Critical Need for Early Pediatric Sleep Apnea Diagnosis with Insights from Dr. Asher Tal
Sleep is fundamental to a childs development, behavior, and overall quality of life. Yet, pediatric sleep disorders, particularly obstructive sleep apnea (OSA), are often overlooked or misdiagnosed, leading to a cascade of serious long-term consequences. Dormotech, a leader in innovative sleep diagnostics, recently sat down with Dr. Asher Tal, a globally respected pediatric pulmonologist and sleep medicine expert, to shed light on the urgent need for early and accessible diagnosis of these conditions in children. Dr. Tal, whose career took a pivotal turn after witnessing a childs terrifying apneic episode, has dedicated decades to advancing the understanding and treatment of pediatric sleep issues.
His insights underscore a critical message: children are not simply small adults when it comes to sleep disorders. The impact of untreated sleep apnea on a developing child is uniquely profound, affecting everything from behavior and academic performance to cardiovascular health and growth.
Q&A with Dr. Asher Tal: Navigating the Nuances of Pediatric Sleep
In this in-depth Q&A, Dr. Tal shares his expertise on the distinct challenges and crucial importance of timely intervention in pediatric sleep medicine.
Q: Can you briefly introduce yourself and your current role in sleep medicine?
Dr. Tal: I'm a pediatric pulmonologist. My fellowship in 1992 introduced me to sleep medicine, which became a significant focus. After returning, it took about 10 years to establish the first pediatric sleep lab. We conducted numerous clinical studies on the consequences of snoring and sleep apnea in children, resulting in many publications. Since then, I've been actively involved in sleep medicine. While I previously split my time between pulmonology and sleep, I am now retired from hospital work and serve as the medical director of a private sleep lab. Approximately 80% of my time is dedicated to sleep medicine, encompassing both adult and pediatric cases. I find pediatric sleep medicine particularly challenging.
Q: How did you first become interested in the field of sleep, and more specifically, why did you choose to focus on pediatric sleep?
Dr. Tal: Everything starts with an event. I was in Winnipeg, Canada, in a pulmonology clinic. A father complained that his daughter was very active at night, couldn't sleep, and was hyperactive with strange behaviors. I didn't know much about sleep apnea. My boss thought the father was exaggerating and suggested family treatment. But the next morning, the father came with a videotape. When he showed me the tape, I was almost ashamed. I saw a young girl, four or five years old, not breathing—it was scary. That day, my 'seals went out,' and I understood there was something I knew nothing about, nor did my famous pulmonologist boss. That was the beginning. In 1992, I found a paper from Stanford by the late Professor Guillemino, written in 1980, about the consequences of sleep apnea in children. Everything he wrote by observation then; we know today by research. It's amazing. Since then, I've seen many kids treated for asthma or chronic cough, still with misdiagnosed sleep apnea, which is very common.
Q: In today's industry, are children just small adults when it comes to their sleep? Or more specifically, what makes diagnosing and treating sleep disorders in children fundamentally different from adults?
Dr. Tal: Its different, of course, in children. The most important issue is the complication. So what if the child snores and has sleep apnea? For years now, we know that untreated or undiagnosed children with sleep apnea may have hyperactivity, many behavioral problems—hyperactive, aggressive, short-fused. They can also have cardiac and cardiovascular issues that persist into adulthood, and growth problems, especially in height. So you try to prevent these complications by early diagnosis and treatment. When we started the sleep lab, ENT surgeons used to say they dont operate on children less than five years old in the early 80s. Today, whenever you diagnose sleep apnea, you send them to ENT surgeons, and they take out tonsils and/or adenoids. So, early diagnosis and early treatment is the name of the game. Still, with 3 to 4% of children worldwide having obstructive sleep apnea, many are undiagnosed. The difference from adults is that the sleep study is totally different. It has the same components, but the analysis for kids is different. The number of events per hour for small kids is different. Two events per hour is normal in an adult but mild sleep apnea in a child. More than 10 events in a child is severe sleep apnea, while in an adult, it would be mild. Most centers now acknowledge this and have pediatric sleep physicians or know how to analyze sleep studies for children. But the main problem is that adults can do home sleep tests if sleep apnea is suspected. Children cannot do these home studies because theres no available technology, which leads to long waiting lists—months worldwide. Thats a major problem today.
Q: Can you speak about the specific diagnostic challenges that clinicians face in pediatric studies?
Dr. Tal: When you analyze the study, first for the technicians, it is more challenging to prepare the child. They have to be very patient and know how to manage small kids. For the analysis, you have to know the rules for analyzing sleep studies in children. But I think the main issue is the child's need to come to the lab with the parents for an overnight study—not at home, not in his own bed, but in a lab with a lot of wires all over the nose, head, finger, and around the chest. It's not fun for the child at all.
Q: From your perspective, what are the main challenges in testing and monitoring for sleep in children and sleep studies? You mentioned a lot of it already, but is there something that stands out?
Dr. Tal: I have to emphasize that waiting lists for kids can be harmful to their health. We need much shorter waiting lists. We should have technology that enables us to do reliable sleep studies at home, studies you can trust. That would be a major advance: less waiting list, easier sleep studies, and earlier diagnosis. That's very important.
