Ep 207: Helping Babies Breathe Easier: with Dr. Nina Shapiro (Part 1)

In this episode of Your Child Is Normal, Dr. Jessica Hochman sits down with Dr. Nina Shapiro, pediatric ENT and author of Take a Deep Breath: Clear the Air for the Health of Your Child, now out in its updated edition.

Together, they dive into one of the most common worries for parents: their baby’s breathing. Dr. Shapiro explains why newborns are “obligate nasal breathers,” what normal baby breathing actually sounds like, and when parents should (and shouldn’t) worry. You’ll also learn practical, evidence-based tips on:

• The safest and most effective way to use nasal saline
• When (and when not) to use suction devices
• How safe-sleep practices like “A B C — Alone, on their Back, in a Crib” protect babies from SIDS
• Simple tools like the "A B C D E" checklist for spotting breathing trouble

This conversation will help parents feel calmer, more confident, and better equipped to care for their baby’s breathing.

👉 Stay tuned for Part 2 next week, when Dr. Shapiro returns to discuss breathing issues in older kids — including chronic stuffy noses, snoring, and when to see a specialist.

Your Child is Normal is the trusted podcast for parents, pediatricians, and child health experts who want smart, nuanced conversations about raising healthy, resilient kids. Hosted by Dr. Jessica Hochman — a board-certified practicing pediatrician — the show combines evidence-based medicine, expert interviews, and real-world parenting advice to help listeners navigate everything from sleep struggles to mental health, nutrition, screen time, and more.

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Transcript

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Nina, hi everyone, and welcome to your child as normal. I'm your host. Dr Jessica Hochman, and I'm so glad you're joining us today, because we have a very special returning guest. Dr Nina Shapiro, a pediatric ear, nose and throat specialist. Dr Shapiro is not only a fantastic doctor, but she's also the author of take a deep breath, clear the air for the health of your child. In this first part of our conversation, we're focusing on the questions I hear all the time from parents of young babies, how to help them breathe easier, whether your baby has a cold, sounds stuffy, or struggles to sleep comfortably. Dr Shapiro explains how to support healthy breathing in babies and young children with safety and comfort in mind. I know you're going to learn a lot. And before we get started, if you could take a moment to leave a five star review wherever it is you listen to podcasts, I'd be so grateful your reviews help other parents discover your child is normal, and this helps our community continue to grow. Now onto my conversation with Dr Nina Shapiro. Dr Nina Shapiro, I am so happy to have you back on the podcast. Thank you so much for being here. Great to be here. Thanks for having me back so you have a second edition of your book. Take a deep breath that is in print and ready for distribution. I'm so excited for you. Thank you. Yeah, it was a lot of fun to work on. It was my first book, originally back in 2011 and you think that so many breathing issues are evergreen in children, which is true, there are things that just don't change, but there are actually things that have changed over the last 15 years. So it was really fun to work on an update and get the latest information and give it a bit of a refresh. So yeah, I'm really excited. Yeah, absolutely. I noticed you talked about chat GPT, AI, you talked about updated Vaccine Information. So it was really a great book. I really enjoyed reading it. And kudos to you. Thank you. So what inspired you to write? Take a deep breath to begin with. So to begin with, this was back in, I guess, 2010 when I started working on it, and I was in practice at UCLA taking care of children pediatric ENT, and I was seeing so many parents with a huge range of issues with their babies. A lot of it was babies with normal breathing issues that we see in babies, and it was a lot of reassurance that I needed to provide. Then there was a large group of parents that had babies with mild issues, but they were so worried about these really mild issues. But, you know, as pediatricians or Ents, we see this, and we know that it's really nothing to worry about, but I think it was really important to reassure parents. And then lastly, the group of parents with really severe issues in their babies. I really wanted to provide sort of a road map for all parents who have babies, infants, toddlers, how to deal with mild problems, severe problems, what's normal, what's not normal? When to worry, when to really just relax. So I put it in sort of a question, answer format. It's age based and also location based. So it's all chunks of ages, and then it's nose to lungs for each section. Really, just give them a road map when they have