Obstructive Sleep Apnea (OSA) in Children

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

• Obesity (the most common cause)

• Enlarged tonsils or adenoids

• Allergic rhinitis (ie, causing significant nasal congestion)

• 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)

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). Waketime 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

Obstructive sleep apnea is considered in children with snoring or risk factors (1). If symptoms of OSA are present, diagnostic testing is done in a sleep laboratory using overnight polysomnography 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 can also be used but is less likely to be successful in obtaining accurate data.

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 radiograph, arterial blood gas measurement, and imaging of the upper airway or flexible nasopharyngoscopy.

• Sometimes watchful waiting

• Adenotonsillectomy or correction of congenital micrognathia

• CPAP and/or weight loss with intensive support

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. Adenotonsillectomy may also improve some behaviors, quality of life and blood pressure compared with watchful waiting (1). 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 (2). 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 (3).

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 (4).

Treatment of allergic rhinitis should be intensive. Corticosteroids and antibiotics are not usually indicated.