Obstructive Sleep Apnea in Kids

In my practice, I see many children with medical sleep problems, including Obstructive Sleep Apnea (OSA). OSA is a common and serious sleep problem in children that can affect the quality of your child’s sleep. It occurs when a child has breathing pauses while sleeping and causes sleep fragmentation, daytime sleepiness, and behavioral problems. Like adults, untreated sleep apnea is related to poor health outcomes, and it should be diagnosed and treated early.

What is OSA?

OSA occurs when the muscles in the back of your throat collapse partially or completely, causing pauses in breathing. Because we breathe in oxygen and breathe out carbon dioxide, repeated episodes can decrease oxygen levels in the blood and increase carbon dioxide build-up. Also, when the brain senses this upper airway obstruction, the body tries to overcome it by causing a brief awakening. As the arousals occur throughout the night, your child’s sleep can become more fragmented. This can cause your child to wake up in the morning and still feel tired. While sleep fragmentation is more common in adults, it can also occur in children. 

The most common symptom of OSA is snoring. Snoring is a hoarse sound that occurs when airflow passes through narrow upper airway structures, causing a vibration. This sound is different from congestion or wheezing. If you are not sure if your child snores, you can record the sounds you hear and show your pediatrician. However, not every child with snoring has sleep apnea. Some studies have shown that while up to 30 percent of children snore, 2 to 6% have sleep apnea. 

OSA is commonly seen in children ages 2 to 8 years but occurs across all ages from newborn to adolescence! Black children are at an increased risk of developing OSA compared to white children. Before puberty, the risk of OSA in boys and girls is equal. After puberty, OSA tends to be more common in boys. If you’re wondering if your snoring child may have sleep apnea, sit tight and read this post through the end.

What causes OSA?

Anything that narrows the upper airway can cause sleep apnea in children. Imagine the upper airway like a flexible tube, anything blocking the airway from inside or collapsing it from the outside will cause OSA. Any other structures that make the upper airway crowded can also contribute. The most common cause of OSA in children is enlarged tonsils and adenoids. The peak age of this enlargement occurs between 2 and 8 years of age. Other causes of OSA are:

• Structural problems of the face or jaw. For instance, some children have a flatter face or small jaw, and this will cause the upper airway to be more crowded.

• Muscle weakness or hypotonia. Children with muscle weakness or hypotonia can have more floppiness of their upper airway. Examples include children with Down syndrome or cerebral palsy.

• Obesity is a widespread cause of sleep apnea in adults and is becoming problematic in children. We are seeing an increase in the number of obese children, particularly teenagers. Obese children have extra fat deposits in their tongues and neck, leading to upper airway crowding, placing them at risk.

• Allergies can cause narrowing of the nasal passages and cause OSA.

OSA is commonly seen in children ages 2 to 8 years but occurs across all ages from the newborn to adolescence. Black children are at an increased risk of developing OSA compared to white children. Before puberty, the risk of OSA in boys and girls is equal. After puberty, OSA tends to be more common in boys.

What are the symptoms of OSA in kids?

Children with sleep apnea can have symptoms at night as well as during the day. Some night time symptoms of OSA include the following:

• Frequent snoring (outside of colds and usually more than three nights a week)

• Gasping

• Pauses in breathing

• Sleeping in unusual positions (e.g., neck hyperextended) to keep the upper airway open

• Bedwetting (after a period of being dry at night)

• Excessive nighttime sweating

• Waking in the morning with a dry mouth, headaches, or a sore throat

Children with OSA may also have daytime symptoms which include the following:

• Excessive daytime sleepiness (more common in adults but can be seen in older kids)

• Hyperactivity (especially in younger children)

• Mood problems and irritability

• Learning difficulties

• Persistent mouth breathing

What are long term effects of OSA in kids?

Similar to adults, several studies have shown that untreated OSA has long term consequences in kids. These consequences affect brain development, cardiac health, growth and overall quality of life.

• Learning and behavior problems: OSA is associated with hyperactivity and inattentive behaviors. Children with OSA have learning difficulties and poorer academic performance than children without OSA. In addition, parents of children with OSA report that their children have excessive daytime sleepiness and aggressive behaviors. After effectively treating OSA, these learning and behavior problems can improve.

• Heart problems: similar to OSA in adults, kids in OSA have a higher risk of developing conditions such as hypertension, and they can develop heart strain.

• Obesity and risk for diabetes: Children with OSA may have difficulty with processing insulin, a hormone that helps them break down sugars, increasing their risk for developing diabetes. This is more commonly seen in obese children.

• Quality of life and depression: OSA in kids leads to increased tiredness, irritability, and depressed mood. Children with OSA may not be interested in their typical daily activity, including relationships with family and peers. Fortunately, these symptoms tend to improve when their OSA is treated.

How is OSA diagnosed in kids?

As I mentioned earlier, not every child who snores has sleep apnea. However, since one of the treatments of sleep apnea in kids involves surgery, it is important to have an accurate diagnosis. If you are concerned that your child has OSA, speak to your pediatrician or a sleep specialist to discuss.

The only way to rule out sleep apnea is by doing a sleep study. A sleep study (also called a polysomnogram) is a noninvasive test done in a sleep lab. This test is not painful or dangerous but involves your child staying overnight in the hospital. The sleep study involves placing different stickers and belts on your child to monitor their brain waves, breathing patterns, and heartbeat. The sleep study can also monitor your child’s leg movements which can rule out other sleep problems like restless leg syndrome. The sleep study results will show if your child has sleep apnea or not and the degree of severity (mild, moderate, or severe). Based on these results, the sleep doctor can develop an individualized treatment plan for your child.

How is OSA treated in kids? 

For most children, removing tonsils and adenoids is often curative (up to 80% success rate). This surgery, called adenotonsillectomy, is the first-line treatment for OSA in kids. For children with high-risk conditions such as obesity, severe OSA, or those with underlying syndromes (like Down syndrome), the success rate of surgery is not as high. Therefore, we usually recommend a repeat sleep study in high-risk children or those with persistent symptoms after surgery. 

There are other options for treating OSA in kids depending on the severity. 

• Medications for allergies such as nasal corticosteroids can treat mild sleep apnea in kids. However, if symptoms do not improve with medications, other sleep apnea treatment options should be considered.

• Continuous positive airway pressure (CPAP), a common adult treatment, is also effective for OSA in kids, particularly when surgery is not an option or does not provide a cure. CPAP device includes three main parts, a mask worn over the nose or face, tubing, and the machine that delivers pressure. The goal of CPAP is to pump air to the upper airway through tubing connected to the device. This keeps the airway open at night. Young children and even infants can wear CPAP successfully, with some behavioral support.

• Rapid maxillary expansion: this is a palate expander that corrects the narrow upper jaw of children. You can discuss this with your child’s orthodontist to see if this is an option for your child.

• Other jaw surgeries: Children with facial abnormalities, including tiny jaws, can undergo surgical procedures called mandibular distraction osteogenesis (MDO). This surgery involves placing hardware in the child’s lower jaw and gradually advancing to the desired jaw length.

• Weight loss: This is an effective way of decreasing the severity of sleep apnea in children that are obese or overweight. However, since weight loss takes time, it should be combined with another treatment option.

Remember, not every child that snores has sleep apnea, and not every child with sleep apnea needs surgery. If you have concerns that your child has sleep apnea, speak with your pediatrician or a sleep specialist. They can help you determine to decide on the right treatment plan.