Solve Your Child's Sleep Problems

Part V

The Sleepy Child

Chapter 17

Noisy Breathing, Snoring, and Obstructive Sleep Apnea

When a child snores loudly in her sleep, parents often dismiss it lightly, joking that no one would ever be able to share a room with her. But other parents worry. Watching and listening to your child each night, you may have come to believe that she is actually struggling to breathe—perhaps, at times, unable to breathe—rather than “just snoring.” You may even sit by her bed or take her into yours when she has a cold to make sure that she doesn’t stop breathing. Even if your friends or doctors have told you that snoring is nothing to worry about, you watch and listen, and worry anyway.

It is not unusual or abnormal for children to snore occasionally, such as when they have a cold, but they should not snore most nights, and they should not routinely struggle to breathe or even have to sleep with their mouths open.

Although snoring used to be dismissed as a mere annoyance, we now know that it is often associated with significant breathing problems in sleep. It can be a sign of a disorder called obstructive sleep apnea, which requires medical attention. Even if she does not have the fully developed syndrome, a child who snores is not breathing freely and normally at night, and it could be disrupting her sleep, even to the extent of affecting her daytime behavior and her ability to learn.

What Happens in Sleep Apnea

Physicians have been aware of sleep apnea for many years, but it is only since sleep laboratories appeared in the 1970s that we began to recognize just how common it is. Although the problem is especially prevalent in men over forty and in women after menopause, a great many children suffer from it as well. Unfortunately, sleep apnea in children has been largely overlooked, perhaps because children’s daytime symptoms are often less obvious than those of adults, or because most sleep centers mainly see adult patients.

“Apnea” means the absence of breathing. When a child with obstructive sleep apnea is asleep, her upper airway narrows or closes off repeatedly, typically for periods of eight to thirty seconds at a time (why this happens is explained below). Little or no air can pass through the obstruction no matter how hard she tries to breathe. Sleep specialists distinguish between the syndromes of “obstructive sleep apnea” and “upper airway resistance,” but the difference is really just a matter of how much obstruction there is and whether the blockage of airflow is nearly complete or only partial. For simplicity, I will use the single term sleep apnea to describe the entire spectrum of disorders.

Sleep apnea is a problem not only because of the repeated temporary loss of oxygen, but because the sleeper has to wake partially to start breathing again. Depending on the severity of the apnea, that can happen up to several hundred times a night. With these frequent interruptions, good sleep becomes impossible. (Often these wakings are too small and too brief to observe directly and can only be detected in the laboratory, but they are nevertheless effective at disrupting sleep.)

If there is some airflow during an apnea event, the sleeper snores. The sounds will be soft and squeaky if only a tiny amount of air gets through, loud and raspy if the airflow is a bit better, and softer again if the airflow is even better still. If the airflow is temporarily blocked completely, there is no noise at all because the sleeper isn’t breathing. While the airflow is reduced, oxygen levels in the bloodstream drop until, usually after eight to thirty seconds, the sleeper wakes slightly, semiconsciously adjusts the muscles of her tongue and throat to open her airway, and takes in several relatively unobstructed breaths. If her breathing was completely blocked before this point, these breaths will be accompanied by loud snoring or snorting. Thus, a complete blockage produces periods of silence alternating with ones with loud snoring. But if the obstruction is not complete—and there is continuous snoring during the period of decreased breathing (or hypopnea)—alternating periods of louder and softer snoring result. After a few good breaths have improved her oxygen level again, at the end of an apnea event, the apnea sufferer falls back asleep (unaware of the partial waking), only to have her breathing become obstructed once more. Her sleep, disrupted by these efforts to breathe, may be quite restless. In extreme cases, sufferers sleep sitting up or bent forward in an effort to improve respiration.

In sleep apnea the actual obstruction usually occurs in the back of the throat, behind the base of the tongue. The walls of the throat are relatively floppy in this region; if they collapse and the tongue falls backward, the airway can be blocked. While awake, we are able to prevent this from happening by holding our tongue sufficiently forward and our throat sufficiently taut so we can breathe. In sleep, however, we lose some of that ability, and this is why even people without any trouble breathing during the day can still suffer from sleep apnea at night.

