Hi everyone and welcome to Airway First, a podcast from the Children's Airway First
Foundation.
I'm your host, Rebecca St. James.
My guest on the show today is Dr. Tina Ricardia.
She is an American trained prosthodontist that's currently practicing in Dubai.
I'll list Dr. Ricardia's bio in the show notes along with a link to her website so you can
check out her information at your leisure.
So let's go ahead and jump right into my interview with Dr. Tina Ricardia.
All right, thanks so much for joining us today, Dr. Ricardia.
It's my pleasure.
Thank you for having me.
I appreciate it.
I know it's late over there, so I truly, truly appreciate it.
So let's just jump right in.
I have heard you speak on the impacts of poor sleep on children's health, specifically
around growth hormones, which that's something new for me.
So I'd like to start there if that works.
And if you would just explain about how sleep and the release of growth hormones are related
and then how mouth breathing and snoring and sleep apnea can also impact this for children.
Sure.
So logically speaking, if you told any parent that their child doesn't sleep well, they
would conclude that that child will not grow well.
But in the field of medicine, we need research to tell us every step of that.
So you know, Maurice and Almeida did a really amazing study in 2018.
And what they saw is that it was more like a review around other studies.
They said that sleep begins at what we call the NREM stage, the non-rapid eye movement
stage.
And it gets broken down into, you know, stage one, stage two, or stage three deep sleep.
It is this deep sleep stage where growth hormone is secreted by the pituitary gland.
Now we also know that when children don't sleep well, or they sleep in broken phases
of sleep, or if they are mouth breathing, they don't get into the deeper stages of sleep.
The most affected part of the sleep cycle is the stage three deep sleep.
So if they haven't had enough time in that deep sleep stage, then there hasn't been enough
secretion of the growth hormone.
So they also tested this in animals as well as in children to say that the growth hormone,
releasing hormone, which acts on the pituitary gland, that amount is reduced in children
with poor sleep.
And they gave a lot of explanations around this, that you know, if you have nocturnal
hypoxemia, nocturnal acidosis, also we have to understand that a child who is mouth breathing
is getting the same amount of oxygen in, but is struggling harder to get that amount of
oxygen in.
So there is increased energy consumption, which is also affecting their growth by increasing
their calorie intake, literally by, sorry, calorie output by the amount of effort they
have to do breathing through that.
Okay, got it.
And to build on that, so what are some of the physiological impacts that mouth breathing
and poor sleep have on children?
Such a long list, isn't it?
I like to start with literally the brain.
So Dr. G. McIntosh talks about this a lot, that there are studies which show that in
just six months of poor breathing, and it could be sleep apnea, but it could also just
be mouth breathing.
So there is neurocognitive changes in the brain, which means that literally brain is
not developing like it needs to in these children.
So you know, that leads to learning disabilities, problems in school, but now like look at the
other aspect of a child who's not slept well enough, they are tired by day, but children
are not like adults who drink coffee or can cope better with it.
So they are often hyperactive by day.
So parents will often say my child sleeps well, and they are like really active by day,
but actually they are hyperactive by day.
So that's another physiological effect of not getting enough sleep.
Further down into the body, you're not breathing in the correct levels of carbon dioxide, nitric
oxide, oxygen.
This puts your body in a state of fight or flight throughout the night.
So heart rate, heart rate variability is increased.
In adults, we know that causes a huge range of cardiovascular issues as well.
In children, bed wetting is very common because again, the blood volume that increases because
of these gases imbalance results in the bladder being over full and children have to, you
know, read the bed to return physiology back to normal.
We also have challenges with growth of the jaws.
So you know, a mouth breathing results in the tongue lying low in the mouth.
The minute the tongue is lying low in the mouth, the maxilla is more affected by the
cheeks and the lips, forcing the upper jaw to cave in.
This caving in in children causes the palate to waltz up into the nose.
Now we are sort of in the midst of a cycle.
