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Sleep Apnea in Children

Quick Overview

Sleep apnea, a condition which causes disordered breathing during sleep, is on the rise in children. The most common type is obstructive sleep apnea (OSA), which causes brief periods during which children stop breathing during sleep. This happens when throat muscles relax and tissue obstructs the airway.

Children with OSA always wake up (often without remembering it later) to breathe again. However, these periods of breathlessness, as well as the fractured sleep they cause, can result in severe physical, cognitive, and behavioral symptoms.

There are a variety of treatments available for childhood sleep apnea. Although each of these has an excellent success rate, there are benefits and drawbacks to each. Depending on the cause of a child’s OSA, their care team will suggest different treatments.

While sleep apnea is serious no matter the sufferer’s age, children are susceptible to unique challenges. Luckily, successful treatment has been shown to reverse many of the worst symptoms of sleep apnea.

Understanding Sleep Apnea in Children

How Can Sleep Apnea Affect Children?

Obstructive sleep apnea (OSA) is a disorder which causes sufferers to briefly stop breathing while they sleep. This happens multiple times a night, even up to 20 to 30 times an hour. OSA can occur in people of any age and is the most frequently diagnosed sleep disorder in children, affecting 1-3 percent of pre-school and school-age children.

Our muscles, including our throat muscles, naturally relax when we sleep. In people with OSA, this relaxation causes a partial blockage of the airway. (Snoring, a common symptom of sleep apnea, occurs due to the vibration of these lax muscles.)

When the blockage becomes complete, the pause in breathing causes a lack of oxygen and an excess of carbon dioxide which causes the sleeper to wake up enough to breathe again, often with a gasp or a snort. OSA sufferers are usually unaware of these brief awakenings, but they prevent them from achieving the restorative deep-sleep stages.

Sleep apnea in children is often due to excessively large tonsils, but there are several other common causes:

  • Obesity
  • A large tongue or small jaw
  • Allergies
  • Craniofacial disorders such as Treacher Collins syndrome
  • Lack of muscle tone due to conditions like Down syndrome and cerebral palsy

We also know that boys are more likely to have sleep apnea than girls and that there may be risk factors of which we’re still not aware.

The regular oxygen/carbon dioxide imbalance and sleep loss associated with OSA can cause significant problems for children. These include both short-term issues (such as falling asleep in class) as well as long-term concerns such as cognitive and physical delays, stress on the body due to chronic inflammation, and behavioral changes.

Although OSA is a serious condition, successful treatment usually corrects these problems. In one study, children with disordered sleep breathing who received a tonsillectomy showed significant improvement in their symptoms and even experienced a growth spurt.

Symptoms of Sleep Apnea in Children

Sleep apnea can cause both nighttime and daytime symptoms in children. Some of these symptoms may not be immediately obvious, making OSA more difficult for parents to recognize.

Snoring and Disordered Breathing

The most well-known symptom of sleep apnea is snoring, which is caused by tissue vibrating within the constricted airway. However, not every child who snores has sleep apnea, and not every child with sleep apnea snores audibly.

In addition to snoring, children with OSA may also exhibit other types of disordered breathing at night. The classic example is snoring punctuated with periods of silence, which are then followed by a snort, gasp, or choking sound. Very heavy breathing through the mouth can also be a symptom of sleep apnea.

Nighttime Symptoms

While some children can be restless sleepers without there being an underlying cause, it is also one of the symptoms of sleep apnea. This is often paired with sleeping in odd positions, such as with their neck arched back. In the morning, children may be difficult to rouse, unusually cranky, or otherwise resistant to waking up.

Sleepwalking and bedwetting (known as nocturnal enuresis) are also well-documented sleep apnea symptoms. The latter is particularly prevalent, with one third of children with OSA experiencing bedwetting episodes.

Daytime Symptoms

Sleep apnea is unique in that it can influence both excessive hunger or a failure to thrive, depending on its underlying causes. Children who are overweight or obese are more likely to experience the former, as the fractured sleep caused by OSA affects hormones which control appetite.

OSA can also cause behavioral changes in children. Crankiness, headaches, depression, poor school performance, poor memory, and other symptoms are all well-documented. Hyperactivity in particular is a classic sleep apnea symptom. When diagnosing ADHD, doctors are advised to consider sleep apnea as a potential culprit.

