Did you know that mouth breathing can significantly contribute to abnormal development of children’s faces, crooked teeth, snoring, obstructive sleep apnea, poor concentration, ADHD, respiratory problems including asthma, hay fever and poor sports performance? The purpose of Breathe Through Your Nose Week is to highlight the negative health consequences associated with this seemingly innocuous habit.
BENEFITS OF NOSE BREATHING
Nose breathing imposes approximately 50 percent more resistance to the air stream in normal individuals than does mouth breathing, resulting in 10-20 percent more O2 uptake.
Nasal breathing warms and humidifies incoming air. (Air entering the nose at 6 °C will be warmed to 30 °C by the time it touches the back of the throat, and a cosy 37 °C (body temperature) upon reaching its final destination – the lungs);
Nasal breathing removes a significant amount of germs and bacteria from the air you breathe in;
Nasal breathing results in more regular breathing;
Nitric oxide (NO) is released in the nasal airways in humans. During inspiration through the nose this NO will follow the airstream to the lower airways and the lungs.
Lundberg JO. Nitric oxide and the paranasal sinuses. Anat Rec (Hoboken).2008 Nov;(291(11)):1479-84
Lundberg – Read abstract – Nitric Oxide and paranasal sinuses.
Nitric oxide plays an important role in vasoregulation, homeostasis, neurotransmission, immune defence and respiration.
Rabelink, A J (1998), “Nobel prize in Medicine and Physiology 1998 for the discovery of the role of nitric oxide as a signalling molecule”, Nederlands tijdschrift voor geneeskunde (1998 Dec 26) 142 (52): 2828–30
Culotta E, Koshland DE Jr.. NO news is good news. Science.1992 Dec 18;(258(5090)):1862-5
Nitric oxide from the back of your nose and your sinuses into your lungs. This short-lived gas dilates the air passages in your lungs and does the same to the blood vessels.
Roizen, MF, and Oz, MC, 2008. You on a diet revised, The Owners Manual for waist management. New York. Collins.
Since NO is continuously released into the nasal airways the concentration will be dependent on the flow rate by which the sample is aspirated. Thus, nasal NO concentrations are higher at lower flow rates.
Lundberg J, Weitzberg E. Nasal nitric oxide in man. Thorax.1999;(54):947-952
NOW COMPARE THE EFFECTS FROM MOUTH BREATHING
Mouth breathing children are at greater risk of developing forward head posture, and reduced respiratory strength;
Breathing through the mouth results in a dry mouth, which increases acidification of the mouth and results in more dental cavities and gum disease;
Breathing through the mouth contributes to dehydration (mouth breathing during sleep results in waking up with a dry mouth); Mouth breathing causes bad breath due to altered bacterial flora.
Breathing through the mouth has been proven to significantly increase the number of occurrences of snoring and obstructive sleep apnea
The effect of mouth breathing on asthma, sports performance, sleep disordered breathing, ADHD and craniofacial development is explored below.
MOUTH BREATHING AND ASTHMA
We speculate that asthmatics may have an increased tendency to switch to oral breathing, a factor that may contribute to the pathogenesis of their asthma.
Chest. 1999 Dec;116(6):1646-52. Route of breathing in patients with asthma. Kairaitis K, Garlick SR, Wheatley JR, Amis TC
Enforced oral breathing causes a decrease in lung function in mild asthmatic subjects at rest, initiating asthma symptoms in some. Oral breathing may play a role in the pathogenesis of acute asthma exacerbations.
Respirology. 2008 Jun;13(4):553-8. Enforced mouth breathing decreases lung function in mild asthmatics. Hallani M, Wheatley JR, Amis TC.
In the first step of a study of the relation of nasal and oral breathing during moderate treadmill exercise to the onset of bronchoconstriction in young patients with perennial bronchial asthma, it was observed that most subjects spontaneously breathed with their mouths open when instructed to breathe “naturally.” Subsequently, when they were required to breathe only through the nose during the exercise, an almost complete inhibition of the postexercise bronchoconstrictive airway response was demonstrated. When instructed to breathe only through the mouth during exercise, an increased bronchoconstrictive airway response occurred, as measured by spirometry, flow-volume relationships, and body plethysmography. These findings suggest that the nasopharynx and the oropharynx play important roles in the phenomenon of exercise-induced bronchoconstriction.
