1 00:00:00,000 --> 00:00:29,000 Hi everyone, and welcome to another video. 2 00:00:29,000 --> 00:00:34,000 Hi everyone, and welcome back to Airway First, the podcast from the Children's Airway First Foundation. 3 00:00:34,000 --> 00:00:38,000 I'm your host, Rebecca St. James. 4 00:00:38,000 --> 00:00:51,000 I'm excited to welcome back today's guest, Dr. Shering Lim, a Perth-based dentist with a postgraduate diploma in dental sleep medicine from the University of Western Australia. 5 00:00:51,000 --> 00:01:03,000 As one of Australia's first handful of dentists to obtain a qualification in dental sleep medicine, she has spent more than a decade working with patients with snoring and obstructive sleep apnea. 6 00:01:03,000 --> 00:01:11,000 Rather than managing dysfunctional breathing and its consequences, Dr. Lim focuses on promoting airway health. 7 00:01:11,000 --> 00:01:21,000 This means reinforcing nasal breathing and promoting good airway development from infancy, as keys to sleeping well, thriving, and greater future health. 8 00:01:21,000 --> 00:01:31,000 Dr. Lim regularly sees infants to adults and has been able to pinpoint the issue of infancy that led to bigger problems down the track. 9 00:01:31,000 --> 00:01:46,000 She is passionate about educating child health professionals from a variety of fields to recognize the earliest warning signs of poor airway health, including poor oral function and poor jaw development. 10 00:01:46,000 --> 00:01:53,000 She is also an advocate of promoting collaborative care to address these issues as early as possible. 11 00:01:53,000 --> 00:02:05,000 Her vision is to help children receive timely care to breathe, sleep, and thrive to their full potential and avoid growing into more serious problems later in life. 12 00:02:05,000 --> 00:02:12,000 Dr. Lim is a renowned speaker and the author of Breathe, Sleep, Thrive, which is available on Amazon. 13 00:02:12,000 --> 00:02:20,000 You can find out more about Dr. Lim at drsheringlim.com.au. 14 00:02:20,000 --> 00:02:25,000 And now let's jump into today's episode with Dr. Shering Lim. 15 00:02:25,000 --> 00:02:30,000 All right. Good morning, Dr. Lim. Thank you so much for joining us again. 16 00:02:30,000 --> 00:02:36,000 Thanks very much for inviting me, Rebecca. I'm just really thrilled to be here. I love what you guys are doing and the momentum you are creating. 17 00:02:36,000 --> 00:02:39,000 So to be a part of this is a great opportunity. 18 00:02:39,000 --> 00:02:52,000 Thank you so much. And we love having you. And for anyone that has not read your book yet, I'll make sure to put a link in the show notes, but parents can also find it on our recommended reading list. 19 00:02:52,000 --> 00:02:59,000 And it is a great read. Let me just say for both parents and clinicians, if you haven't read it, check it out. 20 00:02:59,000 --> 00:03:09,000 And just the way you explain everything, you put it in such terms that parents can understand it, but it's still very informative for clinicians. So it's a great, great book. 21 00:03:09,000 --> 00:03:17,000 Yeah, appreciate your support and promotion of it. I think this information, it takes a long time to be able to connect all these stops. 22 00:03:17,000 --> 00:03:25,000 And so I really wanted to make it easy for not only parents, but other colleagues who need to convey this information as well. 23 00:03:25,000 --> 00:03:39,000 Yeah, yeah, we talked about that a lot. This is not something that is talked about in dental school or med school. So yeah, we're happy to get conduit to help get the word out and promote your book because like I said, it's fantastic read and it's really, really informative. 24 00:03:39,000 --> 00:03:51,000 And before we dig in, I just want to let any clinicians know that if you'd like to talk to Dr. Lim or hear more, you can join us at Airway Palooza in 2024. She will be speaking there. 25 00:03:51,000 --> 00:03:58,000 And she's also going to be signing copies of her book at the event. So kind of an exciting opportunity. 26 00:03:58,000 --> 00:04:07,000 No, I'm looking forward to that event. I really wanted to be a part of it because there's such a big lineup and I think I'm looking forward to the networking as well. 27 00:04:07,000 --> 00:04:12,000 Yeah, yeah, it's a great event. We're excited to be a part of that with with our partners Airway Health Solutions. 28 00:04:12,000 --> 00:04:21,000 So with that said, let's go ahead and just jump into our conversation today. Today we're going to talk a lot about palate expansions. 29 00:04:21,000 --> 00:04:36,000 As you and I were talking a little bit before we started recording this really is it's a hot topic. And it's one that parents have a lot of questions about we receive a lot of questions so let's just use that as our jumping off point so 30 00:04:36,000 --> 00:04:42,000 what what is palate expansion and and how does this work? 31 00:04:42,000 --> 00:04:47,000 Yeah, so palette expansion really is about widening the top jaw. 32 00:04:47,000 --> 00:04:54,000 And why do we want to widen the top jaw? Really that top jaw is the floor of the nose and it's the housing for the tongue. 33 00:04:54,000 --> 00:05:00,000 And it's part of the bony framework that supports our upper collapsible airway. 34 00:05:00,000 --> 00:05:12,000 And so when we can develop the jaws to the full potential, it is actually going to optimize our breathing passages and our sleep, which is so key for children to function really well. 35 00:05:12,000 --> 00:05:25,000 And so with a palette expansion, the way that we do this is we use an appliance that's worn inside the mouth, usually 24 seven, and there's normally some sort of screw mechanism in the middle. 