swollen tonsils.

swollen tonsils during tonsillitis. (Photo credit: Wikipedia)

I can’t believe school will start in 3 weeks and summer is over! Claire can’t believe it either! As excited as we are for her to start her new school, we are definitely dreading that period of transitioning to a rigid morning schedule to make sure everyone’s fed (including Shiro) and off to their day on time. As schools require you to bring an updated physical form for your child, here are things you can ask your child’s primary care provider to check to make sure that he/she is ready to have a great year.

First topic: SLEEP

1)   Duration of Sleep

Most pre and school-aged children probably can use at least 10 hours of sleep each night, (so can we but I doubt most parents get that) in order to function at their best the next day. I am talking about a level of general pleasantness, ability to follow not all but perhaps most instructions, and as they become school aged children, there is no doubt ability to focus during the day is highly correlated to their duration and quality of sleep the night before. I know this point should not require emphasis for most parents and caretakers, since you have likely experienced the emotional meltdowns and crankiness whenever a child has lack of sleep due to fun, activities, and staying up late the night before. (Or whatever reason). If your child seems to snore most nights, and your provider does not specifically make a comment about his/her throat exam, please ask them to tell you whether the child’s tonsils appear to be overly enlarged. Even if they are not impressed, if your child can open his/her mouth and you can see two relatively large “meatballs”

crowding the punching back ( “Uvula”), consider seeing an ear, nose, and throat specialist (especially a pediatric ENT if you can find one in your area.  For more information specifically on this you can check out my blog on “Does my child need his tonsils/adenoid out?”

Hopefully, your child sleeps through the night most of the nights. There is no question every child will have the occasional nightmare, some even have sleep terror (they wake up screaming but you can’t seem to wake them and make them oriented), and there are definitely other medical abnormalities related to sleep that a sleep medicine specialist can diagnose and discuss treatments with you based on results of an overnight sleep study (Polysomnogram).  Discuss with your child’s primary care provider about the possible need to get referral to see either an ENT and/or sleep medicine specialist (pediatric one if available) if you and your child’s lives are disrupted by poor sleep.

There are other reasons your child may not sleep through the night. The most common one in my experience, especially in the preschool age toddler group, is drinking milk and eating close to bedtime. Research has shown that just having stuff in the stomach may result in reflux which then make “wake” the brain from deeper stages of sleep. This was studied by measuring the brain waves during full overnight sleep studies.  It makes sense, since if stuff comes back up into the throat, the body may have to swallow and/or cough to prevent aspiration of whatever stuff into the lungs resulting in pneumonia, and the act of coughing and swallowing is certainly not something we generally do during quiet sleep. So “A Healthier Wei” and my enthusiasm to discourage routine habit of before bed time eating or drinking of sugar and dairy is based on trying to make sure children sleep well and avoid the nasal congestion, cough, and other responses the body makes due to indigestion during sleep.

I often discuss with parents about sleep hygiene, which includes set times for going to bed each night and a routine which “trains” the body to slow down and prepare for sleep. Watching TV shows and/or playing computer games with excessive violence, activity, or stimulation right before bed is obviously not ideal. This is particularly challenging with pre-teens and teenagers who are likely listening to music, talking to friends, and texting!

2.  QUALITY of sleep

Just because your child was in bed 10-12 hours does not mean he/she had great sleep. This is where providers hopefully are asking questions about whether your child is snoring during sleep, and indicators that your child may not be getting restful sleep includes restlessness (tossing and turning, blankets everywhere), loud breathing with mouth open, and of course, frequently getting up to come into your room which of course disrupts your sleep. You can take this quick Pediatric Sleep Questionnaire (PSQ), which is a validated research tool to detect whether your child may have Sleep Disordered Breathing (a spectrum describing breathing abnormalities during sleep from mild snoring to obstructive sleep apnea).  Whenever I see a patient whose parents report snoring, I ask them to fill one out so that based on the results shown when researchers compared the results of this questionnaire to an actual overnight sleep study (performed in a lab), the sensitivity was 87% (so 87% of the time when the questionnaire scores were deemed “positive” for SDB the overnight sleep study was also abnormal based on the calculated and “index” by taking number of apnea (complete stop in airflow) and hypopnea (when airflow was decreased by 50%) events per hour. The point is, I find this to be very helpful to help determine which children may have a problem, since overnight sleep studies are expensive, often uncovered by government insurance types, and deemed medically unnecessary in otherwise healthy children who do not have medical risk factors such as obesity, Down syndrome, congenital cardiac problems, etc.