Certain conditions make collapse of the throat walls more likely—for example, an abnormal narrowing higher up in the airway, in or behind the nasal passages, that forces a person to breathe very hard. Think of your upper respiratory tract like a drinking straw that you breathe through, as shown in Figure 18. As long as the straw is intact, you can breathe without difficulty. However, if you bend the straw in the middle several times so that it becomes less rigid, you will find that if you breathe in too sharply, the weakened part of the straw will collapse. If you breathe slowly and regularly it will not. If now you pinch the far end of the straw between your fingers to make the opening narrower, you will have to suck harder than usual to breathe, which in turn will collapse the floppy part of the straw and produce an obstruction. This is analogous to what happens in a sleeping child whose upper airway is narrowed, perhaps by enlarged tonsils or adenoids. To get enough air, she has to breathe harder, but in the process the floppy area at the back of her throat may be sucked closed.

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FIGURE 18. OBSTRUCTIVE SLEEP APNEA

In Figure 18A, a girl with normal-sized tonsils and adenoids breathes well, with little effort, like breathing through a straw of sufficient width (Figure 18B).

    In Figure 18C, the girl’s air passages are narrowed by enlarged tonsils and adenoids. Now the girl must breathe in strenuously to get air past the narrowed region. But the floppy part of the airway just below the tonsils and adenoids is sucked closed by the increased force of the girl’s breathing so that there is little or no airflow—like breathing through a straw that is pinched off at the end (Figure 18D)—and an obstructive apnea event is produced.

Unlike adults, children with sleep apnea rarely have completely blocked airways—the child continues to breathe, but with difficulty. She must work harder to get air in, and even if this extra effort produces enough airflow, the struggle to breathe interferes with her sleep. The degree of difficulty breathing varies from child to child, and in a given child the severity may wax and wane over the course of a night. At one extreme is full-blown sleep apnea. Toward the other end is mildly obstructed breathing, where the child still expends more effort than normal to get each breath in: her breathing will be mildly hampered, and probably openmouthed. There maybe heavy breathing, or intermittent soft snoring, with intervening periods of even greater difficulty or louder snoring. She may have particular trouble breathing when sleeping on her back, because the tongue falls back and blocks the air passage, and during REM sleep, in which the muscles of the head and face relax profoundly. She is likely to have less trouble, or even none, in non-REM sleep and when sleeping on her side. Her breathing is likely to be best during the deep non-REM sleep of the first three to four hours of the night, and most compromised during the second half of the night, when dreaming is longest and most intense. Therefore, if all you know about your child’s breathing comes from looking in before you go to bed, you may not have a complete picture, since you may never see her when she’s having the most difficulty.

In the past, doctors often failed to recognize sleep apnea in children except in very severe cases where the strain from working so hard to breathe, coupled with low levels of oxygen in the blood, affected the functioning of the heart and the level of blood pressure. Fortunately, such problems are uncommon complications in children—unlike in the adult—usually occurring only in cases of such severe obstruction that the child’s breathing is impaired even when she is awake.

What Causes the Obstruction

Although we cannot always pinpoint the site of narrowing that causes sleep apnea, any narrowing of the upper airway or unusual floppiness in the throat tissues can bring it about. Many adults with sleep apnea have thick, short necks; usually they are also overweight, and excessive soft, fatty tissue deposited in the walls of the throat contributes to the narrowing. Obesity can likewise be a major factor in sleep apnea in children. Children whose muscles are weak or who suffer from muscle-control problems (as in muscular dystrophy, spasticity, and hypotonia) are also at risk.