issues with their babies. That's really excellent. And as you're talking, I feel like your inspiration to write the book is similar to why I'm so motivated to do this podcast because as a pediatrician, I noticed that most of my day is spent reassuring families, making them feel better about very normal processes that happen with kids. But also we have to know when to worry, when there actually is an issue, how to help guide them, and then how to draw awareness to when there is a problem when there is something to do about it. So very similar, motivation, similar. And I'm sure you give them a lot of guidance in the office, like, well, here's something that is normal and here's something that maybe not so normal. If this happens, you may need to give us a call or be a little concerned. But in all likelihood, most of these issues are normal, and it's really just scary for the parents? Yes. And I think maybe if we can impart good knowledge, let people know what to look for, when to worry, hopefully that can alleviate a lot of concerns. Yeah, all right, so speaking of common concerns, absolutely something that I see a lot with parents are concerns when it comes to breathing and how to help a child who seems to be having difficulty with breathing. So I'm excited to talk to you about this, because hopefully it helps parents. Yeah, I mean, it's terrifying. I mean, as scary as it is to have a breathing problem yourself, it is magnitudes more scary when it's your child that's having a breathing problem. You feel it when it's your child. A lot of these problems are something to worry about potentially or something certainly to address. But I think if parents had more understanding about how babies work, we always say this, as people who take care of children, children are not just little adults, and certainly infants and newborns are really not just little children. They're their own. Beings unto themselves with different breathing patterns, different physiology, different anatomy, different structures that we don't really understand what's going on on the inside. And I think understanding a little bit of that will give parents, hopefully, some tools and a little bit more knowledge to really address these issues Absolutely. So first, I'd like to ask you, what is a normal nasal sound in a baby? It's just such a common worry from parents, to the point where when a child comes in for their one month visit, I can predict that a parent will be asking me if breathing sounds are normal or have questions about breathing. It's just so common. So what can parents expect? Right? So something that sometimes parents find interesting, and doctors who take care of adults don't always know this, is that newborns, up until anywhere up to age five months, are obligate nasal breathers, and that makes them very different from the rest of us, meaning that if they can't breathe through their nose, they can't breathe. Not to make that scary, they can breathe, but they will cry, and that's how they will move air back and forth into their lungs. But if a baby is stuffy, they are absolutely miserable, and in turn, parents will be miserable. So a little nasal stuffiness is very, very normal in everybody, adults, babies, newborns, but if they have any more than a little bit of nasal stuffiness to the point where it's hard for them to breathe through their nose, it will be hard for them to breathe period. So I think, you know, a focus that I try to give to parents is you have to keep their nose clean and life will be okay for everybody, especially when we have winter babies and, you know, and babies that are born in the fall, in the winter, and they have older children at home, and they have a little nasal stuffiness, even from a very mild cold, that's a pretty cranky baby, for sure. Yes. And I think, to your point, they are obligate nasal breathers. They have to breathe through their nose, as you said, except for when they're crying. And the other thing is, they have very small noses, very small nostrils, so you know, with a little bit of mucus, which all babies make, if they reflux a little bit, they're going to sound stuffy, and so it's also very normal for babies to sound loud. Yes, yes, it is. And sometimes it's literally a little tiny booger crust in front of their nose. It could be like a two millimeter Bing, and then I'll literally take it out in the office, and all is well. So you know, I think if parents knew that, then they'd feel a lot more comfortable addressing how to keep their baby's nose clean. One of the things that I talk about, and that is very popular for parents, are those nasal suctions. You know, whether it's different brands, some are now battery powered electric, or some of them, like you put the little straw in your own mouth and you suck the baby's nose, which I'm so glad was not created when my infants had wonderful and just it is the notion of doing that is