mouth it's more flaccid and more likely to block or obstruct the airway, so that can be implicated as well. So there could be a variety of factors that contribute to poor airway and we need to rule out all of them.
Denise:
So let me see if I understand this correctly. So the development of the jaw in the facial skeleton is the bony structure that supports a good airway.
Shereen Lim:
Absolutely. So, those jaw structures, the palate is really the floor of the nose. When the palate is high and narrow, we're going to have a narrow nasal passage. So we know the research tells us that when we widen the palate, even in the range of a few millimeters, we're going to get an exponential improvement in nasal airflow. It's also the space for the tongue. So when we have a broader palate we're going to have more room for the tongue to sit high and make contact with the palate. And so when we have that good tongue-to-palate seal, it prom otes nasal breathing - it's impossible to breathe through the mouth, so it's easier to breathe through the nose and then it allows the tongue to suction to the roof of the mouth. More space for that to occur. And then when that tongue is suctioned, we know that it's a good tone, that this is a tongue that's going to be less likely to obstruct the throat during sleep. So yes, it is. The jaw is really out of the floor of the nasal passage, the housing for the tongue and the skeletal framework for our collapsible upper airway or throat.
Denise:
So we really need to think of the whole system, not just the mouth, the whole system. Now, when you see a high, narrow palate in child, how soon can you address that as widening the palate as a dentist, because sometimes I don't see it till a child is perhaps, you know, around 11 or 12 or 10 maybe.
Shereen Lim:
Sure, the traditional age for early interceptive treatment with palate expansion is around the age of seven to eight years. Usually the idea is to wait until the first permanent teeth come through. However, I see these high arch palates from infancy because I see a lot of infants in my practice and I know straight away that this is a risk factor for the development of mouth breathing, for the development of snoring, and children with narrow high arch palates are going to be at greater risk of having glue ear or recurrent ear problems because it affects the way that they swallow and they don't get good use station tube function. So it's a problem, a functional problem when we see these high arch palates and I don't think that it's necessary to wait until seven to eight years old. Children are having problems and if we can address this risk factor, I become more and more comfortable addressing it. From the age of three and a half to four, as long as a child can sit in the chair, take a bunch of photos, we can engage with them and I think they're going to be compliant. I will look at it if they're having difficulties, Because sometimes if they're not sleeping well or they're having behavioral problems and becoming really difficult for their parents to manage - it's eggshells at home.
Denise:
That can be a very effective intervention within six weeks. And we talked a little bit earlier about a myo munchie. Which I have had a couple of clients use. I'm a little bit familiar with it. Describe for our listeners what a myo munchie is and how it's used and the benefits of it.
Shereen Lim:
Yeah, a myo munchie is a silicone appliance that can be placed inside the mouth and I would recommend just googling what a picture is and the main benefits when putting it inside the mouth. Number one we want children to close their lips around it. So it takes a little bit of effort to close the lips around it. But we're training that lip seal, encouraging and promoting that lip seal, because if they can get really good at closing their lips around it we know they're gonna have a more reliable lip seal during sleep. The other thing that it does it promotes more normal swallowing. So when it's inside the mouth the tongue cannot thrust forward, it has to go up and backwards a more normal swallow. And it disengages all the cheek muscles, so the inward pressures of the lips and cheeks, and so it really promotes more normal swallowing. And then when they're really good at closing their mouth, we get them to chew on it. So it provides a lot of functional stimulus for those muscles to chew and to exercise their jaw muscles. So there are a lot of the factors that we're looking at and the other thing I think it does the feels are very important sensory need for some children as well that want a mouth, things. So we put it inside their mouth. When do I use it? They have a baby version so it can be used as early as five to six months, for which babies do I think it has a value in is those babies that may have been bottle fed and had an altered swallowing from bottle feeding or used a lot of dummies. Sometimes If the baby has an open mouth posture and I really wanna exercise those jaw muscles, I'll use it for those type of babies or babies that drool, they have their low lying tongue any of those babies and then it can be used all the way through to adulthood. So nearly everyone that does my functional therapy with us. I like to introduce it because, without really having to do a lot of exercises, when it's inside the mouth it's promoting more normal muscle balance and swallowing.
