July 09, 2007
Snoring In A Two-Year Old—A Problem, Or Not?
Eric is a cute two-year-old boy who came in for his well-check. His growth was fine, as was his development and speech. The only finding of concern was that his tonsils were enlarged, and he seemed to be a mouth breather. When I asked mom about his sleeping, she laughed and said, “It’s sort of a joke around our house. Who snores louder, Eric or his father?” Questioning in more detail, I found out Eric falls asleep quite easily, but he snores significantly. There are times when, at the end of a big inspiration, he pauses for a second or two—then gasps before the next breath. Mom went on to say, “We weren’t too concerned about it because he seems rested when he wakes up. And he is extremely active during the day.”
My thinking was that we should at least look into this to be sure it was NOT a problem yet. I asked her to take Eric to the hospital for a lateral neck x-ray. This is a single x-ray of the neck area taken from the side. It will show how large the adenoids are, and how much they are impinging on the airway.
The adenoids are tissue just like the tonsils. Whereas the tonsils are located on either side of the back of the throat and easily visible, the adenoids are directly in the back. Hence it is impossible to gauge how large they are because you are seeing them en face.
I asked her to videotape Eric sleeping, and to try to capture a good representation of his typical snoring. Following this it was recommended that they see the pediatric otolaryngologist (ear, nose and throat surgeon, or ENT). An evaluation could be made whether or not Eric was a candidate for a nocturnal polysomnography, or sleep study. This is a non-invasive test that measures the respirations, heart rate, chest excursion and oxygenation when a person sleeps.
Eric met with the ENT specialist a few days later and it was determined that he definitely needed surgery to remove his adenoids. The x-ray showed large adenoids that were actually blocking the airway. The videotape of him sleeping was enough for the surgeon to make that determination. No sleep study was necessary.
So, what is all the fuss about snoring in an otherwise healthy child? When a person sleeps and is relaxed, the upper airways can somewhat collapse on themselves, thus narrowing the passageway for air into the lungs. During sleep, the breathing pattern is naturally shallower and slower. This creates a potential for the blood oxygenation to drop during this time. That is why a child like Eric seems fine during the day. But when he is asleep it seems he isn’t going to take the next breath. The airways are relaxed and as a result are compromised. This phenomenon is greatly magnified by the fact that Eric has large adenoids which further compromise the airway.
If we had done a sleep study on Eric, it would have shown that his oxygen levels would have dropped to worrisome levels for a good portion of his sleep time. This could not have been determined by merely observing him sleep. Eric had obstructive sleep apnea, or OSA. Approximately ten percent of all children are habitual snorers. Of these, around 1-3 percent actually suffer from obstructive sleep apnea. During sleep, subtle signs of OSA may include sweating because of the increased work of breathing, thrashing about or making gasping or choking sounds. One may wake up in the morning with a headache because of carbon dioxide retention. Children between 2-5 years of age are commonly seen with OSA. That is because this is the time when the tonsils and adenoids are at their largest size relative to the airway. Obese children are also common candidates. This is becoming more of a problem for it is estimated that 15 percent of all school-age children and adolescents are obese.
Untreated OSA can cause increased pressure in the right side of the cardio-pulmonary circuit. This can cause the right side of the heart to work harder to pump the blood into the lungs. As a result it can cause the right heart to become enlarged and actually go into failure.
Children with OSA do not get good healthy sleep. They may become chronically sleep deprived. These children may have problems as they are shifting their attention to maintain wakefulness. This can present exactly like attention deficit disorder (ADD). There are many children who were erroneously diagnosed with ADD when, in fact, they had sleep apnea instead.
Poor school performance has definitely been associated with OSA. One study from the University of Louisville looked at nearly 300 first graders who were in the bottom 10th percentile of their class academically. Of these students, 66 were identified as snorers, and 58 of these had abnormal sleep studies. Twenty-four of the 58 had their tonsils and adenoids removed. At follow-up the following year which was the end of second grade, the 24 students that had the surgery made significant improvement in their grades and school performance. Whereas the group that did not have the surgery was doing exactly the same. Certainly a tonsillectomy in and of itself isn’t going to make a child a good student. But this study is compelling.
It is important to know that children do snore quite often, especially in the toddler years between 2-5 years of age. This is due to the relative large size of the tonsils and adenoids that is common at this age. In most cases, the snoring is NOT a problem or a concern. However, this must be evaluated on a case-by-case basis because they may actually have OSA without obvious symptoms in the early stages. If one has a child who snores, it is well worth discussing this with their doctor and letting him make the determination how much of a work-up is warranted.