Snoring and Sleep Apnea in Children

Just like adults, almost all children will snore occasionally.

The mechanics of snoring are no different in children. Inhaled air becomes partially obstructed which causes excess soft tissue in the upper airway to flap and make noise.

But how do you know if your child’s snores are normal or not?

Normal snoring vs. sleep apnea

We all snore occasionally, particularly if we are unwell. But 10% of children will snore on most nights. This is not normal and could be a sign of something more serious [1].

1-3% of children even experience obstructive sleep apnea (or OSA for short) [2]. This is where airway blockage leads to breathing pauses – a condition that has health implications beyond sleep.

Side note: what is the difference between snoring and sleep apnea?

Normal snoring (a.k.a. “habitual” snoring or “primary” snoring) does not involve breathing stoppage. This is usually benign. When a child has sleep apnea, their breathing stops for at least 10 seconds, generally followed by a big gasp or choke. Those with OSA often snore loudly, but importantly, not all loud snorers have sleep apnea.

Obstructive sleep apnea is problematic in children

Children need lots of healthy sleep for good physical, mental and emotional development. OSA disrupts sleep, therefore sleep deprivation is the biggest concern for children with sleep disordered breathing.

Studies have also linked the sleep fragmentation experienced with sleep apnea to ADHD [3]. Even without an ADHD diagnosis, sleep deprivation can affect children’s behaviour, focus and overall development.

What causes snoring in children?

The various reasons for snoring are the same in children as for adults. Sleeping position, being overweight and allergies can all be implicated in your child’s snoring.

To understand why your child snores, try to explore their triggers:

  • Are they sleeping on their back?
  • Could dust allergies be triggering their snoring? Are there a lot of soft toys in their room that could be collecting dust?
  • Does their snoring happen seasonally? If so, could they be suffering from hay fever? Understand the other signs of this seasonal pollen allergy.
  • Is your child’s face shape responsible? A pronounced overbite (retrognathia) reduces space behind the tongue and is a common anatomical cause of snoring.
  • Is your child overweight?
  • Are they ill? If so, their snoring should be short-lived.

Unlike in adults, the tonsils and adenoids are frequently cited as causes of snoring and sleep apnea. This is because the adenoids are regions of soft tissue that (usually) disappear after puberty. Further, tonsils reach their peak mass between 5-7 years – well before a child’s airway has reached its peak size. These are therefore key obstruction triggers in childhood snoring and sleep apnea.

When is a child’s snoring problematic? The signs to look out for

There are some key signs that can suggest that your child’s snoring is a cause for concern.

5 sleeping flags are:

  1. They snore more than 4 nights per week
  2. They snore frequently throughout the night
  3. The snoring is noisy
  4. You can hear pauses in the child’s breathing
  5. They often sleep with an open mouth.

It can be hard for you to identify these sleeping flags in your child; beyond a certain age, parents don’t usually share a room with their child.

Therefore, it is important to also keep watch for these 5 flags whilst your child is awake:

  1. They have trouble waking up
  2. They are unusually irritable
  3. There are behavioural issues and problems at school
  4. You are told that they fall asleep at school
  5. They report having headaches or a sore throat.

If they are ticking many of these boxes, it is a good idea to seek advice and further investigation from a specialist.

Before a medical consultation, it is recommended that you start a sleep journal. This can help a specialist glean some insight into your child’s snoring. Focus on the 10 sleeping and waking flags above.

The logistics of listening to your child’s entire night of sleep are difficult if they are at the age where you aren’t sharing a room. This is where SnoreLab can be helpful.

Side note: is SnoreLab suitable for children; will my child’s privacy be protected?

Your child’s privacy is not at risk when using SnoreLab. We do not collect audio recordings and therefore cannot share or listen to any audio picked up by the app. We do collect some anonymised, non-audio data on the session – this cannot identify you personally and is nothing more than some numbers on a screen.

Further investigation – do children have sleep studies?

Yes, children have sleep studies too. A sleep study is a way of looking at how your child’s body behaves when they are asleep. This is the reliable way to understand their sleep disordered breathing.

The process is almost identical to adult sleep studies.

On the day of the sleep study, parents are encouraged to help make the process as normal as possible. This means sticking to normal routines, both before and after arriving at the hospital. If an afternoon nap is part of your child’s routine, then don’t deny them it.

To help make the hospital feel as comfortable and homely as possible, bring things from home that help your child to relax and sleep – whether it’s a toy, a blanket, a book or a film to watch before bed.

