Yes, your child snuffling away in their sleep with a little snort here and there can be pretty cute – but can snoring in kids be a serious health problem?
Snoring in children and adolescents during sleep is not uncommon, found in up to 20% of kids at some point during their childhood. It may be due to temporary illness, such as an upper respiratory tract infection but a potential problem arises if that adorable snort is actually due to obstructive sleep apnea (OSA), which studies show occurs in about 6% in children.
The American Academy of Pediatrics (AAP) defines pediatric OSA as “a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.”
In other words, sleep apnea occurs when the muscles around the upper airways relax during sleep to the point of partial or full collapse. This obstructs the passage of air during inhalation and exhalation resulting in noisy breathing and snoring during sleep. Apnea refers to a temporary pause in breathing due to blockage of the airways and contributes to decreased oxygen intake overnight, which can disrupt a child’s quality of sleep.
The signs and symptoms associated with OSA in children include:
- Snoring during sleep three or more nights a week
- Moments of paused breathing during sleep, which may be observed as a sudden gasp, choking noise, or snort
- Unusual sleeping positions, such as sleeping upright propped against pillows or with the neck hyperextended
- Bedwetting, particularly if the child had previously been dry for more than six months
- Facial abnormalities
- Enlarged tonsils
- Attention disorders
- Learning difficulties
In some children, behavioral problems and difficulties with attention or learning may be the only clue that he or she may not be dreaming as sweetly as you’d like them to be. Although daytime fatigue and sleepiness is a common symptom of adult OSA, it is less likely to be observed in children.
The most common cause of OSA in children
While disproportionately large eyes for face size in little kids is adorable, disproportionately large tonsils for throat diameter is slightly less adorable and is, in fact, the most common cause of OSA in children. This OSA-inducing ratio of tonsil to throat size peaks at around five to seven years old. Dental issues, such as development of the jaw (maxillomandibular development) or misalignment of the upper to lower rows of teeth (crossbite), can also contribute to snoring and OSA.
Parents of children with OSA have reported various other observations of their little angels, both during sleep and waking hours. Sleep walking and talking, sweating during sleep, agitated and disturbed sleep all may be signs of OSA, while daytime clues may include abnormal aggression or shyness, being a little mister or miss grumpy-pants, breathing through the mouth, headaches in the morning, poor eating, and failure to thrive.
Some genetic risk factors have been identified in the development of disturbed breathing during sleep. Though no specific genes have yet been discovered in relation to the likelihood of OSA, the strongest inherited link appears to be related to facial structure, particularly narrow faces. African American and Far East Asians are noted to have a significantly increased risk when compared to Caucasians when matched for age, gender, and body mass index.
The problem with OSA in children
In 2012, the AAP revised its clinical practice guidelines regarding the investigation and management of snoring in children in light of the possibility of developmental and long-term health consequences of undiagnosed OSA. It is now recommended that clinicians should ask about snoring as part of routine questioning during healthcare visits and if there are any signs or symptoms indicative of OSA then further investigations are warranted.
Similar to OSA in adulthood, sleep apnea in children bears implications for cardiovascular health, though the long-term impacts are not yet fully known. OSA induces increased blood pressure during sleep and subsequent structural changes to the heart muscle itself, such as thickening of the ventricle walls. It is thought that hypertension in children may increase the risk of hypertension later in life.
Behavioral problems and neurocognitive impairment are well-established consequences of OSA, adding to the importance of prompt diagnosis and treatment in young children during their developmental years. Studies have shown that children with OSA, and in fact, many children who snore but without diagnosed OSA, may demonstrate deficits in cognition and mental processing, and perform more poorly than their peers during learning activities.
Diagnosis and treatment of OSA in children
Luckily for your child, the majority of OSA cases can be easily and successfully treated. Careful questioning of any history of snoring or indicative sleeping behaviors, as well as daytime behavioral observations, can be quite helpful as well as a clinical examination of the throat, tonsils, nasal structures, jaw, and any other sources of potential obstruction to airflow. However, though a physical exam by an ENT specialist is valuable, while the child is awake the appearance of the airway structures may not be representative of what they do when it’s bedtime.
The AAP guidelines recommend an overnight laboratory sleep study (polysomnography) as the gold standard for diagnosis although it also admits that access to this resource is difficult due to the lack of availability of clinics with pediatric experience throughout the US. In the absence of access to polysomnography, other tests are available, including nocturnal video recording or overnight oxygen saturation testing.
In up to 90% of children, surgical removal of the tonsils (tonsillectomy) is sufficient to cure OSA. Surgical removal of adenoids from the back of the nose may also be required to resolve sleep apnea fully, though on occasion these may regrow. The AAP recommends this surgery as the first line of treatment in children if a physical exam indicates adenoids and tonsils to be the offending intruders of your child’s sweet dreams.
For some cases, an adenotonsillectomy may not be suitable, either due to certain contraindications to surgery or simply because the adenoids and tonsils are not the cause. Obesity appears to be less strongly linked to OSA in kids compared to that in adulthood but is still considered to be a risk factor. Often a tonsillectomy can improve OSA in obese children but as there is a higher possibility of some remaining persistent OSA in this population, a weight-loss management program is still beneficial. Dental therapies, such as a technique known as maxillary distraction, aims to widen the space between the bones of the upper jaw, though has limited success at eliminating OSA completely. A continuous positive airway pressure machine (CPAP) is recommended in severe OSA or if other treatments, such as an adenotonsillectomy, were unsuccessful or unable to be performed.
Because of the potential consequences of untreated OSA on your child’s health and wellbeing, it is important to see a pediatrician or ENT specialist if you suspect your child may be suffering with OSA or any sleep breathing disturbances, even that cute little raspy snore.
Snoring in children. https://www.sleepfoundation.org/articles/snoring-children
Obstructive sleep apnoea (OSA). https://www.rch.org.au/kidsinfo/fact_sheets/Childhood_obstructive_sleep_apnoea_OSA/
Sleep apnoea in the child. https://www.racgp.org.au/afp/2015/june/sleep-apnoea-in-the-child/
Diagnosis and management of childhood obstructive sleep apnea syndrome. https://pediatrics.aappublications.org/content/130/3/576
Pediatric obstructive sleep apnea syndrome. https://jamanetwork.com/journals/jamapediatrics/article-abstract/486098