Snoring and obstructive sleep apnea


Matt Dwyer: Hey, I’m Matt Dwyer and  welcome to Sleep where  professor Harrie Hiscock and associate professor Emma Sciberras from the Murdoch Children’s Research Institute help you identify sleeping problems in your children from infancy through to secondary school and give you easy to understand steps to improve their sleep cycles and overall health.

So we’ve touched on things like sleeping apnea and snoring and restless legs, but I’d like to get into that a little bit more. So what actually is sleep apnea? 

Professor Harriet Hiscock: So sleep apnea affects about 1 to 5% of all children and it occurs in conjunction with snoring. Usually they have periods overnight where they stop breathing and that can be anywhere from 5, 10, 15, up to 20 seconds.

It tends to occur more in the later part of preschool or early primary school years where the adenoids and tonsils are big in the airway compared to the diameter of the airway, which is quite small. When we go to sleep at night, the muscles in our airway relax and close down a bit which causes snoring. Then there are periods where they stop breathing because they obstruct in the upper airway and then the oxygen level in the blood drops, which then triggers the brain to take that big gasp in. Typically with obstructive sleep apnea in kids, as well as adults, you get snoring, then a period of silence when they’re not breathing, followed by a big gasp.

The other thing that children can do is sleep with their neck extended on the pillow to try and open up their airway. You might go in and find your child lying in an unusual position. The child is usually not aware that this is happening at all. They’re doing it maybe several times a night and they’re completely oblivious but they tend to wake up in the morning, not refreshed.

They might complain of a headache in the morning as well and just feeling like they haven’t had a good night’s sleep 

Matt Dwyer: Is there a difference between just sleep apnea and obstructive sleep apnea or is it the same thing? 

Professor Harriet Hiscock: It’s the same thing. There are certain children who are more at risk of it.

Children who are overweight or obese are more at risk of obstructive sleep apnea. Children with Down Syndrome also are more at risk and children with neurological conditions are more at risk as well of obstructive sleep apnea. 

Matt Dwyer: What if it’s left untreated? What are the effects?

Professor Harriet Hiscock: It’s really important to get onto this one and treat it. Left untreated, there’s what we call cardiac effects, particularly high blood pressure, persistently high blood pressure in the child. The fragmented sleep leads to problems with cognition, especially attention and focus the next day, memory consolidation, behavioural  problems and regulation of emotion and behavioural issues as well are really common if it’s left untreated. 

Matt Dwyer: What about in adults? 

Professor Harriet Hiscock: It’s similar with adults. It really puts them at risk of high blood pressure and all the correlaries of that; increased risk of heart attack and stroke all can lead on from that if they’ve got persistent obstructive sleep apnea. Typically with adults we see it a lot if they’re overweight or obese, which then adds to all of the cardiometabolic risk factors for them as well.

Matt Dwyer: So it affects our sleep cycles?

Professor Harriet Hiscock: It does in terms of interrupting the sleep and having periods of just not breathing, then rousing, gasping, and going back to sleep. You just get very fragmented sleep. The quality of sleep is very poor and that affects behavior and learning the next day in adults, as well as in children, and for adults, particularly, or adolescents who are driving that’s a real risk.

Matt Dwyer: What about the difference between sleep apnea and just regular snoring?

Professor Harriet Hiscock: So it’s a continuum, really. Snoring, obviously, is common particularly with children. If your child only snores when they’ve got a cold, you don’t need to worry about it. That that’s typical and that’s normal.

There is some evidence that habitual snoring, or snoring more than four nights a week every week, is associated with some slight increases in blood pressure and heart rate in children. I think there’s a bit of debate about how to best manage that because some of the management involves medical management and some of it’s surgical management. Certainly for obstructive sleep apnea, you need to definitely treat that. For primary snoring without obstruction, it’s a bit more debatable but I think we’re leaning towards treating that as well. The first line would be a steroid nasal spray that you use for around six weeks. 

Matt Dwyer: So when does snoring become a serious issue?  I had an old housemate, their parents stayed and her dad snored so loudly.

Professor Harriet Hiscock: Yep. 

Matt Dwyer: It basically shook the house. 

Professor Harriet Hiscock: Well I think that’s when you go to your GP and check your blood pressure and heart rate and look at your weight and everything else that’s going on. It’s probably getting a bit out of my field with commenting on adult medicine, but if you had snoring like that in association with high blood pressure and being overweight or obese, the first step is to try and lose that weight.

Then maybe even talking about some of the options like the C-PAP mask, which helps to keep positive air flow and pressure to keep your airways open so that you don’t snore like that overnight.

