This is my interview with Dr. Meghna Dassani, where we discuss sleep apnea.
Dr. Dassani talks about pediatric sleep apnea, who is at the greatest risk, and what parents need to be on the lookout for to protect their children – especially in a post-pandemic world.
Approximately 5.9 million people in the U.S. are diagnosed with obstructive sleep apnea, yet a staggering 23.5 million people live with undiagnosed cases of moderate to severe OSA.
With a respiratory disease gripping the planet, timing has never been more urgent for parents to be on the lookout for signs of in their child, get a proper diagnosis, and take appropriate next steps to keep their family safe. We talk to Dr. Dassani about signs to look out for, including:
Snorting, coughing or choking.
Pauses in breathing
Poor weight gain
More and more parents are concerned about their kiddos. Think about it, we just don’t spend enough time together, and unfortunately, that’s the norm for most families today.
With kids in activities and parents working, we spend more time running around until the pandemic forced us to stay home and actually spend time together. Now parents realize, oh my goodness, my child is a poor sleeper or my husband snores or a list of things like suddenly realizing your child has trouble focusing. Because guess what, until now, it was the teachers that dealt with this, and now we are seeing it and worrying about it at home. So for many parents, it’s been a blessing because they’ve been able to identify these problems in their children and actually seek help. It’s a whole different world for sure.
What obstructive sleep apnea is, and how it affects children and adults differently?
Sleep apnea is when a person, adult or child, stops breathing for 10 seconds or more. And typically, this happens multiple times throughout the night. When that obstruction happens in children, it typically is the tonsils or adenoids. Often, it’s the tongue falling back; if you have excess weight around the neck, the muscles relax when you fall asleep. And if you’re sleeping on your back, those muscles have nowhere to go but back, as does the tongue. That is what causes that obstruction causing the apnea, which is the lack of breathing. When this happens, our hearts slow, and we have reduced oxygen going to our brain. There’s nothing to do, so when the heart slows down because it doesn’t have oxygenated blood to carry, the brain says I need oxygen. The heart has to start pumping harder to get that oxygen to the brain; this happens multiple times throughout the night. What truly needs to happen at night is healing, rest, repair, and rejuvenation. When we put our heart through those cycles of stopping breathing, it slows down, we wake up, which puts our heart through more stress cycles, rather than letting it rest and heal throughout the night.
This is why patients, adults as well as children can suffer and are at higher risk for heart attack, higher risk for high blood pressure and diabetes.
How many young children do we now see that have hypertension that has cardiac issues? Even obesity because your brain isn’t getting that oxygen that it needs? Think about it? What do you and I reach for when we don’t wake up rested? Sugar, right? As adults, we have the liberty of reaching for caffeine, but your go-to for the energy is the processed foods, the sugary foods, the junk foods; unfortunately, your brain doesn’t have the oxygen to top off the levels of hunger and satiety hormones. The most common sign I tell parents or anybody in the chair worried about this is the most common sign that we see is snoring. Snoring is the first sign that there’s something wrong with this person’s sleep. If we see snoring no matter how adorable that person is, snoring is never good. So I always tell parents, please, if your child snores, make sure we’re talking to their doctors about it. But snoring is only one symptom that we see and is very common in adults and children. Other symptoms, besides the classic symptoms of snoring, are choking or gasping for breath. They’re tired during the day. Daytime sleepiness, they’re the ones that are falling asleep at the wheel, waking up at night to use the bathroom multiple times throughout the night. Typically in children, you could have five children with seven different symptoms. And we could all be positive for sleep-disordered breathing, which is why it becomes so important that we start to screen these patients; we have awareness about this. So not only our parents recognizing this, but as healthcare providers, we can identify and connect the dots for the parents. Right. We want to be the resource for these parents.
We talked about how they parent differently; snoring is always common. ADHD is a big one for children with sleep-disordered breathing, and you have a child that has trouble focusing in school, constantly being told to write neater, do better, has ants in their pants, or can’t spell and is unable to get along. I say this in air quotes with their peers; we constantly have to correct them. Trouble focusing doesn’t finish the homework on time has to be corrected and being disciplined. That lack of focus is key to making sure we’re addressing that. And unfortunately, in a society where we are so eager to medicate, I tell parents that your child may need medication for ADHD; I don’t know; some doctors are much better qualified to figure that out. But get their sleep evaluated. First, a child that is sleep deprived will present with the same signs and symptoms as a child with ADHD. And the only way I can address this is to get a sleep study first and get their sleep evaluated before adding medications. Make sure they’re getting good quality sleep and enough oxygen. Then if they need the drugs, at least we are making sure you’re getting the quality to sleep that their bodies and brains need first. This is a big one. I can’t tell you how many kids I see within the practice on multiple drugs and are still struggling. Often, it’s as easy as flip the switch and gets them a better sleep.
