How your child breathes during sleep can affect academic performance

A New Zealand team of researchers reviewed the results of 16 studies dealing with sleep apnea or related disorders in children and academic achievement. The findings were published last month in the journal Pediatrics. The investigators found that children with sleep-disordered breathing did worse in language arts, math and science tests compared to those without such conditions.

So what exactly what is sleep disordered breathing?

Sleep-disordered breathing (SDB) in children covers a spectrum of breathing abnormalities ranging from habitual snoring, to upper airway resistance syndrome, to frank obstructive sleep apnea (OSA).

·      Typical snoring is rhythmic, and usually has more to do with minor airway blockage like what is seen with nasal allergies or slight enlargement of the tonsils or adenoids.

·      Upper Airway resistance syndrome occurs during sleep when the muscles of the airway become relaxed. The relaxation of these muscles in turn reduces the diameter of the airway. Typically, the airway of a person with UARS is already restricted or reduced in size, and this natural relaxation reduces the airway further. Therefore, breathing becomes labored. It can be likened to breathing through a straw. These kids snore, sometimes with a higher pitch, and have excessive daytime sleepiness.

·      Obstructive Sleep Apnea is much more obvious – this happens when tonsils or adenoids, alone or in combination with an abnormal airway, almost completely block the airway when a child lies down. Typically OSA involves thrashing, multiple awakenings, gasping, choking sounds, startles and snoring with no rhythm.

Is sleep disordered breathing dangerous?

We know that disordered breathing during sleep places stress on the heart and lungs of children and adults, and can lead to behavioral and academic difficulties. According to the NIH, sleep apnea can also increase the risk of heart attack, hypertension and type 2 diabetes.  So identifying which children have obstructive sleep apnea and intervening has health benefits beyond school performance.

How can a parent tell if a child has sleep disordered breathing?

 If a child wakes refreshed in the morning, is alert and attentive during school and has consistent academic performance, likely there is low risk.  However if a child is irritable, tired, showing signs of difficulty in school, or his snoring is audible to parents at night, it’s time to bring this to his doctor’s attention. I’ve even had parents place a tape recorder or MP3 player near the bed to record snoring. Another observation, especially with OSA, is a bed that is trashed the next morning. Kids with OSA thrash all night and their bed is evidence!

 Are there tests for worrisome snoring?

Yes.  There are now sleep centers available to perform sleep studies on children and adults with suspected sleep apnea.  A child is hooked up to oxygen, CO2 and heart monitors, and as sleep progresses measures of breathing, interruption and apnea are taken. It’s important to have proof positive of sleep apnea before considering adenotonsillectomy. If there are concerns about craniofacial/orthodontic/airway issues, there are specialty orthodontists and ENTs (ear, nose and throat physicians) who can assess if orthodontia, tonsillectomy/adenoidectomy or jaw surgery are the answers.

How common is sleep disordered breathing?

Based on parent reporting, 1.5% to 27.6% of their children are reported to snore, but best research estimates that number is closer to 6% to 12%. Obstructive sleep apnea is estimated to affect up to 1% to 4% of children. Larger than normal adenoids and tonsils are the major contributors to sleep disordered breathing in children, and removing these (adenotonsillectomy) leads to significant improvement in sleep disordered breathing symptoms for most children. However, further research is necessary to tell us whether the correction of OSA will reverse the effects of academic impairment seen in some children.  It's also important to realize that obesity, craniofacial genetics, abnormally shaped airways and nervous system control mechanisms keeping the upper airways open are other contributory factors.

So what did the New Zealand study show?

The data from 16 large studies from worldwide sources were collected and examined to see if sleep disordered breathing affected academic performance in school aged children.

Academic performance was measured in several ways in the literature and categorized broadly as follows: (1) general performance (2) language arts  (3) math (4) science; and (5) unsatisfactory progress (learning problem, grade failure, poor school performance).

To best illustrate the results: if a large sample of children without sleep-disordered breathing achieved an average 70% score for a test examination a comparable sample of children of the same age with sleep-disordered breathing would be estimated to achieve an average score of 59%. Hence for those children with sleep disordered breathing, the potential exists to cross percentiles academically that may make the difference between passing, and failing.

The results of this review combined evidence in the literature to show that Sleep Disordered Breathing in children is significantly associated with poorer academic performance. As a result, screening for SDB should be included in pediatric and multidisciplinary assessments of children’s learning difficulties, with appropriate medical follow-up as indicated.

For a link to the segment on Home & Family go to: