Obstructive Sleep Apnea

What is obstructive sleep apnea (OSA)?

Obstructive sleep apnea in children is a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal breathing during sleep and normal sleep patterns.”

The American Academy of Pediatrics recognizes that “obstructive sleep apnea syndrome is a common condition in childhood and can result in severe complications if left untreated.” Some of the consequences of untreated pediatric OSA include:

1. Snoring: A problem if a child shares a room with a sibling and during sleepovers.
2. Sleep deprivation: A child may become moody, inattentive, and disruptive both at home and at school. Classroom and athletic performance may decrease along with overall happiness.
3. Abnormal urine production: OSA causes increased nighttime urine production which may lead to bedwetting.
4. Growth: Growth hormone is secreted at night. Those with OSA may suffer interruptions in hormone secretion resulting in slow growth or development.
5. ADHD: There are research findings that identify OSA as a contributing factor to attention deficit disorders.
   
6. Cardiovascular complications: Long term or significant OSA can cause serious strain on the heart and lungs.

What causes obstructive sleep apnea in children?
There are a number of potential causes of OSA in children but the large majority of cases are due to large tonsils and adenoids. There is evidence that suggests that obstructive sleep apnea in children may result from a complex interplay between this enlarged tissue and loss of neuromuscular tone. Other children with craniofacial abnormalities have fixed anatomic variations that predispose them to airway obstruction.

How common is obstructive sleep apnea?
Approximately 10% of children snore. Ten percent of these children have obstructive sleep apnea. Other studies have suggested that obstructive sleep apnea may affect from 1% to 10% of all children. The majority of these children have mild symptoms, and many outgrow the condition.

How do I know if my child has obstructive sleep apnea?
Unlike adults with sleep apnea who are often overweight and frequently wake up at night, children with OSA are more difficult to recognize and diagnose. In addition to continuous loud snoring, other signs and symptoms of OSA in children include:

1. failure to thrive (weight loss or poor weight gain)
2. mouth breathing
3. problems sleeping or restless sleep
4. excessive daytime sleepiness
5. daytime cognitive and behavior problems, including problems paying attention, aggressive behavior and hyperactivity
6. witnessed gasping or cessation of breathing at night
7. bedwetting
8. enlarged tonsils and adenoids

Diagnosis
The diagnosis is usually based on the characteristic symptoms and evidence of large tonsils and adenoids. In these cases, your doctor will most likely refer you to a pediatric ENT surgeon for possible tonsillectomy and adenoidectomy. In certain cases your child may be referred for an overnight sleep study called polysomnography. A sleep study is not required in most cases but should be considered for diagnosis and treatment of patients with multiple medical problems, children with craniofacial syndromes, and patients with an unclear etiology (i.e., modest physical findings or examination findings inconsistent with the severity of apnea).

Treatment
Tonsillectomy and adenoidectomy remains the treatment of choice for most children with a strong clinical history of OSA or with OSA documented by a sleep study. This surgery achieves a 90% success rate for children with OSA and has been shown to improve snoring, bedwetting, behavior and growth issues. Of course other medical problems like obesity and allergies must also be addressed. Certain children may benefit from CPAP (continuous positive airway pressure) as an alternative to surgery or for those children who continue to show signs of OSA 6 weeks after surgery.

When should I see an Ear Nose and Throat specialist?
Nowadays, many primary care physicians are screening children for snoring. For those with signs and symptoms of sleep disordered breathing or OSA, a referral to a pediatric ENT surgeon is recommended. Remember the symptoms, diagnosis, and treatment options for obstructive sleep apnea can be quite different in the pediatric population.