About 20% of children in Singapore suffer from bronchial asthma. 20% of normal children also snore occasionally and 7 to 10% habitual snoring.

Dr Teoh Oon Hoe, Head and Senior Consultant from the Department of Paediatrics, Respiratory Medicine Service at KK Women's and Children's Hospital, gives detailed answers to your questions.

Question by margietan05

Hello there,

My girl is 2 years and 2 months ago and have been snoring for some time. She used to have colds very frequently and we had been told that is the cause for her snoring. However, we noticed the problem persisting even after she is well and we are very concerned. Sometimes, she appears to snore and sleep ok, but sometimes, she would appear to be breathless from snoring. What should we do about this? Is there anything we can do to make her snoring better? Should we consult a doctor for this?

cheers,
margaret

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear margietan05,

You should consult your family doctor or paediatrician regarding your daughter’s snoring if you have noticed that she sometimes appears to be “breathless” from snoring. It is possible that she may have obstructive sleep apnoea, a condition where there are recurrent intermittent obstructions of the upper airway during sleep. Your family doctor or paediatrician will be able to assess your child’s nose and throat to look for signs of allergic rhinitis, enlarged tonsils and other risk factors for obstructive sleep apnoea. Depending on his/her assessment of the cause of the snoring after reviewing the symptoms and physical examination, he/she may start your child on oral and/or nasal medications for allergic rhinitis and review for improvement, or refer her to a paediatric sleep specialist for evaluation for possible obstructive sleep apnoea.

Question by rachel

My son has asthma and occasionally has trouble breathing, which Ventolin resolves.

Recently I do notice that he does snore, rather loudly sometimes. Is this a casue for concern? What are the indications and any way to prevent complications?

Is snoring hereditary?

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear rachel, Children with asthma often have the associated condition of allergic rhinitis, and allergic rhinitis may cause snoring, sometimes louder when the condition is worse with the nose being very congested.

However, snoring can also be a symptom of obstructive sleep apnoea. Some of the symptoms suggestive of obstructive sleep apnoea that parents should watch out for in snoring children are

• Cyanosis (bluish or purplish discoloration of the lips, nail beds or skin) or apnoea (transient cessation of breathing) during sleep
• Snorting, gasping associated with snoring during sleep
• Laboured breathing during sleep
• Unusual sleeping position, such as hyperextending the neck to breathe better
• Restlessness and frequent awakening during sleep
• Diaphoresis (profuse perspiration) during sleep
• Mouth breathing in the day or during sleep
• Difficulty getting up in the morning
• Unrefreshed after an overnight sleep
• Morning headaches

Children with persistent snoring associated with any of the above symptoms or complications of obstructive sleep apnoea should be evaluated. Some of the complications of untreated significant obstructive sleep apnoea include

• Learning and/or behavioral problems
• Poor growth Hypertension (high blood pressure)
• Gastroesophageal reflux (backward flow of stomach contents into the food passage)
• Insulin resistance and metabolic syndrome (group of medical conditions associated with high blood pressure, heart disease and diabetes)
• Death in very severe untreated cases

Appropriate treatment of obstructive sleep apnoea can prevent the complications above. Treatment options for obstructive sleep apnoea depend on the cause for the obstructive sleep apnoea. The majority of children with obstructive sleep apnoea have enlarged tonsils and/or adenoids as the cause, and are usually well after the tonsils and/or adenoids are surgically removed. The other main group of children who have obstructive sleep apnoea related to obesity should lose weight. Some of them may need to use a machine which delivers a continuous positive airway pressure (CPAP) to keep their upper airways open during sleep. Children who have snoring due to allergic rhinitis but no obstructive sleep apnoea can be treated with topical nasal steroids and/or oral antihistamines.

Yes, snoring can be hereditary.

Question by serenetwg

My son will be 11 years old this year. He has problems at sleeping and most of the time, his nose seems to be blocked at night during sleeping and he has to breathe through his mouth. He does not have asthma. What can I do or must I bring him to see a specialist for it?

