Approximately 2-3% of children in the UK have a severe type of snoring known as obstructive sleep apnoea where the throat muscles relax during sleep and cause a temporary blockage in the breathing passages. It typically results in disturbed sleep as the child wakes up suddenly, gasping for air frequently during the night. This disruption in their quality of sleep can cause problems for them during the day.
We spoke to Mr Christopher Pepper, a leading consultant paediatric ENT surgeon based in London, to understand the causes of this condition, how it can affect your child and the treatment options available to help them.
What is snoring and sleep apnoea in children?
When a child is awake, the muscles in the throat are working subconsciously to keep the throat and airway passages open. However, when they sleep, all the muscles in the body relax, including those in the throat.
When these throat muscles are relaxed, it can narrow the air passage. However, for most people, there is still enough space to breathe. If the throat muscles relax further it can narrow the airway and cause snoring. The sound comes from the vibration of the throat muscles while the child breathes.
If further relaxation of the throat muscles occurs it can lead to temporary blockage of the breathing passages (apnoeas); a condition known as obstructive sleep apnoea. In this situation, the body will partly or fully wake the child up so that the muscles can open the airway and allow breathing to return to normal. You may notice your child suddenly wakes up with a large gasp of air.
Although breathing does go back to normal when the child returns to sleep, the same problems of airway obstruction tend to reoccur once they enter deeper sleep. This creates a cycle of deeper sleep and obstructed airways, followed by partial waking with a return to normal breathing.
What causes sleep apnoea in children?
Any factor which narrows a child’s upper airway can make sleep apnoea more common. The most common causes are:
Other factors include:
- craniofacial syndromes, such as Crouzon syndrome and achondroplasia
- metabolic or neuromuscular problems, such as cerebral palsy
What problems can be caused by snoring and sleep apnoea?
Sleep apnoea disrupts the normal sleep cycles as the body has to wake itself up frequently to maintain adequate breathing. Normal sleep involves several important sleep cycles that alternate between light and deep sleep, as well as REM sleep (dream sleep). These cycles are important for your child’s brain development, effective processing of information and memory and allowing them to feel positive and energised during the day.
Many of the symptoms of sleep apnoea are associated with a reduced quality of sleep. If your child suffers from sleep apnoea, they may be able to get a good number of hours of sleep, but if the quality of sleep is reduced, it may not be enough to keep up with their rapid development. Furthermore, in particularly severe cases of sleep apnoea, it can cause excessive strain on the heart as it then has to work harder to pump blood.
Recently, experts have understood that severe snoring without sleep apnoea can cause significant symptoms. As a result, the threshold for treatment may be reduced.
Problems from snoring or sleep apnoea include:
- Daytime tiredness
- A constant need to sleep during the day
- Not wanting to wake up or get of bed in the morning
- Reduced concentration
- Significant variability in mood
- Impaired growth (height or weight)
- Wetting the bed
How can I tell if my child has sleep apnoea?
The most common symptom is significant snoring most of the night. Additional symptoms may include:
- A restless night’s sleep
- Excessive sweating
- Unusual extension of the neck to help open the airway
- Gasping for air
- Waking up frequently during the night
- Increased work of breathing (sucking-in of the chest; and sucking-in low in the front of the neck)
How is sleep apnoea diagnosed in children?
It is possible to diagnose sleep apnoea in most children based on their history and examination. If you have a video recording of your child sleeping, it can be very helpful to aid diagnosis. Sleep testing can be helpful for some children, although is not usually needed.
There are two main, non-invasive techniques to study sleep apnoea in children:
- Pulse oximetry
Both of these techniques aim to assess your child's breathing patterns and any disruptions that occur while your child is sleeping.
What is pulse oximetry?
By using a simple finger probe, experts can measure your child's oxygen levels throughout the night while they're sleeping. A small machine records the data which is then sent and analysed by a team of sleep experts. The presence of oxygen de-saturations (drops in oxygen level) is often a sign your child is holding their breath and signals the presence of sleep apnoea.
This test does have limitations in that it can miss many children who have sleep apnoea. This is known as a high false-negative rate.
What is polysomnography?
Polysomnography is considered the 'gold standard' test. It is a more detailed and thorough analysis and requires your child to be admitted to a specialist sleep department. Whilst there, experts will study your child while they are sleeping and monitor their oxygen and carbon dioxide levels, as well as chest and stomach movement, snoring volume and other parameters. Polysomnography is usually only available in specialist children’s centres.
Although this test is more detailed, it does have limitations. For example, as the severity of sleep apnoea can fluctuate, even over a few weeks, any sleep test is therefore just a snap-shot of one night’s sleep and not necessarily representative of an average.
What is the treatment for sleep apnoea in children?
Treatment for sleep apnoea focuses on treating the underlying cause. Many children will only experience a short period of sleep apnoea when it is associated with an upper respiratory infection - due to the tonsils and adenoids becoming temporarily enlarged and the nose blocked. Often, a child’s sleep apnoea will clear up once the infection has gone and no additional treatment is needed.
If the problems are long-term, then there are medical and surgical treatment options available.
The majority of children with sleep apnoea will eventually grow out of the condition as their throat grows and their tonsils and adenoids slowly shrink. Yet the difficulty is knowing when this improvement will happen. In my experience, if symptoms have been present for six months or more, early improvement is less unlikely.
If your child’s airway obstruction is caused by swelling of the lining of the nose - which is often allergy-related - then simple medications can be effective. For example, a combination of a non-drowsy antihistamine taken orally and a topical steroid nasal spray can reduce the swelling inside the nose and improve the airway and their quality of sleep.
For some children, enlarged tonsils and/or adenoids are the main contributing factor. Surgery can be very effective in settling their symptoms promptly. Even children with additional medical problems, such as cerebral palsy, will often benefit greatly from surgery.
Coblation intra-capsular tonsillectomy and/or adenoidectomy is the preferred surgical treatment for children with sleep apnoea. This surgery can reduce the pain and recovery time and also any further risk of bleeding post-surgery.
There is also a surgical option to shrink down the lining of the nose. This procedure is called a reduction of inferior turbinates and reduces the size of the soft tissue inside their nose called the inferior turbinate. This will help improve nasal airflow and can be combined with tonsil and adenoid surgery if necessary.
If you are concerned about your child’s snoring and would like them to see a specialist, visit Mr Christopher Pepper’s Top Doctors profile and book a consultation with him.