nasty. So what I always tell parents is it's more about irrigation than suctioning, because parents feel when they hear that their baby is so congested that it must be filled with a ton of mucus. I'll look at the baby's nose front to back with a little, tiny camera, little telescope, and I will reassure them. There is almost no mucus in there. It's just stuffy. And the more they do the suctioning, the more inflamed it gets, the stuffier it gets. But nasal saline is really like the best stuff on Earth. There's no chemical or any sort of toxin to worry about. It really just flushes out the baby's nose because they can't do it themselves. Yeah, so I'd love to break this down. I think it's so wonderful to talk about how to clean a baby's nose and how to do it safely and effectively. You talked about nasal sailing. Let's talk about this. Because questions that I hear a lot from parents are they want to know how to do it. Sometimes they put in nasal sailing and they feel like the child doesn't like it, or maybe they gag on it a little bit, and sometimes they worry they're doing it too much, right? So what are best practices to give saline in a baby? So one of the reasons why babies feel like they're choking is a lot of times parents will give it to their baby when they're on the changing table lying flat, and it really does make them choke. It's like the saline goes back into their throat, and they feel like they're gagging, and it's pretty uncomfortable. You feel like you're restraining the baby, and you can hold the baby down and then sort of put the saline in while they're on the changing table, but it's much more comfortable. And think about it for your yourself, you probably wouldn't want that on yourself. So I always say to hold the baby upright, and then when you stick the nozzle in, you want to have it not exactly straight up and not exactly parallel, but sort of in the middle at an angle inside the nose. You put the nozzle in first and give it a good squirt. The worst thing that happens is the baby swallows a little bit of it, and they probably won't, because it's really such a fine myth. Just, most of it just comes out. And that's fine too. It's, this is a little irrigation up and down, up and down. It doesn't have to go all the way back. You're not doing sinus irrigation. This is really just to keep the nose clean. I sort of use the greenhouse metaphor that it should be like a greenhouse in there. It should be a little bit moist and a little bit kind of damp in there, and the ceiling just creates that. You can use it once a day. You can use it 10 times a day. It doesn't get absorbed into their system. It's not going to change their electrolytes or anything like that. It's just a local way to keep everything clean. So I think that's a great point to bring up, that you can use it really as much as you want. There are no side effects to it. It's not like when we give kids medications, where we have to be mindful of how many hours are between each dose. You can really give it as much as you want. It's salt water, yeah. And same for pregnant people, because a lot of pregnant people are very stuffy. So a little note for them, nasal saline is great, because there are a few medications you can use in your nose when you're pregnant. Okay, so saline, great. Check. Now you also mentioned suctioning. Sometimes the advice is given to put in Saline first and then suction afterwards to get the saline out. I agree that I think suctioning has a helpful role, but also there's a fine line where parents can overly suction. Can you talk about that a little bit? Because I think that's an important point to bring up to parents, right? So sometimes suctioning is great, especially when there is a really goopy nose. Babies certainly don't know how to clear their noses. They can't blow their nose. They're just really uncomfortable. A lot of babies don't mind the suctioning. A lot of babies hate it, but they all feel better afterwards, regardless of how we get through it. So if your baby has a cold or just happens to have a really goopy nose, you can flush it out with a little nasal saline first, just a great idea, do the suctioning, and then even nasal saline afterwards, just to coat the lining. As far as how often to do suctioning, it really just depends on how goopy that nose is. Sometimes it gets gooped up an hour later. Sometimes it's just a few times a day. So that's just really based on how comfortable your baby is. I'm thinking back when my kids were little, I used to really like using the bulb suction, and my husband used to say, you know, don't make perfect the enemy of the good, because I would just want to clear out every little booger that appeared. And the truth is, sometimes the kids would sneeze it out on their own, I had to learn to just reserve it for when it was really necessary, and it puts pressure on their little delicate tissues, and then it just gets more