I know my daughter was bedwetting, and that’s kind of why I became an oral myofunctional therapist. I myself was seeing a urologist because I was waking up in the middle of the night and going to the bathroom; I thought something was wrong with my bladder. And then I started mouth taping about six months ago, and I don’t get up in the middle of the night anymore. And I sleep five or eight hours now without waking up… Whereas before I was getting up every two hours and I have been a dental hygienist for over 30 years, I had no idea that it was my mouth breathing that was causing the other problems that I was having.
Unfortunately, when we go through school, at least when I did, there wasn’t enough education. There’s so much to learn. So I’m glad that you know we now have this increased awareness for this and are helping spread the word.
I started the healthy mouth movement to connect the mouth with the body. I think that it’s becoming more standard of care. But you know, before we just separated the mouth from the body, you saw a dentist for your mouth, and you see a doctor for your body you don’t connect or even understand that some of the signs that are happening in your mouth are actually a sign of what’s going on in your body.
My biggest thing, getting that awareness out, getting parents to know that we can help. Because think about it, we have healthy individuals walking into our practices every single day. They see their MD’s other health or other health care providers maybe once a year, I see my Dr. once a year, but I see my dentist regularly at least every six months, if not sooner, so and there are so many clues now, you know, that we can pick up on and start these conversations to be able to guide these parents to get more help.
Another big symptom I see with children is bedwetting. And I tell parents, we’re not talking about our two and a half-year-old, three-year-old that has regressed potty training. We’re talking about older kids that have been potty trained and stayed dry for a long period of time. We’re talking eight, nine ten-year-olds. Two weeks ago, we had a 16-year old that’s in practice. Now I know that child is not wetting their bag because they’re lazy. There’s more going on. And we also know that these are kids that the parents have done everything they can to help this child right even your eight-year-old. They’ve cut out the water, they eat healthily, use the bathroom before going to bed, whatever needs to be done. We’ve tried every trick in the book, plus some seen all the specialists, right? And no answers. And sometimes, we’re able to just make that connection. Hey, how are you sleeping? Is your child a messy sleeper? I’m fond of saying kids should sleep like the dead. We all have those stories or those kids that are hard to wake up. That is their body and brain trying to get more sleep because you are at some point having either a complete obstruction or a partial obstruction of the airway. That’s your reflex, your instinct to keep you alive that’s kicking in. If I move just enough, then to start breathing. But what does that do to those children, that patience, it takes them out of deep sleep. So they’re never truly getting to the deep sleep to the REM sleep that our brains or bodies need to be able to heal. And when that doesn’t happen, I now have a child that slept for 10 hours. They are still grumpy in the morning. I cannot figure out why that is so familiar for so many parents. So these are little things that if we can help parents understand. You literally see the light bulbs going off for a second. Oh my gosh, that is my child. I wish I knew this. Not breathing is a big one, and you’re supposed to breathe through your nose, not your mouth.
The nose does the job of humidifying the air, warming it up purifying it before it passes into the lungs. For whatever reason, that nasal breathing goes away, and we quickly learn to breathe through our mouths. When that happens, who gets to do the job of purifying that air. It’s our tonsils, and the tonsils were not made for that. That is not their primary job. Tonsils then react to the viruses that we are inhaling; they are not equipped to filter air. I’m just going to grow bigger and have more cells that can help our little bitty kids that are still growing, and me, those tonsils start to come together in the back of their throat when they touch we call them kissing tonsils. Now they have an obstruction that contributes to them not getting the quality of sleep that they need.
Sometimes it’s because they have a tongue tie where the tongue is tied tight to the floor of their mouth, our tongue is not supposed to rest in the floor of the mouth, the tongue should be resting passively in the roof of the mouth, our tongue as a natural expander, an actual retainer, that is what shapes the roof of the mouth. When the tongue is unable to sit there, remember, the roof of the mouth is also the floor of the nose. When that doesn’t get shaped the way it needs to our upper airway, that is the beginning of sleep apnea. Then just snowballs into another with the child sitting there with an open mouth posture because the tongue is resting on the floor of the mouth. They’re also now not breathing through their nose.