Q: Which sleep disorders in children are most common in your experience?
Dr. Tal: Behavioral problems are common in the first few years, manageable by a pediatrician or psychologist. But the more common problem in young children is obstructive sleep apnea and snoring with upper airway obstruction, causing apneas and oxygen desaturation in the blood. These are harmful and have many consequences. In adolescence, another problem is delayed sleep phase; the biological clock shifts, and many students study or watch TV late, going to sleep at 3-4 AM. They wake up tired for school and sleep during the day. We have ways to reset the biological clock, but I see more and more young students and high school children with this. Insomnia in children is not common, but we do see it. Before treating insomnia, you must rule out sleep apnea. In adults, we now have a new definition: comorbid insomnia and sleep apnea (COMISAP), where both need treatment. In children, insomnia is less common than in adults. I think the most important challenge for us is obstructive sleep apnea because its truly harmful. I saw a child today, treated for eight months with inhalers due to a misdiagnosis of asthma. My impression was she fell asleep in the clinic, and I saw her struggling to breathe. She will do a sleep study tomorrow because we dont have a waiting list. This is the major problem: early diagnosis of sleep apnea.
Q: Insomnia and parasomnias, do they present uniquely in children opposed to adults?
Dr. Tal: Sure, sure. First, parasomnias are much more common in children than in adults—not REM parasomnias like REM behavior disorder, but parasomnias like sleepwalking and sleep talking are very common in kids. Most are not harmful; you just need to teach parents sleep hygiene and enforce at least 9 to 10 hours of sleep because sleep deprivation is the main trigger for parasomnias. Very few patients need medication. Parasomnias are uncommon in adults, and sometimes during REM sleep, they might be dangerous for the patients or those around them, so they more frequently need medication. Insomnia in children, specifically in adolescence, is not very common, much less common than in adults. The most effective reason today for insomnia in adolescence is Cognitive Behavioral Therapy for Insomnia (CBTI). This was developed in Canada and is very effective—6 to 8 meetings where the therapist teaches you how to sleep, good sleep habits, relaxation, etc., with no drugs, just behavioral therapy. But we have very few adolescents receiving CBTI, not as many as adults.
Q: How critical is timely diagnosis and treatment when it comes to supporting a child's development, their behavior, and their quality of life?
Dr. Tal: Well, of course, the early treatment of sleep apnea in children can prevent, can increase the quality of life. Of course, they may prevent attentional ADHD, attention deficit and hyperactivity—it's not a formal ADHD, but children exhibit ADD-like behavior. And academic achievement. There's a very nice study by David Guzal in New Orleans at that time. He looked for children in the first two or three classes in school and asked teachers for a list of those in the lower percentile for marks in math and other subjects. He sent students to each of those 250-something children and found 20% of them with gas exchange problems—lower saturation and higher CO2. He called the parents and said, 'I think your children have a problem because of sleep apnea. I recommend going to your pediatrician and asking for adenotonsillectomy.' As parents, we're afraid. Some said it looked like very aggressive treatment. Anyway, 50% of them underwent the surgery. One year after the surgery, the children who were treated were in the more than 50th percentile in their marks, and those who didn't undergo the surgery were still in the 10th percentile. That's a very remarkable paper that changed the world because pediatricians understood it's not just about more antibiotics or attention. It's something that changes the life of the family, the quality of life, the mobility of the child. In Beer-Sheva, we did a study showing that children four years of age diagnosed with sleep apnea, if you look back at the big data we have in Israel from 2000, you see that from the first year of life, their healthcare utilization—hospital visits, use of medical services—is significantly higher. So you need to catch it early to prevent the progression of the consequences of sleep apnea.
A Brighter Future Through Early Detection
Dr. Tal's compelling narrative and extensive experience highlight a critical gap in current pediatric healthcare. The reliance on traditional, inconvenient, and often traumatic in-lab polysomnography (PSG) for pediatric sleep diagnostics has created significant bottlenecks, leading to harmful waiting lists for children in need.
This is precisely where innovations like Dormotech's DormoVision X™ can make a profound difference. By offering a clinically validated, at-home sleep study solution, Dormotech aims to break down barriers to early detection. Its portability, multi-night capability, and high equivalence with in-lab PSG provide a patient-centric approach that can drastically reduce diagnostic turnaround times and ensure more children receive timely intervention.
Empowering early detection and effective treatment of sleep disorders is not just about medical intervention; it's about safeguarding the crucial developmental and behavioral well-being of children. With the invaluable insights from experts like Dr. Tal and the continued advancement of innovative at-home solutions, we can work towards ensuring a healthier future for the next generation.
Article by Jessica Coggins
Jessica Coggins serves as the U.S. Marketing Manager for Dormotech through her agency, Jessica Creative Strategies. As a strategic partner, she leads brand positioning, digital marketing, and content development to help Dormotech grow its presence in the U.S. market. With a background in healthcare and a focus on clear, purposeful communication, Jessica bridges innovation and audience needs with thoughtful, effective storytelling.