Denise:
I had a couple of young clients use it and they both really did enjoy the sensation. It's a little bit textured.
Shereen Lim:
Yeah, it's nice and squishy, lots of little tongs. You know, we know that the mouth is so important. I think about a third of our sensory input comes from our mouth. There's a lot of sensory receptors that needs stimulation, so I do think that it can be a very important piece. The children that are missing it or they had their mouth hanging open a lot.
Denise:
Now, I did say we had some general questions and we had some deep dive questions and we're about to go into that. This stuff is so fascinating. So I want you to tell us about Dr Ferrante's research on the relation between thumbs sucking, neuro transmission, that spot we call the Avila Ridge, yes, where the tongues should be.
Shereen Lim:
Yeah, really important work. Antonio Ferrante he's a dentist and my functional therapist in Italy. He's actually published four textbooks and I happened to hear him in 2015 in Los Angeles and it was actually an English speaking talk, so maybe one of the only ones he's done, but I have heard it five times. I bought the recording and listened to it so many times because I thought it was a very good presentation. But basically, what he has taught is that the 'n' spot when you say 'n' with the tip of your tongue and it shouldn't touch a teeth that spot in the palate is richest in sensory nerve endings and so when the tongue stimulates that spot, it sends signals to the brain, so it's involved in neurotransmission and then what happens is we release at least four chemicals like dopamine, serotonin, there's a couple of others, which make us feel calm, relaxed, and it's involved in our balance, and so in the presentation he did some work to suggest that with Parkinson's patients he watched their gait and they've got a lot of posture analyzers there - that it could improve when that tongue was hitting the spot. Now he's also published research on thumb sucking children and what he found was that when children could put their tongue on the spot, that could also improve their posture and balance, and so a lot of thumb sucking children. We know in my functional therapy circles that if they're ready to give up thumb sucking, it's very predictable to get them to stop thumb sucking within a day with a combination of strategies, including teaching their tongue tip where to sit, so it's a very important spot in the mouth.
Denise:
Because then they're getting that sensation or that feedback that they need, that the tongue was filling that role, but now their tongue is filling that role. Yes, yes, that neuro transmission role. and I have noticed this balance thing did just interest me so much. There's a connection between balance and where the tongue is and speech, because I will often have children practice what we call a neutral resting posture. So the tongue is up, the teeth are gently closed, the lips are gently closed and I'll have them just do like what you call a mountain posing, yoga or something like that. And so many of them, just they can't even close their mouth and they're doing that and they'll turn their feet, they'll wiggle their feet, they're trying to put one foot behind the other. They don't sometimes really have good balance If they're trying to stand in that way. We call that really balanced mountain pose with the feet parallel to each other. But when they can do that and when they can maintain a neutral resting posture, I see a huge gain in their speech. It's just amazing. It's like something in their brain is integrating and you're like wow.
Shereen Lim:
I think that spot's very critical. We even know that there's research to suggest that children who use a pacifier are going to have increased risk of delayed speech development. And there's research to suggest you need a free tongue. It's involved with perceiving sounds, so there's a sensory motor component where we need that tongue up to perceive the sound. So that's really important for speech development. So there's a lot of reasons why we want the tongue up. Even with speech articulation, that's where the tongue belongs. If the tongue is resting in the bottom of the mouth, it's going to be a low-tone tongue and we're going to have more increased risk of lisping or unclear speech. But when I get people to put their tongue on the spot, when we train them, a lot of adults and children will report lots of various things. Number one it's easier to breathe through the nose, they have less tension in their jaw. Some people will just report they didn't realize how good it feels to put your tongue on the spot, or more balanced, and some people may even feel less headaches. I've had children say that as well. So it's really important critical spot. I think it's really key that we have that tongue on the spot.
