How To Tell If Your Child Has Sleep Apnea

Sleep apnea - repeatedly stopping breathing while sleeping - in infants, children and teenagers left untreated can negatively impact their health and learning. Arkansas Children's Hospital in Little Rock and Arkansas Children's Northwest in Springdale regularly diagnose and treat patients with sleep apnea.

There are two types of sleep apneas:

• Central sleep apnea is due to some central cause. These can include brainstem lesions, increased intracranial pressure, primary abnormalities in the brainstem, acid reflux, infection or medications (like sedatives) that can suppress breathing. In this case, the infant or child will stop breathing with no effort to start breathing again. Oxygen levels can drop, and CO2 levels rise, which may prompt breathing again.
  
  
• Obstructive sleep apnea is where the upper airway closes during sleep. Causes include, but are not limited to, enlarged tonsils and adenoids, a large tongue or uvula and a small chin or flat midface that impacts airflow. It can also be caused by low muscle tone in conditions like cerebral palsy and Down syndrome, causing the chin and/or the tongue to fall back while laying down. In this case, the infant or child will snore or make sounds that indicate an attempt to breathe.

Both types of sleep apnea can cause daytime symptoms like being overly tired, attention deficit, behavioral or performance problems (both in school and with extracurricular activities) and mood issues. Sleep apnea can impact the heart and brain in the long run, leading to risks of high blood pressure, stroke and headaches in adulthood.

Sleep apnea in infants

Central sleep apnea is more common in infants, particularly those born prematurely. Supriya Jambhekar, M.D., the medical director of the Pediatric Sleep Disorders Center at ACH and a professor of Pediatric Pulmonology at the University of Medical Sciences (UAMS), said it is normal for both premature and healthy infants to have some central apneas in sleep. She added that when an infant is in REM sleep, breathing can be very irregular with obvious short pauses in breathing.

"The brain and brainstem are not yet completely developed. You will see a lot of what we call periodic breathing, where they take a breath, and they stop breathing and take a breath and stop breathing," Jambhekar said.

Typically, by 2 to 3 months old, an infant has settled into a fairly regular breathing pattern, and by six months, a regular pattern.

"Central apneas are very common. You don't necessarily need to do anything about it," she said.

Jambhekar cautioned that it's unnecessary to watch an infant breathing for extended periods, but a sign to casually watch for is if an infant consistently stops breathing for more than 20 seconds.

Parents or caregivers should call 911 if the infant:

• Stops breathing long enough to turn blue or lose tone in their body
• Becomes flaccid or limp
• Has rolling up of eyeballs
  
  

An infant who has experienced a central apnea event of not breathing for an extended period will be tested with an apnea monitor in the hospital as thought necessary following a detailed history. If the infant is not experiencing oxygen desaturation and continues to start breathing on their own, doctors may send a child home without further treatment. If doctors discover an underlying cause for central apnea, like acid reflux or an infection, they treat the cause. An MRI might be ordered for suspected brainstem conditions, and surgery could be an option if an abnormality is detected.

Obstructive sleep apnea (OSA) is less common in infants. Diagnosing OSA requires an overnight polysomnogram, where sensors detect breathing rate, airflow, heart rate and oxygen, as well as carbon dioxide levels. If OSA is diagnosed, surgery can be an option, depending on the clinical findings. Infants can be treated with oxygen, a continuous positive airway pressure (CPAP) machine or a bilevel positive airway pressure (BiPap) machine to help with OSA if needed. As a child grows, sleep studies are repeated, as necessary, to monitor progress as the upper airway grows with age and the obstruction can resolve or become worse with time.

"Doing surgery in very young babies has more complications. Removing tonsils in children under 2 has a higher risk of complications. So, you have to determine risks and benefits when deciding management," Jambhekar said.

It is common to outgrow central sleep apnea that has no underlying cause. A child can outgrow OSA sometimes. For example, as the airway around the tonsils grows along with the child, tonsils may no longer obstruct airflow.

Sleep apnea in children

While Central sleep apnea can be seen in children, obstructive sleep apnea is the most common type in children and teenagers. Common causes of OSA in toddlers and younger children are enlarged tonsils or adenoids. Recurrent infections can trigger an immune response from the tonsils, causing them to be enlarged or hypertrophic. Apnea, in this case, is due to enlarged tonsils. Surgery typically corrects it.

Obesity or genetic disorders that cause obesity, like Prader-Willi syndrome, is another common cause of OSA at an early age.

Some children also have airway abnormalities due to underlying conditions or syndromes. For example, children with Down syndrome have midface hypoplasia, where facial structures are less developed, obstructing airways. It can result in OSA.

