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Hi everyone and welcome to Airway First, a podcast from the Children's Airway First

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Foundation.

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I'm your host, Rebecca St. James.

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My guest on the show today is Dr. Tina Ricardia.

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She is an American trained prosthodontist that's currently practicing in Dubai.

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I'll list Dr. Ricardia's bio in the show notes along with a link to her website so you can

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check out her information at your leisure.

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So let's go ahead and jump right into my interview with Dr. Tina Ricardia.

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All right, thanks so much for joining us today, Dr. Ricardia.

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It's my pleasure.

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Thank you for having me.

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I appreciate it.

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I know it's late over there, so I truly, truly appreciate it.

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So let's just jump right in.

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I have heard you speak on the impacts of poor sleep on children's health, specifically

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around growth hormones, which that's something new for me.

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So I'd like to start there if that works.

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And if you would just explain about how sleep and the release of growth hormones are related

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and then how mouth breathing and snoring and sleep apnea can also impact this for children.

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Sure.

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So logically speaking, if you told any parent that their child doesn't sleep well, they

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would conclude that that child will not grow well.

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But in the field of medicine, we need research to tell us every step of that.

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So you know, Maurice and Almeida did a really amazing study in 2018.

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And what they saw is that it was more like a review around other studies.

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They said that sleep begins at what we call the NREM stage, the non-rapid eye movement

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stage.

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And it gets broken down into, you know, stage one, stage two, or stage three deep sleep.

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It is this deep sleep stage where growth hormone is secreted by the pituitary gland.

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Now we also know that when children don't sleep well, or they sleep in broken phases

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of sleep, or if they are mouth breathing, they don't get into the deeper stages of sleep.

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The most affected part of the sleep cycle is the stage three deep sleep.

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So if they haven't had enough time in that deep sleep stage, then there hasn't been enough

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secretion of the growth hormone.

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So they also tested this in animals as well as in children to say that the growth hormone,

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releasing hormone, which acts on the pituitary gland, that amount is reduced in children

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with poor sleep.

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And they gave a lot of explanations around this, that you know, if you have nocturnal

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hypoxemia, nocturnal acidosis, also we have to understand that a child who is mouth breathing

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is getting the same amount of oxygen in, but is struggling harder to get that amount of

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oxygen in.

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So there is increased energy consumption, which is also affecting their growth by increasing

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their calorie intake, literally by, sorry, calorie output by the amount of effort they

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have to do breathing through that.

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Okay, got it.

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And to build on that, so what are some of the physiological impacts that mouth breathing

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and poor sleep have on children?

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Such a long list, isn't it?

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I like to start with literally the brain.

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So Dr. G. McIntosh talks about this a lot, that there are studies which show that in

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just six months of poor breathing, and it could be sleep apnea, but it could also just

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be mouth breathing.

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So there is neurocognitive changes in the brain, which means that literally brain is

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not developing like it needs to in these children.

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So you know, that leads to learning disabilities, problems in school, but now like look at the

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other aspect of a child who's not slept well enough, they are tired by day, but children

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are not like adults who drink coffee or can cope better with it.

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So they are often hyperactive by day.

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So parents will often say my child sleeps well, and they are like really active by day,

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but actually they are hyperactive by day.

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So that's another physiological effect of not getting enough sleep.

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Further down into the body, you're not breathing in the correct levels of carbon dioxide, nitric

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oxide, oxygen.

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This puts your body in a state of fight or flight throughout the night.

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So heart rate, heart rate variability is increased.

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In adults, we know that causes a huge range of cardiovascular issues as well.

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In children, bed wetting is very common because again, the blood volume that increases because

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of these gases imbalance results in the bladder being over full and children have to, you

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know, read the bed to return physiology back to normal.

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We also have challenges with growth of the jaws.

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So you know, a mouth breathing results in the tongue lying low in the mouth.

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The minute the tongue is lying low in the mouth, the maxilla is more affected by the

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cheeks and the lips, forcing the upper jaw to cave in.

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This caving in in children causes the palate to waltz up into the nose.

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Now we are sort of in the midst of a cycle.