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear serenetwg,

From your description your son may have allergic rhinitis and possibly also enlarged adenoids and/or tonsils. These conditions can cause snoring and if severe may also cause obstructive sleep apnoea. You may consult your family doctor or paediatrician, who will review the symptoms and examine him. Depending on the assessment by your doctor, he may either prescribe oral and/or nasal medications mentioned above to treat allergic rhinitis and review your child for improvement, or refer him to a paediatric sleep specialist for evaluation if he suspects obstructive sleep apnoea.

Question by ctlb

I understand this section is to address kids snoring.Please allow me to ask a question about snoring for adults. In my limited knowlege, snoring is an issue that we are concerned. My husband snore alot, it seems to be getting worst as the yrs past.I am not sure if this is due to work stress,as he stay awake til 2-3am each night before he can get to sleep. Or it is his eating habit.He tends to eat a lot(meaty stuff) including supper and he has a bulging stomach. Any advise will be greatly appreciated as his snoring is affecting my sleep.Almostly everynight I will wake up around 4-5am as a result of his snoring.

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear ctlb,

I do not have sufficient information to give specific advice, and I am also a paediatric sleep specialist, so I would suggest that your husband consult your family doctor regarding his sleep problems as they can have a significant impact on his health and seem to be affecting your sleep.

As a general advice, it sounds like he may be overweight from your physical description. Your family doctor would be able to assess if your husband is overweight, and whether he is at risk for obstructive sleep apnoea and refer him to an adult sleep specialist for evaluation if needed. Your specific concern that his snoring is getting louder is certainly a valid one. The fact that he sleeps late and takes supper regularly before sleep is also of concern. He may not be getting sufficient sleep by sleeping late. It is difficult to tell why he is sleeping late from the information provided. Some of the reasons may be related to stress, poor sleep hygiene, his natural circadian rhythm, or related to obstructive sleep apnoea. Going to bed with a full stomach is also unhealthy and can increase risk of gastroesophageal reflux as well as affect his quality of sleep.

Question by grandmafull

Hi Dr Teoh

My granddaughter, 8, often talks in her sleep. She and her brother, 6, often grind their teeth, too. Her brother would sometimes wake up in the night crying from pain from cramps in his calves. Since he started school this Jan, he complains of cramps in both legs. Both snore but not nightly. My granddaughter was on a inhaler and nose spray but have stopped since June 2010. Please advise. Thank you.

Margaret

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear grandmafull,

Sleep talking or “somniloquy” in medical terms is common in childhood, affecting up to 50% of children. In children sometimes it is brought on when the child is unwell with a fever, sleep deprived, or due to external factors such as stressful events during the daytime. It may run in the family. Most times it is harmless and does not require treatment in children.

Teeth grinding or “bruxism” in medical terms is fairly common in childhood, affecting up to 20% of children under 11 years of age in one study. Most times it is self-limiting and does not require treatment. Anxiety and stress may be a factor in bruxism in some children, so this is an area that parents may want to assess in children with frequent or severe bruxism. If the teeth grinding is associated with painful or swollen jaw, headache, sensitive teeth or evidence of teeth damage, the child should be referred to a paediatric dentist for evaluation and treatment.

Considering his age and that his problem began soon after starting school, I would say that your grandson’s pain or cramps in his calves during sleep are most likely due to “growing pains” in children or perhaps nocturnal leg cramps, both generally benign and fairly common conditions in children. The pain is usually relieved by massaging, stretching or warm compresses. If the pain is persistent or occurs even during the day, increased on handling or movement, localised to a joint, causes a limp while walking, associated with any localised weakness, wound, bruise, redness, swelling or a rash on the body, you should consult your family doctor or paediatrician.

Regarding the snoring, please refer to the replies earlier.

Question by nhk080104

Hi,

My daughter is coming to 4 years this March and she is still waking up several times crying in the night NOT for milk but bad dreams etc. I read from books that this is quite common among young children and it will normally stop at about 3 years. My son had the same problems when he was young but it stopped after he turned 3 years.

Should I consult a doctor to resolve this problem or should I wait till she grows older and maybe, it will stop.

