What is Apnea in Children?
Apnea refers to when someone stops breathing for more than 20 seconds, or for a shorter period if it’s coupled with a slowed heart rate or a bluish skin color. This condition is more common in infants and premature babies, but it can happen to anyone at any age. Although similar causes can lead to apnea in babies, children, and adults, the majority of causes in older children and adults align. Apnea can indicate various serious health issues, so it’s important to differentiate it from harmless causes like holding one’s breath or snoring. Apnea can be grouped into central (where the brain doesn’t send proper signals to the muscles that control breathing), obstructive (where something is physically blocking the airway), or mixed (a combination of central and obstructive).
What Causes Apnea in Children?
Apnea in infants usually happens without an identifiable cause, but in children, it’s often caused by enlarged tonsils or adenoids, conditions often found with obesity. Certain things can make a person more likely to suffer from sleep apnea, which is a condition where someone’s breathing repeatedly stops and starts while they’re asleep.
Things that can cause sleep apnea include facial shape abnormalities, such as those seen in conditions like Pierre Robin sequence and Treacher Collins syndrome, as well as obstructions in the nose due to severe nasal deviation, allergies, or nasal polyps. Down syndrome, metabolic irregularities like mucopolysaccharidosis, and certain infections can also lead to sleep apnea. An asthma attack, a foreign object in the airway, or a deformed chest at birth can also be contributing factors.
Although sleep apnea is linked to Sickle Cell Anemia, it is unclear how this connection works. Other reasons for breathing interruption include infections affecting the central nervous system, increased pressure inside the skull due to head injury, water in the brain, or tumors. Exposure to toxins affecting the nervous system like carbon monoxide can also be a significant factor. Conditions related to the muscles and nerves, like Guillain-Barré syndrome and Duchenne muscular dystrophy, can result in mixed types of apnea. Severe obesity can cause a type of sleep apnea known as Pickwickian syndrome due to the difficulty of ventilation. Lastly, laryngospasm, a spasm of the vocal cords, can happen as a protective mechanism when acid from the stomach refluxes back. This can be suspected when these episodes are associated with eating.
Risk Factors and Frequency for Apnea in Children
There is limited research on the topic of apnea and obstructive sleep apnea (OSA) in children. According to existing studies, 1% to 3% of healthy children may have OSA, and the risk is believed to be four to five times higher in those with obesity. The condition appears to be more prevalent amongst black children (3.5 times higher) and Hispanic children compared to white children. OSA typically is seen in children between the ages of 2 and 10, with the most common age being around 4 years old.
Signs and Symptoms of Apnea in Children
When diagnosing health conditions in a child, many aspects of their life should be considered. This includes specifics about the event or symptom, such as how long it lasts, any accompanying symptoms, and whether it occurs during sleep or feeding. Details about the child’s birth (if they were born prematurely), any known health disorders, previous similar events, or potential exposure to toxic substances should also be reviewed.
- Color and mental status change
- Relationship of symptoms to sleep and feeding
- Child’s prematurity
- Known health disorders
- Previous episodes of similar symptoms
- Possibility of exposure to toxins
A family history, including instances of snoring, tobacco smoke exposure, and nasal allergies, can give clues to a condition called obstructive sleep apnea. Signs of an infection could be a fever, a cough, or a runny nose. Chronic mouth breathing and snoring, as well as excessive daytime sleeping, are also indicators of sleeping disorders. Other symptoms of obstructive sleep apnea might encompass restlessness, nightmares, trouble waking up, bed-wetting, behavioral issues, and irregular sleep patterns.
Usually, the child may appear well when evaluated, but any abnormal signs, such as size and appearance, can provide hints of underlying metabolic or genetic disorders. Unexplained bruising could be a clue of potential child abuse. Specific conditions can be suggested by other signs: blue-toned skin can mean poor blood flow or low oxygen levels, and a pale complexion could indicate anemia. Meanwhile, altered mental status and bulging fontal bone could be due to increased pressure inside the skull. Fever and a runny nose could denote an upper airway infection or an inflammation of the bronchial tubes in the lungs.
