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Obstructive sleep apnea is episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation. Symptoms include snoring and sometimes restless sleep, nocturnal sweating, and morning headache. Complications may include growth disturbance, cor pulmonale, pulmonary hypertension, and learning or behavioral disturbances. Diagnosis is by polysomnography. Treatment is usually adenotonsillectomy.

The prevalence of obstructive sleep apnea (OSA) in children is about 2%. The condition is underdiagnosed and can lead to serious sequelae.

Etiology

Risk factors for OSA in children include the following:

• Enlarged tonsils or adenoids
• Certain dental abnormalities (eg, large overbite)
• Obesity
• Craniofacial abnormalities (eg, micrognathia, retrognathia, midfacial hypoplasia, excessively angled skull base)
• Certain drugs (eg, sedatives, opioids)
• Mucopolysaccharidoses
• Disorders causing hypotonia or hypertonia (eg, Down syndrome, cerebral palsy, muscular dystrophies)
• Possibly genetic factors

Symptoms and Signs

Almost all affected children snore. Other sleep symptoms may include restless sleep, sweating at night, and observed apnea. Daytime symptoms may include nasal obstruction, mouth breathing, morning headache, and problems concentrating. Children may have nocturnal enuresis. Excessive daytime sleepiness is less common than among adults with OSA.

Complications of OSA may include cor pulmonale, pulmonary hypertension, growth disturbance, and problems with learning and behavior.

Examination may reveal no abnormalities or may show anatomic facial, nasal, or oral abnormalities contributing to obstruction, increased in the pulmonic component of the 2nd heart sound, or growth disturbance.

Diagnosis

• Polysomnography with end-tidal CO₂ monitoring

OSA is considered in children with snoring or risk factors. If symptoms of OSA are present, diagnostic testing is done; clinical criteria are not accurate. Diagnosis is by overnight polysomnography in a sleep laboratory that includes end-tidal CO₂ monitoring. The accuracy of home polysomnography is under evaluation. Although criteria for OSA in adults do not apply to children, experts disagree on what criteria should be used to diagnose OSA in children. Outcome data are lacking. However, OSA is generally considered present if polysomnography shows the following:

• > 1 apneic or >2 hypopneic events/h (an event lasts > 2 breaths)
• End-tidal CO₂ >50 mm Hg for > 10% total sleep time together with paradoxical respiration or snoring in patients without lung disorders

Patients with OSA are evaluated for cardiopulmonary complications with ECG and chest x-ray.

Treatment

• Adenotonsillectomy or correction of congenital micrognathia
• CPAP as 2nd-line therapy

Otherwise healthy children are treated with adenotonsillectomy, which is usually effective. Adenoidectomy alone is often ineffective. The risk of perioperative airway obstruction is higher in children with OSA than among children without OSA who undergo adenotonsillectomy; thus, close monitoring is important.

For children who are not otherwise healthy, who have complex anatomic abnormalities, genetic conditions altering respiratory control, or who have cardiopulmonary complications, a physician experienced in management of OSA in children should be consulted. Adenotonsillectomy may be effective or may provide some relief. Depending on the anatomic abnormality causing OSA, an alternate surgical procedure may be indicated (eg, uvulopalatopharyngoplasty, tongue or midface surgeries).

CPAP can be used for children who are not candidates for corrective surgery or who continue to have OSA after adenotonsillar surgery. Weight loss can decrease OSA severity in obese children and has other health benefits but is rarely sufficient treatment for OSA as monotherapy. Nocturnal O₂ supplementation may help prevent hypoxemia until definitive treatment can be accomplished. Corticosteroids and antibiotics are not usually indicated.

Last full review/revision November 2007 by Kingman P. Strohl, MD

Content last modified November 2007