A discussion of snoring would be incomplete without acknowledging the fact that snoring in children can be as socially disruptive and as medically demanding as that of adults. One of the problems arising from any discussion of children is the tendency to make generalizations about a group which undergoes complex changes from infancy to adolescence. Size of airways, breathing rate and shape of the chest wall are just some of the variables which change significantly in the first few years of life, highlighting the need to specify the age group in question. Another problem relating to the investigation of young children is the inability of parents to give an adequate description of the child’s symptoms. Difficult breathing during sleep, whether it be described as wheezing, coughing or choking can be symptomatic of any number of disorders, the doctor’s task being made all the more challenging if these symptoms only occur at night.The first priority is to identify these nocturnal events either by having the child observed during a hospital admission or by making a sound recording of the events on a portable tape recorder. Any abnormal breathing associated with sleep should be investigated but for the purpose of this discussion it will be assumed that nocturnal snoring has been confirmed. Data on the incidence of snoring in healthy children is unreliable, ranging between 10% and 25%, a variation possibly arising from different age groups and populations selected from one study to another. It is therefore not an uncommon occurrence and parents should not be alarmed by the observation of occasional snoring.The common factor in both adult and childhood snoring is a comparatively narrow upper airway compromised by a lack of muscle tone during sleep. Whilst accepting that obstructed airways of different age groups have something in common, there are differences in the incidence of underlying causes. Enlarged tonsils and adenoids remains one of the most common findings in snoring children and, although there has been some reticence in recent years to remove tonsils and/or adenoids, surgery is certainly warranted in cases of persistent heavy snoring which is accompanied by complete and repetitive airway closure. Upper respiratory tract infections and nasal congestion are more likely to cause problems in newborns and young children, given the narrow diameter of their airways and susceptibility to collapse. In the absence of other predisposing factors, a return to normal breathing would follow the successful treatment of such infections or allergies.Children born with structural abnormalities of the head and face (or craniofacial abnormalities) will be prone to snore if the structure results in compression or narrowing of the upper airway. There are several well described syndromes, each with characteristic facial and anatomic features which interfere with normal breathing. Children with Down’s Syndrome, for example, with the characteristic flattened face and nose, short neck, small jaw and mouth, and general lack of muscle tone, may have symptoms of obstructive sleep apnoea (OSA) depending on the severity of the syndrome. Other anatomical factors common to both young and older snorers include a large or poorly positioned tongue, abnormal jaw alignment, an excessively fleshy soft palate and obesity.

These two vitamin deficiencies will be discussed together because they often coexist and have similar symptoms. Vitamin B12 is found in meat (especially liver). It combines with a substance in the stomach and is then absorbed in the small bowel where it enters the bloodstream. It is vital for healthy blood, and it is important in the nervous system. Some elderly people fail to produce the substance in the stomach which vitamin B12 needs in order to get absorbed. Also there are many people who have had part of the stomach removed (usually because of ulcers) and they too may fail to get any B12 in. (The other name for this condition is pernicious anaemia, because of its slow and debilitating onset.) Folic acid is another vitamin found especially in fresh vegetables. It too is needed for blood making and a healthy nervous system. Lack of this vitamin is usually due to a poor diet. Poor diets are probably 20 per cent ignorance and 80 per cent poverty.

The two conditions present in the same way. There are usually complaints of tiredness and lethargy. If the nervous system is affected there may be complaints of abnormal sensation in the arms and especially the legs with unsteadiness and a feeling that one is walking on cotton wool. Walking may become difficult and a gradual onset of confusion may develop. The person looks pale and is usually anaemic. They often have a pale lemon tinge to the colour of their skin. A neurological examination will often reveal many abnormalities and a blood test shows abnormally big red blood cells. All these symptoms lead the doctor to consider the diagnosis and send off more specific tests. Vitamin B12 can be measured in the blood, but as there are numerous causes, often more sophisticated tests have to be done as well. The folic acid content of red blood cells is the best blood test and this is routinely performed.

Unfortunately, vitamin В12 cannot be given by mouth as it is destroyed in the stomach. Therefore, when the diagnosis is made the treatment is by injection of B12. These are usually given every three months. The injections have to be continued for life. Folic acid deficiency is easily treated by either improving the diet generally or by giving folic acid in tablet form daily.

The longer the conditions have been present the less likely all the neurological complications will be reversed. The anaemia seems to improve well, but if established chronic confusion is present there are few reported cases of the mental state going back completely to normal.

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