36 00:05:25,000 --> 00:05:45,000 And so the palette has two halves, there is a midline palette suture. And when we can separate the two halves of the palette with a gentle expansion force by turning a little screw in the middle, it actually stimulates bony expansion in the midline of the palette, which corresponds to the nasal floor. 37 00:05:45,000 --> 00:06:04,000 And so palette expansion is really well studied and proven to improve nasal airway and improve nasal airflow. And in some cases it can be a really effective treatment to help with obstructive sleep apnea in conjunction with other procedures such as removal of the adenoids and the tomsons. 38 00:06:04,000 --> 00:06:21,000 And I just want to clarify, because as a parent, when I first heard this, I went through. And I think Dr. Leao explained it that it's about a hair's width. So when you say you turning the screw because we're widening it, it's not like you're taking it and going on a kid each time. 39 00:06:21,000 --> 00:06:27,000 It's these very subtle just over a period of months, correct. 40 00:06:27,000 --> 00:06:39,000 For sure. Yeah, it's it's imperceptible to a child. So the most commonly studied and used rate of expansion is in the range of point two five millimeters a day. 41 00:06:39,000 --> 00:06:51,000 So that's considered semi rapid, rapid palette expansion. And so I use something like half the rate of that. So a lot of different providers will use different things. 42 00:06:51,000 --> 00:07:00,000 But we know that that point two five has been really well studied minimal side effects and problems with that. 43 00:07:00,000 --> 00:07:03,000 So we really want to do this when children are younger. 44 00:07:03,000 --> 00:07:12,000 Because around the age of nine, for instance, that midline palette suture becomes more fused. And it's more difficult to separate the two halves of the palette. 45 00:07:12,000 --> 00:07:29,000 So we may not get those changes as much as we work on teenagers and older adults. If we try to apply that separating force with traditional expanders, we're going to tip or move the teeth, which is not quite the same as getting new born in the mid palette. 46 00:07:29,000 --> 00:07:35,000 So, but we can use this on older children and adults though. 47 00:07:35,000 --> 00:07:41,000 It's still effective. It's just it's better if we can do this when they're younger. 48 00:07:41,000 --> 00:07:47,000 Definitely better when they're younger. And we can make greater changes when they're younger. 49 00:07:47,000 --> 00:07:58,000 There are other options that are available for older children that have particularly bad breathing, particularly narrow pellets that actually can make it more effective. 50 00:07:58,000 --> 00:08:09,000 But yes, generally the younger the better. Because when we have a narrow pellet and we're not breathing optimally, we want to restore that better breathing and sleep in the earliest years of life. 51 00:08:09,000 --> 00:08:19,000 When children are growing rapidly, we know that even problems like mouth breathing may be associated with more problems with attention and concentration. 52 00:08:19,000 --> 00:08:29,000 And this can impact a child's future learning. So the earlier on we can treat it the better because the traditional approach is really to do it at age seven to eight years. 53 00:08:29,000 --> 00:08:34,000 And at that time it's more about how can we make space for the teeth to fit. 54 00:08:34,000 --> 00:08:43,000 But from a functional point of view, more and more people are recognizing that this intervention plays an important role in helping with nasal breathing. 55 00:08:43,000 --> 00:08:46,000 And so we don't necessarily need to wait. 56 00:08:46,000 --> 00:08:57,000 And how early when you say younger the better how early can you explore this as an option for treatment. 57 00:08:57,000 --> 00:09:06,000 It can be done when children have all their baby teeth through. So I have colleagues that are waking on two year olds. 58 00:09:06,000 --> 00:09:09,000 But my comfort level is around the age of four. 59 00:09:09,000 --> 00:09:20,000 Yes, and I don't want to expand every child at age four either. So like if there's not too many functional concerns, I may be more inclined to wait a little while. 60 00:09:20,000 --> 00:09:28,000 My favorite age right now is around the age of five and a half to six if there's no big concerns with how a child is functioning. 61 00:09:28,000 --> 00:09:38,000 I prefer to get in before the adult teeth start to come through because sometimes if the jurors too narrow and all the baby teeth have no spaces, 62 00:09:38,000 --> 00:09:44,000 what happens is all the adult teeth tend to crowd in and they may erupt through in the wrong position. 63 00:09:44,000 --> 00:09:49,000 So I kind of like to get in earlier before the adult teeth come through. 64 00:09:49,000 --> 00:09:58,000 So I guess what I really want to let people know is that it has a really important role to help restore nasal breathing in certain children. 65 00:09:58,000 --> 00:10:08,000 But it can be very difficult sometimes to find the right providers that are on board with doing the early intervention, which can make it challenging for parents. 66 00:10:08,000 --> 00:10:19,000 And you know, we have that potential to do it as they get a little bit older. So don't get super upset if you can't find someone to start at age four. 67 00:10:19,000 --> 00:10:26,000 Right, right. Or if you've, you know, quote unquote missed the boat and now you're 13 year old, you can still do this. 68 00:10:26,000 --> 00:10:30,000 It's not too late. It's just going to be different, correct? 69 00:10:30,000 --> 00:10:41,000 More complex, difficult because what I found is starting younger and younger, what I noticed is the quicker that we can restore the nasal passages and the tongue space, 70 00:10:41,000 --> 00:10:46,000 children can function better. It's easier for their muscles to adapt. Even things like speech. 