swollen, and then it just becomes a vicious cycle. So unlimited saline suctioning when needed, right? And then, what are some other ways that we can help clear out the nose? I know in your book, you also brought up, humidification can be a helpful measure to clear out the nose. Sure, if you if you live in a home, certainly where you have the heat on and it's very dry heat, or in the warmer months, if you have the air conditioning and it's a very dry environment, you can usually tell because your baby's nose is going to be pretty crusty. You can have a humidifier in their bedroom or in your room, if they're sleeping in your room. Just to give a little moisture, you don't necessarily have to have it on all day, every day, but sometimes, especially if it's extra dry, humidifier helps. You want to make sure that it's cool. Mist is best. And another thing about those humidifiers, it's a little bit labor intensive. You have to keep them clean. They get kind of moldy and dusty, so then you're just spreading other particulate matter into the air. So you keep those humidifiers as clean as possible. It's a little bit of work. I think that's the reason why I never got a humidifier. Just do that daunting to clean all the time. Let's do that bulb suction, correct. Yeah, exactly. Okay. Now, something that you also brought up using Afrin. Now, admittedly, this is something that I didn't realize, that newborns can safely take Afrin, so this was helpful for me. Can you talk about Afrin? What are the limitations? How often to use it? Because Afrin can be a great help. So yes, please educate us. Tell us about Afrin. So what Afrin is? It's a local decongestant, anti inflammatory. It also shrinks all the blood vessels in the nose, and it is typically not indicated or recommended for infants and even young children. But, and there's a big sort of caveat for that, we as Ents use it all the time. We use it certainly if we need to do surgery in newborn noses. We use it in the hospital. We use it in the office setting. And I think it should be really limited, because it is a medication, but in the right setting, if it's a baby with very, very severe nasal congestion from a bad cold or some sort of exposure, and it's temporary and the baby is absolutely miserable. That's a time to consider using Afrin. It's not neosinephrine, which is another topical decongestant that is a definite no for children, but Afrin doesn't have the side effects that something like neosinephrine has, as far as your heart racing and your blood pressure, it's much safer. For in that way, to use it in very limited it's really just in rare situations. One of the times to consider using Afrin is if you're flying with your baby, babies are absolutely miserable on planes. They can't equalize pressure with their ears. And even for older children, meaning older infants and toddlers, a couple of squirts of Afrin before the flight makes everybody much more comfortable. And describe the rule of twos, because I think this is a really helpful way to remember how much Afrin to use where it's still safe, right? And that goes for everybody, not just infants and newborns. The rule of twos for Afrin is no more than two sprays each nostril twice a day for two days. So two sprays each nostril twice a day for two days. And there's the 222, certainly, if you're an adult with a sinus infection, and if you use it for three days, it's really fun, but you know that, but you really want to limit it. Afrin is something that will cause what's called a rebound reaction, meaning that if you use it for too long, it starts causing the reverse and you will be very, very, very stuffy, and then you'll feel like you keep needing to use the Afrin, and it's going to become worse and worse. So you really want to limit how long you use it for, how often you use it, and just a couple squirts in each nostril. I've read it would really take using Afrin for, you know, seven plus days to see that rebound effect. So you're certainly within the realm of safe practices if you stick to the rule of twos. Yes, yes. I mean, I'm just thinking when I have a cold, I'm miserable because I can't breathe through my nose. So these poor babies that have to breathe through their nose, anything that we can do to help them make them make them more comfortable, I think this is good knowledge to have when they inevitably sound stuffy. Yes. So now the question I'd like to ask you about is when to worry. Let's say a baby is stuffy. We're helping them, we're making them feel better, but they still don't seem comfortable. What are the signs that parents can think about when they should seek medical attention. If a baby is stuffy and it's really not able to be cleared, then you're going to start to see other issues related to the baby. The rate of their breathing is probably going to pick up. And you know, all babies breathe faster than older children and adults, but if it