Sleep Apnea in Kids: More than a Sleep Problem?

SAN ANTONIO – Between one and 10-percent of kids have difficulty breathing when they sleep, which could be a serious condition called obstructive sleep apnea.  It does more than just disturb a good night's sleep; it can create serious behavioral and health problems, and is often misdiagnosed as something else. 

Michelle Huegel's four-year-old son Avyn was born prematurely, with respiratory distress syndrome, but even as he grew into a healthy little boy, a good night's sleep just wasn't part of this family's routine.

Huegel told Ivanhoe, "None of us got a whole lot of sleep for a long time." 

It took an overnight hospital sleep study to find out Avyn had obstructive sleep apnea.  He now sleeps with a ventilator that works just like a C-Pap would for an adult.

Sleep specialist David Dubose, MD, FAAP, FAASM, Medical Director at the Children's Hospital of San Antonio Sleep Center says poor sleep in kids can create serious problems such as, "hyperactivity, aggressive behavior, inability to complete tasks, inability to stay awake." 

Those behaviors can be mistaken for the symptoms of ADHD.

"Children, before they are diagnosed with ADHD, should be evaluated by a sleep specialist to make sure that they are having adequate sleep," Dr. Dubose explained. 

The disorder is also linked to heart disease, high blood pressure, Type Two Diabetes and adult asthma.

After getting his C-Pap, and better sleep, Avyn's teacher told Michelle her little boy had changed.

Huegel told Ivanhoe, "She said he can focus, he's sitting still now during our reading time, and he's paying attention!" And now, everyone is getting a good night's sleep!

Avyn might be able to sleep without a C-Pap in a few years when his jaw grows.  That will open his airway, allowing him to breathe on his own.  Some kids with sleep apnea are also treated by having their tonsils or adenoids removed. The cost of a sleep study runs between 4,500 and 7,500 dollars, which is covered by most insurance companies.


BACKGROUND: Sleep apnea is a disorder that affects one in every 15 Americans. Sleep apnea occurs when breathing is interrupted during sleep, slowly depriving vital oxygen to the brain and other organs. Snoring can also accompany the disorder. There are two types of sleep apnea: obstructive sleep apnea and central sleep apnea. In obstructive sleep apnea, the most common type of sleep apnea, something blocks the airways. In central sleep apnea, the brain fails to send a signal to muscles to breathe. If left untreated, sleep apnea can cause many health problems including high blood pressure, stroke, heart failure, diabetes, depression, and headaches. Poor sleep can also cause poor performance in school or work activities and the worsening of ADHD. In general, men are more prone to sleep apnea than women. On average, someone with sleep apnea may have 60 apneas, or breathing interruptions, an hour, or 400 a night. 

TREATMENTS: The type of treatment for sleep apnea differs based on the severity and type of sleep apnea, but possible treatments include:

·     Losing weight

·     Avoiding alcohol and sleeping pills

·     Changing sleeping positions

·     Continuous positive airway pathway (a mask you where over your nose and mouth while you sleep)

·     Nasal surgery

·     Uvulopalatopharyngoplasty (a surgery increases the width of the airway at the throat opening)


SLEEP APNEA IN CHILDREN:  Sleep apnea can especially cause problems in children. Sleep apnea in kids can cause hyperactivity, aggressive behavior, and the inability to stay awake, leading some to diagnose those children with ADHD. In fact, researchers with the National Sleep Foundation found that more than two out of every three children under the age of 10 have experienced some type of sleep problem. Bedwetting, daytime sleepiness, abnormal growth, and hyperactivity could be signs of sleep apnea. Obstructive sleep apnea in children can also be the result of large tonsils. Parents who suspect that their child has sleep apnea can sign up for an overnight sleep study. The cost of a sleep study is usually between $1,500 and $3,000, but most insurance policies can cover it. 


David DuBose, M.D., FAAP, FAASM, Medical Director of the of the Sleep Center of Children's Hospital San Antonio explains the cause and effect of adolescent sleep apnea.

Interview conducted by Ivanhoe Broadcast News in February 2015.


Do you work exclusively with children here?

Dr. Dubose: Yes, we work with children from birth to under 18 years of age with some very few exceptions. In the sleep center itself we only do under 18.

Can infants have sleep problems?

Dr. Dubose: Yes, we actually do sleep studies in the NECU or the Neonatal Intensive Care Unit and some of those kids with a born prematurity or have structural defects or chromosome defects are at a risk for having problems with their breathing. And typically, problems with breathing get worse in sleep. We actually will do sleep studies on kids in the ICU.

Is this something that medicine has only discovered or found in the last so many years?

Dr. Dubose: Well it's one of the newer fields of medicine. The big push came back in the late 70s and they have gradually found more information and more research. There probably has been an expediential growth in the knowledge of sleep medicine in the last 10 years. It's a large field that involves a lot of different specialties; a lot of the pioneer work was done by psychologists as well as physicians. Now they're discovering that sleep is actually a very important part of a person's wellbeing. And pediatrics medicine in general has lagged behind adults and now we're catching up and finding that there are a lot of issues with children's sleep and pediatric sleep that can affect their wellbeing.

Evan's mother told us that after he was fitted with a CPAP he changed so much. He's paying attention better and his behavior is better. Do you hear that a lot when children finally get their sleep issues taken care of?

