Snoring | Warning Signs | Sleep Apnea in Kids
Consequences of Obstructive Sleep Apnea
Treatment Options | Fast Facts

Snoring

Almost everyone is likely to snore at one time or another. It has been found in all age groups. About 10 percent or more of children snore on most nights. Snoring is a noise that occurs during sleep when a child breathing in and there is some blockage of air passing through the back of the mouth. The opening and closing of the air passage causes a vibration of the tissues in the throat. Children who are three years or older tend to snore during the deeper stages of sleep. Nasal obstruction raises the risk of snoring. Primary snoring is defined as snoring that is not associated with more serious problems, such as obstructive sleep apnea (OSA), frequent arousals from sleep, or inability of the lungs to breathe in sufficient oxygen.

Loud and regular nightly snoring is usually abnormal in otherwise healthy children. It can be a sign of a respiratory infection, a stuffy nose or allergy, or a symptom of underlying sleep apnea. Parents of a child with sleep-disordered breathing (SDB) are much more likely to report that their child has behavioral or emotional problems. In 2002, the American Academy of Pediatrics recommended that all children be screened for snoring and that a diagnosis be made to determine if a child is experiencing normal primary snoring or OSA.

People who snore have a higher rate of heart disease, which is a leading cause of death in the U.S. Snoring can also be a sign of obstructive sleep apnea (OSA). OSA raises your risk of having heart problems.

Contributing factors to sleep apnea may be obesity, nasal allergies, asthma, GERD (gastroesophageal reflux disorder), an abnormality in the physical structure of the face or jaw, and medical and neurological conditions. In children, the most common physical problem causing sleep apnea is large tonsils.

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Warning Signs

• Snoring or “squeaking” during sleep

• Appearing to have difficulty breathing during sleep

• Restlessness or sleeping in abnormal positions with the head in unusual positions

• Experiencing night terrors, sleep walking, or bed wetting

• Mouth breathing

• Daytime hyperactivity or being irritable, agitated, aggressive, and cranky

• Having problems in school

• Difficulty in waking up in the morning

• Appearing very sleepy or actually falling asleep during the day

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Sleep Apnea in Kids

By the age of two years, most children have spent more time asleep than awake. Overall, a child will spend about 40 percent of his or her childhood asleep. Sleep is especially important for children, because childhood is an important time for the brain to mature and to develop. Thus, anything that disrupts the integrity of a child’s sleep can result in significant impairment of mental or physical development. As mentioned before, parents of a child with sleep-disordered breathing (SDB) are much more likely to report that their child has behavioral or emotional problems. SDB causes sleep disruption and changes in oxygen levels that may affect how a child’s brain develops. Sleep apnea in infants has been linked to some cases of Sudden Infant Death Syndrome (SIDS).

Sleep apnea is a disorder in which there are pauses in breathing during sleep. Children with sleep apnea may snore loudly, experience restless sleep and be sleepy during the day. Enlarged tonsils or adenoids, nasal allergies, asthma, GERD (gastroesophageal reflux disorder), obesity, and medical and neurological conditions may contribute to sleep apnea. In children, the most common physical problem causing sleep apnea is large tonsils.

Undiagnosed and untreated sleep apnea may contribute to daytime sleepiness and behavioral problems, including difficulties at school. One recent study of 866 children found that children who frequently snore or have sleep disorders are twice as likely to have learning problems. Following a night of poor sleep, children are also more likely to be hyperactive and to have difficulty paying attention. These are also signs of attention-deficit hyperactivity disorder (ADHD). Failure to treat OSA or SDB puts children at risk for long-term behavioral problems. Indeed, obstructive sleep apnea (OSA) may also be associated with impaired growth and cardiovascular problems. Evidence suggests that growth hormone secretion is adversely affected, thereby disturbing growth.

Fortunately, there is convincing evidence that treatment of OSA in children results in improvement in several quality of life measures, including reduced sleep disturbance, physical symptoms and hyperactivity. Other effects of treatment are improved school performance and reduction of cardiovascular abnormalities. It is estimated that up to 25% of children with ADD or ADHD may have sleep apnea, which, once treated, may lessen or resolve the behavioral problems completely.

