Does your child snore? If your child snores, it may mean he has sleep apnea and this means he is not getting enough restful sleep. When children don't get enough restful sleep, it affects their ability to focus in school and consequently it will affect their grades.
“They don't really reach Stage 3, the deepest level of sleep, or the REM (Rapid Eye Movement) sleep which is the dream sleep and just after Stage 3.
“They have very superficial sleep and in the end they do not get restful sleep. Because of their multiple episodes of sleep apnea at night, they have periods of wakefulness – either fully or partially awake. All these repeated episodes of wakefulness causes fragmented sleep and it impacts the child's subsequent school performance,” explains Dr Raymond Tan Suan-Kuo, consultant ENT, snoring surgeon and sleep medicine specialist, head and neck surgeon.
According to him, in a New Zealand study on kids with sleep apnea, it was found that the decrease in IQ and higher mental functions can be permanent if the children are not treated by the time they reach 18 years old.
“We know that typically if the child is younger and they are treated for their sleep apnea, their school grades will typically improve by one grade. So, it would go from a C to a B or a B to an A after treatment,” says Dr Tan.
Besides the impact on the child's IQ and study performance, sleep apnea can also cause hypertension and heart function problems.
This is because of the lack of oxygen during these apneic episodes at night and also because of the increased strain on the heart when the child goes through repeated episodes of breathing stoppages at night.
What are the symptoms of sleep apnea?
Parents will notice that these children are loud snorers, they might have episodes of choking and gasping at night, and sometimes there are long periods of silence in between breaths.
These children will be very sleepy in the daytime. Typically they demonstrate features of ADHD (Attention-Deficit Hyperactivity Disorder). They will be fidgety and won't be paying much attention in class. They will be prone to causing a disturbance and very quickly they'll be labelled as naughty children. According to Dr Tan, when children don't get enough sleep they demonstrate all these hyperactive symptoms.
Why do children snore?
There are several causes of snoring:
With more and more children being obese these days, the incidence of problems with snoring also will be on the increase. Dr Tan explains that this is because when kids put on a lot of weight, the airways at the back of their nose and at the back of their throat become more narrowed.
“When we sleep at night, the muscle tone is less than the muscle tone of the upper airways when we're awake. So, when we're asleep everything relaxes and if you're fat it can collapse and the airways can close up or constrict. Then they go into a syndrome called Obstructive Sleep Apnea (OSA) because the areas in the upper airways get obstructed when they sleep at night,” he says.
* Large tonsils and adenoids
Usually, when children have large tonsils, typically they also have large adenoids. Adenoids are the tonsils of the nose. They're situated right at the back of the nose. These are basically lymph nodes and when they get enlarged they enlarge simultaneously.
According to Dr Tan, children could be born with large tonsils and adenoids or they could have large tonsils and adenoids because of an allergy.
“We know that roughly 40% of kids nowadays have nasal allergies. The prevalence of allergies has increased dramatically over the past few decades and this is attributed to the increasing pollution in the air around us.
“Usually there's also a very strong genetic component to a child's risk of inheriting the allergy gene. We know if mum has the allergy gene – which may manifest in one or more allergic diseases like nasal allergy which is the most common, followed by bronchial asthma, skin allergy also known as eczema or allergic conjunctivitis – the chances of her passing it on to the kids will be four times higher than dad's chances of passing the allergy gene to the kids.
“So, the children follow the mother's side more than the dad's side. They will not necessarily be allergic to the same things and not even necessarily have the same allergic disease. It is worse when both parents have the allergy gene,” explains Dr Tan.
Usually when children have very big adenoids, they have an elongated face with an open mouth look, a much thicker lower lip (sometimes even three times larger than the upper lip) and very flat cheekbones from years of breathing through their mouth.
Dr Tan says that once the children with big adenoids past the age of 16 or 18, they will permanently have those facial features. Hence, doctors typically try to help these children before the facial features become permanent.
* Facial abnormalities and other reasons
Other less common causes of snoring and OSA would be facial abnormalities. Dr Tan explains that one of these would be Crouzon Syndrome where children have a very small chin. In these cases, although their tongue is of normal size, it falls backwards and causes sleep apnea.
Neuromuscular diseases where children have poor nerve and muscle control also cause snoring and OSA. But these are quite rare.
