Children and Sleep Apnea

Overview

Pediatric Obstructive Sleep Apnea (OSA) is a sleep disorder in which your child’s breathing is partially or completely blocked repeatedly during sleep. The condition is due to narrowing or blockage of the upper airway during sleep. Sleep apnea leads to poor-quality sleep in all affected people, but the daytime symptoms can be different between adults and children. Adults are more likely to exhibit daytime sleepiness and fatigue, while children are more likely to show behavior issues such as difficulty concentrating and hyperactivity. 

The estimated prevalence of OSA affects 1 to 10% of children. Most of these children have mild symptoms, and many outgrow the condition. Pediatric OSA is a timely public health concern, given the increasing rates of obesity and hyperactivity in this population. Studies have shown that a large percentage of children with hyperactivity or inattentive behaviors had underlying OSA. Many of these children will be treated more effectively if the underlying OSA is properly treated, rather than relying on the use of stimulant medications to treat the resulting ADHD. 

There are differences in underlying causes, physiological reasons and clinical manifestations between pediatric obstructive sleep apnea and adult sleep apnea.:  

The underlying cause in adults is often obesity, while in children the most common underlying condition is enlargement of the adenoids and tonsils. However, obesity also plays a role in children. Other underlying factors can be craniofacial anomalies and neuromuscular disorders. 

Children tend to have a faster breathing pattern than adults. They also have smaller lungs, so they have less oxygen in reserve. For these reasons, even brief pauses in breathing can cause a child to have low levels of oxygen in the blood.  

Children tend to take frequent, shallow breaths rather than slow, deep breaths. This also can cause a child with sleep apnea to have too much carbon dioxide in the blood. 

Adults with sleep apnea often have fragmented sleep. They tend to wake up briefly after their breathing stops. Children with sleep apnea often do not wake up in response to pauses in breathing. They have a higher arousal threshold than adults. As a result, their sleep pattern tends to be normal.  

Younger children have a very flexible rib cage. As a result, the breathing problems can produce unusual movements of a child’s chest and abdomen. The rib cage may appear to move inward as the child inhales. Parents often notice that the child seems to be working hard to breathe. For healthy children over three years of age, this type of breathing is not normal. 

Many children with sleep apnea have a history of snoring. Snoring may be loud and may include obvious pauses in breathing and gasps for breath. Sometimes the snoring involves a continuous, partial obstruction without any obvious pauses or arousals. The child’s body may move in response to the pauses in breathing, and the child may appear to have restless sleep. 

Early diagnosis and treatment are important to prevent complications that can affect children’s growth, cognitive development, and behavior. Sleep apnea is treated differently in children than in adults. In adults, the most common treatment is CPAP, while the most common treatment for children is surgery. Certain orthodontic treatments are only helpful in actively growing children and are not an option for adults with sleep apnea. 

Learn More About Sleep Apnea and Children
Symptoms

Symptoms of sleep apnea tend to appear in the first few years of life but can occur at any age. Sleep apnea often remains undiagnosed for several years. In early childhood, sleep apnea can slow a child’s growth rate.  

During sleep, signs and symptoms of pediatric sleep apnea might include: 

  • Snoring 
  • Pauses in breathing 
  • Restless sleep 
  • Snorting, coughing or choking 
  • Mouth breathing 
  • Nighttime sweating 
  • Bed-wetting 
  • Sleep terrors or sleep walking 

Note: Infants and young children with obstructive sleep apnea do not always snore. They might just have disturbed sleep. 

 

Because it’s hard for them to get a good night’s sleep, children with sleep apnea might: 

  • Have a tough time waking up in the morning 
  • Perform poorly in school 
  • Have difficulty paying attention 
  • Have learning problems 
  • Have behavioral problems (irritable/aggressive) 
  • Poor school performance 
  • Have poor weight gain/ Delays in development 
  • Be hyperactive/Have Attention-deficit/hyperactivity disorder (ADHD)symptoms 

Note: Children may have difficulty conveying what they are feeling, leading to a misdiagnosis of ADHD when in fact their problems stem from a sleep disorder. Sleep apnea affects up to 1/3 of patients with ADHD. Sleep apnea leads to disturbed sleep and daytime sleepiness, and often causes symptoms typical of ADHD. 

