Snoring is noise produced during inspiration, when one is asleep, due to partial obstruction of the upper airway. It is due to the vibration of the soft palate, uvula, base of tongue and other soft tissues in the throat when one inhales. As much as 30% of the adult population or 60% of men over 40 years of age snore.
Snoring child may sound funny; but sometimes it’s a sign of a serious medical problem that should be treated. It is important to know if snoring is just normal or child has obstructive sleep apnea.
Children who snore or struggle to breathe while sleeping may suffer from Obstructive Sleep Apnea Syndrome (OSA). OSA is common in children more so in the age of 2-6 yrs when tonsils and adenoids are relatively larger.
Sleep problems and sleep apnea in children usually go unnoticed by parents. It may be the cause of poor school performance, learning disabilities, bed wetting, hyperactivity and even heart failure. Persistent open mouth, open mouth while sleeping, hypo nasal speech, nocturnal snoring, and abnormal sleep positions may be considered habitual or may escape the parents notice as patients may not be aware of significance of these symptoms.
Some common medical terminologies and definitions
Apnea means “without breath” in Greek. Sleep Apnea is described as cessation of breathing (For 10 seconds or longer) while asleep.
Hypopnea is 10 second event where breathing is continuous but ventilation is reduced by 50%.
Sleep apnea syndrome is when 30 or more episodes of apnea occur during a 7 hour sleep period.
Sum of Apnea and Hypopnea in per hour is Apnea –Hypopnea Index (AHI) and OSAS is AHI more than 5. Obstructive Sleep Apnea Syndrome by definition is excessive day time sleepiness with irregular breathing at night.
Severity of OSA is measured in terms of the number of pause of breathing per hour at night during sleep.
AHI 5-14 is mild, 15- 30 is moderate and more than 30 is severe. OSA has physical, mental and social impact on the child
Types of apnea
Obstructive Sleep Apnea – OSA is repeated episodes of airway blockage during sleep, and usually associated with snoring and reduction in blood oxygen level.
Central Sleep Apnea – Airway is not blocked but breathing centers in brain are suppressed and fail to give signals to respiratory muscles to breathe.
Mechanism of Obstructive sleep apnea
The stoppages in breathing are usually caused by the upper airway being partially or completely collapsed during sleep. During sleep upper pharyngeal airway muscles tone decrease leading to narrowing. Increase respiratory effort causes arousal from deep sleep. This circle continues several times.
Upper airway collapse may occur at various levels – palate, base of tongue, hypo pharynx. Nasal block exacerbates it.
Causes/ Risk factors of obstructive sleep apnea in children may be physical or dysfunctional
- Nasal congestion
- Blocked nose (b/c cold or sinusitis/deviated nasal septum/nasal polyp)
- Allergic rhinitis
- Enlarged adenoids
- Enlarged tonsils
- Large tongue
- Elongated Uvula
- Thick neck as in obese child
- Down syndrome
- Children with abnormal face
- Cerebral palsy or neuromuscular disorder
- Asthmatic children
- Smoking (active and passive)
- Family history of Sleep apnea
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Features/symptoms/consequences of sleep apnea
Dominant symptoms of OSAS are excessive daytime sleepiness, impaired concentration and snoring.
Child with sleep apnea will actually stop breathing for short amounts of time many times a night. After apnea event child may wake up to resume normal breathing and again goes to sleep thus sleep may be disturbed or poor quality and child may have excessive day time sleepiness (though it is more common in adults as sleep arousal threshold is higher in children).
Child may not get enough oxygen because of apneas which in long-term puts strain on heart and lungs and may cause heart attacks, heart failure, high blood pressure, strokes and sudden death while sleeping.
