Misdiagnosing Pediatric Sleep-Disordered Breathing

By Hillary Eames
Friday, November 1, 2019

An estimated nine out of 10 children with sleep-disordered breathing are undiagnosed, often because physicians attribute symptoms to behavioral issues rather than to common sleep issues such as sleep apnea, according to a recent study in The Journal of the American Osteopathic Association (JAOA).

A decade ago, an article published in The Ochsner Journal identified obstructive sleep apnea as “an underrecognized and underdiagnosed medical condition.” At the time of publication, more than 85% of adults with clinically significant obstructive sleep apnea had never been diagnosed. Now, a similar epidemic may be on the rise, with pediatric sleep apnea remaining routinely unrecognized in children. Research published this year in JAOA estimates that up to 15% of children may have sleep apnea, with 90% of those remaining undiagnosed. According to the research, misdiagnosing symptoms for children’s sleep apnea and related conditions — or ignoring the issue altogether or not providing proper treatment — can have dire consequences.

Affecting Function

Snoring, daytime sleepiness and restless sleep are some common sleep apnea symptoms in both adults and children, but researchers report that other sleep apnea symptoms in children can be misdiagnosed because they can mirror behavioral or psychosocial issues, such as ADHD.

“Some evidence shows that significant sleep apnea may interfere with daytime behavior [and] daytime aggressiveness,” explains Ibrahim Abdulhamid, MD, Chief of Pulmonary Medicine and Director of the Pediatric Sleep Lab at Children’s Hospital of Michigan in Detroit, who was not involved with the study. “Kids may have some hyperactivity symptoms, and it can affect their cognitive and academic functioning.”

Sleep is critical to children’s health, as their brains receive growth hormones during deep sleep stages. When their sleep is interrupted, it can affect the development of the prefrontal cortex.

“Sleep is the only time that growth hormone is released, and children need it more than adults,” says John White, DDS, co-author of the study who recently retired as Dental Sleep Director at Family Dental Health in Greenville, South Carolina. “If they don’t receive that growth hormone, [it affects] executive function, hyperactivity, depression and social behavior.”

“Nobody knows much about pediatric sleep. Dentists don’t get much at school, and pediatricians don’t either. ... I think the interdisciplinary part is important.”
— John White, DDS, who recently retired as Dental Sleep Director at Family Dental Health in Greenville, South Carolina

Multidisciplinary Treatment for Anatomical Sleep Issues

In the JAOA article, the authors highlight the case of 9-year-old twins whose mother reported that both had snored heavily since age 2. Numerous care providers had disregarded the twins’ symptoms, which also included enlarged tonsils and daytime sleepiness. After a dentist identified the symptoms and prescribed an at-home sleep test, the children were diagnosed with sleep apnea and required treatment.

“Usually, the reason children have sleep apnea is because of the size of their jaw,” Dr. White says. “If the upper jaw doesn’t grow properly, the nasal cavity is too small and breathing is harder to do, so it’s easier for the airways to collapse at night.”

To combat the twins’ sleep issues, they received rapid maxillary expansion, followed by an adenotonsillectomy by an otolaryngologist and myofunctional rehabilitation by a speech pathologist. The study highlighted the need for multidisciplinary treatment efforts when caring for pediatric patients with sleep apnea and identified the need for additional sleep medicine training in healthcare providers.