Facial Clues to Sleep Disordered Breathing: The I-Spy Tool

I would like to express my gratitude to Dr Biju Krishnan, BDS FICD FCGDent FRSM, a dentist with a special interest in airway-focused orthodontics, for developing a practical I-Spy tool that has helped me look at breathing in a new way.

Using this approach, I have become more aware of facial features and breathing behaviours that may contribute to difficulties with breathing during sleep. While this article focuses on children, the tool has also encouraged me to reflect on how adults breathe while sleeping and the factors that may affect their sleep quality.

This illustration was created with Gamma to respect privacy and consent requirements for children

I-Spy: Facial Clues That Might Hint at Sleep-Disordered Breathing in Children

Sleep should be peaceful.  But for many children, restless nights, snoring, mouth breathing, and daytime tiredness, can actually point to something more than ‘just being tired.’

Sleep Disordered Breathing (SDB) ranges from mouth breathing, habitual snoring to airway obstruction during sleep. Recognising external clues early gives caregivers a chance to flag concerns and empower families to seek appropriate support.

Below is a simple I-spy guide to common facial and oral features that are associated with increased risk of SDB features you can spot without being a clinician, followed by next steps to take if you see them.

I-Spy Clues on the Face and Mouth

1. Mouth-Breathing at Rest

Often the first visible sign:

• Lips apart at rest

• Habitually open mouth even when not speaking or eating

This can signal nasal obstruction or airway resistance, something that alters how the face grows over time.

Why this matters

Nose breathing helps normal airway tone, nitric oxide production and jaw development. Mouth breathing shifts the tongue and jaw position in ways that can narrow airway spaces as children grow.

2. Long, Narrow Face

Look for:

• A vertically “long” lower face

• Reduced cheek width

• Less pronounced nose bridge

Why this matters

Children with this elongated facial pattern are more likely to have airway constriction during sleep. 

3. Small Chin (Mandibular Retrusion)

If the child’s chin seems small or set back:

• The lower jaw does not align forward

• The profile appears “soft” around the jawline

Why this matters

This can narrow the upper airway space behind the tongue leading to a restriction in normal breathing and encouraging mouth breathing.

4. High-Arched, Narrow Palate

Peek inside the mouth (only if appropriate):

• Roof of the mouth looks unusually tall and narrow

• A high-arched palate often develops when the tongue isn’t resting against the palate a key factor in healthy airway and dental arch growth.

Why this matters

The roof of the mouth is also the floor of the nose. The higher the roof of the mouth the less space there is in the nose to help with normal nasal breathing.

5. Dental Crowding or Crossbites

This is a dental pattern you can spot even from social photos:

• Teeth appear crowded – in young children if jaws are developing properly then spacing between teeth is more likely.

• No gaps, or worse, crowding, is a good indication that the jaws are not developing optimally.

• Teeth not meeting evenly

• Crossbite (one side doesn’t align when biting down)

Why this matters

These patterns often reflect underlying narrow jaws and altered tongue posture and both are linked to airway restriction.

6. Signs Suggesting Large Tonsils or Adenoids

You can’t see tonsils from the outside, but some children show an ‘always blocked’ look in the face, such as:

• A consistently stuffy or blocked-nose appearance

• Breathing through the mouth rather than the nose

• A muffled or “nasal” voice

Why this matters

These can sometimes reflect enlarged tonsils or adenoids, which are a common cause of night-time airway obstruction in children.

Other Signs to Look Out For

As well as the facial and oral features above, many children with sleep-disordered breathing also show daytime and night time signs. These don’t diagnose anything on their own, but together with the ‘I-spy’ facial features they are important to mention to a clinician.

If you’re seeing one or more of these and you’ve noticed one or more of the facial clues, it’s a good prompt to suggest the family speaks to their GP, paediatrician or dentist for further assessment.

Why This Matters: Breathing Shapes Growth

How a child breathes, especially during formative growth years, influences how their face, jaws, palate and airway develop.

