It is NOT Normal...

Unpacking Truth

….for children to snore!

There have been increasing discussions about the impact of sleep disordered breathing in adults over the past decade. We talk about the severity of the health impacts from snoring, spouses complain that their snoring partner keeps them awake and we joke about how many ‘logs you sawed’ last night. But, did you know that not only is it abnormal for children to snore, the health impacts are far more serious than what we see in the adult population??

What Causes Snoring?

The most common cause of snoring in children is a stuffy nose during an acute illness. This is normal and definitely not of grave concern. Adults and children alike can experience transient breathing difficulties during springtime allergies or the winter cold/Flu season.

Snoring in children on a frequent or nightly basis can be caused by:

• Enlarged tonsils or adenoids—these are lymphatic tissues found in the back of the nasal passageway and the lateral oropharynx.

• Obesity—a growing epidemic in this country.

• Anatomic characteristics—a deviated septum, high palatal arch and an enlarged tongue may make it more challenging to nasal breathe during sleep.

• Contaminated air—whether from secondhand cigarette smoke or low air quality in the home.

• Shorter duration of breastfeeding—breastfeeding encourages the proper formation of the oral and nasal cavities helping the upper airway to have adequate shape and contour to facilitate nasal breathing.

Children who snore could also be suffering from obstructive sleep apnea (OSA). This is when the child will stop breathing for a period of time throughout the night, causing them to gasp for air. IMPORTANT: most children with OSA snore but not all children who snore have OSA.

Indications

Since most children sleep in their own room, it’s possible parents may not know whether their child is struggling to breathe while he or she is sleeping. Here are some common behaviors or signs that may indicate there is an issue:

• Frequent bed wetting

• Hyperactivity or diagnosis of ADHD

• Morning headaches

• Prone to temper tantrums

• Dark circles under the eyes

• Falling asleep at school

• Poor grades in school

• Frequent ear aches/ear infections

• Night terrors

• Dry cracked lips

In my training to help treat adults with obstructive sleep apnea, I have run across many case reports of children with this condition. I believe these case studies are discussed to highlight the profound impact treatment can offer these little people as they are going through their most formative years. Even though the case reports are about individual children, they all have a common theme: a poorly behaved child who is falling behind and causing trouble at school. This often is misdiagnosed by labeling the child as ADHD and the parents are handed prescription drugs.

Fortunately, some parents seek to avoid pharmaceutical solutions to the problem and press for answers to the many questions they have. Their children will benefit from a multifaceted approach to care utilizing both the medical and dental profession. Most treatment plans will involve management of any allergies, address swollen tonsils and adenoids, correct poor oral development and train the child on how to breathe properly so that he/she can sleep without interrupted breathing patterns. These children typically experience a profound improvement in their grades because they are able to pay attention and avoid causing trouble during class.

Harmful Effects to Development

Occasional snoring is not generally considered to be problematic and typically resolves on its own. But children who snore three or more nights per week may be prone to obstructive sleep apnea and this loss of oxygen saturation at night can have serious health consequences.

Children not only need more sleep than adults, they require far more NREM and REM sleep. NREM (non-rapid eye movement) is also known as deep sleep and it is when the body repairs and restores itself, bone and muscles are built and the immune system is strengthened. Additionally, deep sleep stages are critical to the development of the prefrontal cortex, the area of the brain that processes new information and learning. When this stage of sleep is interrupted because the body is fighting to get adequate oxygen, it can weaken the child’s immune system, it can jeopardize the child’s growth and development and it can compromise the child’s ability to learn, reason and problem solve.

REM (rapid eye movement sleep) is when the muscles of the body are essentially paralyzed and is commonly known as the stage of sleep when dreams occur. It is theorized that this stage of sleep helps with the learning of new skills and language development. When REM sleep is interrupted and diminished due to oxygen deprivation, the child may struggle to process new information.