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So I often like to give this analogy that the tongue is the car and the upper jaw is

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the garage.

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And it is hard for this tongue.

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When this tongue can park in the garage, we will all nose breathe and there will be very

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little incidents of sleep apnea into adulthood.

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So it's my job to figure out what is stopping this tongue from parking into its garage and

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what is, how do we get it there?

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How do we teach it to stay there?

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So whether we are looking at tongue ties or, you know, just posture or that garage being

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too small, the maxilla being too small, we go on those correction parts.

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But once we are in the cycle, it's a bit harder to break that cycle.

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So you know, when the mouth, when we've already been mouth breathing snoring for a long time,

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that tongue is lying low and the nose is congested.

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So it's not easy to say close your mouth, tape your mouth and go to sleep.

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There needs to be some, you have to break that cycle by emptying the nose correcting

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habits.

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During this process, what often happens is the continuous mouth breathing can cause inflammation

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and you have enlarged tonsils and adenoids, which then sets up another cascade of physiological

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changes.

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Okay.

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Well, let's, let's talk a little bit about that because I know you've shared some information

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and studies about the cause and effect of tonsil and adenoid enlargement specifically

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around sleep disorder breathing.

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Yeah.

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This is a topic that, you know, I, I was very close to my heart because removal of tonsils

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and adenoids in the research is considered as the first line of treatment for sleep apnea.

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And as I started on this journey, I kept finding patients who've already had their tonsils and

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adenoids removed, but are still mouth breathing and are still snoring.

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And the ENTs are sort of at a loss at this point to say what's next, or they kind of

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conclude that mouth breathing is just a habit and that's okay.

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So this was really heartbreaking for me to chance upon.

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I understand that, you know, ENT education everywhere in the world is also varied, but

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I started speaking to people in the region and even at like ENT Congresses and learned

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that mouth breathing is not a diagnosis in the ENT world.

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They do not see this as a problem.

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And we know that the spectrum of sleep disorder breathing starts at mouth breathing and probably

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ends at sleep apnea.

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So to not treat mouth breathing or to, you know, consider it a non-diagnosis is just

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a random symptom means that we're only looking at treating end stage disease.

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So to backtrack back to the tonsils and the adenoids, Dr. Giumino has a lot of research

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which showed that, you know, it was a cycle of oral dysfunction.

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It's been added upon by the amazing Dr. Zaghi.

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But it basically points to the idea that if we are mouth breathing, there is going to

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be a higher level of inflammation in the body.

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Now the tonsils and the adenoids are lymphoid tissue.

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Their job is to enlarge in the face of inflammation and to protect the tissues.

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We're also breathing in more unfiltered air, lack of nitric oxide.

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It just logically makes sense that if we mouth breathe, children especially, for long enough

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our tonsils and adenoids would enlarge.

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But if we are removing the tonsils and adenoids, we're not treating the cause.

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We're just treating one of the symptoms of mouth breathing.

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So, you know, put in some great studies on my Instagram if you'd like to refer to them,

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which show, you know, some are like distanced children and other are like thousands of children,

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where they've concluded that just removing the tonsils and the adenoids by themselves

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is not going to take away sleep apnea in most of the patients.

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There is going to be, there's going to need to be some other form of intervention, either

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mouth functional therapy or expansion, some other way to stop the mouth breathing if you

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don't want them to relapse.

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But that's one population who's already had surgery, where we talk about the other half

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of the children who are mouth breathing and have not had them so enlarged that they need

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surgery.

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Okay.

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And this is why I identify with the foundation so much to say, if we jump in early enough,

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we can do more noninvasive things to, you know, treat the root cause rather than jump

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in, do surgery and then try to correct.

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And try to backfill.

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Yeah.

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So what about older children?

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I mean, one of the things we talk about, obviously, is we really want to fix before

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six.

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And even before that, because, you know, you can now see it in utero, which is amazing.

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So what about older children?

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I mean, is it too late for them?

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How do we course correct, you know, a 10 year old, a 12 year old, a teenager?

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It's never too late.

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We have 60 year old people in treatment as well.

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And it's never too late, especially with children who are still, you know, have growth potential

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in them or even in their early 20s, it's not too late.