Denise:
And when my clients can do that, they are calmer. Yes, yes, their executive function improves.
Shereen Lim:
Yeah, and I you know a lot of children that have fidgeting or they're always sitting around and their mouth is moving when they're watching TV or tongue between their lips. We just teach them to put their tongue on the spot. That's often my first step before I look at doing any orthodontic treatment, because I don't want them to be flicking out expanders or plates. So I think it's important.
Denise:
That leads us into talking about tongue ties, because some children have trouble putting their tongue on the spot or keeping their tongue up because they have a tongue tie. Now, as a speech therapist, I know the problems a tongue tie causes with speech. But what do you see as a dentist? What problems do you see a tongue tie causing in the development and from infancy? App, yeah, okay, great.
Shereen Lim:
So the main problem with a tongue tie is that it restricts normal tongue elevation. So, starting from infancy, the most common problems that we're going to see are breast feeding challenges. So when the tongue can't elevate or suction, we're not going to get efficient transfer of milk, and so we may have perception of low milk supply, may have more shallow latch and pain, unfeeding, or pulling on and off. It's very frustrating. Babies that have short feeds or tire very easily. So there are common problems with the breastfeeding. But even with breastfed and bottle fed babies we may have problems with reflux, like symptoms where they're unable to swallow correctly, with their tongue going up and their gulping air, and so babies have these symptoms of reflux. They're screaming, arching, stomach distention, vomiting, very, very gassy, and they may be put on reflux medications. But if we are medicating babies for reflux, we really need to make sure that they've got a good latch, whether it's on the bottle or the breast, and making sure they're not swallowing air. So the next things we might see are swallowing problems, children having difficulties with swallowing and they're gagging or choking. There may be more picky eaters because they want to eat softer foods and avoid certain other types. And then the speech problems where it might be difficulties with their speech, speech, articulation, so those type of problems. And then the next thing is the teeth grinding. It's a common thing. That can be linked, it's a sign of disturbed breathing and with that all the accompanying increased risk of behavioral and learning difficulties. So those are the type of things that we see. And then, as we get more into the adults, the things that I'm seeing a lot of is, for instance, if you have a tongue tie, you can still breastfeed, you can still speak, you can still do a lot of things, but you may be compensating or using and recruiting other muscles which shouldn't be working. So you may overuse your lips and cheeks, you may overuse your jaw muscles and some people even strain and use their neck. So with the adults I may be seeing more of the chronic neck tension and they've got these trigger points of tight muscles inside their neck and these may actually be linked to cervical genic headaches or referred headaches. And so we have a lot of adults that come because of their chronic headaches and if I see that they're overusing their neck, it's quite often linked and we may address the tongue twister. But the biggest problem really is that the tongue doesn't develop sufficient tone to rest in the roof of the mouth and when we don't have a well-toned tongue during sleep is when it will play out eventually down the line we're going to have more risk that the tongue is going to cause a base of tongue is going to cause obstruction and it will disturb the sleep, so we won't get the fullest quality of sleep possible. So a lot of implications. We don't know when it will play out because a lot of people compensate. But it's a fact of life that we need the tongue to work well, because the genioglossus muscle, which forms the bulk of the tongue, is the main upper airway dilator muscle. It's the main muscle that needs to function well to keep the throat open during sleep.
Denise:
So there's a lot of things that can happen with a tongue tie and not just speech. Because I have been saying and I have heard well, let's see what they can do, and I would never say this with an anterior tongue tie, but a posterior tongue tie is sometimes kind of difficult to tell. So you're like well, let's see if this child can learn to articulate with what they have and try for a little bit not too long. But we should be looking at this whole range of symptoms or things that could occur and not just speech.
Shereen Lim:
Yeah, because people can speak perfectly fine with a tongue tie. I see a lot of people that have no problems with their speech, but because I take video of every single child speaking, what I can see when there is a tongue tie is that they're often making their speech sounds with their mouth, their lips and they're moving too much, or they're using their jaw to brace with their jaw, they're overusing their jaw or their neck, and so the ultimate problem is that that tongue is not developing good tone, and that tone is necessary for palate development as well as good breathing throughout life.