Am Rev Respir Dis. 1978 Jul;118(1):65-73. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Shturman-Ellstein R, Zeballos RJ, Buckley JM, Souhrada JF.
The effect of nasal as well as oral breathing during level-ground running for 6 min on the post exercise bronchial response was studied in fifteen people (five asthmatics with exercise liability, five asthmatics with no such liability and five normals). Each patient did the exercise twice; once with the nose clipped and once with the mouth closed. FEV1 was measured before exercise, immediately after exercise and at 5, 10, 15, 20 and 30 min thereafter. A fall in FEV1 of 20% or more from the basal level was taken as evidence of bronchoconstriction. When the patients were required to breath only through the nose during the exercise, the post-exercise bronchoconstrictive response was markedly reduced as compared with the response obtained by oral breathing during exercise, indicating a beneficial effect of nasal breathing. Nasal breathing was beneficial as compared with oral breathing in normals as well. In the five asthmatics with no exercise liability no appreciable difference was observed. This study suggests that the oropharynx and nasopharynx play important roles in the causation of exercise-induced asthma.
Clin Allergy. 1981 Sep;11(5):433-9. Effect of nasal and oral breathing on exercise-induced asthma. Mangla PK, Menon MP.
Mouth breathing is a trait of hyperventilation. Bronchoconstriction was induced in asthmatic patients by means of isocapnic hyperventilation with dry air. Responses both within a day and between days did not differ significantly and corresponded closely with those observed after exercise. The mean fall in forced expiratory volume in one second (FEV1) observed with both techniques was equivalent to 36%. Isocapnic hyperventilation with dry air, as used in this study, was a potent stimulus and provoked a reproducible response. The method was physically less demanding than exercise and was more acceptable to patients.
Thorax. 1981 Aug;36(8):596-8. Hyperventilation of exercise to induce asthma? Tweeddale PM, Godden DJ, Grant IW.
Mouth breathing is a trait of hyperventilation. The appearance of an asthmatic crisis in the minutes following physical exercise is common in symptomatic asthma. Exercise induced asthma (EIA) is linked to hyperventilation; voluntary isocapnic hyperventilation is capable of triggering a crisis. It is well established at present that EIA and post-hyperventilation asthma (HIA) are triggered by a rise in heat and water loss by the airways, which is inherent in hyperventilation. The respective role of water loss and cooling the airways are uncertain but one tends to think at the present time that the primary stimulus is the variation in osmolality of the liquid lining the epithelium. However, a relationship between the quantity of energy dissipated in the airways and the severity of EIA or HIA exists, although it is less tight than was once thought. Hyperventilation lends itself better than exercise to establishing dose-effect curves linking bronchial response to minute ventilation.
Rev Mal Respir. 1987;4(5):217-23. [Bronchial provocation tests using hyperventilation]. [Article in French] Lockhart A.
A link between the upper and lower airways has been convincingly demonstrated both in health and disease. To what extent the nose may be involved in children’s asthma, has so far not been thoroughly investigated. In this study, we compared symptoms and signs from the upper airways in children with asthma and in children without to find out more about this. Methods The study group included 27 asthmatic children, the control group 29 age and sex-matched healthy volunteers. The children were investigated by a senior ENT-specialist. Their parents completed questionnaires about symptoms and signs of upper airway disorders. Skin prick tests, total IgE, acoustic rhinometry, and an X-ray of the epipharynx were performed. The data from the groups were compared. Results Nasal blockage, mouth breathing, day time sleepiness, apnoeas, itching, sneezing, and hearing impairment were more prevalent in asthmatics compared with controls (p<0.05). For nasal blockage the mean VAS-scores were 52.4 and 30.6 for asthmatics and controls, respectively. For daytime sleepiness the corresponding figures were 34.6 and 23.1. The adenoid-nasopahrynx-index was larger, indicating reduced palatal airway in the former compared with the latter (p<0.05). Conclusions As the site of upper airway obstruction in asthmatic children appears to be the epipharynx, the adenoids may play a key-role.
