Sleep-disordered breathing (SDB) is a general term for breathing difficulties during sleep. SDB is when sleep is interrupted sometimes several times during the night, and you are in a fight or flight, so you don’t get the rest your body needs. Symptoms can range from getting up to pee, bed wetting, teeth grinding, and frequent loud snoring to obstructive sleep apnea (OSA), a condition where part, or all, of the airway, is blocked repeatedly during sleep. Causing this disruption in sleep. Our bodies compensate by creating things that can wake us up or unblock our airways.
Sleep-disordered breathing (SDB) is a common and growing problem affecting the health of our children. Studies show that nearly 20% of all children snore and grind their teeth at night due to an airway issue.
What Are the Symptoms of Pediatric SDB?
Potential symptoms and consequences of untreated pediatric Sleep Disordered Breathing may include:
- Snoring—This is the most obvious symptom of SDB… loud snoring that is present on most nights. The snoring can be interrupted by a complete blockage of breathing, where breathing stops, with gasping and snorting noises associated with waking up from sleep. Loud snoring can also become a significant social problem if a child shares a room with siblings or at sleepovers and summer camp.
- Teeth Grinding or clenching..it’s important to note here that while nocturnal bruxism can be a symptom of sleep-disordered breathing in kids, not ALL kids who grind their teeth have this problem. But if the child is a grinder AND a mouth breather, it would be prudent to investigate her tonsils and adenoids because this is a good indication there may be a need for intervention.
- Mouth Breathing…leads to restless nights and waking up with a dry mouth in the morning or dark circles under their eyes.
- Abnormal tongue swallowing and positioning. These patients breathe chronically through their mouths and position their tongues in a forward position.
- Severely Crowded teeth or teeth in crossbite– A crossbite is when the child bites down, and the lower teeth come over the upper teeth on one or both sides when closing or chewing.
- Irritability—A child with SDB may become irritable, sleepy during the day, or have difficulty concentrating in school. He or she may also display busy or hyperactive behavior.
- Bedwetting—SDB can cause increased urine production at night, which may lead to bedwetting (also called enuresis).
- Excessive daytime sleepiness
- Learning difficulties—Children with SDB may become moody and disruptive or not pay attention, both at home and at school. SDB can also be a contributing factor to attention deficit disorders in some children.
- Behavioral Problems–Many studies have shown that a large number of these children diagnosed with ADHD were later shown to have a sleep disorder that caused them to exhibit behavior problems during the day due to a lack of adequate sleep at night.
- Slow growth—Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.
- Cardiovascular difficulties—OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.
- Obesity—SDB may cause the body to have increased resistance to insulin, and daytime fatigue can lead to decreased physical activity. These factors can contribute to obesity.
- Large tonsils and adenoids… will often cause patients to breathe through their mouths to compensate for the lack of air through their nose. This creates a problem because the air you breathe through your nose produces nitric oxide, which helps to dilate blood vessels and allows a greater rate of oxygen absorption into the tissues. Breathing through the mouth does not provide this same function, and as a result, the child is working harder to breathe and receiving less oxygen in the process. This results in decreased brain development, particularly in the areas responsible for decision-making and reasoning.
What Causes Pediatric SDB?
A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue, or neuromuscular deficits such as cerebral palsy, have a higher risk of developing SDB.
How is Sleep Apnea Diagnosed?
If you notice any of the symptoms described in this article, have your child checked by an ENT (ear, nose, and throat) specialist or otolaryngologist. Sometimes physicians will make a diagnosis of SDB based on history and physical examination. In other cases, like children suspected of having severe OSA due to craniofacial syndromes, morbid obesity, neuromuscular disorders, or for children less than three-years-old, additional testing such as a sleep test may be recommended.
The sleep study, or polysomnography (PSG), is an objective test for SDB. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.
Could my child have Obstructive Sleep Apnea?
Approximately 10 percent of children snore regularly, and about 2-4 % of the pediatric population has OSA. Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.
The most obvious symptom of sleep-disordered breathing is loud snoring that is present on most nights. The snoring can be interrupted by a complete blockage of breathing with gasping and snorting noises and is associated with awakenings from sleep. Due to a lack of good quality sleep, a child with sleep-disordered breathing may be irritable, sleepy during the day, or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed.
Bed-wetting is also frequently seen in children with sleep apnea.
A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue or neuromuscular deficits, such as cerebral palsy, have a higher risk of developing sleep-disordered breathing.
Potential consequences of untreated pediatric sleep-disordered breathing
- Social: Loud snoring can become a significant social problem if a child shares a room with siblings or at sleepovers and summer camp.
- Behavior and learning: Children with SDB may become moody, inattentive, and disruptive both at home and at school. Sleep-disordered breathing can also be a contributing factor to attention deficit disorders in some children.
- Enuresis: SDB can cause increased nighttime urine production, which may lead to bedwetting.
- Growth: Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.
- Obesity: SBD may cause the body to have increased resistance to insulin or daytime fatigue with decreases in physical activity. These factors can contribute to obesity.
- Cardiovascular: OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.
What are the symptoms of ADHD?
Hyperactivity, difficulty focusing, easily distracted, poor schoolwork, and sometimes aggressive or grouchy behavior. I don’t know about you, but when I was a child, I had those exact same symptoms – when I was overtired! Yech still have them as an adult. If a child is never able to achieve a good night’s sleep because and cannot breathe properly when sleeping, these same symptoms rear their ugly heads.
