What is Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)?
Pediatric obstructive sleep apnea (OSA) is a health condition in children where the upper airway doesn’t function properly. This problem causes a complete or partial blockage in the airway while the child is sleeping, resulting in lower levels of oxygen or waking up from sleep. It can heavily impact a child’s behavior, brain development, metabolism, and general health. Identifying, assessing, and treating OSA early can help prevent lasting health issues.
What Causes Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)?
Sleep apnea, a disorder where breathing stops and starts during sleep, can be categorized into two types depending on its cause. These are central sleep apnea and obstructive sleep apnea.
Central sleep apnea is caused by issues related to the central nervous system. It’s a brain-based issue that affects your body’s respiratory drive- the mechanism that tells your body to breathe. During this, even though your brain isn’t telling you to breathe, there’s no noticeable struggle or effort to breathe.
On the other hand, obstructive sleep apnea, which accounts for 95% of sleep apnea diagnoses, is caused by a full or partial blockage of the upper airway. This blockage disrupts sleep and leads to a drop in oxygen levels of 3% or more. Things like physical abnormalities, genetic issues, or problems with the nerves and muscles can reduce the size or stability of the airway and contribute to obstructive sleep apnea.
The likelihood of your upper airway blocking or collapsing is determined by intrinsic and extrinsic factors. Intrinsic factors are based on the amount of pressure in your airway necessary to keep it open. Extrinsic factors such as fat deposits, enlarged tissues, and facial features that deviate from normal anatomy can make your airway more prone to collapsing.
Risk Factors and Frequency for Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
Pediatric Obstructive Sleep Apnea (OSA), a sleep disorder in children, is most commonly seen in kids aged 2 to 8. This is because, during these ages, the tonsils and adenoids (glands in the throat area) tend to grow faster compared to the upper airway. Certain factors can increase the chances of a child developing OSA early in life. These include being born prematurely, having Down syndrome, being of African American descent, and attending daycare.
Obesity, exposure to tobacco smoke, and low family income can make the condition more severe. After puberty, boys seem to be more at risk, but before puberty, the risk is the same for both boys and girls.
- Pediatric OSA is most common in children aged 2 to 8 due to the rapid growth of tonsils and adenoids compared to the upper airway.
- Risk factors for the early onset of OSA include prematurity, Down syndrome, African American race, and attending daycare.
- Conditions like obesity, exposure to tobacco, and low family income can worsen the severity of OSA.
- Post-puberty, boys are at an increased risk, whereas the risk is the same for boys and girls before puberty.
Signs and Symptoms of Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
During the evaluation of children’s health, it’s important to pay attention to both the quantity and quality of their sleep. Although there is no common tool used specifically to screen sleep patterns in children, doctors should consistently ask about sleep habits, including snoring, at every health check-up visit. If there are concerns about a child’s sleep quality, questions about frequent night-time wakes, unusual sleep positions, and a lot of bedding movement might offer signs of increased nighttime activities. It’s crucial to ask these questions because parents might not talk about their child’s sleep unless asked directly.
Children are different from adults in their sleep patterns and symptoms. Behavioral changes, snoring, mouth breathing, witnessed pauses in breathing, waking up frequently during the night, and bedwetting are often reported. Sleep interruptions in children with Obstructive Sleep Apnea (OSA) might lead to behavioral problems like hyperactivity, irritability, or even aggression, which are often the reasons parents bring their children to the doctor.
- During a physical exam, children may seem tired or overactive
- Allergy-related dark circles under the eyes may be noticed
- Swollen nasal tissue
- Micrognathia (small jaw)
- Macroglossia (large tongue)
- High arched palate
- Physical signs suggestive of enlarged adenoids
- Enlarged tonsils
- Hyponasal speech (speech sounds as if the nose is blocked) and nasal congestion
- Increased risk of OSA in childhood obesity. Therefore, height, weight, and BMI should be checked at every visit. Each kg/m^2 increase in BMI above the 50th percentile increases the risk for OSA by 12%.
There’s also an increased risk of OSA in children with abnormalities of the head and face, Down Syndrome, and neuromuscular disorders. Additionally, children who were born prematurely are at higher risk for OSA, even if they don’t have other risk factors. Almost 9.4% of school-aged children born prematurely end up being diagnosed with OSA. Since these children may not show typical signs of pediatric OSA, consideration should be given to referring them for sleep studies if there’s any concern.
Testing for Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
If a child’s history and physical examination point towards the potential for Obstructive Sleep Apnea (OSA), the best way to confirm this is through a sleep study called nocturnal polysomnography (PSG). Still, it’s important to know that this test can be expensive, take a long time and require a lot of resources. To gather some additional information without the need for a PSG, an overnight oximetry test at home could be performed. This measures oxygen levels while your child sleeps, but it can’t fully replace a PSG for diagnosis.