How many children do we see in our practices, right, that are sitting there just reading on their phone, even watching TV playing their games with their mouths hanging open, because now that has become their habit rested? It’s a habitual posture for them. It’s their resting posture. There are just so many little things that we can help parents understand and screen and look for to help these kids. So as you can see, every child’s gonna present with different symptoms, ask questions about this. How do you know what questions to ask because not all dentists are aware of this and know about it or look for it? I worked in a mobile setting for seven years; in the mobile setting, we weren’t writing notes or telling parents about any of this. We were telling them if they had cavities. So that’s why it’s important to have other ways to educate families about what’s going on. You know, my daughter was even getting dark circles under her eyes in the darkness here, along with the bedwetting, and so like I said, even as a dental professional, I didn’t know for 30 years. So this is all new to me and the past year; it’s important now I see it everywhere.
Once you see it, you cannot pay attention to it. Having these conversations is big. I still have parents that will go to your dentist. Like you’re supposed to look, and they’re just genuinely baffled. They’re like, why are you talking about her breathing and airway? You’re supposed to look for cavities and clean her teeth. It’s our job to put this out there to educate parents. I saw a patient last week where I told mom that she was tongue-tied. She asked why she was not told before? I didn’t know to look for that until I took this course and got more education for myself. I didn’t really realize that wasn’t something that we looked for until I went through this course, and I experienced some of these things myself with my family. So now I am sharing it, and it’s even the people that I’ve seen, so I was guilty. I’m not talking about it because I didn’t have the education and the knowledge about this area.
It starts today from the day that you actually learn, realize, understands; after knowing about it, if we don’t share, then that’s our mess. But if I didn’t know, I cannot educate everybody that continues to learn because in this day and age of blink and there’s something more that we’ve learned More research out there. So it’s great that We’re able to offer this to parents for sure.
And we’re seeing a lot of these adults in c-pap machines they have been breathing through their mouths since they were children. So had we had seen that when they were younger, maybe they wouldn’t be where they’re at right now. So again, with the knowledge we have now, you don’t know what you don’t know. Now that we have this knowledge, it’s really important to share it with new moms and moms with younger children so they can catch it. They can do things like a palatal expander or Mio munchie or other different tips and tricks.
Moms that struggled with nursing babies when breastfeeding are uncomfortable. There is probably a reason behind it. We need to evaluate things to catch them to see what is preventing the baby from latching just to make sure that we have a team that’s helping this child. When they say it takes a community, they are not lying. It takes the community. There are so many great professionals; the more I talk to people and the more people I connect with, that’s one thing I truly love about social media is like; I can refer you to this person because we all have folks that reach out to us from the other end of the country. So it’s amazing that we are able to have this network to help our patients. If you’re in an area where you don’t know anyone, they can reach out to you, or can we will find someone that can help them that knows about it. And a few things like myofunctional therapy, which is something that you do offer, can be done virtually too.
What are the next steps?
Talk to your dentist, talk to their doctor; they are knowledgeable. For children, I always recommend seeing an ENT first. Because with kids, most commonly, the cause of obstruction is defensive hand or adenoids that ENT is able to address and order a sleep study, get sleep evaluated. Then we know what the problem is. From there, based on what else is going on, you know, if there is a tongue tie, that is a problem working with, again, either the EMT, oral surgeon, or the dentist to release that, that has to happen in conjunction with myofunctional therapy. Like we were talking part of a team actually building that village for that child.
Has the growth of the palate been impacted? Do they need an expander? Do they need a myofunctional? Appliance? What direction is it that they need to head? But for children? I always say start with the ENT.
The medical and scientific advancements that you’ve seen as far as obstructive sleep apnea? In the last few years, there’s so much going on; there’s always something new that comes up; the C pap is considered the gold standard for treatment. We do find that a lot of folks aren’t just able to tolerate it, which is where working with a dentist that is able to make them an oral appliance that’s going to keep that airway open is key. Now in children, we have the advantage of using their growth; they’re still growing, so we can actually guide growth into what is it that the child needs? Where are they lacking, what dimension is one that we need to impact? So again, newer appliances more by way of how we’re able to impact that everything has become less clunky less junky. Now, as I like to say, less hardware in the mouth. If you remember when we were growing up, it was the stuff nightmares are made of. And then now it’s so much better. So there’s stuff there’s always new technology, new modalities of treatment.