Nasal symptoms and signs in children suffering from asthma. S.K. SteinsvågemaiL, B. Skadberg, K. Bredesen
The use of mouth taping, to encourage nose breathing, is currently being recommended by some Buteyko practitioners, but its effects on physiology are unknown. This preliminary study aimed to investigate the effects of mouth taping on end-tidal carbon dioxide (ETCO2). Design Preliminary study with an experimental single group repeated measures design. Setting Nine university students and staff with mild stable asthma. Interventions Physiological data were recorded before and during two experimental breathing conditions: oral breathing and nasal breathing (encouraged by mouth taping), carried out on two separate occasions 5–14 days apart. Between visits, participants familiarised themselves with the mouth taping technique. Outcome measures Primary outcome was ETCO2. Secondary outcomes were respiratory rate, pulse rate, oxygen saturation and lung function. Results There was an increase in ETCO2 from baseline during both breathing conditions. The mean ETCO2 for oral breathing was 4.4 kPa versus 4.7 kPa for nasal breathing, with mean difference of 0.3 kPa (95% confidence interval −0.2 to 0.8 kPa). It was also found that ETCO2 increased more in ‘natural’ oral breathers than ‘natural’ nasal breathers. Conclusions The results of this pilot study provide data to power a larger study and suggest ETCO2 may be increased in people with asthma during nasal breathing, particularly in those who normally primarily breathe through the mouth. The methodology was found to be acceptable to this sample of people with mild asthma.
The use of mouth taping in people with asthma: a pilot study examining the effects on end-tidal carbon dioxide levels
Ajay Bishop, Michelle Rawle, Anne Bruton. School of Health Professions and Rehabilitation Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
Enhanced perception of nasal loading may trigger increased oral breathing in asthmatics, potentially enhancing exposure to nonconditioned inhaled gas and contributing to the occurrence and/or severity of bronchoconstrictive exacerbations.
Eur Respir J. 2008 Apr;31(4):800-6. Epub 2007 Nov 21. Initiating oral breathing in response to nasal loading: asthmatics versus healthy subjects. Hallani M, Wheatley JR, Amis TC.
Airway dehydration triggers exercise-induced bronchoconstriction in virtually all patients with active asthma. Dehydration of the expired air is present in asthmatic patients in the emergency department. The bronchoconstriction triggered by dry-air tachypnea challenge in the laboratory can be prevented by humidifying the inspired air.
Airway Dehydration* A Therapeutic Target in Asthma? Edward Moloney, MB; Siobhan O’Sullivan, PhD; Thomas Hogan, MD; Leonard W. Poulter, DSc; and Conor M. Burke, MD, FCCP
Mouth Breathing affects sports performance
The research within this article seeks to verify and demonstrate the consequences of mouth breathing versus nasal respiration and to view supposed postural alterations in groups of children within specific age ranges. The authors state that children with nasal respiration, age 8 and above, present with better posture than those who continue oral breathing beyond age 8. The importance of picture documentation is stressed in order to provide the most information regarding postural changes. A review of research and literature is provided in the article. Int J Orofacial Myology. 2000 Nov;26:13-23.Relationship between mouth breathing and postural alterations of children: a descriptive analysis. Krakauer LH, Guilherme A. http://www.ncbi.nlm.nih.gov/pubmed/11307345
Chronic and habitual mouth breathing is also associated with postural changes resulting in decreased muscle strength, reduced chest expansion and impaired pulmonary ventilation. In 2011, Brazilian researchers Okuro and colleagues from Campinas State University conducted a study to evaluate exercise tolerance, respiratory muscle strength and body posture in mouth breathing compared to nasal breathing children. Children with asthma, obesity, chronic respiratory diseases, neurological and orthopedic disorders, and cardiac conditions were excluded. Of the 107 children, 45 were mouth breathers and 62 were nasal breathers. Examination revealed that 80% of mouth breathing and 48.4% of nasal breathing children had abnormal cervical posture and breathing pattern. Researchers concluded that “mouth breathing children had cervical spine postural changes and decreased respiratory muscle strength compared with nasal breathing.”3 Braz J Otorhinolaryngol. 2011 Sep-Oct;77(5):656-62. Exercise capacity, respiratory mechanics and posture in mouth breathers. Okuro RT, Morcillo AM, Sakano E, Schivinski CI, Ribeiro MÂ, Ribeiro JD.
