Obstructive Sleep Apnea in Children – Recognition and Treatment

Obstructive Sleep Apnea in Children
Sleeping difficulties such as snoring and obstructive sleep apnea (OSA) can affect people of all ages, sizes, and genders, including children. Approximately 2 to 4 percent of children snore regularly, and about 24 percent of the pediatric population has obstructive sleep apnea.

Obstructive sleep apnea causes a child’s breathing to be interrupted during sleep, which the brain perceives as choking. This triggers several physiologic changes. The heart rate slows, blood pressure rises, the brain is aroused, and sleep is disrupted. Oxygen levels in the blood can also drop. Recent studies have indicated that even mild breathing difficulties or snoring may cause many of the same problems in children as OSA.

Potential Consequences of Untreated Obstructive Sleep Apnea

  • Social Concerns: Loud snoring can become a significant social problem for children who share a room with siblings, attend sleepovers with friends, and go to summer camp.
  • Behavior And Learning Challenges: Children with obstructive sleep apnea may become moody, inattentive, and disruptive both at home and at school. This condition can also be a contributing factor to attention deficit disorders in some children.
  • Bedwetting: obstructive sleep apnea can cause increased nighttime urine production, which may lead to bedwetting.
  • Slow Growth: Children with sleep apnea may not produce enough growth hormone, resulting in abnormally slow growth and development.
  • Obesity: obstructive sleep apnea may cause the body to have increased resistance to insulin, or daytime fatigue leading to decreases in physical activity. These factors can contribute to obesity.
  • Cardiovascular Issues: obstructive sleep apnea can be associated with an increased risk of high blood pressure or other heart and lung problems such as congestive heart failure.

Diagnosis of Obstructive Sleep Apnea

OSA in children should be considered if frequent loud snoring, gasping, snorting, thrashing in bed, or unexplained bedwetting is observed. Due to a lack of good-quality sleep, a child with sleep-disordered breathing may be irritable, be sleepy during the day, or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed.

  • Signs Of Obstructive Sleep Apnea
  • Abnormal breathing during sleep
  • Daytime mouth breathing
  • Difficulty awakening
  • Bedwetting
  • Excessive daytime sleepiness
  • Frequent awakenings or restlessness
  • Frequent nightmares
  • Hyperactivity/behavior problems
  • Poor or irregular sleep patterns

If you notice that your child has any of these symptoms, it is important to consult an otolaryngologist (ear, nose, and throat doctor). Physicians can sometimes diagnose sleep-disordered breathing based on history and a physical examination. Additional testing, such as a sleep test, may be recommended for children less than three years of age or those suspected of having severe OSA due to craniofacial syndromes, morbid obesity, or neuromuscular disorders.

The sleep study or polysomnography (PSG) is a test for OSA. During this test, wires are attached to the child to monitor brain waves, muscle tension, eye movement, breathing, heart rhythm, and the level of oxygen in the blood. While sleep tests can be helpful, they occasionally produce inaccurate results, especially in children.

Causes of Obstructive Sleep Apnea

Enlarged tonsils and adenoids commonly contribute to breathing difficulties in children. Nasal congestion due to enlarged nasal turbinates can also create similar challenges. Overweight children are at increased risk for OSA because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue, or neuromuscular deficits such as cerebral palsy, also have a higher risk of developing OSA.

Surgical Treatment for Obstructive Sleep Apnea

Once the diagnosis for OSA has been determined, an adenotonsillectomy, the surgical removal of the adenoids and tonsils, is usually the preferred course of treatment. Of the over 500,000 pediatric tonsil and adenoid procedures performed in the U.S. each year, the majority are to treat OSA. Most children with sleep apnea show both short- and long-term improvement in both their sleep and behavior after this surgery.

Adenotonsillectomy should be implemented in conjunction with weight normalization in obese children. Caloric intake limitation and dietary counseling are necessary if obesity complicates OSA. Children and adolescents with significant sleep apnea should avoid eating large amounts just before bedtime.

Not every child with snoring should undergo adenotonsillectomy, as the procedure does have risks. Potential problems can include anesthesia or airway complications, bleeding, infection, and problems with speech and swallowing. If the OSA symptoms are mild, there are no academic performance and behavior issues, the tonsils are small, or the child is near puberty (tonsils and adenoids often shrink at puberty), it may be recommended that a child be watched conservatively and treated surgically only if symptoms worsen.

Recent studies have shown that some children continue to have persistent sleep-disordered breathing after an adenotonsillectomy. A postoperative sleep study may be necessary in children with persistent symptoms or increased risk factors, including obesity, craniofacial anomalies, or neuromuscular problems. Additional treatments such as weight loss or the use of continuous positive airway pressure (CPAP), and/or additional surgical procedures, may sometimes be required.

Continuous Positive Airway Pressure (CPAP)

CPAP is the typical treatment for most adults with OSA, as well as some children and adolescents. However, it is often difficult for children to tolerate this therapy. CPAP devices can be uncomfortable and inappropriately fitted masks can leak, leading to the development of pressure sores on the bridge of the nose. Air leaks can also irritate the eyes, causing increased tearing and eye discomfort. Compliance issues are of particular importance in patients treated with noninvasive ventilation.

Relief is Possible

Obstructive sleep apnea can have a profound impact on children and their families. The good news is that effective treatments are available. The first step is to recognize the symptoms of OSA and have your child evaluated by an otolaryngologist.

William A. McClelland, MD, FACS - Board Certified Otolaryngologist (ENT)
About the Author
Otolaryngologist (ENT) at CornerStone Ear, Nose & Throat, PA
Dr. McClelland is a Board Certified Otolaryngologist (ENT) as well as the Founding Partner of CornerStone Ear, Nose & Throat, PA. His particular clinical interest is minimally invasive sinus surgery.
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