Dr. Elliott’s Pediatric Sleep Apnea Article In Dental Economics

Posted on March 9, 2014 by Dr. Erin Elliott

One of the perks of working for me is that I have kids of my own so “I get it.”  When Stephanie, my front office team member, needed Ryan and Jett to be dropped off at the office I immediately said, “YES!”  Jett Ryder (Yes… that’s his real name as his father works on planes) and Ryan were my favorites! I usually sneak away and go play video games with Ryan in our kid’s room and he almost always kills me.  I call him “Michael Jordan” because his tongue was always sticking out when he played.  He doesn’t really know who Michael Jordan is but as soon as his mom told him it was the best basketball player in history, Ryan took it as a compliment.

Between 20 and 50% of the pediatric and adolescent population may have a sleep disorder but because sleep disorders in this age group are often unrecognized, their sleep disorder often goes undiagnosed.  Their sleep disorders can include insomnia, periodic limb movement disorder, restless leg syndrome and sleep related breathing disorder or SRBD which includes obstructive sleep apnea.  Unlike adults, these sleep disorders present themselves differently in this younger population but can still have adverse health effects and can lead to problems as adults.

Living in beautiful Northern Idaho away from family and in-laws on the East Coast means we have to get on a plane, sometimes too often, to visit loved ones.  In the past I tried to help encourage sleep for the long flight by giving my two boys Benadryl.  I was shocked to find out that Benadryl can actually cause hyperactivity instead of drowsiness.  Ask me how I know.  Because a child’s nervous system is still undeveloped they might not react the way you think as symptoms of SRBD present differently in children as compared to adults.  In adults, fatigue and snoring is the usual chief complaint.  Daytime symptoms of inadequate quality sleep in children can present as ADHD and ADD, hyperactivity, behavioral issues and irritability, neurocognitive impairment and poor school performance.  Notice I said “quality sleep.” Ryan got 9-10 hours of sleep a night and slept through the whole night.  His mom told me he had no problems sleeping and fell asleep easily at night and didn’t nap during the day, but as we dug a little deeper we could see that he was struggling to get oxygen and inevitably, proper sleep.

Thanks to my training in sleep apnea and dental sleep medicine I realized that there was more to the story of Ryan’s tongue hanging out.  Ryan didn’t just stick out his tongue when he was playing video games, he stuck it out ALL THE TIME!!.  I also noticed he had his mouth hanging open, tongue out, a runny nose, a muffled voice and “allergic shiners” or bags under his eyes.  During his dental exam I saw him in a whole new light for the first time.  His palate was vaulted, he had a full maxillary/mandibular cross-bite, some acid erosion or pitting in the cusps of his molars, anterior gingivitis due to his mouth breathing 100% of the time and huge tonsils!  When I pointed this out to Stephanie she told me he snored like a train but the pediatrician was never concerned because he didn’t get sore throats.  Who cares about sore throats! This young boy can’t breathe! Included in his laundry list was the story about his bed wetting into adolescence.  Stephanie had tried everything to help him but when a child is struggling to sleep and the “fight or flight” instinct kicks in to restart the breathing process, so too does their bladder.

A new American Academy of Pediatrics (AAP) guideline recommends that children who frequently snore should be tested for obstructive sleep apnea.  The clinical practice guideline “Diagnosis and Management of Childhood Obstructive Sleep Apnea” was published in the September 2012 issue of Pediatrics. The guideline recommends in-lab polysomnography for children with daytime learning problems, labored breathing during sleep and disturbed sleep with frequent gasps, snorts or pauses. The guidelines also call for children and adolescents to be screened for snoring as part of routine physician visits, but these guidelines are not always followed and many children’s OSA goes unnoticed and undiagnosed.

The AAP recommends adenotonsillectomy as the first-line treatment for children with sleep apnea. Pediatricians may also recommend weight loss in obese patients or CPAP if surgery is ineffective or not conducted. Fortunately I work with some great ENT surgeons.  We were able to refer Ryan directly to the ENT who set him up for tonsillectomy and adenoidectomy in which I was able to observe the surgery.  In addition we expanded his palate orthodontically to reduce his nasal obstruction and improve tongue space.

Ryan is now doing wonderfully.  He’s eating better because he can actually swallow food, growing because he’s actually getting restful sleep, and going to sleepovers because he’s no longer embarrassed.  If you know any kids that sound like Ryan please educate the parents and get them help.  As dentists we very well may be the only exposure patients and parents have to learning about this.