becomes really fast, and they seem to be in distress. They have something called Air hunger, where they really look like they're struggling. You can start to see other muscles in their body work hard. So you'll see like the upper part of their neck, their stomach or their ribs, the muscles starting to move to work, to breathe. They just don't seem comfortable. They can't eat, they can't sleep comfortably. They just seem overall miserable. Babies have a few things they need to do, they need to eat, they need to sleep, they need to poop, and they need to grow, and if they're not breathing, they can't do any of that. Well maybe they can poop. But other than that, they're really miserable babies. And so, you know, very early on in the first weeks of life, a parent can recognize the difference between just a cranky baby who's hungry or can't sleep versus a baby who's really struggling in distress. And my mantra, especially when it comes to infants and newborns, is never worry alone. If you are worried, you have to call somebody, because, if nothing else, you'll get reassured that this is normal. This is something that you don't need to worry about, and I am taking that worry away from you. But even if you don't know what's wrong, and there's no reason a parent should understand what's wrong with their baby, they just know that something is wrong, they need to find someone to either allay their fears or to address the issue. And that's where our job comes in, as pediatric care givers to you know, address whether, nope, this is fine. This happens. This is nothing to worry about. Here's what you can do, go back to sleep or come on in. This is something that's urgent. And I completely agree with you. I think when parents are concerned about breathing Absolutely, reach out to your pediatrician, because the best case scenario, and the role that I love to play is hopefully we're just reassuring you. We're letting you know that this is normal, noisy newborn breathing, but also sometimes there are concerning signs and symptoms and we can help. So I agree. Don't do this alone. Seek help. If I can share one mnemonic that I like to tell parents to think about, think about when they're home with their kids and they're trying to assess if there's an issue, I talk about the a, b, c, d, es, so A is for airway, you know, looking at the nasal passages, seeing if they look patent and open. B is breathing, looking at their rate of breathing. Are they breathing too quickly? Are they having a difficult time breathing? Are they retracting and working to breathe? C for color. They shouldn't be blue around the mouth. You talked about this really nicely in your book. D is for diet. Are they still able to feed? Because if their nose is so stuffy, they're going to have trouble feeding, right? Because they have to breathe through their nose. And E, we talk about. About energy. What's their activity like? Are they acting normal? Do they have normal energy? If there's any question about any of those, talk to your pediatrician, reach out and get your baby seen. I like, I like a good mnemonic, okay? And I also tell parents, I try to flip the script a little bit, that if your baby's a noisy breather, it's not always bad, because at night, when you're sleeping, you know, sometimes we worry if they're too quiet, what's going on with them? Are they okay? But if you listen really closely, you can hear them breathing, and know that they're doing all right, that they're breathing, they're thriving, they're sleeping. It's not always a bad thing to have a noisy breather. Yeah, I get that complaint a lot. After I take out a child's tonsils, the parents say we can't hear them anymore. Like, that's actually a good thing, a little noise maturing on that monitor. Yeah, it's a small benefit. Small benefit, right? Okay, now, you talked very nicely in your book about safety and safe practices to help babies with sleeping, right? Can you mention what is the safest way to have a baby go to sleep? Because what we know about babies is the number one reason why a baby passes away in the first year of life is from something called SIDS, and this is something that, with Safe Sleep practices, we can help really mitigate that risk. Yes, so that's another mnemonic, ABC alone on their back in the crib. That is the safest way. That doesn't necessarily mean that they need to be in another room. I think this is a great practice, certainly in the early weeks, to have your baby in the same room as you so you know not necessarily that they're in a huge crib in your room, but in a bassinet, which is a very small crib space in your room is the safest way. And this is very boring. There should be nothing in the crib and no more bumpers, no more toys, no blankets, no pillows, none of the cute stuff that we all loved. You know you see in the pictures, actually, the safest practice is all of that should be gone for a while. Crib