Sleep apnea in children can cause other health, behavioral problems

Justin Colamaria with his mom, Tina Foye, and the breathing machine that helps his sleep apnea.
Justin Colamaria with his mom, Tina Foye, and the breathing machine that helps his sleep apnea.
photos by Victoria Arocho for The Globe

Chandra McGuire thought she’d have to learn to live with her 2-year-old son’s snoring and pauses in breathing that roused him, and her, two to four times a night. “He’s always been hyperactive and had a very quick temper,” McGuire said. “His doctors kept telling me it was colic, but when you can’t sleep it affects everything else.”

Lately, though, her son Francis Massey V has been sleeping through the night for the first time in his life, two months after his enlarged tonsils and adenoids were surgically removed at Boston Children’s Hospital, a procedure his doctors hoped would open his airways and help him breathe better during sleep.

“His personality before and after the surgery is night and day,” said McGuire, 36, a massage therapist from Middleborough. “He’ll pay attention to me reading a book, and he’s awesome in day care. He’s not set off by the smallest things like he used to be.”

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While nearly one-third of children experience sleep issues at some point in their lives, about 2 to 4 percent have structural defects such as Francis had that cause breathing difficulties during sleep, often marked by snoring, gasping for breath, or pauses in breathing. The condition, called sleep apnea, is being treated more frequently at Boston Children’s and other pediatric sleep centers because of increased screening by pediatricians — who are advised by the American Academy of Pediatrics to ask about snoring at well visits — and a tripling in pediatric obesity, a known risk factor for sleep apnea.

A March study published in the journal Pediatrics surveyed 8,000 British parents of children ages 7 and under and found that children who snored or had other breathing difficulties during sleep were 50 percent more likely to have a behavioral issue such as hyperactivity, frequent temper tantrums, or anxiety compared with those who didn’t. Researchers speculate that when the brain gets too little oxygen during sleep, it may have less than optimal functioning in areas such as the prefrontal cortex that govern decision-making and self-control. And preliminary results from a new clinical trial conducted by Boston Children’s and Brigham and Women’s researchers show that surgical removal of enlarged tonsils and adenoids in kids with sleep apnea results in marked improvements in behavioral problems compared with those who don’t have the surgery.

Other research, mostly in adults, suggests that sleep apnea, if left untreated, can raise the risk of hypertension, diabetes, and depression; later in life, it’s been linked to heart failure, heart attacks, strokes, and, a new study suggests, cancer.

How much sleep apnea contributes to childhood attention deficit hyperactivity disorder and learning difficulties, however, remains unknown and difficult to measure. “About half of children diagnosed with ADHD have a sleep disorder, whether it’s sleep apnea, insomnia, or something else,” said Dr. Craig Canapari, a pediatric sleep specialist at Massachusetts General Hospital. “But anything that disrupts a child’s sleep can give them symptoms of ADHD,” he added, and it’s sometimes impossible to determine whether the behavioral disorder is causing the sleep problem or vice versa.

Dr. Umakanth Khatwa, sleep lab director at Boston Children’s Center for Pediatric Sleep Disorders, said every week he sees at least one or two children who were misdiagnosed as having ADHD when the root of their aggressive or distracted behaviors lies in a lack of good quality sleep.

More often, though, treating sleep apnea results in an improvement of behavioral problems, rather than a total solution. After Justin Colamaria, 9, a patient of Khatwa’s, was diagnosed with sleep apnea two years ago and began wearing a breathing mask at night for treatment, he felt less tired and grouchy and performed far better in school, both academically and socially. The continuous positive airway pressure, or CPAP, device Colamaria wears delivers air pressure through his nose, forcing his airways to stay open while he sleeps.

“He’s doing really well, much better than he was,” said his mother, Tina Foye of Brockton, but she emphasized that he still has signs of a defiant behavioral disorder that causes him to thumb his nose at rules or to get into brutal physical fights with his identical twin brother — who also has defiant behavioral disorder, but without the sleep apnea.

Surgery to remove enlarged tonsils and adenoids remains a first-line therapy, especially for younger children with sleep apnea: Nearly half a million of these procedures are performed every year on those under age15, mostly for this indication. But up until now, doctors didn’t know for certain whether the surgery, called adenotonsillectomy, worked better than doing nothing and waiting for kids to outgrow this problem. Last month, researchers from Brigham and Women’s, Boston Children’s, and other institutions presented initial results from a clinical trial involving 460 elementary school-age children finding that adenotonsillectomy resulted in dramatically improved behavioral issues (based on scores from parent surveys) after seven months compared with watchful waiting.

“We did not see an improvement in cognitive scores on objective tests looking at a child’s ability to stay on task, solve puzzles, or remember sequences,” said Boston Children’s pediatric respiratory specialist Dr. Eliot Katz, one of the study researchers. “It could be that moodiness and tantrums are more sensitive to sleep improvement than intellectual abilities.”

Evidence to back the effectiveness of CPAP devices in children remains on shakier ground. One small promising study published earlier this year from the Children’s Hospital of Philadelphia found that 52 children who wore a CPAP mask every night to treat their sleep apnea experienced significant improvements in attention deficits, daytime sleepiness, and mood disorders such as anxiety after wearing the device for three months compared with before they used the mask. But no studies have compared kids with sleep apnea who wear the mask with those who don’t.

Specialists point out that a single treatment approach is not suitable for all cases of sleep apnea in children, which can have multiple causes such as obesity or allergies. A significant one-third of obese children have sleep apnea, and weight loss, while difficult to achieve, has been shown to help open their airways and improve symptoms.

Allergies, which narrow nasal passages and restrict airflow, must be dealt with as well, explained Katz during a March appointment with Daniella Perez, a mother of a 3-year-old with sleep apnea. Allergies, Perez was told, might explain why her toddler breathed loudly — through his mouth, rather than his nose — throughout the day.

“That mouth breathing is the result of swelling in his nasal passages,” Katz said, “and if we don’t fix it early it could cause permanent modifications to the position of his teeth and shape of his face” that would result from the tongue not pressing up against the palate during closed-mouth nasal breathing.

Treatment for his nasal allergies — not an adenotonsillectomy — should come first to see if that resolves breathing issues, Katz advised, with medications and removal of any offending allergens like dust or pet dander.

“My son’s pediatrician never talked to me about allergies,” Perez, of Everett, said in an interview. “That’s a surprise to me.”