71 00:10:46,000 --> 00:10:55,000 I have been recording a lot of speech before and after treatment or before the treatment and just seeing how the tongue fits inside the mouth. 72 00:10:55,000 --> 00:11:04,000 Because I see a lot of people patients that are referred to me with ongoing speech problems, despite having quite a lot of therapy, speech therapy. 73 00:11:04,000 --> 00:11:15,000 And what I noticed is many of them, their tongue can't fit properly in their mouth. And so sometimes when we do the palate expansion, there are changes in the way that their tongue works. 74 00:11:15,000 --> 00:11:20,000 And they don't have to use the muscles of their face and their lips and that as well. 75 00:11:20,000 --> 00:11:34,000 And so I do think there are functional benefits, not just sleeping breathing, but even with a speech and how the mouth works that we shouldn't really be ignoring. 76 00:11:34,000 --> 00:11:48,000 And, and, you know, since you mentioned functional therapy, if you're, if this is a treatment that's proposed for your child and you're looking at it, what you do, you know, tongue tie releases, myofunctional 77 00:11:48,000 --> 00:12:01,000 therapy is things before you start this course of treatment, or is that something you do in conjunction? How would that work if your child was a candidate, let's say for a tongue tie release? 78 00:12:01,000 --> 00:12:12,000 Yeah, typically if a child is four and above and they do for a tongue tie release, my preferred option nearly all the time is to do the palate expansion first. 79 00:12:12,000 --> 00:12:28,000 Why do I want to do this? Well, I want to restore tongue space, because for me, usually doing palate expansion is quite quick. I can do it within six to nine weeks to get the mouth where I want to be and to create that tongue space. 80 00:12:28,000 --> 00:12:35,000 So we can get the tongue working better, and we can do better therapy if they have more tongue space. 81 00:12:35,000 --> 00:12:50,000 Another thing is, I know that a lot of the time when children have a tongue tie, they have a low tongue posture, and they're going to have some symptoms of poor breathing and sleep, or it's not quite optimal. 82 00:12:50,000 --> 00:13:03,000 But I do think the quickest way to get good sleep is to do the palate expansion, usually, because it's less compliant space. We just ask parents to turn a screw and we're kind of changing the mouth and the way that a child can breathe, 83 00:13:03,000 --> 00:13:13,000 compared to the tongue tie release. If we're trying to restore the proper tongue to palate suction and posture for better breathing, we do need to do my functional therapy. 84 00:13:13,000 --> 00:13:23,000 And it's compliant space, it's a lot of effort. There are some people that are quite busy and they find it difficult to do this with their child, or the child might be a little bit lit off. 85 00:13:23,000 --> 00:13:40,000 So if I want to affect their breathing quickest, I'll usually go for the palate expansion first, and then it just becomes an easier process for me. I've tried all sorts of different things, but this is the way that I think is the most efficient and impactful. 86 00:13:40,000 --> 00:13:52,000 That totally makes sense. But when they're younger, you mentioned six to nine weeks. So in these younger children, I mean, it's rapid, it's really fast. 87 00:13:52,000 --> 00:14:01,000 Yeah, and parents really can see the facial changes quite often, or little spaces appearing between the teeth, baby teeth. 88 00:14:01,000 --> 00:14:14,000 And yeah, I hear parents a lot of the time, they're saying things like, oh, my child's sleep is less disturbed, they're not moving and tossing and turning, or their mouth is closing because their tongue can actually fit properly. 89 00:14:14,000 --> 00:14:28,000 And it just translates, not to promise everyone this, but it translates to a more rested child who's able to cope better with their emotions and not so tired. 90 00:14:28,000 --> 00:14:39,000 And so that's why I like to approach it this way first, because I do think it's more predictable and less compliance based. 91 00:14:39,000 --> 00:14:44,000 And if they're going to need it, that's a good time for it. 92 00:14:44,000 --> 00:14:55,000 There are other people that will say, oh, they think a child is really young, we can do tongue tie release, we can get the tongue working better, and that will stimulate the palate development in the right way. 93 00:14:55,000 --> 00:15:10,000 But for me, I actually believe that if a child has had some sort of tongue tie or mouth breathing, there will be a deficit in the way that their jaw has grown. And I'm going to want to restore that quickly in the most predictable manner. 94 00:15:10,000 --> 00:15:21,000 And, you know, having seen a lot of adults with snoring and obstructive sleep apnea and seeing that this poor palate development or narrow palate is a risk factor. 95 00:15:21,000 --> 00:15:32,000 I want to get in there and see what I can do, even if it's, you know, five millimeters, a small amount, because I do think that's really impactful, symptomatically, for many people. 96 00:15:32,000 --> 00:15:46,000 So I'm not really shy about palate expansion. If it was my own child, I would prefer them to just get it done and not, you know, have to rely on the tongue to do all this work. 97 00:15:46,000 --> 00:15:58,000 I'd rather get that quick boost. But there are so many different ways of approaching it. So I don't want a parent to feel bad that they can't get it. I think, you know, go to your different providers and see what they can offer and what is their approach. 