How Sleep Loss Affects Children

While the amount of sleep children need varies by age, the government recommends that children between six and twelve get 9-12 hours of sleep every night. Sleep apnea disrupts this schedule in two ways: by potentially shortening the length of time children spend asleep, and by fracturing the sleep they do achieve.

Fractured sleep occurs when something disrupts the body’s natural sleep cycle. Waking up frequently to breathe stops children from progressing through each of the sleep stages, preventing them from reaching the restorative “deep sleep” stage. While sleep loss as a whole can cause problems, it is this disrupted sleep which researchers believe may be responsible for many of the behavioral symptoms seen in children with sleep apnea.

The symptom of hyperactivity, for example, is also seen in children with periodic limb movement disorder. Researchers have speculated that the common thread is the loss of REM sleep, as well as the overall sleep fragmentation caused by both disorders.

Sleep loss and fragmentation can also cause more obvious symptoms. These include daytime sleepiness unrelated to a usual nap schedule, falling asleep in class, as well as the usual symptoms of sleep deprivation. Since children, particularly young children, may not be able to understand their own emotions, they may express these symptoms through emotional outbursts or moodiness.

While falling asleep in class is an obvious reason for performing poorly in school, OSA-related sleep disturbances can affect grades in other ways. Sleep deprivation, and sleep apnea in particular, are associated with poor executive functioning. This set of skills includes organization, paying attention, prioritizing, self-monitoring, staying on-task, and other critical tools.

Multiple studies have also shown that children with sleep-disordered breathing tend to show cognitive delays, particularly with regards to language and memory. Luckily, those same studies also indicate that successful treatment may reverse these delays.

Treatment for Sleep Apnea in Children

Treatments

Diagnosis

To accurately diagnose sleep apnea, your child’s doctor may order one of several possible tests:

  • Polysomnography, also known as a “sleep study”, is the gold standard of diagnosing childhood OSA. Your child will sleep overnight in a clinical setting where their breathing, brain activity, oxygen levels, and other factors can be monitored.
  • Oximetry measures oxygen levels alone. This test can be done at home, making it a good first step if polysomnography is unavailable or unnecessary.
  • Electrocardiograms, which measure the heart’s electrical impulses, can ensure there are no underlying heart conditions associated with your child’s OSA.

Once sleep apnea has been diagnosed, your child’s care team will work to find its underlying cause. This is a critical step, as treatment for childhood OSA can differ dramatically depending on what is causing it.

Surgery

Many cases of childhood sleep apnea are due to large tonsils and adenoids, which are glands found at the back of the throat. Removing these through adenotonsillectomy surgery is one way to treat OSA, but potential complications mean it may not be the right choice for your child. However, children who undergo adenotonsillectomy to treat sleep apnea often see excellent results.

Other procedures which surgeons use to treat OSA include the removal of excess tissue (such as from the soft palate) and correction of problems with the upper or lower jaw.

If your doctor believes surgery might be beneficial, they will refer your child to an ENT (ear, nose, and throat) specialist. The specialist will discuss the procedure’s benefits and drawbacks with you before making a decision. In some cases they might also suggest “watchful waiting” and the use of other treatments before moving forward with surgery.

Medical devices

One of the standard treatments for sleep apnea in both children and adults is the use of a positive airway pressure device. We cover these devices in greater detail below.

For children whose tongue or palate shape cause sleep apnea, there are also oral appliances, such as night guards, available.

Medication

Children with mild sleep apnea can benefit from medication, as can those whose apnea is caused or aggravated by allergies.

Topical nasal steroids (applied to the sinuses with a spray) are the most common medications for sleep apnea. These sprays have been shown to improve OSA symptoms over a four-week course, potentially by decreasing the size of tonsils and adenoids. Results were positive regardless of the child’s weight or allergies, indicating that steroid medication may be a good first step in many cases. However, research has not yet shown whether topical steroids can help treat OSA in the long term.

For children with allergy-aggravated sleep apnea, medication such as the asthma treatment montelukast may also help, either alone or with nasal steroids. Lifestyle changes, such as the removal of allergens from the home, may also be suggested.

Weight Loss

Obesity is rapidly becoming one of the leading causes of sleep apnea in children. Excess weight can cause disordered breathing due to the development of extra tissue in the throat, causing the periodic airway closures which characterize OSA.

Due to this relationship, doctors often suggest weight loss for children who suffer from sleep apnea. Studies have shown that children who are overweight see more OSA improvement from losing weight than from surgical interventions.

