Synonym: OSA

Please see separate article 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, i.e. OSA.

OSA in children is a similar condition to the form in adults but there are important differences too.¹ 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 episodes per night, with oxygen saturations <85%). Main differences relate to the presentation (see below).

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 hypopnoeic episode per hour and oxygen saturations <92%,² or disruption of sleep and ventilation resulting from prolonged partial upper airway obstruction with intermittent complete obstruction.³

Epidemiology

• Common in children, especially preschool children, the peak age is 3-6 years, which coincides with the growth of adenoids and tonsils.¹
• Prevalence rates are in the order of 0.8- 2% in westernised countries.^1,4
• Obstructive sleep apnoea (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.⁴
• Congenital abnormalities associated with narrow pharyngeal airways, e.g. Down's syndrome or achondroplasia, have an increased risk of OSA.¹

Causes

• Adenotonsillar hypertrophy - but be aware that many children with adenotonsillar hypertrophy do not have obstructive sleep apnoea (OSA).
• Obesity - increases the risk of OSA nearly five times.³
• Neuromuscular diseases, e.g. presence of craniofacial abnormalities.

Presentation

• Snoring - usually parents seek attention; many will just get better as they grow older.
• Mouth breathing.
• Witnessed apnoeic episodes.
• Daytime somnolence and tiredness are not prominent (although more common in adults than children).¹
• Not doing well at school due to poor concentration.
• Failure to thrive.
• Behavioural problems.
• Enuresis - thought to be due to lack of awareness overnight.¹
• Cor pulmonale in severe cases.
• Papilloedema and visual loss have been reported.⁵

Assessment

History

• 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.
• In primary care the following should alert you to taking an obstructive sleep apnoea (OSA) history:¹
  • 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

Examination

• In primary care the following are suggested:¹
  • Nasal airflow - place a cold spatula or tongue depressor under the patient's nose - does it mist?
  • Mouth and pharynx - tonsil size and any palate abnormalities.
  • Presence of glue ear.
  • Presence of lymphadenopathy.

Other tests which may occur in secondary care include:

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

Who to refer¹

• Any child with symptoms suggestive of obstructive sleep apnoea (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.

Investigations

• In children apnoeic episodes may only need to be a few seconds long before desaturation occurs.
• Thus the diagnosis can be made with just overnight oximetry. This is attractive as it is noninvasive, but it can be unreliable. The UK Royal College of Paediatrics and Child Health states that pulse oximetry is a useful screening test but formal polysomnography is needed to distinguish between snoring and obstructive sleep apnoea (OSA).¹
• 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:
  • Earlobe saturations.
  • Airflow at nose or mouth.
  • Chest and abdominal movements.
  • ECG, electroencephalogram, electromyogram and sometimes electro-oculogram (eye movements).⁶
• On average more than one apnoeic or hypopnoeic episode with oxygen saturations <92% is abnormal.
• But polysomnography may be 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.²

Other investigations that may be needed

Management

Medical

• Continuous positive airways pressure (CPAP) - especially if adenotonsillectomy is 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.³
• No role for antibiotics (unless tonsillitis is present), or for steroids.

Surgical

• Adenotonsillectomy for adenotonsillar hypertrophy.⁷
• Uvulopalatopharyngoplasty - thick soft palate and long uvula. (May also be combined with adenotonsillectomy if there is severe obstructive sleep apnoea (OSA).)
• Tracheostomy - very rarely indicated and only as an exceptional last resort.

Complications⁸

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

Prognosis⁸

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

Document references

1. Powell S, Kubba H, O'Brien C, et al; Paediatric obstructive sleep apnoea. BMJ. 2010 Apr 14;340:c1918. doi: 10.1136/bmj.c1918.
2. Chan J, Edman JC, Koltai PJ; Obstructive sleep apnea in children. Am Fam Physician. 2004 Mar 1;69(5):1147-54. [abstract]
3. Ng DK, Lam YY, Kwok KL, et al; Obstructive sleep apnoea syndrome and obesity in children. Hong Kong Med J. 2004 Feb;10(1):44-8. [abstract]
4. No authors listed; Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002 Apr;109(4):704-12. [abstract]
5. Quinn AG, Gouws P, Headland S, et al; Obstructive sleep apnea syndrome with bilateral papilledema and vision loss in a 3-year-old child. J AAPOS. 2008 Feb 19;. [abstract]
6. Muzumdar H, Arens R; Diagnostic issues in pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008 Feb;5(2):263-73. [abstract]
7. Nixon GM, Brouillette RT; Sleep . 8: paediatric obstructive sleep apnoea. Thorax. 2005 Jun;60(6):511-6. [abstract]
8. Capdevila OS, Kheirandish-Gozal L, Dayyat E, et al; Pediatric Obstructive Sleep Apnea: Complications, Management, and Long-term Outcomes. Proc Am Thorac Soc. 2008 Feb;5(2):274-82. [abstract]

Acknowledgements