Confirming sleep apnea
As soon as you suspect your child has sleep apnea you should take the child to see an ENT specialist immediately. The doctors will be able to look at the obstruction of the airways in the clinic itself without having to go to an operating theatre.
Typically a sleep study is done to confirm that a child has sleep apnea. A sleep study can be done in a sleep lab, hospital or even at home.
In a full sleep study, all the parameters are monitored including the brain EEG waves that reveals the stages of sleep that a patient goes through at night when he or she is sleeping.
In the sleep study, some sensors are attached to the child.
“Usually, for kids, I would refrain from doing a full sleep study because all the wires and sensors would make it very uncomfortable. At most we would do a partial sleep study where we would measure the airflow via sensors to the nose and a sensor attached to the tip of the finger to measure the oxygen saturation and some sensors attached to the chest to look at the chest movement pattern. In sleep apnea, the chest moves but the air doesn't move,” says Dr Tan.
He adds that if there's a very clear history of choking and gasping at night and the child has large tonsils, a lot of nasal allergy problems, sinusitis problems, then a diagnosis can be made without even having to do a sleep study.
“The earlier they are diagnosed, the better. We do not want any permanent neurocognitive deficits to set in,” says Dr Tan.
Treatment for snoring
If the sleep apnea is due to obesity then the child will be referred to a dietitian and put on a weight reduction diet. The parents would also be educated on what they should and shouldn't give their child.
The child would also be put on an exercise regime. They would be encouraged to do more aerobic exercises and active physical sports like swimming, badminton and tennis.
“We know from the the Third National Health and Morbidity Survey (NHMS III) 2006 , a 10-yearly nationwide epidemiological study of the current health status of Malaysians, that 20% of Malaysian children are obese.
“This is largely because kids are eating more these days and the foods are more oily and higher in calories. The sedentary lifestyle contributes as well – quite often they are glued to their computer screens or the TV. Because of that we find our children have problems like obesity and sleep apnea,” says Dr Tan.
* Large tonsils and adenoids
The mainstay of treatment in children with large tonsils and adenoids would be an adenotonsillectomy operation.
In a lot of kids, surgery is an immediate cure, says Dr Tan. It's a minor operation and takes about 20 or 30 minutes to complete.
“It is the world's most-performed operation. It is done under general anaesthetic. Usually it's a day care procedure – they come in in the morning and go back in the evening. We have to educate parents that there is nothing to worry about in this operation. Of course, there is a small risk of the usual operation complications, as in any operation. There'll be some amount of pain and bleeding and risk of infection. But there is no other major risk. It is considered a minor operation. It is an operation which the junior ENT trainees do.
“A lot of parents in Malaysia and other Asian countries believe that the tonsils are speaker boxes from which the voice of the child is emitted. We have to educate parents that those are not speaker boxes. The sound is produced from their vocal chords which are very far away from the tonsils. So, their child's voice won't be affected when the tonsils are removed.
“Kids recover much faster from a tonsillectomy operation than adults. Typically, within a few days the child will be back to their normal self and running about and playing with their friends again.
“Younger children recover much faster than older children and adults take the longest to recover. Typically, kids take 5-7 days to recover,” he explains.
He adds that nasal allergies can also be treated. Besides practising good allergy avoidance measures, the child is also put on medication like antihistamine (the latest generation of antihistamines are non-sedating) and they might also be given nasal steroid spray.
Dr Tan encourages parents to ensure their children eat healthy food and maintain healthy lifestyles.
“We know that it's a lifelong healthy living practice that is needed to keep an individual on the slim and healthy side.
“I think if a child is snoring, often tired in the daytime, demonstrates a tendency to become irritable and fidgety, is not able to concentrate and school grades have started to drop, then perhaps they should bring the child to see an ENT doctor to have a look. If there is any choking or gasping episode or periods of sleep apnea where the child stops breathing for longer than 10 seconds, then quickly bring this child to see an ENT doctor.
“You can also flash a torchlight into your child's mouth to see if the child has big tonsils. Tonsils which are large fill up the whole of the back of your mouth,” he says.
According to Dr Tan early diagnosis and early intervention should be the main emphasis as it can make a lot of difference to your child's life and even a small difference in their school grades.