Dan Stratton:
We will get back to the interview in just a moment. We want to take a moment to welcome you to the 2023-24 school year and congratulate you for the great work you will do with your clients this year. We all know that there are going to be some kids that are going to stretch you to the limit, especially with R. Come on under the speech umbrella and get Denise's acclaimed course Impossible R Made Possible. Denise teaches you how to elicit a foundation building R and coaches you every step of the way. Watch over her shoulder as she works with clients of all ages. The two-hour video course gives you everything for elicitation, generalization and grab-and-go therapy. With the 60-plus-page workbook, denise is even there for you during the messy middle, when things can slip sideways. Get ready for those cases that will come rolling in during the next few weeks. Between now and September 30th 2023, save 10% on the Impossible R Made Possible course or the workbook. Buy them bundled together and save 15%. Go to thespeechumbrellacom/ R-course and use the promo code podcast23. That's thespeechumbrellacom/ R-course and promo code podcast23 to save 10% to 15% and get those tough R clients moving today. Now back to the interview.
Denise:
In your book you talked about tongue ties and postural issues. I think that is so fascinating. Tell us about that.
Shereen Lim:
Every day I hear new things that you would not think are connected, so nothing really surprises me anymore. But there is a connective tissue in our body called fascia, so it covers everything in our body, all our muscles and all our organs. It's what helps us move in one piece, and there's a deep-lined fascia that goes from the tongue all the way to the toes, and so that's the main fascial line in the body, and so when we have any restriction in one area of that deep front line, it can actually affect the motion and the way that we use other parts of our body in that same line all the way down to our toes. And so what I see with tongue tie release is that when we release that fascia, we can often see postural changes in the body. When we work closely with manual therapists like osteopaths or chiropractors, craniosacral therapists a really common for me to hear is babies that seem less tense or tight, or they can extend their neck better and cope better with tummy time, or they're just more free and easy to feed on different positions and then all the way into adults as well, so we might get less of those headache and neck aches and people report different things happening in different parts of the body down to their toes. So I've had quite a lot of people report that inward turning toes have now become normal, or even the toe walking. So there's a lot to learn and it's very fascinating. I think even people can breathe easier when there's more release of the diaphragm, if people feel like they open up. So for some adults that have a very significant tongue tie, it's actually like a literal release of them as a person. They feel unwound. So yeah, I love listening to them. Parents and patients share those stories.
Denise:
That is simply amazing. I recently referred two clients to professionals who belong to the International Association of Tongue Tie Professionals because they know that they will know what to do. I've had the experience of some ENT saying that well, it's a posterior tongue tie, you know, it's not really affecting things. But these two children and their parents have real concerns about their eating. Now they are learning how to articulate well with the tongue restricted as it is. But one child is really really underweight, doesn't like to eat anything but soft food. His mom is really concerned and the other mother is just beginning to get concerned and she asked me for referral to an OT maybe who could help him with eating. And I'm like you know what? Let's look at the Tongue Tie. Let's see if there is a Tongue Tie. For myself I can't really tell because it, if it is its posterior, he's able to articulate well, but it does look to me like his tongue is not maybe as free as it could be. So I'm like well, they need to eat. Even if they can speak, they need to be well nourished. So, that's you know. That's just really interesting to me. We have to look at the whole child. I was a whole child and while we're talking about the whole child, in your book you talked about children who have sleep disturbances and how it affected their gray matter. In there was a study that talked about the gray matter in children who have sleep disturbances.
Shereen Lim:
Yeah. So probably the most compelling of those studies is I think it was called the ABCD Longitudinal Study, where they're following up over 10,000 children over the years and what they inquired about is their history of snoring, and then they actually took MRI scans of their brain for all these children and were able to correlate that those children who snored had losses of gray matter compared on average to those children that didn't, and so we don't fully understand the impact or how it's going to affect each individual child, but we know overall there is something detrimental occurring when a child snores, so that's not even obstructive sleep apnea, it's snoring.
