When it comes to sleep disturbances, many of us think of snoring as little more than an annoyance; few believe it to be indicative of a bigger issue.

According to Starship hospital ENT experts, one third of children in New Zealand snore and 10% snore most nights.

However, as a symptom, snoring is chronically underappreciated and rarely reported to GPs as a problem.

However, snoring – along with mouth breathing, chronic dribbling, and a range of other symptoms we too often dismiss as normal – can actually be symptoms of obstructive sleep apnoea (OSA).

Despite OSA being a serious condition, the research shows that the majority of parents in New Zealand don’t understand the symptoms, consequences, or forms of treatment available.

In fact, research has found that less than 20% of parents know that OSA in infants and toddlers can be treated by getting their tonsils out.

But first, let’s have a look at how we recognise obstructive sleep apnoea…

Put simply, OSA is a sleep disorder whereby complete or partial obstructions of the upper airway occur during sleep.

Obstructive sleep apnoea is the most common type of sleep apnoea, and can be caused by anatomical abnormalities (some of which are incredibly slight) that lead to a narrowed airway space.

Other causes tend to be reduced muscle tone, abnormal central ventilatory control, and simply enlarged tonsils or adenoids.

Symptoms of OSA

So, what are the things to look out for?

• Snoring
• Pauses in breathing while sleeping (this is what we think of as the typical apnoea episode)
• Restless sleep
• Snorting, coughing, or choking during sleep
• Sleep terrors
• Chronic bed wetting
• Sweating while sleeping
• Mouth breathing, which could occur during the day or night
• Daytime chronic dribbling, which is often also indicative of mouth breathing. Obviously this one applies only beyond the time that it’s normal for an infant to dribble.

While it may be normal to snore when you’ve got a head cold, or mouth breath while you’re congested, the worry comes when these symptoms are chronic, consistent, and long-term. None of these are what could be considered ‘normal’ and all are potential red flags.

Is a little snoring really so bad?

Some of you might still be reading this and wondering if snoring is really that bad. However, snoring is a sign of not getting a good sleep.

As the breath pauses or is restricted, the body effectively wakes us up more to ensure we keep breathing.

This lack of restorative sleep flows on to overtiredness, bad behaviour, picky eating, and a struggle to learn; a vicious cycle ensues.

More seriously, snoring means a reduction in blood oxygen saturation in the body. Chronic or long-term OSA can be linked to serious cardiovascular health problems.

 In infants, OSA can be linked to a failure to thrive and – more seriously – sudden infant death syndrome (SIDS).

It’s common, when a baby is failing to thrive that we look to rule out allergies, or turn to lactation consultants. It’s worth checking that OSA has also been ruled out.

In school aged children, OSA looks slightly different. It’s common for kids suffering from OSA to perform poorly in school, have difficulty paying attention, experience learning problems and/or behavioural problems, be hyperactive, or struggle to gain weight.

Unfortunately, all but the last one of those could also look a lot like ADHD.

In fact, attention deficits have been reported in 95% of patients with obstructive sleep apnoea.

20-30% of kids clinically diagnosed with ADHD have OSA.

A big symptom for older kids is a difficulty focusing due to chronic tiredness.

While this all may be dismissed as ‘normal’ toddler behaviour, it’s common for OSA to be picked up when a child turns five and struggles to meet a new set of expectations.

If your doctor is going down the path of diagnosing ADHD, check that they’ve ruled out OSA.

Attention deficits can be very real. However, there might be another cause, and the solutions to treat OSA – having the tonsils removed or, in some cases, oxygen therapy – can be preferable to a lifetime of Ritalin.

Heidi’s story

A diagnosis after she started school was exactly what happened in the case of wee Heidi, although how she presented with the problem was not how you might expect.

“Heidi didn’t have any of the classic signs or symptoms of OSA,” explains her mum Sacha. “If she woke during the night, we weren’t aware of it – in fact, as far as we were concerned, she was sleeping through.

She seemed to have quite high sleep needs and still needed a nap each day or else she was a mess by 5pm.”

 Obviously this became a problem when Heidi started school. “Heidi wasn’t making it through the day at all; she had to keep going down to the sick bay to have a little nap, and her behaviour after school was absolutely atrocious.

Her tiredness was such that someone even questioned whether she might have leukaemia.

I took her along to our doctor, and after watching her for a few minutes she pointed out that she was mouth breathing, which meant she wouldn’t be sleeping very well.”

The doctor referred Heidi to see an ear, nose and throat (ENT) specialist, who quickly diagnosed sleep apnoea.

She also pointed out that sometimes in girls this can occur without any snoring. Heidi was soon in to have her tonsils and adenoids removed and Sacha recalls that she was a “completely different kid” just 24 hours later!

“Heidi’s behaviour since the surgery has been so much better.

Where she was previously still having tantrums because she was so tired and emotional, now she’s able to cope with the day and things that happen.

When it comes to advice for other mums, Sacha urges them not to be afraid of getting things checked.