Thanks
Susie (nhk080104)

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear Susie,

Nightmares or bad dreams are part of normal cognitive development and peak between 3 to 6 years in children, so you can probably still observe for a while longer, unless they are severe or persistent, or cause disruption to you and/or your child’s life, in which case you should consult your paediatrician for advice. You can try the following measures for your 4 year old daughter in the meantime:

• Avoid exposure to frightening or overstimulating stories, games, images, movies or television shows before bedtime.
• Ensure adequate sleep and good sleep hygiene
• Reassure her that “it was only a dream” and hold her to provide physical comfort if necessary.
• Give her a security object that she can keep in bed with her may help her to feel more relaxed and secure through the night.
• Leave a light on, to the dimmest setting possible, if she would like to have a light on.
• Leave the discussion about the nightmare to the next day if you want to talk about it to her to see if there is anything bothering her.
• If she is expressive and imaginative, you can try to get her to draw pictures of her nightmares and then throw them away, and get her to imaging different endings to her nightmares.

Question by karen1311

Hi! My daughter is 21mth old, and she has been waking up (1 to 3 times) almost every night for a few months now.

Because she sleeps in my room (next to my bed), she would usually suddenly get up from her bed, still half asleep and crawled onto ours. Sometimes she would fall back to sleep immediately, but most times, she would do alot of tossing, turning, sitting up then flopping back down onto the bed (in all directions). This could last up to 1 hour. Sometimes if she can't get back to sleep, she would cry out in fustration. Her eyes are closed throughout.

Other times, she would suddenly wake, sat up & scream for me, asked to be carried & would demand to go outside etc. She would scream endlessly till her demands are made.

Here is a quick run-through on her night routine.

8pm Bath

8.15pm Night Milk followed by brushing of teeth

8.30pm Sleep

We have not tried to let her fall asleep on her own without either one parent in the room with her. We do not pat or rock her though, just keeping her company while she tries to fall asleep.

No matter what times she eventually falls asleep (normally 9 to 9.30pm), she always wakes around 6.30 to 7.

She takes 1 nap now, around 1pm. Most times for 1.5hrs, sometimes 2hrs if she wakes up very early. This is taking a toil on both my husband and I. Pls help!

Thank you
Panda Mommy :(

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear karen1311,

Your main problem seems to be related to the night wakings and you are also concerned about your daughter’s waking time in the morning. You have established a bedtime routine for her but she sometimes still takes a while to fall asleep. You have also taken care not to encourage the development of bedtime negative sleep onset associations from your description.

You mentioned that the problem has been for a few months, so I am assuming that she has slept well through the night before this. You also did not mention any specific association or action from parents that is required for your child to fall asleep again. Based on the above information, I think you need to find out if there are any factors that may be causing your child to arouse from sleep and/or preventing her from falling asleep during the night. Has there been a change in the bedroom environment that has made it unconducive for her sleep? Has there been a recent illness, significant change of her daily routine or a stressful event? You also need to consider sleep disturbances from medical conditions as a possible cause. The more common medical conditions that may disturb sleep in children include allergic rhinitis, asthma, eczema and obstructive sleep apnoea. Look out for cough, shortness of breath, nasal symptoms, frequent scratching or snoring or any of the symptoms of obstructive sleep apnoea that I have listed above. If you suspect any medical condition as the cause, you should consult your family doctor or paediatrician who would be able to treat most of these conditions, and see if the situation improves. If your doctor suspects obstructive sleep apnoea, he/she will refer you to a paediatric sleep specialist for a sleep study to find out.

The episodes where she wakes up and screams for you may be nightmares. The content of nightmares from toddlers generally involve concerns about being separated from their parents or a recent traumatic event experience by the child, and by 2 years of age, nightmares begin to incorporate monsters and other imaginary frightening creatures. You can refer to the reply above for general advice on nightmares in children.