98 00:15:58,000 --> 00:16:11,000 And it doesn't always have to be done the same way. But that is just what I have noticed, being able to do various approaches and having those skills to do the palate expansion. I kind of think it works. 99 00:16:11,000 --> 00:16:26,000 And when we're talking about this expansion, it's not just laterally side to side. You can also use this device correct to bring the jaw forward or to impact it in other directions. 100 00:16:26,000 --> 00:16:31,000 My favorite appliance is called the Bioblock. I can just grab one. 101 00:16:31,000 --> 00:16:32,000 Yeah, if you like. 102 00:16:32,000 --> 00:16:33,000 I'd be great. Yeah, absolutely. 103 00:16:33,000 --> 00:16:43,000 And if you have a look at that, it's a little removable device. And it actually has these wires that sit behind the back teeth. 104 00:16:43,000 --> 00:16:55,000 And so as we are expanding, naturally, or the width of the palate, it actually uses these wires and it's really moving the front teeth. 105 00:16:55,000 --> 00:17:05,000 And I can actually convert a V shape into a U shape. So it's really bringing that changing the whole shape of the upper jaw. 106 00:17:05,000 --> 00:17:13,000 So for instance, sometimes patients have an underbite where the top teeth are sitting here and the bottom teeth are sitting out the front. 107 00:17:13,000 --> 00:17:20,000 It's related to a mid-face deficiency where the upper jaw hasn't grown in relation to the bottom jaw. So it's not quite sitting well. 108 00:17:20,000 --> 00:17:35,000 I can use these wires as well. If it's not particularly severe to kind of nudge those front teeth into the right place and then it tongue space and we can get that tongue working up and promoting better development as well. 109 00:17:35,000 --> 00:17:44,000 So that's really why this particular appliance is quite impactful and why I like using it. 110 00:17:44,000 --> 00:17:52,000 Despite the concerns that we may have with children complying with it, children may be more prone to flicking it out of their mouth and playing with it. 111 00:17:52,000 --> 00:18:01,000 And I have ways to test whether or not I'm ready to work on a child and how compliant they'll be. But yes, this is why I love this particular expander. 112 00:18:01,000 --> 00:18:15,000 I think it really produces some nice facial results. 113 00:18:32,000 --> 00:18:50,000 Your listening to Airway First, the podcast from the Children's Airway First Foundation. You can find out more about CAF and our mission to fix before six on our website at childrensairwayfirst.org. 114 00:18:50,000 --> 00:19:12,000 The CAF website offers tons of great resources for both parents and medical professionals. In our parents portal and clinicians corner, you can find educational and informational content, including videos, blogs, our recommended reading list, comprehensive medical research, podcasts, events, parent support, and educational opportunities. 115 00:19:12,000 --> 00:19:30,000 Parents are also 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 backslashgroups backslashairwayhuddle. 116 00:19:30,000 --> 00:19:43,000 Are you interested in being a guest on the show? Then shoot us a note via the contacts page on our website or send us an email directly at infoatchildrensairwayfirst.org. 117 00:19:43,000 --> 00:19:55,000 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. 118 00:19:55,000 --> 00:20:23,000 And now let's jump back into today's podcast. 119 00:20:23,000 --> 00:20:34,000 And you mentioned it is a device that can be taken out, so do they take it out when they sleep or do they take it out when they eat? How does that work? 120 00:20:34,000 --> 00:20:43,000 They actually wear it 24-7. They wear it to eat, to sleep. They only take it out to brush their teeth. And when they brush their teeth, their parents can turn the key. 121 00:20:43,000 --> 00:21:00,000 Oh, wow. There's a little screw in the middle. As you turn the screw with a little key, it separates the two halves. And that produces the force that separates the two halves of the palate so that we can stimulate the new bone. 122 00:21:00,000 --> 00:21:11,000 And when they're younger, you would turn the key every day. What about when you're with an older child? Do you do the same with an older child, like a 13-14 year old? 123 00:21:11,000 --> 00:21:23,000 Well, in my practice, I'm really focused on that 4-9 year age group, or 4-8. So I don't know. I haven't tested it enough in the older children. 124 00:21:23,000 --> 00:21:36,000 But definitely the older and older a child gets, it's more difficult to separate those two halves of the palate and we're going to produce more dental movements. We're going to tip the teeth. 125 00:21:36,000 --> 00:21:52,000 Okay. Yeah. So I can't really comment on those teenage groups, but my preference is to work on the younger children because I know it's more reliable. And that's what I see. I see good results with it. 126 00:21:52,000 --> 00:22:09,000 But the younger children, let's say you start on a 6-year-old. Once you've achieved the widening to the optimal width and everything's fitting nicely, is there any kind of follow-up? 127 00:22:09,000 --> 00:22:22,000 Because I know, for example, with braces, there's follow-ups that they do. There's the wires in the back or there's retainers. What does that look like post-treatment for a younger child? 128 00:22:22,000 --> 00:22:30,000 So post-treatment, I get the child to continue wearing the expander without turning the key because that's going to be like their retainer. 129 00:22:30,000 --> 00:22:46,000 But I usually want to let parents know that most optimal retainer is the tongue, likely suction to the roof of the mouth. And so as we can get the tongue better functioning, I will actually start weaning children off the expander, maybe during the daytime first. 