“If you have a concern, going to the doctor for what might turn out to be ‘no reason’ is totally OK. How Heidi was meant I definitely questioned what I was doing as a parent at points; I felt like I was climbing a hill constantly in terms of my parenting. I can’t believe the turnaround in how she is now!”

Testing and treatment

According to starship hospital, we have a gap in the clinical recognition of at-risk children when it comes to OSA.

The thought is that most doctors need to be asking the question “does your child snore?” far more often.

One of the other challenges lies in a concurrent gap in the availability of testing. While OSA can often be diagnosed without the need for elaborate testing, where further investigation is required it’s a case of sleep studies and overnight oxygen studies (oximetry).

These tests are great in that they’re are non-invasive, but they are also expensive, labour-intensive, and relatively scarce, so there may be pressure not to put people forward.

These challenges have led to the development, in 2014, of New Zealand Guidelines for the Assessment of Sleep-Disordered Breathing in Childhood by the National Paediatric Sleep Medicine Clinical Network. 

This is an evidence-based summary for use in assessing children that may have sleep-disordered breathing, and can be accessed here.

If you see the symptoms of OSA, talk to your GP – and don’t be afraid to print the PDF guidelines out and take them along with you.

Our job as parents, after all, is to be our child’s advocate, so follow through with some investigation if you are concerned. OSA, after all, is successfully treatable – occasionally with some forms of medication, or with a one-off adenotonsillectomy, which is surgery to remove the tonsils and/or adenoids. 

August’s story

Unfortunately for wee August, things weren’t quite so straightforward. “August ended up sick with tonsillitis for about seven months the winter after she turned two.

We saw a lot of different GPs who kept her on a course of antibiotics virtually continuously.

I spoke to them about seeing a specialist and getting August’s tonsils removed, but was told that she was just unwell and that they don’t tend to take them out in children under five,” explains August’s mum Louise.

According to Louise, August also “snored like a freight train” and had always been a terrible sleeper. She wasn’t able to go to any form of daycare because she was so persistently unwell.

Add to that the fact that “August was always tired and often fussy. She virtually wouldn’t eat! It might seem awful to say, but those years were a struggle.”

Luckily, on one of their frequent trips back to the doctor, Louise and August saw a visiting locum who suggested that they use their health insurance to book in to see an ear, nose, and throat (ENT) specialist.

“The specialist said that August’s tonsils were touching – which means they were huge – and that they would need to come out. The surgery happened soon after, but wasn’t exactly as we expected – she was in there for a lot longer; almost twice as long as usual for the procedure.”

Apparently, where children’s tonsils are soft, like tissue paper, August’s were like concrete, resembling those of an adult.

“They were so scarred from frequent infection that it was a major to remove them.

Her recovery ended up being immense because the surgery was so massive, but soon things settled down,” Louise recalls. 

However, soon August was snoring again. “I took her back to the GP,” Louise explains “and was told that snoring in children was normal. I wasn’t so sure, so I emailed the ENT specialist we’d seen.

She called us in to check things out further.”

The specialist prescribed nasal spray, as August’s turbinates or nasal passages were enlarged and blocking airflow.

The sprays didn’t work and soon August was back in surgery, having her adenoids and turbinates tended to.

“The next year, we were back in for August’s third surgery and the specialist prepared us for the fact that she was probably going to need annual turbinate surgery until she was 16, when she could have a nose job.”

While to look at August there was nothing wrong with her nose, it appeared to be crooked inside, so it was not taking much turbinate enlargement to get too big and block things.

“At that point we looked into allergies to see why they were enlarging, but they all came back totally fine. Eventually some fancy allergy man determined that she had some sort of breathing issue,” Louise adds.

For August, relief finally came in the form of a small pink pill that is used to treat asthma.

“The pill opened up her airways so, a month later, she could breathe better and no longer snored. She started eating again too and is a totally different kid! She no longer screams and yells; she’s actually super calm. I can only imagine she must have been in so much pain and so tired.

We didn’t know she was waking up – as she settled herself back to sleep – but it’s clear she was. Not getting a restorative sleep was the root of so many issues.”

A final note on sleep

While many parents find their children to be completely different following surgery to remove a problem with tonsils or adenoids, it’s not always a quick-fix for sleep.

In fact, it’s common for kids with OSA to develop poor sleep habits; they tend to be in the habit of waking lots and being settled by parents.

While we need to do what we need to do to get through challenging periods, for a child with OSA, this behaviour tends to have been reinforced for so long that sleep training after surgery may be needed.

The good news is, these patterns resolve quickly with a little effort; these kids want to sleep well, after all! 

Does your child snore?

Tell us your story in the comments.

Emma Purdue

Emma is the owner and founder of Baby Sleep Consultant, she is a certified infant and child sleep consultant, Happiest Baby on the block educator, has a Bachelor of Science, and Diploma in Education. Emma is a mother to 3 children, and loves writing when she isn't working with tired clients and cheering on her team helping thousands of mums just like you.