Maybe It's Not So Cute
Children's Snoring May Signal Apnea, Tied to Irritability and More Serious Problems
Tuesday, April 25, 2006; Page HE01
Alex Perez, 2 1/2 , 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 on Capitol Hill to the new pediatric sleep center at Suburban Hospital 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.
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.
The Little Snorers
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 S. 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.
Several hospitals and sleep labs in the area will see children, including Children's Hospital and Johns Hopkins in Baltimore.
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 Gaithersburg 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, Meghan is "over all just a happier kid," her mother said.
Not Always Diagnosed
As her son slept soundly in one of Suburban Hospital's comfortable sleep study rooms, Yolanda Rodriguez admitted that part of her hoped to find out that her son does have obstructive apnea. "At least, that way, I would know and we could do something to fix it," she said.
Ten days later, after the sleep lab had compiled massive amount of data -- 14 sensors taking measurements every 30 seconds for 10 hours -- Alex's sleep study results finally made it to Tomares's office in Bethesda. The findings were indisputable.
"He does not have obstructive sleep apnea," Tomares said. "He had a totally normal study."
So what about Alex's constant waking? The loud snoring? The stopped breathing? In many respects, Alex's symptoms mirror those of Megan Lynch, who did have serious apnea. "I'm really puzzled," 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 as well, so for now, the family has decided not to put Alex through surgery to take out his tonsils. Rodriguez said her son has shown some improvement since his sleep study, so she hopes he's growing out of his chronic sleep problems.
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.
"That's the story of my life: You never know," Tomares said. "I tell you, when I try to guess, I'm always wrong." ·
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