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What can we do?

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There are slightly more invasive measures needed.

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So you know, if the nasal septum is already deviated, then, you know, we could have surgical

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correction of that if the maxilla midline suture has already fused, you know, you can

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have surgical expansion of the maxilla.

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I'm talking more about like 17, 18 year olds.

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Okay.

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25 year olds would need surgical advancement of both jaws.

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Myofunctional therapy is still very helpful.

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But what I want to point out is that the longer we wait, this strain of trying to breathe

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through a smaller airway, as well as the high-pox induced changes that happen in the tissues

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causes collapsibility.

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And in the ENT world, what they're really trying to treat is collapsibility.

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So there's a lot of surgery done for patients with OSA to just try to keep that airway open

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because it is so easily collapsible by a certain point.

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But we have reached that certain point because of neglecting the earlier stages of disease.

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So even if someone's in their 20s, in their 30s, it's a great idea to start treatment

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because you're still in early stage disease, rather than in end stage disease.

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But in like the, in the eight year olds, 10 year olds, 15 year olds, this is very easily

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correctable.

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You're listening to Airway First with today's guest, Dr. Tina Ricardia.

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You can find out more about the Children's Airway First Foundation and our mission to

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fix before six on our website at childrensairwayfirst.org.

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The CAF website offers tons of great resources for parents and medical professionals, including

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videos, blogs, recommended reading, comprehensive medical research, podcasts, and so much more.

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Parents are encouraged to join the Airway Huddle, our Facebook support group, which was created

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for parents of children with airway and sleep related issues.

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You can access the Airway Huddle support group at facebook.com, backslash groups, backslash

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airway huddle.

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If you'd like to be a guest or have an idea for an upcoming episode, shoot us a note via

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the contacts page on our website, or send us an email directly at info at childrensairwayfirst.org.

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As a reminder, this podcast and the opinions expressed here are not a medical diagnosis.

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If you suspect your child might have an airway issue, contact your pediatric airway dentist

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or pediatrician.

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And now let's jump back into my interview with today's guest, Dr. Tina Ricardia.

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Okay, all right, it's just more as you get older.

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Yes, that that is not like clay like anymore.

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It's not as easy to to expand it.

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To move.

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Like after like, you're 13.

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But it's it's all right.

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You know, we start when we start.

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So I'd like to change gears just a little bit because I saw something.

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I can't remember who's on your Facebook or Instagram.

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When I find it, I'll put a link to it in the show notes.

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But it was something that I wish I had known with my children.

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Specifically around nighttime feeding, whether it's breastfeeding or bottle feeding, because

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you know, we've all been through it.

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You're tired, not feed them, you put them back down, you go to bed.

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But and what I read, this can have an impact on children, especially if they have visible

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teeth showing.

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Right, right.

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Right.

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This topic that I feel very passionately about as a parent, I'm not a pediatric dentist

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and you know, pediatric dentists have a huge range of concessed newspapers and things like

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this.

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But this is something that I went through with my own children and I felt like after

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I had them, I would never ever tell the parent, you must stop breastfeeding today.

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You know, like that that's not really feasible that parent goes home thinking how are we all

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going to ever sleep again?

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Right.

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Right.

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I think breast milk is just perfectly OK.

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Exclusive breastfeeding, even with teeth in place is just perfectly OK.

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There are studies done where they put teeth in glasses of breast milk and nothing happened

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to cursed teeth.

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But the problem is when we add lip ties, tongue ties, easily fermentable carbs into the diet.

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So when the child starts, you know, you could have children who got teeth at three months

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of age.

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And if you did not start solids till like six or seven months of age, nothing happens to

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those teeth.

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But you then suddenly add the wrong sort of initial solids.

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You're not cleaning well or the mouth is not able to sufficiently clean well because of

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lip ties or tongue ties.

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This is where the trouble starts.

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Another aspect that is often neglected is what is the risk?

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You know, is the family high risk or low risk with their K-rease rate?

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So we know that, you know, the bacteria that cause K-rease, it's called streptococcus

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mucous.

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That spreads by spoon sharing, by kissing.

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Kind of say, don't kiss my baby.

