Beyond AHI: Uncovering Hidden Sleep and Breathing Issues in Children

Beyond AHI: Uncovering Hidden Sleep and Breathing Issues in Children

When evaluating sleep-disordered breathing in children, many doctors rely on a measurement called the Apnea-Hypopnea Index (AHI). This number reflects how many times per hour a person briefly stops or slows their breathing during sleep. While AHI is useful for diagnosing sleep apnea in adults, it has significant limitations when assessing children. In fact, a child’s sleep and breathing can be compromised even when their AHI appears "normal." 

What Is AHI and Why Does It Fall Short for Kids?

AHI counts the number of apneas (complete pauses in breathing) and hypopneas (partial reductions in airflow) that occur per hour during sleep. In adults, an AHI of 5 or more is often considered mild sleep apnea, but for children, even an AHI over 1 can indicate a problem. However, AHI alone doesn’t tell the full story when it comes to a child’s sleep quality and health. 

Here’s why AHI may not be the best way to assess sleep-disordered breathing in children:

1. "Mild" Numbers Can Still Have a Big Impact

While adults with an AHI under 5 are often considered "normal," children are much more sensitive to breathing disturbances. Even a few pauses in breathing per hour can affect a child's brain development, growth, and behavior. AHI doesn’t account for these subtler but important changes. 

2. Hidden Breathing Struggles May Not Be Counted

Not all sleep breathing problems show up as full apneas or hypopneas. Many children with airway issues experience increased breathing effort, frequent arousals, or snoring without clear apneas, which AHI does not measure. This means that a child with fragmented sleep and ongoing airway struggles may still have a "low" AHI.

3. Sleep Quality Matters as Much as Breathing Events

A child with a low AHI may still be waking up repeatedly throughout the night due to breathing disruptions, even if they aren’t recorded as full apneas or hypopneas. Sleep fragmentation can cause daytime sleepiness, ADHD-like symptoms, and difficulty focusing in school—even if the AHI suggests "normal" breathing.

4. Certain Sleep Stages and Positions Make It Worse

Breathing difficulties in children often happen more in REM sleep, when the muscles relax the most. If a sleep study doesn’t capture enough REM sleep, the AHI might underestimate how severe the problem really is. Additionally, children who struggle more in certain sleep positions (like on their backs) may not show a high AHI if they weren’t in that position long enough during the study.

5. Symptoms Matter More Than Numbers

Even if a sleep study shows a "normal" AHI, a child may still struggle with:

• Snoring or noisy breathing
• Mouth breathing (instead of nasal breathing)
• Restless sleep (tossing, turning, sweating)
• Bedwetting past the typical age
• Frequent nightmares or night terrors
• Daytime sleepiness or trouble waking up
• Behavioral issues, hyperactivity, or difficulty focusing

These are all signs of sleep-disordered breathing—even if the sleep study’s AHI doesn’t classify them as severe apnea. That’s why parents should pay attention to their child’s symptoms rather than focusing only on sleep study numbers.

What Can Parents Do?

If your child shows signs of sleep-disordered breathing, don’t wait for a “high” AHI to take action. There are many ways to support better breathing and sleep, including:

• Airway-focused dentistry (such as palatal expansion)
• Myofunctional therapy (to strengthen oral muscles for better breathing)
• Tongue-tie evaluations and release (if restricted tongue movement is a factor)
• ENT evaluation (to check for enlarged tonsils/adenoids)

At Flourish Airway Collective, we specialize in assessing and supporting children with sleep-disordered breathing, even when their AHI seems “normal.” If your child struggles with sleep, breathing, or related symptoms, we’re here to help. Book a consultation today to learn more!