The prevalence of pediatric sleep apnea is estimated to be between 1-3% of children with a peak age of two to five years. The American Academy of Pediatrics recognizes that "(o)bstructive sleep apnea syndrome (OSAS) is a common condition in childhood and can result in severe complications if left untreated." Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Yet sleep apnea is relatively rarely diagnosed; hence the American Academy of Pediatrics now recommends that all children be regularly screened for snoring.
Risk factors for sleep-disordered breathing include the following:
- enlarged tonsils and adenoids
- craniofacial characteristics, including mid-facial hypoplasia, retrognathia, micrognathia, high arched palate, choanal atresia
- cleft palate
- Down syndrome
- sickle cell disease
- spina bifida
- cerebal palsy
- neuromuscular conditions associated with hypotonia
- allergic rhinitis
- gastroesophageal reflux
- obesity (although not all with sleep apnea are obese)
- congenital heart disease
- asthma
- family history of sleep-disordered breathing
Presenting nocturnal symptoms include the following:
- snoring or snorting during sleep
- choking or gasping
- apneas
- restless sleep
- diaphoresis
- enuresis
- sleeping in abnormal positions such as with neck hyperextended
Presenting daytime symptoms include the following:
- inattention or daydreaming
- hyperactive behavior
- learning difficulties
- aggressive/oppositional defiant behavior
- morning headaches
- tiredness
- difficult morning waking
- mood changes and irritability
- cor pulmonale
- failure to thrive (in infants)
When sleep-disordered breathing is suspected, pediatricians should refer the child for a sleep study. Because no combination of historical information and physical findings has been shown to predict OSAS in children, the gold standard for diagnosis remains overnight polysomnography.
The most common treatment option for pediatric sleep apnea is a tonsillectomy and adenoidectomy, but surgery may be contraindicated for patients with a cleft soft palate. Caution must be taken with patients for whom T&A surgery is a higher risk, such as children less than three years and those who already have serious medical complications of OSAS (e.g., failure to thrive, pulmonary hypertension, cor pulmonale) and who have underlying congenital or medical conditions (e.g., Pierre Robin, Down syndrome, neuromuscular disorders, sickle cell anemia, a bleeding disorder, and velopalatal insufficiency. Patients with sleep apnea are at an increased risk with anesthesia, so appropriate post-operative monitoring is crucial post-surgery. There are little data on other surgical options (e.g., uvulopalatopharyngoplasty) for OSAS in children.
Age-appropriate weight management strategies are necessary for overweight and obese children with OSAS. Treatment of contributing risk factors such as asthma and allergies is also important. While there is little in the literature about CPAP for children, Continuous (or bi-level) Positive Airway Pressure (CPAP) therapy has been shown to be an effective treatment in children and adolescents for whom other treatment options have failed or are inappropriate. To our knowledge, there are no published studies on the use of oral appliances for pediatric patients.
This piece is written for children age one or older who have not yet entered puberty and does not encompass infantile apnea or apnea of prematurity. As children begin to enter puberty, their symptoms--and hence the diagnosis and treatment of the disorder--become more like those of adults. Pediatricians may refer parents to the ASAA publication "HAVING YOUR CHILD EVALUATED FOR OBSTRUCTIVE SLEEP APNEA" available on the ASAA website, www.sleepapnea.org, or by calling the ASAA.
For more information, pediatricians may want to read the American Academy of Pediatrics' "Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome" Pediatrics 2002;109:704-712; (http://www.aap.org/policy/re0118.html).
This publication is made possible through a generous grant from the R.L. Stine and Jane Stine Foundation.
As a non-profit organization, the ASAA does not endorse or recommend any company or products.
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