Your child will be “wired up” before the study starts. This involves attaching an array of monitors which can take up to an hour to set up. The key ones are:

  • Elastic chest bands. These sense the child’s breathing efforts.
  • Pulse/blood oxygen saturation monitor finger/toe clamp
  • Nasal cannula to assess airflow and look for breathing disruptions
  • Electrodes to monitor heart, brain and eye activity are less common in paediatric sleep studies but are still sometimes used.

Importantly, none of these attachments are painful and they should be attached in such a way to avoid any discomfort. Your child should have no problem sleeping with them on.

The technicians attaching these monitors are well-trained in dealing with children and allaying any fears and anxieties they may have. You as a parent can also play your part here too.

Paediatric sleep studies almost always have two beds set up – one for the child and one for the parent. Your presence should help your child relax and get the sleep needed to make the necessary measurements. People say that typically the child sleeps better than the parent!

Similar to adult studies, the session finishes around 6am. Results are analysed by specialists and will be communicated to you at a later date.

What can be done to treat children’s snoring and sleep apnea?

As with anyone’s snoring, what is the “best treatment” depends on the cause. Almost all snoring remedies apart from mouthpieces – if well matched to the cause – are suitable for children.

Surgery is recommended more for children than it is for adults. This is because children’s snoring is more likely to have a clear physical obstruction that can be corrected with surgery – namely by removing the adenoids and tonsils. Indeed, these procedures are performed more than a quarter of a million times per year in the USA alone [4]. It is generally very safe with only minor risks associated.

Such surgical interventions are usually very successful. Some research indicates that children’s stunted mental capabilities, often attributed to the sleep disturbance that accompanies sleep apnea, reverses completely 3 to 10 months after surgical removal of the adenoids [5].

Surgery is not always an option. If a child is diagnosed with OSA which cannot be managed with surgery or other measures, CPAP can also be used. Whilst CPAP can be quite a drastic change for a child to get used to, if presented and handled well by both the medical professionals and the parents, it can be extremely effective [6].

Further, it is speculated that another potential measure is doing nothing! Children develop and grow quickly so certain conditions can resolve themselves. Recent studies have shown that the non-intervention commonly referred to in the medical world as “watchful waiting” saw almost half of sleep apnea cases reversed within 7 months [7].

Conclusion

Snoring has similar causes in both adults and children and can therefore be managed in the same ways.

Occasional snoring is normal and harmless for children. However, extra attention should be paid if your child snores 4 nights or more per week, and snores frequently through the night [1].

Assess your child’s snoring with the following process:

  1. Is it caused by allergies? Does your child have any symptoms such as a runny nose; are there soft toys potentially trapping dust in their room?
  2. What position do they sleep in? See if side-sleeping reduces their snoring. You can also try elevating their head.
  3. Check if they are showing any of the 5 daytime signs of problematic snoring.
  4. If possible, make a sleep journal. Note how often they are snoring and its frequency per night. SnoreLab can help with some objective nighttime measurements.
  5. If these flags raise concerns, seek medical advice.

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References

  1. Chawla J and Waters KA. Snoring in Children. Journal of Paediatrics and Child Health 2015; 51(9): 847-851. https://doi.org/10.1111/jpc.12976
  2. Fleck RJ, et al. Magnetic resonance imaging of obstructive sleep apnea in children. Pediatric Radiology 2018; 48(9): 1223-1233. https://link.springer.com/article/10.1007%2Fs00247-018-4180-2
  3. Tso W, et al. Early sleep deprivation and attention-deficit/hyperactivity disorder. Pediatric Research 2019; 85(4): 449-455. https://doi.org/10.1038/s41390-019-0280-4
  4. Mitchell RB, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology, Head and Neck Surgery 2019; 160: S1-S42. https://doi.org/10.1177/0194599818801757
  5. Freidman BC, et al. Adenotonsillectomy improves neurocognitive function in children with obstructive sleep apnea syndrome. Sleep 2003; 26(8): 999-1005. https://www.ncbi.nlm.nih.gov/pubmed/14746381
  6. Parmar A, et al. Positive airway pressure in pediatric obstructive sleep apnea. Paediatric Respiratory Reviews 2019; pii: S1526-0542(19)30041-7. https://doi.org/10.1016/j.prrv.2019.04.006
  7. Chervin RD, et al. Prognosis for Spontaneous Resolution of OSA in Children. Chest 2015; 148(5): 1204-1213. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4631037/

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