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 

In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids. 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, making the flow of air more difficult and the work of breathing harder. It is like breathing through a small, flimsy straw with the straw occasionally collapsing and blocking airflow. Many of the short pauses (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 (a comparable image would be someone poking you 15 to 30 times a night) 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, and the parent often describes very restless sleep but usually does not describe the child's waking up completely.

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 or Down syndrome.

Signs and symptoms of sleep apnea

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.
  • 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."
  • Bed wetting — 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.

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 surgical 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.

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 make the evaluation for such surgery. 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.

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 attached to a machine that blows air through the nasal passages and into the airway. This air pressure keeps the airway open and allows the child to breathe normally during sleep.

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