Snoring may suggest an obstruction at the back of the throat. This could be due to swollen tissues such as tonsils or adenoids. A wheezing sound, on the other hand, can suggest a lower airway obstruction, similar to what happens with asthma. In 15-20% of children with obstructive sleep apnea, certain facial characteristics may be present: underdeveloped thin nostrils, short upper lip, dominant upper teeth, a crowded mouth, narrow upper alveolar ridge, high-arched palate, and underdeveloped upper jaw. These can often be associated with mouth breathing, nasal-sounding speech, and swelling around the eyes.
Testing for Apnea in Children
Decisions on lab tests and imaging studies should be guided by the symptoms and physical check-up findings. If there’s a suspicion of Obstructive Sleep Apnea (OSA), a sleep study known as polysomnography is usually the most reliable way to confirm the diagnosis and figure out how severe the condition is. Sometimes, lateral neck x-rays are taken to look at changes in the size of the adenoids or other abnormalities. However, these x-rays can’t confirm OSA by themselves.
If a sleep study isn’t possible, other methods may be used. These can include testing oxygen levels in the blood while the child is sleeping using a method called pulse oximetry or using sleep questionnaires. Both of these alternatives are often used to identify children who may have OSA.
Treatment Options for Apnea in Children
Treating apnea in babies involves figuring out what’s causing it and then specifically targeting that cause with treatment. If a baby has obstructive sleep apnea (OSA), which is when their breathing stops periodically during sleep, the first course of treatment is usually removing the adenoids and tonsils (adenotonsillectomy). However, other treatments might be needed, such as reducing the size of the tongue, performing a tonsillotomy (partial removal of the tonsils), or even a tracheostomy (making an opening in the neck for breathing), in certain cases.
For adults, a common solution for OSA is a device called a continuous positive airway pressure (CPAP) machine, which helps to keep the airways open during sleep. While this device works well for fair to severe OSA in adults, it’s not usually the best solution for children because they often have difficulty tolerating them.
There are some medications that can help with OSA, but these generally offer limited benefits. For instance, a nasal spray called Fluticasone can reduce the number of blocked airway events in children when used for six weeks. But, it’s effect is not long-term, and it’s really only used for mild cases of OSA. Systemic steroids aren’t effective at treating OSA. However, an oral medication called montelukast has been shown in a double-blind, randomized control trial to reduce the seriousness of OSA and decrease the size of the adenoids after six weeks of use.
Getting the advice of specialists is important when deciding on the best way to treat apnea, as the most effective approach really depends on what’s causing it to happen.
What else can Apnea in Children be?
When discussing potential health concerns in children, it’s vital for doctors to consider a range of possible illnesses and conditions. These may include:
- Problems due to inhaling foreign substances (Aspiration syndromes)
- Bloodstream infections (Bacteremia)
- A serious illness caused by eating contaminated food (Botulism)
- Unexplained, brief incidents where a child seems to be seriously ill or at risk (Brief resolved unexplained events, also known as apparent life-threatening events)
- A lung infection making it hard to breathe (Bronchiolitis)
- A chronic lung condition in infants born prematurely (Bronchopulmonary dysplasia)
- Problems with a child’s breathing during sleep (Childhood sleep apnea)
- An infection causing breathing difficulties and a barking cough (Croup)
- Emergency care required for children with a fever
- Heart’s inability to pump blood sufficiently (Congestive heart failure)
- A viral infection causing fever, chills, muscle aches, and cough (Influenza)
- Soft and floppy voice box causing noisy breathing (Laryngomalacia)
- A form of child abuse where a caregiver exaggerates or makes up illness in a child also known as Munchausen syndrome by proxy
It’s crucial for medical professionals to consider these conditions when treating children and to carry out the appropriate tests to reach an accurate diagnosis.