If nasal breathing is restricted long-term, many children adopt mouth breathing and altered tongue posture, which can gradually contribute to:

• Narrow dental arches

• Jaws that are positioned too far back

• Higher risk of airway obstruction

That does not mean every child with these signs has a sleep disorder but it does mean these signs are worth noticing early rather than dismissing them.

What to Do Next

If you spot one or more features above:

• Start a conversation with the child’s parent/guardian.

• Suggest they discuss the signs with the child’s primary care clinician, GP, paediatrician or dentist.

• Clinicians can use validated screening tools and, if needed, refer for ENT/orthodontic assessment or sleep studies

• Early recognition empowers early intervention - and might just help steer a child’s growth and sleep health toward a better path.

Final Thought from Dr Biju Krishnan

This ‘I-Spy’ approach isn’t about diagnosing, it’s about raising awareness. By gently noticing patterns in facial and breathing behaviours, caregivers and professionals can seed curiosity and potentially get children the help they need sooner, when interventions that support airway development and sleep quality are most effective.

Dr Biju Krishnan

BDS FICD FCGDent FRSM

Dentist with a special interest in airway focused orthodontics

Why This is Important from a Medical Perspective

The brain has high oxygen requirements & SDB can decrease oxygen supply. The nose is connected to the hippocampus (learning & memory) & amygdala (emotions & social cognition). During sleep memories are consolidated, emotions processed, brain waste products removed and other restorative processes. SDB interrupts the ability of the body to perform these functions and negatively impacts physical and mental health. How we breathe whilst awake impacts how we breathe whilst sleeping. This is a timeline of evidence:

I am part of a global, multidisciplinary team of health professionals who are highlighting the substantial and growing body of high-quality evidence linking sleep-disordered breathing with behavioural and cognitive impairments that overlap with diagnostic features of ADHD. Our submission sets out four recommendations for consideration by the Independent review into mental health conditions, ADHD and autism.

We are sharing this publicly to help raise awareness and encourage the development of evidence-informed policies. The statement is available with a downloadable PDF here. Please share far and wide.

I would also like to recognise the work of the Functional Airway Evaluation Screening Tools (FAirEST) global, multidisciplinary team of health professionals who have developed simple, cost-effective, and non-invasive ways to help identify individuals who may be at risk for sleep and breathing challenges. 

Click to download Functional Airway Evaluation Screening Tool - FAirEST 6+4:

FAirEST 6+4.

Download • 2.20MB

Please note: While FAirEST tools are available for personal clinical use and research purposes. FAirEST tools are not to be taught, presented, copied, modified, shared, distributed or used commercially without written permission.

Thank you to the FAirEST team for granting permission for me to use within this blog.

Supporting Children Towards Better Breathing

Charlotte Marsh (Healthy Breathing Coach, Children's Author and Educator) and I are thrilled to introduce the Supporting Children Towards Better Breathing course.

An empowering resource designed for parents, caregivers, educators, healthcare professionals, social workers, and anyone with a personal or professional connection to a child.

Recognise unhealthy breathing

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References

Bonuck K, Rao T, Xu L. Pediatric sleep disorders and special educational need at 8 years: a population-based cohort study. Pediatrics. 2012 Oct;130(4):634-42. doi: 10.1542/peds.2012-0392. Epub 2012 Sep 3. PMID: 22945405; PMCID: PMC3457621. 

Conclusions: In this population-based longitudinal study, history of either SDB or behavioral sleep problems (BSP) in the first 5 years of life was associated with increased likelihood of special educational need (SEN) at 8 years of age. Findings highlight the need for pediatric sleep disorder screening by early interventionists, early childhood educators, and health professionals.

Chang JL, Goldberg AN, Alt JA, Mohammed A, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Gillespie MB, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OMG, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SYC, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJL, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Woodson BT, Won CHJ, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol. 2023 Jul;13(7):1061-1482. doi: 10.1002/alr.23079. Epub 2023 Mar 30. PMID: 36068685; PMCID: PMC10359192.

