American Sleep and Epilepsy Centers
Treatment for OSA in children
Treatment for Obstructive Sleep Apnea in Children

  Obstructive Sleep Apnea (OSA) is one of the most common primary sleep disorders in adults. This
disorder is also common in the pediatric population. In 2002, the American Academy of Pediatrics
published practice guidelines informing all pediatricians and child health care practitioners of prevalence,
impact, diagnosis and treatment recommendations. Evaluation and management of children who snore is
important in identification of children at risk for OSA.

  OSA occurs in children of all ages. Unfortunately, as of the year 200, a definitive study outlining the
prevalence of OSA in the pediatric population has not been conducted. Prior studies have been limited
because adult criteria for identification of obstructive and partially obstructive respiratory events had been
used. It is now clear that these criteria are insufficient for identification of OSA in children. Nonetheless,
the prevalence of significant OSA is stated to be about 2 percent of school age children and snoring is
present in 3 percent to as much as 12 percent of preschool-age children. Since criteria for children are
clearly different from adults, the prevalence of clinically significant OSA is not known and may be more
prevalent than previously thought.

  The most common cause of OSA in otherwise normal children is adenotonsillar hypertrophy (enlarged
tonsils). Sleep apnea also occurs in children with genetic, neuromuscular, and/or craniofacial
abnormalities. Obese children, children with Down syndrome, dwarfism, mandibular hypoplasia (small
jaws), cerebral palsy, sickle cell disease, metabolic disease, and children with mid-face anomalies are at
particular risk.

  A sleep history is the first step in evaluation. Searching the history for habitual snoring should be part
of all health maintenance visits. Difficulty breathing during sleep, snoring associated with pauses/snorts
and gasps, restless sleep, daytime sleepiness, hyperactivity, motor restlessness and/or poor school
performance are often present. Mouth breathing, excessive thirst upon waking in the morning, nocturnal
waking, or morning headaches may also be symptoms.

  Unfortunately, history and physical findings of enlarged tonsils are not consistent in identifying children
with even the most severe form of OSA. Overnight polysomnography is the “gold standard” and is the
only method of diagnosis that has been shown to reliably identify those children with OSA and to quantify
the degree of sleep disordered breathing. Children may be studied at any age. It is essential that
evaluation be conducted using age appropriate criteria. Other diagnostic methods cannot significantly
identify children with striking OSA or, as importantly rule out those children without the disorder. Sleep
studies are best carried out in a pediatric sleep disorders center or those centers with specially trained
technical staff and pediatricians who are particularly skilled in evaluating sleep in children.

  In otherwise healthy children, adenotonsillectomy is the most common treatment for OSA, removing the
tonsils and adenoids results in resolution of symptoms and polysomnographic evidence of OSA in 75
percent to 100 percent of these children. Comorbid conditions, such as obesity, result in less optimal
outcome. Although most children can undergo this surgical procedure as outpatients, those with severe
OSA should have post-operative follow up in the hospital. This provides for adequate monitoring of
potential complications of hemorrhage, respiratory complications, or complications secondary to
anesthesia. Children under 3 years of age, those with cardiac conditions, cranio-facial abnormalities,
obese children, and those with failure-to-thrive are at greatest risk and should be monitored closely for
post-operative difficulties.

  Continuous positive airway pressure (CPAP) is effective in treating OSA in adult patients and pediatric
patients. The most important variables in successful use of CPAP in children are an appropriately fitting
mask and desensitization to the treatment procedure. Optimal pressure to maintain airway patency
should be done in a sleep laboratory where the pediatric staff is skilled in fitting masks, behavioral
modification, and titration of young children. In children with severe OSA, these interventions can very
frequently avoid other surgical intervention, such as tracheostomy.

  Although little data currently exist, orthodontic intervention can be helpful in treatment of pediatric OSA.
Appropriate use of oral appliances, rapid maxillary expansion at appropriate ages, and other orthodontic
approaches to craniofacial disorders may be better tolerated in some children than chronic CPAP therapy
and in children where CPAP treatment may be inadvisable.