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Sleep Apnea in Children

Sleep apnea in children occurs due to weakness in the muscles of the upper airway, or due to differences in the structure of the bones of the head and face.

Factors that increase the risk of sleep apnea include: enlarged tonsils, obesity, receding lower jaw, long and narrow face, narrow upper jaw, open space between the top and bottom front teeth, and underdevelopment of the midface. Certain genetic syndromes are also associated with an increased risk, such as Pierre Robin sequence, craniosynostosis, and Down syndrome.

When a child suffers from chronic nasal airway obstruction due to enlarged adenoids or tonsils, this blockage forces the child to breathe through the mouth, preventing the tongue from resting in its natural position against the roof of the mouth. As this condition persists, proper growth of the face and jaws is impaired, resulting in a long face with a constantly open mouth, a receding lower jaw, and a narrow upper jaw.

Symptoms of sleep apnea in children include snoring, pauses in breathing, and choking during sleep. Parents may notice the child sleeping in unusual positions, such as tilting the head back, sleeping in a kneeling position or sitting up. The child may experience excessive daytime sleepiness or, conversely, hyperactivity. Any child who snores should be evaluated to determine their risk level.

This condition is diagnosed through a sleep study. If left untreated, it can lead to poor growth, heart problems, poor academic performance, and bedwetting.

Orthodontists should be attentive to these symptoms when examining patients and refer them to the appropriate specialist. Treatment, in cases where there are structural differences in the facial and jaw bones, may involve a collaborative intervention between a sleep physician, ear, nose, and throat surgeons, and an orthodontist. Tonsillectomy is considered the first-line treatment if the tonsils are enlarged. The doctor may also prescribe medications to reduce the size of nasal tissues, if enlarged. Weight loss is recommended for obese children, and positive airway pressure devices are used in cases of severe apnea. The orthodontist's role in treatment includes:

1. Upper Jaw Expander

This device is custom made for each patient, fixed to the upper teeth, and works to gently expand the upper jaw over several weeks. This expansion not only provides space for crowded teeth but also widens the palatal bone, which forms the floor of the nasal cavity. As this floor widens, the nasal airway space increases, often leading to significant and lasting improvement in nasal breathing and reduced reliance on mouth breathing. Today, the manufacturing of these devices relies on high-tech digital processes, where the fast and comfortable digital scanner has replaced traditional impressions. The device is then manufactured in the laboratory using 3D printing technology, resulting in a device with exceptional precision and comfort that was previously unavailable. The timing of this treatment is crucial for achieving the best results. The ideal period is typically during childhood, specifically between the ages of six and eleven. This is because the two halves of the upper jaw bone are not fully fused until later stages of life. While expansion remains possible for adults, the process is different and more difficult, and may require surgical assistance to achieve similar results. Consulting with an orthodontist is the best step to determine whether a palatal expander is the right solution.

2. Functional Appliances

For a child with underdevelopment and retrusion (backward positioning) of the upper jaw, a maxillary advancement device (facemask therapy), which attaches to the upper teeth and uses elastic bands, can stimulate the entire midface to grow forward, improving facial balance and how the teeth fit together. This treatment aims to increase the airway space behind the nasal area by moving the upper jaw forward.

Another common functional appliance is the mandibular advancement device for children, which consists of two complementary parts fitted on the upper and lower teeth. When worn, this device repositions the lower jaw forward. By holding the jaw in this new position, it effectively helps the smaller lower jaw to grow. It also increases the pharyngeal airway space behind the mouth by moving the lower jaw and tongue forward.

The key to success with these devices, much like with expansion appliances, is timing. These devices are most effective during the child's growth spurt, making the pre-teen and early teenage years (from 7 to 13 years) the ideal time for treatment. An orthodontic evaluation before age seven is often recommended to diagnose these issues early and plan the most effective interventions.

Myofunctional Therapy and Tongue-Tie Release

This therapy is typically conducted with a speech and swallowing specialist and involves specific exercises designed to retrain the function of weak muscles. This step can be important in correcting bad tongue habits or mouth breathing. It is particularly effective when a narrow palate or an opening between the front teeth are corrected using an orthodontic appliance, as it «trains» the tongue to rest correctly against the roof of the mouth. Furthermore, research shows that for patients with tongue-tie (ankyloglossia), combining the surgical release of the tie with myofunctional therapy achieves the best possible outcome.

In conclusion, treating sleep apnea in children requires the collaboration of a multidisciplinary medical team. It is essential for parents to discuss any of the above risk factors with a physician to diagnose the condition or refer the child to the appropriate specialist. Book a consultation in Kuwait.