The classic pediatric sleep apnea patient is a skinny 6-year-old with chronic congestion and dark circles under his eyes.
We still see many kids in the sleep center who match this profile, but over the past 10 years, a new clinical picture has emerged. Coinciding with the dramatic rise in childhood obesity, there is a clear change in our younger patients.
We now see many overweight children in the sleep clinic who have obstructive sleep apnea that resembles the adult version.
The thin child with OSA does not usually act sleepy in the daytime. On the contrary, they often act hyperactive or inattentive. In fact, their symptoms can mimic attention deficit hyperactivity disorder.
Large tonsils and adenoids are the primary cause of OSA in thin children because these and surrounding tissues can relax during sleep and block the airflow to the lungs. In fact, 80 to 90% of such cases of pediatric OSA are cured by surgically removing the tonsils and adenoids.
Overweight or obese children are not such an easy fix. They usually present with loud snoring and significant daytime sleepiness. In obese children, the tonsils often become enlarged due to fatty tissues in the upper airway. Fat deposits in the neck and chest also add to the collapsibility of the upper airway during sleep.
Unfortunately, a tonsillectomy/adenoidectomy is curative in only about 50% of overweight kids who have OSA. The others are encouraged to try continuous positive airway pressure (CPAP) which is the most common treatment for severe OSA.
When adults have mild-to-moderate OSA, we offer them an alternative treatment called an oral appliance (also called a mandibular advancing device). However, we cannot use this treatment in children and teens whose mouth and jaw are still changing.
The important thing for pediatricians and parents to keep in mind is that the connection between weight and sleep is a two-way street.
It’s not just that excess weight increases the likelihood that kids have obstructive sleep apnea, but that having sleep apnea increases the risks of gaining weight.
Sleep deprivation due to poor sleep or too little sleep can cause hormonal havoc that leads to weight gain.
For example, when research subjects were allowed to sleep for only four hours per night, the hormones that control appetite got all out of whack. Leptin, which acts on the brain to make people feel full, was abnormally decreased and ghrelin, which makes people hungry, was unusually high.
These hormonal changes caused the research participants to be very hungry and eat more during the day.
Children and teens with sleep apnea might seem to be sleeping a lot, but their sleep is constantly disturbed by brief turbulence in their brain waves - what sleep experts call micro-arousals. In effect, these kids are as sleep deprived as people who only get four to five hours of sleep.
Not only do obese kids with OSA have a similar clinical presentation as adults, they unfortunately can have the same adverse outcomes if the sleep apnea is not treated. We are seeing pre-teens who have what we use to think of as adult diseases such as high blood pressure, pulmonary hypertension, heart disease and congestive heart failure.
If your child is overweight, please consult a doctor to find out if he or she has the symptoms of sleep apnea, such as snoring, rough breathing, daytime sleepiness, poor academic performance, behavior issues and depression.
OSA is easy to diagnose with an overnight sleep test and as I outlined above, there is more than one treatment option. Treating sleep apnea, if present, needs to be part of the weight loss program for everyone, including kids and teens.