Is something impacting your child’s sleep quality?
When a parent tells me they have a restless or wakeful baby or toddler, I have a series of questions I tend to ask in order to determine the root cause of their sleep challenges. More often than not, frequent wake ups are due to sleep habits (sleep behaviors!) or non-optimal scheduling and routines. But sometimes I come across a case where things just don’t seem to be as clear cut, and we need to consider the possibility that an underlying health challenge could be impacting sleep quality.
This may be things like feeding challenges, food allergies, or discomfort associated with reflux (more on reflux and sleep here!). We also want to watch for signs of other, less obvious conditions too- such as sleep disordered breathing, or restless sleep caused by iron deficiency.
I’ll stop here and remind you that I am NOT a doctor, and I do not provide medical advice. The purpose of this blog is to provide an overview of what I have parents speak to their care providers about when certain signs or sleep patterns are present. Please also don’t let this blog scare you! The health conditions I am speaking about are NOT the most common causes of sleep challenges like night waking or tough bedtimes. Talking about these topics is simply meant to empower and educate parents who feel there could be something beyond routines and behaviors impacting the quality of their child’s sleep.
Sleep Disordered Breathing
The first thing I want to say about sleep and breathing is that regular snoring is NOT normal. Not for babies, not for toddlers, not even for adults! Though it may be a “cute” or somewhat endearing trait for little kids, snoring is a sign that they are struggling to breathe well while asleep.
Frequent snoring is a common sign of something called sleep disordered breathing, which is a generalized term for breathing difficulties occurring during sleep. Sleep disordered breathing can range from mild (snoring or open mouth breathing) to Obstructive Sleep Apnea (OSA) which involves episodes of partial or complete airway blockage during sleep. Common causes of disordered sleep breathing in children include enlarged tonsils or adenoids, and craniofacial structural development leading to smaller ariways (recessed jaw, teeth crowding, narrow/high palate etc.).
Some signs of disordered sleep breathing include:
Frequent snoring (snoring while sick or congested is normal!)
Gasps or snorting noises while sleeping
Nighttime wetting (especially if it’s new)
Teeth grinding
Drooling while asleep
Sleeping with their neck hyperextended (almost as if they are looking for better airflow)
Open mouth breathing
Frequent cavities, despite good oral hygiene
Sleep disordered breathing is really a problem with sleep quality! A child may not have any behavioral challenges around sleep, and may even “sleep through the night” but if they are working hard to maintain their airway they aren’t getting the deep, restorative sleep they need. This is because each time their airway becomes blocked their body responds by trying to increase air flow. Their heart rate and blood pressure increase, their brain is awakened, and deep sleep is disrupted. The body will choose more airflow over sleep quality - everytime!
This poor sleep quality can lead to a number of daytime symptoms:
Daytime sleepiness
Headaches
ADHD like symptoms- challenges with attention, focus, or hyperactivity
Learning problems
Irritability
If you feel your child has symptoms of sleep disordered breathing the next step is to seek out a diagnosis and appropriate treatment - depending on where you live this can be pretty tricky! I recommend four avenues:
See your doctor or request a referral for an ear nose throat specialist for an in-depth exam and possible sleep study. Removal of enlarged adenoids and tonsils are a common part of treatment for sleep disordered breathing.
Find an Orofacial Myofunctional Therapist- these professionals are often also speech language pathologists or dental hygienists/dentists. Orofacial Myofunctional Therapy involves strengthening of the tongue and facial muscles and re-teaching them to function in the appropriate position. Research has shown that this can be a very effective treatment to reduce the airway blockages associated with sleep disordered breathing- especially in conjunction with other treatments.
Have your child assessed for oral ties by someone who is very experienced in this area (a ILBCLC-lactation consultant, speech language pathologist, or specialized dentist are your best bet!). Tongue and lip ties are often considered just a “breastfeeding problem” but they can also lead to improper/low tongue position causing mouth breathing, and eventually altered craniofacial structure.
See an airway focused dentist. Dental work can also be a component of treatment for sleep disordered breathing! Structural concerns with the face and jaw such as narrow/high palate can be modified through various dental appliances. Early palate expansion can be a really important tool to establish better nasal breathing, reduce tonsil/adenoid size, ensure proper tongue position, and promote healthy jaw development.
