Obstructive sleep apnea (OSA) in children is both common and serious problem. Although I write a lot about insomnia and sleep training issues, much of my practice concentrates on evaluating and treating children with sleep disordered breathing, the most common type being OSA. OSA is the most important diagnosis which we look for in our sleep laboratory. (For more on the experience of having a sleep study for a child, here is a short video about our sleep program).

What is obstructive sleep apnea?

Obstructive sleep apnea (OSA) is a condition where obstruction of the upper airway (breathing tube from nose and mouth to the larynx (voice box)) occurs frequently during the night. It is usually associated with snoring and may be associated with labored breathing, gagging or choking, and frequent nocturnal awakenings. Whenever the upper airway is closed completely (called an apnea) or partially (called a hypopnea), the brain needs to wake up a bit to open the airway. This results in poor quality sleep, daytime behavioral and attention problems, and can even make other health problems worse. It occurs in about 3-5% of children. In obese children, it is more common, occurring in about a third of kids, and over 50% of snoring children.

What causes obstructive sleep apnea in children?

Anything that narrows the upper airway of children makes it more likely for OSA to occur. By far the most common cause is enlargement of the tonsils and adenoids, which typically peaks between ages 3-6. Other factors which can predispose kids to OSA include:

• Bony problems with the jaw or skull (such as a small jaw or a flattened center of the face, called the midface)
• Weakness in the muscles which open the airway (common in children with low tone (hypotonia) or other neurological conditions)
• Obesity
•  Narrowing of the nasal passages (as in allergic rhinitis)

What problems does sleep apnea cause in children?

The best way to answer this is to think about the nighttime manifestations of OSA, and the daytime symptoms, which are caused by the disruption in sleep, drops in oxygen, and elevation in carbon dioxide which may occur in this disorder.

Nighttime symptoms:

• Snoring, gasping, or choking
• Frequent awakenings at night
• Mouth breathing
• Extension of the head backwards on the neck
• Wetting the bed
• Sore throat in the morning
• Sweating a lot at night.

Daytime symptoms:

• Difficulty waking up in the morning
• Daytime sleepiness
• Hyperactivity during the day (especially common in younger children)
• Problems paying attention or learning in school
• Mouth breathing

Long Term Consequences of OSA in Children

There is a large body of literature supporting a relationship between sleep apnea and both short and long-term. These occur in a few domains:

• Problems with learning and attention.  As an example, a study was published following about 11,000 children born in England during the early 90s. The authors found that a history of snoring, mouth breathing, and/or witnessed apneas (episodes of stopping breathing) were associated with behavior problems such as hyperactivity, emotional problems, conduct problems, and issues with peers. This study has its flaws but is part of a growing body of work relating sleep disordered breathing to behavioral problems and brain development.
• Problems with metabolism: OSA has been associated with insulin resistance (prediabetes), problems with cholesterol, and fatty liver disease in children.
• Problems with cardiovascular health including high blood pressure and problems with the functioning of small blood vessels and right heart function.

Obesity and snoring: A special case

Things are different now. That classic picture of the child with OSA still exists. However, with the obesity epidemic in the USA and worldwide, the evaluation and management of children with snoring has become more complex. Obesity is defined by the Centers for Disease Control as a body mass index (measure including height and weight) greater than the 95 percentile for age. In other words, an obese child is heavier than 95% of “normal” sized children. In the most recent data, 16.9% of children ages 2-19 years of age were obese; 9.5% of infants and toddlers were obese. How do you know if your child is obese? You can see it on your child’s growth chart at the pediatrician. Or you can can just put your child’s height and weight into this calculator.

Why does this matter if a child is obese and snoring?

• Because the risk of obstructive sleep apnea is much higher. One third of obese children will suffer from OSA, compared with 2-4% of non-obese children. Fifty percent of obese snoring children will have OSA. It is not clear why this is. It may be because the upper airway is smaller and thus easier to collapse. Or, as we have shown in our research, fat in the belly is more likely to be associated with OSA, perhaps by pushing up on the lungs and making them smaller.
• Because OSA in obese children usually looks more like adult OSA in that it is associated with daytime sleepiness and depression.
• Because OSA pushes obese children towards obesity related medical conditions such as hypertension, cholesterol problems, and prediabetes.
• Because the sleep apnea is more severe. Drops in oxygen levels are more common and more severe in children with obesity.
• Because OSA is more difficult to treat. Removal of the tonsils and adenoids is still helpful but significantly less likely to result in a cure. Surgery is more likely to have complications in obese children. Obese children frequently gain more weight after surgery and have a higher rate of recurrence of sleep apnea.

Evaluation and treatment of an obese child with OSA

• Sleep studies are criticalfor both determining whether OSA is present or not, and if surgery is undertaken, determining if there has been a cure.
• Overnight observation in the hospital after adenotonsillectomy is recommended for children with severe OSA as the risk of surgical complications is higher.
• Alternative treatments are frequently necessary. Most commonly, this consists of continuous positive airway pressure (CPAP) which is pressure applied via a mask during the night. These keeps the airway open. Although it takes a bit of getting used to, I have school age kids and older who have done well with this therapy. Orthodontic work and further airway surgery may be helpful as well.
• Weight loss is critical. I routinely refer all of my patients with obesity to a nutritionist. If this is ineffective, I send them my colleagues in Endocrinology.

How is OSA diagnosed in children?

Unfortunately, the only way to rule out obstructive sleep apnea is an overnight sleep study. This test is not painful or dangerous, but it is an overnight in the hospital.  For a typical child with loud snoring and disrupted sleep older than age 3, a sleep study is not necessary– they should just have their tonsils and adenoids removed.  A recent position paper outlined reasons for a sleep study.

1. Children with complex medical problems including obesity, Down syndrome, sickle-cell anemia, or more exotic medical problems.
2. If the need for surgery is uncertain a study is recommended.
3. Children with severe OSA on a sleep study should be watched overnight after surgery as there is higher risk of complications.

I would add that children with severe OSA need a study after surgery to make sure that they are cured, as many children may have some residual disease.

How do you treat OSA in children?

For many children, removal of the tonsils and adenoids may be curative. Although these surgery has some associated risk, it is generally quite safe and fairly effective. Other treatments include medication for allergy (e.g. nasal corticosteroids and montelukast), jaw surgery, and weight loss. There are two other treatment options that I would like to mention:

• Rapid maxillary expansion: This is also known as a palate expander. It consists of a piece of hardware put in the upper jaw which slowly expands the upper jaw over time. This has been shown to treat sleep apnea in children with narrow upper jaws and persistent sleep apnea after adenotonsillectomy. Here is a picture if you are interested. 
• Continuous positive airway pressure: Also known as CPAP, this is the most common treatment for OSA in adults. It consists of two parts:  a mask, and a machine which delivers air pressure to keep the airway from collapsing. Children, even young children, can learn to wear it successfully. The problem is that it is a treatment and not a cure. Perhaps I’m biased as a pediatrician, I think that the goal in children (who have many years ahead of them) should be a cure and not long-term CPAP treatment, event if it requires multiple (medical, surgical, orthodontic) treatments.

My child snores. What should I do?

Not every child who snores needs surgery, or even a sleep study. Consultation with your pediatrician or a specialist can help determine the need for these interventions. Bringing in a video shot on your phone or camera of the breathing you are worried about is really helpful.

Let me leave you with one final thought. Sleep fragmentation (or too little sleep) can cause attention problems and hyperactivity. If your child snores and the school is recommending that she be treated for attentional deficit hyperactivity disorder, she should be screened for OSA.