130 00:22:46,000 --> 00:22:55,000 And then as things get more and more well-functioning, we want to reduce some of the nights as well to reduce the reliance on this. 131 00:22:55,000 --> 00:23:12,000 So how do we get the tongue back up? Well, I want to introduce my functional therapy, which is exercises to promote better muscle function and better muscle balance and tongue control and isolation and strength coordination, those type of things, because we want that tongue sitting better. 132 00:23:12,000 --> 00:23:23,000 And some children will need tongue-tie release because if their tongue is tethered and they can't get their tongue up, the tongue-tie release will be an important thing to do better therapy. 133 00:23:23,000 --> 00:23:33,000 So the tongue-tie release itself is not going to get the tongue working well. It's actually the therapy that gets the tongue working well. And the tongue-tie release helps to do better therapy. 134 00:23:33,000 --> 00:23:51,000 And the other thing that I like to use is habit-correcting devices. And people might have heard things like Healthy Start or Myobrace, those type of appliances are trainers to help children close their lips together, to restore nasal breathing, to promote nasal breathing, 135 00:23:51,000 --> 00:24:03,000 to help them swallow better without overusing their lips and cheeks. They tend to disengage all those muscles that would normally have overworked and created the collapse of the mouth in the first place. 136 00:24:03,000 --> 00:24:13,000 And it has a tongue shelf, so we want to promote better tongue posture as well. So these are the things, it's not really quick, like expansion is super gratifying and parents love it. 137 00:24:13,000 --> 00:24:24,000 It can really create a big change, quick and functionally works, but we need to understand that we need to follow up and get the muscles working better. 138 00:24:24,000 --> 00:24:32,000 We need to achieve those goals of tongue-to-pellet suction, lip seal, nasal breathing, better swallowing. And I think that's what's really difficult. 139 00:24:32,000 --> 00:24:46,000 In the past, a lot of orthodontists have done pellet expansion and they say it doesn't really work because it's unstable, it tends to relapse. But that's because the underlying muscle dysfunction has been overlooked. 140 00:24:46,000 --> 00:25:01,000 And this is why now there's more attention to myofunctional therapy and tongue-to-release. And so to incorporate that into orthodontic practice, it's challenging when you've got a model of seeing children and having the braces. 141 00:25:01,000 --> 00:25:10,000 So you actually have to kind of follow this up for quite a period of time to make sure that children are meeting those goals. 142 00:25:10,000 --> 00:25:22,000 And that's what is at the base for this kind of, I'll call it for lack of a better word, controversy around it, right? Because we hear this a lot. Those are questions we get from parents. 143 00:25:22,000 --> 00:25:30,000 I was looking into this, but my provider, orthodontists or dentists, is saying no because they don't work. 144 00:25:30,000 --> 00:25:40,000 So it's probably more around they're just not doing the full components. They're not doing the follow-up perhaps with myofunctional therapy and things like that. 145 00:25:40,000 --> 00:25:52,000 Yeah, for sure. Because even within my own patients, I have seen times where people might have lost a plate and they haven't really progressed with orthodontic treatment. And yes, you will get relapse. 146 00:25:52,000 --> 00:26:06,000 So when you expand bone and you're doing that, stimulating that destruction osteogenesis where you've sort of separated the two halves of the palate and you've stimulated bone in that center, the bone itself tends to be quite stable. 147 00:26:06,000 --> 00:26:21,000 It doesn't actually tend to shrink. But what tends to move is the teeth. Because the teeth erupt or they stay in the equally boom zone where the pressures of the tongue on the inside and the pressures of the lips and cheeks on the outside are in the same zone. 148 00:26:21,000 --> 00:26:36,000 And the teeth on the outside are in balance. It's called the neutral zone. And so if we really haven't changed anything about the tongue or the lips and cheeks, those teeth will tend to go back to those original positions. 149 00:26:36,000 --> 00:26:38,000 And that makes sense. 150 00:26:38,000 --> 00:26:54,000 So as a parent, you have a two, three, four, five, six year old. How do you recognize that, hey, this might be something good that option and then maybe I need to talk to my provider about this for my child. 151 00:26:54,000 --> 00:26:58,000 Yeah, I mean, two year olds are very difficult to work on. 152 00:26:58,000 --> 00:27:14,000 What sort of two year old would benefit the most? Very significant narrow high arch palate. So when the palate is very narrow, and usually these children will have open mouth posture, low tongue, their mouth will just be hanging open. 153 00:27:14,000 --> 00:27:27,000 So they have, there's some sort of low tone around their mouth, which is contributed to that narrowing. Yeah, if a child is snoring. So those children combined with factors like snoring and obstructive breathing. 154 00:27:27,000 --> 00:27:48,000 In terms of what their daytime function looks like, it could be just a very difficult emotional regulation or really poor attention concentration tantrums meltdowns big two year old type of behavior, which can actually relate to their disturbance of sweep quality. 