Had I been armed, as I am now, with more knowledge
about functional dentistry , I would have known that the better solution
would have been to embark on the development of her airways. Genetically ,
my daughter has a similar facial profile to me, with the same narrow upper
airways. Postsur gery, I brought her to the functional dentist, Dr. Tony O’Connor ,
where she had her airways developed using an easy and noninvasive
appliance known as the advanced lightwire functional appliance (ALF). Since then, I recommend to any parent presenting a child with enlar ged
adenoids to look at maxillary expansion  (wideni ng of the upper jaw) and
forward develop ment of the face first. Try that, along with continued nasal
breathing and practicing the Steps  exercise for children (in Chapter T wo). In
most cases, this approach will result in maxillary expansion, develop the
airway , restore nasal breathing,  and reduce inflammation of the adenoids
and tonsils within three months . All of these methods are noninvasive, so
there is little or no trauma involved. The airways are developed, and good
breathing patterns are restored for the long term. If your child’ s breathing proble m persists for more than three months,
then consider an adenotonsillect omy. However , children must still be taught
to breathe nasally after surgery, or SDB is likely to recur within three
years.12
One 2019 review examined the effects of nose-breathing exercises in
mouth-breathing children. The report concluded that nasal breathing isbetter for the respiratory system.21 The authors also cited results  from a
2008 paper, which demonstrated that a protocol of respiratory muscle
training and nasal breathing improved respiratory muscle streng th and nasal
inspiratory flow in children who had mouth breathed.22 This study
discusses the importance of nasal respiratory training for reestablishing lung
volume and nostril elasticity in children. For over a century , researchers have investigated the effect of rapid
maxillary expansion on the functioning of the nose.23–26 Maxillary
expansion involves wearing a dental appliance positioned in the roof of the
mouth. The device exerts gentle pressure over time to widen the jaws and
airways. Numerous studies have shown how this procedure causes positive
development in the top jaw and nasal cavity and that the result ing changes
improve breathing throughout a child’ s life. THE VIT AL ROLE OF THE DENTIST
Dr. William Hang, a Los Angeles–based airway-centric orthodontist,
describes the dentist as the gatekeeper to the airways.27 Researchers Peter
Catalano and John W alker also state,
The most likely person to diagnose a child with SDB is their family
dentist or orthod ontist. This is directly related to the fact that nasal
breathing has a tremendous impact on craniofacial developm ent,
which in turn determines dental profile and occlusion (how the teeth
align). Over 90% of children with crooked teeth, teeth grinding, or
malocclusion (misalignment of the teeth) have compromised nasal
breathing.9
In the United States, thanks to a joint effort by American Acad emy of
Pediatrics and American Academy of Pediatric Dentistry , children are
ensured a “dental home” by the time they reach the age of 1 year. This
means that pediatric dentists have a higher frequency of patient encounters
than most other allied health professionals.15 A 2017  study of 55 children,
more than 65% of whom were mouth breathers, conc luded that
“Recognition of mouth breathing in young persons by orthodontists ispoor.”28 But why is this the case? Why isn’t SDB in children, its causes and
treatment, prima rily the domain of the pediatric dentist? And why is it so
often not even picked up by dentists? The connection between nasal breathing and dental issues was first
observed in the 1970s by a Norwegian orthodontist, Dr. Egil Harvold. Harvold noticed that many patients who came to him with dental issues
were also mouth breathers, and he decided to investigate furth er. In 1981,
he publi shed the results of his landmark study , “Primate experim ents in oral
respiration,” in which he compared baby monkeys whose nostrils were
blocked with silicone plugs with a control group.29 For six months , as the
monkeys grew , those animals whose noses had been plugged began to
mouth breathe by default. This led to many changes in craniofacial
development. The faces of the monkeys whose noses had been blocked
looked very different from those who were able to breathe nasally . They
developed long faces, misaligne d teeth, and altered face and neck muscles
as the body adap ted to form an oral airway . Even after the nasal  obstruction
was removed, they continued to mouth breathe for as much as a year, while
their altered facial features were retained.29
A 1998 paper by American orthodontist Katherine Vig questioned
Harvold’ s result s. Vig explains that, while Harvold fully blocked the noses
of the monkeys, total nasal obstruction in humans is “extremely rare.”30
However , I believe that Dr. Vig is missing the point. The issue is not the
extent of nasal obstruction, it is whether or not the child is mout h breathing. The studies by Harvold inves tigated if persistent mouth breathing in
monkeys caused craniofacial abnormalities. The study results showed this
to be the case. A new review published in 2018 reported that children with
nasal obstruction were 5.55 times more likely to mouth breathe.5
A study in the American Journ al of Orthodontics  in 1997  also looked at
the effects of nasal obstruction on craniofacial growth in young Japanese
macaque monkeys.31 Researchers studied 11 animals, of which 7 were
subject to either light or heavy nasal obstruction, while 4 acted as a control
group. Nasal breathing was assessed in terms of nasal airway resistance,
and craniofacial development was measured. In the monkeys whose noses
were blocked, the mandible (lower jaw) rotated downward and backward,
the condyle (jaw joint) grew upward and backward, and the gonial angle ofthe jaw changed. The monkeys also developed anterior open bites and
spaced dental arches. Notably , these changes in growth were significantly
more apparent in the monkeys who had the heavy nasal obstruction. These
results support the theory that a blocked nose in childhood, before and
during puberty , may result in permanent deformities in the structures of the
face and skull. More specifica lly, it may result in skeletal open bite, a
condition where there is no contact between anterior and posterior teeth,
one of the most challenging dentofacial deformities to treat.31
Another paper from 2011 looked  at the effects of short-term forced oral
breathing on baby rats. Result s showed that even very short -term nasal
obstruction created significant hormonal changes, including an increase of
stress hormones of more than 1,000%. While the stress hormone level
normalized by adulthood, other hormonal changes persisted long term, the
development of the olfactory bulb was impaired, and alterations were seen
in the development of the respiratory muscles.32
A 2019  assess ment of preschool children in Italy examined the
relationship between mouth breathing and severe malocclusions.33
Researchers observed oral habits in 1,616 children aged betwe en 3 and 6
years to determine the prevalence of dental problems and the statistical
significance of their connection with mouth breathing and sucking habits. The results showed that 38% of the children needed orthodontic treatment,
and 46% had signs of malocc lusion that required monitoring and risk
factors that needed to be remove d so that the problem could correct itself as
the child grew . Only 16% of the children were completely healthy . Common dental problems included tooth displacement, tooth decay , and
early loss of primary teeth, overbite, overjet, crossbite, and open bite—all
symptomatic of dental misalign ment and poor oral hygiene. It was found
that oral breathing increases as malocclusion gets worse.33 Separate
research has confirmed the link between oral breathing and poor dental
health, tooth decay , and halitosis.2
The 2019 study concluded that mouth breathing is a risk factor for
dental malocclusion and should  be intercepted and corrected as early as
possible to prevent the developm ent or worsening of craniofacial problems. However , a 2017 cross-sectional study of patients aged betwee n 10 and 25
years old had concluded that recognition of mouth breathin g in youngpeople by orthodontists is poor.28 Orthodontists must aim to address these
risk factors to promote correct dento-skeletal growth. This requires
pediatricians, allergists, orthodontists, speech therapists, and ENT
specialists to work closely together to promote early diagnosis and
treatment.33
SDB in children  is serious and potentially life threatening. Numerous
sources underlin e the fact that dentists may be in the best position to
recognize a potential airway-rel ated sleep problem.34 It is vital, then, that
dentists enter the profession with a reasonable knowledge of sleep disorders
and their assessment. Only with this understanding can they ensure that
timely referrals and appropriate treatments are offered. Currently , limited
diagnostic norms exist for both children and adults, and more research is
desperately needed, particularly into childhood sleep disorders. The dentist
is trained to look into the mouth. The medical doctor is not. To meet the
best standards of patient welfare, it is clear that sleep medicine requires an
overhaul. Medical doctors must form partnerships with their dental
colleagues. Studies have defined the risk factors of obstructive sleep apnea in
children as a narrow palate, long face, enlar ged tonsils and/or adenoids, and
minor malocclusions (misaligned teeth), and not, as some might expect,
obesity . It should therefore be clear why dentists must be involved in
identifying SDB in children. Indeed, since obstructive SDB affects between
1% and 5% of the pediatric population35 and has been  found to be
implicated in sudden infant death syndrome, this fact should be considered
with some ur gency .35
Since 2018, the American Dental Association has endorsed sleep and
airway hygiene risk assessment as a primary responsibility of dentists who
provide services for children.36 It is encouragin g to see that the definition of
optimal pediatri c health is changing and now includes the ability to breathe
nasally during wakefulness and sleep. However , from a convers ation with a
friend of mine, who is a dentist with 40 years of experience, it is clear that
there is still some way to go. He explained to me that when  he talks to
colleagues about breathing, theyare consistently resistant to talking with their patients about the
problems of mouth breathing and dental health. . . . They are waiting
for a “new” dental specialty to evolve . . . I tell them this
responsibility belongs in every general dental practice. If their
patients . . . ask them . . . what to do about dry mouth, snoring,
tongue thrusting, anxiety , teeth grinding or clenching, and sleep
problems, they might be nudged to get involved and really care for
their patients. A UK orthodontist who developed a technique called orthotropics to
correct the effects of childhood mouth breathing has been heavily criticized
within dentistry . Dr. John Mew , who promotes the idea of preventive
measures in younger children rather than surgery later in life, was dismissed
as an “idiot” by a prominent American orthodontist in 2020 in the New York
Times.37 Mew fell foul of the General Dental Council in 2017 when, at the
age of 89, he lost his license after publishing an advert slamming the
orthodontic community . His son Dr Mike Mew still practices Orthotropics
and increasing research now supports his ideas. Dr. Mew stron gly believes
that the teeth should not be pushed or pulled. He works on the principle
(called the “Tropic” Premise) that if the tongue rests on the palate, with the
lips sealed and the teeth in or near contact, the growth and position of the
jaws will be ideal. In other words, the teeth and jaws know how to grow ,
they only need guiding into position with correct posture. Over the years,
Dr. Mew found that the teeth often align themselves if the posture is right. In this fundamental he is copying the natural growth of most mammals. I first reached out to Dr. Mew in 2010, when I was writing my book
Buteyko Meets Dr. Mew  to help teenagers with their breathing. I
immediately felt a genuine welcome from both Dr. John and Mike Mew ,
and their passion for helping children develop correct facial growth was
obvious. I was fortunate enough over the course of two years to attend Dr.
