Tommy seemed unusually withdrawn and reluctant to try new things.
His mood was fragile, swinging from teary to explosive, and he didn't joke and laugh with his family anymore, says his mom, Liana Groza, a dentist and coordinator of the Spokane Regional Sleep Apnea Network, in an email interview.
"There were several years worth of photos where he is always looking somewhat absent, tired or sad," Groza writes. "This was particularly heartbreaking for me, because I remembered a child who had a remarkable sense of irony and sparkling humor only a couple of years earlier — and now that child was gone."
It would be several years before the cause was discovered. Tommy, now 9, had sleep-disordered breathing.
Although most research focuses on adults, insufficient sleep in the formative years has been associated with metabolic, cognitive and emotional effects, and pediatric sleep-disordered breathing is a growing area of interest among experts. It's a relatively new field, and many providers don't receive in-depth training on the topic. With a lack of clear, universal screening and treatment protocols at the primary care level, kids can fall through the diagnostic cracks.
Getting a breath
Causes of sleep-disordered breathing can be obstructive (think large adenoids or tonsils, or a tongue displaced back into an airway), environmental (allergies or chronic sinusitis), genetic (mismatched, narrow jaws), and anatomic/structural (misaligned jaws or airway dysplasia).
The symptoms can be obvious — mouth breathing, loud snoring, tossing and turning, and gasping and choking during sleep. But in some cases, symptoms (attention difficulties, aggressive behavior at school, even depression) may be only indirectly related to sleep.
"That's the tricky thing," says Sean Park, a pediatrician at Lakeside Pediatric & Adolescent Medicine in Coeur d'Alene. "It can be hard to find sometimes."
Twenty to 25 percent of kids diagnosed with Attention Deficit Hyperactivity Disorder have sleep apnea, Park says. That doesn't mean they don't have ADHD. Some might be misdiagnosed, or "they might have both and the sleep apnea is making things worse."
One study concluded that a history of sleep-disordered breathing in the first five years of life is associated with a 40 to 60 percent greater chance of special educational needs by age 8.
Park says he may refer patients for a sleep study, or to an otolaryngologist if large tonsils or adenoids need to be removed, or simply prescribe allergy meds.
Weight management, oral appliances, or positive airway pressure therapy are other treatments. Managing the condition is complicated by the fact that there are currently no universally accepted guidelines as to when children's obstructive sleep apnea is sufficiently severe as to warrant treatment.
Park says that sleep apnea could be more common than previously thought. It's also getting more attention with the rise in childhood obesity, because "childhood obesity actually plays a role in sleep apnea," he says. Several studies show a strong association between between pediatric sleep disorders and childhood obesity.
One study of adolescent patients found that obstructive sleep apnea increased the odds of metabolic syndrome — a cluster of conditions that increase the risk of heart disease, stroke and diabetes — sixfold.
Bed-wetting, sleep-walking, diminished growth and other hormonal, metabolic problems and dental problems can result.
Sleep-disordered breathing is underdiagnosed, says Spokane-based orthodontist Duane Grummons, and sometimes even if a problem is suspected, clinicians will take a wait-and-see approach with the hope that a child will outgrow it. The child can suffer in the meantime, and invasive interventions may be needed to correct the problem later.
"Clinicians can do harm by doing nothing," he notes. "The key factor is recognizing and preventing worsening problems by intercepting sleep-disordered breathing conditions when the patient is younger."
In his office, Grummons uses a patient questionnaire and cone beam-computed tomography — CBCT for short — to create 3-D images of a person's head and identify airway restrictions. He can then use facial orthopedics to open the airway, or refer a patient to another specialist for treatment.
He says he would like to see pediatric providers use consistent referral flow charts and collaborative protocols for diagnosing and treating children: "We know a lot, but we need to integrate that."
For Groza, the first indication that something unusual was going on was Tommy's bruxism, causing his front teeth to become significantly worn down by the time he was 5. He also had frequent and severe ear infections starting at age 2, a lisp requiring speech therapy that may have been caused by inadequate tongue space, chronic dark circles under the eyes, difficulty getting up in the morning, irritability, mouth breathing and recurrent episodes of nasal congestion.
When Groza was in dental school, students were taught not to worry about teeth grinding, and it wasn't until she started attending courses on sleep apnea a couple of years ago that the connection between bruxism and sleep-disordered breathing became apparent, she says.
"All these other puzzle pieces fell instantly into place," she says. "Suddenly I became acutely aware of every little sleeping noise and movement pattern possibly indicating that Tommy had some trouble breathing, and the daily struggles to get him out of bed in time for school were overshadowed by a guilty suspicion that he might simply be sleep-deprived and coping with unarticulated morning headaches."
Tommy underwent an imaging study in Grummons' office and the radiologist's report clearly showed a significant narrowing of the airway.
He had his tonsils and adenoids removed and underwent rapid orthodontic expansion to correct his narrow maxilla. Within a few weeks, the dark circles under his eyes disappeared and he started waking up early all by himself.
Other results of getting a good night's sleep? "I am delighted to become reacquainted with my child's wonderful sense of humor, the calm and sunny disposition that almost nothing seems able to disturb anymore," she writes, "and the zest with which he now approaches whatever adventure life throws his way." ♦