Paediatric Sleep Disordered Breathing – Snoring

Does my child snore or mouth breath?

Sleep disordered breathing is a common paediatric condition affecting between 8 to 12% of children.   Of these only 1 in every 7 children are currently being treated for this. 

It is characterised by recurrent partial, or complete obstruction, of the upper airway during sleep.  Each child may lie on a spectrum of between simple snoring or mouth breathing when they have an upper respiratory tract virus, through to significant obstructive episodes associated with pauses (apnoeas) in breathing overnight.   This can lead to recurrent episodes of oxygen de-saturation and/or sleep fragmentation, and has well documented consequences.  This is called obstructive sleep apnoea and occurs in around 5% of children. 

It is not normal for children to be noisy or restless when they sleep. 

Sleep is crucial for a healthy childhood physically and intellectually. Sleep disordered breathing is a disruption to the normal respiratory pattern of sleep. It is associated with physical health issues, as well as behavioural problems. If left untreated, and at the severe end of the spectrum, it can lead to hypertension (high blood pressure), cardiovascular disease, metabolic disorders, neuropsychiatric, developmental problems and “failure to thrive.”

Spectrum of Upper Airway Resistance Syndrome

In a study of 1760 Australian children (aged 1 to 17 years) snoring and sleep disordered breathing occurred in 17% of males and 10% of females. 

Under-reported:

In addition it is likely that sleep disordered breathing is under-recognised by parents.  A recent study identified that only 6% of parents thought their children snored, and only 4 % recognised apnoeic events (where their child stops breathing). 

Symptoms:

A cluster of both night-time symptoms and daytime symptoms occur. 

Causes:

In an otherwise healthy child, he most common cause for sleep disordered breathing and/or obstructive sleep apnoea in children is enlargement of the adenoids and tonsils.  These are usually different to children who have recurrent tonsillitis.  The adenoid tissue lies at the back of the nose, and can cause obstruction of the nasal airflow.  The tonsils in the oropharynx (back of the mouth) collapse together when asleep causing upper airway obstruction and snoring.  This causes sleep arousals and disruption stopping the child remaining in the appropriate sleep level/stage.

Other contributors to sleep disordered breathing include allergic rhinitis (hay fever) with nasal obstruction, facial features, muscle tone and children with high body max indexes (elevated weight for age). 

Consequences:

Both sleep disordered breathing and obstructive sleep apnoea have been recognised as increasing the risk of behavioural problems such as irritability, aggression, depression and mimic or exacerbate attention-deficit hyperactivity disorder (ADHD).  Daytime symptoms such as tiredness, poor concentration, inattention and memory can also impact significantly on school performance.  Some children also note morning headaches.  In addition to these neuropsychological effects, there is evidence obstructive sleep apnoea can have cardiovascular consequences in the long term and even hypertension (high blood pressure) in children.     These symptoms often improve with removing the adenoids and tonsils, although can be multifactorial. 

Recurrent Tonsillitis: 

Viral infections are the most common cause of tonsillitis, and as such do not require antibiotics, with adenovirus being the most common.  Group A B-haemolytic streptococcus (strep throat) is the most common bacterial cause, with a peak incidence in children 5 to 6 years old.   Symptoms of acute tonsillitis include fever, throat pain and swallowing pain, earache (referred pain), body aches, lymph node enlargement and often last for 7 days. 

Tonsillectomy is recommended for recurrent tonsillitis according to the “Paradise criteria”