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I want to kiss my baby.

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But if I am high risk, if I presently have active decay in my mouth or generally have,

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you know, the microbiome, which is more high risk for decay, then I need to add up all these

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factors together for this child.

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So that becomes the dentist job, right?

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The parent is not aware around these things.

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So the simplest thing to do is to go to the dentist from that first birthday.

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You know, it's been like four or five months since those teeth have come in at a very time.

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And if they're examining, they're asking the right questions to say, whereas what is your

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diet like?

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What is your, as a parent, what is your K-rease risk like?

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Then exclusive breastfeeding is perfectly okay.

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Bottles are a slightly different story.

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Data has a slightly higher risk of decay.

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Again, it's just, we're just adding up all these little risks, right?

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It's not one thing, which is just the bad thing.

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So it becomes sort of the dentist barogated to see how many of these risks does that family

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have?

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And hence, would they actually benefit from stopping the nighttime bottle, which by about

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14, 15 months of age, you know, should either be diluted or gradually weaned off.

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But that's okay.

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That's what you have to watch.

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So I want to make sure I get this quoted correctly.

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On your Facebook page, you mentioned that most professionals and parents don't consider

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mouth breathing as poor sleep.

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And that's where the medical system fails us.

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So in your perfect world, how do we resolve this disconnect?

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I mean, the studies are there, the science is there.

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How do we resolve this?

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So you know, what led me to like say that statement.

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So when I started on my journey, and I'm a recovering mouth breather myself, I had severe

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allergies and had allergies my whole life, and these to really affect my quality of life

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as well as my work.

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So I had visited so many practitioners by that time, few years earlier, my son had severe

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picky eating.

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He had a strong gag reflex, you know, we had seen pediatricians osteopaths.

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He was later diagnosed with a posterior tongue tie.

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And it had just shocked me why nobody had asked me these questions before.

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So entities for congested noses, osteopaths for generalized body tension, physiotherapists

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for neck strains, allergies for my chronic allergy, rhinitis, my child's physician at

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a wellness check, orthodontist before treating me with Invisalign, my child's pediatrician,

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a feeding therapist, nobody in all these, you know, few professions that I mentioned had

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ever asked if I was mouth breathing and told me that I should see how I could change that.

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And that's when I mentioned that, you know, I recently sat at an ENT Congress where I

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learned that mouth breathing is not considered a diagnosis.

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This thing that's making us tired is making our children not grow correctly, giving us

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blood pressure is, you know, leading to sleep apnea is not considered to be an issue.

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So what would my ideal world will look like?

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It would be a world where all medical professionals understood the benefits of nasal breathing.

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Right.

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So it's not from like breastfeeding support, early recognition of the signs of disorder,

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breathing, you know, like parents know that their child is supposed to just have that

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six month old baby is supposed to have their lips closed at all times, where like 10 year

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olds know that their tongue is supposed to be up on their palate, you know, at all times,

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where tongue and lip strength are considered important, like crawling and walking milestones

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are today when our babies don't crawl, we know that.

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So why don't we know that what is what is the capability of their tongues, right?

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And where sleep is looked at before a cardiovascular diagnosis and ADHD diagnosis and Alzheimer

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diagnosis and asthma diagnosis.

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So if you take mouth breathing seriously and resolve that, that's what my ideal world

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would look like.

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Work on prevention and treatment of early stage signs instead of end stage disease.

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I like that.

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I really like that.

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And in the UAE, which is to remind listeners is where you are.

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We have our own set of challenges that we're facing here.

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What are you facing there as far as combating mouth breathing and sleep apnea specifically

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in children?

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Right.

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So I practice in Dubai and I've been here like 17 years now.

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So I do have a good understanding of the region.

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And as the sleep practice has gotten busy, my training is all from the US.

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So I'm able to like compare and contrast a few things.

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And there's some distinct advantages and I want to share those first.

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In the Islamic culture, breastfeeding is huge, the Quranic texts say that women should breastfeed

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for up to two years if they choose to.

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So culturally more women choose to breastfeed than not.

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So that's a great advantage.

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We have a lot of like Asian population, Indian subcontinent along with the Arab population

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here.