Denise:
And so we've got, besides speech, we've got problems, potentially problems with cognition, potentially problems with behavior. You did mention in your book that many children are diagnosed with ADHD. When actually the true underlying problem is sleep disturbances, airway problems, a tongue tie, something like that.
Shereen Lim:
Yeah, I think it's important to recognize that there's very, very compelling research a meta analysis paper which has compiled all the findings from various studies that showed us that children who have obstructive breathing are going to have a greater risk of ADHD type symptoms and that when they are treated with removal of adenoids and tonsils there is a reduction in those ADHD symptoms. So it's important when children are medicated for these problems that we don't overlook disturbed sleep and disturbed breathing. And it's not just the adenoids and tonsils, because the airway problems are multifactorial. If there's no response to that, we also need to be looking at what are the other risk factors to ensure complete resolution. So we need to address the palate and we need to address poor tongue tone or tongue ties that restrict the normal movement and tone development of tone of the tongue, as well as ensuring that children close their mouth and breathe through their nose.
Denise:
I feel like maybe there should be a course for all pediatricians on this.
Shereen Lim:
Because they're so busy, like here, the waiting list is like a year to see a pediatrician and they're the only people that can prescribe the stimulants. So for me, I think, whilst we're waiting for that appointment, let's rule out breathing disturbance, because I've done palate expansion for children as young as three and a half and parents who are really struggling with their child's behavior, just really not able to enjoy their child, and when they get a better night's sleep, their child can function a bit better and it's just much more of a relief for parents. So I think that we mustn't overlook it and use opportunities to spread this information.
Denise:
And which is exactly why we're having this podcast. Because we did not know this. Or maybe, if we knew it years ago, maybe we forgot it. Because in your book you also talk about our modern lifestyle affecting the development of our jaws, our teeth, our face. So maybe we didn't need to know these things a century ago or before the industrial age. Maybe these things weren't problems. So talk a little bit about that about our modern lifestyle and how that's affecting us.
Shereen Lim:
So a lot of people ask is the teeth genetic, narrow jaws genetic? But really it's thought to be epigenetic because it's only been in the last few hundred years that we've seen a very rising prevalence of crooked teeth. And so when we have crooked teeth it's a symptom of poor jaw development. And so when we have poor jaw development it means there's an underlying change in the way that our muscles are functioning and providing the stimulus for good jaw development. And some of the changes that have been put forward is number one a difference in our diet. We're having more processed foods that don't require as much chewing. So we're cooking our foods and offering purees to babies, even the sippy pouches of foods, and we're not chewing hard foods. So that's one problem, as well as breastfeeding. So previously breastfeeding, most babies were breastfed before industrialization, for six months exclusively and up to three years in complement with their solid foods. So that's no longer occurring. We're not having as much as been introduction of bottles and pacifiers. So that's the key change, as well as the increase in mouth breathing. So we're having more allergies with indoor living and more pollutants. So mouth breathing has become more prevalent and when we breathe through our mouth we have our mouth open, our jaw muscles become slack.
Denise:
and so our perception that we have that every teenager, or almost every teenager, is going to have to have braces just a right a passage is really just effect of our modern lifestyle.
Shereen Lim:
Yeah, that's right. If we understand, for instance, when they've brought more refined diets into new indigenous populations, that crooked teeth can become prevalent within one generation. So if we kind of understand that, then we know what we can do to stimulate the muscles better and provide a better trajectory.
Denise:
There's one more really fascinating part of your book that I thought I wish I'd known this years ago. But there is a score, a mella sorry, I say it right. Mellum and potty score Mellum and potty score yeah, for tonsil grading. And of course, as an SLP, I'm not going to diagnose this kid needs its tonsils out. Child needs their tonsils out, necessarily. But I have looked in some throats and thought it looks pretty crowded back there. But what am I looking at? What should I tell parents? If I could just tell them this is something that you could be concerned about. So describe that a little bit.