In another study to evaluate submaximal exercise tolerance and respiratory muscle strength in mouth breathing and nasal breathing children. A total of 92 children aged between 8 and 12 years were studied, of which 30 were mouth breathers and 6 were nasal breathers. Following the study, the paper concluded that respiratory biomechanics and exercise capacity were negatively affected by mouth breathing.4 J Bras Pneumol. 2011 Jul-Aug;37(4):471-9.Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children. Okuro RT, Morcillo AM, Ribeiro MÂ, Sakano E, Conti PB, Ribeiro JD.
Results from the above studies are confirmed by another paper entitled “Assessment of the body posture of mouth-breathing children and adolescents.” It was reported following a study of 306 mouth breathing and 124 nasal breathing children that “postural problems were significantly more common among children in the group with mouth breathing syndrome, highlighting the need for early interdisciplinary treatment of this syndrome.” Interestingly, researchers noted that mouth breathers were more likely to be male.5 J Pediatr (Rio J). 2011 Jul-Aug;87(4):357-63. Epub 2011 Jul 18. Assessment of the body posture of mouth-breathing children and adolescents. Conti PB, Sakano E, Ribeiro MA, Schivinski CI, Ribeiro JD.
Mouth-breathing is a common clinical condition among school-age children and some studies have correlated this condition with quality of life and postural alterations. Therefore, the objective of this study was to investigate the orientation and position of the scapula, thoracic spine and head posture among mouth-breathing (MB) children and nasal-breathing (NB) children.
Mouth Breathing children increased scapular superior position in comparison to Nasal Breathing children due probably to the position of forward head, leading to an alteration in the positioning of the mandible. The absence of significantly difference in posture pattern between groups in the present study could attributed to height-weight development in this age, as the posture of children changes in order to adapt to new body proportions, regardless of health status. The results observed in this study demonstrate the importance of using reliable measurements in the postural assessment of MB and NB children helping physical therapists to focus their strategies during rehabilitation in more specific conditions. Int J Pediatr Otorhinolaryngol. 2009 Feb;73(2):227-36. Epub 2008 Dec 3. Orientation and position of head posture, scapula and thoracic spine in mouth-breathing children. Neiva PD, Kirkwood RN, Godinho R. Source Biological Science and Health Institute, Pontifícia Universidade Católica de Minas Gerais, Minas Gerais, Brazil. email@example.com
Abnormal growth of the face due to mouth breathing
Did you know that if your child grows up breathing through their mouth, their face may develop abnormally? In summary, mouth breathing causes unattractive and unhealthy children.
Please read extracts from medical papers below.
1) ‘116 paediatric patients who had undergone orthodontic treatment. Mouth breathers demonstrated considerable backward and downward rotation of the mandible, increased overjet (buck teeth), increase in the mandible plane angle (longer face), a higher palatal plane (affects upper airways), and narrowing of both upper and lower arches at the level of canines and first molars compared to the nasal breathers group (overcrowding of teeth). The prevalence of a posterior cross bite was significantly more frequent in the mouth breathers group (49%) than nose breathers (26%)(P = .006). Abnormal lip-to-tongue anterior oral seal was significantly more frequent in the mouth breathers group (56%) than in the nose breathers group (30%).’ Doron Harari DMD et al. 2010 The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. The American Laryngological, Rhinological, and Otological Society, Inc. 2010 Oct;120(10):2089-93.
