Mouth breathing in children is more than a habit—it’s a common sign of sleep‑disordered breathing (SDB), including obstructive sleep apnoea (OSA). Kids with SDB often look “hyper” by day and struggle with attention, emotion regulation, and school performance. That daytime picture can mimic ADHD. Paediatric sleep texts and guidelines note that OSA can present as inattention and hyperactivity rather than obvious sleepiness, so it’s easy to miss if no one asks about breathing and sleep.
Why the overlap? Repeated arousals and oxygen dips fragment sleep, stress the nervous system, and impair executive function. Large studies and reviews link SDB with ADHD‑like symptoms; importantly, when the airway problem is treated, behaviour typically improves. In the landmark randomized Childhood Adenotonsillectomy Trial (CHAT), children with OSA who had early adenotonsillectomy showed significantly greater improvements in behaviour, quality of life, and symptoms than those in watchful waiting. Recent randomized data in mild SDB add nuance: adenotonsillectomy improved symptoms and quality of life, even when executive‑function endpoints were unchanged at 12 months.
How do misdiagnoses happen? If a clinician focuses on daytime behaviour without a quick airway/sleep screen—snoring, mouth‑open sleep, restless nights, bed‑wetting, morning dry mouth—an ADHD label may be applied while the root cause (SDB) goes untreated. Medical and dental bodies urge routine screening for paediatric sleep‑related breathing disorders and referral when suspected. Dentists, in particular, are advised to look for tonsillar hypertrophy, tongue posture issues, and craniofacial contributors and to coordinate care with ENT and paediatric sleep medicine.
Bottom line for parents and providers:
- Ask targeted sleep/airway questions or use a validated screener.
- Examine tonsils, nasal patency, and oral posture.
Refer for ENT/sleep evaluation (and dental/orthodontic input) as needed. Treating the breathing problem—medical, surgical, or interdisciplinary—can meaningfully improve attention, behaviour, and learning.
Selected References (with links)
- AAP Clinical Practice Guideline: Diagnosis & Management of Childhood OSA (Paediatrics, 2012)
- AAP Guideline: ADHD—Diagnosis, Evaluation, and Treatment (2019 update)
- NEJM—Childhood Adenotonsillectomy Trial (CHAT), 2013
- JAMA RCT—Adenotonsillectomy for Snoring/Mild Sleep Apnoea in Children (2023)
- AAPD Policy on Obstructive Sleep Apnoea (Dentists should screen & refer)
- StatPearls: Pediatric Obstructive Sleep Apnea (overview; ADHD‑like presentation noted)
- Paediatrics Review—Sleep‑Disordered Breathing and Academic Performance (2015)