I am certainly not suggesting that all kids with disorders (ADHD, ODD, RAD, etc.) are really suffering from sleep apnea, but there are many studies in the literature indicating that there is a fair amount of misdiagnosis occurring.
A 2004 study indicated that 50% of children with ADHD showed evidence of sleep-disordered breathing.1. A large study of over 11,000 children indicated that among children with sleep-disordered breathing, 40-100% showed symptoms mimicking ADHD.
How is sleep apnea diagnosed?
Sleep-disordered breathing in children should be considered if frequent loud snoring, gasping, snorting, and thrashing in bed or unexplained bedwetting is observed. Behavioral symptoms can include changes in mood, misbehavior, and poor school performance.
Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior, or school performance problems, sleep-disordered breathing should be considered. If you notice that your child has any of those symptoms, have them checked by an otolaryngologist (ear, nose, and throat doctor).
Sometimes physicians will make a diagnosis of sleep-disordered breathing based on history and physical examination. In other cases, such as in children suspected of having severe OSA due to craniofacial syndromes, morbid obesity, or neuromuscular disorders or for children less than 3 years of age, additional testing, such as a sleep test, may be recommended.
The sleep study or polysomnography (PSG) is an objective test for sleep-disordered breathing. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests can occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.
What Are the Treatment Options?
Enlarged Tonsils and adenoids are common causes of SDB. A child just cannot breathe through their nose efficiently to get the oxygen they need. Surgical removal of the tonsils and adenoids, called a tonsillectomy and adenoidectomy (T&A), is generally considered the first-line treatment for pediatric SDB if the symptoms are significant and the tonsils and adenoids are enlarged.
Sometimes drops with xylitol can reduce the inflammation called XLEAR. You put two drops in the nose before bed. If they have allergies, you can use them a few times a day during the allergy season.
Not every child that snores needs to undergo a T&A procedure. If the SDB symptoms are mild or intermittent, academic performance and behavior are not an issue, the tonsils are small, or the child is near puberty (because tonsils and adenoids often shrink at puberty), it may be recommended. Watch the child consistently be conservative and treated surgically only if symptoms worsen.
Removing the adenoids and tonsils results in an 80-90% cure rate for SDB or sleep apnea in most children. In children with childhood obesity, however, that number shrinks down to 50%. For these kids, a CPAP machine may be an option. Make sure they can breathe through their nose and are not using their mouth primarily for breathing. CPAP uses positive pressure to force air up the nose, but if they are still mouth breathing, it is not as effective, and mouth breathers will struggle or still wake up.
There has been evidence that treatment with a CPAP machine will help increase metabolism, helping to treat obesity as well as sleep apnea.
Recent studies have shown that some children have persistent SDB after T&A. I did, but since I could breathe better, it went unnoticed.
A postoperative sleep study or myofunctional therapy may be necessary, especially in children with persistent symptoms or increased risk factors for persistent apnea after T&A, such as obesity, craniofacial anomalies, or neuromuscular problems.
Additional treatments such as weight loss, the use of continuous positive airway pressure (CPAP), or additional surgical procedures to widen the airway may sometimes be required.
What Questions Should I Ask My Doctor?
- Tonsils and adenoids often shrink at puberty.
Should my child have them removed?
- After SBD gets missed during a sleep study that looks for apnea.
Is a sleep study required to make a diagnosis?
- After my child has had their tonsils and adenoids removed.
Should they see a myofunctional therapist to help retain the brain to breathe through their nose to restore proper function?
Grinding their teeth, snoring and mouth breathing are all signs of a sleep disorder in kids.
If your child has any of the above symptoms, they may be a candidate for tonsil and adenoid removal, as well as an evaluation by an ENT and an airway orthodontic specialist for maxillary palatal expansion.
When we know better, we do better. We need awareness of these issues
to know what to look for so we can help our children breathe better, get more oxygen so they can sleep better, and live healthier, happier lives. So they don’t grow up needing a CPAP machine or having an SDB-related illness.
When we spot these signs and symptoms early, we can use their growth and development to expand the palate, open their airway, and avoid expensive and invasive procedures. I was the child who threw herself on the floor and had tantrums; my symptoms we so mild they went unnoticed.
Maybe your child hasn’t been able to get a good night’s sleep in a very long time.
I have lived this. I know what it feels like as a child to not understand why you are so angry and feel like you can’t control your emotions. I had no idea I was tired. Now, as an adult, I know when I feel this way, I need sleep. So do my loved ones now.
Before I knew about this, people would look at my daughter like something was wrong with her and that I was a bad parent. I knew she was overtired, and saying anything in public would make it worse. So I let people just judge. They had no idea what I was dealing with. It was still embarrassing some days.
I would love to be able to approach some parents when I can clearly see there is an issue because I don’t want to offend anyone. I said something to a Mom that had never heard of this, and the conversation did not go well. I know how I would have felt.
Together we can make a difference. Share this information let’s have discussions about what we are seeing. Evaluations with moyfunctional therapists are free or less than a night out.
Our kids need our help. They are suffering in silence. We can be the change.
- Golan, N. et al. “Sleep Disorders and Daytime Sleepiness in Children with Attention Deficit Disorder.” Sleep. 2004 Mar 15;27(2):261-6.
- Bonuck, Karen et al. “Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years” Pediatrics, April 2012, Volume 129/Issue 4