Mew’ s practice and sit in the clinic room as he and his son worked. While
John Mew worked with one child, Mike would work with another , and there
was often a lively interaction as the two would share opinions and argue
concepts. The parents looked on as the particulars of each child’ s treatment
unfolded betwee n the two dedicated orthodontists. I have seen for myself
the positive changes to children’ s faces. I also spoke with parents to gettheir insight, and I cannot reme mber anyone having anything negative to
say about the treatment. To this day, I am in touch with both John and Mike
Mew , and before the COVID restrictions struck, I brought my daughter
Lauren to their clinic. I admire their work and their tenacity . I sometimes feel a sense of bewilderment about the fact the dental
industry has ignored the impact of chronic mouth breathing and incorrect
tongue resting posture on craniofacial development. The Mews’ arguments
may not be perfect. Sometimes in their drive to generate awareness of the
importance of forward growth of the face to make room for the airway , they
can be critical of traditional treatments, but there is room  for both
approaches. The unwillingness of the orthodontic industry to even conduct
a clinical trial of Dr. Mew’ s work makes me wonder why there is such a
vested interest in the status quo. Perhaps the German physicist Max Planck
was correct when he suggested that advances in science take place only
when their opponents die out. For the sake of the patient, medicine, like other industries, should be
about continued  development. While it is obviously essential to question
everything and to ensure that new treatments are thoroughly tested, it is
important that progress is not held back by dinosaur thinking, personality ,
or ego. The airline industry , for instance, works with a policy of ongoing
improvement and has made continuous upgrades to safety a top priority
since the first commercial airlin e flight in 1914.38 I don’t see any reason
why dentistry shouldn’ t do the same. THE IMPOR TANCE OF EARL Y INTER VENTION
It may be that the dental industry is not more active in its approach to
mouth breathing because there are still “chicken or egg” questions about its
cause. In practical terms, however , the question is somewhat irrelevant. Does a child mouth breathe because he or she has been born with a small
nose and nasal cavity? Or does habitual mouth breathing create the small
nose and restricted airway? Either way, the solution lies in developing the
child’ s airways at an early age. Unfortunately , most orthodontis ts will wait
until their patient is 11 or 12 years old before acting. By then, the face is
already grown, and it is too late to fully intervene. A study of 24 male and
24 female children discovered that not only does the face develop mostsignificantly in the first five years of life, growth changes to the facial
bones are most rapid during the first six months, decreasing incrementally
thereafter .39
A 2018 article published in the American Journ al of Otolaryngology
and Head and Neck Sur gery reports that 60% of facial growth occurs before
the age of 4 and 90% by age 12. The speed of growth during the early years
will not be news to any parent  who is constantly replacing clothes their
child has outgrown, but it underlines the fact that the window of
opportunity is fairly limited when it comes to restoring nasal breathing and
treating compromised airways and sleep problems in children. This does not
mean that things are hopeless for preteens, teenagers, and even adults. Catalano and Walker explain that it’s never “too late” to treat a breathing
pattern disorder .40 As time passes, the problem simply becomes more
challenging for dentists and surgeons to correct and more difficult and
unpleasant for the patient. Incredibly , this exact issue was already written about in 1922. The
dental profession has been debating it for 100 years, while millions of
children have suffered. In 1922, Samuel Adams Cohen, a New York doctor ,
described how the normal growth of the teeth and jaws goes hand in hand
with sound teeth, proper chewing, correct breathing, well-formed jaws,
normal brain development, and normal speech41. He explained that nasal
breathing does not naturally follow the removal of adenoids unless the child
is taugh t to breathe properly . Cohen cites the example of children seen at
the Forsyth Dental Infirmary , 75% of whom still breathed orally 3 years
after the removal of their adenoids and tonsils. His pape r preced es the work of Dr. Kevin Boyd, whose research  we will
get to soon, in stating that breastfeeding gives a baby an advantage in terms
of developing the mouth and jaw when compared with an artificial nipple
and that soft food does not enable the child to develop the facial muscles
responsible for chewing. According to Cohen, misalign ment of the teeth and jaws always
indicates abnormal functioning. If there is no space for the temporary
“milk” teeth, there is unlikely to be enough room for the permanent adult
teeth. He states, “The presence of perfectly close, regular teeth after five
years of age is an indication for treatment.” At three and a half years, thedental arch should measure at least 27 mm. If, by four years of age, it
measures less than 28 mm, the child will not have a normal dental arch
unless intervention takes place.41 About two years before the adult teeth
appear , their growth within the tissues causes the dental arches to begin
widening. This means that the baby teeth appear to be widely spaced. There
should be space between all of the teeth at this point. Cohen insists that once malocclusion is diagnosed, treatment should
begin immediate ly, as early as possible. He suggests “thirty months of age”
as the ideal time. In early treatment, only a slight “force” is necessary . He
also states that
treating dental deformity before the sixth year insures not only good
mouth functioni ng but also correct breathing, since the width of the
maxillary arch determines whet her or not there is room for normal
nasal breathing. Cohen says that the child’ s brain at six years old is “within 40 grams of
its weight at 19 years.”41 For this reason, it is vital that any problems in the
growth of the face and teeth should be corrected before age six. He argues
that the child’ s doctors and dentists should check for normal arches in
children between two and a half and six years. Cohen concludes that the
dental “apparatu s” is not an organ with a single function in the same way as
the eyes and ears. Any impairment in the teeth and jaws also impacts
chewing, voice production and sound, dental health, facial expression, and
the “beauty” of the face.41
Attractive faces are always forw ard grown.42 I often use photos of Kate
Middleton and Prince William (the Duke and Duchess of Cambridge) to
illustrate this. They have distinctly different jaw sizes. When you look at a
photo of them both smiling, try counting the number of teeth you can see in
each of their mouths as they smile. In Kate, you might see 10 teeth. She has
a beautifully wide-shaped face, good jaws, and with that, a good airway . On
the other hand, it’s only possib le to see about 7 teeth as Prince William
smiles. There are dark triangles to either side of his jaw. This indicates that
his jaw is not wide enough. I don’t know Prince William’ s dental history ,
but I would speculate that he may have had teeth removed to give him a
nicer smile. As a result, the width of his jaw has been reduced  so there isnot enough room for the tongue. This would cause airway limitations,
resistance to breathing, and possibly sleep apnea. Personally , I would rather
have an ample airway and a poorer smile. At least, a poorer smile is not
going to kill me! SAFE SLEEP FOR YOUR BABY
A furthe r and extremely concerning consequence of SDB in children is
SIDS. Dentists are well positioned to address the risk for children born with
deficient airway s, but, as yet, it is very rare for babies to be checked for
tongue-tie or a high, narrow palate. In 2012, Caroline Rambaud of the
Hôpital Raymond-Poincaré in Paris, France, and Stanford University’ s
Christian Guille minault looked at correlations between airway  obstruction
and SIDS in seven infants43. The authors compared the post-mortem
findings for the seven dead children with seven age and gender -matched
living children with OSA. In all seven SIDS cases, medical histories
indicated chroni c signs of abnormal sleep, and a significant proportion of
the babies had presented with acute, often mild, rhinitis just before death. Four of the children normally slept prone (on their tummies). All of them
displayed enlar ged upper airway soft tissues and features consistent with a
small nasomaxillary complex  (narrow upper airway), with or without
mandibular retroposition  (backward displacement of the lower jaw). They
all died of hypoxia (oxygen deprivation) in their sleep. The living children
with OSA had similar facial features and upper airway complaints. The paper explains that the anatomical risk factors for a narrow upper
airway can be identified early in life. SDB is most frequently related to a
small upper airway . When abnormal resistance to nasal breathing is present,
the child  will switch to mouth breathing. This leads to greater  respiratory
exertion during sleep. These traits are often inherited, so family dentists
