It takes a mouth to eat and a nose to breathe: abnormal oral respiration affects neonates' oral competence and systemic adaptation

The environmental burden of inhalation

Inhalation systems, mostly metered dose inhalers (MDIs) and dry powder inhalers (DPIs), are currently submitted to a critical assessment for their carbon footprint (CF) and environmental impact. They are related to greenhouse gas (GHG) emissions and they produce waste of used devices with withheld drug residues and unused doses. However, with estimated contributions to anthropogenic GHG-emissions of 0.03 % for MDIs and 0.0012 % for DPIs globally, it may not be expected that mitigating the GHG emissions from inhalers will have a meaningful effect on the current climate change and global warming, notwithstanding that nationally these percentages may be somewhat higher, depending on the ratio of MDIs to DPIs and the total national CF. MDIs are particularly the preferred type of inhalers over DPIs in the USA and UK with ratios of 9: 1 and 7: 3 respectively. In such countries, a partial switch from MDIs to DPIs is to be recommended, providing that such a switch does not jeopardize the therapy. Using renewable energy only for the production and waste management of DPIs will make this type of inhaler almost climate neutral. A greater concern exists about inhaler waste, more particularly about the residual drug and unused doses in discarded devices. Inhalers contribute <0.02 % to global plastic waste annually and most plastic inhalers end in the domestic waste bin and not as litter polluting the environment with plastic. However, they do contain retained drug and unused doses, whereas even full inhalers are disposed. Because globally most municipal waste (70 %) ends up in dumps and landfills, leakage of the drugs into the soil and surface waters is a serious problem. It pollutes drinking water and endangers species and biodiversity. Therefore, a good collection system and an adequate waste management program for used inhalers seems to be the most meaningful measure to take for the environment, as this will stop inhalers and drugs from putting ecosystems at risk.

Heated humidified high-flow nasal cannula: a new conservative approach for neonatal nasal stenosis

PURPOSE

The aim of this study is to evaluate the efficacy of heated humidified high flow nasal cannula (HFNC) therapy as a conservative treatment option for newborns suffering from nasal stenosis, a condition that often leads to respiratory distress and feeding difficulties. Given the increasing utilization of HFNC in various upper and lower respiratory tract indications, characterized by its flow-based mechanism and minimal mucosal damage, we seek to investigate its potential benefits in this specific patient population.

METHODS

A retrospective chart review of newborns with congenital nasal stenosis treated with HFNC for respiratory distress or feeding difficulties in a pediatric tertiary center between 2014 and 2022. Data were collected for demographic characteristics, clinical presentation and ventilatory requirements, pre and post HFNC application.

RESULTS

Six infants with nasal stenosis were included in the study cohort. Five were diagnosed with congenital pyriform aperture stenosis, three of whom had additional midnasal stenosis. One patient had nasal synechiae. Two patients had failed surgical treatment and all patients failed conservative treatment prior to HFNC treatment. Following HFNC use, improvement was noted in oxygen saturations, heart and respiratory rates, meal volumes and weight. None of the patients required any additional sinonasal surgical treatment. No complications were observed.

CONCLUSIONS

In this case series, we present the first documented use of HFNC treatment for nasal stenosis, showing favorable results. Further studies with a larger cohort, wider range of conditions and extended follow-up periods are needed to establish the risks and benefits of HFNC for neonatal nasal stenosis.

Comparison of Surgical Techniques for the Treatment of Congenital Nasal Pyriform Aperture Stenosis: A Systematic Review

INTRODUCTION

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare condition that results in neonatal respiratory difficulty. The purpose of this systematic review was to compare surgical outcomes of drilling versus dilation techniques in the treatment of CNPAS.

METHODS

Pubmed, Embase, and Cochrane Clinical Trials databases were searched for terms "congenital nasal pyriform aperture stenosis" or "pyriform aperture stenosis" from 2010 to 2021. Twenty-five studies were included that evaluated pediatric patients treated surgically for CNPAS with available outcomes data including complications, revisions, and length of stay.

RESULTS

A total of 51 patients with CNPAS were pooled from included studies. The median age was 29 days, 56.9% were female, and 54.9% were born full-term. The median pyriform aperture width before surgery was 5.00 mm (IQR = 4.10, 6.45). Forty (78.4%) patients underwent sublabial drilling, while 6 had a dilation procedure performed with hegar cervical dilators, 2 had a balloon dilation, and 3 were dilated with either an acrylic device, endotracheal tube, or bougie. There were no post-operative complications for 76.5% of patients, while a second surgery was required in 9 (17.6%) patients. The median length of stay was 11 days (IQR = 4, 26). No statistically significant difference was observed between sublabial drilling and surgical dilation techniques with respect to complications, need for revision surgery, or length of stay.

CONCLUSION

Current literature is insufficient to determine if drilling or dilation is more effective in the treatment of CNPAS.