2) ‘a mouth breather lowers the tongue position to facilitate the flow of air in to the expanding lungs. The resultant effect is maldevelopment of the jaw in particular and deformity of the face in general. Setting of the teeth on the jaw is also affected. All these make the face look negative.’ Care of nasal airway to prevent orthodontic problems in children J Indian Med association 2007 Nov; 105 (11):640,642)
3) ‘the switch from a nasal to an oronasal (mouth and nose combined) breathing pattern induces functional adaptations that include an increase in total anterior face height and vertical development of the lower anterior face’ Tourne. The long face syndrome and impairment of the nasopharyngeal airway. Angle Orthod 1990 Fall 60(3) 167- 76
4) ‘Long-standing nasal obstruction appears to affect craniofacial morphology during periods of rapid facial growth in genetically susceptible children with narrow facial pattern.’ ‘The deleterious effects of nasal obstruction are virtually complete by puberty so the window of opportunity is relatively brief. Delay in intervention may result in unsuccessful orthodontic treatment which may require surgery at an older age.’ ‘Effective orthodontic therapy may require the elimination of the nasal obstruction to allow for normalization of the facial musculature surrounding the dentition.’ Schreiner C (1996) Nasal air way obstruction in children and secondary dental deformities. UTMB, Dept. of Otolaryngology, G rand Rounds Presentation
5) In a study of 47 children between the ages of six to 15 years to determine the correlation between breathing mode and craniofacial morphology, ‘findings demonstrated a significant predominance of mouth breathing compared to nasal breathing in the vertical growth patterns studied. Results show a correlation between obstructed nasal breathing, large adenoids and vertical growth pattern.’ Baumam I, Plindert PK (1996) Effect of breathing mode and nose ventilation on growth of the facial bones. HNO 44(5): 229-34
6) Children with obligate mouth-breathing due to nasal septum deviations show facial and dental anomalies in comparison to nose-breathing controls. Int J Pediatr Otorhinolaryngol. 2010 Oct;74(10):1180-3. Craniofacial growth in children with nasal septum deviation: a cephalometric comparative study. D’Ascanio L, Lancione C, Pompa G, Rebuffini E, Mansi N, Manzini M.
7) A study of 73 children between the ages of three and six years concluded that ‘mouth breathing can influence craniofacial and occlusal development early in childhood ’ Mattar SE et al (2004) Skeletal and occlusal characteristics in mouth-breathing pre-school children. J Clin Pediatr Dent 28(4): 315-318
8) ‘The main characteristics of the respiratory obstruction syndrome (blocked nose) are presence of hypertrophied tonsils or adenoids, mouth breathing, open bite, cross bite, excessive anterior face height, incompetent lip posture, excessive appearance of maxillary anterior teeth, narrow external nares and V-shaped maxillary arch.’ Lopatiene K, Babarsk as A (2002) Malocclusion and upper airway obstruction. Medicina 38(3): 277-283
9) “Lack of growth affects the whole face and is associated with flat cheeks, unattractive lips, large noses, tired eyes, double chin, receding chins and sloping forehead, features that will be readily recognised when there is a pronounced crowding of teeth.” (Mew JR C, 1986)
10) The nose will seem larger, similar to that of a roman nose. The ‘nose is more pronounced in an ideal occlusion but in the various malocclusions where the maxilla is underdeveloped it appears larger, although in fact it is smaller ’ (Mew JR C, 1986).
11) “Children whose mouth breathing is untreated may develop long, narrow faces, narrow mouths, high palatal vaults, dental malocclusion (crooked teeth), gummy smiles and many other unattractive facial features.” General dentist: Mouth breathing: adverse effects on facial growth, health, academics and behaviour. Jefferson Y, 2010 Jan- Feb; 58 (1): 18-25
12) ‘Clinical and cephalometric data of 207 children who presented for evaluation of tonsil and/or adenoid problems were evaluated. Specifically, a more open lip posture was associated with a more backwardly rotated face and larger lower facial height. Reduced sagittal airway size was associated with en bloc backward relocation of the maxilla and mandible.’
Trotman CA, McNamara JA Jr, Dibbets JM, van der Weele LT. (1997) Association of lip posture and the dimensions of the tonsils and sagittal airway with facial morphology. The Angle Orthodontist 1997;67(6):425-32.
13) In a dreadful study involving monkeys who were forced to breathe through their mouths; ‘The experiments showed that the monkeys adapted to nasal obstruction in different ways. In general, the experimental animals maintained an open mouth. All experimental animals gradually acquired a facial appearance and dental occlusion different from those of the control animals.’ All the mouth breathing monkeys developed craniofacial changes and crooked teeth. Egil P Harvold. Primate experiments on oral respiration. American Journal of orthodontics. Volume 79, issue 4, April 1981, pages 359- 372)
14) The mouth-breathing monkeys developed crooked teeth and other facial deformities, including “a lowering of the chin, a steeper mandibular plane angle, and an increase in the gonial angle as compared with the eight control animals.” Tomer, Harvold Ep. 1982 Primate experiments on mandibular growth direction. Am J Orthod 1982 Aug: 82 (2): 114-9
15) ‘His granddaughter had pinched nostrils and narrowed face. Her dental arches were deformed and her teeth crowded. She was a mouth breather. She had the typical expression of the result of modernisation after the parents had adopted the modern foods of commerce, and abandoned the oatcake, oatmeal porridge and sea foods.’
