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Obstructive Sleep Apnea in Children

by Kingman P. Strohl, MD

Obstructive sleep apnea (OSA) is episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation. Symptoms include snoring and sometimes restless sleep, nocturnal sweating, and morning headache. Complications may include learning or behavioral disturbances, growth disturbance, cor pulmonale, and pulmonary hypertension. Diagnosis is by polysomnography. Treatment is usually adenotonsillectomy.

The prevalence of OSA in children is about 2%. The condition is underdiagnosed and can lead to serious sequelae.


Risk factors for OSA in children include the following:

  • Enlarged tonsils or adenoids

  • Obesity (now the most common cause)

  • Craniofacial abnormalities (eg, micrognathia, retrognathia, midfacial hypoplasia, excessively angled skull base)

  • Certain drugs (eg, sedatives, opioids)

  • Mucopolysaccharidoses

  • Disorders causing hypotonia or hypertonia (eg, Down syndrome, cerebral palsy, muscular dystrophies)

  • Possibly genetic factors (eg, congenital central hypoventilation disorders that can include obstructive and central apneas and possibly Prader-Willi syndrome and others)

Symptoms and Signs

In most affected children, parents note snoring; however, snoring may not be reported even when OSA is severe. Other sleep symptoms may include restless sleep, sweating at night, and observed apnea. Children may have nocturnal enuresis. Daytime signs and symptoms may include nasal obstruction, mouth breathing, morning headache, and problems concentrating. Excessive daytime sleepiness is less common than among adults with OSA.

Complications of OSA may include problems with learning and behavior, cor pulmonale, pulmonary hypertension, and growth disturbance.

Examination may reveal no abnormalities or may show anatomic facial, nasal, or oral abnormalities contributing to obstruction, increase in the pulmonic component of the 2nd heart sound, or growth disturbance.


  • Polysomnography with oximetry and end-tidal CO 2 monitoring

OSA is considered in children with snoring or risk factors. If symptoms of OSA are present, diagnostic testing is done in a sleep laboratory using overnight polysomnography that includes oximetry and end-tidal CO 2 monitoring. Home polysomnography is under evaluation.

Polysomnography can help confirm the diagnosis of OSA, but diagnosis also requires that the child not have a cardiac or pulmonary disorder that could explain the polysomnographic abnormalities. Analysis of sleep stage and the effects of position during polysomnography can help indicate the contribution of upper airway obstruction. Thus, results of polysomnography can help determine initial treatment (eg, continuous positive airway pressure [CPAP] with autotitration or oral or surgical appliances).

Patients with OSA are evaluated with other tests based on clinical judgement. Other testing may include ECG, chest x-ray, ABG, and imaging of the upper airway.


  • Adenotonsillectomy or correction of congenital micrognathia

  • Sometimes CPAP and/or weight loss

Adenotonsillectomy is usually effective in children who are otherwise healthy and have enlarged tonsils and/or adenoids. Adenoidectomy alone is often ineffective. The risk of perioperative airway obstruction is higher among children with OSA than among children without OSA who undergo adenotonsillectomy; thus, close monitoring is important.

For children who are not otherwise healthy, who have complex anatomic abnormalities or genetic conditions altering respiratory control, or who have cardiopulmonary complications, a physician experienced in management of OSA in children should be consulted. Adenotonsillectomy may be effective or may provide some relief. Depending on the anatomic abnormality causing OSA, an alternate surgical procedure may be indicated (eg, uvulopalatopharyngoplasty, tongue or midface surgeries).

CPAP can be used for children who are not candidates for corrective surgery or who continue to have OSA after adenotonsillectomy.

Weight loss can decrease OSA severity in obese children and has other health benefits but is rarely sufficient treatment for OSA as monotherapy.

Nocturnal O 2 supplementation may help prevent hypoxemia until definitive treatment can be accomplished.

Corticosteroids and antibiotics are not usually indicated.

Key Points

  • Risk factors for childhood OSA include obesity, anatomic (including craniofacial) abnormalities, genetic abnormalities, drugs, and disorders causing hypertonia or hypotonia.

  • Problems with learning and behavior are potentially serious complications.

  • Diagnose childhood OSA based on caregiver-confirmed symptoms and the results of polysomnography.

  • Correct anatomic causes of obstruction (eg, by adenotonsillectomy or correction of micrognathia).

  • Consider CPAP and/or weight loss if surgery is not indicated or not completely effective.

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