SNORING AS A PROBLEM: A WORD ABOUT CHILDREN

A discussion of snoring would be incomplete without acknowledging the fact that snoring in children can be as socially disruptive and as medically demanding as that of adults. One of the problems arising from any discussion of children is the tendency to make generalizations about a group which undergoes complex changes from infancy to adolescence. Size of airways, breathing rate and shape of the chest wall are just some of the variables which change significantly in the first few years of life, highlighting the need to specify the age group in question. Another problem relating to the investigation of young children is the inability of parents to give an adequate description of the child’s symptoms. Difficult breathing during sleep, whether it be described as wheezing, coughing or choking can be symptomatic of any number of disorders, the doctor’s task being made all the more challenging if these symptoms only occur at night.

The first priority is to identify these nocturnal events either by having the child observed during a hospital admission or by making a sound recording of the events on a portable tape recorder. Any abnormal breathing associated with sleep should be investigated but for the purpose of this discussion it will be assumed that nocturnal snoring has been confirmed. Data on the incidence of snoring in healthy children is unreliable, ranging between 10% and 25%, a variation possibly arising from different age groups and populations selected from one study to another. It is therefore not an uncommon occurrence and parents should not be alarmed by the observation of occasional snoring.

The common factor in both adult and childhood snoring is a comparatively narrow upper airway compromised by a lack of muscle tone during sleep. Whilst accepting that obstructed airways of different age groups have something in common, there are differences in the incidence of underlying causes. Enlarged tonsils and adenoids remains one of the most common findings in snoring children and, although there has been some reticence in recent years to remove tonsils and/or adenoids, surgery is certainly warranted in cases of persistent heavy snoring which is accompanied by complete and repetitive airway closure. Upper respiratory tract infections and nasal congestion are more likely to cause problems in newborns and young children, given the narrow diameter of their airways and susceptibility to collapse. In the absence of other predisposing factors, a return to normal breathing would follow the successful treatment of such infections or allergies.

Children born with structural abnormalities of the head and face (or craniofacial abnormalities) will be prone to snore if the structure results in compression or narrowing of the upper airway. There are several well described syndromes, each with characteristic facial and anatomic features which interfere with normal breathing. Children with Down’s Syndrome, for example, with the characteristic flattened face and nose, short neck, small jaw and mouth, and general lack of muscle tone, may have symptoms of obstructive sleep apnoea (OSA) depending on the severity of the syndrome. Other anatomical factors common to both young and older snorers include a large or poorly positioned tongue, abnormal jaw alignment, an excessively fleshy soft palate and obesity.

As with adults, the differentiation between mild snoring and OSA in children ultimately depends on the results of overnight studies in hospital. However, a clue to the need for further investigation is provided by the observation of certain behavioural changes. Snoring accompanied by laboured breathing and frequent arousals is suggestive of OSA. Sleep disruption then manifests itself as lethargy, sleepiness, irritability and possible learning difficulties and behavioural problems at home and at school. The weight and stature of these children often falls behind that of their peers, commonly referred to as a «failure to thrive».

Hospital or sleep unit admission screens for the same physiological changes seen in adults with OSA, with blood oxygen saturation being the most important measure of airway obstruction. The options available for treatment of heavy snoring or OSA in children are not as diverse as those available for adults. Middle-aged, overweight adults with the problem show considerable improvement with weight loss and alcohol avoidance, conditions which may be difficult to enforce or which simply do not apply to young children. Continuous Positive Airway Pressure (CPAP) applied through a nose mask has been used successfully on infants and older children, but in general cooperation by younger people who are unaware of its benefits remains a problem.

In summary, snoring in children is fairly common. Parents should not be alarmed by mild snoring but should consult their doctor if sleep disruption or difficult breathing becomes a regular feature at night.

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