Nasal Disorders

Nasal obstruction, rhinorrhea, and epistaxis are common presenting concerns in primary care clinics. Nasal disorders affect the quality of life for many children and families. Rarely, these complaints may represent a life-threatening condition among infant obligate nasal breathers or cases of unusual pathology. The most common causes of rhinorrhea and nasal obstruction vary by age and include physiologic, infectious, allergic, foreign body, irritant, and traumatic causes. Less commonly, children may have congenital malformations, sinonasal masses, or autoimmune disease. The most common causes of epistaxis are inflammatory, environmental, and traumatic causes and medication misuse, but rarely, children may have predisposing anatomic, hematologic, or vascular abnormalities or even sinonasal tumors. In this article, we provide a thorough review of the common nasal disorders treated every day in primary care clinics and mention briefly some of the rare but serious cases that may be overlooked without considering a full differential diagnosis.

Sleep Disordered Breathing and Risk for ADHD: Review of Supportive Evidence and Proposed Underlying Mechanisms

BACKGROUND

Accumulating evidence suggests that sleep disordered breathing (SDB) is under-recognized in youth and adults with ADHD. SDB may contribute to exacerbating pre-existing ADHD symptoms and may play a role in the development of cognitive deficits that may mimic ADHD symptoms.

METHOD

We conducted a focused review of publications on cross-prevalence, overlapping clinical and neurobiological characteristics and possible mechanisms linking SDB and ADHD.

RESULTS

Exiting studies suggest that co-occurrence of SDB and ADHD is as high as 50%, with frequent overlap of clinical symptoms such as distractibility and inattention. Mechanisms linking these conditions may include hypoxia during sleep, sleep fragmentation and activation of inflammation, all of which may affect brain structure and physiology to produce disturbances in attention.

CONCLUSIONS

The relationship between SDB and ADHD symptoms appear well-supported and suggests that more research is needed to better optimize procedures for SDB assessment in youth being evaluated and/or treated for ADHD.

Nose vs. mouth breathing- acute effect of different breathing regimens on muscular endurance

BACKGROUND

It has been reported that the way we breathe (whether through the nose or mouth) can influence many aspects of our health and to some extent, sport performance. The purpose of this study was to evaluate the acute effects of different breathing regimens on muscular endurance and physiological variables.

METHODS

A randomized experiment to verify the acute effect of different breathing regimens (NN- inhaling and exhaling through the nose; NM- inhaling through the nose, exhaling through the mouth; MM- inhaling and exhaling through the mouth) on the muscular endurance performance was conducted. 107 physically active college students (68 males, 39 females) performed repeated bench press testing protocol (repetitions to failure (RTF) with 60% of body weight for males (BP60), respectively 40% of body weight for females (BP40)) with various breathing regimens (NN, NM, MM) in random order. Heart rate (HR), blood oxygen saturation (SpO2) and perceived exertion by Borg scale (RPE) were measured as well. A short questionnaire, given after the testing protocol and observation during familiarization, was used to detect each subject's normal breathing approach during resistance training.

RESULTS

In both genders, no significant differences in RTF, RPE and SpO2 were found. No individual case of deviation of arterial oxygen saturation outside the physiological norm was recorded. ​​In the male group, significantly lower HR values were found during the NN trials, compared to during the NM (p = 0.033) and MM (p = 0.047) trials with no significant differences in females. The HR differences in the males demonstrated a small effect size (NN < NM, d = 0.32; NN < MM, d = 0.30). Questionnaire results suggest that 80% of our participants use NM breathing, 15% use MM breathing and 5% use NN breathing during resistance training.

CONCLUSION

It seems, that various breathing regimens have none or only minor effect on muscular endurance performance and selected physiological parameters. NN seems to be as efficient as other two regimens, which are mostly used in practice (NM, MM).

Craniofacial and olfactory sensory changes after long-term unilateral nasal obstruction-an animal study using MMP-3-LUC transgenic rats

Nasal obstruction exerts considerable physiological effects on the respiratory system and craniofacial morphology during the developmental stage. This study used MMP-3-LUC transgenic rats for in vivo tracking of long-term expression in the rat nasal region after unilateral nasal obstruction. Skeletal changes of the craniofacial, nasal, and sinus regions were measured through micro-computed tomography examination and analysis with 3D image processing and calculation. Matrix metalloproteinase-3 and olfactory marker protein expression were also investigated through immunohistochemistry (IHC). Unilateral nasal obstruction significantly reduced the MMP-3 signal in the nasal region of MMP-3-LUC transgenic rats, which was mainly expressed in the respiratory epithelium. Long-term obstruction also caused morphological changes of the craniofacial hard tissue, such as nasal septal deviation, longer inter-jaw distance, and increased maxillary molar dental height. It also caused compensatory growth in olfactory nerve bundles and the olfactory epithelium, as confirmed by IHC. In our study, long-term unilateral nasal obstruction caused nasal septal deviation toward the unobstructed side, hyper divergent facial development including longer molar dental height, and reduced MMP-3 production. However, further investigation is necessary to explore the mechanism in depth.

A simple home test to differentiate habitual from pathological mouth breathing

BACKGROUND

Mouth breathing (MB) is defined as breathing through the mouth alone or the mouth and the nose for more than six months. Unfortunately, after managing its mechanical causes, MB may continue due to habit, obscuring the results of surgical correction of nasal breathing and misleading to unnecessary or aggressive maneuvers.

OBJECTIVE

to develop and evaluate a new test to define children of habitual MB.

MATERIALS AND METHODS

Design: a prospective observational study conducted from May 2022 to February 2023.