bumpers, which are like the sort of cloth puffy liners of the crib, were considered very safe so the baby wouldn't get their arms stuck like in the in the slats of the crib. But then they were finding that the bumpers were not safe because babies can get stuck under the bumpers. So now it's no bumpers in a very boring, plain mattress, tight fitting sheet on a crib, on their back and alone fed. Sharing is really a very, very high risk factor. It's unfortunately and I think this is a really important topic to bring up, because I hear a lot of concerns from parents about this recommendation for a couple of reasons. One is they're worried if their child spits up a lot, which a lot of babies do. They're worried if my child's on their back, will they aspirate? Will they spit up and then swallow it? The other concern I hear is parents like to co sleep. I just heard this week, a parent said to me, we're the only mammal that doesn't sleep with their young ones, and it feels so unnatural to have them alone, sleeping by themselves. I hear what they're saying, but at the same time, something that I understand as a pediatrician, the best recommendation we can make to a parent when they come in for their first visit is to emphasize sleeping on their back, because we will actually inevitably save lives, because sleeping on your back, following those ABCs decreases the incidence of SIDS by over half. Correct, it's dramatic, and you know the issue of co sleeping, of course. I mean, everyone loves that. For that, I say, let them sleep on you, next to you, while you're holding them, or even in your bed, but you cannot sleep during that time. If you want to have your baby in your bed, in your arms or in a chair with you, that's a time for you to be awake and watching your baby. And that's certainly fine. And babies certainly newborns. They sleep 1819, hours a day, so there's plenty of time for that. But when you are asleep, they need to be somewhere else. And what would you say about as a pediatric ENT, the concern about babies spitting up and the concern for aspiration is that something that you see as an ENT, so all babies have a little bit of reflux, meaning there's a little bit of acid, a little bit of stomach contents that come up the esophagus into the back of the throat, and sometimes that causes a little bit of irritation. Usually it doesn't cause any problems. Babies are so tiny, the distance between the stomach and the airway is just a few inches, there's always going to be a little bit of spit up. But babies have reflexes, just like we have reflexes when they're asleep. If they are actually going to spit up, they will wake up and cough and be miserable and cry. So the notion of vomiting in their Slee is not a normal baby reaction. The idea of it is terrifying, of course. And you know. You've heard of adults who've done that, who've been, you know, horrible drug overdoses, and they aspirate in their sleep because they're overdosing on drugs. This is a human who has reflexes, so if your baby's going to be spitting up, it's not something they do while they're asleep. If it starts while they're asleep, they're going to wake up and cry and like yes and and they have a very, very sensitive gag reflex, which is really helpful, really helpful for babies. For parents, they protect themselves, yes, all right, well, this has been such a helpful overview on infants and stuffy noses and safe sleep practices. I'm curious, are there any myths that you hear a lot from parents that you'd like to clear up about breathing? Any myths that we haven't talked about that you'd like to clear up that can help parents worry less? I think you know, one of the myths, I don't know if it's a myth, but just sort of a misunderstanding, is, again, that it's better to be in the same bed. I think there are a lot of parents who still believe that co sleeping is safer and healthier and more nurturing and will lead to sort of a more robust development, I think that's a myth. There's plenty of time during the other 24 hours of the day, or 18 hours of the day, to have you know with your baby, otherwise, the irregularity to breathing that babies have, they don't necessarily have the regular breathing that older infants and children have, and so if you watch a sleeping baby, you may notice that there are periods of time where it looks like they're not breathing, and they're not breathing, they have something called Central apnea, where their brain is not fully developed To start breathing at a regular rate all the time. So if you watch a baby, you may notice that they just pause for, you know, 510, seconds, which is a lifetime for you as a parent, and then they just start breathing again. They're not gasping, they're not struggling, they're not waking up. So that's something that I think a lot of parents don't know about. It's scary, but usually these episodes go away in the first few months, and they