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And in this culture, table food is very big.

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So baby lead weaning is not a thing.

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It is just the way of life.

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So from the start, children, I encouraged us to sit at the table, taste curry flavors,

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eat vegetables and fruits like adults do.

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The foods are this.

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So I've heard Dr. Miralia speak about this, that if they have like one child who's growing

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normally, they're like, this is our unicorn and we're going to go take pictures of this

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child because you know, all of us have forgotten what that looks like.

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I wouldn't say that's the case over here.

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I would say that we have more at about an 80% affected, not a 95, 97% affected population.

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So these are some of the advantages.

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The disadvantages are that it's harder for newer education to reach everybody.

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The uptake of new education is slower than in the US.

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So in each field, whether it's in vineyards or in implants or in like other fields of

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medicine, there are a few cutting edge professionals doing some really amazing work, but it takes

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time for it to just become the standard practice.

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The other thing, at least in dentistry is that we don't have much of a referral culture

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as much as we have in the US.

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So it is not very common for people to refer to specialists outside of their practices.

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They try to keep, it's a population demographic.

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I don't blame anybody on it, but we generally have a much larger population of dentists than

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of patients.

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And there is very little dental insurance.

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It's all private paid, predominantly, or dental insurance covers.

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It's not as lovely as Medicaid or I know that the Americans don't love Medicaid.

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So we don't have that.

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To add to it, sleep apnea is something that is treatable only by ENTs and sleep surgeons

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on record.

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So it is harder for dentists to claim insurance even if there was any on that front.

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So I've tried to keep these disadvantages separate and I really am trying to be an advocate

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for every to spread knowledge within the community.

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I'm Eliza for the AMPD for the UAE, hoping to start a study club of some wonderful people

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that have met over these past couple of years, ICBLC's, breathing coach, oxygen advantage

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trainers, ENTs, people have been open and receptive to wanting to do more.

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So while there are some distinct challenges and being sort of the path breaker has not

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been easy.

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Right.

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But I'm determined to go on and to use my voice to spread the word to say we need to

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do more for our children.

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Right.

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Right.

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And anything we can do to help you spread the word, you know, we will be there for sure.

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Thank you.

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I appreciate that.

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Absolutely.

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So at the end of every podcast, I always like to just hand the floor back over to our guest

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and it's open to you.

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You can talk to parents, you can talk to medical professionals, you can talk to both, just

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your final thoughts that you would like to leave for either group.

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Okay.

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All right.

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I found to tell parents that it is very overwhelming to hear that there is so much going on that

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you haven't seen before and that, you know, how could this be?

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And how could nobody be talking about it?

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But I want you to know that just because you haven't heard of it before doesn't mean that

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it's not real.

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And there are practitioners out there who are working really hard on educating themselves

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and teaming up and collaborating to make this work in the best way possible.

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But what we do know is that prevention and early stage disease is so much easier to treat

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than waiting and waiting.

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Right.

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And I think that the end game is not the end game.

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I have five year olds, four year olds in my practice and we all rejoice over nasal breathing

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is if we breathe right, everything will be right.

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Breathing is life.

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And I do want to leave a little message for the practitioners around me as well.

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Dentists as well as other, as well as other professionals.

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There's a lot of work to be done over here.

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We have not looked at some of these basic aspects for many, many decades now.

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And here's a chance for us to sort of come together and, you know, collaborate and work

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on resolving things from all our different viewpoints, but together.

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And I'm really looking forward to being part of that journey in the UAE.

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Love that.

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Well, thank you so much for being on our podcast and sharing your insights.

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Plus, you know, just giving us a little bit of perspective about your challenges in the

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UAE and just really appreciate it.

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Thank you so much for having me.

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I really, really loved the chance to be able to talk to you.

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Thanks again to today's guest, Dr. Tina Ricardia for sharing her medical insight into each

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of you for listening to today's episode.

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00:28:52,880 --> 00:28:56,840
And finally, thanks to all the parents and medical professionals out there that are working

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hard to help make the lives of kids around the globe just a little bit better.

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Take care, stay safe, and happy breathing everyone.