As a pediatric otolaryngologist, I see many children with sleep disorders. Often, they come to see me after their pediatrician or dentist has noted large tonsils, and I hear a similar story being repeated. “My child tosses and turns all night. She just can’t get comfortable. She snores like a grown man.” When I probe further, I find out that the breathing pattern is somewhat erratic, characterized by pauses, gasping, coughing or simply waking up. Some parents describe night terrors, nightmares, sleep walking or talking. Some just have a child that wakes up multiple times throughout the night, keeping their siblings awake or crawling into their parents’ bed.
Is it sleep apnea?
Sleep apnea in children is defined as a pause in breathing for the duration of two breaths. Any sleep apnea is abnormal because it has been shown to have a detrimental effect on behavior, mood, concentration and cognitive ability during the day. When sleep apnea is severe or has been present for a prolonged period of time, there are risks of deleterious effects on the heart, lungs and blood stream. Overall inflammatory conditions like asthma, allergy and acid reflux may be exacerbated.
When the tonsils and/or adenoid are obstructive, they prolapse into the airway while breathing in, blocking or significantly narrowing the back of the nose and throat. When the airway is narrow, airflow is more turbulent and this creates more audible sounds of breathing – snoring! The gasping that occurs at the end of a pause in breathing, or apneic spell, is your child moving air around the obstruction. The human body finds a way. Unfortunately, in order to open up and move air around a blockage, your child has to at least partially wake up. This means that each gasp is a small or large disturbance in sleep.
The cost of sleep apnea
Imagine not sleeping for a few nights. Now picture this happening every night for months on end. This is what it’s like to have severe sleep apnea. Young children with sleep apnea tend to wind up, not down. They lose the ability to control their mood and behavior and are often described as hyperactive or temperamental. School age children may be “spacey” or have poor concentration. Preteens and teenagers often mimic adult sleep apnea, with fatigue. If you have a young child (under 10) who complains of fatigue, it’s important to have a thorough medical workup. Fatigue in young children with sleep apnea often represents a subtype in which gas exchange is impaired and carbon dioxide levels rise throughout the night.
When I see a child with sleep apnea, the history is as important as the size of the tonsils and/or adenoids. I ask about the symptoms described above and try to get a sense of what is most concerning for the child and parents. If the anatomy of the upper airway fits the history, often no further work up is needed. Many times I will want more concrete information and recommend a sleep study. A sleep study, or polysomnogram, requires an overnight stay in a sleep lab. These labs usually resemble hotel rooms with a lot of extra equipment. Parents room in with their child. During a sleep study, monitors are placed to measure nasal airflow, chest rise, the number of pauses in breathing, the duration of pauses, oxygen, carbon dioxide, and phase of sleep. These studies are administered and read by sleep-trained physicians who often come from the disciplines of neurology, pulmonology or otolaryngology (like me).
Once sleep apnea is diagnosed, we can discuss treatment. In neurologically normal, nonsyndromic children, the most common treatment is removal of the tonsils and adenoids. This short, routine procedure cures 85 percent of children who are otherwise healthy. In very young children or those with severe apnea, this requires an overnight stay in the hospital. For most children, adenotonsillectomy is outpatient. Recovery times vary, but I generally recommend taking a week off from scheduled activity, and two weeks off from sports or strenuous physical activity. If symptoms of sleep apnea persist after the removal of the tonsils and adenoids, there are many other options that can help children sleep.
I get a small thrill when I see my patients after their operation. “Dr. K, I can breathe better. I can dance more. I can run farther. I can focus at school!” Parents tell me that their child no longer snores, no longer has dark circles under the eyes, and that the moodiness has improved. I love to hear it. The evidence bears this out. Children with sleep apnea who have undergone adenotonsillectomy improve on scores of concentration and cognition. Additional evidence shows that in children with both obstructive sleep apnea and asthma, adenotonsillectomy lessens the severity of asthma in comparison to similar peers who keep their tonsils. Children with sleep apnea and autism experience improved daytime function post-operatively as well.
The benefits of a good night’s sleep are myriad and well proven. I, too, sleep better at night knowing that I’m helping children sleep.
By Jonathan Kopelovich, MD Pediatric Otolaryngologist
Jonathan Kopelovich, MD (bellevueent.com) is a board certified otolaryngologist who specializes in complex pediatric otolaryngology and has extensive experience in airway, craniofacial and ear surgery. He believes in a collaborative and holistic approach to caring for every child.