Why is snoring a red flag?
by Consuela Hendriks
Despite the fact that noisy sleep in children is very common and to some extent normal, snoring definitely isn’t. It can be a sign your child isn’t able to breathe properly which results in poor sleep quality. Snoring children may present symptoms suggestive of obstructive sleep apnea (OSA) (Nieminen,Tolonen & Löppönen (2000).
Difference OSA and snoring
OSA is different from snoring.
OSA is defined as “a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns” (ATS, 1996).
Primary snoring is snoring without associated apnea, hypopnea (overly shallow breathing), hypoxemia (low blood oxygen), hypercapnia (increased carbon dioxide in bloodstream) or sleep fragmentation (Section on pediatric pulmonology, 2002).
Snoring is frequently associated with OSA, and patients who initially have only primary snoring may be at risk for the future development of OSA with age or weight gain (American Academy of Sleep Medicine, 2005).
Diagnosis can’t be done by questionnaires and clinical history alone. In order to distinguish childhood primary snoring from OSA there needs to be additional diagnostic testing (Section on Pediatric Pulmonology, 2002). Nocturnal sleep laboratory–based PolySomnoGraphy (PSG) is considered the gold standard for the diagnosis and assessment of OSA in children and should include cardiorespiratory monitoring (heartrate and breathing), as well as electroencephalographic (brain activity), electrooculographic (eye-movements) and electromyographic (muscle response) monitoring.
Because children with sleep disordered breathing (SDB) are at an increased risk of neurocognitive impairments (Menzies et.al., 2022) and problem behaviors in later childhood (Isaiah et.al., 2021). it’s important to speak to your doctor when you notice your child (structural) snoring.
There can be many reasons for snoring or open mouth breathing, and we’re not talking about the occasional snoring during a cold or due to positioning. Amongst (many) underlying causes of snoring or sleep disordered breathing are adenotonsillar hypertrophy (enlarged adenoids/tonsils), obesity, craniofacial, laryngeal, neurological, anatomical and neuromuscular abnormalities (Chandrasekar et. Al., 2022; Huang & Guilleminault, 2017).
Depending on the underlying cause, the clinician can choose an appropriate treatment.
Because snoring and obstructive symptoms may resolve over time, a normal PSG finding may help the clinician decide on an observation period. Adenotonsillectomy is, in most cases, a curative treatment of pediatric OSAS, while adenoidectomy alone does not seem to be enough (Nieminen, Tolonen & Löppönen, 2000).
American Academy of Sleep Medicine. International classification of sleep disorders: diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.
American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med 1996;153:866–878.
Chandrasekar, I., Tablizo, M. A., Witmans, M., Cruz, J. M., Cummins, M., & Estrellado-Cruz, W. (2022). Obstructive Sleep Apnea in Neonates. Children, 9(3), 419.
Huang, Y. S., & Guilleminault, C. (2017). Pediatric obstructive sleep apnea: where do we stand?. Sleep-Related Breathing Disorders, 80, 136-144.
Isaiah, A., Ernst, T., Cloak, C. C., Clark, D. B., & Chang, L. (2021). Associations between frontal lobe structure, parent-reported obstructive sleep disordered breathing and childhood behavior in the ABCD dataset. Nature communications, 12(1), 1-10.
Lumeng, J. C., & Chervin, R. D. (2008). Epidemiology of pediatric obstructive sleep apnea. Proceedings of the American Thoracic Society, 5(2), 242-252.
Menzies, B., Teng, A., Burns, M., & Lah, S. (2022). Neurocognitive outcomes of children with sleep disordered breathing: a systematic review with meta-analysis. Sleep Medicine Reviews, 101629.
Nieminen, P., Tolonen, U., & Löppönen, H. (2000). Snoring and obstructive sleep apnea in children: a 6-month follow-up study. Archives of Otolaryngology–Head & Neck Surgery, 126(4), 481-486.
Section on Pediatric Pulmonology, & Subcommittee on Obstructive Sleep Apnea Syndrome. (2002). Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 109(4), 704-712.