SETTING

multicenter; outpatient university clinics and a private ENT center.

PARTICIPANTS

577 children aged 2-12 years and complaining of MB during sleep (±daytime) for ≥6 months were assessed for eligibility, 340 were excluded due to a lack of inclusion criteria, 29 declined or discontinued participation, and 208 were enrolled. Of these, 180 gave reliable data.

THE TEST

After about 1 h of the child's sleep, the parent applies one warmed hand to close the child's open mouth recording his awakeness time (AT) for a maximum of 3 min for three nights. On the next visit, the child's examination started for obstruction causes, including endoscopy, and the test results were collected.

MAIN OUTCOME AND MEASURES

The AT was compared to examination results aiming to find a significant diagnostic relation. Children with no abnormality in the clinical and endoscopic examination were considered habitual mouth breathers.

RESULTS

Among 94 males and 86 females aged 2-12 years, MB duration ranged from 6 to 42 months, with a mean of 15.9. The home test results were presented by the mean AT in seconds. The awakeness time (AT) could discriminate patients' abnormalities at a cut-off level of <133 s, with 98.5% sensitivity and 89.7% specificity. Results <133 s are considered positive. Positive results mean the presence of a cause of obstruction. Negative results suggest no reason could be detected by endoscope or clinical examination. True positive children were 120 (66.7%), and 12 (6.7%) were false positive. True negative children were 43 (23.9%), and 5 (2.8%) were false negative.

CONCLUSIONS

Test results ≥133 s are associated with habitual MB. We recommend the test for the initial assessment of night MB.

Inhalation boosts perceptual awareness and decision speed

The emergence of consciousness is one of biology's biggest mysteries. During the past two decades, a major effort has been made to identify the neural correlates of consciousness, but in comparison, little is known about the physiological mechanisms underlying first-person subjective experience. Attention is considered the gateway of information to consciousness. Recent work suggests that the breathing phase (i.e., inhalation vs. exhalation) modulates attention, in such a way that attention directed toward exteroceptive information would increase during inhalation. One key hypothesis emerging from this work is that inhalation would improve perceptual awareness and near-threshold decision-making. The present study directly tested this hypothesis. We recorded the breathing rhythms of 30 humans performing a near-threshold decision-making task, in which they had to decide whether a liminal Gabor was tilted to the right or the left (objective decision task) and then to rate their perceptual awareness of the Gabor orientation (subjective decision task). In line with our hypothesis, the data revealed that, relative to exhalation, inhalation improves perceptual awareness and speeds up objective decision-making, without impairing accuracy. Overall, the present study builds on timely questions regarding the physiological mechanisms underlying consciousness and shows that breathing shapes the emergence of subjective experience and decision-making.NEW & NOTEWORTHY Breathing is a ubiquitous biological rhythm in animal life. However, little is known about its effect on consciousness and decision-making. Here, we measured the respiratory rhythm of humans performing a near-threshold discrimination experiment. We show that inhalation, compared with exhalation, improves perceptual awareness and accelerates decision-making while leaving accuracy unaffected.

Mouth breathing induces condylar remodelling and chondrocyte apoptosis via both the extrinsic and mitochondrial pathways in male adolescent rats

The prevalence of mouth breathing is high in children and adolescents. It causes various changes to the respiratory tract and, consequently, craniofacial growth deformities. However, the underlying mechanisms contributing to these effects are obscure. Herein, we aimed to study the effects of mouth breathing on chondrocyte proliferation and death in the condylar cartilage and morphological changes in the mandible and condyle. Additionally, we aimed to elucidate the mechanisms underlying chondrocyte apoptosis and investigate any variations in the related pathways. Subchondral bone resorption and decreased condylar cartilage thickness were observed in mouth-breathing rats; further, mRNA expression levels of Collagen II, Aggrecan, and Sox 9 were lower in the mouth breathing group, while those of matrix metalloproteinase 9 increased. TdT-mediated dUTP nick end labelling staining and immunohistochemistry analyses showed that apoptosis occurred in the proliferative and hypertrophic layers of cartilage in the mouth breathing group. TNF, BAX, cytochrome c, and cleaved-caspase-3 were highly expressed in the condylar cartilage of the mouth-breathing rats. These results suggest that mouth breathing leads to subchondral bone resorption, cartilage layer thinning, and cartilage matrix destruction, inducing chondrocyte apoptosis via both the extrinsic and mitochondrial apoptosis pathways.

Predicting the clinical trajectory of feeding and swallowing abilities in CHARGE syndrome

To date, the feeding and oral-motor abilities of patients with CHARGE syndrome (CS) have not been longitudinally assessed. This study aims to investigate the level of these abilities at different ages and evaluate how they evolve during growth. We retrospectively analysed oral-motor features of 16 patients with molecularly confirmed CS (age range 4-21 years old; mean 11 years; SD 6 years; median 10 years). Nearly 100% of CS new-borns had weak sucking at birth, and half of them demonstrated poor coordination between breathing and swallowing. Over time, the percentages of children with tube feeding dependence (60% at birth) faced a slow but steady decrease (from 33% at 6 months, 25% at 12 months, to 13% at school age) in tandem with the decreasing risk of aspiration. The ability of eating foods requiring chewing was achieved at school age, after the acquisition of an adequate oral sensory processing. A mature chewing pattern with a variety of food textures was not achieved by more than half of patients, including those requiring artificial enteral nutrition. Most patients started prolonged oral-motor treatments with speech language therapists in early childhood.