should be able to identify or even predict which children may be at risk. While more research is needed into the role of upper airway infection and
anatomically small airways in SIDS, dentists must pay close attention to
any sleep-relate d complaints in children with features consistent with a
small airway .43
In the study , death was associated with abnormal sleep in six out of
seven cases. Symptoms such as rhinitis or infection in the upper airways inthe days prior to death were not marked enough to cause concern when
mentioned to the child’ s doctor , but in each instance, the child essentially
suffocated during sleep. Although many of the deaths were preceded by an
abnormal sleep history , and the children displayed the anatomical risk
factors for SDB, none were recognized as having SDB, so they were left
untreated. Rambaud and Guilleminault concluded that it is vital to
recognize the risk factors leadin g to a narrow upper airway as early in life
as possible and that educating dentists and pediatric doctors regarding the
facial features symptomatic of SDB may be valuable.43
The work of Dr. Kevin Boyd, a pediatric dentist who specializes in
anthropology , helps us understand the connection between facial structure
and SDB . Dr. Boyd works with young children from the age of six months
old, developing  the maxilla and nasal cavity in those with anatomically
small airways. He believes that many craniofacial traits can be altered
during the early childhood stages of dentofacial growth and that these
features are likely to be a significant factor in SDB and OSA.15 In his
anthropological work, Dr. Boyd explains that sleep-related breathing
disorders were not even part of the human experience until very recently . He points to the fact that skeletal malocclusion wasn’ t found in humans
until the mid-eighteenth century. While he attributes many of the
dentofacial and physical risk factors for malocclusion to the considerable
changes in diet and lifestyle since the Industrial Revolution, he is also clear
that these factors increase the incidence of SDB and OSA.15
The shape of the human face is changing. According to Dr. Boyd, it is
likely that feedi ng behaviors in infancy are partly to blame. As his paper
indicates, “ancestral-type” breastfeeding and weaning are important for the
development of the face and jaw. While we might equate dental decay with
diet in adulthood, the highly processed baby foods, artificial  baby milk
formulas, and “commercial nipples” that are all so common in use today
were simply not available before the Industrial Revolution.15
Dr. Boyd concludes that treatment, prevention, or reversal of
malocclusion may help to address SDB. From an evolutionary standpoint,
he argues that pediatric dentists are uniquely placed to identify those
patients who are at risk of OSA and SDB, and that their practices should
acknowledge aspects that impact long-term health, such as airway size. Thefact is that set-back jaws increase the risk of sleep apnea for the rest of a
child’ s life. Dr. Boyd proposes that pediatric sleep medicine centers should
employ at least one dentist experienced in dentofacial issues related to sleep
problems and OSA, and sugges ts rewriting the rulebook when it comes to
cephalometric norms (the models used by dentists to measure “correct”
proportions of the skull and face).15 The current models are almost entirely
based on twentieth-century skulls and fail to take the evolu tion of the
human chewing apparatus into account. These considerations apply to
traditional orthodontic techniques such as tooth extraction and retraction of
the jaw for aesthetic alignment. In his paper on airway-centric dentistry , Dr. William Hang explains that
it has been recognized for more than 30 years that the upper jaw rarely
protrudes and is more commonly set back, yet treatment is still often
directed to correcting protrusio n of the upper teeth. Dr. Hang argues that
extraction of bicuspid (premola r) teeth and retraction of the incisors and
canine teeth negatively affects airway size and that dentists must consider
how these procedures impact the airway , concluding , “Clearly ,
extraction/retraction must stop.”27
TREA TMENT OPTIONS
Obstructive sleep apnea (OSA) is the most severe form of SDB. It is caused
by a series of anatomical factors  that reduce the size of the space  at the back
of the nose, mouth, and throat, and problems that make the upper airway
more likely to collapse. This explains why children with craniofacial
syndromes and conditions including cerebral palsy , allergic rhinitis, asthma,
and obesity are more at risk. Anatomically , children with OSA have a soft
palate that is on average 30% larger than normal.44 This causes extra
restriction to the airway . Furthe r contributing features include a buildup of
fluid in the eardrum and inflamed sinuses, perhaps indicating that a more
general disorder af fects the airway as a whole.44 The simplest explanation is
that most children with OSA have dif ficulty breathing through the nose. Not all children  with enlar ged adenoids and tonsils suffer from OSA—
craniofacial structure, genetic, and neuromuscular functions can also play a
part—but the severity of OSA is related to the size of those tissues. One2002 study confirms that the top two-thirds of the upper airway is around
50% smaller in children with OSA than in other children.45 While further
research is needed, it is thought that this narrow point is where airway
obstruction occurs in OSA. For this reason, the most common treatment for
OSA in nonobese children is surgical removal of the tonsils and/or
adenoids.15 However , adenotonsillectomy can leave a child with residual
SDB.43 Despite  its popularity , the overall effectiveness of the operation as a
treatment for OSA was unknow n until the following 2010 study . It was
acknowledged that success rates were likely to be lower than estimated, and
factors that leave the child with unresolved OSA after treatment were still
undefined. In 2010, scientists from the University of Chicago’ s Department of
Pediatrics carried out a multicenter review of otherwise healthy children
under going adenotonsillectomy as a treatment for OSA.46 The study looke d
at 578 children who were treated in pediatric sleep centers in the United
States and Euro pe. Around 50% of the children were obese. Data included
results from all preoperative and postoperative nocturnal polysomnograms
—a polysomnogram is a test that records brain waves, blood oxygen levels,
heart rate, respiratory rate, and eye and leg movements during sleep. Removing the adenoids and tonsils significantly reduced the number of
apneas and hypopneas per hour of sleep (AHI), but OSA was only
completely resolved in 27% of the children. While this was considered a
significant improvement, symptoms persisted after treatment for a large
number of subjects, particularly those who were obese, having asthma and
older than 7 years.46 The fact that nearly three-quarters of the children
continued to have sleep apnea post-tonsillectomy and adenoidectomy points
to causative factors aside from enlar ged adenoids and tonsils. It is logical to
argue that a child with underdeveloped airways and/or a habit of
mouth/faster breathing is more likely to experience resistance to breathing
during sleep and therefore suf fer SDB. There is growing evidence that medications including intranasal steroids
may be helpful in mild OSA.44 The very fact that nasal decongestants can
help with minor  instances of the condition points to nasal stuffiness as a
problem. That means that exercises to unblock the nose can be used
successfully in place of medic ation. Widening the upper jaw (maxillaryexpansion), known to be a useful treatment for SDB, can also be considered
in cases of childhood OSA. According to an article published in the
American Journ al of Orthodontics and Dentofacial Orthopedi cs in 1987,
the procedure may be warranted on the basis of airway size alone.47
TONGUE-TIE AND BOTTLE FEEDING
Distinct from the adult conditi on, the onset of OSA in children can be
caused by abnormal activity of the tongue.48 This may be down to genetic
and anatomical factors such as tongue-tie, though it is more commonly the
result of bottlefeeding and habits including pacifier use, digit sucking, or
sucking the lip, arm, or a blanke t. In adults, OSA is affected by poor tongue
resting position and tongue size. In a healthy child, the tongue rests high in the palate.49 This is the
resting position conducive to nasal breathing. Correctly placed , the tongue
shapes the upper jaw into a wide U, forming the basis for an attractive,
well-proportioned face and jaws that are big enough to house all of the adult
teeth without crowding. The activity of the tongue—sucking, swallowing,
and chewing—s timulates oral-fa cial development, a process that continues
until the child is around 13 to 15 years old. However , narrow jaws or
constrictions of the tissues can make it difficult for a baby to suckle or hold
his or her tongue in the correct place. When the mouth hang s open, the
tongue cannot rest easily in the roof of the mouth, and poor breathing habits
form. A tongue-tie, or short lingual frenulum, occurs when the tissue that
attaches the tongue to the floor of the mouth is too tight.49 Babies with this
condition may find breastfeedin g difficult because they are unable to lift
