(See also Obstructive Sleep Apnea Obstructive Sleep Apnea Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more .)
The prevalence of obstructive sleep apnea in children is about 2%. The condition is underdiagnosed and can lead to serious sequelae.
Etiology of Obstructive Sleep Apnea in Children
Risk factors for obstructive sleep apnea in children include the following:
Enlarged tonsils or adenoids
Obesity (now the most common cause)
Allergic rhinitis (ie, causing significant nasal congestion)
Craniofacial abnormalities (eg, micrognathia Micrognathia (small mandible) The jaw can be missing, deformed, or incompletely developed at birth. (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders and Overview of Congenital Craniofacial... read more
, retrognathia, midfacial hypoplasia, excessively angled skull base)Certain drugs (eg, sedatives, opioids)
Disorders causing hypotonia or hypertonia (eg, Down syndrome Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more
, cerebral palsy Cerebral Palsy (CP) Syndromes Cerebral palsy refers to nonprogressive syndromes characterized by impaired voluntary movement or posture and resulting from prenatal developmental malformations or perinatal or postnatal central... read more , muscular dystrophies Introduction to Inherited Muscular Disorders Muscular dystrophies are inherited, progressive muscle disorders resulting from defects in one or more genes needed for normal muscle structure and function; dystrophic changes (eg, muscle fiber... read more )Possibly genetic factors (eg, congenital central hypoventilation disorders that can include obstructive and central apneas, and Prader-Willi syndrome Secondary hypogonadism and others)
Symptoms and Signs
In most affected children, parents note snoring; however, snoring may not be reported even when obstructive sleep apnea is severe. Other sleep symptoms may include restless sleep, sweating at night, and observed apnea. Children may have nocturnal enuresis Nocturnal incontinence (enuresis) Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more . Daytime signs and symptoms may include nasal obstruction, mouth breathing, morning headache, problems concentrating, and hyperactivity (ie, as a manifestation of sleepiness). Waketime sleepiness is less common than among adults with OSA Obstructive Sleep Apnea Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more .
Complications of OSA may include problems with learning and behavior, cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular enlargement secondary to a lung disorder that causes pulmonary artery hypertension. Right ventricular failure follows. Findings include peripheral edema, neck... read more 
, 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.
Diagnosis of Obstructive Sleep Apnea in Children
Polysomnography with oximetry and end-tidal carbon dioxide monitoring
Obstructive sleep apnea 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 Testing that includes oximetry and end-tidal carbon dioxide monitoring. Polysomnographic criteria for diagnosis (apnea-hypopnea index > 2/hour) is lower than for adults. Home polysomnography is under evaluation.
Polysomnography can help confirm the diagnosis of obstructive sleep apnea, 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 judgment. Other testing may include ECG, chest x-ray, arterial blood gas measurement, and imaging of the upper airway.
Treatment of Obstructive Sleep Apnea in Children
Adenotonsillectomy or correction of congenital micrognathia
CPAP and/or weight loss with intensive support
Adenotonsillectomy is usually effective in children with obstructive sleep apnea 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 Surgery , tongue or midface surgeries).
Continuous positive airway pressure (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 oxygen supplementation may help prevent hypoxemia until definitive treatment can be accomplished.
Treatment of allergic rhinitis should be intensive. Corticosteroids and antibiotics are not usually indicated.
Key Points
Risk factors for childhood obstructive sleep apnea (OSA) include obesity, enlarged tonsils or adenoids, 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 continuous positive airway pressure and/or weight loss if surgery is not indicated or not completely effective.
More Information
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
American Sleep Apnea Association: Provides consumer information, education, and support for patients with sleep apnea