'Common craniofacial physical exam findings that are associated with OSA risk include: retrognathia, micrognathia, high arched palate, larger thyromental angles, and shorter thyromental distances. Dental findings may also be suggestive of underlying craniofacial deficiency and include: open bite, overbite, overjet, and proclination of the mandibular incisors'

Guilleminault C, Akhtar F. Pediatric sleep-disordered breathing: New evidence on its development. Sleep Med Rev. 2015 Dec;24:46-56. doi: 10.1016/j.smrv.2014.11.008. Epub 2014 Dec 4. PMID: 26500024.

Practice points: SDB in children persists and re-occurs after T&A. Naso-maxillary and mandibular development has an important impact on the size of the upper airway, and any impairment in this development will consequently impact the size of the upper airway. Development of the facial structure is under the control of genetic and environmental factors.

Guilleminault C, Huang YS. From oral facial dysfunction to dysmorphism and the onset of pediatric OSA. Sleep Med Rev. 2018 Aug;40:203-214. doi: 10.1016/j.smrv.2017.06.008. Epub 2017 Jul 6. PMID: 29103943.

Summary: The upper airway is a collapsible tube, and its collapsibility increases during sleep. Extrinsic factors such as atypical craniofacial features may increase the risks of airway collapse. We review early development of oral-facial structures and the anatomical variants that may be present at birth and can impact nasal breathing. After birth, there is a continuous interaction between orofacial functions and growth of anatomic features. We review the dysfunctions identified to date that may impact orofacial development leading to sleep-disordered-breathing through changes in the orofacial growth. The identification of risk-factors, ultimately leading to full-blown obstructive sleep apnea, may allow early recognition of these factors and the development of treatments to eliminate early problems or at least decrease their impact.

Ikävalko T, Närhi M, Eloranta AM, Lintu N, Myllykangas R, Vierola A, Tuomilehto H, Lakka T, Pahkala R. Predictors of sleep disordered breathing in children: the PANIC study. Eur J Orthod. 2018 May 25;40(3):268-272. doi: 10.1093/ejo/cjx056. PMID: 29016983.

Conclusions: The results indicate that among children, deviant craniofacial morphology, mouth breathing, body adiposity, and male gender seem to have implications in the pathophysiology of SDB.

McIntosh, D. (2024) The ABC of ENT, ASD, and ADHD: From breathing to brain, hearing to hyperactivity. [e-book] Amazon Digital Services.

Summary: Explores the often overlooked relationship between Ear, Nose & Throat (ENT) health and neurodevelopment disorders like Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).

Menzies B, Teng A, Burns M, Lah S. Neurocognitive outcomes of children with sleep disordered breathing: A systematic review with meta-analysis. Sleep Med Rev. 2022 Jun;63:101629. doi: 10.1016/j.smrv.2022.101629. Epub 2022 Mar 31. PMID: 35439720.

Overall, our study provides robust evidence of multiple neurocognitive impairments in children with SDB, with no evidence of sparing in children with Primary Snoring.

Stupak HD. The mechanics of mouth-breathing and its role in nasal and sleep disorders. Eur J Rhinol Allergy. 2023;6(1):21-27.

Conclusions: Apneic/hypopneic events can be simplified to 3 steps: (1) failure of mouth closure due to strain upon the lips, (2) release of tongue restraint by oral compression or intrinsic tongue tone causes collapse, and (3) partial or complete tongue collapse into the pharynx causes a distal negative pressure surge.

Vaishnavi P, Sushmita S, Vivek K, Selvakumar H, Ramanathan R, Swaminathan K. Association between mouth breathing and pediatric obstructive sleep apnea: a systematic review. Eur Arch Otorhinolaryngol. 2026 Feb;283(2):1215-1224. doi: 10.1007/s00405-025-09999-1. Epub 2026 Jan 12. PMID: 41524934.

Conclusion: The available literature suggests that mouth breathing is closely linked to P-OSA, playing a key role in both early diagnosis and ongoing assessment of treatment efficacy. Recognizing mouth breathing as an early marker of P-OSA underscores the need for vigilant assessment by healthcare providers.

#SleepDisorderedBreathing #MouthBreathing #NasalBreathing #SleepMedicine #DentalEducation #ChildDevelopment #AirwayHealth