What Is Sleep Apnea and How Does it Present in Children?

Sleep apnea is a common, but serious sleep disorder in which breathing is interrupted during sleep. 

Obstructive sleep apnea (or OSA) is the most common type of sleep apnea and occurs when throat muscles are unable to keep the airway open during the night. 

The most common indications of obstructive sleep apnea are loud snoring, fatigue, weight gain, headaches and waking abruptly at night while gasping or choking. 

This loss of breath causes disruption in sleep, deprives the body of oxygen, and can lead to multiple ailments in adults such as diabetes, increased risk of Alzheimer’s, high blood pressure, obesity and more. 

But how does obstructive sleep apnea present itself in children? 

Many people do not realize that children can also be affected by OSA because it shows itself very differently in pediatric patients. 

Children often start to have mouth-breathing tendencies, restless sleep, and bed-wetting episodes when nasal passages become blocked or obstructed. 

Pediatric sleep apnea leads to lower quality sleep and the development of dark rings under the eyes, forward head posture, slumping shoulders, and behavioral problems. 

Dark Rings under the eyes

Causes and Effects of Airway Obstruction in Children

Airway obstruction can occur in children for a variety of reasons, including:

  • Congenital abnormality, 
  • Adenoid hypertrophy (enlarged adenoids), 
  • Tonsil hypertrophy (big tonsils), 
  • Retruded maxilla (over-bite), a 
  • Retruded mandible (under-bite). 

Children often compensate for these issues by breathing through their mouths at night which can lead to sleep disorders like obstructive sleep apnea.

Characteristics of chronic mouth breathing and respiratory obstruction syndrome include:

  • Mouth breathing at rest
  • Chronically enlarged tonsils and/or adenoids
  • Open-bite
  • Cross-bite 
  • Excessive anterior facial height
  • Incompetent lip posture
  • Excessive appearance of the maxillary anterior teeth and gums
  • Narrow external nares (opening of the nose)
  • Allergic salute
  • “V” shaped palate and 
  • Venous pooling under the eyes (dark rings: allergic shiners). 

Research shows there is a significant association of nasal resistance and :

  • Increased over-jet
  • Open bite 
  • Maxillary crowding 
  • Angle Class II malocclusion 
  • Posterior cross-bite

Though mouth breathing is a common sign of sleep apnea in children, did you know that breathing through one’s mouth could adversely alter facial growth in pediatric patients? 

It’s true. Prolonged oral respiration (obligate mouth breathing) often results in dental and skeletal malformation in growing children. 

Some of these negative changes include:

  • Excessive molar eruption
  • Clockwise rotation of the mandible 
  • Increased anterior vertical face height 
  • Retrognathia  
  • Open bite 

Low tongue posture can also result in reduced lateral expansion and anterior development of the maxilla. 

Normal, well-developed airways allow breathing to occur through the nose with the mouth closed.

 Nasal breathing is known to be vital to good health and research has shown that air breathed through the nose is quite different to the body than air breathed through the mouth. 

The benefits of nasal breathing begin within hours of birth when nasal nitric oxide gas can first be detected. 

Nitric oxide is a potent gas and a key component of human health. It is produced in the nasal sinuses, secreted into the nasal passages and inhaled through the nose. It is well known to prevent bacterial growth and improves the ability to absorb oxygen. Nitric oxide is a strong vasodilator and brain transmitter that increases oxygen transport throughout the body and is vital to all body organs.

Mouth breathing caused by airway obstruction can cause children to lose the benefits of nitric oxide and can be a sign of breathing disorders like obstructive sleep apnea which could lead to craniofacial deformation in children (where their face doesn’t grow symmetrically) and malocclusion (teeth not aligning properly) in addition to other serious long term consequences such as failure to thrive, behavioral disturbances, developmental delay, sleep disorders and cor pulmonale (disease of the lung). 

Chronic obligate mouth breathing from impaired nasal respiration can cause progressively worse abnormal craniofacial development and malocclusion beginning at a very early age. Chronic mouth breathing interferes with proper maxillary and mandibular arch development by disrupting tongue, cheek and lip muscle formation. 

Chronic oral breathing causes a down and backward positioning of the mandible, a vertical long-faced growth pattern and multiple abnormal growth patterns in the face, jaws, and dentition that are interrelated.

