Snoring and Mouth Breathing: When to Worry?

Have you peeked into your child’s bedroom to check on them? Did you hear them snoring & mouth-breathing? If they are snoring and mouth-breathing nearly every night, this is abnormal and unhealthy.

When should you be concerned about your child’s snoring? Snoring may be a sign of sleep apnea in children which can range from mild to severe airway obstruction. Sleep apnea is a health condition which causes the airway to become blocked during sleep. In the young child, the top 3 suspects are nasal allergies, enlarged tonsils and adenoids.

If your child snores sometimes, then that’s probably fine. But if your child is constantly snoring and mouth-breathing nearly every night when asleep, then that’s not a good sign that they are breathing clearly.

Lying flat on their backs is the worst position for a snoring person, child or adult. The airway muscles relax and close off the airflow, leading to a dip in the blood oxygen levels when asleep. These abnormal breathing events may recur many times during sleep and last as long as up to 2 minutes! Of course, if you fall ill with the flu, then things worsen with more nasal congestion and trapped mucus inside your airway.

The tonsils and adenoids play an important role in fighting infection in the young child, usually under age 5. But guess what? The tonsils and adenoids should get smaller on their own from the age of 5 to 8. So they should shrink naturally as the child grows older, but this does not always happen! We still see quite a few older children, teenagers and adults coming to see us with the same breathing problem they had as a young child! Their snoring & mouth-breathing just didn’t improve with time, despite waiting many years.

It is important to sort out your snoring and mouth-breathing child before they either stop growing or hit their growth spurt!

You may not even be aware that your child is snoring and mouth-breathing! Your child may sleep in a separate room from you. So sometimes, you only notice your child snoring when you go on holiday together!

Snoring may be a sign of underlying obstructive sleep apnea in children and adults. However, the child with sleep apnea may present differently from the adult with the same problem. It’s not just about poor quality sleep in your child but also the daytime repercussions of behavioural changes, low energy levels, and even their academic performance.

If your 7 year old child is still having to take an afternoon nap daily, then this is unusual. It means that he or she isn’t sleeping well at night. With the snoring & mouth-breathing, suspect sleep apnea in children!

• Persistent snoring: If your child is snoring louder than his Dad, this is definitely NOT normal!
• Persistent mouth-breathing in daytime and at night
• Strange breathing noises including “heavy breathing”: The child with poor sleep quality and sleep apnea may not always snore. Sometimes, it just sounds like noisy breathing and something stuck inside their airway!
• Recurrent gasping for air and snorting during sleep
• Restless sleep
• Recurrent episodes of nighttime waking: If it’s not to go to the toilet or look for Mummy, then these may be happening because they can’t breathe!
• Daytime tiredness: “I need to take an afternoon nap, Mummy!”
• Feeling grumpy and irritable with mood swings and temper tantrums
• Watch out for new bedwetting at night especially if they were already toilet-trained: This is a sign of severe stress due to poor sleep quality!

Don’t ignore these danger signs of sleep apnea in children! Please act early to bring your snoring child to see a paediatric ENT specialist in Singapore. It is always better to sort out these snoring and mouth-breathing symptoms early before they stop growing. For girls, they stop growing at puberty, around the age of 11 or 12 years.

The child who breathes and sleeps well is going to be healthier than the one who doesn’t! When your child sleeps well, they also grow well because the brain produces higher levels of growth hormones during good sleep.

I think the Top 3 most common causes of snoring in children are nasal allergy, enlarged tonsils and adenoids!

1. Nasal Allergies: A blocked nose means that air doesn’t enter your child’s nose easily. So any obstruction in your child’s airway will disturb the airflow and cause soft tissue to vibrate. This leads to funny noises like snoring and mouth-breathing. The most common trigger for nasal allergies is House Dust Mite allergy.
2. Enlarged Tonsils and Adenoids: Very often, children snore and breathe through their mouths because their tonsils or adenoids are enlarged. This leads to airway obstruction and hence snoring with mouth-breathing in children. The adults can sometimes end up with sleep apnea due to enlarged tonsils and adenoids too!
3. Severe bad flu or viral infection: Of course, if your child falls ill with a bad cold or flu, he or she will start to snore and mouth-breathe, due to the nasal and throat congestion. But if your child is snoring loudly every night, then this is abnormal. Sometimes, the child may frequently fall ill because the adenoids and tonsils are enlarged, trapping multiple viruses and bacteria too easily! Then some parents wonder why this becomes a vicious cycle because the adenoids and tonsils grow bigger with every infection, worsening the snoring and mouth-breathing.

It’s quite straightforward usually and here is a checklist of what we do:

1. Careful History: I always ask a lot of questions about your snoring child’s daytime and sleep patterns. I also want to find out your child’s eating habits and behavioural changes. Some children with Attention Deficit disorders (ADHD) may have underlying sleep apnea as a risk factor. I want to check that your child is up to date with his or her vaccination schedule too.
2. Nasoendoscopy: Done easily in the clinic and a video of your child’s entire airway is done. Takes a matter of seconds! Many children tolerate this quite well awake but some need some reassurance from their parents.
3. Sleep study: Usually can be done at home but some insurers only reimburse for hospital sleep studies in those under age 16 so please check. One night of data from an overnight sleep study is usually enough. Please be aware that sleep studies can sometimes show a false “normal” result if your child didn’t sleep enough or if the sleep is too disrupted.

I usually try a course of medications like a nasal spray and allergy meds first. Sometimes antibiotics may be important to treat any sinus or nose infection. If your snoring child still doesn’t improve with the nasal meds, then it is usually because the adenoids and tonsils are enlarged. There isn’t really any medication to make the adenoids and tonsils grow smaller except time. The adenoids and tonsils should shrink around the age of 5 to 8 years but of course, this doesn’t always happen in every child! Then the problems of blocked nose, snoring and mouth-breathing persist or worsen!

For children with enlarged tonsils or adenoids causing snoring or sleep apnea, surgical removal of the tonsils or adenoids can be highly effective. Nearly 90% of snoring and mouth-breathing children start to breathe and sleep better after adenoid and tonsil surgery! The surgery can be done as a day case but sometimes, if the sleep apnea is severe, we may prefer to monitor the child overnight postoperative before they go home the next day.

For the minority of children with residual symptoms of sleep apnea, a trial of Continuous Positive Airway Pressure (CPAP) may be helpful. This involves wearing a mask that delivers constant air pressure to prevent the airway closing off during sleep. However, CPAP is not very popular with many children. Don’t forget to have a paediatric dentist examine your child too in case they have palate or jaw structure abnormalities which narrow their airway!