Matt Dwyer: Are snoring or sleep apnea genetic?  

Professor Harriet Hiscock: They certainly run in families, definitely, but you can get a child who has obstructive sleep apnea with no history of anyone in the family having that problem.

One of the best ways to really diagnose is obviously to listen at the bedroom door, but also to take a video of what’s happening with your child’s sleep. You can take that along to your doctor. Even pulling up their pyjama top so you can see when they stop breathing and capturing that on film can be really useful.

The gold standard is a sleep test in a sleep laboratory called a PSG or polysomnography but that requires going into, usually, a hospital for the night where your child sleeps. They’re wired up to several sensors; sensors of their brain waves, of their oxygen levels, their heart rate, et cetera. Then they have a sleep overnight and that gets analysed the next morning. You can see how often they’re stopping breathing, how often their oxygen levels dip, and that can help differentiate if they’re mild or moderate or severe OSA with the severe and the moderate ones tending to go on to surgery.

The children with moderate OSA, now, we’re gearing them more towards the intranasal steroid therapy first to see if that can help. 

Matt Dwyer: Those are the two options you have?

Professor Harriet Hiscock: The third option we have is actually something we call watchful waiting. There was a big study conducted in the States across a number of sites called the CHAT Study and they compared surgery, taking out the adenoids and tonsils, to watchful waiting. 

Actually 47% of kids got better just by themselves just naturally. This was seven months down the track so not a huge amount of time. That was their airways getting bigger; their tonsil and adenoid size shrinking relative to their airways.

They were improving with no  management. That’s always an option, particularly for the milder obstructive sleep apnea.

Matt Dwyer: Snoring and sleep apnea are the big ones. What other physical sleeping problems are there? 

Professor Harriet Hiscock: Certainly we know that children with uncontrolled asthma can have a lot of dry coughing overnight that wakes them. So people always think of wheezing being associated with asthma, which is right, but a dry cough, particularly a nocturnal cough, is indicative of asthma.

If your child is doing that, take them to the GP. They need to get their lung function or their lungs listened to and checked out. Uncontrolled asthma will cause wheezing overnight so that’s another issue. There’s something called restless legs syndrome, which actually happens at the start of the night. We talked about this in the ADHD episode. It can cause this feeling of pins and needles or ants crawling up their legs and they need to move their legs in order to relieve that symptom and that feeling.

Their legs are moving constantly at the start of the night and that makes it really difficult to fall asleep, but it doesn’t tend to happen overnight. Restless leg syndrome is associated with low iron levels. It’s worth taking your child off to the GP to get those levels checked and treated if they’re low as that’s been shown, in case studies, to reduce those symptoms. It can also help, particularly in older kids, making sure they’re not having caffeine or alcohol because that worsens restless leg syndrome symptoms as well. 

Matt Dwyer: Can it also happen in adults as well? 

Professor Harriet Hiscock: Definitely. It’s probably more common in adults and that’s when we actually get into different medication options, which we try to avoid in kids.

We try to treat it with iron and the other thing which can help is moderate physical activity in the afternoon, but not just before bedtime. All of those things help for adults. There are also some Parkinson light medications that you can use for adults with restless legs syndrome. We tend not to go there with children because of the side effects. I think the other issue that can happen overnight, particularly in younger kids

and this is why it’s always good before you start any behavioural strategies to get your child checked out by your GP physically, is recurrent ear infections. So whilst sometimes it’s really obvious, the child gets a fever or they seem like they’re in pain, some children will get ear infections and just have low grade symptoms of being a bit grizzly, a bit out of sorts, bit of favour. Sometimes  the first real clue, in these cases, is the eardrum is perforated and you find discharge coming out of their ear. With ear pain, when you lie down at night the fluid collects and the pain can be worse so that’s worth getting ruled out as well. Another medical condition, it’s actually really rare, is something called narcolepsy. This is excessive, excessive, daytime sleepiness. Not just falling asleep on the way home from school or in front of the television, but children actually dropping asleep in the classroom or, and it happens to adults as well, just falling asleep on the desk during the middle of the day. This is rare. It can happen more commonly in children with attention deficit, hyperactivity disorder. It’s something that requires a sleep specialist to measure and requires a test that’s conducted in a lab. The test is called a multiple sleep latency test where they’re allowed the chance to fall asleep multiple times during the day and it’s timed to see how quickly they can fall asleep and that forms part of the diagnosis. It’s certainly a fairly rare occurrence in children. 

Matt Dwyer: Do you think that physical sleeping problems like these start to occur earlier or later in life? 