During the night:
- Loud snoring (Cardinal symptom)
- Apnea (stop breathing)
- Gasping for air
- Choking sensation
- Restless sleep / tossing & turning in bed
- Disturbed sleep/Frequent arousal
- Sleeping in unusual positions (sitting position and hyper extended neck)
- Waking up with a loud snore/ nightmare
- Nocturia (frequent urine passing)
- Enuresis (bed wetting)
During the day:
- Un refreshing sleep/ difficulty getting up in the morning
- Morning headache
- Dry mouth / throat
- Daytime sleepiness, tiredness
- Poor concentration
- Poor memory
- Poor school performance
- Mood changes
- Paradoxical hyper activities (ADHD)
Diagnosis of Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) must be differentiated from simple snoring. which is usually not accompanied by reduced levels of oxygen , increased co2 levels, or sleep disruption.
Other causes of excessive day time sleep are to be ruled out like Chaotic sleep schedules, Sleep deprivation, fragmented sleep., restless leg syndrome, narcolepsy, hypothyroididm, drugs-sedatives, previous encephalitis, previous head injury, stimulants-caffeine, amphetamines, b blockers
Thorough medical history, including sleep history like total sleep time, bedtime routine & sleeping environment; and any behavioral problem are to be asked very thoroughly.
Asking the parents to video record the child during sleep is often useful.
Height and weight, Neck Circumference, Blood Pressure should be recorded.
Nose and Throat examination are to be done thoroughly.
Video Flexible Nasal Endoscopy and Laryngoscopy are helpful to identify and quantify the site of the obstruction accurately.
X-Ray Nasopharynx –for adenoid and tonsil enlargement
X-Ray chest-to see heart size
Sleep observation, oxygen saturation and ECG in most children may be sufficient to document the need for adenoids and tonsil removal.
Overnight Sleep study (polysomnogram)-
It is detailed examination during sleep to record the sleep stages, heart rate, oxygen and carbon dioxide levels, eye movement, chest wall movement, and the flow of air through the nose.
Child is attached to machines that check EEG (Encephalogram –measure brain waves), EMG (Electromyogram-leg movement ) EOG (Electroocculogram-measure eye movement) ECG/EKG (electrocardiogram- measure heart rate and rhythm); chest and abdominal movement (measure breathing movements); and monitoring of oxygen and carbon dioxide levels in the blood.
None of the devices is painful still it may be a little frightening for a young child.
A sleep technologist monitors the recordings during sleep and after wards report is analyzed by sleep physician.
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- Regular exercise
- Weight loss
- Avoid heavy diner
- Healthy high fiber diet
- Develop regular sleeping patterns
- Tilting the top of a bed upward a few inches,
- Sleeping on the side
- Avoid alcohol/smoking
- Avoid allergy triggers (stuffed animals, pets, and feather/down pillows from the bedroom.
Nasal Continuous Positive Airway Pressure (CPAP)
CPAP (Continuous Positive Airway Pressure by a nasal mask throughout the night) is the most effective and frequently used treatment for OSA.
Compliance is a major problem but family should be motivated as major surgeries can be avoided. Sleep study should be repeated every 6-12 months with upper airway growth with age.
Oral Appliances (OA)
Mouthpieces worn at night works by repositioning the tongue or mandible forward
Nasopharyngeal airway – It may be the only treatment required for some children. Like Adequate airway is developed by the age of about 3 months in Pierre Robin syndrome.
Major complication of OSAS are reversible before the end stage heart and lung disease therefore surgery should be done for obstructive lesions of upper airway as soon as possible.
Tonsillectomy and Adenoidectomy (TAR / T&A) cures most children and it should be the initial treatment in children with other factors also.
In patients with craniofacial anomalies specific surgery can be done.
UPPP is done in selected cases.
Sleep apnea can have serious significant complications yet vast majority remain undiagnosed and untreated because of lack of awareness by the parents and health care providers.
All children with ADHD, behavioral problems and poor academic performances should be assessed for sleep apnea by ENT specialist or pulmonologists and upper airway should be evaluated by ENT specialists for every sleep apnea child.
Tonsillectomy and adenoidectomy results in dramatic resolution of symptoms of OSAS.