their tongue sufficiently to extract milk from the breast. This may cause
frustration or fussy feeding in the baby , and the mother may experience
nipple soreness, blocked ducts, or mastitis. When breastfeeding is
problematic because of tongue-t ie, the answer is usually to introduce bottle-
feeding, while the underlying cause goes undiagnosed. Tongue-tie is a relatively comm on condition in newborns, but it does
have an impact on development if left untreated.50 Without the freedom to
suckle correctly , the child can develop a tongue thrust that leads tomisalignment of the jaws, and infants with a tongue-tie are more likely to
be exclu sively bottle fed by one week of age. Lip-tie has not received the
same attention in studies as tongue-tie, but it is also known to cause
difficulty in breastfeeding.51
In older  children, an untreated tongue-tie has been shown to create
speech difficulties and contribu te to SDB. The modified tongue position
leads to mouth breathing, the development of an anterior and posterior
crossbite, and imbalanced, disproportionate growth of both the upper and
lower jaw . All these anatomical changes af fect the size of the upper airway . An article by Brian G. Palmer published in Sleep Review  in 2003
explains that a high palate can also affect breathing and the alignment of the
teeth.52 Palmer writes, “Since the roof of the mouth is also the floor of the
nose, any increase in the height  of the palate decreases the volume size of
the nasal chamber .” This reduce d size increases nasal air resistance. A high
palate can cause the opening at the back of the nose to narrow , which means
the soft-tissue region of the airway is smaller and more likely to collapse. Palmer points out that skulls from eras where children were universally
breastfed rarely have small nasal apertures and conjectures that OSA may
not have existed prior to the invention of artificial nipples. While the breast
tissue is soft and shapes itself to the baby’ s mouth, bottle teats and pacifiers
are firmer and require the mouth to adjust. Equally , the effort required for
an infan t to express milk from the breast gives the muscles of the face a
workout, promoting the development of good muscle tone and ensuring
nasal breathing. This cannot be replicated by an artificial teat.52
Tongue-tie may also contribute to the enlar gement of the tonsil s that is
so prevalent in OSA.53 The restrictive tissues can lead to mouth breathing,
which increases upper airway resistance and causes inflamm ation to the
back of the throa t. Swollen adenoids and tonsils further obstruct  the airflow ,
exacerbate the need to breathe through the mouth, and contribute to
abnormal oral-facial growth. T ongue-tie, left untreated, can therefore lead to
SDB and OSA. A tongue-tie in a newborn shou ld be clipped to facilitate the necessary
movement of the tongue during breastfeeding. I remember  hearing a
speaker at a sleep conference explain that sixteenth-century French
midwives grew one fingernail extra long so they could use it to cut thetongue-ties of newborn babies . By today’ s standards, this may sound
grotesque, but at a time when formula feeding was not an option, it may
have saved the lives of those children. If you suspect that your child has a short lingual frenulum, seek advice
from a healthcar e professional or myofunctional therapist trained in
identifying tongue-tie. You can find a specialist in your area by visiting
AomtInfo.or g.
DEVELOPMENT OF POSTURE, SPEECH, AND
LANGUAGE
Mouth breathin g in children also has impacts on speech, auditory
processing, and postural development. In a 2011 study of the effect of
chronic nasal obstruction on speech in children aged between 4 and 12
years, it was found that 76.6% of children with nasal blockages suffered
dysphonia—problems speaking due to anatomical disorders in the throat,
mouth, tongue, or vocal cords.54 More than 68% of the children with
blocked noses demonstrated vocal abuse, a behavioral condition that causes
strain to the vocal cords. A 2013 paper that explored the correlation between oral breathing and
speech disorders in children found that mouth breathing could affect
socialization, academic perform ance, and the development of speech.55
Researchers underlined that early detection of mouth breathing is essential
to reduc e or prevent its harm ful effects on development. Changes in
posture, mobilit y, and muscle tone of the lips, cheeks, and tongue, when a
child habitually mouth breathe s, lead to a loss of efficiency in basic
functions like swallowing, chew ing, and speaking. This can encourage the
development of flaccid jaw muscles, poor head posture, and speech
disorders, including lisps and the inability to pronounce specific sounds. Children who mouth breathe may also have underdeveloped auditory
processing. In 2014, scientists undertook a first-of-its-kind study looking at speech
difficulties in children who had swollen adenoids and found a connection
between adenoid  hypertrophy and articulation errors during speech.56 The
study compared 19 children with adenoid hypertrophy to a control group of33 children with functional articulation disorders but no physical
symptoms. The mean age of the subject group was higher than that of the
control group because the incidence of adenoid hypertrophy in children
generally increases with age. They found that the kind of speech errors made by children with
swollen adenoids were not the same as those present in children with
speech disorders. Children with enlar ged adenoids were more likely to
substitute one sound for anothe r and less likely to drop sounds, reflecting
the fact that swollen adenoids, rather than the children’ s understanding of
phonetics and language, were the cause of defects in speech. The sound “s”
was particularly affected in these children. This sound requires a specific
placement of the tongue, but children with swollen adenoids have reduced
airway space and tend to drop their lower jaw and tongue to maximize their
oral airway. As we’ve already seen, this affects the developmen t of the face
and leads to poorly aligned teeth and jaws. It is also believed that enlar ged adenoids can lead to changes in voice
quality . The children in the study were found to have frequent nasalization. This is consiste nt with previous research that found adenoid hypertrophy
could lead to hypernasal speech, alter the resonance characteristics of the
airways, and cause changes in the dimensions of the vocal tract that can
manifest as roughness in the voice. Mouth breathing  and SDB breathing in children has also been found to
impact auditory  processing—th e ability to understand speech, distinguish
sounds from one another , concentrate against background noise, and enjoy
music.57 Scientis ts in Brazil found that children with mouth breathing and
OSA, as determined by polysomnography , displayed levels of auditory
processing that were statistically significant when compared with children
who had no airway problems.58 The children with OSA performed less well
in tests to determine auditory processing and nonverbal sequence memory . We have already explored the impact of mouth breathing on the
development of the face, jaws, and teeth. However , the problem extends
further . Children  with narrow or blocked airways tend to mouth breathe by
default, and so they adjust the position of their head to get enough air in
through their mouths. Information on the connection between mouth
breathing and changes in postur e in children is limited, but one 2018 studyof children explains that problems in the positioning of the shoulders,
including the shoulder blades and trapezius muscles, can occur in children
who mouth breathe.59
While much research has focused on the position of the head, not
looking any further down the spine, the fact is, the forward positioning of
the head , which  is necessary to draw air orally into the lower respiratory
tract, will lead to further postu ral adaptations that can impact the whole
body . Forward head posture requires the child to extend the upper cervical
spine and flex the lower cervical and thoracic spine, leading to curvature in
the lumbar spine. Over time, this causes muscle strain that pulls the lower
jaw back, decreasing the airway even more. The 2018 study recorded a significant reduction in forward head
position and poor shoulder posture after adenotonsillectomy .59 It woul d be
interesting to see the results of a study that made the same comparison
following upper  airway development and nasal breathing training; it seems
likely they would be similar and perhaps more sustainable. ADVICE T O PARENTS OF CHILDREN AND
TEENAGERS
It is important to monitor your child for signs of mouth breathing. Take the
opportunity to observe the breathing when your child is concentrating on
homework, watching TV, or sleeping. It can be helpful to monitor the
breathing of younger children after they have eaten, particularly if you
suspect specific  foods such as dairy or wheat may be triggering
overbreathing. Avoid overdressing your child, and keep your house cool and well
ventilated. Enco urage your child to play outside and to breathe through
their nose as much as possible during physically active play. Notice if your
child maintains an open mouth posture for significant periods. If the mouth
is open for 40% of the time or more, you must act. If your child’ s nose is
blocked, try using the exercise to decongest the nose. (You will find this
