Sleep Disordered Breathing in Children: Its Health Implications, Diagnosis, Treatment and Prevention

Sleep issues in children are strongly associated with improper growth, oral habits and various orthodontic issues.1,2,3,4 These factors are correctible, preventable and can be treated with appliance therapy.

Figure 1

Design features of the HealthyStart® Habit-Corrector®.

Identifying characteristics of sleep disordered breathing. Sleep disordered breathing is a condition involving the reduction of the pharyngeal airway. A complete closure of the airway is called Sleep Apnea while a partial closure with struggled breathing is called hypopnea. The airways of children only rarely exhibit these severities. It has been estimated that about 1.6% have habitual apnea, while it occurs occasionally in 3.4%.5 There are several variations in percentages of incidence depending on the degree of severity, snoring, oxygenation of the blood and the actual apneic events.6

There are many symptoms and skeletal characteristics frequently presented in the literature, many of which represent questionable significance when statistically analyzed in relation to the frequency and severity of snoring. Various questionnaires regarding sleep symptoms in a child have been developed7-9 while the author has developed a questionnaire specifically for the dental profession.10 It consists of the symptoms that have the highest statistical significance (level of confidence P=0.001) and have been obtained by mainly 5 different sources.11,12,13,14,15 A complete description of this dental sleep questionnaire is presented in a study by the author in 2015.10

There have been several possible explanations for the many symptoms of abnormal sleep issues. A recent study by Xie et al16 describes research on live mice regarding the toxins produced by normal daytime brain activity (specifically beta-amyloid, alpha-synuclein and tau). During sleep these toxins are flushed out by the cerebrospinal fluid (called the glymphatic system similar to the lymphatic system). By preventing quality sleep, this flushing of toxins from the interstitial space is severely reduced due to the brain cells not being reduced in size during normal nighttime sleep, which would normally provide an increase in intercellar space. As a result, it is concluded that the reduction of oxygen caused by the restriction of the pharyngeal airway affects the brain, as well as the endocrine and immune systems.

Several studies have linked abnormal sleep issues with school performance17,18, behavioral problems19, dental arch size,20 ADHD (Attention Deficit Hyperactivity Disorder),21,22 depression23 and daytime sleepiness.24 The research of Stevens et al25 indicates that many of the symptoms in the dental sleep questionnaire (Fig. 2) can be categorized by their rank in severity, as well as to their level of incidence, and according to various ages (Fig. 3). Various symptoms seem to be more prevalent and at certain ages, but the last column presents the mean percentage at all ages from two to 12 years. The most frequent symptom and the one that does not seem to vary much from age to age is nighttime mouth breathing. Also, the category of “snore at all” is a “catch all” phrase and encompasses any severity of snoring. However, when it is segregated according to various degrees, it does vary with age. It must be stressed that nighttime mouth breathing occurs 42.7% of the time from two to 12 years. When observing snoring, the mouth is typically open, so that any child that snores audibly is also usually mouth breathing. On the other hand, not every child that mouth breathes will snore. Mouth breathing while sleeping is associated with an average of seven other symptoms (namely snoring 45.7%, talks in sleep 43.9%, difficulty listening and often interrupts 41.5% and allergic symptoms 37.8%). Of the children that mouth breathe at night, 47% also mouth breathe during waking hours.25

Figure 2

The Healthy Start® Sleep Questionnaire to be filled out by parent.

Figure 3

Ranking of most frequent outward symptoms of Sleep Disordered Breathing.

A few simple questions can alert a parent that problems exist and warrant an investigation, namely:

a) Does your child have difficulty with school achievement – especially math, spelling or science?18
b) Does your child often have nightmares or night terrors?17
c) Restless sleep?17
d) Bedwetting?17
e) Tooth grinding?17
f) ADHD?21,26
g) Allergies, asthma, throat infections?17

Many of these symptoms trigger a parent’s interest in finding out more about serious sleep issues (sleep disordered breathing).