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Consequences of
Obstructive Sleep Apnea

• Restless sleep

• Daytime hyperactivity or attention deficit
(e.g., ADD or ADHD)

• Emotional problems (being irritable, agitated, aggressive or cranky)

• Behavioral and social problems

• Delayed mental development

• Impaired physical growth

• Poor academic performance

• Excessive daytime sleepiness

• High blood pressure and cardiovascular problems

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Treatment Options

Contrary to treatment practices in adults, surgery remains the first line of treatment for OSA in children. The most commonly performed surgical procedure for the treatment of pediatric OSA is adenotonsillectomy (T&A). In children the size of the airway is relatively smaller in relation to the size of the tonsils and adenoids, as compared to adults. This increased size of the tonsils and adenoids results in a greater role in obstruction of the airway during sleep. Indeed, the disorder is most common between 2 to 6 years of age, when the lymphoid growth is greatest in childhood. Through T&A, the removal of tissues in the upper airway relieves obstruction and improves airflow. Following T&A, the upper airway stability is improved. It is important to emphasize that both tonsillectomy and adenoidectomy should be performed, if the objective of the operation is to improve airway obstruction in OSA. Although isolated adenoidectomy or tonsillectomy does improve OSA, the improvement may be incomplete, thus leading to further surgical procedures down the road. A sleep study should be performed after surgery as well, to determine the extent of improvement from surgery. Although the success rate of surgery is quite high (about 80%), many children still exhibit residual problems.

In some cases, T&A may not completely treat pediatric OSA. These cases occur when a child has significant nasal obstruction or maxillomandibular deficiency (i.e. a small jaw). In these cases, the other problem area or areas need to be addressed. Significant nasal obstruction can be treated in a few different ways. If nasal allergies are a contributing factor, then inhaled nasal corticosteroids can be used to treat the symptoms. This treatment is usually successful but not ideal, because the inhaled corticosteroids may need to be used long-term. If nasal turbinate enlargement is a contributing factor, then turbinate reduction by radiofrequency ablation may be performed in conjunction with T&A. Radiofrequency ablation is a method of applying heat to a local area of soft tissue to cause scar tissue to form, thereby reducing the size of the soft tissue. This procedure can be performed under local anesthesia.

If obstruction is caused by a narrow nasal airway or narrow upper and lower jaws, then orthodontic expansion (i.e. maxillomandibular expansion) to widen the upper airway can be successful. The upper and lower jaws can be expanded by orthodontic treatment, usually without the need of surgery. Maxillomandibular expansion is often performed in children with obvious jaw deformity or when there is residual OSA after T&A have been performed. The goal of the treatment is to widen the upper and lower jaws with an orthodontic appliance. This treatment can be performed in children as young as 5 years old. Occasionally, limited surgery to facilitate expansion may be necessary in teenagers when a significant degree of jaw maturation has already occurred.

Finally, a few pediatric OSA patients may be best treated with nasal continuous positive airway pressure (CPAP). This option may be indicated in a small portion of cases which remain unresolved after surgery or orthodontic treatment. Another indication for CPAP would be a situation where surgery or other methods may not be suitable for treatment. For a further description of nasal CPAP, please refer to “Treatment Options” under the “Adult Sleep Apnea” section.

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Fast Facts

• Research suggests that children require an average of 9 to 10 hours of sleep each night

• More than 18 million Americans suffer from sleep apnea

• It is conservatively estimated that 10 million Americans with sleep apnea remain undiagnosed

• For people suffering with untreated sleep apnea, their sleep is disrupted up to hundreds of times each night, causing daytime fatigue, sleepiness, and irritability

• People who snore have a higher rate of heart disease

• Children who frequently snore or have OSA are more likely to have learning problems in school and behavioral problems such as ADHD

• Mouth breathing or bed wetting in children are red flags for sleep-disordered breathing

• Treatment of pediatric OSA can reverse symptoms of daytime fatigue or hyperactivity, sleep disturbance, poor concentration, and behavioral problems

• For OSA in children, the most common treatment options are adenotonsillectomy (T&A) and maxillomandibular expansion by orthodontic treatment

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