exercise in Chapter T wo.) Look at the follo wing list of questions. If your answer to any of these is
“yes,” your child might be displaying the harmful ef fects of SDB:• Do you notice your child breathing through an open mouth? • Does your child wake up with tangled sheets in the morning after a night of twisting
and turning during sleep? • Does your child hold his or her breath during sleep? • Does your child have a stuf fy nose on waking, or complain about his or her mouth
being dry? • Do you hear your child snoring? • Does your child experience disrupted sleep? • Does your child have nightmares, wet the bed during sleep, or wake up needing to
use the bathroom? • Is your child’ s breathing audible during sleep? • Is your child tired on waking, or fatigued and struggling to concentrate during the
day? We have looked in detail at the many factors that lead to breathing
pattern disorders . Nasal breathing not only prevents and relieves the many
symptoms related to breathing pattern disorders and SDB but is also
essential to the correct development of the jaws and face. The foundation of
breathing reeducation for children and teenagers is restoring full-time nasal
breathing with the lips closed, jaws relaxed, and tongue in the correct
resting posture, both during wakefulness and sleep. As the many studies have shown, the growth of the face and airways in
childhood is often directly related to the way a child breathes. Enlar ged
adenoids or any other restriction  of the airways causes the child to switch to
mouth breathing because of the difficulty in getting enough air through the
nose. While it may seem count erintuitive, this only exacerbates the nasal
obstruction. Further, it causes poor development of the airways and can
result in lifelong issues with breathing. MOTIV ATING CHILDREN
In helping children and young people change their breathing habits, they
need to understand the importa nce of breathing through the nose. When I
work with young people, I ask them which reasons they consid er to be the
most important when it comes to breathing nasally . The most popular
replies tend to focus around athletic performance and the development of a
good-looking face. I find it best not to highlight the negative features of
mouth breathing when talking to children. Instead, I find they respond wellto hearin g about  the many bene fits of nasal breathing. The following ideas
may be helpful. Nasal breathing makes you more intelligent:  Explain to your child
that intelligent people breathe  in and out through their noses. Nasal
breathing impro ves cognition, concentration, alertness, and energy levels
because it promotes better sleep and delivers more oxygen to the brain. This
helps your child focus better in class so learning will be easier and more
enjoyable. Nasal breathing impr oves sports performance:  When children
habitually mouth breathe, they tend to quickly become breathless during
sports or physical exercise. This might make them reluctant to take part in
healthy activiti es they would otherwise enjoy . Professional athletes,
Olympians, Special Forces, and military personnel all use breathing
techniques from the Oxygen Advantage to improve their performance
during training. Mouth breathing causes crooked teeth and bad breath:  No teenager
wants to have bad breath. Nasal breathing helps maintain a healthy mouth
and prevents smelly breath.3,60 It can also avert problems  in the
development of the face, such as narrow jaws, crooked, overcrowded teeth,
and small upper airways. Breathing through the nose helps you sleep better and gives you
more energy:  Mouth breathing interferes with a good night’ s sleep, and
you will have less energy to enjoy life. Also, children who sleep poorly are
10 times more likely to develop learning dif ficulties.3
Mouth breathi ng is bad for postur e: Persistent mouth breathing
during early childhood can lead to changes in posture as the head is thrust
forward to optimize the oral airway . This, along with a tendency to breathe
into the upper chest, will have a knock-on effect on the stability of the
spine. These things may not be particularly motivating for children, but
parents will understand their importance. Nasal breathing leads to good table manners:  If your child has a
blocked nose, he or she may have difficulty eating. Nasal conge stion makes
it tricky to coordinate breathing and swallowing, so the child may need to
stop chewing or chew faster to breathe through the mouth. Thisbreathlessness may look like bad table manners as the child sniffs and gulps
his way through each meal.61
In all cases, the best place to start is by encouraging nasal breathing
both day and night. Children under five years of age may find it difficult to
practice breathing exercises, so parents of young children must take
preventive action to avoid the factors that contribute to overbreathing. Children tend to mirror their parents, even in their breathing habits. If you
tend to walk around the house with your mouth open, puffing and panting,
not paying attention to your breathing, your child will do the same. Equally ,
a child will struggle to learn if everybody else in the house continues with
their own bad habits. I often see the behavior of parents interfering with the
progress of their children in this way. You need to lead by example. Only
then can you ensure success with breathing reeducation. Luck ily, this is a
win-win situation because everybody involved will enjoy the benefits. Help your child understand what “breathing too much” means and that
overbreathing is what causes tiredness, wheezing, coughing, and a stuffy
nose. The best way to do this is by giving a physical demonstration. Ask the
child to hold out a finger and blow a large puff of air onto their finger . Let
them feel the strength and quant ity of air on their finger . Explain that this is
“big breathing.” Then ask the child to blow a tiny amount of air onto their
finger . This should be so light they can hardly feel it at all. Expl ain that this
is correct breathing. You can also ask your child to explain the ideas behind good breathing
to other people in your household. This will allow your child time to reflect
on his or her breathing. By listening to the storytelling and description your
child gives, you will be able to tell how well the theory has been
understood. If you are conce rned about your child’ s breathing and want to explor e
maxillary expansion, there are healthcar e professionals who can assist with
gently widening  the palate even in very young childr en. I would advise
looking for a myofunctional therapist or specialist pediatric dentist. Contact AomtInfo.or g to find a practitioner near you. OceanofPDF .comGCHAPTER NINE
THE BREATHING SECRET FOR HEALTHY
BLOOD PRESSURE
lobally , 1.13 billion people are thought to suffer with hypertens ion,
the majority living in low- and middle-income countries. In
America in 2020, around 108 million people, or 45% of the adult
population, have high blood pressure1 and fewer than one in five sufferers
have the problem under control.2 The risk is higher for those who have
reached retirem ent age. Under new guidelines published in 2017, nearly
80% of Americans aged 65 and older qualify as high risk for blood
pressure.3 In the United Kingdom, 2020 figures show that one in three
adults have the condition, rising to one in two in people over 65—that’ s
around 16 million people in total.4
High blood pressure is a problem that can affect anyone, regardless of
income, race, gender , or age. The risk increases as you get older , with
certain lifestyle choices, and if you have a genetic predisposition to
hypertension. But whether or not you are likely to develop the condition
often depends upon the health of your heart. The good news is that it is
actually fairly straightforward to ensure that your heart stays healthy ,
simply by eating a sensible diet, maintaining a moderate exercise regime,
and learning to breathe correctly . THE HEART AND HIGH BLOOD PRESSURE
The heart is the organ respons ible for pumping blood around the body
through the blood vessels. It operates all day, every day, beating
approximately 109,000 times every 24 hours.5 It pumps deoxygenatedblood to the lungs where it can be replenished with oxygen, and it circulates
oxygenated blood back around the body , supplying the brain, muscles,
organs, and every cell with oxygen. In other words, the primary  role of the
heart is to distribute the oxygen brought into the lungs during inhalation,
and to bring carbon dioxide back to the lungs where the excess can be
breathed out. As the heart pumps, blood pushes against the walls of the arteries,
creating pressur e. Like many of the body’ s homeostatic systems, this
pressure is in constant flux. It is regulated by the movement-sen sitive nerve
endings called baroreceptors (which we read about in Chapter Four ). Problems with blood pressure occur if the pressure rises and remains too
high over a sustained period of time. This can damage the body in many
ways, leading to heart failure, stroke, kidney disease, and a number of other
health problems.6
High blood pressure is the buildup of pressure caused by a restriction to
blood flow. Picture the scene: On a beautiful sunny day, you decide to water
the flowers in the front garden. You attach the hose to the tap and turn it on
