Sleep Apnea in Children
When thinking about an individual with sleep apnea, what images come to mind? Do you picture an older adult? Someone carrying more weight than necessary? What if you were told that the individual with sleep apnea was a 6-year-old child? While contrary to popular images, an important and growing population faced with sleep apnea are children. While around 20% of children snore, it is estimated that 1–4% of children in the United States ages 2–8 have sleep apnea. Compared to the much more publicized 3.9% childhood rate for allergies, parents and pediatricians often are unaware of the need to diagnose and treat this condition.
What is Sleep Apnea?
Sleep apnea is characterized by interrupted breathing during sleep. The two types of sleep apnea are obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea (OSA) is the more common type; it is caused by a blockage or constriction of the airway, usually when the soft tissue in the back of the throat collapses during sleep. OSA stops the full flow of air and results in reduced oxygen intake. Central sleep apnea occurs when the part of the brain responsible for breathing does not send the appropriate signals to the breathing muscles and the patient actually stops breathing for 10 seconds or more. Some of the risk factors for pediatric sleep apnea include having a family history of sleep apnea, being overweight or obese, having certain medical conditions (e.g., cerebral palsy and Down syndrome), being born prematurely, having a large tongue, and taking certain medications (e.g., opioids).
Snoring is a more obvious symptom among individuals with obstructive sleep apnea because air is pushing to get through the narrowed passageway. Among adults, symptoms of sleep apnea include snoring, daytime sleepiness, fatigue, restlessness during sleep, gasping for air while sleeping, and trouble concentrating throughout the day. Fatigue, daytime sleepiness, and snoring are also seen in children, but children experience additional symptoms such as bed-wetting, sleep terrors, sleeping in odd positions, and stunted growth. It is important to keep in mind that some infants and young children may not snore, especially if they have central sleep apnea. In this case, it is very important to pay attention to the main symptom of disrupted sleep.
Untreated Sleep Apnea
If sleep apnea goes untreated, the result is chronic excessive daytime sleepiness due to poor sleep quality. This is because when someone stops breathing or isn’t getting enough oxygen, their mind says “Wake up and take a deep breath.” For children, this excessive daytime sleepiness can cause inattention during school and can lead to poor academic performance and learning problems. Some children become easily excitable or hyperactive as a consequence of this sleep disturbance, resulting in a misdiagnosis of attention-deficit hyperactivity disorder (ADHD). Studies estimate that as many as 25% of children diagnosed with ADHD display symptoms related to obstructive sleep apnea and suggest that much of the learning difficulty and behavior problems seen in these children could be an outcome of chronically disrupted sleep. A study on the treatment of ADHD by using either methylphenidate (MPH) or treating sleep apnea through adenotonsillectomy (removal of adenoids and tonsils) revealed that both MPH and surgical interventions significantly improved ADHD symptoms compared to a nontreatment control group. For some outcomes (e.g., attention span, impulse control), the surgical group showed more of an improvement than the group treated with medication. Physically, untreated sleep apnea can cause high blood pressure and it may also be associated with childhood obesity.
Treatment for sleep apnea looks different from child to child, but there are several interventions. Some children outgrow sleep apnea, so the disorder may be monitored instead of being treated immediately depending on the risk of long-term complications. For others, topical nasal steroids are prescribed to relieve nasal congestion. Surgical removal of the tonsils and adenoids is usually performed to open up the child’s airway when those tissues are the cause of obstructive sleep apnea. Physical activity and diet may also be recommended to treat sleep apnea if obesity is the origin of the disorder. Children can also be fitted with dental mouthpieces and/or CPAP devices.
If sleep apnea is severe, the child may need continuous positive airway pressure (CPAP) therapy. While wearing a mask that covers the nose and mouth during sleep, the machine provides a continuous flow of air to keep the airway open. Dental mouthpieces designed to keep the jaw in a forward position to keep the airway open can also be worn by children with sleep apnea while they sleep. CPAP machines are more effective, but children tend to tolerate the mouthpieces better and are more likely to use the mouthpieces consistently. For children with central sleep apnea, a device called a noninvasive positive pressure ventilation (NIPPV) device may be more effective. These machines ensure that a set number of breaths are taken every minute even without a brain signal to breathe. Apnea alarms can be used for infants with central sleep apnea. An alarm goes off when an episode of apnea occurs to wake the infant and stop the apneic episode. Sleep apnea treatment is effective for many children.
If your child is experiencing symptoms associated with sleep apnea, discuss these symptoms with your pediatrician. The pediatrician will perform a physical exam and may refer you to a sleep specialist who will help to determine whether or not your child should undergo a sleep study, either in the home or at a sleep lab. A sleep study (or polysomnogram [PSG]) is a multiple-component test that electronically transmits and records specific physical activities while your child sleeps, including brain waves, oxygen level, heart rate, muscle activity, and breathing pattern. This will help determine the best course of action for treatment for your child.
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