Snoring And Sleep Apnea
 
 
1. My Child Snores All The Time; Should I Be Concerned?
Sleep disorders and sleep-associated breathing problems are being recognized more often by doctors as a significant health problem in children.

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2. What Is Sleep Apnea?
Sleep apnea is part of a spectrum of obstructive sleep disorders. Sleep apnea is manifested by repeated episodes of decreased breathing during sleep due to problems in the upper part of your child's airway, that is the area above the main windpipe.

To maintain good air movement through the partially obstructed airway, the child must increase his effort at breathing. However, when the effort of breathing reaches a certain point, it actually worsens the obstruction. During sleep, a repeating cycle occurs where airflow through the obstructed airway totally stops. These pauses in breathing are called apnea episodes.

Apnea is defined as complete absence of airflow for 10 seconds in adults and 6 seconds in children. Apnea results in low levels of oxygen in the body, higher acid levels in the blood vessels, and extra carbon dioxide gas which is supposed to be blown away when your child breathes. When the levels of acid, oxygen and carbon dioxide reach certain levels in the blood vessels, warnings are sent to the brain to stimulate more normal breathing by arousal or awakening.

This repeating cycle of sleep awakenings and restless sleep may occur many times a night. The length of time and number of times apnea episodes occur vary according to your child's ability to tolerate and compensate to the changes in oxygen, carbon dioxide and acid levels.

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3. Is Sleep Apnea Harmful?
Some of the many long-term effects, which are directly related to the new levels of oxygen, carbon dioxide and acid, include:

1. Decreased heart rate, extra heart beats, or abnormal heart beat patterns: These responses have been associated with "unexplained" deaths while sleeping and the sudden infant death syndrome also known as SIDS.

2. Tightening of blood vessels within the lungs: These tightened blood vessels make it harder for the lungs to deliver more oxygen and remove carbon dioxide, making the entire problem worse. It makes it harder for the heart to pump fresh blood into the lungs. The heart has to work harder which results in enlargement of the right side of the heart. This change in the heart and lungs is called corpulmonale and can eventually lead to heart failure.

3. Increased production of blood cells: Because the oxygen content is so low, the brain stimulates the production of more red blood cells. An excessive amount of blood cells can clog up the blood vessels by making the blood too thick.

4. Loss of sleep: Due to frequent arousals and awakenings throughout the night, sleep is not obtained in large blocks of time but instead it is fragmented into many pieces. The total time asleep may be normal but it is less effective and of poor quality. Eventually the effects of poor sleep result in excessive daytime sleepiness, behavioral disorders, personality changes, and school and learning problems.

5. Slowed growth and development: Because excessive amount of energy is required for breathing, children with long standing sleep disorders fail to gain weight as expected and may be slower at achieving developmental milestones.

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4. What Causes Sleep Apnea?
Enlarged tonsils and adenoids are the most common cause of obstruction of the upper part of the airway during sleep in children. Other causes include narrowing of the nasal passageways, enlarged tongue, small lower jaw which pushes the tongue backwards, birth defects which alter the development of the bones of the face, cerebral palsy, Down syndrome, narrowing of the voice box, paralysis of the voice box, and simply being an overweight child.

Newborn babies and young infants represent a special group of patients with sleep disorders. These children have not fully developed the normal responses to changes in oxygen, carbon dioxide and acid levels in the blood stream. The warning system to alert the brain of these changes is also immature. Therefore, sleep disorders in newborns and young infants may be more severe than those seen in older children.








Symmetrically enlarged tonsils
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5. How Do I Know If My Child Has A Sleeping Disorder?
The evaluation of a child with possible sleep apnea is complex. Many of the signs and symptoms, which occur at night, are not witnessed by parents and sometimes are only subtle during the day. Since the disorder is chronic, the child gets used to some of the symptoms and begins to associate these with his normal healthy state. Because the changes slowly occur, many parents are unable to recognize the changes.

Some children alter their growth rates as a means of compensation.

Important information need includes the length of time the snoring has been present and if is has become more severe over time. The severity of the snoring alone does not necessarily equal the severity of the obstruction. Some loud snorers have constant, rhythmic breathing cycles, while some quiet snorers have prolonged periods of apnea. You may even be aware of episodes where your child gasps for air. This is common after an episode of apnea.

Other common symptoms of sleep apnea can be divided into those present at night and those which occur during the day. Daytime symptoms include mouth-breathing, excessive sleepiness, poor school performance, hyperactivity, short attention span, excessive aggressiveness, weight problems (overweight and underweight), frequent colds, chronic runny nose, choking on food, difficulty swallowing food, abnormal speech. Nighttime symptoms include snoring, pauses in breathing, frequent awakening from sleep, nightmares, excessive sweating, and bedwetting.

Children with obstructive sleep disorders may be classified into four groups based upon the severity of the symptoms:

* Class I: Snoring alone-noisy breathing but breaths are orderly and regular

* Class II: Snoring with irregular breathing cycles with pauses up to 5 seconds, pauses are well spaced apart

* Class III: Snoring with pauses in breathing less than 6 seconds, or frequent short pauses of 3 seconds or more.

* Class IV: Obstructive sleep apnea-snoring with pauses greater than 6 seconds, 20-30 episodes of apnea per night, behavioral changes, daytime sleepiness and poor school performance, poor growth and development, heart failure.
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6. Does My Child Need A Sleep Study?
A frequently used, inexpensive study is the nighttime recording of your child's sleep using an audiocassette tape recorder. This tape provides information regarding sleep sounds such as snoring, pauses, gasping, choking and coughing episodes. Some families have made video recordings, which document the sounds and the associated abnormal sleep movements and behaviors.

The sleep study is the most accurate way to diagnose sleep apnea. The sleep study can monitor oxygen and carbon dioxide levels, brain waves, heart rate, amount of air flowing through the nose and mouth, amount of effort the chest muscles use to breathe, and the amount of acid from the stomach which travels to the upper airway. The frequency and length of apnea episodes is well documented by the sleep study, but more importantly, the type of apnea is determined.

Although the sleep study is extremely useful, it is very expensive and often requires sleeping overnight in the hospital or sleep lab which performs the study.

Sleep studies are not practical in the routine evaluation of the snoring child. It is best reserved for a child who is strongly suspected of having sleep apnea but whose history and examination do not clearly support the diagnosis, or in children with significant brain disorders to distinguish between central and obstructive apnea.

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7. How Is Sleep Apnea Treated?
There are many treatment options available for children with obstructive sleep apnea. The options basically fall into the categories of non-surgical and surgical. The non-surgical therapies include medications which may stimulate the brain to increase breathing, weight loss, placing a flexible tube through the nose to by-pass the obstruction, creating a dental appliance which moves structures to improve airflow, and a machine which delivers a continuous stream of pressured air into the nose or mouth. These treatments are for specific patients but remain mostly ineffective in the treatment of most children.

In general, surgery remains the mainstay of treatment for obstructive sleep apnea in children. The surgical therapies are directed toward removing the obstruction or bypassing the obstruction. Since adenoid and tonsil enlargement is by far the most common cause of sleep apnea in children, an adenoidectomy and tonsillectomy are the most commonly performed surgeries.

Although tonsillectomy and adenoidectomy in obstructive sleep apnea patients is technically the same procedure as when it is performed for recurrent infections, the immediate 24 hours after surgery is extremely critical. These patients should be monitored overnight in the hospital, often they are observed in an intensive care unit. Other surgical procedures include trimming the soft palate, reducing an enlarged tongue, and nose surgery to remove the obstructing tissue.

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