So I often like to give this analogy that the tongue is the car and the upper jaw is
the garage.
And it is hard for this tongue.
When this tongue can park in the garage, we will all nose breathe and there will be very
little incidents of sleep apnea into adulthood.
So it's my job to figure out what is stopping this tongue from parking into its garage and
what is, how do we get it there?
How do we teach it to stay there?
So whether we are looking at tongue ties or, you know, just posture or that garage being
too small, the maxilla being too small, we go on those correction parts.
But once we are in the cycle, it's a bit harder to break that cycle.
So you know, when the mouth, when we've already been mouth breathing snoring for a long time,
that tongue is lying low and the nose is congested.
So it's not easy to say close your mouth, tape your mouth and go to sleep.
There needs to be some, you have to break that cycle by emptying the nose correcting
habits.
During this process, what often happens is the continuous mouth breathing can cause inflammation
and you have enlarged tonsils and adenoids, which then sets up another cascade of physiological
changes.
Okay.
Well, let's, let's talk a little bit about that because I know you've shared some information
and studies about the cause and effect of tonsil and adenoid enlargement specifically
around sleep disorder breathing.
Yeah.
This is a topic that, you know, I, I was very close to my heart because removal of tonsils
and adenoids in the research is considered as the first line of treatment for sleep apnea.
And as I started on this journey, I kept finding patients who've already had their tonsils and
adenoids removed, but are still mouth breathing and are still snoring.
And the ENTs are sort of at a loss at this point to say what's next, or they kind of
conclude that mouth breathing is just a habit and that's okay.
So this was really heartbreaking for me to chance upon.
I understand that, you know, ENT education everywhere in the world is also varied, but
I started speaking to people in the region and even at like ENT Congresses and learned
that mouth breathing is not a diagnosis in the ENT world.
They do not see this as a problem.
And we know that the spectrum of sleep disorder breathing starts at mouth breathing and probably
ends at sleep apnea.
So to not treat mouth breathing or to, you know, consider it a non-diagnosis is just
a random symptom means that we're only looking at treating end stage disease.
So to backtrack back to the tonsils and the adenoids, Dr. Giumino has a lot of research
which showed that, you know, it was a cycle of oral dysfunction.
It's been added upon by the amazing Dr. Zaghi.
But it basically points to the idea that if we are mouth breathing, there is going to
be a higher level of inflammation in the body.
Now the tonsils and the adenoids are lymphoid tissue.
Their job is to enlarge in the face of inflammation and to protect the tissues.
We're also breathing in more unfiltered air, lack of nitric oxide.
It just logically makes sense that if we mouth breathe, children especially, for long enough
our tonsils and adenoids would enlarge.
But if we are removing the tonsils and adenoids, we're not treating the cause.
We're just treating one of the symptoms of mouth breathing.
So, you know, put in some great studies on my Instagram if you'd like to refer to them,
which show, you know, some are like distanced children and other are like thousands of children,
where they've concluded that just removing the tonsils and the adenoids by themselves
is not going to take away sleep apnea in most of the patients.
There is going to be, there's going to need to be some other form of intervention, either
mouth functional therapy or expansion, some other way to stop the mouth breathing if you
don't want them to relapse.
But that's one population who's already had surgery, where we talk about the other half
of the children who are mouth breathing and have not had them so enlarged that they need
surgery.
Okay.
And this is why I identify with the foundation so much to say, if we jump in early enough,
we can do more noninvasive things to, you know, treat the root cause rather than jump
in, do surgery and then try to correct.
And try to backfill.
Yeah.
So what about older children?
I mean, one of the things we talk about, obviously, is we really want to fix before
six.
And even before that, because, you know, you can now see it in utero, which is amazing.
So what about older children?
I mean, is it too late for them?
How do we course correct, you know, a 10 year old, a 12 year old, a teenager?
It's never too late.
