Snoring Tots More Likely to Turn into Troubled Kids
The findings came as little surprise to the pediatricians contacted by ABC News in collaboration with MedPage Today.
Stephen Lauer, MD, PhD, of the University of Kansas Medical Center in Kansas City, said he sees problems related to sleep-disordered breathing every day in clinic.
“It used to be that I would ask if I child snored if I saw large tonsils,” he noted. “It has now become a standard part of the well-child check. And when there are issues of behavioral problems, school performance, and especially attention deficit hyperactivity disorder concerns, the first question I ask has to do with sleep and snoring.”
First, the causes of mouth breathing in children can include chronic allergies, such as dust, molds or pet dander in the home. This can begin the day the infant is brought into the home. The allergies can cause nasal congestion that forces the child to breathe through their mouth and can become a long term problem. However, it should be noted that the common cold may cause temporary mouth breathing, which does not have the long term effects. Excessive use of a pacifier, thumb sucking, or a lack of suckling as an infant can also cause a backward positioning of the lower jaw that forces mouth breathing in order to obtain oxygen that the body requires.
The affects of mouth breathing can include a jaw deformity, with the lower jaw positioned backward, obstructing the airway and causing snoring and creating the look of a long face as well as malocclusion (a misalignment of the upper and lower sets of teeth) and tooth crowding as a child’s teeth grow in. Early treatment can prevent the necessity for braces and other facial orthotic appliances to realign the jaws and prevent the look of a small chin or other facial deformities that can affect the child throughout life. Mouth breathing also causes a change in the posture of the neck and head in order to facilitate better breathing, resulting in permanent posture changes that can affect the upper back and neck.
Sleep problems are quite common in such cases, but treatment helps, agreed Rajiv Naik, MD, a pediatrician with the Gundersen Lutheran Health System in La Crosse, Wis.
“Many children have been cured of their behavioral problems with appropriate treatment of their sleep disturbance,” he wrote in an e-mail.
Longitudinal observational data supports that conclusion, but only multicenter, randomized controlled trials, like the ongoing National Institutes of Health–funded Childhood Adenotonsillectomy study, can prove the cause-and-effect relationships, Bonuck’s group noted.
Their study included more than 9,000 children in the Avon Longitudinal Study of Parents and Children, a birth cohort study of children in a region of southwest U.K.
Based on parent reports of children’s snoring, mouth breathing, and witnessed apnea for ages 6 to 69 months, the children were broken into five “clusters” for presence and duration of sleep-disordered breathing. Early clusters were defined as:
Cluster 1: Symptoms peaked at 6 months and then abated
Cluster 2: Symptoms peaked at 18 months and then abated
Cluster 3: Symptoms peaked at 30 months and then persisted (“worst case”)
Cluster 4: Symptoms emerged at 42 months and then persisted (“late symptom”)
Cluster 5: “Normals” who were asymptomatic throughout
Five comparable later clusters demonstrated similar patterns to the early clusters, except in a “late symptom” cluster where snoring and mouth breathing peaked together at lower levels at 57 months with no marked apnea. Also, the peak at 6 month apnea levels was nearly double those of the early clusters.
Compared with the 45% of kids with no symptoms, all the other groups showed significantly elevated risk of being in the worst 10% for behavioral screening score on the Strengths and Difficulties Questionnaire (all P<0.01 or P<0.05).
The 8% of "worst case" kids (cluster 3) had 49% elevated risk of being in the top 10% for total behavioral problem score at age 4 and up to two-fold excess risk at age 7.
Hyperactivity was the outcome most consistently associated with symptomatic sleep-disordered breathing across the groups.
Significant odds ratios for hyperactivity at age 4 ranged from 1.19 for the 20% in cluster 1, whose symptoms abated after peaking at 6 months, to 1.56 for the "worst case" group (cluster 3).
For hyperactivity at age 7, the odds ranged from 1.48 for cluster 1 to 1.88 for the 20% of kids with symptoms in cluster 2.
Conduct problems, such as aggressiveness and rule breaking, showed associations similar to those with emotional problems.
Being in the top 10% for problems getting along with other kids was 33% to 48% more likely for the worst case group at age 4 and 7 but wasn't consistently elevated in the other groups.
These risks appeared to be independent of 15 potential confounding factors, such as socioeconomics, exposures during gestation, breastfeeding, birth weight, and gender.
But the results are likely conservative, the researchers suggested.
They noted limitations from using parental reports of sleep-disordered breathing rather than objective testing and difficulty of distinguishing observed apnea form central apnea in infancy.
The study was supported by grants from the National Heart, Lung, and Blood Institute.
The researchers reported having no conflicts of interest.
This article was developed in collaboration with ABC News.
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Primary source: Pediatrics
Source reference: Bonuck K, et al. “Sleep-disordered breathing in a population-based cohort: Behavioral outcomes at 4 and 7 years” Pediatrics 2012; 129: 1–9.
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