CONCLUSIONS

Although feeding and swallowing disorders are constant features in CS patients, a slow and gradual development of feeding abilities occurs in most cases. Rehabilitation plays a key role in overcoming structural and functional difficulties and attaining appropriate eating skills.

WHAT IS KNOWN

• Feeding problems and swallowing dysfunction have been noted in CHARGE syndrome. • The involvement of multiple factors, including structural problems in the mouth, throat, or esophagus, and neurological impairment, make feeding a complicated task in CHARGE individuals.

WHAT IS NEW

• Dysphagia gradually improves in most CHARGE children over time, though with a wide interindividual variability. • The percentages of children with tube feeding dependence decrease over time from 60% at birth to 33% at 6 months and 13% at school age.

Factors related to mouth breathing syndrome in preschool children and the effects of incompetent lip seal: An exploratory study

OBJECTIVES

A set of orofacial signs and symptoms completely or partially present in individuals who replace the correct pattern of nasal breathing with an oral or mixed pattern is defined as mouth breathing syndrome (MBS). In a previous report, it was clarified that an incompetent lip seal (ILS) affected the occurrence of MBS among primary school children. However, the factors related to MBS and the effect of ILS in preschool children remain unclear. The purpose of this study was to clarify the factors relevant to MBS in preschool children and investigate the relationship of ILS to MBS.

MATERIAL AND METHODS

We surveyed 285 preschool children between 3 and 5 years of age. Their guardians completed the questionnaire, which consisted of 44 questions regarding the children's daily health conditions and lifestyle habits. To classify the closely related questions into their respective factors and to examine the strength of the correlation between the newly revealed factors, an exploratory factor analysis with promax rotation was performed.

RESULTS

The factor analysis identified nine items representing four factors. Factors 1-4 were defined as "diseases of the nose," "ILS," "problem with swallowing and chewing," and "eating and drinking habits," respectively. Factor 2 most strongly correlated with Factor 1, and both Factors showed a relatively strong correlation with Factor 3.

CONCLUSIONS

The initial stage of MBS may be present in preschool children. ILS and diseases of the nose can cause poor development of oral functions, such as breathing and eating.

Consensus on Nasal Irrigation in Infants: A Delphi Study

INTRODUCTION

Nasal irrigation is regularly used in infants to relieve upper airway symptoms. However, because there is no consensus on good practice, nasal irrigation in infants is described and applied heterogeneously among clinicians and between clinical trials.

OBJECTIVE

The aim of this study was to establish consensus regarding the use of nasal irrigation in infants.

METHODS

A panel of Belgian physiotherapists and physicians experienced in performing nasal irrigation in infants were surveyed using the Delphi technique. Three survey rounds were used. Participants rated their level of (dis)agreement to each statement in each round using a 6-point Likert scale. Consensus was defined for statements which collected at least 75% of responses in agreement or disagreement. The questionnaire of Round 1 was built on nasal irrigation practice habits previously collected from parents, childcare workers, and healthcare professionals. Questionnaires from rounds 2 and 3 were amended based on experts written feedback.

RESULTS

Thirty experts (12 physicians and 18 physiotherapists) completed all 3 questionnaires. Consensus was achieved for 47 of 75 statements (63%) distributed over the following domains: "contraindications," "indications and frequency of use," "irrigation means," "solution preparation," "solution volume," "realization of the technique," and "assessment of the efficacy of nasal irrigation."

CONCLUSION

This study provides the first well-constructed consensus on good practice on nasal irrigation in infants. Consensus on several statements across different domains were established but require validation in future trials. This study also proposes direction for future research focusing on statements that did not reach consensus.

Effects of mouth breathing on maxillofacial and airway development in children and adolescents with different cervical vertebral maturation stages: a cross-sectional study

Background

To examine the influence of mouth breathing on maxillofacial and airway development in children and adolescents with different cervical vertebral maturation stages.

Methods

Lateral cephalometric radiograph of a total of 120 children and adolescents, 64 girls and 56 boys (7–15 years old), diagnosed with mouth breathing were examined. Maxillofacial hard tissue, soft tissue and airway measurements were obtained using both manual and digital techniques. Independent samples t-test was performed to compare the difference between the measured indexes and the standard values.

Results

As for maxillofacial hard tissue, SNB (CS1–CS5), GoGn (CS1–CS5), ArGoNa (CS1–CS5), ArGo (CS1–CS2) and SNA (CS1–CS2) in mouth breathing children and adolescents were below the standard values (P < 0.05). NGoMe (CS1–CS5), SN-MP (CS1–CS4), SN-PP (CS1–CS4), PP-MP (CS1–CS3) and SN-GoGn (CS1–CS2) in mouth breathing children and adolescents were above the standard values (P < 0.05). As for maxillofacial soft tissue measurements, H angle (CS1–CS5), lower lip length (CS1–CS5), upper lip protrusion (CS1–CS5), upper lip length (CS1–CS4), lower lip protrusion (CS1–CS3), surface Angle (CS2–CS3) and nasolabial angle (CS2) in mouth breathing children and adolescents were above the standard values with statistically significance (P < 0.05). As for airway measurements, PAS (CS1, CS2, CS5) in mouth breathing children and adolescents was above the standard value with statistical significance (P < 0.05).