Shereen Lim:
Okay, well, it's ideal if people can Google mellum potty score, because they have a really nice classification with visual diagrams. But basically that was something developed by an anesthetist who wanted to be able to relate to their colleagues how easy will it be to intubate a patient? How crowded is their throat, the back of their mouth? And so there's grade one to four. One is when you open a mouth, stick the tongue out and you can kind of see the uvula hanging down and you can see the back of the throat. That's a more open airway. And the other end of the spectrum is grade four, when you can't see the uvula. The tongue is just filling up a lot of that space and, you can, it's just all you can see is the soft tissue there. You can't really see the back of the throat. So that's more crowded. So we know as we go higher it's going to be more risk of having disturbed breathing, and usually the more crowded it is, it is a reflection of the jaws not developing properly forward. With the tonsil grading, what we're really looking at is to see how large are the tonsils in proportion to the throat, and so we have grade zero to grade four. Zero is where they've already been surgically removed. You can't see any signs of tonsil enlargement. And grade four is kissing tonsils where they're meeting in the middle and generally speaking, those grade four tonsils, they're going to be very obstructive and affect breathing. So grade three and four are the more, if a child is having any breathing concerns or red flags of sleep, disturbed breathing like snoring, they're the ones that we want to refer to ENT specialists to check out as well.
Denise:
So a parent could look at that and look at those pictures and think, okay, so this is something I need to bring up. Yeah, absolutely, a child who mouth breathes habitually may develop the perception that they can't breathe through their nose. But that's not really true. So you talk about that in your book a bit about how just nasal disuse that's right.
Shereen Lim:
Yeah, so sometimes you know, when children can't breathe through their nose, it's not necessarily always an obstruction. Yeah, in fact, one of the largest studies of mouth breathing children actually found the most common risk factor associated with mouth breathing was allergies, not true obstruction. It was much greater prevalence of that compared to things like enlarged adenoids and tonsils and deviated symptoms. And so the thing about allergies when children have allergies, they may be more congested, and so they may be prone to having a mouth breathing habit which actually makes the nose more congested. But if we actually use our nose, then it will become clearer to breathe through our nose, and so we've got to really differentiate. Is it nasal disuse, where they're not really used to using their nose and it's more congested, or is there a true obstruction? And so the work of Dr Sirush Saki and his team he's an ENT. He published some work to suggest that one little thing that we can try is test out how well a child can sit with their mouth closed and breathe through their nose. So they use micropore tape, just a little bit of breathable tape on the lips to keep the mouth closed. Or you can also put a paddle pop in between the lips or just some water inside the mouth and see how long a child can hold it for and if they can breathe comfortably through the nose for three minutes. The suggestion is don't necessarily need to jump into ENT surgery. We might want to focus on retraining that habit of nasal breathing through my functional therapy, and so I think it's really important we do nasal sprays, clear the nose, nasal hygiene, remove any mucus and that and see if we can get a child to breathe through their nose first, that is a really good tip.
Denise:
I've often wondered, as I work on closed mouth breathing, what is a good benchmark? How long should they be able to do this? So I love having that number because I will time you, sometimes like, hmm, how long can you go? And that's good for parents to know too. Well, that is a deep dive into airway obstruction, tongue ties, all the things that I like to geek out on. So thank you, Shereen. I love your depth of knowledge about airway health and how it affects so much down the line, and this book that you wrote is a book I'm going to keep in my waiting room and recommend to every parent who needs it, because with the information in this book we can intervene in airway issues earlier, we can stop a cascade of poor outcomes in speech, behavior, cognition, health, so many things down the line, and also it's just a great way to retrain all of us professionals in this really critical aspect of airway health and what we can do at the very beginning, instead of waiting, as you said, until maybe they're eight, nine, 10, and now we're intervening and the pallets already narrow, the jaw and the facial structures are already less pliable than they were. Habits have been put into place that are harder to break.
