Obstructive Sleep Apnea

What is obstructive sleep apnea?

Obstructive sleep apnea (OSA) occurs when a child stops breathing during sleep. The cessation of breathing usually occurs because there is a blockage (obstruction) in the airway. Obstructive sleep apnea affects many children and is most commonly found in children between 2 and 6 years of age, but can occur at any age.

Causes of sleep apnea 

The most common cause of obstructive sleep apnea in children is enlarged tonsils and/or adenoids. Both the tonsils and adenoids are lymph tissue. The tonsils are located in the back of the throat, and the adenoids are located at the back of the nose. During sleep there is a considerable decrease in muscle tone, which affects the airway and breathing. Many of these children have little difficulty breathing when awake; however, with decreased muscle tone during sleep, the airway becomes smaller, and the tonsils and adenoids block the airway. This makes the flow of air more difficult and increases the work the child has to do to breathe. It can be compared to breathing through a small, flimsy straw with the straw occasionally collapsing and blocking airflow. Many of the short pauses in breathing (lasting only a few seconds) cause a brief arousal that increases muscle tone, opens the airway and allows the child to resume breathing.

Although the actual number of minutes of arousal during the night may be small, the repeated disruptions can result in a poor night's sleep, which can lead to significant daytime problems in children. The child is usually unaware of waking up because he/she is not waking up completely. The parents often describe the child as a very restless sleeper.

Risk factors of sleep apnea

Sleep apnea is more common in children who are overweight. However, some children with enlarged tonsils and/or adenoids may even be underweight. Other children who are at high risk for sleep apnea include those with a small jaw, craniofacial syndromes, muscle weakness (hypotonia) or Down syndrome.

Obstructive sleep apnea symptoms

The following are the most common symptoms of obstructive sleep apnea. However, every child is different and symptoms may vary. Symptoms may include:

  • Snoring — loud snoring or noisy breathing during sleep.
  • Periods of not breathing — although the chest wall is moving, no air or oxygen is moving through the nose or mouth into the lungs. The duration of these periods is variable and measured in seconds.
  • Mouth breathing — the passage to the nose may be completely blocked by enlarged tonsils and adenoids leading to the child only being able to breathe through his mouth.
  • Restlessness during sleep — the frequent arousals lead to restless sleeping or "tossing and turning" throughout the night. Many children will move all over their bed, or wake up in completely different positions from when they went to sleep
  • Sleeping in odd positions — the child may arch his neck backwards (hyperextend) in order to open the airway or sleep sitting up.
  • Behavior problems or sleepiness — may include irritability, crankiness, frustration, hyperactivity and difficulty paying attention.
  • School problems — children may do poorly in school, even being labeled as "slow" or "lazy."
  • Bedwetting — also known as nocturnal enuresis, although there are many causes for bedwetting besides sleep apnea.
  • Frequent infections — may include a history of chronic problems with tonsils, adenoids and/or ear infections.

In addition, the symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Be sure to always consult your child's physician.

Testing and diagnosis of sleep apnea

Talk to your child's physician if you are concerned about your child's breathing during the night. Your child may be referred to a specialist, such as a sleep specialist, an otolaryngology (ear, nose and throat) physician or a pulmonary (lung) doctor for further evaluation.

In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include an overnight sleep study (also called polysomnography) and an evaluation of the upper airway by visualization and/or X-rays. A lateral neck X-ray can be performed in the office on the same day of the appointment to allow for immediate review of the size of the adenoids. This is non-invasive and will allow the provider to determine if the adenoids are enlarged, which could be contributing to sleep apnea. 

Your doctor will discuss the usefulness of a sleep study at our Sleep Laboratory in the evaluation of obstructive sleep apnea. During a sleep study, a total of 16 electrodes are placed on your child to record his sleep activities, from brain function and breathing patterns to eye activity and muscle tone. More than 1,000 sheets of readings are recorded for each child during the night, with two technologists present at all times to monitor your child and evaluate the recordings.

An overnight study often reveals the full extent of a medical problem. Treatment for upper airway obstruction often includes surgery to remove the tonsils and adenoids. In more complicated cases, other procedures are considered, as well as applying ventilatory support during sleep. For primary sleep disorders other than sleep apnea, behavioral modification and specific medications are also prescribed.

Obstructive sleep apnea treatment

The treatment for obstructive sleep apnea is based on its cause. Since enlarged tonsils and adenoids are the most common cause of obstructive sleep apnea in children, surgical removal of the tonsils (tonsillectomy) and adenoids (adenoidectomy) is usually the recommended treatment (see tonsils and adenoids). An ear, nose and throat specialist will evaluate for and make the recommendation for surgical removal. Other types of surgery are occasionally needed in children with craniofacial abnormalities. Weight loss and treatment of other medical problems may also be helpful in the management of obstructive sleep apnea. Oftentimes, the child can be referred to the Healthy Weight Clinic, which can help focus on ways to improve health and contribute to healthy weight loss.

In cases where surgery is not helpful, another effective treatment is continuous positive airway pressure (CPAP). CPAP involves wearing a mask over the nose during sleep. This mask is attached to a machine that blows air through the nasal passages and into the airway. This will be managed by a lung specialist, or pulmonologist.

If left untreated, obstructive sleep apnea can cause poor growth ("failure to thrive"), high blood pressure and heart problems. Obstructive sleep apnea can also affect behavior and cognition. Therefore, it is important to get it evaluated early.

In all cases, the specific treatment for obstructive sleep apnea depends on many factors and is tailored for each child. Please discuss your child's condition, treatment options and your preference with your child's physician or healthcare provider.

Reviewed by Steven D. Handler, MD, MBE, FACS, FAAP