In todays post, I wanted to discuss snoring and sleep apnea in children.
Sometimes our children snore! Especially after a cold, nasal congestion or if they have allergies, but if we notice that snoring continues after the acute episode has subsided, we may want to seek professional help.
The upper airway is really important for normal breathing, swallowing and speech. Snoring can happen when there is vibration of the soft palate and walls of the throat, known as the pharynx. The airway can also become partially or completely blocked due to the relaxation of throat muscles, which results in interruptions in breathing, and we call this sleep apnea. Waking up from sleep can happen during apneas when the brain senses that the oxygen in the body is low. You can live about 40 days without food, about 7 days without water, but only a few minutes without oxygen.
Children with sleep apnea may present with symptoms such as snoring, gasping or witnessed pauses in breathing during sleep, bed wetting, and restless sleep. In some cases, children may not snore, but they might have daytime sleepiness, difficulty paying attention in school, learning problems, behavioral problems, hyperactivity, difficulty concentrating, and failure to grow and develop normally.
In children, obesity might be a risk factor for sleep apnea, and additional risk factors might include a family history of obstructive sleep apnea, Down Syndrome, Sickle cell disease, neuromuscular disease and cerebral palsy.
At night, parents may find their children in unusual sleep positions, or parents may notice that they hyperextend the neck while sleeping in the car but sometimes obstructive sleep apnea in kids may go unrecognized because although they may have heavy breathing or interruption of breathing, if child sleeps in a separate bedroom from the adults.
So I want to talk for a minute about how children can be screened for sleep disorders…the gold standard test is called the polysomnography test. This is an overnight sleep study that uses sensors on the body to record brain wave activity, heart rate, muscle movements, and also uses a microphone and video to record snoring sounds. Sometimes, if this test is not available, doctors may use oximetry, which records oxygen levels, but this test sometimes may not quite fully reveal the problem.
Beyond the gold stand of the sleep study, a complete clinical evaluation may reveal additional problems worth identifying and possibly correcting, and I am going to go ahead and describe a couple of these next.
Let’s talk for a second about mouth breathing… there can be clues that your child is a mouth breather, these include noticing that your child is keeping the mouth slightly open most of the time, or noticing that the lips are cracked, and you may also notice dark circles around their eyes. Mouth breathing can be an indication of sleep disordered breathing too.
Nasal breathing, on the other hand, ensures that we have a healthy respiratory system by warming the air, by humidifying and filtering the incoming air ,and by transporting a compound called nitric oxide to the lungs and blood. This is a colorless gas which plays an important role in cardiovascular health.
A mouthbreather may have a blockage of the nasal cavities, and ear nose and throat doctors can help us to figure out whether this is the case. In some cases, the mouth breathing may not be related to a blockage, but more out of habit due to allergies. If the child is a mouth breather, steroid medications inserted into the nose might ease sleep apnea symptoms in mild cases of obstructive sleep apnea. If the child has allergies, medications like antihistamines might help relieve the symptoms too.
Over time, there can be an increase in airway collapsibility as a result enlargement of the adenoids and tonsils, so removal of the tonsils and adenoids by an ear nose and throat doctor may improve sleep apnea in moderate to severe cases when the tonsils and adenoids are enlarged and are causing blockage of air. In children, this is the most common cause of obstructive sleep apnea, but there are causes of sleep that might be identified through a thorough evaluation.
So… I want to mention two structures called the upper and lower frenulum. This was discussed on a previous Dental Chat Podcast when I interviewed my colleague Dr Richard Baxter, who wrote a book called Tongue Tied… a frenulum is a thin band of fibrous tissue in the mouth. It is that thing when you look in the mirror under the tongue and see a band of tissue connecting the tongue to the floor of the mouth – that’s the lower frenulum, and there is also an upper frenulum which connects the upper gum to the upper lip, which you can see if you roll your lip upwards.
Sometimes these tissues can create functional abnormalities. For example, if the frenulum that is located under the tongue is shortened, it can restrict tongue movement that may cause speech difficulties and swallowing problems. A shorted frenulum has been linked to obstructive sleep apnea and it is thought to potentially impact normal function and development of the face and mouth during childhood development.
An upper shortened frenulum can cause a space between the upper teeth and may appear like there is a short upper lip, and this can make the upper lip less mobile.
We should also talk about the role of the pediatric dentist and orthodontists we look at child at early stages of growth development.
These specialists can detect misalignment of teeth. We look for crossbites, which is when the upper teeth fit inside the lower teeth, instead of outside, which is normally the case. An anterior crossbite is when the top teeth land behind the front lower teeth, an anterior open bite is when the back teeth are together but the front teeth don’t overlap,
and a posterior open bite is when the front teeth meet but the back teeth do not.
We also evaluate for crowding, when there is insufficient space for the teeth as result of the teeth being large, or the jaws being too small.
All of these types of dental byte problems cause narrowing of the airway.
Oral appliances may be recommended if any of these problems are detected. These oral appliances may help expand the roof of the mouth, which we refer to as the palate. By expanding the palate we are expanding the nasal passages too. Some devices can also move your child’s bottom jaw and tongue forward to keep your child’s upper airway open.
The best treatment is going to depend on the severity of clinical symptoms, the child’s age, the results of the sleep test and also the overall health of the child. A multidisciplinary team and collaboration between multiple specialties including the pediatrician, sleep medicine specialist, ear nose and throat doctor, pediatric dentist, orthodontist, myofunctional therapist and speech pathologist may prevent serious consequences that may occur if obstructive sleep apneas are left untreated.
Bottom line: If you are concerned about any topics discussed today, please ask your child’s doctor to evaluate your child for sleep apnea…