Sleep apnea can also be caused by oral or facial anomalies, especially an abnormally small, receding lower jaw (micrognathia or retrognathia), or a flattening of the middle region of the face. In some children the obstruction may be created intentionally, for instance when the roof of the mouth (palate) is surgically connected to the back of the throat (making a pharyngeal flap) to create a blockage. This procedure helps correct speech problems caused by an inability to appropriately block airflow out the nose—as is sometimes the case in children born with a cleft palate—but if too much obstruction is created, sleep apnea can also result. Abnormalities of the nose, such as a deviated septum or a polyp, are only rarely causes of sleep apnea. Nasal obstruction from allergies can lead to some snoring but is very unlikely to cause significant apnea. For several reasons, children with Down syndrome are prone to sleep apnea: their tongues are often too large for their mouths, their nasal passages are relatively small, they often have enlarged and chronically infected adenoids with persistent nasal discharge, and they may not have completely normal neurological control of their tongue and throat muscles.

In the vast majority of children with sleep apnea, enlarged tonsils or adenoids are the source of the problem.

Enlarged Tonsils and Adenoids

The tonsils are pink, roundish glands that are easily seen at the back of the mouth just above the tongue and against either side of the throat. When infected, they can become quite swollen; afterward, they usually shrink back to a normal size, but not always.

You can’t easily see your child’s adenoids, which lie against the back of her throat above the roof of her mouth, but they look much like the tonsils. Enlarged adenoids can block normal airflow through your child’s nose, forcing her to breathe through her mouth. Her speech may take on a nasal quality and her nose may run constantly. Also, when adenoids are enlarged, the tube that normally drains her middle ear can become blocked: if that happens, fluid collects in the middle ear, and your child may suffer temporary hearing loss and repeated ear infections.

Not all children with enlarged tonsils or adenoids develop sleep apnea. This is probably because of individual differences in respiratory control and anatomy. For instance, the size and shape of a child’s throat may determine whether or not enlarged tonsils will significantly interfere with her breathing at night. And a child with large adenoids may still be able to breathe fairly well at night if she can automatically switch completely to mouth breathing during sleep (although having to breathe through her mouth at night is far from ideal: her mouth dries out and sleep may still be disrupted).

Children who have difficulty breathing because of enlarged tonsils or adenoids often snore at night for many years. The snoring may or may not get worse over time. Occasionally symptoms begin suddenly in association with a bout of tonsillitis. Often breathing difficulties worsen in the winter months, when colds are more frequent.

Grace, a three-year-old girl, had a typical story. She was happy and alert during the day, except that she sometimes seemed unusually tired in the afternoon, despite a daily nap. She was well behaved and played cooperatively with her friends. When she was three months old she had begun snoring, and over the years her snoring had grown worse. She now snored most of the night, so loudly that she could be heard all over the house. As she slept, Grace seemed to struggle to breathe; her mouth would be open, and at times her chest would actually be pulled inward rather than expanding with each breath. Her parents noticed that sometimes her chest seemed to go in and out without any apparent airflow, and at these times they would shake her awake to help her start breathing normally again. After such episodes, Grace would shudder and make strange snorting sounds as air finally entered her lungs. When she had a cold, her breathing troubles were even worse.

Needless to say, Grace’s parents were quite worried. They had discussed the problem with their pediatrician on several occasions. He noted that Grace’s tonsils were large, and since she breathed mostly through her mouth, he believed that her adenoids were probably also enlarged. Nevertheless, he felt that removing her tonsils and adenoids was unnecessary, because (he said) “snoring itself is nothing to be concerned about and will be outgrown,” and because Grace had not suffered from repeated throat or ear infections.

To find out for certain what was happening to Grace when she slept, we had her spend one night in the sleep laboratory. Throughout the night we monitored her stages of sleep as well as the airflow into and out of her nose and mouth. We recorded her chest and abdominal movements as she attempted to breathe and, using one sensor clipped painlessly around her finger and another placed by her nose, we measured the amount of oxygen in her bloodstream and the carbon dioxide levels in her lungs. What we found was typical of many other children with similar stories, although Grace’s problem was more serious than most.