halfway to provide enough wate r flow to spray the flowers with a fine mist. All is going well until your absent-minded neighbor unknowingly parks his
car with a tire pressing firmly down on the hose. In an instant, the blockage
reduces the flow to a trickle, while water pressure increases inside the hose. The blood vessels work in a similar way. When arterial blood  vessels
are dilated, wide and relaxed, blood flows easily , circulation is good, and
blood pressure is normal. However , when arteries are constricted due to
age-related hardening or a buildup of fatty deposits along their inner walls,
flow becomes restricted, and pressure begins to rise. The main function of the heart is to pump blood back and forth from the
lungs, around the body . When the blood vessels are restricted, the heart will
increase the blood pressure to keep the blood moving, much as you might
turn up the garden tap when the water coming out of the hose dries to a
trickle. While this extra pressure may temporarily provide the body with an
adequate blood flow, it puts extra strain on both heart and blood vessels,
which over time is damaging. If the blood vessels remain constricted,
circulation gradually gets worse, and blood pressure continues to rise.Normal blood circulation is vital to health. The blood carries oxygen to
everywhere it is needed, so if circulation is cut off to any part of the body ,
that area will become starved of oxygen. The sensation of pins and needles
you might get if you sit with your legs crossed for too long is a mild
example of what happens when blood flow becomes constricted. In the case
of a “dead” leg, a few stretch es and a short walk will quickly restore
circulation, but when blood vessels are restricted on a long-term basis, the
reduced blood flow will have a detrimental effect on the heart and brain. Ultimately , when circulation to any part of the heart is cut off, the lack of
oxygen causes cells in the heart to die, and this can result in a heart attack. If there is insuf ficient blood flow to the brain so it gets too little oxygen,
you may suf fer a stroke. Hypertension occurs when the heart is pushed to beat faster or more
forcefully than it should. This can happen when the body contains a greater
volume of blood than normal, when the arteries become too narrow , or
when blood vessels harden and lose some of their elasticity . While genetic
predisposition is a risk factor , a family history of high blood pressure is not
definitive. In fact, understanding your inherited potential for hypertension
can empower you to take the steps to avoid developing it. Many lifestyle choices that promote healthy blood pressure are well
within your control. These include:
• Eating a nutritious, healthy diet
• Avoiding foods known to increase blood pressure
• Taking adequate exercise
• Quitting smoking
• Addressing snoring and sleep apnea
• Managing stress
• Practicing slow breathing
Even with a family history of hypertension, the exercises in this book
can help you avoid high blood pressure, often without the need for
medication. MEASURING BLOOD PRESSUREBlood pressure is typically recorded as two measurements: systolic and
diastolic pressur e. Systolic pressure, the higher of the two numbers, refers
to the pressure of the blood when the heart is actively pumping blood. Diastolic, the lower figure, measures blood pressure between heartbeats
when the heart is at rest. Blood  pressure measurements are presented with
the systolic number above or before the diastolic number , for example:
120/80 mmHg. The mmHg refers to millimeters of mercury , the units used
to measure pressure. When your blood pressure is taken, a healthcare professional places an
inflatable cuff on your upper arm. Air is pumped into the cuff to increase
the pressure around the arm. As the cuff becomes tighter , the pressure
becomes sufficient to temporarily collapse the artery and restrict blood
flow. The doctor or nurse then places a stethoscope on the artery and gently
releases the pressure from the cuff, listening attentively for signs of blood
flow while observing pressure levels. When the first pulse of blood flows
back through the artery , the reading is noted. This is the systolic pressure. The cuff is then gently released,  and the sound and pressure of the blood
flow is carefully  monitored. At first, as blood begins to flow, it makes a
turbulent noise, because the artery is still partially constricted. The diastolic
reading is taken at the first moment the blood begins to flow effortlessly ,
without restriction. One of the most  confusing things about hypertension is that there may
be no warning signs or symptoms until blood pressure reaches 180/1 10, yet
once the conditi on has developed, it can last a lifetime. Unless your blood
pressure is checked, you may not even know that it is high. When
symptoms are present, they can include a persistent headache, blurred or
double vision, memory loss, low libido, dizziness, nose bleeds, palpitations,
nausea, vomiting, and shortness of breath. The following table summarizes normal blood pressure levels for adults. It also shows which measurem ents put you at greater risk for health
problems.If you are told that your blood pressure is 120 over 80 (120/80 mmHg),
it means that you have a systolic pressure of 120 mmHg and a diastolic
pressure of 80 mmHg. Hypertension is defined as blood pressure that is
140/90 or more for a sustained period. TAKING YOUR OWN BLOOD PRESSURE READINGS
Nowadays, anyo ne can measure their own blood pressure by purchasing a
good quality blood pressure monitor or using a blood pressure  cuff with a
smartphone. Some people may find this provides more accurate
measurements as they feel more relaxed at home than at the doctor ’s office. If you want to take your own blood pressure measurements, follow these
simple steps:
• Sit quietly  for a few minutes with your back supported and your feet resting on the
floor. Roll up your sleeve and rest your arm on a table or armrest so that your elbow
is at the same level as your heart. • Secure the blood pressure cuff over the bare skin of your upper arm and
measure your blood pressure according to instructions. After the first reading,
leave the cuf f in place. T ake a break of one minute, then take a second reading. If
the two readings are close, work out the average, and take that as your
measurement. If not, take a third reading, and find the average of the three.• Repeat the procedure for the other arm. It may sound odd, but it is useful to check
the readings from both arms for consistency . Readings that dif fer by more than 10
points between the left and right arm may signify a buildup of fatty deposits in the
arteries.7
To improve the accuracy of self-monitoring, it is important to bear in
mind the following guidelines:
1. Measure consistently:  Blood pressure fluctuates throughout the day , so try to
measure around the same time each day . To assess accuracy , take two or three
readings in a row and record the average. Do this at least once a month. 2. Avoid coffee:  It’s best not to drink cof fee for at least two hours before measuring, as
caffeine can cause a temporary but dramatic increase in blood pressure. 3. Wait 30 minutes after exercise:  Vigorous exercise can temporarily increase blood
pressure, so it’ s best not to take a measurement immediately after physical activity . BREA THING FOR LOWER BLOOD PRESSURE
The relationship between breathing and blood pressure was first
documented in the 1930s in a handbook for physicians, The Cure of High
Blood Pressur e by Respiratory Exercises .8 Since then, the fact that regula r
practice of slow breathing can help lower blood pressure has been widely
acknowledged in medical literature. Recent studies include a 2006 paper that compared the effects of mental
relaxation and slow breathing  on high blood pressure.9 Researchers
examined 100 participants durin g practice of 10 minutes mental relaxation
and 10 minutes slow breathing. They concluded that slow breathing
activated the parasympathetic response and resulted in a fall in systolic
blood pressure, diastolic blood pressure, heart rate, and respira tory rate. In
this study , slow breathing performed better than relaxation, causing a
significantly greater reduction in heart rate and blood pressure. Regular slow breathing practice also produces long-term benefits for
blood pressure, as demonstrated in a 2009 study .10 Sixty subjects aged
between 20 and 60 years practiced slow breathing for three months. They
showed improve ments in both sympathetic and parasympathetic reactivity ,
which researchers deemed to be favorable for patients with high blood
pressure.10Research into the effects of mental relaxation and slow breathing
exercises on patients with high blood pressure has repeatedly proven that
these techniques successfully activate the parasympathetic response. The
calming physical reaction reduces blood pressure, heart rate, and respiratory
rate. The value of practicing reduce d breathing exercises and relaxation is
reinforced by the fact that peop le with high blood pressure tend to have a
stronger than normal response to stress. One study reported greater impacts
from stress on people who already had high blood pressure. Scientists tested
115 peop le with a series of challenging activities such as menta l arithmetic,
thinking unplea sant thoughts, staring at a fixed point, and catching a
