Obstructive Sleep Apnoea in Children

Synonym: OSA

Please read our general article on Obstructive Sleep Apnoea (OSA).

Sleep disorders in children form a spectrum from snoring (mostly thought to be benign), upper airways resistance, hypopnoea to apnoeic episodes i.e. OSA.

OSA in children is a similar condition to the form in adults. That is to say, there is sleep disruption due to respiratory pauses that last more than ten seconds. There may also be hypopnoeic episodes (usually > 5 - 10, with oxygen saturations < 85%).

However, due to anatomical and physiological differences between adults and children the definition of OSA in children is less clear. One view, is more than one apnoeic or hypopnoiec episode per hour and oxygen saturations < 92 %,¹ or disruption of sleep and ventilation resulting from prolonged partial upper airway obstruction with intermittent complete obstruction.²

• Common in children especially preschool children.
• Prevalence rates are in the order of 1- 2 % in westernized countries.³
• OSA is becoming an increasing concern as obesity in children increases and hyperactivity may be related to poor sleeping.
• Therefore, all children with a history of snoring should be screened.³

• Adenotonsillar hypertrophy - but be aware that many children with adenotonsillar hypertrophy do not have OSA.
• Obesity - increases the risk of OSA nearly five times.²
• Neuromuscular diseases e.g. presence of craniofacial abnormalities.

• Snoring – usually parents seek attention - many will just get better as they grow older
• Mouth breathing
• Witnessed apnoeic episodes
• Daytime somnolence (more common in adults than children)
• Not doing well at school due to poor concentration
• Failure to thrive
• Behavioural problems
• Enuresis
• Cor pulmonale in severe cases
• Papilloedema and visual loss has been reported⁴

History

• Include symptoms as above so that have a full sleep history. Parent/carer observation of the childs sleep pattern is useful for the initial history but maybe too unreliable to make the diagnosis.

Examination

• Nasal obstruction
• Septal deviation
• Nasal polyps
• Tonsillar examination
• Craniofacial abnormalities e.g. micrognathia
• Evidence of complications of OSA e.g. systemic hypertension, RV heave, cor pulmonale and poor growth
• Record BMI
• Videotaping may be used

• Any child with symptoms suggestive of OSA should be referred for further investigations.
• Referrals are usually to paediatric physicians – although, sometimes paediatric neurologists or respiratory doctors may have a specialist interest.

• In children apnoeic episodes may only need to be a few seconds long before desaturation occurs.
• Thus rarely the diagnosis can be made with just overnight oximetry. This is attractive as it is non-invasive but it is unreliable.
• However, the gold standard is probably polysomnography, commonly called sleep studies.

Polysomnography

• The current gold standard in adults.
• However, its role in children is less well defined.
• During sleep studies the following are monitored:
  • Ear lobe saturations
  • Airflow at nose or mouth
  • Chest and abdomen movements
  • ECG, electroencephalogram, electromyogram and sometimes electroculogram (eye movements)⁵
• On average more than one apnoeic or hypopnoeic episode with oxygen saturations < 92% is abnormal.
• But polysomnography maybe normal despite sleep disturbance. This is particularly so when there is upper airways obstruction rather than the full-blown OSA. If this is causing reduced academic performance or behavioural problems it is just as important as a diagnosis of OSA.¹

Other investigations that may be needed

Medical

• Continuous positive airways pressure (CPAP) - especially if adenotonsillectomy not possible or has failed. This may be difficult for children to tolerate for the required duration e.g. due to tight fitting masks.
• Weight loss programme in obese children.²
• No role for antibiotics (unless tonsillitis present) nor steroids.

Surgical

• Adenotonsillectomy for adenotonsillar hypertrophy.⁶
• Uvulopalatopharyngoplasty - thick soft palate and long uvula. (May also be combined with adenotonsillectomy if severe OSA).
• Tracheostomy - very rarely indicated and only an exceptional last resort.

• Daytime hyperactivity
• Cognitive deficits
• Cardiovascular problems e.g. hypertension, left ventricular hypertrophy, raised pulmonary artery pressure
• Failure to thrive
• Association with insulin resistance

• Treatment is associated with improved learning and behaviour and quality of life.
• However, adenotonsillar surgery does not always lead to symptom resolution.