If your doctor recommends a weight loss plan for your child, they may also suggest the use of a positive airway pressure device. Not only will this alleviate symptoms in the short term, but it may also make it easier for your child to lose weight.

Medical Devices for Children with Sleep Apnea

The most common non-surgical treatment for sleep apnea is the use of a PAP device at night. These machines generate a humidified, pressurized airflow which a nose or face mask then directs into the user’s airway. By controlling the air pressure, the device can open up the airway, prevent obstructions, and ensure that there are no moments when the user stops breathing.

The most common form of PAP therapy is known as continuous positive airway pressure (CPAP). These machines create constant air pressure which does not vary throughout the night.

Less common are BiPAP (bilevel positive airway pressure) and ACPAP (automatic continuous positive airway pressure) machines, both of which vary the air pressure for inhaling and exhaling. These are more often used for sufferers who do not tolerate CPAP devices or who have lung disorders.

CPAP machines are an effective treatment for childhood OSA, with one study showing improvement in 86 percent of users. People who use CPAP report feeling more refreshed, alert, and better overall than they did previously.

Choosing a CPAP Machine and Mask

Your care team may be able to suggest the right CPAP device, but with so many on the market it can be confusing to choose one on your own. There are four criteria to consider when choosing a CPAP machine for your child:

  • Price point (most are between $200 and $800)
  • Operating range (whether the air pressure is appropriate for children)
  • Size (particularly for those who plan to travel with their child)
  • Extra features (such as sleep tracking, alarms, and timers)

Modern CPAP devices tend towards being reasonably lightweight and high-tech. Tracking features are particularly useful for children, as it allows for a deeper understanding of how well your child is adhering to the treatment.

It is also likely that your child’s doctor will direct you towards a mask style which will work for them. There are four primary types:

  • Full face, which creates a seal around both the nose and mouth
  • Nasal, which covers the entire nose
  • Nasal pillow, which seals the nostrils and is held in place by a cushion
  • Nasal prong, which seals the nostrils

Some children are able to use the slimmer nasal masks, while others will see the best results with a full face mask.

Adherence

Adherence, or how often a patient uses their PAP machine correctly, is the most significant factor in determining whether PAP therapy will be successful. In one study of childhood OSA sufferers it accounted for 92 percent of treatment failures.

Children may be alarmed by various elements of their PAP machine, the presence of the nose or face mask, or the feeling of the air pressure itself. While most children become accustomed to these things with time, that too requires using the machine for long enough to overcome their fear.

Parents can alleviate their child’s fears by addressing their own concerns and by desensitizing their child to the device.  If the parent also needs to use a PAP machine, their ability to be a “role model” will help.

Side Effects and Solutions

While PAP devices do occasionally cause minor side effects, many of these can be addressed easily. This is particularly important for children, as ongoing side effects may result in poor adherence.

Some side effects and their solutions include:

  • Discomfort is usually caused by the mask and hose, particularly for children who don’t tolerate the slimmer nasal options. Special pillows are available for PAP users and can help make sleep more comfortable.
  • Bloating is caused by swallowing air, usually because the air pressure is set too high.
  • Skin irritation is the result of wearing a mask in the same place every night. It’s essential to choose a mask with an appropriately soft seal, as well as using PAP-friendly cream regularly.

Final Thoughts

With more children than ever suffering from sleep apnea, understanding the condition’s sometimes confusing array of symptoms is critical. Medical professionals have been advised to consider an OSA diagnosis for symptoms as disparate as ADHD and bedwetting. Parents should also be alert for indications that their child may be suffering from the disorder.

If your child’s doctor is considering a sleep apnea diagnosis, they will either refer you to a sleep clinic for a sleep study or help you conduct a less-intensive study at home. Once a diagnosis has been made, the cause of the OSA will play a significant role in deciding which treatment will work best for your child.

For some children, surgery to remove the tonsils, adenoids, or excess tissue might be the best course of action. Other children may be directed to lose weight, while some might benefit from the use of medications to treat allergies or calm enlarged adenoids and tonsils.

The use of continuous positive airway pressure, or CPAP therapy, is another tool in the treatment of sleep apnea. It can take time for children to adjust to the use of a CPAP device, but there are steps parents and children can take together to ensure that it is as easy to use as possible.

Additional Resources

Understanding sleep apnea in children can be a confusing process. Follow the links below to learn more and find support.

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