Dr Weston Price Nutrition and physical degeneration. Price Pottenger Nutrition; 8th edition (January 31, 2008)
16) Study of 26 children, Kerr showed how development of the lower jaws began to normalise after they switched from mouth to nasal breathing Kerr WJ, McWilliam s JS, et al. Mandibular form and position related to changes mode of breathing – a five year longitudinal study. Angle Orthod 1987;59:91-96
17) A good-looking face is determined by a strong, sturdy chin, developed jaws, high cheekbones, good lips, correct nose size and straight teeth. When a face develops correctly, it follows that the teeth will be straight. Straight teeth do not create a good-looking face, but a good-looking face will create straight teeth. Patrick McKeown M.A (TCD) FRSB 2010 Buteyko meets Dr Mew Conclusion ‘If mouth breathing is treated early, its negative effect on facial and dental development and the medical and social problems associated with it can be reduced or averted.’ General dentist: Mouth breathing: adverse effects on facial growth, health, academics and behaviour. Jefferson Y, 2010 Jan- Feb; 58 (1): 18-25
Snoring and obstructive sleep apnea
Children who breathe through their mouths develop craniofacial changes which may result in life long obstructive sleep apnoea. Both adults and children who mouth breathe significantly increase the risk of holding their breath during sleep, leading to fatigue, poor health, cardiovascular disease and a myriad of other problems. The solution is simple, learn to unblock the nose and breathe through the nose! Please find links to papers below:
1) “Open-mouth breathing during sleep is a risk factor for obstructive sleep apnea (OSA) and is associated with increased disease severity and upper airway collapsibility.” The study which involved 52 patients found that “the more elongated and narrow upper airway during open-mouth breathing may aggravate the collapsibility of the upper airway and, thus, negatively affect OSA severity.” Kim EJ, Choi JH, Kim KW, Kim TH, Lee SH, Lee HM, Shin C, Lee KY, Lee SH. The impacts of open-mouth breathing on upper airway space in obstructive sleep apnea: 3-D MDCT analysis.Eur Arch Otorhinolaryngol. 2010 Oct 19.
2) In another study, 385 patients with obstructive sleep apnoea were examined through a questionnaire. Results showed that upper airway symptoms were common, (indicative of mouth breathing) with 61% of patients reporting mouth dryness, 52% with nasal stuffiness, 51% with dryness of the nose, 30% with sneezing, 24% with mucus in the throat, and 17% with a runny nose.2 Kreivi HR, Virkkula P, Lehto J, Brander P.Frequency of upper airway symptoms before and during continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome. Respiration. 2010;80(6):488-94.
3) Ohki et al. performed a study to determine the relationship between oral breathing and nasal obstruction in patients with obstructive sleep apnea. The study involved 30 normal subjects and 20 patients with snoring or sleep apnoea. Researchers found that chronic nasal obstruction and resultant mouth breathing may induce obstructive sleep apnea.3 Ohki M, Usui N, Kanazawa H, Hara I, Kawano K. Relationship between oral breathing and nasal obstruction in patients with obstructive sleep apnea.Acta Otolaryngol Suppl. 1996;523:228-30.
4) In a paper entitled, “How does open-mouth breathing influence upper airway anatomy?”4, Lee et al. tested the hypothesis that open-mouth breathing during sleep may increase the severity of obstructive sleep apnea. After an analysis of 28 patients, researchers concluded that “open-mouth breathing is associated with reduction of the retropalatal and retroglossal areas, lengthening of the pharynx and shortening of the MP-H in the upper airway.”4 Lee SH, Choi JH, Shin C, Lee HM, Kwon SY, Lee SH. How does open-mouth breathing influence upper airway anatomy? Laryngoscope. 2007 Jun;117(6):1102-6.
5) After reviewing texts and articles on Medline, the centre for research disorders in Cincinnati, Ohio concluded that obstructive sleep apnoea, sleep fragmentation, and disturbed sleep often result from nasal obstruction.5 The authors of the paper observed that “since breathing through the nose appears to be the preferred route during sleep, nasal obstruction frequently leads to nocturnal mouth breathing, snoring, and ultimately to OSA.”5 The paper advised that allergic rhinitis and other upper respiratory disorders should be treated more aggressively.5 http://www.ncbi.nlm.nih.gov/pubmed/9809490 Scharf MB, Cohen AP Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep apnea. Ann Allergy Asthma Immunol. 1998 Oct;81(4):279-87; quiz 287-90.
