Dr David McIntosh is a Paediatric Ear, Nose and Throat (ENT) Specialist. He has a special interest in airway obstruction, facial and dental development, and its relationship to ENT airway problems and middle ear disease.

In adults we talk about ‘snoring’ vs. ‘sleep apnoea’. But “a child is either breathing normally or having sleep disordered breathing”.

There is a spectrum of Sleep Disordered Breathing in children:

• Mouth breathing or heavy breathing
• Snoring (quietly or loudly)
• Struggles to take breaths (Upper Airway Resistance Syndrome)
• Stops breathing (Obstructive Sleep Apnoea)

Signs of sleep disordered breathing in children:

• • Turning up to school tired
  • Difficulty with concentration
  • Poor emotional regulation
  • Low energy levels

3-10% of children have Obstructive Sleep Apnoea. About 20% of children have some sort of airway compromise that is affecting their daytime functioning. If one family member (child or adult) has sleep disordered breathing, other family members within one generation have a 50% chance of having a compromised airway.

In adults, being overweight is a big factor for Obstructive Sleep Apnoea. Unfortunately, we are seeing the normalising of weight gain and sleep disordered breathing such as snoring. Men are also more likely to have sleep disordered breathing with lifestyle being a contributing factor.

The brain’s development is most active in the first few years of life. This is when we learn to walk, talk and all the important skills that we gradually refine over adulthood. Hence, children have far more active brains than adults. During sleep, our brain filters out the day’s information and selects information to be retained and learned. Information filtered out is lost. As such, one of the physiological roles of sleep is for brain function and development. Any interference with sleep has a knock-on effect on our learning and memory. This then translates to difficulties in school and the workplace.

Let’s look an analogy of a travelling ship. From the moment it departs from a port, it relies on navigation to reach its destination. Any errors in navigation and the ship will go off course. How long it takes to arrive at the destination, if at all, will depend on when and how long the ship went off course for, and when the correction was made. Similarly, the earlier disordered breathing is corrected, the better the outcomes. The longer and older a child has sleep disordered breathing, even with gains with intervention, they may not resolve all the negative impact on brain development. This shows the importance of advocating for early intervention and need for multi-disciplinary work for holistic management of a child’s development.

Children who experience breathing issues before they were 6 years old have worse outcomes than those who have an onset of issues after they are 6. Children experiencing issues before 18 months are the most vulnerable. Strong evidence show that if problems persist for 6 months or longer, there is less success of negating the effect of sleep disordered breathing on development. 

While children with sleep disordered breathing may exhibit symptoms similar to children with ADD and/or ADHD issues, we need to be cautious to not equate both issues. Some children may have one or the other, or have both. Sometimes fixing sleep is not the only issue, but it is definitely one to proactively address.

Strong evidence show that any form of a compromised airway will affect a child’s development and subsequently, the child is not able to reach their full potential. Sleep studies are commonly recommended as the measurement tool to investigate sleep and breathing. However, it can only identify Obstructive Sleep Apnoea and not Sleep Disordered Breathing, which we know is a spectrum of issues including mouth breathing and snoring. About 50% of children show improved results on a sleep study after a year, but this only reflects gains on a specific measurement of Obstructive Sleep Apnoea with no reflection of the child’s function. They essentially improved on the wrong measurement tool. We need to look at the symptoms as a normal sleep study doesn’t necessarily mean normal breathing. Instead we should rely on case history and clinical assessments. This could include parents video recording their children during sleep. A sleep study may be warranted as an investigation tool later in the child’s management, not as a first step.

Enlarged tonsils and adenoids are removed when it makes it difficult to breathe via the nose and the child ends up mouth breathing. However, some children are still observed to mouth breathe after removing their tonsils and adenoids. Adenoids are located at the back of the nose so if there is any inflammation or blockage in the nasal passage, the air is blocked before even reaching the adenoids. We need to address this area including hay fever, allergies and a deviated septum. A narrow jaw can also compromise the airway.

In addition, we need to be careful when noting whether a child has received an adenoidectomy (removal of their adenoids in surgery). The traditional way of surgery is for the surgeon to feel the tissue post removal to check if the adenoid has been removed. However, a research study which used a telescope via the nose, to visualise the tissue post remove, noted that in 69% of cases, the adenoids were still there. Overall, 24% of children had so much tissue that they may as well not have undergone surgery. This reflects that the current method of visualising the results is not accurate. Also to note, there is a possibility that adenoids can grow back, in particularly for children under the age of 2.

Once everything is unblocked, breathing retraining may be warranted.

There is widespread speculation that there is a relationship between having a tongue tie and mouth breathing. At this stage, there is no evidence to show this. We know that mouth breathing affects muscle tone which in turn affects facial growth. Releases of tongue ties do have a place for addressing a narrow top jaw but again, there is no evidence that tongue ties cause narrow jaws. There is evidence to show that nasal obstructions such as adenoids are contributors to a narrow jaw.

Some children with a deviated septum are advised to wait until they turn 18 before having surgery to correct it. This is under the premise of concerns that the surgery may interfere with the growing nose and growing facial structure. However, we know that a deviated septum does interfere with breathing patterns which will affect facial growth. We should perform these surgeries very mindfully and conservatively, not aggressively. The aim is to improve and not perfect the septum, and it will benefit the child for the long term.

Rhinitis is hay fever and allergy. This causes swelling of the lining of the nose and cause mouth breathing which causes mouth breathing. There is great argument whether breathing patterns affect jaw development. This is due to a number of observations. If a child has nasal problems, they tend to have a narrow upper jaw and the lower jaw doesn’t grow as forward. Children with large tonsils also tend to have lower jaw that grows more forward than in should. However, the conversation should not be around the relationship between jaw development and breathing, but whether there is a breathing problem. The main premise is that the child can’t breathe properly. We need to address the breathing and use a multi-disciplinary team effort to provide best care. This includes orthodontics who are really airway health professions, and not just about aesthetics.

To find out more, contact SPOT Therapy Hub on 9389 3322 or spottherapyhub@gmail.com or Dr David McIntosh on Facebook. Also check out his book ‘Don’t Ignore the Snore’ available directly from David or via Amazon.