January 4th, 2011
11:25 AM ET
The young mother looked tired and sad, and when she started to speak, her voice quivered with frustration: “I don’t know what we’re doing here. Jimmy sleeps fine. It’s the other 14 hours of the day that’s the problem.”
The reason she was there in my sleep center was because her 6-year-old son, Jimmy, was being evaluated for ADHD (attention deficit hyperactivity disorder). Her astute pediatrician was up on the latest research that shows an association between sleep disorders in school-age children and behavior disorders such as ADHD. The sleep disorder that has been studied the most in this regard is obstructive sleep apnea, or OSA.
There are many population studies from all over the world showing that approximately 2-3% of children have OSA. Just as in adults, this disorder is caused by a collapse of the upper airway during sleep. This results in a drop in oxygen, a rise in carbon dioxide, and fragmented sleep because the brain is disturbed by these fluctuations in oxygen and CO2. The classic example of a kid with sleep apnea is the skinny kid with big tonsils. Often these kids also have large adenoids, which make it difficult for them to breathe through their nose even in the daytime. So one clue that kids have OSA is if they have trouble breathing in the daytime, whether from chronic congestion, allergies or asthma, then they just might have problems breathing at night.
Because of the growing problem of pediatric obesity, we are starting to see a new group of pediatric OSA patients who have weight as the major contributing factor to their sleep apnea.
The telltale sign of pediatric sleep apnea is the same as for adults: snoring. Although with children, observers often describe “heavy or rapid breathing” rather than snoring. Per the recommendations of the American Academy of Pediatrics, pediatricians are supposed to ask about sleep problems and about snoring at every well-child visit. I am afraid that they are already overburdened by all the things they must check and ask about. So it is not surprising that if the parents don’t complain about the child’s sleeping habits, then often this vital aspect to growth and development can get overlooked.
And parents of kids with sleep apnea often have no idea that their children have disturbed sleep. These are usually kids who go through their bedtime routine with little resistance, including even the children with behavior problems in the daytime, and they seem to fall asleep readily, and as far as the parents know, they sleep through the night without disturbing them.
Besides large tonsils, snoring and daytime breathing problems, another symptom that should make parents or educators suspicious of sleep apnea is bedwetting (especially if the child is over the age of five and has had a dry spell). Also, kids with OSA often sleep in contorted positions as they attempt to arch their necks and open their throats. Sometimes these kids will get very sweaty at night, we think because of their increased work of breathing. Even though these days children with sleep apnea often have weight issues that cause or contribute to their sleep apnea, in some children, their sleep apnea can cause failure to thrive and stunted growth. The explanation is that growth hormone is secreted during sleep and if the kids have disturbed sleep then they have disturbed this hormone and the many vital developmental processes that depend on it.
And finally, if children are having behavior problems, learning difficulties or psychiatric issues, the possibility of a sleep disorder in general and of sleep apnea in particular should be explored.
The case of Jimmy is quite illustrative. He had behavior and attention issues; he had medium-sized tonsils and he had occasional “rough breathing.” The overnight sleep study showed moderate obstructive sleep apnea. We recommended an evaluation by an otolaryngologist and indeed tonsillectomy and adenoidectomy were performed. When I saw Jimmy and his mother two months later, the first thing she said was: “It’s a miracle! A week after the operation, I saw a difference in his mood and his behavior. His teachers are amazed. No one thinks that he needs any further evaluations for ADHD.”
In this case, it appears that the symptoms of the sleep disorder were mimicking those of ADHD. I have seen this many times, and there is a growing body of research showing that indeed as many as 30% of the children with a diagnosis of ADHD may have a sleep disorder instead.
Many children with behavior, learning, or psychiatric problems may have sleep disorders that, if left undiagnosed and untreated, can aggravate their other disorders and make them harder to treat. So even if the sleep disorder is not the whole story, finding the right treatment and helping children get the sleep that their brains so desperately need is crucial to the management of these other problems that greatly impact their health, their social integration and their academic achievement.
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