Obstructive Sleep Apnea in Children

  • Gregorio Anselmetti Bachelor of Science - BSc, Neuroscience. University of Warwick
  • Richa Lal MBBS, PG Anaesthesia, University of Mumbai, India

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Introduction 

Sleeping is essential for physiological and psychological functioning and well-being in humans. Children need to get good quality sleep as they are still in the process of growing and developing both physically and mentally.1 In this article, we will focus on a sleep disorder called obstructive sleep apnea, a condition where children's breathing during sleep is obstructed, which can impact healthy development and optimal health. 

Obstructive sleep apnea in children

Obstructive Sleep Apnea (OSA) in children is a sleep disorder whereby breathing is blocked due to the partial or complete ‘obstruction’ of the upper airway.2 This partial/complete blockage can result in low oxygen levels and high carbon dioxide levels in the blood. Therefore, as a result, children try to breathe even more, which causes changes in pressure in the chest during sleep. At night, to manage these changes, the body signals the child to wake up partially or completely, interrupting the child's sleep cycle and quality of sleep. When this happens frequently throughout the night, it can have consequences like sleep problems, health issues, and an impact on quality of life. OSA occurs most frequently in children aged between 2 and 8 years.3 The prevalence of OSA among children is estimated to be around 1-5.7%.4

Causes and risk factors

OSA in children can develop due to multiple causes and risk factors (increase the likelihood of developing OSA). The following causes and risk factors include:

  • Enlarged tonsils and adenoids –Tonsils (can be seen using a mirror and located in the back of your throat) and adenoids (cannot be seen using a mirror and located higher up at the back of your throat) are part of your immune system that protects your body against germs.6 Enlarged tonsils and adenoids may not cause problems in some children, while in others, the overgrowth of tonsils and adenoids can make the airway narrow, which results in snoring and breathing interruptions during sleep7
  • Obesity is the most common risk factor that may lead to the development of OSA. OSA can affect around 60% of children diagnosed with obesity
  • Craniofacial abnormalities are deformities that impact head/facial bones (e.g., Crouzon, Pierre-Robin, or Apert syndromes, cleft lip or palate). Many of the craniofacial abnormalities lead to obstruction of the upper airway. Thus, those with the condition are at an increased risk of developing OSA9 
  • Family history–Genetics is known to play a part in the development of this condition although the exact mechanism is still not very clear. Individuals with family members having OSA have about 50% more chances of having this condition compared to those without a family history
  • Neurological disorders –Up to 75% of children with epilepsy, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder can have at least one sleep problem by the time they reach adolescence3,9

Signs and symptoms

The most common signs and symptoms associated with sleep apnoea in children include the following:2

  • Snoring 
  • Breathing pauses 
  • Interruptions during sleep and frequent awakening 
  • Gasping
  • Mouth breathing
  • Fatigued 
  • Daytime hyperactivity

Diagnosis

Diagnosis of sleep apnea requires a detailed history along with some investigations to confirm it.

  • Sleep study (polysomnography) is one of the most common ways to diagnose OSA in children. This test is conducted overnight and polysomnography evaluates the condition of children using various parameters like electrocardiogram tracing, oxygen saturation, body position and movement2. Polysomnography allows the differentiation between OSA and other conditions (e.g., allergic rhinitis, ADHD, developmental delay) with similar symptoms3
  • Medical history is important to evaluate and understand the symptoms
  • Physical examination includes examining the child using different methods by specialists. For example, observation of behaviours (e.g., breathing through mouth), head and neck exam, voice quality, tonsil size, and child growth2
  • Parental observations include the signs and symptoms mentioned in this article. 

Potential complications

If untreated, the following complications associated with OSA are

  • Cardiovascular problems–children are more likely to develop conditions such as hypotension, chronic inflammation, and endothelial dysfunction, leading to cardiovascular issues at an early age.5 These conditions may lead to atherosclerosis and cardiovascular disorders in adulthood
  • Neurologic impairments and cognitive dysfunction 
  • Impaired learning 
  • Cause or worsen obesity
  • Behavioural issues (e.g., aggression, impulsiveness, hyperactivity)
  • Growth impairment 
  • Developmental delays10,11

Treatment options 

There are various approaches to treating OSA in children: 

  • Adenotonsillectomy (AT) is the first line of treatment in children. AT is a surgical procedure that removes tonsils and adenoids and can help improve symptoms.2
  • Tracheotomy is surgical management for severe children OSA cases. The surgery involves a tube inserted in the front of the neck (i.e. windpipe) that helps with breathing.2
  • Positive airway pressure therapy is a non-surgical management approach. This therapy is offered when surgery is not required or desired. This method uses a machine that generates ‘pressure’ to keep the airway open during breathing, aiming to relieve obstruction in the upper tract, provide ventilation, and reduce awakening.2,12
  • Weight management is recommended for children diagnosed as either overweight/obese2

Importance of timely intervention

Untreated OSA can lead to metabolic, cardiovascular, and behavioural derangements, leading to consequences such as obesity, hypertension (high blood pressure), and academic impairment, respectively.5 Timely interventions are important due to the potential impact OSA has on long-term health.

