“Ask Dr. HKSH” - Snoring in Children

Dr. HO Chung Wai, Ambrose

Specialist in Otorhinolaryngology

Q1. Is it normal for children to snore while sleeping?

Many parents wonder whether it is normal for children to snore frequently during sleep. Snoring is often mistaken as a sign of deep sleep. In fact, those who snore may actually be suffering from obstructive sleep apnoea. Obstructive sleep apnoea occurs when the upper airway becomes obstructed during sleep, leading to temporary pauses in breathing. Oxygen levels may drop when one stops breathing, causing sleep apnoea.

Parents should look out for signs such as excessively loud snoring, frequent tossing and turning throughout the night, poor sleep quality, daytime inattentiveness, and irritability. If any of the above symptoms are noted, parents should consult a doctor for comprehensive evaluation.

Q2. Why do children develop obstructive sleep apnoea?

Obstructive sleep apnoea is most commonly caused by enlarged tonsils or adenoids. The tonsils are located at the back of the throat, while the adenoids are situated at the back of the nasal passage. Both tissues are part of the upper respiratory tract. They can block the airway when enlarged.

In children aged three to nine, these lymphoid tissues are particularly prominent. Parents may notice that their child starts snoring as never before. A doctor will perform a physical examination and take a clinical history during consultation. Besides snoring, the doctor will check if the child breathes through the mouth during the daytime, has any learning difficulty, or shows signs of delayed physical growth. If any of the above symptoms are noted, further examinations are arranged.

Q3. How is obstructive sleep apnoea diagnosed? Is a sleep test necessary?

The doctor will usually ask parents about their child's symptoms and medical history, such as whether the snoring is unusually loud, whether the child tosses and turns during sleep, or even wakes up suddenly. Certain examinations will then be arranged. While some examinations may be difficult for children, we will first try to ask them to open the mouth for enlarged tonsils. As the adenoids are located deep inside the nasal cavity, some children may need to undergo a nasendoscopy, or if they refuse, an X-ray examination can be arranged instead to assess these areas.

While doctors may arrange a sleep test when indicated, it is not always necessary for all children. As one’s body is connected to many sensors during sleep test, these devices may cause sleep disturbance and affect result accuracy. An ear, nose and throat (ENT) specialist may perform a procedure called sleep nasendoscopy, which involves insertion of an endoscope after the child falls asleep to observe the site of obstruction. This allows for more precise treatment planning for the child.

Q4. What are the benefits of tonsillectomy/adenoidectomy? Is it safe?

If enlarged tonsils or adenoids are confirmed as the cause of sleep apnoea in children, a tonsillectomy or adenoidectomy is the preferred treatment option as these can achieve optimal therapeutic outcomes. Many patients show improvements in both quality of life and sleep quality after the procedure.

Speaking of safety, it is a well-established procedure. Parents often ask the following three questions about this treatment: Is my child too young for the procedure? Will it affect health after surgery? If tonsils/adenoids shrink on their own, can sleep aponea improve without surgery? Let’s address the issue about timing first: is my child too young for the procedure? Generally speaking, it is safe for children aged three or above to undergo surgery under general anaesthesia.

As for health impact after surgery, let us look at the alternative: obstructive sleep apnoea will continue if left untreated by surgery, and keep affecting your child’s health and development. The surgery actually helps improve the quality of life.

Many parents may wonder if they can wait for the tissues to shrink and skip surgery. However, it usually takes time for the tonsils or adenoids to shrink, usually not very significantly until puberty, while one may already snore and have obstructive sleep apnoea at six to eight years old. It should not be left untreated until puberty, as delayed treatment may lead to unsatisfactory outcomes.

Q5. When should surgery be considered? Are there any other alternatives?

The timing of surgery depends on whether the child's obstructive sleep apnoea is caused by enlarged tonsils or adenoids. Surgery is advised once the cause is clinically confirmed as enlarged tonsils or adenoids.

While many parents may prefer closer observation for any impairment in sleep quality,  tossing and turning during sleep, impact on quality of life during the daytime or attention problems,  early intervention is all the more important in preventing long-term adverse effects on children’s growth and health.

Other treatment options are available if the condition is relatively mild, snoring is not excessively loud, or the child does not wake up during sleep, such as weight management or treatment for allergic rhinitis, followed by close monitoring for improvement. For a small minority of patients deemed not suitable for surgery, positive airway pressure ventilation is recommended as a supportive measure. However, parents should consider surgery if the child is suitable for surgery.