Conclusions

Mouth breathing had a real effect on maxillofacial and airway development, which differed among mouth breathing children and adolescents with different cervical vertebral maturation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02234-x.

Nasal Obstruction in the Infant

Neonatal nasal obstruction is common in both the hospital and clinic settings. Causes can range from rhinitis to congenital masses, with a wide variety of congenital nasal masses described. A complete history and physical examination are necessary for correct diagnosis and management. Arhinia and bilateral choanal atresia will present with complete obstruction leading to forced mouth breathing. Partial obstruction will require assessment of nasal patency with possible nasal endoscopy and imaging. Medical and surgical options for treatment are discussed.

The Ogival Palate: A New Risk Marker of Sudden Unexpected Death in Infancy?

OBJECTIVE

Ogival palate (i.e., a narrow and high-arched palate) is usually described in obstructive breath disorder but has been found in infants unexpectedly deceased. We studied the association between ogival palate and sudden unexpected death in infancy (SUDI) on the basis of a computed tomography (CT) evaluation.

METHODS

We conducted a monocentric case-control study of children under 2 years of age who died of SUDI, for which a head CT scan and an autopsy were performed between 2011 and 2018. Each case was matched by sex and age (± 30 days) to two controls selected among living children in the same center who benefited from a cranio-encephalic CT scan. Four parameters of the hard palate were measured by CT: height, width, length, and sagittal angle; the height/width ratio was calculated. The presence of an ogival palate was also subjectively evaluated by the radiologists, independently from the measurements. Standardized odds ratios (OR) were calculated using conditional logistic regression models, all expressed for +1 standard deviation (SD).

RESULTS

Thirty-two deceased children were matched to 64 living control children. Mean ages were 5.0 and 5.3 months, respectively. Twenty-eight cases were considered to have died as a result of SIDS. The mean heights of the hard palate were significantly higher in the deceased children [4.1 (± 0.7) millimeters (mm)] than in the living children [3.2 (± 0.6) mm], with OR (+1SD) = 4.30 (95% confidence interval [CI], 2.04-9.06, P = 0.0001). The mean widths of the hard palate were 21.0 (± 1.9) mm and 23.2 (± 2.1) mm, respectively, with OR = 0.15 (95% CI, 0.06-0.40, P = 0.0001). The mean sagittal angles were significantly more acute in deceased children [134.5° (± 9.3)] than in living children [142.9° (± 8.1)], with OR = 0.28 (95% CI, 0.14-0.56, P = 0.0003). The mean height/width ratios were 19.8 (± 3.7) and 14.1 (± 3.3), respectively, with OR = 6.10 (95% CI, 2.50-14.9, P = 0.0001). The hard palate was subjectively considered as ogival in 59.4% (19/32) of the cases versus 12.5% (8/64) of the controls.

CONCLUSION

Radiological features of the ogival palate were strongly associated with SUDI. This observation still needs to be confirmed and the corresponding clinical features must be identified.

Thermographic analysis of postoperative changes in the nasal breathing efficiency in infants and young children with unilateral cleft lip

PURPOSE

Nowadays, cheilorhinoseptoplasty is one of the most efficient methods of cleft lip primary surgical treatment eliminating both functional and esthetic issues. In this work, we have proposed, developed, and experimentally tested a new thermography-based algorithm for studying the efficiency and symmetry of nasal breathing prior to and after the surgery.

METHODS

To investigate and analyze the external respiration function of an infant with unilateral cleft lip after surgical respiration symmetry restoration followed by anatomically shaped postoperative endonasal retainer installation, we have applied contactless thermal imaging in real time.

RESULTS

The developed algorithm enables effective analysis of the respiratory function in infants before and after the surgery. Its combination with applied surgical technique experimentally demonstrated the potential of this approach for improving further the efficiency and symmetry of the airflows through the patient's nasal passages after the primary cheilorhinoseptoplasty.

CONCLUSIONS

The results of our study constitute a novel and promising avenue of investigation into the breathing function in infants and young children prior to and after their surgery for unilateral cleft lip. The adaptation of our technique to the conditions of a pediatric hospital will make it a safe and informative tool for noninvasive diagnosing the respiratory function in infants in the early postoperative period.

Multidisciplinary approach to assessment and intervention of feeding problems in children with autism spectrum disorders: a clinical perspective

Purpose

The aim of this paper is to share the details of a multidisciplinary approach, which includes occupational therapy, and to review the factors that should be considered in the evaluation and treatment of children with autism spectrum disorders (ASD) who are excessively selective in their food choices. Issues in this area are complex and often related to several complementary domains (medical, nutritional, psychosocial, sensorimotor, etc.). However, feeding disorders are frequently assessed and treated from a single discipline and important issues are missed or confounded.

Design/methodology/approach

A team of experienced clinicians in the field of paediatric feeding disorders gathered the knowledge and experience they acquired from working with individuals with ASD as well as with individuals with other neurodevelopmental diagnosis. A review of current literature in paediatric feeding disorders was used to document and explicate the multifactorial nature of feeding disorders in children with ASD and justify the need for a multidisciplinary approach to issues in this area.