If there’s concern about a possible heart and lung condition related to OSA, getting a chest x-ray and an EKG is also advised. For severe OSA cases, the child might need an echocardiogram, a type of ultrasound scan that shows the heart in action, before having surgery.
Certain chemical signals in the body, known as inflammatory biomarkers, may also be measured. These include kallikrein-1, uromodulin, urocortin-3, and orosomucoid-1, which are often higher in children with OSA. Other medical tests, like a complete blood count (CBC), a measure of iron levels, and a test for thyroid-stimulating hormone (TSH), should also be done to investigate other potential sleep-disrupting conditions.
Additionally, imaging tests can help spot physical issues that might contribute to OSA, but these should be used alongside a PSG to reach a final diagnosis.
During a PSG, specific sleep parameters are measured using sensors. These track brain activity, heart rate, nasal and oral movement, blood oxygen levels, limb movement, eye movement and any occurrences of snoring. The data captured allows calculations to determine sleep onset time, sleep efficiency, and time spent in each stage of sleep.
One of the most critical measurements for diagnosing OSA is the Apnea/Hypopnea Index (AHI), which reveals the average number of apneas (pauses in breathing) and hypopneas (shallow breathings) per hour of sleep. An AHI of 1 to 4.9 events/hour is considered mild OSA, 5 to 9.9 events/hour is moderate, and over 9 events/hour is severe. If a child up to 13 years old has an AHI of 1 or above, this is abnormal, however there’s some controversy over whether an AHI of 1 to 1.9 events per hour is clinically significant.
In children aged 13-17, either pediatric or adult criteria for diagnosing OSA can be used, depending on the child’s specific clinical picture and level of development. As children tend to have sturdier airways and are less at risk of the airway collapsing compared to adults, their sleep studies usually show more shallow breathing events rather than total breathing pauses. Interestingly, amongst children with OSA, there may be high levels of carbon dioxide in their bodies due to prolonged periods of breathing at decreased levels, which is unusual for adults with OSA.
Treatment Options for Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
The treatment options for Obstructive Sleep Apnea (OSA) can vary based on its severity and they include both surgical and non-surgical options. For mild to moderate OSA in children, trying out a medicine called montelukast could be beneficial. This medication has been demonstrated to reduce the size of the adenoids and tonsils after three months, thereby leading to a decrease in sleep disturbances.
Glucocorticoids, a type of steroid, are not effective in treating pediatric OSA. But, surprisingly, using steroid nasal sprays for six weeks have proved to help. These nasal sprays may be used alongside montelukast resulting in most patients seeing a significant improvement in their sleep patterns.
If the child has enlarged adenoids or tonsils, surgery to remove them (adenotonsillectomy or A&T) is usually the most effective treatment. It is recommended particularly for patients who have more than 9 sleep disturbances per hour or even those with mild OSA but have significant symptoms. There’s also a tendency for the tonsils to grow back after a partial tonsillectomy.
‘Watchful waiting’ for up to six months is acceptable for patients with mild to moderate OSA. This is done in hopes of correcting the primary issues, like obesity or allergies, that could improve OSA. Surgery could be avoided if these primary issues are addressed properly. However, in children who are not obese or suffering from syndrome-related problems, adenotonsillectomy has shown to be better in improving sleep patterns.
Continuous positive airway pressure or CPAP is also considered. Although commonly used for adults, using it for children comes with challenges. It should be considered if surgery is not an option or if OSA continues despite surgery. However, it’s important to note that children may have difficulties complying with CPAP treatment and long-term use of the mask may potentially change facial structure.
Oral appliances that help decrease sleep disturbances in adults might not work in the same way for children due to lack of enough studies. But one technique called Rapid maxillary expansion might work for pre-teenage patients, particularly those with certain dental features and for those who still have sleep problems after adenotonsillectomy.
Myofunctional therapy, a technique that involves training muscles in the mouth and throat for better positioning, is also being studied as a potential treatment for pediatric and adult OSA. At this point, data about its efficacy in children is limited.
Lastly, children with factors that increase the risk of OSA, especially obesity, should be advised to manage these issues. Weight loss can help improve OSA and should be considered as part of the treatment, particularly in older children. Additionally, children should be protected from second-hand smoke and tobacco use at home as they can worsen OSA.
What else can Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids) be?
Snoring in children is not always because of Obstructive Sleep Apnea (OSA). So, it’s important to talk to parents about other possibilities during their first visit and properly treat nasal congestion if present.