It’s really important air and oxygen are everything. I mean, we need it to survive and thrive. I talked about the four things we need to survive, air, water, food, and sleep, all things that start with our nose and mouth. I honestly think that if you’re having issues anywhere, you should always look at your mouth and your nose first because they don’t necessarily cause things in the body, but they’re all connected.
We definitely know what to look for; there are always clues that we’ll find, right within our realm of what we can impact for our patients. It just knows what to look for, and actually connecting the dots, and getting the parents to where they need. So and here’s the struggle that I’ve had just in the past year is that people don’t seek treatment until it’s a problem. They’re not looking at prevention. But since the pandemic, I think people are more aware and looking at things because this virus has attacked our weakened immune systems. So I think bringing this awareness now is why it’s more important because people are more aware and are looking, and now we’re looking to prevention, instead of waiting until it’s a problem.
What can parents and adults do right now to move in the right direction for making sure their children are healthy and breathing through their nose?
Along with good quality sleep, I find we tend to skip one or the other. It’s, we’re either spending not enough time in bed asleep. There’s always Facebook, Netflix, whatever it is that our children play on their phones or watching TV that does not give them the hours of sleep. When we sleep, we go through the REM as well as non-REM sleep, the earlier part of the night, we get more of the non-REM sleep, which is what heals our bodies. And then the latter half of the night, the latter one-third of the night, we get more REM sleep, which our brain needs for healing. So guess what happens when we don’t get enough hours of sleep. We are skipping out on the REM sleep, which is why we wake up still feeling tired. So making sure that
We need enough hours of sleep, which is going to also give our brains the opportunity to get good quality rest.
Creating a routine is key. If we can have our kids go to bed and wake up at set times that set their circadian cycles. That is key in creating that routine for the brain to get to the type of sleep that we need.
For adults, no caffeine. What I say to adults, even children nowadays, I see how many kids drink those little caffeinated drinks?
No caffeine after 3 pm! Caffeine sneaks up on us creates an acid so many things that we don’t realize that it keeps us awake. I know devices in bed, that is a big one, if we can turn off our phones, iPods, reading on the Kindle, reading on the phone, all of those things exposure to blue light, it delays the release of melatonin in our brain.
It pushes back our sleep cycles; it disrupts everything. So no devices, things like that are key for those with children. A hot bath, a cold room right before bed bedtime is key.
That causes a drop in body temperature. When the body temperature drops, again, it releases melatonin. And Melatonin is going to help us fall asleep faster. So making these subtle, small changes do have a big impact. It’s what you and I call sleep hygiene.
Making those changes is going to help. It’s not going to address sleep apnea, but it’s definitely going to help with getting better quality sleep for sure. There is so much information, and it’s coming at us so fast, especially over the last year. We’ve learned so much just by wearing masks and being home, and it’s crazy what we’ve learned even in the past just six months alone. So there’s no way that everyone can know all this because there is so much information constantly. Even touching our face, we touched our face 16 times an hour before we started wearing masks, and our touching them even more, adjusting our masks.
Awareness is key, understanding what sleep-disordered breathing is?
How does it impact us?
What are the changes that it can cause in our life?
And where can you look for help?
Bringing all of the information together for the parents to complete the picture, nothing’s ever complete. So we put the puzzle pieces together. There’s always stuff that you can add; Dr. Dassani wrote a book that anybody should be able to pick that book up and go to the part they need. YOU DON’T NEED TO READ THE WHOLE BOOK COVER TO COVER.
If left unchecked possible complications later in life such as heart disease, failure to grow, and even death are risks that lay before children with OSA.
Ask questions; if there is something not sitting right with you, it probably is not. Go with what you are feeling.
The more questions they ask, the better for your child. Ask questions! Ask Questions! Ask questions!
Dr. Dassani is passionate about helping patients with sleep-disordered breathing get the treatment they need to live healthier, happier lives. Throughout Dr. Dassani’s career, she has gained invaluable insight into what it takes to implement those services and currently shares her knowledge and experience in her role as an international speaker and a dental practice in Houston. Her new book, AIRWAY IS LIFE: Clearing the Air About Sleep Apnea, will be available in February 2021