6) Mouth breathing, snoring, and sleep apnoea in children A Polish study noted that children with sleep respiratory disorders wake up tired, with blocked noses, were breathing through their mouth, tire easily, have concentration problems, are irritated, and demonstrate hyperactivity that may resemble ADHD symptoms. The paper further states that “long-term disease leads to exacerbation of all-systemic symptoms, results in cardiovascular complications, induces developmental inhibition and cognitive dysfunction, and is responsible for school/social failures and reduced life quality.”6 Wasilewska J, Kaczmarski M Obstructive sleep apnea-hypopnea syndrome in children [Article in Polish] Wiad Lek. 2010;63(3):201-12.
7) In a paper entitled, “The nose and sleep disordered breathing: what we know and what we don’t know,” performed an analysis of medical literature on the subject.7 The analysis confirmed that “SDB (sleep disordered breathing) can both result from and be worsened by nasal obstruction.” It was stated that “nasal congestion typically results in a switch to oronasal breathing that compromises the airway.” Furthermore, “oral (mouth) breathing in children may lead to the development of facial structural abnormalities associated with SDB.” The paper concluded that the change to mouth breathing that occurs with chronic nasal obstruction is a common pathway for sleep-disordered breathing.7 Rappai M, Collop N, Kemp S, deShazo R. The nose and sleep-disordered breathing: what we know and what we do not know. Chest. 2003 Dec;124(6):2309-23.
8) Mouth breathing was also recognised to be a factor in a study to determine the prevalence and association of sleep disorders and school performance. Based on a total of 1,164 completed questionnaires on children aged between 7 and 13 years, it was found that the overall prevalence of snoring was 38.9% with 3.5% habitually snoring. “Allergic symptoms, daytime mouth breathing, shaking the child for apnea, restless sleep and hyperactivity were significant and independent risk factors and sleep-related symptoms for HS.”9 Sahin U, Ozturk O, Ozturk M, Songur N, Bircan A, Akkaya A. Habitual snoring in primary school children: prevalence and association with sleep-related disorders and school performance. Med Princ Pract. 2009;18(6):458-65. Epub 2009 Sep 30.
9) A study was conducted to determine the risk factors of habitual snoring and symptoms of sleep-disordered breathing. Based on a study of 1030 children aged from 12 to 17 years, it was found that “habitual snorers had significantly more night time symptoms including observed apneas, difficulty breathing, restless sleep and mouth breathing during sleep compared to occasional and non-snorers.”10 Sogut A, Yilmaz O, Dinc G, Yuksel H, Prevalence of habitual snoring and symptoms of sleep-disordered breathing in adolescents. Int J Pediatr Otorhinolaryngol. 2009 Dec;73(12):1769-73. Epub 2009 Oct 20.
10) And finally, data from 248 medical charts of mouth-breathing children were analysed to determine the prevalence of obstructive sleep disorders in such children. It was found that 58% of children were primary snorers and 42% had obstructive sleep apnoea. The paper concluded that, “primary snoring and OSAS are frequent findings in mouth breathing children.”11 Izu SC, Itamoto CH, Pradella-Hallinan M, Pizarro GU, Tufik S, Pignatari S, Fujita RR. Obstructive sleep apnea syndrome (OSAS) in mouth breathing children. [Article in English, Portuguese] Braz J Otorhinolaryngol. 2010 Oct;76(5):552-6. There is no doubt that mouth breathing is a significant causal factor for snoring and sleep apnea in both adults and children.