Shereen Lim:
And we need to establish good sleep in the earliest years of life, because that's when brain development is the most rapid. Yeah, so I actually really appreciate the opportunity to speak with you and highlight this issue amongst your colleagues because in practice, you know, I am seeing a lot of those children that are having on going speech therapy without any progress, and when it comes to speech, I think that if that is the case, we really need to be looking at how the mouth is structured and how the muscles are working as root causes of speech concerns.
Denise:
So I hope it inspires others to kind of look more into that and we really need to know a speech therapist what we're looking at. What should the jaw look like, what should the palate look like, what should the muscles look like, to recognize these things, to recognize these issues, because we often don't get taught that in college. So that's why I so appreciate your book. I think we have to learn most of our profession after we gradua te.
Shereen Lim:
Absolutely. You know, it's always hard for people to find the right providers because not everyone has received this training. Most people haven't received this training in their professional qualification course. It's looking for those that have committed to finding those answers and a lot of the time it's people looking for answers for their children that they become passionate about this area.
Denise:
So where can our listeners find you? I know you have a book out. Where can they find the book? And I don't know if you have any other resources out there for them, if you've done podcasts or things like that.
Shereen Lim:
Yeah, the book is available on Amazon now. That's the widest distribution, but that's available through many online stores. And in terms of where I'm most active, I am most active on Facebook. So, Dr Shereen Lim, and if for any healthcare professionals that are really interested in Airway Health for children, I have a professionals only Facebook group called Airway Health 4, number four, Kids as well. So I share a lot of new research. I think it's really important that we have ongoing discussions about new research between different professions. We're all seeing the same children. They have different problems, but many of the time the underlying problem is poor oral function and jaw development Airway Health 4 Kids.
Denise:
Number four. Okay, I love that. I'm going to look that up on Facebook. Thank you so much. I have learned so much, and my listeners out there, especially SLPs, you're going to want to get this book and you're going to want to stand with a highlighter, like I did, and go through and put in post-it notes and then when a parent has a question, you're going to open right up to that and say look right here, Shereen Lim laid it all out for us and here's the information you need. Thank you, Shereen, I enjoyed this so much. No, thanks very much for having me Taa. I want to thank Dr Lim for reaching out to me and sharing this information with speech therapists. This is so critical for us to know. This is one of the things that fascinated me the most. When we have a correct oral resting posture, our tongue is resting up in the upper dental arch and we know that. But what I didn't realize is that area is rich with nerve endings and when our tongue is resting there, it's sending information to our brain and it helps children with balance. It helps children with self-regulation. Wow, that is just so cool to know that, having your tongue in the correct resting spot is helping with all of those other areas of a child's development. And remember, Dr Lim's book is 'Breathe, Sleep, Thrive. I read this book with a highlighter in my hand and there is so much good information for us as SLPs, and for doctors and for parents. So be sure and check out her book Breathe, Sleep, Thrive by Dr Shereen Lim. Thank you for joining me under the speech umbrella today. I hope you learned something to help you in your therapy. If you did, please share this podcast with a fellow speech therapist and leave a five-star review on Apple, itunes, spotify or wherever you get your subscriptions. While you are online, come on over to the SpeechUmbrella. com, where you will find transcripts, links and my free resource library. I also have some other valuable courses and therapy aids in my store. That's all at the SpeechUmbrella. com. Let's connect on social media. I'm DStrattonSLP on Instagram and T he Speech Umbrella on Facebook and YouTube. You can also find me on TPP. Hope to talk to you soon. Bye.
Dan Stratton:
Thanks for listening to the SpeechUmbrella. We invite you to sign up for the free resource library at thespeech umbrella. com. You'll get access to some of Denise's best tracking tools, mindfulness activities and other great resources to take your therapy to the next level. All this is for free at thespeech umbrella. com. If you've enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.
