Sleep Apnea in Children vs. Poor Sleep Hygiene

Does your child seem fatigued during the day or have difficulty falling or staying asleep? Does your child struggle with school work or have difficulty concentrating? Does your child have emotional outbursts or seem inattentive or hyperactive? These signs may be symptomatic of bad habits surrounding bed time (poor sleep hygiene) or a more serious sleep disturbance, such as obstructive sleep apnea.

Why We Sleep

As human beings, we spend nearly one-third of our lives sleeping. Getting a good night’s sleep has been proven to be crucial for physical and emotional health. Yet, we learn so little about the health benefits of sleep and proper sleep hygiene in our formal education, unlike the other basic cornerstones of health, including nutrition, exercise, and sex. From a physical health standpoint, sleep is involved in healing of heart and blood vessels, keeping a balance between hormones that tell us when we’re hungry, releasing hormones that allow us to grow and develop normally, as well as maintaining a robust immune system to fight infections. Sleeping well is also associated with improved attention, learning, memory, and regulation of emotions. Conversely, sleep deprivation is linked to increased risk of heart disease, high blood pressure, obesity, diabetes, stroke, inattention, learning problems, depression, anxiety, increased infections, and accidents. If sleep deprivation is associated with such severe consequences, how do we ensure a good night’s sleep for us and our children?

What is Sleep Hygiene? How to Guarantee Yourself a Good Night Sleep

A child with poor sleep hygiene can appear very sleepy, have trouble concentrating, be forgetful, or behave in a hyperactive or impulsive manner. It is crucial that you help create a calm, consistent bedtime routine for your child. Ask yourself if the following apply to your child:

Uses an electronic with a light-emitting screen (e.g. cell phone, tablet, laptop, computer, video game) in the hour prior to desired bedtime
Watches television in his/her bedroom or keeps TV on in background
Shares a bedroom with another sibling or family member, who may delay bedtime or awaken him or her in the middle of the night
Necessitates a specific condition (e.g. parent, evening snack, song, TV) to be met in order to fall asleep
Bedroom is too stimulating (e.g. bright lights, background noise, toys)
Eats food or candies with high sugar content prior to sleep
Drinks coffee, tea, soda or other caffeinated beverage after lunch time
Bedroom is too hot or too cold (cooler than 60 degrees, warmer than 75 degrees)
Has irregular bedtime and wake times
Naps excessively (more than 1-2 hours daily)

If your child meets one or more of these criteria, then sleep hygiene is an area upon which to improve. Correcting sleep hygiene is imperative BEFORE considering other sleep disorders, such as obstructive sleep apnea, narcolepsy, insomnia, or restless legs syndrome. Please adhere to the following guidelines for sleep hygiene:

No electronic use for one full hour prior to bed. Instead, encourage reading a book prior to bed or reading a story to younger children.
Reserve the bedroom exclusively for sleep. Play time, meals, homework, and other stimulating activities should be done elsewhere.
Keep bedroom ambient temperature cool, between 60-75 degrees
Use light-blocking shades
Stick to a consistent bedtime and wake time
Avoid caffeine, sugar, large meals, and other stimulating activities (e.g. exercise, TV, video games) prior to bed
Follow recommended hours of sleep for age (see recommendations below)

How Much Sleep Does My Child Actually Need?

According to a consensus statement by the American Academy of Sleep Medicine, the recommended amount of sleep for infants and children for optimal health is as follows:

Infants 4 months to 12 months: 12 to 16 hours per 24 hours (including naps)
Children 1 to 2: 11 to 14 hours per 24 hours (including naps)
Children 3 to 5 years: 10 to 13 hours per 24 hours (including naps)
Children 6 to 12 years: 9 to 12 hours per 24 hours
Teenagers 13 to 18 years: 8 to 10 hours per 24 hours

Maintaining Consistency Is Key

It is very important to acclimate your child to a consistent bedtime and wake time as much as possible. This can be more challenging in infants and young children whose nap and feeding schedules are erratic, but it is important still to set clear boundaries. Children that necessitate a particular condition in order to fall asleep, such as a parent in the bed or evening snack, need to be trained to fall asleep on their own. Rather than lying in bed with your child, try sitting in a chair next to the bed. Reassure your child that you are there as they are falling asleep but do not get back into bed with him or her. Eliminate distracting factors (e.g. electronics, siblings sleeping in the same room, toys) that may be keeping your child from obtaining the optimum number of hours of sleep.

