No morning alarms were necessary in the home of Stephanie Witsken, 41, of Trenton, Ohio.
Her daughter Mallory's "loud snoring and disruptive breathing" kept Witsken and her family awake throughout the night ever since the girl was 2 years old.
"Mallory snored so loud it disturbed our entire household," Witsken says. She recalls Mallory "gasping for breath throughout the night," so much so that during a school sleepover Mallory's teachers took turns keeping watch on her as they felt she was "unsafe" from the gasping spells.
Mallory's snoring -- all night, every night -- spurred the Witsken family's quest for answers by the time she turned 3. Their questions led them from their pediatrician to an ear, nose and throat specialist -- and even a sleep specialist.
It turns out that their concern may have been warranted. Aside from being a nocturnal annoyance, a new study confirms, snoring in young kids can have implications for their behavior later on.
Previous research has shown that poor sleep quality in children, including snoring, is linked to hyperactivity. However, little is known about "how much" snoring is too much, and whether the behavioral effects last over time.
The link between snoring and effects on behavior may be related to hypoxia, or decreased oxygen delivery to the brain. Snoring may be a sign that not enough air is going through a person's airway -- a situation many doctors believe occurs frequently with sleep-disruptive breathing disorders. Less oxygen delivery to the brain can mean inflammation, and even changes in the brain tissue itself.
"Many preschool children snore for brief periods, [for example] when they have a cold," says Dean Beebe, a neuropsychologist at Cincinnati Children's Hospital Medical Center. "But loud snoring that lasts for months or years is abnormal and may signal a sleep-related breathing problem that could affect a child's behaviors during the day."
Beebe and colleagues explored these issues in a new study published Monday in the journal Pediatrics. Their goal was to focus on younger children and "follow kids over time to get a sense of what happens when snoring persists," he says.
Researchers looked at 249 mother/child pairs at 2 and 3 years of age and asked parents how frequently they heard "loud snoring" coming from their child's bedroom. Children were characterized as "non-snorers" if they snored less than once per week, "transient snorers" if they snored more than two times per week at age 2 or age 3, or "persistent snorers" if they snored more than two times per week both at age 2 and at age 3.
The same children were also assessed for behavioral problems -- including hyperactivity, aggression, depression, and inattention -- based on a validated questionnaire known as the Behavior Assessment System for Children.
The results of this study demonstrated that the persistent snorers had significantly worse overall behavioral functioning at age 3, specifically in the areas of hyperactivity, depression, and attention, compared to the transient snorers and the non-snorers. In fact, 35 percent of persistent snorers were found to be at risk for behavioral problems.
Witsken says the results did not surprise her in the least. "When Mallory was 3 years old, she was a crabby toddler all the time," she says, describing her daughter's past behavior as hostile and whiny, with frequent crying. When Mallory reached first grade, Witsken says, "she struggled in school from being tired and having poor attention."
Several teachers guessed that Mallory had ADHD based on her behavior and performance in school -- a common misunderstanding, says Shelby Harris, director of the behavioral sleep medicine program at Montefiore Medical Center.
"A sleepy kid doesn't always look sleepy, he may look more hyperactive," Harris says. "As a result, an overtired child may look more like an ADD child and confuse the diagnostic picture even more."
Remarkably, Witsken noticed a distinct improvement in Mallory's behavior when her snoring resolved. After each of Mallory's three adenoid removal surgeries, her mother remembers a temporary period lasting for roughly one year during which Mallory was both snore-free and bad behavior-free.
"Mallory was like a completely different person," Witsken says. "She turned into a sweet child."
Pediatric sleep specialists say they are enthused by the findings.
"In my opinion, this study is very important," states Dr. Frisca Yan-Go, a neurologist from UCLA, "because it gives data to support clinicians in emphasizing that habitual snoring is not normal at any age."
Yan-Go explains that if a sleep-related breathing disorder disrupts a child's sleep, "[It] definitely will affect the child's daytime function, including behavior, learning and development."
Sleep experts say parents who have kids who snore loudly and persistently should inform their pediatricians as soon as they can.
"Snoring, especially in children, should not be ignored," Harris advises.
Yan-Go agrees, adding that parents should also check with their pediatricians to see if their child should be referred to an ENT or a sleep specialist. "The sooner the diagnosis and management, the better the outcome."
In the meantime, she suggests, the child should "sleep on a wedge pillow with the upper body elevated," and "other medical conditions like allergies, asthma then need to be evaluated and treated concurrently."
For Witsken's family, referral to the proper specialists made all the difference. She notes that after Mallory's third corrective adenoid surgery and uvuloplasty by an ear, nose and throat specialist, Mallory, now 8, can now play and enjoy her childhood.
"The biggest part," Witsken says, "is it completes your family and allows your family to live a normal life."