155 00:27:48,000 --> 00:28:08,000 So they're the type of children that may benefit more from early intervention. And we don't want to panic because it's not always easy to work on a two year old or to find that provider that will work on it, but I do work on them but I do think it's important to recognize the important 156 00:28:08,000 --> 00:28:18,000 contribution or impact that this can have on children so that we're prepared to act at that soonest opportunity. 157 00:28:18,000 --> 00:28:21,000 Right, yeah, it's different, right. So I would say yes, may tolerate it. 158 00:28:21,000 --> 00:28:36,000 Yes, that's right. Yeah, personally for me, I can't even see two year olds in my practice because we're so busy right so you're not always going to be able to see find that right provider but yeah as children get a little bit older other clues might be 159 00:28:36,000 --> 00:28:46,000 that are spacing between the baby teeth or anytime we have problems like cross bites where there's a little bit of asymmetry the teeth aren't fitting together the jaws aren't fitting together. 160 00:28:46,000 --> 00:28:52,000 Usually if they're not fitting together. We know that there is an under development of the palate. 161 00:28:52,000 --> 00:29:02,000 Yeah, and even like lower teeth crowding you know all these problems when there's lower teeth crowding, it usually means that there is a small upper jaw. 162 00:29:02,000 --> 00:29:14,000 The first step is let's get that top jaw correct. Because everything on the bottom will be constricted. If we have a small jaw on the top. 163 00:29:14,000 --> 00:29:22,000 So okay I had a question but I would like to change that now. I'll come back to that so because you said if you see lower teeth crowding. 164 00:29:22,000 --> 00:29:26,000 Yes, that usually means that it's a smaller upper jaw. 165 00:29:26,000 --> 00:29:42,000 So I think that the upper is somehow squeezing the bottom or how does that? Absolutely, definitely. It's squeezing so I think it's quite normal for the lower inside the teeth to erupt on the inside so there will be that stage where they're not quite right. 166 00:29:42,000 --> 00:29:52,000 But then anytime there is that lower crowding. Yeah, it is a reflection that the top jaw is not growing well. 167 00:29:52,000 --> 00:30:02,000 Okay, yeah, so often what will happen is I just do the palate expansion on the top and we can actually see the lower teeth unraveling. 168 00:30:02,000 --> 00:30:21,000 Yes, but the other thing that contributes to lower crowding, I mean there is a dysfunction. So if we see like a child that has a lot of mental strain on their lower chin dimpling when they close their lips, that is the type of pressure that actually can contribute to the lower crowding as well. 169 00:30:21,000 --> 00:30:37,000 So sometimes after the top jaw is we've got it to the right spot, we still need to address that dysfunction to help with the unraveling. But the younger a child is I find the more automatic things fall into place. 170 00:30:37,000 --> 00:30:46,000 But then when we've got a child who's like more like seven, eight, they have more ingrained habits, it may be more challenging but yeah, it still can be done. 171 00:30:46,000 --> 00:30:50,000 Definitely just need to address the top jaw. 172 00:30:50,000 --> 00:31:07,000 So what do you, I'm trying to figure out the right way to ask this question I'm not asking for a product endorsement I'm asking for just the treatment this kind of treatment, especially for younger children you know maybe a two year old that needs work, but probably can't 173 00:31:07,000 --> 00:31:19,000 tolerate a palate expansion at this point. What about something like a mile munchier that kind of a tool. How would that work as a precursor to getting them ready for palate expansion. 174 00:31:19,000 --> 00:31:41,000 When I was seeing a lot more tollers that would be something pre-authentically, because I think that if a child can breathe okay through their nose, then they can actually pop a mile munchie in to actually start chewing and you know we want to, we know that at the end of the day we're going to have to address the muscle problem and the structural problem. 175 00:31:41,000 --> 00:31:56,000 So we can actually just start using the mile munchie to help promote lip seal and good chewing and jaw exercise and better swallowing where they're not thrusting their tongue out forward and it's disengaging all the muscles, the ring of muscles around their lips and cheeks. 176 00:31:56,000 --> 00:32:05,000 So we, those ones that tend to inward distort the palate. So yeah, I do think there's a lot of value in using the mile munchie. 177 00:32:05,000 --> 00:32:18,000 There's compliance as well. It can be a little bit difficult, but where possible if a parent can work with a child and slowly build their child up with little increments, 20 seconds a minute. 178 00:32:18,000 --> 00:32:25,000 I do think that there is a lot of value because children are so moldable at that age of two years old. 179 00:32:25,000 --> 00:32:40,000 And when we can really get the muscles working in a better way, and they're growing so rapidly, I have actually seen some really nice changes with that as well, particularly people that give up dummies or thumb sucking or pacifiers for American people. 180 00:32:40,000 --> 00:32:55,000 When we can get that and try to retrain or change the muscle habits through a mile munchie, I've seen some really nice results. So not always lost by doing that. 181 00:32:55,000 --> 00:33:16,000 I think that is really quite a good option. And a lot of, not a lot. I've got a couple of colleagues that are using in-visa line, in-visa line, which is, I don't know if the line at ClearAlienas, because they've actually found it quite helpful in that population to move things around. 