A progression of symptoms usually leads to serious problems with neuro-brain function, as well as the endocrine and immune systems. These three issues have a serious impact on a child’s wellbeing. The progress of these factors and their implication to health are outlined in Fig. 4. There is a strong emphasis by the medical profession on upper airway resistance and the importance of gaining proper nasal breathing,27 which the author is also very interested in achieving. To stress nasal breathing and the naso-pharynx as the primary important cause of abnormal sleep issues is misleading in the author’s opinion. Most children have restriction of the oro-pharynx rather than the upper airway (naso-pharynx). It has been reported that 84% of improper breathing issues involve the oropharynx,28 as opposed to the nasopharynx (upper airway). In an unpublished study of 151 children29, 83% were able to breathe normally through the nose while 17% had either moderate or severe problems in nasal breathing, forty-two percent of the Stevens et al study of 501 children25 exhibited nighttime mouth breathing which directly impacts the oropharynx.

Figure 4

Sleep deprivation and its affects.

There are several suspected causes of mouth breathing. It appears to the author that mouth breathing is a habit since it can be so easily changed by preventing it with an appliance that forces the child to breathe through the nose. Figure 5 explains the several suspected and varied causes such as prolonged bottle feeding and pacifier use. These nipple devices encourage an inferior tongue resting posture, and also encourages tongue thrust swallowing. During swallowing, a negative pressure (vacuum) is developed in the oral cavity and since the tongue is not positioned within the palate, there is a tendency for the palate to narrow itself. In unpublished research29 of 168 cases, the following data outlines the status of the upper posterior arch width:

a) Normal arch widths 50%
b) 3 mm or less constriction 39%
c) 4-6 mm constriction 9%
d) 7 mm or more constriction 2%

Figure 5

The cause and effect of Sleep Disordered Breathing.

It is interesting that those with a normal upper arch width (50% is almost the same as those that do not nighttime mouth breathe (57.38%).

An interesting case (courtesy of Dr. Harrell) while after one month’s use of the HealthyStart Habit Corrector appliance (Fig. 1) shows an initial airway area of 53.6 mm2 while after correction of the nighttime mouth breathing the airway is 337 mm2 (Fig. 6). Of particular interest is not only the increase of the oropharynx, but a dramatic increase of the nasopharynx. Figure 7 indicates that the airway was increased after one month’s wear by 624% or 3.7 times the normal area for a 9-year-old child.

Figure 6

CBCT scan of 9-year-old HealthyStart® patient that mouth breathed.

Figure 7

Nine-year-old male HealthyStart® patient following one month of Habit Corrector®.

Figure 8

Restricted/Normal airway of 5-year-old.

The problem with techniques for increasing the nasal airway such as rapid palatal expansion therapy (RPE appliances) is that nasal breathing is increased, but this procedure does not necessarily correct mouth breathing. In fact, it can interfere with normal tongue posture and swallowing because the appliance is positioned in the upper posterior arch. If the problem is with nasal air exchange and there is no evidence of mouth breathing, this is a very efficient procedure. Similar reasoning can be used with the removal of swollen adenoid tissue or surgical correction of an enlarged uvula. If the problem is mouth breathing, these surgical procedures may have little effect on the oropharyngeal airway restriction as well as the other symptoms. Importance of nighttime mouth breathing is the distalization of the mandible and tongue while sleeping which reduces the oropharynx. The HealthyStart Habit Corrector® advances the mandible with an excessive overjet or the presence of a retrognathic mandible. The appliance prevents the mandible from being posteriorly displaced, and at the same time encourages nasal breathing and terminates the mouth breathing habit.

Figure 9 shows the sleep questionnaire of a 6-year-old male. This boy has 18 of a total of 27 symptoms filled out as present, which occurs in only about 2% of the population. He also had 11 of 14 symptoms for ADHD (Fig. 10). If eight out of 14 questions are present, the child is considered to have ADHD. This 6-year-old has serious ADHD. He was given extra recess time at school and periodically was told to run up and down the staircase to try to calm him down. In fact, his chair was tied to his desk, but this was also not successful. What is of particular interest is his math and reading progress. His Student Progress Report (by NWEA) (Fig. 11) was registered for math at the 6th percentile at the start of the HealthyStart treatment. Three months later, he registered at the 53rd percentile in math and his reading showed similar progress, however, at a slower rate. Similar reports three years later (Fig. 12) showed that he remained at the high level in both math and reading. His sleep questionnaire at 13 years of age (Fig. 13) shows a 94.5% improvement with only one item marked. Figure 14 shows a similar improvement in his ADHD American Psychiatric Association ADHD questionnaire (1987), which shows a 91% improvement to 13 years of age. The patient initially was recommended Ritalin, but the mother refused this route prior to his HealthyStart program. Figure 15 is a pilot study on the result of HealthyStart Habit Corrector therapy.