If you decide to take the PSQ, simply answer “Y” for yes, “N” for no, and “DN” for don’t know for each of the 22 questions about your child. For those age 6 and older answer all 22. If your child is younger than 6, don’t answer the last 6 items which are specifically focused on behavior. Appearing overly fidgeting at age 3 or 4 may be acceptable and not indicative of a problem.  In this case you are only answering 16 questions.  To score this, we calculate the ratio of all “Y” for the total number of questions you know the answer to. So, all “Y” gets counted as 1 point and you need to add up all the “yes” to get the numerator. The denominator will be total number of questions you answered “yes” or “no”, but if you answered “DN” then take that away from total possible number for the denominator.  Confused yet?

Anytime the score is > 0.33 it is considered a positive screening and your child may have SDB. If you answered more than 7 yeses out of a total of 22 questions (if your child is age 6 or older), then 7/22 = 0.32 so I would definitely make sure the tonsils and/or adenoid is not the cause of obstruction for your child and the primary reason for less than perfect sleep.

If you answered 10 “yeses”, but your child is only 4, then score is 10/16 = 0.625 (denominator should be 16 since 22- 6=16, because you should ignore the last 6 questions assessing behavior). Clearly 0.625 is > 0.33 so again a positive screening.  For this child, if you had two “DN” as answers for those 16 questions, then the denominator would be 16-2 = 14, and then you would calculate the score as 10/14 = 0.714.

While this questionnaire was developed as a research tool, it has been used in many studies in the past decade to measure outcomes after tonsil and adenoid surgery as a treatment of SDB and has been found to be a useful instrument by not only ENT surgeons but researchers who study sleep as well as behavior. Your primary care provider likely does not use this tool, nor do most ENT specialists. This is because the tool was developed as a research tool and I believe underutilized in this day and age of the challenges of our constantly shrinking healthcare dollars to meet the constantly growing expenses for healthcare. We simply do not have enough sleep centers nor the ability to get an overnight sleep study in every child to decide if they have SDB, so I believe the PSQ is a great tool, especially when most research has shown that there is not strong correlation between symptoms and severity of SDB. Surprisingly, loudness of snoring or how many seconds a child seems to stop moving air during obstructive episodes do not directly correlate with severity of the findings on sleep studies.

Sleep matters, since research shows as many as 1 in 4 children who have been diagnosed with ADHD actually may not have ADHD, but likely have undiagnosed and untreated obstructive sleep apnea/SDB. Even better news, if the cause is enlarged adenoid and tonsils, surgery actually provide similar benefit, if not slightly better, when compared to treatment with ADHD medications like Ritalin for hyperactivity/ADHD.

Bottom line, it is not normal for children to have habitual snoring, and if they have it they are probably not getting the best rest they can. We can help our children be at their best, perform at their best at school both academically and behaviorally, if we make sure they have great quality and duration of sleep.

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Dr. Julie Wei is a pediatric ear, nose, and throat specialist and the author of A Healthier Wei. As a mother herself, Dr. Wei is a passionate advocate for improving children's health through better diet and dietary habits. She has been committed to helping parents learn how to eliminate their child's ear, nose, and throat problems simply by reducing excessive sugar and dairy intake, as well as minimizing habitual late night snacking. She hopes to raise awareness for the need for accountability by both medical professionals and parents to ensure that children are not prescribed or take unnecessary medications long term.

When she is not in the clinic, operating room, or conducting research, you will find her in the kitchen preparing food with love along with her daughter Claire. If you sit next to her on the plane, she will likely share with you information about how to minimize choking hazards in young children, and many other tips for improving your child's health.