Does My Child Have Obstructive Sleep Apnea?

Obstructive sleep apnea can present similarly to poor sleep hygiene with symptoms such as daytime sleepiness, inattention, forgetfulness, and hyperactivity/impulsivity in small children.

Obstructive sleep apnea occurs in 1-5 percent of otherwise healthy children and can be higher in certain conditions, such as Downs Syndrome, children with craniofacial abnormalities, and neuromuscular disorders such as the muscular dystrophies. It can occur at any age, but is most common between 2-6 years of age. Untreated sleep apnea can result in severe health consequences, including high blood pressure, pulmonary hypertension (high blood pressures in the lungs), arrhythmias, heart failure, stroke, diabetes, fatty liver disease, and more. Children with sleep apnea may also have difficulty gaining weight and growing.

How does Obstructive Sleep Apnea Occur in Children?

When we sleep, the muscles in our airway relax. Sleep apnea occurs when there is complete or partial obstruction or blockage of the airway, leading to arousal and fragmented sleep. Fragmented sleep is not restorative and thus, causes the child to be very sleepy the next day. The most common causes of sleep apnea in children include large tonsils and adenoids (adenotonsillar hypertrophy) and obesity. Size of tonsils/adenoids does not always correlate with symptoms as even “small” tonsils can cause obstruction in the airway during sleep and arousals. Obesity and neck circumference are strong risk factors for sleep apnea, and this risk increases during adolescence.

Symptoms Concerning for Sleep Apnea in Children

Frequent snoring (more than three days/week), especially if loud.

Labored breathing during sleep
Coughing, choking, gasping for air
Periods where your child stops breathing
Paleness or blue lips or face
Headaches upon awakening in the morning
Excessive sleepiness during day
Hyperactivity/impulsivity
Learning difficulties
Night time bed-wetting
Sleeping in seated position or with neck hyperextended.

If any of the preceding apply to your child, you should immediately seek a more thorough evaluation from your child’s primary care pediatrician or sleep specialist. Obstructive sleep apnea can lead to the previously mentioned serious health consequences, many of which cannot be reversed. Early identification of sleep apnea is extremely important to prevent your child from developing these health problems, which can significantly shorten his or her life span.

If your child’s symptoms are concerning for sleep apnea, your pediatrician may order a sleep study or polysomnogram. You would stay overnight with your child in a sleep laboratory. While your child is sleeping, a sleep technician will monitor various parameters, such as oxygen level, respiratory effort, heart rhythm, and brain electrical activity. The sleep study will determine with high accuracy whether your child has sleep apnea. Conversely, your pediatrician may refer your child to a sleep specialist or ear, nose, and throat physician for further evaluation. Your child may require surgery to remove his or her tonsils/adenoids. Allergies can also cause significant nasal congestion that triggers awakenings.

The Bottom Line

Daytime sleepiness, learning difficulties, inattention, forgetfulness, and hyperactivity are different manifestations of poor sleep quality in children. These may stem from poor sleep hygiene or more rarely from a serious sleep disorder, such as obstructive sleep apnea. Pay close attention to the signs and symptoms in this article and how they relate to your child. Bring any of your concerns to your child’s primary care physician. You may be referred to a sleep specialist or ear, nose, throat physician for further evaluation. Regardless of the underlying cause, sleep hygiene problems and organic sleep disorders, such as obstructive sleep apnea, both benefit from early detection to prevent long-term, irreversible health problems.

Authors: Cheryl Tierney, MD, MPH and Grace Wang, MD

Penn State Hershey Children’s Hospital