182 00:33:16,000 --> 00:33:26,000 Now, it's not going to, yeah, yeah, because they thought that they can adapt better to that. So I have a couple of colleagues that are doing that. 183 00:33:26,000 --> 00:33:44,000 And what it does, it actually sort of moves the teeth around and it actually creates more tongue space. I don't think it's necessarily proven to create that same nasal airway remodeling, like where we get that new bone in the mid-pellet, like the excander with a screw does. 184 00:33:44,000 --> 00:34:00,000 But even creating tongue space could be helpful for some of those children, or that's what they're finding. And I do think that the company is starting to look into how can we actually make it possible to get more of that bony expansion in the mid-pellet. 185 00:34:00,000 --> 00:34:05,000 So, you know, there's going to be new innovations that are being examined. 186 00:34:05,000 --> 00:34:18,000 Yeah, of course. So, and by the way, thank you for clarifying the dummy thing, because for those that are listening and not watching, there was a head tilt on my part, like, what, what did you say? 187 00:34:18,000 --> 00:34:33,000 What are some other things that parents can do? And again, I'm really talking about this younger group that may or may not be able to tolerate an expansion, specifically around maybe nutrition. 188 00:34:33,000 --> 00:34:50,000 One of the things we're hearing right now is we've all done it. So mom guilt, put it aside, we all did this, the little pouches. So we all know from this point forward, pouches are a new, but what are some other things that we as parents could do, especially with our 189 00:34:50,000 --> 00:35:05,000 younger to help stimulate this this palate development and drive it in the right direction. Yeah, so we want to minimize pacify use because that alters the tongue posture. It keeps the tongue low. 190 00:35:05,000 --> 00:35:10,000 So minimizing that and any sucking habits. 191 00:35:10,000 --> 00:35:31,000 Yeah, the chewing is really good for children, making sure that they have clear nasal passages. You know that whether it be nasal sprays to do nasal clearing, or to investigate further if there are nasal obstructions, such as enlarge adenoids, or if there are enlarged tonsils that 192 00:35:31,000 --> 00:35:47,000 they promote mouth breathing. We want children to grow up with their mouth closed and their tongue up if possible. And there are other people that are more skilled at dealing with younger children through feeding therapy or motor therapy, getting the 193 00:35:47,000 --> 00:36:02,000 mouth working better through toys and feeding and the way they introduce foods and where to place them. So there are other people that can be looked at, such as speech and feeding therapist as well. 194 00:36:02,000 --> 00:36:19,000 And there are little things that I think children should be able to do. I do think that if I see it like a sibling come in the practice and I'm not going to see them yet I do think my spots like their little spots that can be placed in the mouth to train the tongue up. 195 00:36:19,000 --> 00:36:32,000 So for instance today one of my patients had a brother that was only really young. So I just suggested he was watching TV with his mouth hanging open and I couldn't really understand his speech his speech wasn't super clear. 196 00:36:32,000 --> 00:36:47,000 So I just suggested why don't they've been using the spots for the older child why don't you place the spot inside the child's mouth where they put their tongue and say and so the idea being, we try to get children to melt the spot to use their 197 00:36:47,000 --> 00:37:02,000 tongue. So we just placed that tongue on that spot. It's like a magic switch when their tongue touches it lights up bits of their brain that's involved in neuro transmission, not for the parents purposes like dopamine serotonin makes them feel calm. 198 00:37:02,000 --> 00:37:12,000 So we want that tongue up. And he was pretty keen he's in his sister do it all the time. And when the tongue tip is up in the right spot. 199 00:37:12,000 --> 00:37:23,000 So he was putting it in trying to melt it and his mouth was close versus having it hanging open so you know obviously he had a clear nasal passage. 200 00:37:23,000 --> 00:37:36,000 But I think those type of things can be very impactful because you know he's not speaking clearly either when we want to speak clear that tongue needs to be resting up. 201 00:37:36,000 --> 00:37:45,000 Not down if it's resting down we're going to have more this thing so I think it's just a really tiny little thing that can be quite impactful if parents are on board to do it. 202 00:37:45,000 --> 00:37:47,000 Yeah. 203 00:37:47,000 --> 00:37:49,000 But that's a really good idea. 204 00:37:49,000 --> 00:38:02,000 Yeah, and little things like tongue clicking they can always practice tongue clicking or you know paddle pop between the lips, little things like that, I think can be introduced. 205 00:38:02,000 --> 00:38:11,000 And you mentioned something that I want to just touch on again, I think parents need to hear this over and over and over and over. 206 00:38:11,000 --> 00:38:18,000 In our in our society we think teeth together perfectly straight that's what we're going for but in the littles. 207 00:38:18,000 --> 00:38:24,000 We want gaps gaps are good before the adult teeth come in. 208 00:38:24,000 --> 00:38:39,000 Absolutely if a lot of parents are quite surprised to find that if we have no gaps between the baby teeth, it's a severe dental crowding problem when the adult teeth come through. 209 00:38:39,000 --> 00:38:53,000 And in fact, sometimes we can get blocked out teeth where because of the degree of crowding that the lack of spacing that second the first permanent tooth comes through and it takes up the space of two baby teeth. 210 00:38:53,000 --> 00:38:58,000 The next one comes on the inside like right in the middle of the palette. 