Findings

Feeding disorders in children with ASD are linked to multiple sensory, motor, behavioural, nutritional and gastrointestinal comorbidities. A multidisciplinary approach is needed and increasingly recommended. However, multidisciplinary teams, specialised in the care of children with ASD and feeding issues, continue to be difficult to locate and access for families. The authors sought to highlight the signs of feeding problems in children with ASD from different domains and share a model of a multidisciplinary approach that can lead to more successful interventions.

Originality/value

The detailed description of the domains linked to feeding issues and the clinical descriptions provided throughout the paper create a roadmap for other clinicians aiming to set up similar teams.

Congenital bony nasal cavity stenosis: A review of current trends in diagnosis and treatment

Congenital bony nasal cavity stenosis is caused by alterations of the normal embryological development of the nasal cavity. Depending on the site of the obstruction, the most important types of stenosis are: choanal atresia and stenosis, congenital nasal pyriform aperture stenosis, congenital midnasal stenosis, arhinia and nasal septum deviation. Although they are uncommon, they could be potentially life-threatening conditions that require early diagnosis and proper treatment. In case of neonatal nasal obstruction, appropriate differential diagnosis with other causes, such as rhinitis and sinonasal masses, are performed by nasal endoscopy and radiological exams. Treatment strategy consisting of medical nasal therapies and endoscopic or open nasal surgery should be tailored according to the types and the degree of the stenosis. When indicated, endoscopic endonasal approach is considered the most effective technique in neonates warranting minimal surgical invasiveness and maximum effect. In order to promote the management of these rare yet clinically relevant neonatal nasal breath disorders, we review the current trends in diagnosis and treatment of congenital bony nasal cavity stenosis.

Influence of mouth breathing on atopic dermatitis risk and oral health in children: A population-based cross-sectional study

Background/purpose

Previous studies have suggested that mouth breathing has harmful effects on atopic dermatitis (AD) and oral health in children, but the evidence has been insufficient. To investigate the association of mouth breathing with AD and oral health in Korean schoolchildren aged 8–11 years.

Materials and methods

Cross-sectional data were obtained from March to April 2016. A questionnaire was used to investigate children's mouth breathing habits and personal/family histories related to allergic disease. Oral health status was determined through a clinical oral examination. Data were analyzed with multivariable logistic regression.

Results

In total, 1507 children were included. A moderate relationship was observed between mouth breathing and AD (adjusted odds ratio, 1.05; 95% confidence interval, 1.00–1.10; p-value, 0.035), whereas no association was found between mouth breathing and dental caries in children. Mouth breathing during sleep (MBS) was closely related to allergic diseases and other respiratory diseases. Furthermore, mouth breathing was associated with child's tonsillitis and was identified as a possible risk factor for class II dental malocclusion.

Conclusion

We confirmed the positive association between mouth breathing (especially during sleep) and allergic diseases, including the AD in school-aged children. The influence of mouth breathing on dental caries remains uncertain. An intervention trial is required to evaluate whether the prevention of mouth breathing can reduce the risk of allergic diseases.

Could nasal nitric oxide help to mitigate the severity of COVID-19?

The nasal cavity and turbinates play important physiological functions by filtering, warming and humidifying inhaled air. Paranasal sinuses continually produce nitric oxide (NO), a reactive oxygen species that diffuses to the bronchi and lungs to produce bronchodilatory and vasodilatory effects. Studies indicate that NO may also help to reduce respiratory tract infection by inactivating viruses and inhibiting their replication in epithelial cells. In view of the pandemic caused by the novel coronavirus (SARS-CoV-2), clinical trials have been designed to examine the effects of inhaled nitric oxide in COVID-19 subjects. We discuss here additional lifestyle factors such as mouth breathing which may affect the antiviral response against SARS-CoV-2 by bypassing the filtering effect of the nose and by decreasing NO levels in the airways. Simple devices that promote nasal breathing during sleep may help prevent the common cold, suggesting potential benefits against coronavirus infection. In the absence of effective treatments against COVID-19, the alternative strategies proposed here should be considered and studied in more detail.

Airway Obstruction Risk in Unique Infant Cleft Phenotype: PSIO Protocol Modification Recommendations

Patients presenting with a unique unilateral cleft phenotype may be at risk of nasal airway obstruction which can be exacerbated by presurgical infant orthopedic (PSIO) appliance therapy and lip taping. Four patients presented to the UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center with a cleft phenotype characterized by: An anteriorly projected greater alveolar segment and medial collapse of the lesser segment posteriorly, leading to cleft alar base displacement posteromedial to the anteriorly projected greater segment. Resultant bilateral nasal airway obstruction: cleft ala drape over the leading edge of the greater segment's alveolus (cleft side obstruction) and caudal septum displacement secondary to attachments to the orbicularis oris from the noncleft side (noncleft side obstruction). The patient described presented at 3 months old from an outside institution, where PSIO therapy was undertaken. A second opinion was sought due to concern of significant difficulty in breathing and feeding with the PSIO oral plate. Lip-nose adhesion (LNA) was elected and airway obstruction was immediately relieved after this intervention. Lip-nose adhesion releases the tethered cleft side alar base from the pyriform rim of the posteromedially collapsed lesser segment and unites the superior lip and nostril sill-relieving the cleft side nostril obstruction. During the LNA, the caudal septum is surgically released from the anterior nasal spine and is uprighted, relieving the obstructed noncleft nostril. In this cleft anatomy, the treatment alternatives of modification to the PSIO appliance or LNA should be carefully considered in consultation with the surgeon, PSIO provider, and the infant's caretakers.