We have 60 year old people in treatment as well.
And it's never too late, especially with children who are still, you know, have growth potential
in them or even in their early 20s, it's not too late.
What can we do?
There are slightly more invasive measures needed.
So you know, if the nasal septum is already deviated, then, you know, we could have surgical
correction of that if the maxilla midline suture has already fused, you know, you can
have surgical expansion of the maxilla.
I'm talking more about like 17, 18 year olds.
Okay.
25 year olds would need surgical advancement of both jaws.
Myofunctional therapy is still very helpful.
But what I want to point out is that the longer we wait, this strain of trying to breathe
through a smaller airway, as well as the high-pox induced changes that happen in the tissues
causes collapsibility.
And in the ENT world, what they're really trying to treat is collapsibility.
So there's a lot of surgery done for patients with OSA to just try to keep that airway open
because it is so easily collapsible by a certain point.
But we have reached that certain point because of neglecting the earlier stages of disease.
So even if someone's in their 20s, in their 30s, it's a great idea to start treatment
because you're still in early stage disease, rather than in end stage disease.
But in like the, in the eight year olds, 10 year olds, 15 year olds, this is very easily
correctable.
You're listening to Airway First with today's guest, Dr. Tina Ricardia.
You can find out more about the Children's Airway First Foundation and our mission to
fix before six on our website at childrensairwayfirst.org.
The CAF website offers tons of great resources for parents and medical professionals, including
videos, blogs, recommended reading, comprehensive medical research, podcasts, and so much more.
Parents are encouraged to join the Airway Huddle, our Facebook support group, which was created
for parents of children with airway and sleep related issues.
You can access the Airway Huddle support group at facebook.com, backslash groups, backslash
airway huddle.
If you'd like to be a guest or have an idea for an upcoming episode, shoot us a note via
the contacts page on our website, or send us an email directly at info at childrensairwayfirst.org.
As a reminder, this podcast and the opinions expressed here are not a medical diagnosis.
If you suspect your child might have an airway issue, contact your pediatric airway dentist
or pediatrician.
And now let's jump back into my interview with today's guest, Dr. Tina Ricardia.
Okay, all right, it's just more as you get older.
Yes, that that is not like clay like anymore.
It's not as easy to to expand it.
To move.
Like after like, you're 13.
But it's it's all right.
You know, we start when we start.
So I'd like to change gears just a little bit because I saw something.
I can't remember who's on your Facebook or Instagram.
When I find it, I'll put a link to it in the show notes.
But it was something that I wish I had known with my children.
Specifically around nighttime feeding, whether it's breastfeeding or bottle feeding, because
you know, we've all been through it.
You're tired, not feed them, you put them back down, you go to bed.
But and what I read, this can have an impact on children, especially if they have visible
teeth showing.
Right, right.
Right.
This topic that I feel very passionately about as a parent, I'm not a pediatric dentist
and you know, pediatric dentists have a huge range of concessed newspapers and things like
this.
But this is something that I went through with my own children and I felt like after
I had them, I would never ever tell the parent, you must stop breastfeeding today.
You know, like that that's not really feasible that parent goes home thinking how are we all
going to ever sleep again?
Right.
I think breast milk is just perfectly OK.
Exclusive breastfeeding, even with teeth in place is just perfectly OK.
There are studies done where they put teeth in glasses of breast milk and nothing happened
to cursed teeth.
But the problem is when we add lip ties, tongue ties, easily fermentable carbs into the diet.
So when the child starts, you know, you could have children who got teeth at three months
of age.
And if you did not start solids till like six or seven months of age, nothing happens to
those teeth.
But you then suddenly add the wrong sort of initial solids.
You're not cleaning well or the mouth is not able to sufficiently clean well because of
lip ties or tongue ties.
This is where the trouble starts.
Another aspect that is often neglected is what is the risk?
You know, is the family high risk or low risk with their K-rease rate?
