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More Children With Sleep Problems Seek Overnight Tests

Washington, D.C.

As new research raises awareness of the impact of poor sleep in children, more are finding their way to pediatric sleep clinics for testing. Andrea Petersen and Children's National Medical Center Director of Sleep Medicine Dr. Judith Owens explain on Lunch Break. Photo: Melissa Golden for The Wall Street Journal.

As more research spotlights the damaging effects of a poor night's sleep on children, a growing number of kids are undergoing pricey, sci-fi-like overnight sleep studies.

The studies, conducted at hospitals and free-standing sleep clinics, are used to diagnose slumber issues like sleep apnea as well as to get at the root cause of behavioral and attention problems.

A sleep technologist prepares Mason Brock, 5, for a study. ENLARGE
A sleep technologist prepares Mason Brock, 5, for a study. Melissa Golden for The Wall Street Journal

Recent studies have linked sleep problems in children to a host of issues including obesity, learning and memory problems and an increased risk of developing mental illness—particularly anxiety disorders and depression—later in life. The growing number of children diagnosed with attention deficit hyperactivity disorder and autism is spurring interest in sleep, too, as sleep problems are common in these kids. As many as three-quarters of children with neurodevelopmental or psychiatric conditions have insomnia.

Also, the symptoms of ADHD and sleep problems can look quite similar. "We see more and more parents who come in saying, 'My pediatrician wants to put my child on Ritalin because he thinks he has ADHD, but I want to make sure there's not a sleep problem,' " says Judith A. Owens, director of sleep medicine at Children's National Medical Center in Washington, D.C.

Sleep-deprived children are "fidgety, distracted, inattentive and may have a short fuse," says Merrill S. Wise, a sleep medicine specialist at the Methodist Healthcare Sleep Disorders Center in Memphis, Tenn.

In 2012, there were 2,517 sleep centers accredited by the American Academy of Sleep Medicine, of which 623 saw patients younger than 13. In 2007, there were 1,395 accredited centers; 493 treated children. More adult sleep centers are starting to see children, too, partly because of an increase in adult patients who are choosing at-home sleep studies, says Dr. Owens. Pediatric sleep specialists tend to be pediatricians who then have acquired a subspecialty certification in sleep medicine from the American Board of Pediatrics.

Sleep studies cost between $2,000 and $5,000 and are mostly covered by insurance.

On a recent Tuesday night, 5-year-old Mason Brock, a toy dragon and two wrestling action figures by his side, was doing an overnight sleep study at the Children's National Medical Center to find out why he snored. He had seven colorful wires attached to his head, more stuck to his legs, and two bands wrapped around his torso.

"I snore like an engine on top of a car. Daddy said that," he said.

Judith A. Owens of Children's National Medical Center in Washington, D.C. ENLARGE
Judith A. Owens of Children's National Medical Center in Washington, D.C. Melissa Golden for The Wall Street Journal
Data collected during just one minute of an overnight sleep study on an 18-month-old boy with sleep apnea. ENLARGE
Data collected during just one minute of an overnight sleep study on an 18-month-old boy with sleep apnea. Melissa Golden for The Wall Street Journal

The most common sleep problems in children are difficulty falling asleep and staying asleep and overall insufficient shut-eye. Another growing problem is sleep apnea. Usually thought of as an adult disorder, sleep apnea—in which children frequently stop breathing or have episodes of reduced airflow during sleep—afflicts between 1% and 3% of children, though many doctors believe the number is greater.

The biggest red flag is loud, persistent snoring, says Haviva Veler, director of the Weill Cornell Pediatric Sleep Center in New York, which opened in 2012. "If you hear it outside the room" it is a problem, she says. "So many kids snore and parents think it is normal and cute. They don't know it is actually a symptom."

The major causes of sleep apnea in children are enlarged tonsils and adenoids, tissue in the back of the nasal cavity. Between ages 3 and 5 "the airway is still small but the tonsils and adenoids are at their largest," says Jodi Mindell associate director of the Sleep Center at the Children's Hospital of Philadelphia. As in adults, obesity can cause sleep apnea, too.

