Symptoms such as snoring, restless sleep, and pauses in breathing while sleeping in children cause worry in every parent. If they repeat, it is time to visit a pediatrician or an ENT specialist as it might point to obstructive sleep apnea – occurring mainly in children with enlarged tonsils. In the following article, I  will explain the main symptoms of child sleep apnea, the diagnostic process, and the treatment of this condition.

Obstructive sleep apnea (OSA) is a medical condition caused by the reduction of airflow in the respiratory tract during sleep. It is characterized by short, frequent pauses in breathing, accompanied by symptoms such as snoring, restless sleep, and difficulty focusing during the day.  Tonsil hypertrophy is reported as the principal cause of sleep apnea in a child. Untreated sleep apnea leads to severe complications.

OSA is a condition that affects 1.2–5.7% of children. Symptoms of night apnea can appear at any stage of a child’s development – both in an infant and in a teenager. However, the peak prevalence occurs between the ages of 3 to 8.

Pre-school children are the most vulnerable and prone to frequent infections as their immunity is just developing and they are in regular contact with their peers.

The most common cause of obstructive sleep apnea in children is hypertrophy of the pharyngeal tonsil (the so-called third tonsil) and/or the palatine tonsils. When the tonsils are too large for a child’s airways,  they cause obstruction and difficulties breathing during sleep.  Sleep apnea in a child is hardly ever  triggered by the ailments such as:

• obesity,
• allergy,
• asthma,
• gastric reflux,
• hypotonia – decreased muscle tension at the back of the pharynx and the soft palate.

The characteristic symptoms of obstructive sleep apnea occur mainly at night, during sleep; your child can experience snoring, but it is not a given.  It should also be pointed out that not all children who snore will have sleep apnea. Therefore, you need to observe your child and watch out for any symptoms, both day and night.

At night, in addition to snoring in a child, you can notice:

• short, several-second breaks in the air intake;
• difficult, noisy breathing;
• restless sleep – frequent tossing and turning, and waking up;
• bedwetting;
• profuse sweating;
• sleeping in unusual positions, e.g., excessively tilted head or sitting.

Obstructive sleep apnea also affects a child’s functioning during the day.  There might appear:

• morning headaches;
• excessive sleepiness;
• neurocognitive disorders – problems with concentration at school, poor academic performance;
• irritability, hyperactivity, aggression, and other behavioral problems;
• deterioration of relationships with peers.

Complications of obstructive sleep apnea include, among others:

• recurrent oxygen deficiency, the so-called hypoxia;
• cardiovascular disorders, including high blood pressure (by 10-15 mmHg compared to healthy children),
• left ventricular hypertrophy;
• growth disturbance (rare).

When children’s night apnea persists for a long time, it can lead to severe cardiovascular disorders in adulthood, including high blood pressure, coronary artery disease, heart failure, arrhythmia, stroke, and metabolic disorders.

To protect your child against severe complications of obstructive sleep apnea, you should visit a pediatrician or a pediatric ENT specialist as soon as you notice any disturbing symptoms. The doctor will go over the complete medical history of the child and will examine the upper respiratory tract – the size of the tonsils in particular. If something draws concern, the doctor can additionally recommend allergy tests or consultation with a pulmonologist. Yet, polysomnography is currently the standard in OSA diagnosis.

It is performed under laboratory conditions at the hospital. A child is connected, via electrodes, to a specific device that monitors sleep. The device measures the brain activity, the heart rate, airflow through the mouth and nose, amount of oxygen and carbon dioxide in the blood, muscle activity, chest and abdominal movements as well as sleep interruptions. The parent is present during the examination, and the procedure itself is painless yet uncomfortable and stressful for the child as it takes place in out-of-home conditions.

A milestone in the diagnosis of sleep apnea in children is the Clebre sensor which permits monitoring sleep at home in an accurate manner. This device is an excellent alternative to  a polysomnogram test and allows you to obtain detailed data on the quality of the sleep pattern. It also determines whether a child requires treatment and verifies the effects of the therapy. The advantage of the study is that it is carried out in comfortable, home conditions, which is of great importance for young patients.

A small sensor is stuck to a child’s neck for several or a dozen or so consecutive nights.  Since the data is gathered by the device for a longer period of time, the picture of the quality of a child’s sleep is more precise than during a one-night polysomnogram test. All the information gathered by the Clebre sensor is saved in the mobile application.

Obstructive sleep apnea in a child is a severe but treatable disorder. Its symptoms cannot be neglected, but neither should you panic.  Upon a complete diagnosis, an ENT specialist will recommend the appropriate therapy.

As obstructive sleep apnea is usually caused by enlarged tonsils, the treatment focuses on eliminating the problem. Therefore, the most effective therapy is adenotonsillotomy – a procedure of removing the pharyngeal tonsil and/or the palatine tonsils.

According to current scientific reports, adenotonsillotomy significantly reduces the symptoms of OSA in children. It improves the parameters of sleep and the quality of life, reduces hyperactivity and aggression as well as increases neurocognitive abilities – especially memorization, focus, and learning performance.  Moreover, the procedure improves the functioning of the cardiovascular system, particularly lowering blood pressure, and it has also been found to stabilize the heart rate and reduce inflammation in the body.

Adenotonsillotomy is performed as a refund under the National Health Fund. All you need is a referral from a pediatrician or an ENT specialist. If you want to skip the lines, you can take your child to have the tonsils removed privately, but you need to consider the costs of several thousand zlotys.

Another form of treatment for obstructive sleep apnea is CPAP. A child is given a special mask, connected to a small, portable device that blows air through the nasal passage or nose and mouth into the respiratory tract. The pressure generated by the machine allows the airways to open, and the child can breathe normally while sleeping. The downside of this therapy is significant discomfort. Therefore it is only used in children who do not qualify for adenotonsillotomy or if the procedure has not brought about much improvement.

In the case of CPAP devices, you can also count on a refund from the National Health Fund. Each patient is entitled to it once every 5 years and it amounts to PLN 1,890.00, i.e., 90% of PLN 2,100.00 (the lowest price of the CPAP device approved by the National Health Fund).

In some cases of sleep apnea, an ENT specialist may recommend steroids such as fluticasone or montelukast – applied to the nose to open the airways. This treatment is often very effective in children who snore.

It is a necessary component of therapy for overweight and obese children who suffer from obstructive sleep apnea. Achieving a healthy body weight (through diet and exercise) minimizes OSA symptoms.