So we know that, you know, the bacteria that cause K-rease, it's called streptococcus
mucous.
That spreads by spoon sharing, by kissing.
Kind of say, don't kiss my baby.
I want to kiss my baby.
But if I am high risk, if I presently have active decay in my mouth or generally have,
you know, the microbiome, which is more high risk for decay, then I need to add up all these
factors together for this child.
So that becomes the dentist job, right?
The parent is not aware around these things.
So the simplest thing to do is to go to the dentist from that first birthday.
You know, it's been like four or five months since those teeth have come in at a very time.
And if they're examining, they're asking the right questions to say, whereas what is your
diet like?
What is your, as a parent, what is your K-rease risk like?
Then exclusive breastfeeding is perfectly okay.
Bottles are a slightly different story.
Data has a slightly higher risk of decay.
Again, it's just, we're just adding up all these little risks, right?
It's not one thing, which is just the bad thing.
So it becomes sort of the dentist barogated to see how many of these risks does that family
have?
And hence, would they actually benefit from stopping the nighttime bottle, which by about
14, 15 months of age, you know, should either be diluted or gradually weaned off.
But that's okay.
That's what you have to watch.
So I want to make sure I get this quoted correctly.
On your Facebook page, you mentioned that most professionals and parents don't consider
mouth breathing as poor sleep.
And that's where the medical system fails us.
So in your perfect world, how do we resolve this disconnect?
I mean, the studies are there, the science is there.
How do we resolve this?
So you know, what led me to like say that statement.
So when I started on my journey, and I'm a recovering mouth breather myself, I had severe
allergies and had allergies my whole life, and these to really affect my quality of life
as well as my work.
So I had visited so many practitioners by that time, few years earlier, my son had severe
picky eating.
He had a strong gag reflex, you know, we had seen pediatricians osteopaths.
He was later diagnosed with a posterior tongue tie.
And it had just shocked me why nobody had asked me these questions before.
So entities for congested noses, osteopaths for generalized body tension, physiotherapists
for neck strains, allergies for my chronic allergy, rhinitis, my child's physician at
a wellness check, orthodontist before treating me with Invisalign, my child's pediatrician,
a feeding therapist, nobody in all these, you know, few professions that I mentioned had
ever asked if I was mouth breathing and told me that I should see how I could change that.
And that's when I mentioned that, you know, I recently sat at an ENT Congress where I
learned that mouth breathing is not considered a diagnosis.
This thing that's making us tired is making our children not grow correctly, giving us
blood pressure is, you know, leading to sleep apnea is not considered to be an issue.
So what would my ideal world will look like?
It would be a world where all medical professionals understood the benefits of nasal breathing.
Right.
So it's not from like breastfeeding support, early recognition of the signs of disorder,
breathing, you know, like parents know that their child is supposed to just have that
six month old baby is supposed to have their lips closed at all times, where like 10 year
olds know that their tongue is supposed to be up on their palate, you know, at all times,
where tongue and lip strength are considered important, like crawling and walking milestones
are today when our babies don't crawl, we know that.
So why don't we know that what is what is the capability of their tongues, right?
And where sleep is looked at before a cardiovascular diagnosis and ADHD diagnosis and Alzheimer
diagnosis and asthma diagnosis.
So if you take mouth breathing seriously and resolve that, that's what my ideal world
would look like.
Work on prevention and treatment of early stage signs instead of end stage disease.
I like that.
I really like that.
And in the UAE, which is to remind listeners is where you are.
We have our own set of challenges that we're facing here.
What are you facing there as far as combating mouth breathing and sleep apnea specifically
in children?
Right.
So I practice in Dubai and I've been here like 17 years now.
So I do have a good understanding of the region.
And as the sleep practice has gotten busy, my training is all from the US.
So I'm able to like compare and contrast a few things.
And there's some distinct advantages and I want to share those first.