Unilateral nasal obstruction alters sweet taste preference and sweet taste receptors in rat circumvallate papillae

Nasal obstruction causes mouth breathing, and affects the growth and development of craniofacial structures, muscle function in the stomatognathic system, and the taste perceptive system. However, the detailed mechanism underlying the effects of nasal obstruction on taste perception has not been fully elucidated. In this study, we investigated this mechanism using the two-bottle taste preference test, immunohistological analysis, and quantification of the mRNA expression of taste-related molecules in the circumvallate papillae. Neonatal male Wistar rats were divided randomly into control and experimental groups. Rats in the experimental group underwent unilateral nasal obstruction by cauterization of the external nostril at the age of 8 days. Arterial oxygen saturation (SpO₂) was recorded in awake rats using collar clip sensors. Taste preference for five basic taste solutions was evaluated. Immunohistochemical analysis and quantitative real-time polymerase chain reaction (RT-PCR) were conducted to evaluate the expressions of taste-related molecules in the taste cells of the circumvallate papillae. Body weights were similar between the two groups throughout the experimental period. The SpO₂ in the 7- to 12-week-old rats in the experimental group was significantly lower than that in the age-matched rats in the control group. In the two-bottle taste preference test, the sensitivities to sweet taste decreased in the experimental group. The mRNA expression of T1R2, T1R3, α-gustducin, and PLCβ2 was significantly lower in the experimental group than in the control group as determined by quantitative RT-PCR, and the immunohistochemical staining for α-gustducin and PLCβ2 was less prominent. These findings suggest that nasal obstruction may affect sweet taste perception via the reduced expression of taste-related molecules in the taste cells in rat circumvallate papillae.

Influenza-Mediated Lung Infection Models

Laboratory rodent influenza infection models have been and continue to be a critical tool for understanding virus-host interactions during infection. The incidence of seasonal influenza infections coupled with the need for novel therapeutics and universal vaccines highlights the need to uncover novel mechanisms of pathogenesis and protection. Mouse models are extremely useful for the evaluation of influenza vaccines and provide an invaluable tool to probe the immune response. This chapter describes the technique of intranasal inoculation of male C57BL/6J mice with an H1N1 strain of influenza (A/Puerto Rico/8/1934) and methods for assessing the optimum dose for infection, viral titers in lung tissue, and severity of disease.

[The nose, an orthodontic-surgical marker]

INTRODUCTION

Inthe quest for a universal marker to describe the physiological function of facialmechanics, the author has found nasal ventilation at rest to be a major factor to beborne in mind.

MATERIALS AND METHODS

Factors related to embryology, anatomyand respiratory physiology, along with analysis of the literature in the relevantareas, now enable us to view the nose in a different light.

CONCLUSION

The authorconcludes that nasal ventilation at rest constitutes a mandatory objective in theperformance of all types of therapy.

Disorders of the neonatal nasal cavity: Fundamentals for practice

Neonatal nasal obstruction is a well-known clinical entity. Fortunately, it is rarely life-threatening and usually resolves with conservative management. As with most conditions, a systematic history and thorough physical examination are crucial for correct diagnosis and management. The initial diagnosis may be elusive and require either serial or more in-depth evaluations. Occasionally, examination may reveal structural abnormalities necessitating surgical intervention. Fortunately most of these abnormalities are amenable to surgery; however, a select few are notoriously difficult to treat.

Intermittent hypoxia induces disturbances in craniofacial growth and defects in craniofacial morphology

OBJECTIVES

To investigate intermittent hypoxia (IH) induced changes in craniofacial morphology and bone mineral density (BMD) in the mandible of growing rats.

DESIGN

Seven-week-old male Sprague-Dawley rats were exposed to IH for 4 days or 3 weeks. Sham-operated rats simultaneously breathed room air. Lateral and transverse cephalometric radiographs of the craniofacial region were obtained, and the linear distances between cephalometric landmarks were statistically analyzed. BMD and bone microstructure of the mandible were evaluated using micro-computed tomography (micro-CT).

RESULTS

Cephalometric analyses demonstrated that exposure to IH only in the two groups for 3 weeks decreased the size of the mandibular and viscerocranial bones, but not that of the neurocranial bones, in early adolescent rats. These findings are consistent with upper airway narrowing and obstructive sleep apnea (OSA). Micro-CT showed that IH increased the BMD in the cancellous bone of the mandibular condyle and the inter-radicular alveolar bone in the mandibular first molar (M1) region.

CONCLUSIONS

This study is the first to identify growth retardation of the craniofacial bones in an animal model of sleep apnea. Notably, 3 weeks of IH can induce multiple changes in the bones around the upper airway in pubertal rats, which can enhance upper airway narrowing and the development of OSA. The reproducibility of these results supports the validity and usefulness of this model. These findings also emphasize the critical importance of morphometric evaluation of patients with OSA.

