Synonym: obstructive sleep apnoea, OSA
Sleep disorders in children form a spectrum from snoring (mostly thought to be benign), upper airways resistance and hypopnoea to apnoeic episodes, ie obstructive sleep apnoea syndrome (OSAS).
Paediatric OSAS is characterised by partial or intermittent complete airway obstruction during sleep, which affects the child's ventilation and disrupts their normal sleep pattern. In general, all children with OSAS will snore.
OSAS is a common and serious cause of metabolic, cardiovascular and neurocognitive morbidity in children.
OSAS in children is a similar condition to the form in adults but there are important differences too. There is sleep disruption due to respiratory pauses that last more than ten seconds. There may also be hypopnoeic episodes (usually >5-10 episodes per night, with oxygen saturations <85%). The main differences relate to the presentation (see 'Presentation', below).
- It is common in children, especially in preschool children; the peak age is 3-6 years, which coincides with the growth of adenoids and tonsils.
- It has been estimated to occur in 5-6% of children.
- OSAS is becoming an increasing concern as obesity in children increases and as hyperactivity may be related to poor sleeping.
- Congenital abnormalities associated with narrow pharyngeal airways (eg, Down's syndrome or achondroplasia) have an increased risk of OSAS.
- Adenotonsillar hypertrophy. However, many children with adenotonsillar hypertrophy do not have OSAS.
- Obesity - the likelihood of an obese child developing OSAS is four to five times greater than in a non-obese child.
- Neck-to-waist ratio, an index of body fat distribution, predicts OSAS in older children and youth, especially in those who are overweight or obese.
- Neuromuscular diseases - eg, presence of craniofacial abnormalities.
- A small maxilla and/or mandible may predispose children to OSAS.
- Snoring - usually parents seek attention; many will just get better as they grow older.
- Mouth breathing.
- Witnessed apnoeic episodes.
- Daytime sleepiness and somnolence is less important in childhood OSAS, in contrast with adults who often fall asleep during the day.
- Not doing well at school due to poor concentration.
- Failure to thrive.
- Behavioural problems.
- Cor pulmonale, or pulmonary hypertension, can develop in severe cases.
- Include symptoms as above so that you have a full sleep history. Parent/carer observation of the child's sleep pattern is useful for the initial history but may be too unreliable to make the diagnosis.
- The question of whether a child stops breathing is a poor discriminator of apnoea and is better phrased by asking whether a child sounds 'strangled' during sleep, or whether a period is noted where the child's breathing goes quiet and is then overcome by a gasp.
- Enuresis may occur in these patients.
- In primary care the following should alert you to taking an OSAS history:
- Symptoms of recurrent blocked nose.
- Recurrent nasal or throat infections.
- Recurrent ear infections.
- Any risk factors as above.
- Any children whose parents are concerned about snoring.
Whom to refer
- Any child with symptoms suggestive of OSAS should be referred for further investigations.
- Referrals are usually to paediatric physicians, although sometimes paediatric neurologists, respiratory doctors or ENT consultants may have a specialist interest.
- The majority of cases are diagnosed on clinical grounds.
- In children, apnoeic episodes may only need to be a few seconds long before desaturation occurs.
- The overnight in-laboratory polysomnography (PSG) continues to be the gold standard instrument for the investigation of sleep-disordered breathing in children.
- During sleep studies the following are usually monitored:
- Oxygen saturations and heart rate.
- Airflow at nose or mouth.
- Chest and abdominal movements.
- ECG, electroencephalogram, electromyogram and sometimes electro-oculogram (eye movements).
- On average, more than one apnoeic or hypopnoeic episode with oxygen saturations <92% is abnormal.
- However, PSG may be normal despite sleep disturbance. This is particularly so when there is upper airways obstruction rather than the full-blown OSAS. If this is causing reduced academic performance or behavioural problems, it is just as important as a diagnosis of OSAS.
Other investigations that may be needed
- Airway assessment - to determine the cause of OSAS - eg, video photography (invasive).
- Several radiological techniques (eg, lateral neck radiography, CT and MRI) may be used to investigate the role of any possible structural alterations.
- NB: pulse oximetry alone is inadequate for the diagnosis of OSAS.
Children who have intermittent snoring only, with no history of apnoeas, no underlying medical conditions and no daytime features, can be managed conservatively. The goal of treatment is to restore optimal breathing during the night and to relieve associated symptoms.
- Continuous positive airway pressure (CPAP) can effectively treat OSAS in selected groups of children, improving both nocturnal and daytime symptoms. However, poor adherence is often a limiting factor.
- Weight loss is very important in obese children.
- There is no role for antibiotics (unless tonsillitis is present) or for steroids.