During the night Grace experienced 350 episodes in which her breathing was either completely or partially obstructed for periods lasting between eight and fifty seconds, which is a huge number of obstructions; most normal children have none at all. She spent a full quarter of her sleep time struggling with these obstructions. She did sleep reasonably well in the early part of the night, during the deeper stages of non-REM sleep, when her breathing was fairly good and her snoring only moderate. But during the rest of the night, when her breathing was obstructed and she had to struggle to breathe, her sleep was severely disrupted. During most of the obstructive episodes, her blood oxygen level dropped significantly. As one would expect, the most severe obstructions occurred during REM sleep when Grace’s throat muscles were most relaxed and her breathing was least automatic.

Watching Grace struggle to breathe all night was heartbreaking. Given the extent of her sleep disruption, it was surprising that she wasn’t more tired and irritable during the day. Grace’s parents were relieved to learn that their concern had been justified and that we would be able to help her.

Jonathan was a five-year-old boy whose story was almost identical to Grace’s. He, too, had enlarged tonsils and adenoids, and in the laboratory he also snored and slept with his mouth open. Nevertheless, we found his breathing troubles to be less severe than Grace’s: he had only forty episodes of obstructed breathing, and each of those times his airflow was only mildly blocked for brief periods of time. Although Jonathan’s oxygen and carbon dioxide levels did not change much, his snoring and mouth breathing took a toll. His sleep was broken by many brief wakings to swallow and moisten his dry mouth and to try to find a more comfortable position. Judging only by the number of obstructive events and his normal oxygen level, Jonathan had only a mild case of sleep apnea. Taking into account the effect on his sleep, however, his problem was fairly severe.

Obesity

Sleep apnea is common in children who are markedly obese. Most physicians are familiar with the so-called Pickwickian syndrome, which, generally speaking, refers to a child who is both very fat and chronically sleepy. The term derives from the character of Joe in Charles Dickens’s The Pickwick Papers, “a fat and red-faced boy” who always seems to be “in a state of somnolency.” When Mr. Pickwick is told that Joe “goes on errands fast asleep, and snores as he waits at table,” he responds, “How very odd!” Perhaps, but these characteristics are common enough that we routinely perform a sleep study on almost every extremely obese youngster who is treated at the hospital where our sleep laboratory is located.

Justin was such a youngster. He was a twelve-year-old boy with two obvious problems: at almost 180 pounds he was quite obese, and he constantly fell asleep during the day even though he seemed to get enough sleep at night. He often fell asleep at his desk in school and at home while doing his homework. As a result he had had to repeat fifth grade. His teachers and parents saw his sleepiness as laziness and reacted with anger instead of sympathy.

When they came to see me, Justin’s family did not mention snoring; they were worried only about his sleepiness. But in response to my questions, they told me that for years Justin had snored loudly for much of each night. As it turned out, his sleep apnea was even more severe than Grace’s. He had over six hundred apneas in one night, each lasting between twenty and seventy seconds. He suffered profound oxygen deprivation, and often his oxygen levels did not completely return to normal during the arousals that followed each obstruction. Unlike Grace, he got no deep sleep at all, and few periods even of regular breathing. It was no wonder that he was so sleepy in the daytime.

Treating Sleep Apnea

Naturally, the methods we use to treat a child with sleep apnea depend on the cause of the disorder. At our center we work closely with ear, nose, and throat specialists as well as with doctors from other disciplines such as oral surgery, plastic surgery, pulmonary medicine, neurology, and nutrition. This cooperative approach enables us to diagnose and treat children who have apnea regardless of the cause.

If enlarged tonsils and adenoids are responsible, as they are in most children with sleep apnea, we usually recommend they be removed. For example, Grace’s tonsils and adenoids were much too big; even though she had not had problems with ear or throat infections, we felt the severity of her sleep apnea more than justified their removal. After the operation, Grace improved remarkably. Her breathing became completely quiet at night and her sleep returned to normal. Her mother, unused to the silence, went in periodically for the first few weeks after surgery to make sure Grace was really breathing. Although Grace had not seemed especially sleepy or irritable during the day, her parents nonetheless noticed a change for the better after the surgery. Grace’s spirits improved, she complained less, and she was full of energy, which she put to good use.