All the above conditions or factors excluded, there may be an element of negative sleep onset association requiring your attention or action after the night waking. This negative sleep onset association may have been present from the start or developed along the way when the underlying cause of the night wakings remained unresolved for a period of time. In your situation, I am thinking it may be better to adopt the “wait and see” approach where you continue to train your child to fall asleep using a suitable “graduated extinction” approach described in most books, and continue to respond to your child the way that would soothe her to sleep quickly during her night wakings. Usually once your child develops self soothing skills at bed time, the skills are likely to generalise to self soothing during the night within the next few weeks. This approach will likely be less stressful and allow both you and your child to get more sleep.

Regarding your concern about her early morning wake time, this may be due to her natural circadian rhythm, or may actually be her last night waking, but you can put this aside for the time being. It may sort itself out when her sleep improves.

My advice above is based on the information you have provided, and is limited by the fact that some details cannot be clarified in this method of interaction. I would advise you to bring your child to consult a general paediatrician who would be able to ask more specific questions and examine your child. Most general paediatricians would be able to provide advice and guidance on behavioural sleep problems in children, and if there are any concerns, they can refer your child to a paediatric sleep specialist for further evaluation.

Question by merlion

Hi Dr Teoh,

I notice that my almost 3 years old son snored while sleeping. It becoming more noticeable as I'm concerned as my elder son 14 years old develop asthma when young. So could this be deal to hereditary? How can I address this problem when he is still young?

I'll be bringing him to swimming lessons soon. Hopefully, it will help to improve the situation.

Thanks in Advance.
TAN, EP

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear merlion,

Snoring itself does not lead to asthma, but allergic rhinitis, which can cause snoring, is strongly linked to asthma. Both allergic rhinitis and asthma can run in the family. You should watch out for the symptoms of obstructive sleep apnoea that I mentioned in my earlier replies. If any is present, you should see a paediatric sleep specialist to see if you child needs to have a sleep study to evaluate for obstructive sleep apnoea. If you have any concerns about asthma or his snoring, you should see your family doctor or paediatrician for assessment.

Question by pranav

hi doctor,

My son is on age 5, he is having snoreing problem in night some times, and sleeping is also not deeply. if i make him sleep on 8p.m. or 10.pm he wake up around 6.30 to 7.00 a.m. in the morning.

and he says i dont want to sleep even 12'o' clock midnight, many time he feel difficult to breathe, because of blocked nose. he is breathing through his mouth. his father is having snoring problem, is it come to my son also.

what is the solution, pls help me through the answer.

thanks & regard
sudha

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear sudha,

Your son may have allergic rhinitis and his sleep sounds disturbed. You should consult your family doctor or paediatrician to see if he has allergic rhinitis and enlarged tonsils, and for treatment if he has allergic rhinitis. If his tonsils are very large, or if he still snores with difficulty breathing or poor sleep despite treatment of his allergic rhinitis, you doctor will refer him to a paediatric sleep specialist for evaluation for obstructive sleep apnoea with a sleep study.

Your son may be stalling and refusing to go to bed, from your limited description. You should set ageappropriate limits for him by establishing clear bedtime rules and be firm with the rules. Positive reinforcement in the form of small rewards for positive behaviours and larger rewards for continued positive behaviour.

Question by hxtyc

My Baby girl was borned on 7 Oct 2010.She sleeps only about 10 hrs a day, sometimes less.She has problem falling asleep.

She won't sleep unless we pat her, sometimes we need to pat her for an hour before she falls asleep.Though hungry, she will not drink unless she is sleeping. She often falls into deep sleep while drinking and hence does not finish drinking her formula.Then, she will cry and wake up about half and hour of sleep, she will then be awake for at least 2 hours before another nap of half an hour or sometimes less. She is easily awaken, a little sound will stir her frantic crying.Every night, she only sleep after midnight, most day about 2:30 am.

She likes looking at colourful things and get excited when looking at colourful towels, bedsheets and pillowcases, when she is excited, she 'speaks' and her leg move violently.

In total, she sleeps about 10 hours a day: one long sleep that lasts for 4 - 5 hours. One short sleep of 2-3 hours, 3 half an hour nap. she can turn her body when she is 3 months old . That make feeding her more difficult as she will not lay still.

She refuses to settle on her bed or her cradle unless she has fallen into a deep sleep. She sucks and licks both her hands all the time unless when held upright facing outward. She refuses a pacifier. She weighs about 5.8kg, length 60 cm, feeding time not certain, about 100 ml 2 1/2 hours once. The formula is Karihome.