During a sleep study, wires attached to the head monitor brain waves that reveal which stage of sleep a person is in. Leads attached next to the eyes can capture eye movement, useful for revealing when a patient is in rapid eye movement, or REM, sleep. Leads on the legs measure limb movement. Bands around the chest and abdomen can show how hard a child is working to breathe. Probes at the nose and mouth measure air flow and temperature. A monitor placed on a finger measures blood oxygen levels.

Sleep studies are sometimes used to diagnose so-called parasomnias such as sleep walking and sleep terrors. They also can help identify restless leg syndrome, a chronic neurological disorder often characterized by the urge to move the legs. Sleep studies don't usually need to be done on children who have trouble falling asleep or staying asleep. For those kids, there tend to be behavioral reasons for their sleep problems, such as caffeine use, TV watching before bed or other issues such as anxiety.

There are unique challenges in doing sleep studies on children. Technicians at pediatric sleep centers must be adept at getting even squirmy toddlers to tolerate wires on their heads. (At Weill Cornell, technicians wait until children are asleep to put on the facial leads.)

An hour past his usual bedtime, Mason was awake and transfixed by the glowing orange light on the oxygen monitor taped to his finger, ET-style. He put his luminous finger in and out of the mouth of his green, plastic dinosaur doll. Kike Ogbonlaiye, the sleep technologist, was watching this on a small black-and-white monitor. When Mason began fiddling with the probe near his nose, she said into a microphone that could be heard in his room, "I can see you. Don't touch it." Mason stopped moving.

Matteo Battisti, age 2, at his overnight sleep study at the Weill Cornell Pediatric Sleep Center in New York. He was diagnosed with sleep apnea. ENLARGE

Doze Decision

Here are factors that sleep experts say to consider when deciding whether a child could benefit from a sleep study:

  • Does loud, persistent snoring occur more than three times a week?
  • Is it accompanied by choking or gagging sounds?
  • Can the snoring be heard from outside the child's room?
  • Is a potty-trained child wetting the bed at night?
  • Does the child seem tired during the day despite getting enough sleep?
  • Are there daytime behavior, attention or mood problems?

Source: Judith A. Owens and Haviva Veler

Children's sleep is different than grown-up sleep. Kids spend a lot more time in deep sleep and in REM sleep. "This is why when your kid falls asleep in the car, you can take them in [the house], change them and they never wake up," says Dr. Mindell. Sleep terrors happen during deep sleep, which is why kids tend to outgrow them by puberty.

If sleep apnea is caused by enlarged tonsils and adenoids, the treatment is often surgery to remove them. Some doctors will first try a course of antibiotics and nasal steroids to shrink the tonsils and adenoids.

Vikash Modi, a pediatric otolaryngologist at New York-Presbyterian/Weill Cornell Komansky Center for Children's Health, says about 80% of his practice consists of "kids that snore and have difficulties with sleep." There have been advances in tonsil surgery in recent years. In the past, the entire tonsil was removed. Now, surgeons remove only about 95% of the tissue. This reduces the risk of bleeding and means much less pain for the child, says Dr. Modi.

If obesity is the cause of sleep apnea, children are often put on a weight-management program. And as with adults, they are often prescribed continuous positive airway pressure or CPAP treatment. With CPAP, a machine pushes air into the airway, preventing it from collapsing. The machines are the same for adults and kids, but a child-sized mask is used. Dr. Mindell says her clinic now has about 300 children on CPAP.

In a small study published in 2011, after obese adolescents with sleep apnea were prescribed CPAP and actively used it, their attention and grades in school improved.

Matteo Battisti wasn't even 2 years old when his mother, Nicole, became concerned about his breathing during sleep. "You could hear him snoring from the next room, followed by these gasps and choking noises," says Ms. Battisti, a stay-at-home mother in Manhattan. "He was so tired during the day and irritable."

So Ms. Battisti took Matteo, who turns 3 in June, for a sleep study at Weill Cornell, where he was diagnosed with sleep apnea. He had surgery to remove his tonsils and adenoids in January. Now, Matteo no longer snores. "To see him breathe and sleep so soundly and peacefully, it makes me feel good," Ms. Battisti says.

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