Figure 9

Case Study: Sleep Questionnaire of 6-year-old male.

Figure 10

Case Study: ADD/ADHD Questionnaire of same male.

Figure 11

Case Study: Student progress report of same male.

Figure 12

Case Study: Student progress report over 3 years of same male.

Figure 13

Case Study: Follow sleep questionnaire of same male.

Figure 14

Case Study: Follow up ADD/ADHD Questionnaire of same male.

There are four important factors that are of primary interest in analyzing a child for abnormal sleep issues as part of a regular dental exam. They are:

a) Mouth breathing
b) A narrow posterior upper arch in relation to the lower arch.
c) Improper tongue position at rest and during swallowing
d) Improper jaw relation with the mandible being retrognathic (more posterior than it should be)

It should, however, be understood that many attributes of the occlusion are involved: either as being affected by sleep disordered breathing, and are important to be corrected to enhance the correction of the sleep issues, or as a preventive procedure. Figures 16, 17 and 18 outline 22 such items and their affects on improper breathing. Serious sleep issues can be the cause of cardiovascular problems in children (high blood pressure, hypertrophy of left side of heart, less blood to lungs from right side of heart, or cor pulmonaile), depression, increased allergies, infections, interference with normal growth and can also play a part in many social issues. In that school achievement can be improved, there is a considerable advantage in starting prior to school age to increase their success in school. Proper oxygen levels in the blood are extremely important for the health of a child. As stated previously, insufficient oxygen affects the brain and its ability to rid itself of the toxin buildup during the day (particularly beta-amyloid). In fact, beta-amyloid toxin present in children with sleep issues is the same toxin found in Alzheimer and dementia patients, responsible for interfering with the communication between brain cells. Insufficient oxygen also affects the endocrine and immune systems. Oxygen deficiency reduces REM sleep, which is considered the reparative segment of sleep, while delta sleep (deep sleep) does not require oxygen and increases as REM decreases. When the pharynx remains open with a free exchange of air (oxygen and CO²) the child will almost immediately feel the difference. Often personality changes may be seen, a child may experience an increase in their social ability with other children. They may see an increase in friends and the elimination of symptoms such as bedwetting, frequent headaches, difficulty with school work, daytime sleepiness, irritability and lack of concentration. These are just a few of the changes that can dramatically change a child’s life.

Addressing the habitual problems with implementation of the Habit Corrector usually takes precedence over the factors of occlusion. However, as seen in Figures 16, 17 and 18, the occlusion factors are important to aid in the future stability of the corrected sleep issues. The orthopedic and habit corrector appliances are worn primarily while the child sleeps and are designed to address the underlying root causes of Sleep Disordered Breathing including narrow palate, improper swallowing habits, mouth breathing, improper growth and development, jaw relationship and airway issues. The appliance is worn nightly until almost all of the symptoms are corrected or significantly reduced. This orthopedic technique can begin as early as age two.

Figure 15

HealthyStart® Habit-Corrector® improvements after 5 months of wear.

Figure 16

Common Orthodontic issues related to sleep problems.

Figure 17

Common Orthodontic issues related to sleep problems.

Figure 18

Common Orthodontic issues related to sleep problems

All of these symptoms discussed above do not self-correct with an increase in age25 and it is suspected that adults that suffer with sleep issues may have experienced these same problems during childhood. Giving a child a healthy start in life by recognizing these symptoms and treating them early can enhance a child’s success and their confidence in their future.

A second article will discuss the diagnostic analysis and treatment of dental factors that affect sleep issues. OH

Oral Health welcomes this original article.

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Dr. Bergersen taught at Northwestern University for 25 years on the growth and development. Dr. Bergersen has lectured throughout Europe, the United States, Canada, Asia, Africa, and South America on growth and development research, as well as at the pediatric post-graduate school of dentistry at Tufts University in Boston, Massachusetts. He has done extensive research on the use of skeletal age assessments of maturity in relation to facial and body growth and its influence on orthodontic treatment and retention timing.

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