Sitting at his desk at attention, with pencil in hand, Ryan Corwin of Modesto looked like he was ready to learn.
But his teachers could see it in his eyes. The first-grader soon lost focus and his mind drifted away, not paying attention to the lesson.
Educators and doctors suspected he had attention deficit hyperactivity disorder, autism or perhaps a brain tumor.
When his father brought him home from school, Ryan complained of headaches and wanted to lie in a dark bedroom, with no noise or TV, until the migraines passed. He also was smaller than other boys his age.
"I knew it wasn't (ADHD) and I wasn't going to put him on the drugs," said Michael Corwin, a single father to Ryan and a younger brother. "We kept pushing and pushing for different tests."
After getting no answers, grandmother Kathy Sbragia was crying on the phone with a referral manager at Sutter Gould Medical Foundation when the manager suggested they see Dr. Amer Khan, a child neurologist and sleep disorder expert in Sacramento.
Last June, a study at the Sutter Health sleep center in Sacramento was the last test 8-year-old Ryan would flunk.
Khan noticed that Ryan's tonsils were unusually large, and when Ryan was hooked to test leads and his sleep monitored by sophisticated equipment, it revealed he suffered from sleep apnea. His enlarged tonsils obstructed the flow of oxygen in his throat.
The condition may cause children to wake up frequently, snore, drool, toss and turn, or not get enough rapid eye movement sleep. Although Ryan seemed to sleep quietly at home, the study revealed he often awoke from the deep sleep that is vital to proper rest.
That accounted for his chronic fatigue during the day. "He was awake in class, but his brain was going to sleep," Sbragia said.
In September, a tonsillectomy at Modesto's Memorial Medical Center did away with Ryan's sleep apnea.
He now bounces out of bed every morning and is eager to get to Modesto Christian School. His grades have improved dramatically. On a recent report card, the third-grader got A's in reading, spelling, social studies and Bible, and B's in other subjects.
Ryan has joined a karate class and plans to play youth football. Instead of hitting the pillow when getting home from school, he's more likely to wrestle on the carpet with his 6-year-old brother, Justin.
Khan said he often sees children with obstructive sleep apnea caused by tonsils inflamed by infections or allergies. Some of the children have been diagnosed with attention deficit disorder or other behavioral problems. Severe cases can retard the child's growth, he said.
"Once we deal with the sleep apnea, they may still have behavior issues, but often it is not to the extent it has a major effect on their lives," he said.
With so many children put on medication for ADHD, Khan talks to primary care doctors about considering obstructive sleep apnea in some of those cases, especially children with abnormal tonsils or adenoids.
A small number of studies suggest that obstructive sleep apnea occurs in 2 percent of children. But some experts believe it's more common given that 10 percent to 25 percent of children snore. Besides loud snoring, other signs of the disorder include morning headaches, irritability, poor school performance and bed-wetting.
Several studies have shown that removing the tonsils improved sleep and behavior in children with the condition.
It was common to remove tonsils and adenoids in children a few decades ago. But doctors shied away from the practice because the clumps of tissue are part of the immune system.
Some experts believe the pendulum shift caused primary care doctors to disregard the tonsils. "Unfortunately, it does not get enough attention," Khan said.
Dr. Donald Doyle, an ear, nose and throat specialist with Tower ENT in Turlock, said there is more awareness of obstructive sleep apnea in children today than 10 years ago.
"We want to have a sleep study done to document it and prove to the parents that is the problem," he said. "If you can get the patient to go back three months later for another study, you can see if the procedure improved their sleep."
The American Academy of Pediatrics offers guidance to parents. It recommends a tonsillectomy if a child has four tonsil infections in a year or a proven case of sleep apnea. The procedure isn't as routine as widely assumed: Recovery is painful, and there's a 10 percent chance of post-surgery hemorrhage.
Ryan felt sick to his stomach for a few days after the surgery, but it was a small price for putting his life on track, his family said.
"Parents have to be advocates for their children," Sbragia said. "You have to push and push until you get the answers."
Bee staff writer Ken Carlson can be reached at firstname.lastname@example.org or 578-2321.