Sleep Apnea
In The News
Children's snoring may signal apnea, other
serious problems
By MargarThe Washington Post
- August 11, 2006
Alex Perez, 21/2, stared blankly as his
mother pushed his little limbs into his blue
footie pajamas. Alex had spent the afternoon
running around the play area at a local mall
and had been allowed only a short nap, so he
was good and tired just the way his
parents wanted him.
For the next 40 minutes, the boy sat nearly
motionless, watching a cartoon of "The Three
Musketeers,'' as 14 electrical sensors on
long wires were taped to his legs, chest,
neck, temples, cheeks and scalp.
"I can't believe how good you're being,
Alex,'' his mother, Yolanda Rodriguez, cooed
at him.
Alex fell asleep before the connections were
finished, his eyelids closing improbably as
two grown-ups hovered over him. For the rest
of the night, he slept attached to the mass
of rainbow-colored wires, while technicians
with computers in another room monitored his
respiratory, neurological and physical
activity throughout the night.
Yolanda Rodriguez had been waiting for this
night for months. She wanted to know why her
youngest son snores so loudly, wakes
constantly throughout the night, is always
congested, gets repeated ear infections and
has delayed speech. His sleep problems have
ruled her life almost since he was born.
She had come from her home here to the new
pediatric sleep center at Suburban Hospital
in Bethesda, Md., to identify one possible
culprit: obstructive sleep apnea (OSA). A
much-publicized condition in adults, OSA
causes a person's breathing to cease
temporarily and repeatedly throughout the
night. Yet it often goes undetected in
children, and only in recent years has the
pediatric form been widely recognized and
studied.
"People used to think snoring in children
wasn't a problem, it was just cute," said
Stuart Tomares, director of Suburban
Hospital's pediatric sleep center. "But it's
not cute. It can be indicative of a serious
disorder."
On the mild side, the condition can cause
daytime sleepiness and irritability in young
children. On the severe end, it can lead to
learning disabilities, bed-wetting, heart
problems and even stunted growth.
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On its Web site, the American Sleep Apnea
Association says childhood apnea is also
associated with hyperactivity,
inattentiveness, aggressive behavior and
mood swings, making apnea a major new area
of study for doctors who deal with
attention-deficit disorders. Apnea has even
been implicated as one factor contributing
to obesity in children: Some sleepy kids get
sluggish and don't want to run around as
much as others.
Tomares is convinced that even mild sleep
apnea is creating behavioral issues in many
preschool and kindergarten classes
nationwide, without anyone noticing the
pattern and connecting the cases.
Obstructive apnea is surprisingly common in
little kids. The main warning signal is
nightly snoring; 8 to 12 percent of children
are habitual snorers. Roughly a quarter of
those, or about 2 to 3 percent of all young
children, suffer from actual apnea, said
Michael Schechter, a pediatric pulmonologist
at Brown University's Hasbro Children's
Hospital in Providence, R.I. "That's a very
big number," Schechter said.
One possible reason for underdiagnosis of
OSA in kids is that pediatricians are so
pressed for time that they often don't ask
the kinds of questions that might reveal the
presence of sleep apnea. Parents may not
notice or worry about snoring in their kids.
And sleep difficulties are often chalked up
to "behavioral" issues by doctors, making a
child with OSA harder to single out.
Most of the time, OSA in kids is caused by
developmental quirk: Until about age 6, a
child's tonsils and adenoids grow faster
than the rest of the body. They can collapse
over a child's airway when the muscles relax
during sleep.
Tonsils and adenoids are masses of soft
tissue at the back of the throat and behind
the nose whose purpose is not completely
understood. They are thought to aid in the
body's immunity protection by catching germs
that enter the mouth and nose.
When chronically enlarged tonsils cover a
child's airway, no air gets in and the
oxygen level in the blood slowly drops. If
an apnea episode lasts long enough, rising
levels of carbon dioxide in the blood cause
the child to awaken suddenly, as happens in
adults with apnea. In children, apnea events
often come and go repeatedly without fully
awakening the child. But either way, the
condition interferes with the child's sleep
cycles and can rob the body of needed
oxygen.
"If the kid's not getting a good night's
sleep, he's going to have difficulty with
learning and behavior and all kinds of
things," Schechter said. "It's as simple as
that."
The only way to diagnose sleep apnea
definitively is with an overnight sleep
study such as the one Alex Perez took. The
National Academy of Sleep Medicine has
accredited nearly 1,000 sleep centers
nationwide, triple the number 10 years ago,
and about 90 percent of those accept
pediatric patients. But a spokeswoman for
the academy couldn't say how many of those
labs have the specialized equipment and
training for child patients. Tomares
cautioned that this distinction is important
because adult and pediatric OSA are not the
same disorders.
"The diagnostic criteria are entirely
different" in children, he said.
If apnea is clearly detected in a child's
sleep study, the recommended treatment is
usually removal of the tonsils and adenoids.
"Surgery is curative in 95 percent of
cases," Tomares said. "People bring their
kids in to get their tonsils out and the
next day take home an entirely different
child."
Andrea Lynch, of suburban Maryland, began to
wonder about her daughter's sleep
difficulties when the girl was 2. Megan had
never slept as well as her two older
siblings, she constantly suffered from
allergies and ear infections and was tired
and cranky pretty much all the time, her
mother recalled.
"I knew this was not a spoiled child thing
this was something else," Lynch said. An
ear, nose and throat specialist said Megan's
tonsils were enlarged, but "nothing really
bad," Lynch said. The girl had seen many
doctors and had taken numerous medications,
none of which worked.
But then Lynch noticed that when Megan was
snoring loudly while asleep, she would
sometimes go completely quiet. For 15 or 20
seconds, Megan would just stop breathing,
then wake up with a choking noise. Lynch did
her own research online and discovered the
possibility of sleep apnea. She scheduled a
sleep study last summer, which showed
"pretty severe" apnea, she said.
The ENT said Megan could use steroids to
shrink the tonsils or could have her tonsils
and adenoids removed. It would be serious
surgery, requiring general sedation, but
Lynch decided to do it.
"It was a much harder and longer recovery
than I expected it took a week," Lynch
said. But immediately after that, Megan
began sleeping soundly and through the night
for the first time in her life. Her runny
nose stopped and her demeanor improved. Now
4, Megan is "overall, just a happier kid,"
her mother said.
The results were not as positive for Alex
Perez. After the lab had compiled a massive
amount of data 14 sensors taking
measurements every 30 seconds for 10 hours
Alex's sleep study results showed no
obstructive sleep apnea. "He had a totally
normal study,'' Tomares said.
So what about Alex's constant waking? The
loud snoring? The stopped breathing? In many
respects, Alex's symptoms mirror those of
Megan Lynch. "I'm really puzzled," Yolanda
Rodriguez said of the results. "I'm happy,
in a way. But for me it's really frustrating
because I don't know where to go from here."
Surgery may still be the answer, according
to Mark Dettelbach, Alex's ear, nose and
throat specialist. The boy previously had
his adenoids removed, but his tonsils are
enlarged and clearly causing severe snoring.
The noise alone could be interfering with
his sleep. "The kicker is he's had a normal
sleep study," Dettelbach said. "But
truthfully, taking the tonsils out will
still probably cure him."
It's possible that allergies or some other
issues are interfering with Alex's sleep, so
for now, the family has decided against
surgery.
Tomares said the surprising results of
Alex's sleep study prove an important point:
There is simply no way to tell from
examining or observing a child if there is
an apnea disorder. The only way to know for
sure is to do a sleep study.
If you
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