When a child struggles to breathe during sleep, the brain thinks it is being suffocated and sends a host of chemical messengers throughout the body that cause deep and REM sleep to be disrupted into a lighter stage of sleep. The repeated nature of sleep disordered breathing puts the brain on high alert and it goes into survival mode. The constant flood of stress hormones and adrenaline can increase the chance that the child experiences anxiousness throughout the day. The fragmented sleep can lead to learning disabilities and hyperactivity. The constant alertness caused by these breathing interruptions can also decrease the child’s ability to cope with normal social skills and interfere with peer related behavior.

One of the neurological deficits caused by sleep disordered breathing is the potential lowering of the child’s IQ. Researchers in Tucson studied the relationship between sleep apnea in children and their ability to remember, learn and perform. Children who experienced higher rates of sleep disordered breathing were found to perform lower on tests and tended to have lower IQs overall.

Landmark Study

The Avon Longitudinal Study by Dr. Karen Bonuck followed over 11,000 children for 7 years, starting at their birth. Her study found that sleep disordered breathing (SDB) is relatively common in childhood. Based on the reporting from parents, the prevalence of habitual snoring ranged from 10-21% from 6-81 months. The most important finding from her study was the link between SDB and behavioral difficulties noted at older ages of the study:

• SDBs were most strongly linked to inattentiveness and hyperactivity

• children with SDB were far more likely to experience anxiety and depression

• children with SDB were more likely to to have problems getting along with peers

• children with SDB were less likely to engage in positive social behaviors like sharing and helping

• SDBs at age 4 had positive predictive value with problems at age 7

Early intervention is key to helping children recover normal sleep patterns and to prevent the long term risks from breathing improperly. Most parents would likely prefer to not see their child medicated at an early age!! According to the CDC over 100k toddlers are being medicated for ADHD. Early treatment of SDB could be the intervention most likely to reverse this behavior pattern and empower the child to grow and flourish.

Prevention and Early Intervention

In my opinion, prevention of airway problems would be the most important recommendation that I would give to my patients who are expecting. As a mother of two and a dentist of 25 years, I can honestly say that no pediatrician, obstetrician or dental school professor ever gave any instruction on the basic requirement for existence as a human….how to breathe properly. Here are some tips to ensure your child will minimize his/her chances of suffering from this avoidable condition:

• Breastfeeding—the work of the child’s tongue and cheek muscles during breastfeeding helps to create pressure on the palate to prompt more bone to be deposited along the suture lines of the mouth. This widens both the maxilla and mandible helping to shape the floor of the nasal cavity and proper space for the tongue. Bottle feeding does not require the same about of force (aka it’s easier to feed) and can lead to certain malocclusions that increase the chances of poor tongue posture.

• Healthy weight—encourage your child to get exercise/play outdoors and feed him/her a healthy diet, reducing exposure to processed foods.

• Orofacial Myofunctional Therapy—this is an early intervention and/or treatment that will help a child to learn tongue posture, tongue placement and learn how to breathe and swallow properly.

• Adenoid/Tonsil removal—thirty years ago, almost 90% of children had their adenoids and tonsils removed to treat recurrent tonsillitis infections. Today this number has dropped to 20% and most of the procedures are performed to treat pediatric OSA.

• Medications for allergies—by treating children with allergies that cause sinus congestion, the nasal passageways can be opened to encourage nasal breathing during sleep.

• Oral Appliance Therapy—children who were bottle fed, used a pacifier or thumb for an extended period of time and who breathe through their mouths are more likely to have a poorly formed maxilla (upper arch). The maxilla will be narrow and vaulted, compromising nasal airway space. This can be mitigated with maxillary arch expansion through orthodontic intervention.

Conclusion

Children are far more dependent on the quantity and quality of their sleep than we are as adults. Their developing bodies and brains require proper stages of sleep fueled with adequate oxygen to circulate and perfuse their tissues. In a world of quick fixes, most will be challenged to learn that treating a child with OSA may take a multidisciplinary approach and several months to correct. But the hassles of navigating treatment and intervention will set the child on a course of a lifetime of healthy breathing patterns that encourage proper brain development, minimize trauma to the cardiac muscles, help to establish an ideal weight, support metabolic health and improve social behavior.

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