As for Jonathan, whose sleep was also badly disrupted, even though his sleep apnea was otherwise less severe than Grace’s, he underwent the same surgery. He, too, showed a great deal of improvement. When he returned to school, his teachers remarked that he had an easier time paying attention and learned his lessons more quickly than he had before.

If Grace and Jonathan had been born in the 1940s, it is unlikely that they would have suffered so long. Doctors are less inclined now than they once were to perform tonsillectomies. In the past, tonsils were often removed simply because they were large, but we now know that large tonsils (and adenoids) do not always cause problems. Nowadays, most pediatricians recommend their removal only if complications develop. The most common complications are chronic middle-ear disease, recurrent strep throat, and sleep apnea. Of these, only sleep apnea is likely to go undetected.

If your child is obese, like Justin, treatment must include a program of weight loss, which may cure the apnea by itself. If other medical factors are contributing to the apnea, they may need to be treated as well. For example, Justin’s tonsils were considerably enlarged. After they were removed, a repeat sleep study showed a significant improvement in his breathing, though not yet to a fully normal or satisfactory pattern. Over six months of closely supervised dieting, Justin was able to lose forty pounds. He now experienced only a few obstructions at night, his sleep was fairly continuous, and he was getting enough deep sleep. The result was that he was now able to stay awake all day without signs of sleepiness or “laziness,” and he was doing much better in school, to the delight of his parents, his teachers, and most of all himself.

Although dieting is a straightforward solution, it is not easy. For very obese children, satisfactory weight loss is best accomplished under supervision, in a carefully run medical program. Such programs supply proper, individualized diets and close attention by a nutritionist, careful medical management and supervision by a physician, and essential counseling services and support groups. If your child has any medical condition causing or caused by obesity, that condition must be treated at the same time. Long-term hospitalization with closely supervised dieting, or stomach or intestinal surgery, is recommended only in rare, extreme cases.

If the cause of sleep apnea is an oral or facial abnormality, corrective surgery may be helpful. For example, if your child has a markedly recessed chin, it can be brought forward and her teeth readjusted. This is a major undertaking, however, and although a cosmetic improvement is fairly well assured, it is as yet impossible to be certain ahead of time that the apnea will improve significantly (although newer techniques are continually improving our ability to predict results). If your child has apnea caused by a surgically created pharyngeal flap, the flap may have to be removed or at least narrowed to allow more room for air to pass around it.

In some cases surgery is not an immediate option. This may be because there is no anatomical problem requiring surgery, or the surgical outcome will likely be of only limited value, or the child needs to grow further before surgery will be useful or practical, or the family prefers to try other approaches first, or other medical considerations make surgery too dangerous. In addition, if the child is not overweight, or the apnea is too severe to wait for her to lose weight, or if other preferable interventions have failed, then continuous positive airway pressure (CPAP) can be used (see Figure 19). At night, the child wears a mask over her nose. A hose connects the mask to a pump that blows air through the mask into the child’s nasal passages. As long as the pressure blowing in is greater than the suction generated by the child breathing in—the pressure needed is determined in the sleep laboratory—the airway will stay open and the child will be able to breathe freely. (Remember the floppy straw analogy. Now imagine that, as you inhale through the straw, a machine blows air into the other end hard enough to keep it from collapsing.) Masks come in a variety of sizes and materials for comfort and proper fit, even for small children and infants. A humidifier can be attached to keep the airway from drying out. Still, getting a young child accustomed to sleeping with a mask on may take considerable effort. Usually, children start by practicing in the daytime without the pump attached; most children eventually learn to wear the mask and sleep with it on without complaint.

FIGURE 19. USE OF CPAP

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For some children with sleep apnea, the best treatment is nightly use of continuous positive airway pressure, or CPAP. The child wears a mask over her nose, and the CPAP machine blows in air at a pressure sufficient to prevent obstruction and assure normal breathing.

Obviously, sleeping with such an apparatus is not ideal, but it does work very well. It can be used on a permanent basis or until the child grows and her airway enlarges sufficiently, until she undergoes planned surgery, or (if she is overweight) until she loses the necessary weight. If Justin’s tonsils had not been enlarged, or if surgery had not been chosen or recommended or had led to little or no improvement, we would have treated him with CPAP until he had achieved the needed weight loss.