dropped object. Participants who had high blood pressure at the start of the
experiment expe rienced signific antly higher respiratory rate, systolic blood
pressure, and diastolic blood pressure in reaction to the exercise s than those
with normal blood pressure.9
There is no denying that stress is a significant trigger for increasing
blood pressure or that people with high blood pressure are likely to have a
stronger reactio n to stressful events. However , what is less commonly
understood is the potential value of light, slow , and deep breathing exercises
for people with hypertension and how these exercises work to lower blood
pressure, allevia te stress, and avert further health complication s over both
the short and long term. Breathing reedu cation is vital in the management of OSA, a condition
closely linked with hypertension. Both OSA and hypertension are common
and occur more frequently in older people. According to a 2020 paper ,
around 50% of OSA patients have high blood pressure, and between 30%
and 40% of hypertensive patien ts have OSA, though their sleep  disorder is
often undiagnosed.11 Nonobese OSA patients have a less responsive heart
rate (low heart rate variability) and higher blood pressure, even  in a resting
state of wakeful ness and in the absence of any heart problems. In terms of
the impact of OSA on chronic stress, researchers cite a 2001 study, which
demonstrates that hypoxia (where the body is starved of oxygen, as it is
during apneas) induces prolonge d activation of the nervous system’ s stress
response.12Interestingly , the activity of the sensors that regulate blood pressure
changes with the different sleep-wake cycles.13 The function of the
baroreflex during sleep is state-dependent. The scientists suggest that
baroreflex sensitivity increases slightly during light non-REM sleep, and
there is a marked enhancement  during deep non-REM sleep, the stage of
dreamless, resto rative sleep vital to well-being. A clear impairment of
baroreflex control during non-R EM sleep has been documented in patients
with OSA and high blood pressure. It is thought that reduced baroreflex
sensitivity along with a heightened sensitivity to blood CO2 may amplify
the sympathetic  stress response to apneas, increase activation of the
sympathetic nervous system during wakefulness, and create the conditions
for daytime hypertension. Heightened sympathetic nerve activity is
common in patients with OSA, and it also plays a major part in the
development of treatment-resistant hypertension. Since both OSA and hypertension are so common, they can often
coexist indepen dently of each other or, in medical terms, “comorbidly .”
Because high blood pressure is not always the result of OSA, traditional
treatments for OSA may not alleviate hypertension. However , whether the
two cond itions exist side-by-side or one causes the other , both problems can
be helped with the practice of light, slow , and deep breathing. There has been research into blood pressure and using inspiratory
muscle training  devices and whether the benefits of slow breathing are
enhanced by the adding an inspiratory load.14 In a 2010 study , 30 patients
with Stage I or II essential hypertension were divided into three groups. The
first group pract iced slow diaphragm breathing twice a day for eight weeks;
the second practiced the same exercise using a loaded breathing  device; the
third group, a control, continued with normal activities. It is not recorded
whether breathin g in the second group was nasal or oral. The purpose of the
breathing device, which in this experiment was loaded with 20 cm H2O
(water), was to strengthen the breathing muscles in the same way that
adding a load increases musc ular strength in weight lifting. Because
breathing muscles are largely passive on exhalation, this device works to
strengthen the muscles used to inhale. (The SportsMask has the same
purpose.) Resting heart rate and blood pressure were measured before and
after the respiratory training period.The results showed that both systolic and diastolic blood pressure
decreased signif icantly with slow breathing exercises. Diasto lic pressure
decreased by 7 mmHg and systolic by 13.5 mmHg. With the inspiratory
muscle loading devices, the reductions were even more marked. The
improvement in systolic blood pressure was 5.3 mmHg more than it was
with just slow breathing. Heart rate dropped by eight beats per minute with
slow breathing and nine beats per minute with load-added breathing. In a 2019 trial, 20 patients with isolated systolic hypertension (ISH)—a
condition where  the diastolic reading is normal, but the systoli c reading is
high—undertook a similar eight-week breath training program. In this new
study , patients were asked to complete 60 breaths every day at a respiratory
rate of 6 breath s per minute and at 25% of their maximal  inspiratory
pressure.15 Maximal inspiratory pr essur e (MIP) is the most commonly used
measure to evaluate inspiratory muscle strength.16 Readings were taken of
blood pressure and the response of patients’ heart rates to static hand-grip
and dynamic arm-cranking exercises. At the end of the eight weeks, systolic blood pressure had dropped by
22 mmH g, diastolic blood pressure by 9 mmHg, and heart rate by 12 beats
per minute. Sizable reductions in blood pressure and heart rate were also
seen following the hand-grip and arm exercises. The loade d breathing
exercises at six breaths per minute reduced blood pressure and improved the
body’ s ability to manage both static and dynamic exercise in all
participants.
_OceanofPDF.com_The_Breathing_Cure_-_Patrick_McKeown.txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        Had I been armed, as I am now, with more knowledge
about functional dentistry, I would have known that the better solution
would have been to embark on the development of her airways. Genetically,
my daughter has a similar facial profile to me, with the same narrow upper
airways. Postsur gery, I brought her to the functional dentist, Dr. Tony O’Connor,
where she had her airways developed using an easy and noninvasive
appliance known as the advanced lightwire functional appliance (ALF). Since then, I recommend to any parent presenting a child with enlar ged
adenoids to look at maxillary expansion  (wideni ng of the upper jaw) and
forward develop ment of the face first. Try that, along with continued nasal
breathing and practicing the Steps  exercise for children (in Chapter T wo). In
most cases, this approach will result in maxillary expansion, develop the
airway, restore nasal breathing,  and reduce inflammation of the adenoids
and tonsils within three months. All of these methods are noninvasive, so
there is little or no trauma involved. The airways are developed, and good
breathing patterns are restored for the long term. If your child’ s breathing proble m persists for more than three months,
then consider an adenotonsillect omy. However, children must still be taught
to breathe nasally after surgery, or SDB is likely to recur within three
years. 12
One 2019 review examined the effects of nose-breathing exercises in
mouth-breathing children. The report concluded that nasal breathing isbetter for the respiratory system. 21 The authors also cited results  from a
2008 paper, which demonstrated that a protocol of respiratory muscle
training and nasal breathing improved respiratory muscle streng th and nasal
inspiratory flow in children who had mouth breathed. 22 This study
discusses the importance of nasal respiratory training for reestablishing lung
volume and nostril elasticity in children. For over a century, researchers have investigated the effect of rapid
maxillary expansion on the functioning of the nose. 23–26 Maxillary
expansion involves wearing a dental appliance positioned in the roof of the
mouth. The device exerts gentle pressure over time to widen the jaws and
airways. Numerous studies have shown how this procedure causes positive
development in the top jaw and nasal cavity and that the result ing changes
improve breathing throughout a child’ s life. THE VIT AL ROLE OF THE DENTIST
Dr. William Hang, a Los Angeles–based airway-centric orthodontist,
describes the dentist as the gatekeeper to the airways. 27 Researchers Peter
Catalano and John W alker also state,
The most likely person to diagnose a child with SDB is their family
dentist or orthod ontist. This is directly related to the fact that nasal
breathing has a tremendous impact on craniofacial developm ent,
which in turn determines dental profile and occlusion (how the teeth
align). Over 90% of children with crooked teeth, teeth grinding, or
malocclusion (misalignment of the teeth) have compromised nasal
breathing. 9
In the United States, thanks to a joint effort by American Acad emy of
Pediatrics and American Academy of Pediatric Dentistry, children are
ensured a “dental home” by the time they reach the age of 1 year. This
means that pediatric dentists have a higher frequency of patient encounters
than most other allied health professionals. 15 A 2017  study of 55 children,
more than 65% of whom were mouth breathers, conc luded that
“Recognition of mouth breathing in young persons by orthodontists ispoor. ”28 But why is this the case. Why isn’t SDB in children, its causes and
treatment, prima rily the domain of the pediatric dentist. And why is it so
often not even picked up by dentists. The connection between nasal breathing and dental issues was first
