Mini-Series on Obstructive Sleep Apnea (OSA): Children's Sleep-Disordered Breathing
Discussing sleep apnea in children has boomed in popularity. You might be wondering, I thought sleep apnea was an adult problem? There are actually strong connections of sleep-disordered breathing in children with mood disturbances, stunted growth, obesity, diagnoses of ADHD, and decreased academic performance. Simply put, these kids are unable to live to their potential. Any snoring in childhood is NOT normal! Having an Apnea-Hypopnea Index (AHI) > 1.5 is diagnostic for pediatric OSA. To refresh, the AHI is an hourly measurement of partial and complete airflow cessation, which should not happen in a healthy child.
How common is pediatric OSA? Approximately 1-4% of children have sleep-disordered breathing. While this number is lower than the adult OSA population, it is still quite significant. Some signs that you may notice include mouth breathing, tossing and turning during sleep, night sweats, bedwetting, and what has been coined as “adenoid facies” or “long face syndrome.” I will explain these, don’t worry.
Mouth breathing is an interesting compensatory mechanism for sleep-disordered breathing. This action alone has the potential to alter facial growth, creating a more vertical and narrow lower facial form. This shift contributes to the adenoid facies appearance. Changes in facial posture occur: the upper lip raises and the lower jaw stays in an open position. In severe cases, lip incompetence may develop. This means that the lips cannot come together without tensing muscles around the mouth. The head may tilt forward and the tongue abnormally droops down and forward. This anterior tongue position leads to a tongue thrust habit during swallowing, which is abnormal. The lack of tongue pressure on the roof of the mouth also causes the palate to become narrowed in width and more vertical. Mouth breathing may lead to halitosis in the morning, dried out lips, as well as contribute to inflamed gums.
These characteristic changes, if untreated in a growing child, may lead to what is called adenoid facies/long face syndrome. These children often have hypertrophic (enlarged) adenoid/lymphoid tissues, which commonly cause nasal obstruction. As a result, they often become obligatory mouth breathers. Adenoid facies features include the open mouth posturing with poorly developed nostrils and a short upper lip. This makes the upper teeth look more prominent or gummy. Since oral breathing is not as efficient as nasal breathing, less oxygen is delivered to the body. This means overall fatigue. The eyes may look tired, and you may notice what is called subocular venous pooling (aka dark bags and shadows under the eyes). This is a consequence of inadequate oxygen in the blood. No bueno.
Poor oxygenation also contributes to bedwetting. This may sound odd, but it’s the same concept of when someone may lose bladder control when frightened. A “fight or flight” response occurs during perceived stress. Sleep disordered breathing/OSA and its associated decrease in blood-oxygen saturation is a stress to the body that triggers this sympathetic nervous system response. When an OSA event occurs, the drive to maintain bladder control may become lost since it is not a vital function to the body.
So, not-so-great consequences to having sleep disordered breathing, right? The good news is is that they are usually reversible, if addressed appropriately! There are studies that show rapid palatal expansion orthodontic intervention in children will actually reverse bedwetting as well as convert mouth breathers to nasal breathers. Woohoo! In addition, tongue posture is elevated and improved, which has been documented in MRI studies. Another non-invasive treatment measure includes taping the mouth shut, which forces nasal breathing. Weight management is also helpful. Oral positioners, in addition to rapid palatal expansion, help widen the upper jaw and guide the teeth. This minimizes dental crowding for the permanent adult teeth. Lastly, tonsillectomy and adenoidectomy (T&A) procedures are commonly performed surgical interventions to address enlarged tonsils and adenoid tissues. This in effect removes this physical impingement of the airway.
The take-home message is that children’s sleep quality is extremely important to their health and wellbeing! Snoring is a huge red flag that something is up that needs to be addressed. Stay tuned for Part 3 of this series, wherein I will discuss adult OSA prevention and treatment options.