In the Islamic culture, breastfeeding is huge, the Quranic texts say that women should breastfeed
for up to two years if they choose to.
So culturally more women choose to breastfeed than not.
So that's a great advantage.
We have a lot of like Asian population, Indian subcontinent along with the Arab population
here.
And in this culture, table food is very big.
So baby lead weaning is not a thing.
It is just the way of life.
So from the start, children, I encouraged us to sit at the table, taste curry flavors,
eat vegetables and fruits like adults do.
The foods are this.
So I've heard Dr. Miralia speak about this, that if they have like one child who's growing
normally, they're like, this is our unicorn and we're going to go take pictures of this
child because you know, all of us have forgotten what that looks like.
I wouldn't say that's the case over here.
I would say that we have more at about an 80% affected, not a 95, 97% affected population.
So these are some of the advantages.
The disadvantages are that it's harder for newer education to reach everybody.
The uptake of new education is slower than in the US.
So in each field, whether it's in vineyards or in implants or in like other fields of
medicine, there are a few cutting edge professionals doing some really amazing work, but it takes
time for it to just become the standard practice.
The other thing, at least in dentistry is that we don't have much of a referral culture
as much as we have in the US.
So it is not very common for people to refer to specialists outside of their practices.
They try to keep, it's a population demographic.
I don't blame anybody on it, but we generally have a much larger population of dentists than
of patients.
And there is very little dental insurance.
It's all private paid, predominantly, or dental insurance covers.
It's not as lovely as Medicaid or I know that the Americans don't love Medicaid.
So we don't have that.
To add to it, sleep apnea is something that is treatable only by ENTs and sleep surgeons
on record.
So it is harder for dentists to claim insurance even if there was any on that front.
So I've tried to keep these disadvantages separate and I really am trying to be an advocate
for every to spread knowledge within the community.
I'm Eliza for the AMPD for the UAE, hoping to start a study club of some wonderful people
that have met over these past couple of years, ICBLC's, breathing coach, oxygen advantage
trainers, ENTs, people have been open and receptive to wanting to do more.
So while there are some distinct challenges and being sort of the path breaker has not
been easy.
Right.
But I'm determined to go on and to use my voice to spread the word to say we need to
do more for our children.
Right.
And anything we can do to help you spread the word, you know, we will be there for sure.
Thank you.
I appreciate that.
Absolutely.
So at the end of every podcast, I always like to just hand the floor back over to our guest
and it's open to you.
You can talk to parents, you can talk to medical professionals, you can talk to both, just
your final thoughts that you would like to leave for either group.
Okay.
All right.
I found to tell parents that it is very overwhelming to hear that there is so much going on that
you haven't seen before and that, you know, how could this be?
And how could nobody be talking about it?
But I want you to know that just because you haven't heard of it before doesn't mean that
it's not real.
And there are practitioners out there who are working really hard on educating themselves
and teaming up and collaborating to make this work in the best way possible.
But what we do know is that prevention and early stage disease is so much easier to treat
than waiting and waiting.
Right.
And I think that the end game is not the end game.
I have five year olds, four year olds in my practice and we all rejoice over nasal breathing
is if we breathe right, everything will be right.
Breathing is life.
And I do want to leave a little message for the practitioners around me as well.
Dentists as well as other, as well as other professionals.
There's a lot of work to be done over here.
We have not looked at some of these basic aspects for many, many decades now.
And here's a chance for us to sort of come together and, you know, collaborate and work
on resolving things from all our different viewpoints, but together.
And I'm really looking forward to being part of that journey in the UAE.
Love that.
Well, thank you so much for being on our podcast and sharing your insights.
Plus, you know, just giving us a little bit of perspective about your challenges in the
UAE and just really appreciate it.
Thank you so much for having me.
I really, really loved the chance to be able to talk to you.
Thanks again to today's guest, Dr. Tina Ricardia for sharing her medical insight into each
of you for listening to today's episode.
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