When your toddler snores, wakes up screaming

Corie* was frustrated. Her four-year-old son Neal* was causing her sleepless nights literally and figuratively. Neal was mostly a healthy baby from birth to infancy and the toddling stage.

Trouble started when Neal started playgroup at two-and-a-half years. Being an only child, Corie thought he needed to interact with children his age a little bit more to improve his social skills. She also did not have a nanny, so she felt it would be good for Neal to broaden his social interactions beyond his mother. She enrolled him in a kindergarten near home, where he went half-day, three days a week.
Neal took to his playgroup well. But, the joy came at a price. Neal started having recurrent upper respiratory tract infections. Every other week he would come down with a new episode of common cold, throat or ear infection. Their life turned into an endless cycle of hospital visits. She thought he would outgrow this as his immune system toughened up. Further, most of Neal’s age-mates were battling similar issues.
By three, Neal had joined mainstream kindergarten and though the infections were less frequent, he had a persistent cough. He would cough mostly at night and sometimes it would be so bad that he would vomit. Corie would make countless trips to his room to check on him, depriving herself of adequate sleep.
Her fear of Neal choking on his vomit prompted her to move him to her bed for closer monitoring. Corie continued to be sleep deprived. Neal snored like a tractor overdue for service. When he was not snoring, he was breathing through his mouth. Even worse was the repeated startling at night with nightmarish cries, like he had had a bad dream.
He was constantly on antihistamines and was eventually put on an inhaler as he was thought to have childhood asthma, but this did not result in significant improvement. To make matters worse, Neal’s appetite was down. His weight stagnated at 14kg for a year and a half despite growing taller.
One day after a rough night, Corie was unable to wake up in time to prepare her son for school. When Janice, the housekeeper, let herself in, she was surprised to find the two in bed at 10am. Janice, Neal and Corie went to a paediatrician.
The visit was more cathartic for Corie than anything she had experienced in a long time. She let out her pent up frustrations to the doctor. Corie was relieved to learn she was not responsible for her son’s medical issues and the problem could be corrected.
increased swelling
As the paediatrician explained to Corie, Neal manifested every symptom of adenoid hypertrophy. While most people are familiar with the palatine tonsils seen at the back of the mouth (oro-pharynx), humans also possess adenoid tonsils which are at the back of the nostrils (nasopharynx) and the lingual tonsils located within the posterior one-third of the tongue.
Overall, tonsils form part of an important component of the immune system factory. They are sites for the manufacture of immune cells and antibodies, effectively making them a plant that stocks up our armoury against infections and malignancies. However, these tonsils are also subject to infection, resulting in inflammation and swelling. This swelling increases with every subsequent infection. The degree of swelling varies from child to child hence those with excessive swelling (hypertrophy) develop symptoms while those with minimal swelling will outpace this as they head to adolescence.
For the adenoids, by virtue of their location, enlargement means they extend into the airway, causing narrowing, resulting in obstruction of smooth air flow through the nostrils and to the lungs. This causes snoring and the child sleeps with the neck hyper-extended in an attempt to maximally keep the airway open. In his sleep, should his neck flex forward, the obstruction is worsened and he feels like he is being chocked, resulting in the startling and screaming in his sleep.
There is also obstruction of the flow of mucous secretions, resulting in continuous dripping of these secretions into the airway posteriorly, causing bad breath, chronic cough and recurrent or persistent respiratory infections. The proximity of the auditory tube connecting the middle ear to the throat means that infection from the adenoids easily spreads to the ear and causes otitis media. There is also increased risk of recurrent sinusitis.
Long-term obstruction results in poor appetite, impacting on the child’s growth, poor sleep results in poor concentration while awake and the child may be wrongfully labelled as intellectually challenged. The difficulty in breathing leads to attempts to breathe through the mouth, which can cause staining of teeth.
An X-ray of the face from the side easily confirmed Neal’s diagnosis and a referral to the ear, nose and throat (ENT) surgeon was scheduled. The ENT surgeon affirmed the paediatrician’s recommendation that Neal would benefit from surgery to remove the adenoids. The surgery was done two weeks later on a chilly morning and by afternoon, Neal was back home healthy. Although the inflammation resulting from surgery kept him snoring for a few more days, he could finally sleep through the night, much to Corie’s delight.
Even more reassuring was the return of Neal’s appetite. Last month, they celebrated two years since the surgery by throwing away the expired inhalers.

Dr Bosire is an obstetrician/gynaecologist