- For uncomplicated cases in children, surgical intervention with removal of the tonsils and adenoids can lead to significant improvements.
- Uvulopalatopharyngoplasty - thick soft palate and long uvula. (May also be combined with adenotonsillectomy if there is severe OSAS.)
- Tracheostomy - very rarely indicated and only as an exceptional last resort.
- Orthodontic treatments, such as orthopaedic mandibular advancement or rapid maxillary expansion, have been shown to be effective treatments.
- Starting an orthodontic treatment as early as symptoms appear is important in order to increase the efficacy of treatment.
- Some chlildre actual improve with time, so watchful waiting rather than adenotonsillectomy may be appropriate for some children.
- Medication such as leukotriene antagonists and topical nasal steroids can be beneficial for children with mild forms of OSAS and also in children with associated allergic diseases.
- If left untreated, OSAS is associated with adverse effects on growth and development, including deleterious cognitive and behavioural outcomes.Evidence exists also that untreated OSAS impacts on cardiovascular risk.
- Daytime hyperactivity.
- Cognitive deficits.
- Cardiovascular problems - eg, hypertension, left ventricular hypertrophy, raised pulmonary artery pressure.
- Failure to thrive.
- Association with insulin resistance.
- Some studies have shown that children with OSAS have greater impulsivity when crossing streets which increases their risk of injury.
- School-aged children are at risk of developing future obesity if they have OSAS.
- Treatment is associated with improved learning and behaviour and quality of life.
- Adenotonsillectomy improves short-term and long-term quality of life in children with OSAS.
Further reading and references
Evans CA, Selvadurai H, Baur LA, et al; Effects of obstructive sleep apnea and obesity on exercise function in children. Sleep. 2014 Jun 137(6):1103-10. doi: 10.5665/sleep.3770.
Katz SL, Vaccani JP, Barrowman N, et al; Does neck-to-waist ratio predict obstructive sleep apnea in children? J Clin Sleep Med. 2014 Dec 1510(12):1303-8. doi: 10.5664/jcsm.4284.
Huynh NT, Desplats E, Almeida FR; Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis. Sleep Med Rev. 2015 Feb 17. pii: S1087-0792(15)00029-5. doi: 10.1016/j.smrv.2015.02.002.
Urquhart D; Investigation and management of childhood sleep apnoea. Hippokratia. 2013 Jul17(3):196-202.
Alexopoulos EI, Malakasioti G, Varlami V, et al; Nocturnal enuresis is associated with moderate-to-severe obstructive sleep apnea in children with snoring. Pediatr Res. 2014 Dec76(6):555-9. doi: 10.1038/pr.2014.137. Epub 2014 Sep 8.
Oliveira VX, Teng AY; The Clinical Usefulness of Sleep Studies in Children. Paediatr Respir Rev. 2015 Aug 21. pii: S1526-0542(15)00074-3. doi: 10.1016/j.prrv.2015.08.003.
Sudarsan SS, Paramasivan VK, Arumugam SV, et al; Comparison of treatment modalities in syndromic children with obstructive sleep apnea -a randomized cohort study. Int J Pediatr Otorhinolaryngol. 2014 Sep78(9):1526-33. doi: 10.1016/j.ijporl.2014.06.027. Epub 2014 Jul 7.
Sujanska A, Durdik P, Rabasco J, et al; Surgical and non-surgical therapy of obstructive sleep apnea syndrome in children. Acta Medica (Hradec Kralove). 201457(4):135-41. doi: 10.14712/18059694.2015.78.
Villa MP, Rizzoli A, Rabasco J, et al; Rapid maxillary expansion outcomes in treatment of obstructive sleep apnea in children. Sleep Med. 2015 Jun16(6):709-16. doi: 10.1016/j.sleep.2014.11.019. Epub 2015 Mar 16.
Chervin RD, Ellenberg SS, Hou X, et al; Prognosis for Spontaneous Resolution of Obstructive Sleep Apnea in Children. Chest. 2015 Mar 26. doi: 10.1378/chest.14-2873.
Avis KT, Gamble KL, Schwebel DC; Obstructive sleep apnea syndrome increases pedestrian injury risk in children. J Pediatr. 2015 Jan166(1):109-14. doi: 10.1016/j.jpeds.2014.09.032. Epub 2014 Oct 25.
Lee CH, Kang KT, Weng WC, et al; Quality of life after adenotonsillectomy in children with obstructive sleep apnea: short-term and long-term results. Int J Pediatr Otorhinolaryngol. 2015 Feb79(2):210-5. doi: 10.1016/j.ijporl.2014.12.011. Epub 2014 Dec 16.