In the past, it was necessary to perform a tracheostomy for children with severe sleep apnea. In this procedure a tube is inserted into a hole made through the neck below the vocal cords (larynx) and into the windpipe (trachea) to provide for satisfactory breathing at night. Now such treatment is needed rarely, only for children who have very severe sleep apnea and for whom other treatments, including other surgery and use of CPAP, have failed or are not possible. During the day, the tracheostomy tube can be plugged so air can pass through the vocal cords, allowing the child to speak normally. A child with a tracheostomy requires considerable care and, unless that can be provided in the school, the child may need to be placed in a new school setting where nursing help is always available.

Another procedure, pharyngoplasty, involves tightening the walls of the throat through surgery or laser treatments to make them less floppy. These techniques have been used with mixed results in adults but have not been very successful in children, probably because the walls of their throats are not very floppy to begin with. Finally, various devices that fit inside the mouth and hold the tongue or jaw forward have been used with some success in certain adults, but orthodontic and safety concerns make these devices less useful in children. Unfortunately, medication is not usually helpful in treating obstructive sleep apnea.

Fortunately, most childhood apnea can be treated by removing the tonsils and adenoids, by weight loss, or both, with a smaller number being cured by other corrective oral or plastic surgery procedures. And, since CPAP has become available as a treatment, almost none require a tracheostomy. Tonsillectomy and adenoidectomy are relatively simple procedures and they are usually worth doing in children with sleep apnea, even when the sleep apnea is mild. However, if a child’s tonsils and adenoids have been removed (or are very small) and she isn’t overweight, it’s not always clear how best to treat her if the sleep apnea is very mild and daytime symptoms minimal. In such cases, CPAP may disrupt her sleep more than the apnea did, and some physicians feel it may be best to leave mild sleep apnea untreated—although if that course is chosen, they need to follow the child closely to be sure that no other problems develop and that the sleep apnea does not grow worse. A trial period on CPAP may help with the final decision.

Some Words of Caution

The signs of sleep apnea in children are generally obvious at night (if you watch carefully) with snoring, struggling, and gasping, but symptoms in the daytime caused by the disrupted sleep are often not so apparent. Adults with sleep apnea show more visible effects during the day, because their breathing may be so severely compromised that they get little deep sleep and have hundreds of full wakings. They are often very sleepy, and they are also much more likely than children to develop hypertension, headaches on waking in the morning, and “automatic behaviors” (which are periods of going about a routine activity without apparent awareness, as if sleepwalking). But since children usually have less severe breathing obstructions, their sleep (particularly their deep sleep) is less disrupted and, as a result, daytime symptoms may be absent or (as is the case with daytime sleepiness) at least not very obvious.

But these children may not be sufficiently rested, either, and their ability to learn, attend, and control their behavior may be affected. Carefully designed studies have revealed these deficits where they were once thought not to exist. Even a parent may not recognize subtle daytime symptoms, except by their absence after the problem has been treated. Sleepiness in a child may appear as any of a number of behavioral problems—hyperactivity, irritability, difficulty concentrating, forgetfulness, school problems, or general “laziness”—rather than as constant yawning and frequent napping. Children with sleep apnea may also wet their beds and suffer from other sleep disruptions, such as nightmares, sleep terrors, and sleepwalking. Rarely—when the sleep apnea is very severe—an electrocardiogram will show that the heart is working too hard; occasionally, a child’s blood pressure may be elevated. Children who are very obese are more likely to have all of the symptoms usually seen in adults.

Sleep apnea can be serious and should always be treated by a physician experienced in its diagnosis and management. Sleep apnea in the adult, if untreated, may cause considerable heart disease and occasionally may lead to death from a cardiac arrhythmia caused by low oxygen levels, or from an automobile accident caused by falling asleep at the wheel. Fortunately, since a child’s heart is very resilient and children don’t drive, the chances that sleep apnea will lead to death in children is exceedingly small. It is not zero, however, especially if a child is taking any strong sedating medication that decreases the automatic drive to breathe and makes it harder to wake.

