Obstructive Sleep Apnea (OSA) in Children

Risk factors for obstructive sleep apnea in children include the following:

• Obesity

• Tonsillar hypertrophy or adenoid hypertrophy

• Allergic rhinitis (ie, causing significant nasal congestion)

• Nasal polyps

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

• Certain medications (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 both obstructive and central sleep apneas, and Prader-Willi syndrome and others)

Adenotonsillar hypertrophy is the most common cause of OSA in children and is particularly prevalent in younger children (1). Obesity is a dominant risk factor among older children and adolescents with OSA (after the involution of adenotonsillar tissue which typically occurs before the age of 8 years).

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.

Daytime signs and symptoms may include nasal obstruction, mouth breathing, morning headache, problems concentrating, and hyperactivity (ie, as a manifestation of sleepiness). Wake-time sleepiness is less common than among adults with OSA.

Complications of OSA may include problems with learning, problems with 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 second heart sound (S2), or growth disturbance.

• Child-friendly polysomnography with oximetry and end-tidal carbon dioxide monitoring

• Exclusion of other disorders

• Sometimes additional tests (eg, chest radiographs, arterial blood gas measurement, upper airway endoscopy)

Obstructive sleep apnea is considered in children with snoring or risk factors (1). All children should be screening for snoring as a part of routine healthcare (2). If symptoms of OSA are present, diagnostic testing should be performed in a sleep laboratory using overnight polysomnography that includes oximetry and end-tidal carbon dioxide (ETCO₂) monitoring.

Polysomnographic criteria for diagnosis (apnea-hypopnea index [AHI] > 1 per hour) is lower than for adults. Home polysomnography can also be used but may underestimate mild disease (3).

OSA severity in children (age < 18 years) is sometimes classified as follows (4):

• Normal: AHI < 1 per hour

• Mild: AHI 1 to ≤ 5 per hour

• Moderate: AHI > 5 to ≤ 10 per hour

• Severe: AHI > 10 per hour

However, symptoms, the age of the child, and other polysomnographic features such as hypoxemia or hypercapnia will also be important for evaluation and management.

Polysomnography confirms the diagnosis of OSA, but diagnosis also requires the exclusion of other disorders (eg, a cardiac or pulmonary disorder that could otherwise 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, the 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 radiograph, arterial blood gas measurement, and imaging of the upper airway or flexible nasopharyngoscopy.

Polysomnography

Image

This photo shows an adolescent with narcolepsy being prepared for polysomnography. The electrodes measure brain activity and eye and facial movement when awake and when asleep.

ELISABETH SCHNEIDER CHARPENTIER/SCIENCE PHOTO LIBRARY

• Sometimes watchful waiting

• Adenotonsillectomy or correction of congenital micrognathia

• Continuous positive airway pressure (CPAP) and/or weight loss with intensive support

The management of OSA in children involves a multidisciplinary approach involving primary care physicians (pediatricians or family care practitioners), otolaryngologists, and pediatric pulmonologists or sleep medicine specialists. Additional specialists may be involved depending on the clinical context (eg, endocrinologists for obesity, geneticists for Prader-Willi syndrome). 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.

Watchful waiting for up to 6 months may be appropriate in young healthy children with mild OSA but without daytime symptoms or severe abnormalities on polysomnography.

Adenotonsillectomy is usually effective in children with obstructive sleep apnea who are otherwise healthy and have enlarged tonsils and/or adenoids (1). Adenotonsillectomy may also improve some behaviors, quality of life, and blood pressure compared with watchful waiting (2). 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.

Adenotonsillectomy may be effective or may provide some relief (3). Depending on the anatomic abnormality causing OSA, an alternate surgical procedure may be indicated (eg, uvulopalatopharyngoplasty, 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 (4).

Weight loss can decrease OSA severity in children with obesity and has other health benefits. However, weight loss as monotherapy is rarely sufficient in the long term.

Nocturnal oxygen supplementation may help prevent hypoxemia until definitive treatment can be accomplished (5).

Underlying disorders should be treated. For example, treatment of allergic rhinitis should be intensive and may involve intranasal glucocorticoids. Systemic glucocorticoids and antibiotics are not usually indicated.

The prognosis of OSA in children is generally favorable with treatment. Adenotonsillectomy and correction of modifiable risk factors such as obesity lead to resolution or significant improvement in OSA.

See also treatment of adenoid hypertrophy.