Chronic mouth breathing and nasal incompetence can lead to disordered growth of the Naso-ethmoid-maxillary unit and whole craniofacial complex. 

Chronic mouth breathing has been shown to be 4 times more common in children with orthodontic abnormalities. 

Oral respiration experiments in primates have shown that obstructed nasal airway leads to open mouth, lower,mandible position, and facial appearance and dental occlusion different from control animals. 

Recognition of nasal incompetence in children and proper treatment are important steps needed to ensure proper orthodontic stability and craniofacial growth.

Preventing Craniofacial Deformities in Children 

Craniofacial growth is 80-90% complete by age twelve, so most formation and/or deformation occurs by that age. Unfortunately, age twelve is the average age that orthodontic and orthopedic treatment starts for most children worldwide. 

This must change! 

Earlier treatment, from birth to age twelve can better detect problems like sleep apnea that impact craniofacial growth and development. Disparities must be recognized and addressed much earlier in order to prevent issues down the road. 

Dentists are in a unique position to screen children for the recognizable signs and symptoms of mouth breathing, malocclusion, craniofacial anomalies, and related conditions such as obstructive sleep apnea syndrome. 

Early diagnosis of airway obstruction, obligate mouth breathing, and malocclusions is essential to prevent growth abnormalities. 

It is now understood that early diagnosis can lead to earlier orthopedic treatment, which can be more effective, simpler and less restrictive than care at a later age. 

Diagnosis of dental malocclusions and skeletal deformities associated with mouth breathing requires comprehensive and frequent orthodontic examinations. 

Routine early examination and diagnosis should begin at birth or soon after birth. All infants should be screened for craniofacial deformities that can affect airway form and function. Breastfeeding should be encouraged as it promotes good nasal breathing just as it decreases the incidence of obligate mouth breathing. 

At the age of two and three, subtle dental signs of nasal obstruction and mouth breathing can be seen. Some of the clearest signs include open bite, posterior cross-bite, and excessive over-jet. To better recognize oral breathing caused dento-skeletal dysmorphism (abnormal growth), a cephalometric analysis should be used to evaluate facial architecture when obligate mouth breathing is suspected. 

Dentists and otolaryngologists provide unique treatments that can reduce airway obstruction and craniofacial deformity. 

Dental orthodontic appliances have been shown to improve the sagittal dimensions of the upper airway in children. 

However, the management of pediatric patients requires an interdisciplinary approach.

 Dr. Queen and an ENT (Ear, Nose, Throat) physician must first address the underlying cause of the nasal airway obstruction. 

Common factors include:

  • large adenoids and tonsils 
  • allergies and asthma 
  • bony obstructions such as a deviated septum

After addressing the underlying cause, the child may be a candidate for growth modification through early orthodontic treatment. 

With early treatment, commonly called “Phase I”, it may be possible to redirect jaw growth in a more ideal direction. 

The jaws can be widened orthopedically, which creates space for the permanent teeth, opens the nasal airway, and improves the growth pattern.  

Dental rapid maxillary expansion has been shown to be a simple, conservative method of treating impaired nasal respiration in patients 4 years to 30 years, but the younger the patient the better the long term results. 

Dental maxillary expansion is an effective method for increasing the width of narrow maxillary arches and it also reduces nasal resistance from levels seen with mouth breathing to levels consistent with normal nasal respiration. 

Otolaryngologists play a key role in early airway treatment. It has been shown that within a year following surgery (tonsillectomy and adenoidectomy) to improve breathing, obligate mouth breathers with dental malocclusion have improved dental occlusion.

Children with mouth breathing problems often have sleep disorders, like obstructive sleep apnea. Sound sleep is crucial for growth and development. Growth hormones are produced during deep, delta phase sleep. Without proper sleep, children struggle mentally and physically. They can suffer from fatigue, become frustrated easily and exhibit behavior problems. They can also be improperly diagnosed with ADD and hyperactivity. 

The younger the child, the more favorable the prognosis. Dr. Queen and his team treat mouth-breathing problems. He can screen for mouth breathing in children and adults. If you suspect that your child’s airway may be affecting his/her facial growth, don’t hesitate to ask Dr. Queen at your child’s next visit!

We work to make the entire process efficient and easy, so your child can get a better night’s sleep as quickly as possible. Schedule your appointment now or call us at (703) 689-2480.

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