(See also Obstructive Sleep Apnea Obstructive Sleep Apnea (OSA) Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... 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 OSA in Children
Risk factors for obstructive sleep apnea in children include the following:
Enlarged tonsils or adenoids
Craniofacial abnormalities Introduction to Congenital Craniofacial and Musculoskeletal Abnormalities Craniofacial and musculoskeletal abnormalities are common among children. They may involve only a single, specific site (eg, cleft lip, cleft palate, clubfoot) or be part of a syndrome of multiple... read more (eg, micrognathia Micrognathia (small mandible) The jaw can be missing, deformed, or incompletely developed at birth, often in conjunction with other congenital abnormalities and syndromes. (See also Introduction to 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) Cerebral palsy refers to a group of nonprogressive conditions characterized by impaired voluntary movement or posture and resulting from prenatal developmental malformations or perinatal or... 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 sleep apneas Central Sleep Apnea Central sleep apnea (CSA) is a heterogeneous group of conditions characterized by changes in ventilatory drive without airway obstruction. Most of these conditions cause asymptomatic changes... read more , and Prader-Willi syndrome Secondary hypogonadism and others)
Symptoms and Signs of OSA in Children
In most children with OSA, 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 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 (OSA) Obstructive sleep apnea (OSA) consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of... read more .
Pearls & Pitfalls
Complications of OSA may include problems with learning Overview of Learning Disorders Learning disorders are conditions that cause a discrepancy between potential and actual levels of academic performance as predicted by the person’s intellectual abilities. Learning disorders... read more and problems with behavior Overview of Behavioral Problems in Children Many behaviors exhibited by children or adolescents concern parents or other adults. Behaviors or behavioral patterns become clinically significant if they are frequent or persistent and maladaptive... read more , cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular (RV) enlargement secondary to a lung disorder that causes pulmonary artery hypertension. Right ventricular failure follows. Findings include peripheral edema... read more , pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is increased pressure in the pulmonary circulation. It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels may become constricted... read more , 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 OSA in Children
Child-friendly polysomnography with oximetry and end-tidal carbon dioxide monitoring
Obstructive sleep apnea is considered in children with snoring or risk factors (1 Diagnosis reference 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... read more ). 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 per hour) is lower than for adults. Home polysomnography is being used more frequently, but the failure rate is high.
Polysomnography confirms 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, tonsillectomy, continuous positive airway pressure [CPAP]).
Patients with OSA are evaluated with other tests based on clinical suspicion of comorbidities. Other testing may include ECG, chest x-ray, arterial blood gas measurement, and imaging of the upper airway or flexible nasopharyngoscopy.
1. Gulotta G, Iannella G, Vicini C, et al: Risk factors for obstructive sleep apnea syndrome in children: state of the art. Int J Environ Res Public Health 16(18):3235, 2019. doi:10.3390/ijerph16183235
Treatment of OSA 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 (1 Treatment reference 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... read more ). 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.
Because obesity in children is a risk factor for OSA, weight loss can decrease OSA severity in children with obesity and has other health benefits but is rarely sufficient treatment for OSA as monotherapy in the long term.
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.
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.
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Bitners AC, Arens R: Evaluation and management of children with obstructive sleep apnea syndrome. Lung 198(2):257-270, 2020. doi:10.1007/s00408-020-00342-5
American Thoracic Society: Obstructive Sleep Apnea in Children: Two page OSA summary for patients that includes action steps
American Academy of Sleep Medicine: Detailed patient information explaining the importance of healthy sleep and treatment options for sleep disorders