Long-term impact on health

A 20-year follow-up study compared adults diagnosed with OSA as a child to a healthy control group of adults. The findings showed that adults with a history of severe childhood OSA were more likely to snore, have a raised body mass index, and have compromised academic performance.14

It is important to know that, while the long-term consequences of childhood OSA are not entirely conclusive, it is important to address OSA in childhood due to detrimental effects that may persist until adulthood which include an increased risk of developing chronic diseases.

Parental education and support

Parents need to observe any signs and symptoms of OSA, as this allows them to: 

  • Seek medical guidance from professionals 
  • Start early treatment and intervention 
  • Create a good sleep environment 
  • Promote a healthy sleeping routine
  • Improve the quality of life
  • Prevent potential long-term consequences 

Summary 

  • OSA is a sleep disorder
  • OSA ‘obstructs’ the upper airway, impacting the breathing process during sleep 
  • Parents need to be aware of the signs and symptoms of OSA 
  • By seeking medical guidance, OSA can be diagnosed early for management and treatment
  • OSA has treatment options that can resolve and help relieve symptoms
  • Untreated OSA is associated with complications

References

  1. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, et al. Consensus statement of the american academy of sleep medicine on the recommended amount of sleep for healthy children: methodology and discussion. Journal of Clinical Sleep Medicine [Internet]. 2016 Nov 15 [cited 2023 Nov 20];12(11):1549–61. Available from: http://jcsm.aasm.org/doi/10.5664/jcsm.6288
  2. Bitners AC, Arens R. Evaluation and management of children with obstructive sleep apnea syndrome. Lung [Internet]. 2020 Apr [cited 2023 Nov 20];198(2):257–70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171982/
  3. Gouthro K, Slowik JM. Pediatric obstructive sleep apnea. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK557610/
  4. Marcus CL, Brooks LJ, Ward SD, Draper KA, Gozal D, Halbower AC, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics [Internet]. 2012 Sep 1 [cited 2023 Nov 20];130(3):e714–55. Available from: https://publications.aap.org/pediatrics/article/130/3/e714/30258/Diagnosis-and-Management-of-Childhood-Obstructive
  5. Blechner M, Williamson AA. Consequences of obstructive sleep apnea in children. Current Problems in Pediatric and Adolescent Health Care [Internet]. 2016 Jan 1 [cited 2023 Nov 20];46(1):19–26. Available from: https://www.sciencedirect.com/science/article/pii/S1538544215001698 
  6. Arambula A, Brown JR, Neff L. Anatomy and physiology of the palatine tonsils, adenoids, and lingual tonsils. World J Otorhinolaryngol Head Neck Surg [Internet]. 2021 Jun 27 [cited 2023 Nov 20];7(3):155–60. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356106/
  7. Enlarged tonsils and adenoids: Overview. In: InformedHealth.org [Internet] [Internet]. Institute for Quality and Efficiency in Health Care (IQWiG); 2019 [cited 2023 Nov 20]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536881/
  8. Narang I, Mathew JL. Childhood obesity and obstructive sleep apnea. J Nutr Metab [Internet]. 2012 [cited 2023 Nov 20];2012:134202. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432382/
  9. Cielo CM, Marcus CL. Obstructive sleep apnoea in children with craniofacial syndromes. Paediatric respiratory reviews [Internet]. 2015 Jun [cited 2023 Nov 21];16(3):189. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4454627/
  10. Nachalon Y, Lowenthal N, Greenberg-Dotan S, Goldbart AD. Inflammation and growth in young children with obstructive sleep apnea syndrome before and after adenotonsillectomy. Mediators of Inflammation [Internet]. 2014 [cited 2023 Nov 21];2014. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158570/
  11. Trosman I, Trosman SJ. Cognitive and behavioral consequences of sleep-disordered breathing in children. Medical Sciences [Internet]. 2017 Dec [cited 2023 Nov 21];5(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753659/
  12. Hady KK, Okorie CUA. Positive airway pressure therapy for pediatric obstructive sleep apnea. Children (Basel) [Internet]. 2021 Oct 29 [cited 2023 Nov 22];8(11):979. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8625888/
  13. Tan HL, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: a critical update. Nat Sci Sleep [Internet]. 2013 Sep 25 [cited 2023 Nov 23];5:109–23. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792928/
  14. Nosetti L, Zaffanello M, Katz ES, Vitali M, Agosti M, Ferrante G, et al. Twenty-year follow-up of children with obstructive sleep apnea. J Clin Sleep Med [Internet]. 2022 Jun 1 [cited 2023 Nov 23];18(6):1573–81. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9163630/

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Nithursha Nagendrabalan

Master of Sciences in Cancer, University College London, England

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