Professor Harriet Hiscock: It depends on the nature of the problem. So ear infections are typically in toddlers and preschoolers.  Sleep apnea does start in preschool age and into primary school it remains common because the airways are small relative to the bigger tonsils and adenoids. Problems such as narcolepsy tend to be more with an onset later on, past primary school age into adolescence and adulthood. One of the other things parents will come and see me about, and they’re worried that there might be a medical problem, is their child being really restless and tossing and turning. 

Usually that is normal behaviour relative to adults. Children spend a lot more time in light sleep or REM, rapid eye movement sleep. That’s the time when we can be tossing and turning and then moving our eyes under our eyelids. Parents, particularly if they’re sleeping next to their child, will often come in and be worried about that, but the tossing and turning is completely normal in little babies. They may actually move their head back and forth rapidly on their pillow or their cot. Parents will try and stop them but, a bit like us rocking in a rocking chair which is soothing for us, the child, the baby, or the toddler, find moving their head back and forth to be actually really soothing for them as well. That’s something that you shouldn’t stop them doing.

 Into toddler and primary school-aged kids, they can start head-banging or rocking and that can be really distressing to the family but the child’s actually usually asleep while they’re doing it. The first thing the parents know is that they can hear the bang, bang, bang, coming from the child’s bedroom and they’ll go in and the child might be up on all fours and banging their head against the cot or their bed. The child is not awake. Leave them be. If they continually do it and they’re causing harm to themselves, you can try the scheduled awakening technique, which we talked about for night terrors. If they’re doing it at 10:00 PM every night, you’d go in at 20 to 10:00PM, try and wake them up a bit, just to rouse them and try and reset their sleep cycles so they stop that rhythmic banging. By and large, it’s harmless and they will grow out of it but that might take weeks to months of growing out of it. 

Matt Dwyer: What causes them to do the banging? 

Professor Harriet Hiscock: We don’t really know. It’s certainly worse if they are overtired or they’re sick. It’s probably quite soothing to them because it’s a rhythmic movement and it can come in episodes. It might be there for weeks, then it’s gone for a few months, then it comes again. By and large, it’s not harmful and they shouldn’t worry about it. 

Matt Dwyer: Teeth grinding is another pretty common one as well. I know that was happening to me for a little while. What do you think brings that on? Is that something we should seek medical advice for? 

Professor Harriet Hiscock: It’s certainly something that does happen in children, particularly if there’s a family history of it, it puts them at increased risk. There may be clenching or grinding of their teeth or gnashing them during the night.

They may be aware of it or other siblings or parents can hear them doing it. They’ll typically wake up in the morning with a sore jaw or sore teeth. They may have a headache as well when they wake in the morning and then may report sensitive teeth to certain foods or cold or hot foods.

So if it’s happening, it’s usually something that gets better by itself, but it’s definitely worth checking if your child is stressed or worried about anything, because that will increase that clenching and that grinding. Certainly for adolescents, avoiding alcohol can help as well. Sometimes there’s an underlying problem with the jaw and the teeth alignment and malocclusion, and that needs a trip to the dentist to look at and help with that. So the first thing is, if it’s just happening irregularly, don’t worry about it too much. If there’s underlying stress that your child’s worried about schoolwork or something else, try to address that and look at the techniques we’ve talked about with mindfulness and relaxation to try and manage that. I think yoga can be really helpful in this situation. 

If it’s continuing and it’s stress related, you may need to see a psychologist. If there’s an issues with alignment of the teeth, you may need to see your dentist because they can often fix up a device for the child to wear overnight in their mouth to stop that grinding and clenching.

Even, as you were saying Matt, learning to sleep with your tongue between your teeth, which I think is amazing to be able to achieve that. You’ll know because you’ll wake up pain-free; you won’t have any jaw pain in the morning, you won’t have any headaches, your teeth won’t be so sensitive to hot and cold foods. At that point, you’ll probably know if you’ve fixed it. 

Matt Dwyer: If you need any more help on strategies on getting your babies to sleep, there is a wealth of knowledge over at raisingchildren.net.au.

Sleep was presented by Harriet Hiscock and Emma Sciberras and produced by me, Matt Dwyer. Audio production done by Darcy Thompson and our executive producer is Jen Govern.

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If this series resonated with you, you might also be interested in the concussion podcast. It’s hosted by neuro-psychologist and concussion expert at the Murdoch Children’s Research Institute, Vicki Anderson. In it, she explains to me what really happens during a concussion, the physical and mental effects concussions can have on children and how to tell if that knock on the head could have caused a concussion. Just search concussion podcasts to start listening.