Based on my description, I would like to to know is she an hyper active child and how do I overcome her sleeping and feeding problem. Thanks. TY

Regards
TY

Answered by Dr Teoh Oon Hoe, Head and Consultant, Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital

Dear TY,

It is too early and not possible to diagnose hyperactivity in a child at your daughter’s age. Babies at this age can have a spectrum of different temperaments and it is most likely she is normal like most other babies her age. Although most babies at her age sleep between 14 to 15 hours, sleep duration can vary between normal healthy babies. I often tell parents that the following awareness of how newborns and infants sleep is important, so that parents can set realistic expectations for their newborns and themselves:

• Babies do not understand what is "sleeping through the night"
• Most babies do not sleep through most of the night before 3 to 6 months old
• Every baby is different, your baby may have different sleep patterns from other babies and still be normal and healthy
• Your baby will begin to sleep longer periods of time at night as he/she grows and develops over time.

It appears from your description that you are having difficulty in getting your baby daughter to sleep, and she may be developing negative sleep onset associations with bottle feeding and patting. Babies generally develop the ability to self-soothe to sleep between the age of 3 to 6 months, so your baby daughter is at the stage where she is about ready to learn to fall asleep on her own and remain asleep through the night. I usually give the following advice to parents with newborns and infants, which you can consider to help your baby daughter develop this ability:

• Put your baby to bed when drowsy but still awake, so that she can learn to fall asleep on her own in her own crib/cot/bed. If the mother is breastfeeding, avoid breastfeeding her to sleep, so that she does not associate this as a pre-requisite for sleep. For similar reasons, you should also avoid bottle feeding her to sleep. Some parents find gentle rhythmic patting of their babies helpful in settling them to sleep, but for the same reasons as before, it is best to stop the patting when the baby is quiet and about to fall asleep. Breast feeding, bottle feeding, patting, and other methods of settling your baby until she is completely asleep may result in sleep association with these conditions and make it difficult for her to go back to sleep if she wakes up during the night.
• Learn to identify signs of sleepiness in your baby. Newborns may express their need to sleep in different ways. Some fuss or cry, some indicate by rubbing their eyes, pulling their ears or other gestures, some yawn or lose focus on ongoing play or activity. Putting her to her cot/crib/bed when she is sleepy before she falls asleep allows her to fall asleep quickly and eventually learn how to get herself to sleep.
• When your baby wakes up and cries or fusses at night, wait a few minutes before responding to her. Allow her to try to fall back to sleep on her own first. If she continues to cry or fuss, check on her without turning on the lights, playing with, or picking her up. Consider if it is time for the next feed, if the nappies are soiled, or if she is uncomfortable for some other reason, including having a fever or being unwell. If these issues have been addressed and your baby continues to fuss or cry, you may try gentle rhythmic patting to settle her to sleep. Other settling options include patting the mattress or jiggling the cot/crib gently.
• When feeding or changing your baby during the night, do so in a quiet and calm manner to avoid stimulating her too much.
• Wrapping snuggly with a thin baby blanket / cotton / muslin wrap during sleep may help newborns to sleep uninterrupted by reducing their startles and make them feel more secure. However, you should take care not to overheat her with the wrapping, that the wrapping is not too tight, and that her breathing is not obstructed by the wrapping.
• Play and talk to your baby more during the day, and expose her to comfortable light and sounds, to help to lengthen her awake time, Keep the environment quieter and dimmer with less activity as evening approaches to help her sleep longer periods during the night.

As the specific strategies best to adopt to manage negative sleep onset associations that have developed are dependent on each child’s temperament, the parents’ personality and tolerance for crying, acceptance and expectation of methods, and the home routine and situation, it is difficult to provide advice over this method of communication. My advice would be to consult a general paediatrician for review of your daughter’s growth and general development from birth, and to discuss and review with him/her over a few visits the strategies that are acceptable, practical and workable for you. Most general paediatricians would be able to provide useful advice.

Ref: U11