211 00:38:58,000 --> 00:39:08,000 And it's almost like a child has three layers of teeth because that to gets in cross by, and it just becomes more complicated, which is why I love treating before the baby teeth come through. 212 00:39:08,000 --> 00:39:18,000 And just having that extra time for the teeth to unravel and come through in the right spots. That's my ideal situation. 213 00:39:18,000 --> 00:39:20,000 Five and a half. 214 00:39:20,000 --> 00:39:34,000 Got it. So at the end of every episode, I always like to hand it back to the guest for y'all to have the last word so any final thoughts for parents or even clinicians that you'd like to share. 215 00:39:34,000 --> 00:39:42,000 Yeah, our way health is really about promoting nasal breathing and good airway development. 216 00:39:42,000 --> 00:39:55,000 When children are young, because we know that facial structures are growing the most. And it's also about getting their mouth working their tongue functioning really well as well. 217 00:39:55,000 --> 00:39:59,000 And that will help with promoting good jaw development. 218 00:39:59,000 --> 00:40:09,000 And so one of the number one key factors to promote good jaw development is going to be nasal breathing. 219 00:40:09,000 --> 00:40:23,000 And that's why we're going to focus on nose, mouth, nasal breathing, because it is the time where we spend the most those light persistent forces of the tongue, likely suction to the roof of the mouth. 220 00:40:23,000 --> 00:40:31,000 24 seven. That's actually going to make the biggest difference to the way the facial structures grow. 221 00:40:31,000 --> 00:40:50,000 What I want parents to understand is that it is not just inside the nose looking for the adenoids and you know, deviated septums and the terminates that there is a very structural important structural contribution from the jaw that upper jaw or the palate is the floor of a nose. 222 00:40:50,000 --> 00:41:02,000 And so when we've done every other surgery and the child is still not breathing well through their nose, let's not overlook the palate and let's recreate the space that the tongue needs as well. 223 00:41:02,000 --> 00:41:10,000 So that would be the most important thing I think that we need to understand is not just for children as well that when it comes to nasal breathing. 224 00:41:10,000 --> 00:41:20,000 There's so much new research coming out now that the palate is we need to address the palate. 225 00:41:20,000 --> 00:41:26,000 And when adults have failed the nasal surgeries. What is the common factor. 226 00:41:26,000 --> 00:41:30,000 It is actually a high and narrow palate. So let's get this right. 227 00:41:30,000 --> 00:41:37,000 Early on in life when it's just a lot much easier to recreate that bone. 228 00:41:37,000 --> 00:41:44,000 And that totally makes sense when you can breathe, you can sleep better, and your child will thrive. 229 00:41:44,000 --> 00:41:50,000 And for those who haven't read her book I just actually did a funny there so check out Dr. Lim's book. 230 00:41:50,000 --> 00:42:01,000 And let's all work to make sure children can breathe, sleep and thrive. And thank you so much for being on the show again. I truly appreciate it. 231 00:42:01,000 --> 00:42:08,000 Thank you very much for having me. It's a it's a really hot topic. A lot of parents have so many questions regarding this. 232 00:42:08,000 --> 00:42:18,000 So I really appreciate the opportunity to share my insights and what I feel has worked well for parents and we were talking before about creating more awareness. 233 00:42:18,000 --> 00:42:24,000 Because for instance we tongue ties. A lot of parents got their information from Facebook groups. 234 00:42:24,000 --> 00:42:32,000 And really how come a lot of people have become more knowledgeable and looked into this further and got treatment their child needs. 235 00:42:32,000 --> 00:42:40,000 And so I also wanted to say that there is a child pilot expand the group as well on Facebook. 236 00:42:40,000 --> 00:42:52,000 And so I think you know for parents that is something that they can connect to and hear other people's experiences not just my own but to hear from other providers and other parents also. 237 00:42:52,000 --> 00:42:58,000 And if you have that information you can make the best decision for your child and ask questions. 238 00:42:58,000 --> 00:43:02,000 Yeah, I'll make sure that we put that link in our show notes as well. 239 00:43:02,000 --> 00:43:05,000 Fantastic. Thank you so much. 240 00:43:05,000 --> 00:43:07,000 Thank you. 241 00:43:07,000 --> 00:43:17,000 Thanks again to today's guest Dr. sharing limp for sharing her medical expertise into each of you for listening to today's episode. 242 00:43:17,000 --> 00:43:26,000 If you're new to our podcast, please don't forget to subscribe. And if you enjoyed today's episode, leave us a review or comment telling us about what you enjoyed the most. 243 00:43:26,000 --> 00:43:35,000 You can stay connected with the Children's Airwayverse Foundation by following us on Instagram, Facebook, X, LinkedIn and YouTube. 244 00:43:35,000 --> 00:43:46,000 Parents can also join us via our Facebook support group the airway huddle at facebook.com backslash groups backslash airway huddle. 245 00:43:46,000 --> 00:43:57,000 You can find tons of great content for parents and medical professionals on our parents portal and clinicians corner on our website at childrensairwayfirst.org. 246 00:43:57,000 --> 00:44:10,000 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. 247 00:44:10,000 --> 00:44:19,000 And finally, thanks to all the parents and medical professionals out there that are working to help make the lives of kids around the globe just a little bit better. 248 00:44:19,000 --> 00:44:41,000 Take care, stay safe and happy breathing everyone.