Risk Factors
  • Enlarged tonsils and adenoids: Widely recognized risk factor for pediatric OSA. Tonsils and adenoids are glands located at the back of the throat and are part of the immune system. The tonsils and adenoids may be enlarged due to genetics, frequent infections, or inflammation. When enlarged, these glands narrow the airway, making breathing during sleep more difficult. 
  • Childhood obesity: OSA in children is also often caused by obesity, which also constricts the airway. Obstructive sleep apnea occurs in 60% of obese children. 
  • Other risk factors:  
  • Medical conditions such as Down syndrome, cerebral palsy, Sickle cell disease or neuromuscular disease who produce tongue and throat muscle weakness. 
  • Abnormalities in the skull or face that narrow the airway: 
  • A large tongue, which can fall back and block the airway during sleep 
  • A small jaw or an overbite 
  • History of low birth weight 
  • Family history of OSA 
  • Nasal Allergies 
  • Being around people who smoke 
Complications

Pediatric obstructive sleep apnea can have serious complications, including: 

  • Failure to grow 
  • Heart problems 
  • High Blood Pressure 
  • Sudden Death 

Parents who want to understand the potential impact of sleep apnea on their child should first understand what are sleep cycles, stages and sleep architecture. Sleep apnea in children mostly affects the REM stage of sleep, which explains the difficulty of children with sleep apnea to learn and concentrate. 

Diagnosis

First, a doctor gathers information from the child and parent or guardian about the child’s sleep habits and any daytime and nighttime symptoms. The doctor may also perform a physical examination of the child’s mouth, neck and throat to look for physical characteristics that increase risk for sleep apnea (such as enlarged tonsils and adenoids). 

If this first evaluation shows further testing is appropriate, the doctor may suggest polysomnography, which is a sleep study performed overnight at a sleep clinic. Polysomnography involves measuring specific body functions while a person is sleeping. It is painless, noninvasive and risk-free. Polysomnography is the gold standard method for evaluating suspected sleep apnea, as it produces the most definitive results. 

Home sleep tests are generally not recommended for children, based on the American Academy of Pediatrics and the American Academy of Sleep Medicine guidelines. 

During a sleep study, doctors check: 

  • eye movements 
  • heart rate 
  • breathing patterns 
  • brain waves 
  • blood oxygen levels 
  • carbon dioxide levels 
  • snoring and other noises 
  • body movements and sleep positions 
Treatments

When obstructive sleep apnea is mild, doctors might check a child’s sleep for a while to see if symptoms improve before deciding on treatment. 

  • Tonsillectomy (tonsils removal) or adenotonsillectomy (removing enlarged adenoids) are often effective surgical treatments for sleep apnea in children (when the children have enlarged tonsils/adenoids)  
  • Myofunctional therapy: Mouth and throat exercises, also known as “myofunctional therapy” or “oropharyngeal exercises,” have been shown to improve obstructive sleep apnea and snoring in children when sleep apnea is caused by a structural issue. 
  • Orthodontics: Rapid maxillary expansion and mandibular advancement devices are orthodontic approaches that use dental hardware or oral appliances to create more space in the mouth and improve the flow of air through the airway. The effectiveness of oral appliances in children is still being studied. 
  • CPAP: Also called continuous positive airway pressure, CPAP is a machine that continuously pumps air into the airway through a mask attached to a pump while they are sleeping. Sleeping with a CPAP mask can be a difficult adjustment for children and may require behavioral support. 
  • Treatment of allergies and sinus inflammation: Medications, such as a steroid nasal spray, saline nasal rinses, and/or other allergy medications, may be a possibility for children with mild sleep apnea symptoms. These medications can reduce airway narrowing and poor tongue posture caused by constantly breathing through the mouth. Allergy treatment is often done in conjunction with other treatment options. 
When Should Your Child See a Doctor?

It is a good idea to consult a doctor anytime abnormal sleep symptoms are present. Also, children who do not sleep well often have trouble focusing, display irritability, or have poor impulse control. If a child is struggling with behavior concerns, it could be helpful to ask the doctor whether a sleep disorder such as sleep apnea may be a contributing factor.