Nasal obstruction in children

Nasal obstruction is a very frequent symptom in children, with numerous etiologies. Clinical diagnosis is straightforward, but general impact and rare etiologies should be explored for. Complementary examinations are guided by diagnostic orientation. Although not usually a severe condition, nasal obstruction may be life-threatening in neonates and infants. An exhaustive list of etiologies is impossible and would not be useful, but it is worth distinguishing infantile nasal obstruction and nasal obstruction in older children, as causes differ greatly. This is the topic of the present update.

Effect of unilateral nasal obstruction on tongue protrusion forces in growing rats

Mouth breathing caused by nasal obstruction affects the normal growth and development of craniofacial structures, including changes in the orofacial muscles. Tongue muscles play an important role in patency of the pharyngeal airway, and changes in the breathing pattern may influence tongue function. The purpose of this study was to evaluate the effect of unilateral nasal obstruction during growth on contractile properties of the tongue-protruding muscles. Sixty 6-day-old male Wistar albino rats were divided randomly into control ( n = 30) and experimental ( n = 30) groups. Rats in the experimental group underwent a unilateral nasal obstruction after cauterization of the external nostril at the age of 8 days, and muscle contractile characteristics were measured at 5, 7, and 9 wk of age. The specific parameters measured were twitch force, contraction time, half-decay time, tetanic force, and fatigue index. Repeated-measures multivariate analysis of variance was used for intergroup and intragroup statistical comparisons. Twitch contraction force and half-decay time were significantly increased in the experimental group at all ages. Tetanic forces at 60 and 80 Hz were significantly higher in the experimental group at all ages. The fatigue index was decreased significantly in the experimental group at the age of 5 wk. These results suggest that early unilateral nasal obstruction may increase the contraction force of the tongue-protruding muscles and prolong the duration of muscle contraction, which may influence the shape and development of the craniofacial complex.

Association between Mouth Breathing and Atopic Dermatitis in Japanese Children 2-6 years Old: A Population-Based Cross-Sectional Study

As mouth breathing is associated with asthma and otitis media, it may be associated with other diseases. Therefore, this population-based cross-sectional study evaluated the association of mouth breathing with the prevalences of various diseases in children. Preschool children older than 2 years were included. A questionnaire was given to parents/guardians at 13 nurseries in Tokushima City. There were 468 valid responses (45.2%). We defined a subject as a mouth breather in daytime (MBD) if they had 2 or more positive items among the 3 following items: “breathes with mouth ordinarily,” “mouth is open ordinarily,” and “mouth is open when chewing.” We defined subjects as mouth breathers during sleep (MBS) if they had 2 or more positive items among the following 3 items: “snoring,” “mouth is open during sleeping,” and “mouth is dry when your child gets up.” The prevalences of MBD and MBS were 35.5% and 45.9%, respectively. There were significant associations between MBD and atopic dermatitis (odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.4–4.2), MBS and atopic dermatitis (OR: 2.4, 95% CI: 1.3–4.2), and MBD and asthma (OR: 2.2, 95% CI: 1.2–4.0). After adjusting for history of asthma and allergic rhinitis; family history of atopic dermatitis, asthma, and allergic rhinitis; and nasal congestion; both MBD (OR: 2.6, 95% CI: 1.3–5.4) and MBS (OR: 4.1, 95% CI: 1.8–9.2) were significantly associated with atopic dermatitis. In preschool children older than 2 years, both MBD and MBS may be associated with the onset or development of atopic dermatitis.

Impact of short term forced oral breathing induced by nasal occlusion on respiratory function in mice

Inconsistent findings regarding the experimental nasal obstruction on respiratory functions in small animals have been reported. The purpose of this study was to investigate the impact of short term forced oral breathing on respiratory functions as well as the therapeutic implication of esophageal intubation in BALB/c mice. Thirty BALB/c mice were randomized equally to two groups: an experimental group and control group. Oral breathing was induced by applying petrolatum ointment in nostrils for occlusion both nasal cavities. Esophageal tube was inserted to enlarge the oropharyngeal airway in the experimental mice. Respiratory parameters were measured by barometric whole-body plethysmography (WBP) in the following condition: normal nasal breathing; nasal breathing loading in a soft bag; forced oral breathing loading in a soft bag; forced oral breathing loading in a soft bag after undergoing esophageal intubation. After applying petrolatum ointment of nostrils, all the mice switch to oral breathing with apparent discomfort (bradypnea). Nasal occlusion was associated with a decrease in the average respiratory rate (268±36 vs. 90±10 breaths/min; P<0.01) and an increase in Penh (0.67±0.14 vs. 19.23±2.12; P<0.01). After undergoing esophagus intubation, these mice switched to oral breathing with less discomfort. Compared with the control mice, respiratory rate (175±25 vs. 90±10) was higher; the Penh (8.84±1.05 vs. 18.09±2.03; P<0.01) was lower. Short term forced oral breathing induced by nasal occlusion caused respiratory insufficiency in mice. Stenotic oropharyngeal airway was supposed to be one of the most important factors. Enlarging oropharyngeal airway by esophagus intubation could improve the respiratory insufficiency under nasal occlusion.