In children, OSA is often mistaken for Attention Deficit Hyperactivity Disorder (ADHD) as it can cause hyperactivity and trouble with concentration.
OSA can also lead to learning troubles due to poor focus and attention, sometimes leading to a false diagnosis of a developmental delay.
If your child experiences heartburn at night, it might cause momentary pauses in breathing which could be confused with OSA. However, heartburn can also contribute to OSA by enlarging the tonsils or adenoids.
Primary bedwetting at night is rarely linked to OSA. However, if a child who is usually dry at night starts to wet the bed, it’s a good idea to look for more symptoms of OSA.
Morning headaches could be a result of retaining carbon dioxide overnight due to OSA. However, if the headache is alarming (it wakes them up from sleep or is worse when lying flat), further tests or imaging may be needed. A usual OSA headache is dull and tends to dissolve shortly after waking up without the help of medications or caffeine.
OSA can escalate occurrences of sleepwalking, nightmares, and disordered arousals although these events might be unrelated to OSA.
Rarely in younger children, OSA could cause excessive daytime sleepiness that might be mistaken for narcolepsy, especially if the child is continually falling asleep during the day after turning five years old. The only surefire way to tell the difference between OSA and any of these conditions is through a sleep study.
What to expect with Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
People who are more likely to have Obstructive Sleep Apnea (OSA) are at a greater risk for brain-related disorders later on if the OSA isn’t treated. However, if recognised and treated early, patients typically don’t have to worry about long-term complications of pediatric OSA.
After adenotonsillectomy (A&T), a type of surgery that treats OSA, you can expect normal sleep patterns to return after about 6 months. It’s not usually necessary to undergo another Polysomnography (PSG), a type of sleep study, after this surgery. Instead, doctors will often assess the success of the procedure based on improvements in behavior or cognitive function, and reductions in observed sleep disturbances. If a PSG was done after the surgery, it would provide concrete proof of reductions in the Apnea-Hypopnea Index (AHI), a measure of sleep apnea severity.
Children typically see an improvement after this surgery. Studies also show that A&T leads to better outcomes when compared to merely monitoring the situation. PSG results were normal in about 79% of children who underwent A&T compared to around 46% with only monitoring the situation. In mild cases of OSA, symptoms persist between 19% to 73% of the time. However, in severe cases, symptoms like snoring and disrupted sleep only persist in between 13% to 29% of patients. Most children won’t require long-term monitoring unless symptoms continue.
It’s worth noting, though, that A&T may be less effective in patients with Down Syndrome, craniofacial abnormalities, or a combination of the two. These children require more careful monitoring and regular PSG tests after surgery due to the high rate of persistent or recurring OSA.
Possible Complications When Diagnosed with Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
If not treated, childhood Obstructive Sleep Apnea (OSA) can lead to severe health problems and long-lasting complications. The continuous lack of oxygen can heighten the tension in the artery of the lungs, leading to higher pressure in the lungs and right heart failure at a young age. Cognitive impairment, hindered learning, and poor academic performance are linked to undiagnosed and untreated childhood OSA. Also, difficulty in breathing can relate to failure to achieve adequate physical growth seen in younger age groups.
Still, it’s critical to bear in mind that surgical treatment is not harmless and should be as thoughtfully considered as any other surgical interventions. If a child with OSA undergoes Adenotonsillectomy (A&T), there are certain risks and complications tied to the procedure. Although rare in children, tonsillectomy can have adverse effects. The most frequent are localized pain, reduced eating and drinking, and dehydration shortly after the surgery.
However, more worrying complications following the A&T include:
- Bleeding
- Secondary infection
- Breathing difficulties
- Insufficient airflow from nose to mouth
- Narrowing of the airway below the vocal cords
As with any surgery involving the breathing passages, there’s always a risk of sudden constriction of the bronchial or laryngeal muscles. The severity of OSA forecasts higher chances of post-surgery complications, so those with severe OSA might need longer post-anesthesia care or in-hospital stay after surgery.
Preventing Pediatric Obstructive Sleep Apnea (Sleep Apnea in Kids)
During regular check-ups, parents should be educated on what to look out for regarding signs and symptoms of sleep apnea in children. These signs may include nightly loud snoring, frequent wakings in the night, bedwetting, and changes in behavior. It’s especially important for parents with overweight or obese children to be aware of the risks associated with sleep apnea. Parents also need to be informed about the potential effects of obesity on their child’s ability to sleep normally. After all, it’s not always easy for caregivers to recognize if their child’s sleep patterns are not healthy.