observed in the 1970s by a Norwegian orthodontist, Dr. Egil Harvold. Harvold noticed that many patients who came to him with dental issues
were also mouth breathers, and he decided to investigate furth er. In 1981,
he publi shed the results of his landmark study, “Primate experim ents in oral
respiration,” in which he compared baby monkeys whose nostrils were
blocked with silicone plugs with a control group. 29 For six months, as the
monkeys grew, those animals whose noses had been plugged began to
mouth breathe by default. This led to many changes in craniofacial
development. The faces of the monkeys whose noses had been blocked
looked very different from those who were able to breathe nasally. They
developed long faces, misaligne d teeth, and altered face and neck muscles
as the body adap ted to form an oral airway. Even after the nasal  obstruction
was removed, they continued to mouth breathe for as much as a year, while
their altered facial features were retained. 29
A 1998 paper by American orthodontist Katherine Vig questioned
Harvold’ s result s. Vig explains that, while Harvold fully blocked the noses
of the monkeys, total nasal obstruction in humans is “extremely rare. ”30
However, I believe that Dr. Vig is missing the point. The issue is not the
extent of nasal obstruction, it is whether or not the child is mout h breathing. The studies by Harvold inves tigated if persistent mouth breathing in
monkeys caused craniofacial abnormalities. The study results showed this
to be the case. A new review published in 2018 reported that children with
nasal obstruction were 5. 55 times more likely to mouth breathe. 5
A study in the American Journ al of Orthodontics  in 1997  also looked at
the effects of nasal obstruction on craniofacial growth in young Japanese
macaque monkeys. 31 Researchers studied 11 animals, of which 7 were
subject to either light or heavy nasal obstruction, while 4 acted as a control
group. Nasal breathing was assessed in terms of nasal airway resistance,
and craniofacial development was measured. In the monkeys whose noses
were blocked, the mandible (lower jaw) rotated downward and backward,
the condyle (jaw joint) grew upward and backward, and the gonial angle ofthe jaw changed. The monkeys also developed anterior open bites and
spaced dental arches. Notably, these changes in growth were significantly
more apparent in the monkeys who had the heavy nasal obstruction. These
results support the theory that a blocked nose in childhood, before and
during puberty, may result in permanent deformities in the structures of the
face and skull. More specifica lly, it may result in skeletal open bite, a
condition where there is no contact between anterior and posterior teeth,
one of the most challenging dentofacial deformities to treat. 31
Another paper from 2011 looked  at the effects of short-term forced oral
breathing on baby rats. Result s showed that even very short -term nasal
obstruction created significant hormonal changes, including an increase of
stress hormones of more than 1,000%. While the stress hormone level
normalized by adulthood, other hormonal changes persisted long term, the
development of the olfactory bulb was impaired, and alterations were seen
in the development of the respiratory muscles. 32
A 2019  assess ment of preschool children in Italy examined the
relationship between mouth breathing and severe malocclusions. 33
Researchers observed oral habits in 1,616 children aged betwe en 3 and 6
years to determine the prevalence of dental problems and the statistical
significance of their connection with mouth breathing and sucking habits. The results showed that 38% of the children needed orthodontic treatment,
and 46% had signs of malocc lusion that required monitoring and risk
factors that needed to be remove d so that the problem could correct itself as
the child grew. Only 16% of the children were completely healthy. Common dental problems included tooth displacement, tooth decay, and
early loss of primary teeth, overbite, overjet, crossbite, and open bite—all
symptomatic of dental misalign ment and poor oral hygiene. It was found
that oral breathing increases as malocclusion gets worse. 33 Separate
research has confirmed the link between oral breathing and poor dental
health, tooth decay, and halitosis. 2
The 2019 study concluded that mouth breathing is a risk factor for
dental malocclusion and should  be intercepted and corrected as early as
possible to prevent the developm ent or worsening of craniofacial problems. However, a 2017 cross-sectional study of patients aged betwee n 10 and 25
years old had concluded that recognition of mouth breathin g in youngpeople by orthodontists is poor. 28 Orthodontists must aim to address these
risk factors to promote correct dento-skeletal growth. This requires
pediatricians, allergists, orthodontists, speech therapists, and ENT
specialists to work closely together to promote early diagnosis and
treatment. 33
SDB in children  is serious and potentially life threatening. Numerous
sources underlin e the fact that dentists may be in the best position to
recognize a potential airway-rel ated sleep problem. 34 It is vital, then, that
dentists enter the profession with a reasonable knowledge of sleep disorders
and their assessment. Only with this understanding can they ensure that
timely referrals and appropriate treatments are offered. Currently, limited
diagnostic norms exist for both children and adults, and more research is
desperately needed, particularly into childhood sleep disorders. The dentist
is trained to look into the mouth. The medical doctor is not. To meet the
best standards of patient welfare, it is clear that sleep medicine requires an
overhaul. Medical doctors must form partnerships with their dental
colleagues. Studies have defined the risk factors of obstructive sleep apnea in
children as a narrow palate, long face, enlar ged tonsils and/or adenoids, and
minor malocclusions (misaligned teeth), and not, as some might expect,
obesity. It should therefore be clear why dentists must be involved in
identifying SDB in children. Indeed, since obstructive SDB affects between
1% and 5% of the pediatric population35 and has been  found to be
implicated in sudden infant death syndrome, this fact should be considered
with some ur gency. 35
Since 2018, the American Dental Association has endorsed sleep and
airway hygiene risk assessment as a primary responsibility of dentists who
provide services for children. 36 It is encouragin g to see that the definition of
optimal pediatri c health is changing and now includes the ability to breathe
nasally during wakefulness and sleep. However, from a convers ation with a
friend of mine, who is a dentist with 40 years of experience, it is clear that
there is still some way to go. He explained to me that when  he talks to
colleagues about breathing, theyare consistently resistant to talking with their patients about the
problems of mouth breathing and dental health. They are waiting
for a “new” dental specialty to evolve. I tell them this
responsibility belongs in every general dental practice. If their
patients. ask them. what to do about dry mouth, snoring,
tongue thrusting, anxiety, teeth grinding or clenching, and sleep
problems, they might be nudged to get involved and really care for
their patients. A UK orthodontist who developed a technique called orthotropics to
correct the effects of childhood mouth breathing has been heavily criticized
within dentistry. Dr. John Mew, who promotes the idea of preventive
measures in younger children rather than surgery later in life, was dismissed
as an “idiot” by a prominent American orthodontist in 2020 in the New York
Times. 37 Mew fell foul of the General Dental Council in 2017 when, at the
age of 89, he lost his license after publishing an advert slamming the
orthodontic community. His son Dr Mike Mew still practices Orthotropics
and increasing research now supports his ideas.
The author recommends that parents encourage their children to practice nasal breathing and forward development of the face, and consider maxillary expansion (wideni ng of the upper jaw) and forward development of the face.
According to the author, what is the recommended approach for addressing mouth breathing in children?
The American Academy of Pediatrics and American Academy of Pediatric Dentistry ensure that children have a "dental home" by the age of 1 year, allowing pediatricians and dentists to identify and address potential issues early on.
What is the significance of the American Academy of Pediatrics and American Academy of Pediatric Dentistry in promoting good health practices for children?
The primary role of the heart is to pump blood around the body, distributing oxygen and carbon dioxide, and to bring deoxygenated blood back to the lungs.
What is the primary role of the heart in the body?
The main issue is that it may not address the underlying causes of the problem, leading to a higher risk of long-term complications.
What is the main issue with using a traditional orthodontic treatment approach in children?
The text does not provide a specific frequency for practicing slow breathing exercises, but it does mention that the importance of nasal breathing and the practice of the Steps exercise for children.
What is the recommended frequency for practicing slow breathing exercises?