11) In snoring men improved nasal breathing during sleep has been shown to decrease snoring and morning tiredness. The aim was to evaluate whether improved nasal breathing had any effect on growth hormone (GH) secretion, the nocturnal secretion of GH being associated with deep sleep. Forty-two snoring men, mean age 45 years and mean body mass index 26 kg.m-2, slept every night during one month with the Nozovent nostril dilator. Before and at the end of the test period, we analysed serum insulin-like growth factor 1 (IGF-1), thyrotropin (TSH), free thyroxine (free T4), free 3,5,3′-triiodothyronine (free T3), cortisol and testosterone in blood sampled at 08:00 h. Fifteen of the 37 snoring men who completed the study experienced a reduction in snoring and were less tired in the morning during the test period. In this group, the mean IGF-1 concentration was significantly increased (p < 0.05) after one month. There was no significant difference in mean IGF-1 level between the snorers and a population sample. Likewise, TSH, free T4, free T3, cortisol and testosterone concentrations were within normal limits. Snorers with reduced snoring and morning tiredness due to improved nasal breathing showed an increase in morning IGF-1 concentration which can probably be explained by higher nocturnal GH secretion induced by more deep sleep.
Rhinology. 1998 Dec;36(4):179-83.
Improved nasal breathing in snorers increases nocturnal growth hormone secretion and serum concentrations of insulin-like growth factor 1 subsequently.
Löth S1, Petruson B, Lindstedt G, Bengtsson BA.
It is estimated that 30% of the western population suffer from rhinitis, and while not all children with rhinitis will develop ADHD, many with ADHD have rhinitis and treatment of such has therapeutic implications for ADHD. Teaching a child to unblock their nose and breathe through it has no side effects, and in this vein should be the first step to addressing ADHD.
Please find quotations from a number of peer reviewed studies published in medical journals below.
“The vast majority of health care professionals are unaware of the negative impact of upper airway obstruction (mouth breathing) on normal facial growth and physiologic health. Children whose mouth breathing is untreated may develop long, narrow faces, narrow mouths, high palatal vaults, dental malocclusion, gummy smiles, and many other unattractive facial features, such as skeletal Class II or Class III facial profiles. These children do not sleep well at night due to obstructed airways; this lack of sleep can adversely affect their growth and academic performance. Many of these children are misdiagnosed with attention deficit disorder (ADD) and hyperactivity. It is important for the entire health care community (including general and pediatric dentists) to screen and diagnose for mouth breathing in adults and in children as young as 5 years of age. If mouth breathing is treated early, its negative effect on facial and dental development and the medical and social problems associated with it can be reduced or averted.”
In a paper entitled, “Pediatric allergic rhinitis: physical and mental complications,”Blaiss noted that allergic rhinitis has a far more negative impact on the health of the child than just a simple sneeze. “There are numerous complications that can lead to significant problems both physically and mentally in the child who suffers with allergic rhinitis. Under physical complications, recurrent and/or chronic sinusitis, asthma, and snoring impact children with AR. Sleep disturbances, poor school performance, and hyperactivity are all mental complications seen in many children related to their nasal allergies.”
In a study by Gottlieb et al., parent questionnaires from 3019 children were analysed to assess the prevalence of sleep-disordered breathing symptoms in five-year-old children and their relation to sleepiness and problem behaviours. Sleep-disordered breathing was defined as frequent or loud snoring, trouble breathing or loud, noisy breathing during sleep, or witnessed sleep apnea. The study found “parent-reported hyperactivity (19%) and inattention (18%) were common, with aggressiveness (12%) and daytime sleepiness (10%) reported somewhat less often. SDB symptoms were present in 744 (25%) children.”13 Authors concluded that “children with sleep disordered breathing symptoms were significantly more likely to have parent-reported daytime sleepiness and problem behaviors, including hyperactivity, inattention, and aggressiveness.”
Brawley et al. analysed data from 30 children to determine the prevalence of allergic rhinitis in patients with physician diagnosed ADHD. The paper concluded that “most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis.”
Authors of the paper entitled, “Attention deficit hyperactivity disorder and sleep disorder,” note that “there is a clear correlation between ADHD and sleep disorders” and “by improving these children’s sleep, the symptoms of ADHD are diminished and thus avoid the need to administer psychostimulants, which have undesirable side effects that produce a great deal of anxiety in the parents of these children.”
In a paper published in the journal Pediatrics, researchers concluded that “inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and—especially in young boys—snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.”
“Children undergoing evaluation for ADHD should be systematically assessed for sleep disturbances because treatment of sleep disorders is often associated with improved symptomatology and decreased need for stimulants.”
In a paper entitled, “A practical approach to allergic rhinitis and sleep disturbance management,” Davies et al. comments that “sleep quality can be significantly impacted by nasal congestion. This may lead to decreased learning ability, productivity at work or school, and a reduced quality of life.”