Nova’s story- Sleep Disordered Breathing & Airway Focused Dentistry
If you’ve been following along here on the blog, you’ll know that my oldest daughter, Nova, was a terrible sleeper as an infant. I eventually sought out help from a pediatric sleep consultant who helped me teach her how to sleep independently- and it changed our lives! Since then, she has continued to sleep well, and is generally very well-rested, healthy, and happy. Around age 5, I began to notice some new open mouth breathing overnight (I am totally that mom who creepily watches her kids sleep!). I chalked it up to her having back to back illnesses, but waited and watched. Soon after, we went to the dentist for a regular check up and he noted that in a period of 6 months Nova had 8 cavities- EIGHT!!! He indicated that her teeth were also slowly being pushed way too close together as she grew, and her palate was quite narrow. As a pediatric sleep consultant, this was an light bulb moment for me! I immediately booked an appointment with an airway focused dentist, who confirmed my suspicions based on a physical exam- the way her jaw and teeth were growing meant her tongue could no longer rest easily at the top of her mouth (where it should be). She also had slightly enlarged tonsils which he suspected was being caused by the mouth breathing she was doing overnight. For me, the decision to expand her palate using an appliance and retainer was an easy one. I wanted to protect her sleep quality, AND fix her dental issues now, well before she could have braces (which are a band-aid fix in many cases anyways!). Nine months into her palate expansion Nova is no longer mouth breathing at night, has better oral health, AND has a whole new jaw- she now has plenty of room for her adult teeth to come in!
Iron Deficiency and Restless Sleep
Restless sleep is a concern for many of the parents I work with! Frequent movement during sleep can be normal- the average person moves about 40 to 50 times a night! Certain types of movement however, such as repetitive motions, or uncontrollable movements of the limbs can indicate a problem.
Restless leg syndrome (RLS) is a sleep disorder characterized by an uncomfortable urge to move the legs during sleep. This frequent movement and discomfort is highly disruptive to sleep quality, and can cause daytime sleepiness, irritability and focus issues. Historically RLS was mostly diagnosed and treated in older adults, but more recently, research has indicated children and adolescents can be affected as well. One of the most interesting findings is that children who suffer from RLS and other similar sleep movement disorders are more likely to be iron deficient (with blood ferritin levels below 50 µg/L), and benefit from supplementation. This makes sense as dopamine production (a neurotransmitter involved in the sleep-wake cycle) is impacted by iron deficiency, AND is a key pathway involved in RLS.
Iron deficiency is actually a surprisingly common problem in North America! So much so that the American Academy of Pediatrics suggests breastfed infants over four months of age should receive an iron supplement, and all babies should be screened for iron deficiency at 12 months of age (read more about this here). The clinical guidelines around iron deficiency and screening are quite different here Canada, where iron levels may not be checked at all during infancy or toddlerhood.
According to the Mayo Clinic, some risk factors for low iron levels in children include
Babies who drink cow's milk or goat's milk before age 1
Breast-fed babies who aren't given complementary foods containing iron after age 6 months
Babies who drink formula that isn't fortified with iron
Children ages 1 to 5 who drink more than 24 ounces (710 milliliters) of cow's milk, goat's milk or soy milk a day
Children who have certain health conditions, such as chronic infections or restricted diets
Children who don't eat enough iron-rich foods
If you feel your child is at risk of having low iron, or is exhibiting strange sleep movement patterns overnight, I do suggest speaking to your doctor. Testing iron levels is a simple thing, but could have huge impacts for sleep quality and overall health! Another amazing resource to help you navigate challenges with feeding and nutrition would be a Registered Dietitian. In Canada, you can ask your doctor for a referral, or see one privately.
Signs that a health related condition is impacting a child’s sleep are often clear upon my first conversation with their parents.
In these cases, referral to appropriate healthcare provider is the very first step before we can work together on changing sleep behaviors. But remember, the majority of babies, toddlers, and older children struggling with common sleep issues like frequent night waking, early mornings, or short naps are PERFECTLY healthy. They just need our help to optimize environment, routines, scheduling, and sleep skills!
If you are concerned about your child’s sleep patterns (or you are just feeling really tired and OVER it!) we would love to help! Book a free sleep evaluation call here to discuss your child’s sleep situation, and learn how we can support you!