The obstructive sleep apnea discussed in this chapter should not be confused with so-called central sleep apnea seen mainly in infants, in which babies simply stop trying to breathe for periods of usually eight to thirty seconds with no obstruction present. Newborns, especially those born prematurely, may have long episodes of central apnea that are truly life-threatening. Such episodes usually occur intermittently, not hundreds of times each night, and they may respond to respiratory stimulant medications. Despite much research trying to show that this phenomenon, or one like it, is a cause of Sudden Infant Death Syndrome (“crib death”), no definite conclusions can yet be drawn.

Getting Your Child the Help She Needs

Even though you now have an understanding of the causes and treatments of obstructive sleep apnea, you may have difficulty getting your child the proper evaluation and treatment. Not all physicians are aware of how common this syndrome is in children, and not all hospitals have facilities for studying children’s sleep. Besides, few doctors have had the opportunity to watch a child with sleep apnea during the night. This situation has improved considerably since the 1980s, and awareness of sleep apnea as a problem in children is now much more widespread. Still, even if your pediatrician is well informed, he or she will probably only see your child during the day, when she is awake and probably breathing normally. You may have to work hard to persuade the doctor that your child has a problem at night that needs attention.

You may want to ask your pediatrician for a referral to a pediatric sleep specialist, or at least to a pediatrician or specialist in pulmonary or neurological disorders who is familiar with sleep apnea in children. If there are no pediatric sleep centers in your area, try to find an adult sleep center. Even if they mostly treat adults, they may still be able to evaluate (or properly refer) your child. If at the initial evaluation your child was not seen by a pediatric ear, nose, and throat specialist, ask for a referral. If necessary, make a video or audio recording of your child’s snoring so your doctor can actually listen to and perhaps even see your child having difficulty breathing.

Be persistent, and you will get the attention you need for your child. If necessary, ask your child’s doctor to review the information in this chapter so that you can work together to solve your child’s sleep disorder.

FIGURE 20. HOW TO TELL

WHETHER YOUR CHILD HAS SLEEP APNEA

Main Symptoms

·   Snoring

·   —Loud, raspy, squeaky, snorting

·   —Usually can be heard throughout the house (if you have to stand by the child’s bedside to hear it, sleep apnea is less likely)

·   —Present most nights (not just occasionally or only with a cold)

·   —May be present more in the second half of the night

·   —May only be a problem when the child sleeps on her back

·   Difficulty Breathing

·   —Child works hard or even struggles to breathe

·   —Mouth may be kept open

·   —Upper chest may be pulled inward rather than expanding when the child breathes in

·   —Restless sleep

·   —Repetitive pattern of obstruction: recurrent episodes of breathing difficulty followed by moving about (even “shuddering”) with partial waking and briefly improved breathing with loud snorting, snoring, gasping, or heavy breathing

·   —Episodes of completely blocked breathing: times when attempts to breathe are strong (the chest and abdomen move in and out) but actual breathing (airflow) seems completely, or almost completely, blocked

Associated Features Common in Children

·   Enlarged tonsils or adenoids, or frequent sore throats or ear infections; obesity; abnormalities of the jaw, mouth, or throat

·   Overt daytime sleepiness is often mild; irritability, difficulty concentrating, and school problems are more likely

·   Presence of other sleep problems: bedwetting; sleep terrors or confusional arousals

Other Symptoms, Seen Mainly in Adults and Less Commonly in Children

·   Overwhelming daytime sleepiness

·   Morning headaches

·   “Automatic behavior” (carrying out routine daytime activities without apparent awareness)

·   Cardiovascular problems (high blood pressure and electrocardiogram abnormalities)

Findings in Sleep Laboratory Study

·   Recurrent respiratory obstructions

·   Lowered oxygen values (usually)

·   Elevated levels of carbon dioxide (often)

·   Sleep disruption (of variable severity)

·   Cardiac rhythm disturbances (uncommon in children)