Astryd Menendez, M.D., pediatric pulmonologist at ACNW and professor of Pediatrics and Pulmonary Medicine at UAMS, said there are several questions pulmonologists ask parents to confirm a suspicion of OSA in children and teens. Signs for parents to watch for include:

• Snoring, coughing or high noisy breathing called “stridor” while sleeping.
• Mouth breathing.
• Restless sleep, significant movement throughout the night.
• Waking up during the night.

Menendez said pulmonologists can also conclude OSA by watching a video parents record of their children sleeping because the sounds and chest movements are often "very dramatic." To confirm OSA, ACH performs a sleep study that determines the level of severity.

Parents should take sleep apnea seriously, as it can impact a child's overall health. For example, older children and teenagers can experience tiredness during the day, impacting their performance in school. For younger children, sleeplessness from sleep apnea can have the opposite effect. They can be hyperactive. Menendez said these children are often misdiagnosed with attention deficit disorder (ADD) or other behavioral issues.

"Unfortunately, if you ignore the early symptoms, other organs become affected. When you work hard to breathe, your heart beats faster to compensate. When you have obstructive sleep apnea, your oxygen level is affected. When you exhale, CO2 can be affected as well. And this is a vicious cycle," Menendez said. "Your brain is not doing well either because it needs to rest, grow and learn."

Menendez pointed to research by David Gozal, M.D., an expert and top-rated researcher for sleep apnea, that proved children with OSA had poor academic achievement. It showed that children with OSA from enlarged tonsils and adenoids improved one grade level from where they were following surgery correcting the apnea.

Not every OSA can be resolved with surgery. In many cases, the patient must wear a CPAP or BiPAP to sleep.

Helping diagnose your child and prepare for a CPAP

Pediatric Pulmonology at Arkansas Children's is one of seven specialties nationally-ranked by U.S. News & World Report. At Arkansas Children's Hospital and Arkansas Children's Northwest, subspecialist experts, including pulmonologists and Ear, Nose and Throat doctors, provide comprehensive treatment and evaluation for various conditions, including sleep apnea. Arkansas Children's Hospital is one of few pediatric hospitals nationwide with full-service accreditation from the Association of Sleep Disorders Centers. It is nationally accredited by the American Academy of Sleep Medicine (AASM).

Menendez said at both ACH and ACNW, pulmonologists dig deeper and ask the right questions to determine if a child is suffering from sleep apnea.

"Sometimes we stumble on obstructive sleep apnea or central sleep apnea with patients referred to us for other pulmonary issues. When you have sleep apnea, it might not be your only diagnosis. For example, a lot of patients referred for asthma due to difficulty breathing, coughing or wheezing, can also have sleep apnea," Menendez said.

Arkansas Children's helps mentally prepare children for a sleep study and for using a CPAP or BiPAP. Dr. Amy Seay, a medical psychologist at ACNW and associate professor in the Department of Pediatrics at UAMS, helps ACNW patients through desensitization techniques. These techniques help a child learn how the hook up process for the procedure will feel ahead of the study. Children replicate the sleep study at home, utilizing everyday items like rubber bands and strings for “leads” and stickers or Band-Aids for the medical tape that is used to secure the leads. Psychologists in Little Rock also work with patients using these techniques.

"It can reduce the child's distress, increase their cooperation and improve their experience with regard to the current medical procedure and potentially future medical experiences. It can also allow for a more valid assessment," Seay said, particularly with children who have sensory issues and trouble with medical procedures.

A CPAP and BiPAP pump air into the nose (nose mask) or nose and mouth with a full face mask on the child's face, wrapping around the child's head to keep it in place. It is attached to the machine with a long tube. Wearing this can be a challenge for children. Once a child is properly fitted for a mask, Seay works with families to figure out what each child can tolerate with the mask. This could mean either looking, touching or wearing the mask. Seay said children might practice by putting the mask on a doll or parents, reading a story about a CPAP or putting it on their head like a "crown." It could also mean wearing it sometimes when they are awake, watching a favorite T.V. or reading a favorite book.

“You want to normalize it, desensitize them to the idea that this is a scary or a bad thing,” Seay said.

At ACH, there is a positive airway pressure (PAP) adherence program where a respiratory therapist and a psychologist work closely with the patient to help them use PAP regularly. Telemedicine visits are also offered to the patients.

Learn more about Pediatric Sleep Disorders Center and pulmonology services offered at Arkansas Children’s Northwest in Springdale and Arkansas Children’s Hospital in Little Rock.