Sleep Disorders and Airway Obstruction In Children.

Sleep disordered breathing (SDB) is a term that describes breathing difficulties during sleep. In children, symptoms can be associated with enlarged tonsils and adenoids, a blockage of the nasal airways from allergies, a small and narrow upper jaw or childhood obesity which can also play a part. Sleep position may also increase episodes of sleep disordered breathing, especially when sleeping on the back, and in some cases, children may compensate by sleeping with an over extension of the neck. In addition, silent reflux and periodic limb movement can also be a cause of SDB.

Sleep disordered breathing can range from frequent loud snoring to sleep apnea, a condition where part or all of the upper airway is blocked during sleep causing pauses in breathing during sleep, a drop in blood oxygen levels, increased heart rate, brain arousal and sleep disturbance. These episodes interrupt sleep and cause micro arousals, so the child does not necessarily wake up completely, but the quality of the sleep is drastically reduced.

Signs of Sleep-disordered breathing in Children

• Snoring/Noisy Breathing – A common symptom of airway obstruction during sleep. Sometimes the snoring involves a continuous, partial obstruction without any obvious pauses or arousals.
• Mouth breathing – An indication of difficulty breathing through the nose due to nasal congestion or blockage. 
• Gasping or chocking – Sleep is interrupted with gasping and choking noises from a complete blockage of the airway. 
• Teeth grinding or clenching – Teeth grinding, or clenching is usually associated to sleep arousal in children with sleep disordered breathing.
• Restless sleep – May be a sign of a child struggling to breath during sleep.  The child’s body may move in response to the pauses in breathing.
• Bedwetting – Sleep disordered breathing can cause increased urine production at night, which may lead to bedwetting (also called enuresis).
• Night terrors – Generally occurs when a child is partially aroused from a deep sleep.
• Daytime sleepiness - Children may become sleepy during the daytime due to poor sleep quality.
• Daytime hyperactivity – Unlike an adult, children who experience daytime drowsiness due to reduced quality of sleep, tend to overcompensate which can lead to hyperactivity and poor concentration.
• Irritability– Sleep fragmentation may cause behavioural and mood problems in children.
• Learning difficulties –Children with sleep disordered breathing may find it difficult to concentrate during the day, have poor memory and can become moody and disruptive, both at home and at school.  
• Slow growth - Children with sleep disordered breathing may suffer interruptions in hormone secretion, resulting in slow growth or development.

These episodes can have a significant impact on growth development and behaviour in affected children, which can impact their overall quality of life and have long-term effects if left untreated.

What Causes sleep disordered breathing (SBD)?

Sleep disordered breathing can happen when something is blocking the upper airway. A common cause of airway obstruction is enlarged tonsils and adenoids, gastroesophageal reflux, or narrow nasal passages which can be related to a narrow upper jaw. Other causes include periodic limb movement syndrome.

Diagnosis and treatment

If you suspect your child may have a sleep disorder you should seek medical advice. Chatswood Orthodontics sees children from an early age for orthodontic assessments and if signs of sleep or breathing issues are detected, treatment will be recommended. SBD is a serious condition, and our orthodontist work closely with other specialists such as Ear Nose and Throat specialists (ENT), paediatric sleep specialist, or an allergy specialist to manage sleep disordered breathing. Fortunately, there are many treatment options available such as:  

Tonsillectomy and Adenoidectomy

A tonsillectomy and adenoidectomy is the surgical removal of enlarged tonsils and adenoids, which can cause narrowing of the airway or a constant source of infection. This is a common cause of sleep disordered breathing. It’s common for your child to have recovered fully by two weeks after the procedure and should be able to return to their normal activities after that time. The ENT will recommend a soft diet, plenty of fluids and rest, during recovery.

Nasal obstructions and Allergy Treatment

Children who have long-term allergy symptoms may suffer from chronic congestion and tend to breathe through their mouth, which may contribute to the risk of sleep disordered breathing. Most nasal obstructions are from mucus, a reaction caused by allergens or pollution and can be easily treated with medication such as antihistamines, decongestant nasal sprays and corticosteroids, which can help reduce and manage the symptoms.

However, other nasal obstructions may be caused by:

• Large or swollen turbinates, the boney plates inside your nose that can swell or enlarge due to allergies. If they are too large, they can block airflow.
• Nasal polyps’, which are grape-like growths on the lining of your nasal passages or sinuses, and often result in a blocked nose.
• A deviated nasal septum which occurs when the thin wall between your nasal passages is displaced to one side causing obstruction in the airflow.

In some of these cases, surgery may be required.

Orthodontic Treatment

Children with poor upper jaw development or a small chin can often benefit from orthodontic intervention. The maxillary expander (RME) is a fixed orthodontic appliance that is routinely used to treat narrow upper jaws and can also have a major beneficial impact on breathing function and airway. At a young age, the upper jaw is still made of two halves the right and left. A maxillary expander widens the upper jaw by moving the two halves apart, the jaw then develops to become wider while also encouraging positive lower jaw growth. Thus, more room in the mouth, improved jaw position and correct tongue position to improve breathing.  

The nose is closely related to the upper jaw. In fact, the roof of the mouth corresponds to the floor of the nose, so widening the upper jaw in turn widens the nasal airway. Studies have shown that upper jaw expansion can reduce nasal airway resistance and make it easier for the child to breathe from their nose. Maxillary expansion has also been shown to help resolve obstructive sleep apnea. However, not all expanders work equally well, and our orthodontist will recommend the design that is most appropriate for each individual scenario.

If you suspect your child may have a sleep disorder, you should see a doctor immediately. If left untreated, sleep disordered breathing can worsen and interfere with your child’s quality of life.