Dr. Dubose: Oh definitely. If you don't have good sleep then you will have a higher instance of problems with behavior difficulty and paying attention or inattentiveness. You can have aggressive behavior in hyper activities. If adults don't get enough sleep they'll lean against the wall and fall asleep. If kids don't get enough sleep, typically they become hyperactive and get aggressive and then have problems with paying attention. There's also difficulty initiating sleep and remaining asleep.

What should parents look for that could indicate a sleep problem?

Dr. Dubose: You need to look at the overall sleep behavior. First of all, there needs to be time set aside for sleep. Obviously if you're not setting time for sleep then you're not going to sleep enough. If you look at night time symptoms, snoring has been the big indicator of problems with breathing during sleep as well as pauses in respiration or difficulty breathing during sleep. You can also have increased movements during sleep which could indicate a movement in order to keep the airway open during sleep. Then you have parasomnias which are abnormal sleep behaviors and those include things like sleep walking behavior, night terrors, talking in the sleep and those could be indications of inadequate sleep or a sleep problem. Daytime symptoms can include hyperactivity, aggressive behavior, inability to complete tasks, inability to stay awake and also falling asleep during the day at unexpected times such as during class or in the car on a very short trip. Everyone falls asleep if you're not doing anything in the car for an hour or two but if you're falling asleep going from home to school then that could indicate a problem with overall sleep.

Some of the things you mentioned as symptoms sound almost like a child with ADHD. Is there a possibility we could be seeing kids being treated for ADHD with drugs like Ritalin and yet they really just have a sleep problem?

Dr. Dubose: There is a concern that children, before they're diagnosed with ADHD, should be evaluated by a sleep specialist to make sure that they are having adequate sleep and that the sleep that they're receiving is good quality sleep. And yes, you're right; the symptoms are very similar to ADHD and can be confused with ADD and ADHD.

What kind of things are you looking for? What are some of the things you do monitor at night?

Dr. Dubose: We monitor essentially the whole sleep cycle. We look for the stage of sleep that they're in. There are three stages of non-dreaming sleep and one stage of dreaming sleep. We look for the percentage of each sleep stage. Then we look at the number of times that they have arousal, which is a change from a deeper sleep stage to a lighter sleep stage or to a wake state. We also look for snoring and movements of the arms and legs and then we will look at the respiration to see if they're actually breathing through their nose or mouth. Or we will see that they're being obstructive, not breathing through their nose or mouth while their chest and abdomen are still trying to breathe. We also look for what's called central apnea which is essentially the brain telling the body to forget to breathe. We will also see other things like parasomnias or abnormal sleep behaviors, or seizures. We also watch the amount of oxygen they have in the blood stream as well as the amount of carbon dioxide they have in their bloodstream which indicates how well they're respiratory effort and respirations are during the sleep.

What are some tips for getting your child or even your teenager to get a better night sleep?

Dr. Dubose: What you're looking for is essentially your sleep hygiene and your sleep environment. Sleep environment is what you actually are going to sleep in and this should be a cool, dark and quiet environment. Regardless of what people think, having the TV on in the bedroom is a bad idea. You also have to set time around available for sleep. If you are a 10 year old boy and you're supposed to be getting 10 hours of sleep and you're only setting apart six hours for it, obviously you're not going to get 10 hours of sleep. You have to allocate time in order to sleep. Sleep hygiene applies to or refers to what you do before you go to sleep. Generally you start preparing for sleep an hour before bedtime and this helps calm down the brain and the mind so you actually can go to sleep. It consists of things like turning off your electronic devices, TV's, video games, phones, doing quiet activities and then having a routine that you go to before you go to sleep. Having a set schedule is also very important. Having a pretty regular bedtime and a pretty regular wake time will also help with going to sleep and maintaining sleep.

You mentioned electronic devices, I've heard those actually can be very stimulating. That doesn't help?

Dr. Dubose: Anything that actually has a screen or a backlight flickers. Even though you can't detect it, it does hyper stimulate the brain. Your phone, your tablet, your computer, your TV all can hyper stimulate the brain and it can take an hour or longer before it actually calms down enough to go to sleep.

A book may be a better option?

Dr. Dubose: Books are always good but really the only thing you should be doing in bed is either sleeping or being sick. The bed is made to sleep in, so if you start doing other activities in bed like doing your homework, talking on the phone, or playing games, your mind kind of gets confused. But if you only sleep in bed then your mind will queue, if I'm in bed I'm going to go to sleep and that actually does help. The same rules apply to adults as to kids.

Can any child have sleep apnea?

Dr. Dubose: It's a fair percentage of kids that will have obstructive sleep apnea and the majority of kids that have obstructive sleep apnea are caused because they have big tonsils or adenoids. With these cases, typically you will hear them snoring or pausing while they're sleeping. The second major cause is obesity and obesity in children has become a big problem and it's associated with having obstructed sleep apnea. You gain weight in your belly, you gain weight around your neck and this all can compromise the airway when you're sleeping. There are other less common ones like genetic problems or chromosome problems, premature to the structure of your airway and facial structures that you've inherited by your parents can all influence having obstructive sleep apnea.

These studies aren't funded by any drug company right?

Dr. Dubose:  No.

What does the study cost?

Dr. Dubose: That depends upon which type of sleep study. But they run somewhere around fifteen hundred dollars to do a sleep study. For that there's a lot of time involved because it is a six to eight hour study and there's a lot of equipment involved and then you spend a lot of time interpreting the study. So they are not cheap studies but they do give a lot of information when you complete the study and you actually interpret it.