— When Benjamin Kidd was in pre-K last year, his teachers marveled at how bright, attentive and well-behaved he was — in the morning.
Later in the day, Ben was a different child. He was fidgety and he couldn’t focus. He couldn’t sit still for a story. And he burst into tears and temper tantrums at the slightest provocation.
After taking him to one specialist after another, his mother, Michelle Kidd, who lives in Hillsborough N.J., finally figured out what the problem was: 5-year-old Ben was exhausted. Doctors who ran an overnight sleep study on him last fall said he was suffering from obstructive sleep apnea, a sleep disorder associated with middle age but not uncommon in preschoolers, where it can lead to behavior easily mistaken for hyperactivity — even though it’s actually caused by fatigue.
“You know how it is when you let your kid stay up too late, and they’re bouncing off the walls and don’t listen?” says Kidd, who had consulted physicians at the Somerset Medical Center’s Sleep for Life Center in Hillsborough. “It was a lot of that.”
Obstructive sleep apnea affects 2 percent of children and has made headlines in recent years because it's more common in obese youth. Still, experts say, it's often overlooked by doctors. Ben Kidd, who’s tall and gangly for his age, doesn’t fit the typical profile for sleep apnea, which may be why doctors didn’t identify the problem earlier. Pediatricians are supposed to screen all children for snoring, which is a red flag for apnea, but many fail to do so. And experts fear some children are being inappropriately diagnosed with attention deficit hyperactivity disorder and medicated, while the underlying sleep problem goes untreated.
“Lots of studies suggest that kids with sleep apnea are more likely to be hyperactive, impulsive and inattentive," says Dr. Judith Owens, associate professor of pediatrics at Brown University Medical School, and co-author of "Take Charge of Your Child's Sleep."
"It affects behavior and mood, so these kids can look a lot like a kid with ADHD,” she says.
At the same time, the more experts learn about sleep apnea, the more concerned they become. Left untreated, sleep apnea may affect parts of the brain involved in learning, taking a toll on cognitive function and academic performance, and shaving points off a child’s IQ.
Sleep apnea also seems to play a role in childhood obesity, since children who don’t get enough rest are less physically active. The sleep disorder has been linked to depression, too.
Even more troubling is new research that suggests sleep apnea may in some cases lay the groundwork for serious long-term health problems such as high blood pressure and heart disease that generally don’t show up until adulthood. Experts believe sleep apnea may hasten the development of these conditions by promoting a systemic inflammatory response that causes changes in the blood vessels and the regulation of blood pressure.
“Sleep apnea is not a trivial disorder,” says Dr. David Gozal, director of the Pediatric Sleep Medicine Center at the University of Louisville School of Medicine in Kentucky, who is one of the leading experts on sleep apnea in children. “We’re very concerned, because we’re not just talking about the immediate implications for quality of life. If not recognized early enough, especially in vulnerable children, sleep apnea may accelerate long-term disease processes, leading to advanced disease by the time they’re in adulthood.”
'Like they're being poked all night'
Obstructive sleep apnea occurs when a child’s upper airway is intermittently blocked at night. As the child gasps for air and struggles to resume breathing, which occurs repeatedly throughout the night, normal sleep is disturbed.
Snoring is one telltale symptom, though not all children who snore have apnea. Another clue may be if a child sleeps in a strange position — sitting up in their bed, legs crossed and slumped over a pillow, for example — in an attempt to keep the airway open. Children may wake up frequently at night or be sleepy during the daytime even though they got to bed on time.
During the night, two things are taking place. "The oxygen level dips, which is not good for your health; and the more prominent issue is that these kids are waking up throughout the night, and they’re not even aware of it,” says Jodi Mindell, a professor of psychology who is associate director of the Sleep Center at Children’s Hospital of Philadelphia and co-author, with Owens, of “Take Charge of Your Child’s Sleep.”
“If I poked you on the shoulder all night as you were sleeping, you’d feel pretty crummy the next day,” Mindell says. “So that’s how these kids feel — like they’re being poked all night.”
Ironically, the culprit causing the obstruction is usually the child’s own tonsils and adenoids, which tend to be relatively large in small children and sit near the entrance to the airway. Obesity is another risk factor, because of the pressure on the airway, though in Ben Kidd’s case, poor muscle tone may play a role, his mother says. Craniofacial abnormalities and neuromuscular disorders are also risk factors. Though children often manage to breathe during the day, when they fall asleep and the muscles of the throat relax, the blockages occur.
The recommended treatment in most cases is surgery, called adenotonsillectomy, to remove both the tonsils and the adenoids. If that doesn’t solve the problem, children can learn to sleep with a kind of special nasal mask, called Continuous Positive Airway Pressure (CPAP), that many adults with apnea use. CPAP uses an electronic device to deliver constant air pressure and assure continuous breathing, and children as young as ages 2 or 3 have been reported to adjust to using it.
But first a child must have an overnight sleep study done. The study, called a polysomnogram, is usually conducted at a sleep center, where a parent and child spend a night, the child hooked up to a series of monitors, or leads, that measure brain waves and monitor stages of sleep, breathing movements and blood levels of oxygen and carbon dioxide.
The study is designed to detect pauses in breathing — more than five an hour is considered abnormal in children — as well as drops in oxygen that accompany the pauses.
“The first thing you tell the kids is that there are no needles involved here, just a bunch of wires, and you relate it to their favorite science fiction cartoon,” says Owens.
She strongly recommends having a sleep study done to rule out obstructive sleep apnea if a child is being evaluated for ADHD and has other risk factors for sleep apnea. “I will not start a child on stimulation medication [for ADHD] if the child has a history of snoring or large tonsils — I send them for a sleep study,” she says.
Several studies have found improvement in behavior after adenotonsillectomy. One study, published in the journal Laryngoscope in 2005, followed 52 children from ages 2 to 15 who had their adenoids and tonsils removed. The study assessed behavior before and after the surgery, and found significant improvement in hyperactivity and aggression, as well as a reduction in anxiety and depression.
For 5-year-old Ben Kidd, enlarged tonsils were not the problem, so instead of having surgery, he was fitted with a CPAP mask that he started wearing just before Thanksgiving. The difference in his behavior and his ability to concentrate and learn has been striking, his mother says. He now loves math and has already started to read simple books.
The truth, Michele Kidd says, is that she had been concerned about her son’s breathing ever since he was an infant in a bassinet by her bed. But she says none of the physicians she consulted seemed to take her concerns seriously. Eventually, she took Ben to a neurologist to discuss his behavior, and the neurologist suggested running a sleep study.
Her advice to parents? “Listen to your gut. If you see something wrong with your child, don’t let anybody — doctors or anybody else — poo-poo you or tell you it’s nothing,” she says.
Roni Caryn Rabin is a health writer who lives in New York City. She has written for The New York Times, The Washington Post, Newsday and Real Simple magazine, among other publications, and is author of the book, "Six Parts Love: A Family's Battle with Lou Gehrig's Disease." She teaches journalism at the Columbia University Graduate School of Journalism.