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A Guide for Parents of Children with Sleep Apnea


Table of Contents

1. What Is Sleep Apnea?2. What Are the Types of Sleep Apnea Affecting Children?Obstructive Sleep Apnea (OSA)Central Sleep Apnea (CSA)Complex Sleep Apnea Syndrome3. What Are Signs and Symptoms of Sleep Apnea in Children?4. What Causes Pediatric Sleep Apnea?5. What Are the Risk Factors for Sleep Apnea in Children?6. What Are the Complications of Sleep Apnea?7. How Is Sleep Apnea in Children Diagnosed?8. What Is the Treatment for Children with Sleep Apnea?SurgeryContinuous Positive Airway Pressure (CPAP)Oral/Dental AppliancesLifestyle Changes

Can children have sleep apnea?


Sleep apnea is a disorder that affects 2 to 3 percent of children. Apnea also affects infants, who may have episodes where they cease breathing for at least 20 seconds.  

Sleep is vital for children’s growth, and interruptions to it have an impact on their learning, behavior, and overall health. Parents are usually the first to detect or discover symptoms, and with immediate and appropriate intervention, they can help their children outgrow the symptoms or overcome the disorder.

This guide walks parents through sleep apnea in kids, its warning signs, and interventions to treat the disorder.  

What Is Sleep Apnea?


Apnea refers to breaks, interruptions, or cessations of breathing. An apnea event can last seconds and happen multiple times in the course of sleep. 

Infants can experience apneas or hypopneas (partial reductions in breathing). These apneas may be central, obstructive, or mixed. Per the American Academy of Sleep Medicine (AASM), an infant’s breathing can be unstable and become part of the development.    

For a cessation to be considered an apneic event, it must be 20 seconds or shorter if associated with bradycardia (slow heartbeat) or cyanosis (bluish-purple hue to the skin), according to this study.   

What Are the Types of Sleep Apnea Affecting Children?

The three kinds of sleep apnea that affect children are as follows.  

1. Obstructive Sleep Apnea (OSA)



This is the most common type of sleep apnea and sleep-disordered breathing (SBD).  Muscles, including those that support the head and neck, relax when one sleeps. The muscles can relax too much, causing the upper airway (consisting of the nose, nasal cavity, and pharynx) to collapse. That makes it difficult for air to pass through the lung, making breathing difficult. 




Enlarged tonsils and adenoids can cause this blockage, and this condition is most prevalent in preschoolers, according to the AASM. The event occurs in children two to six years old when the adenoids and tonsils are larger than the throat. 



What causes snoring?

The air that squeezes through the narrowed passage can produce snoring. When the passageway is completely blocked, the level of oxygen drops and the level of carbon dioxide increases. The brain alerts you to wake up briefly to breathe, thereby opening your airway and disrupting your sleep in turn. 



2. Central Sleep Apnea (CSA)

This happens when the brain is unable to send signals to the muscles in charge of breathing. The underlying cause of CSA is the instability of the breathing control system due to serious diseases that involve the lower brainstem, where respiratory activities are produced and modulated. 

Under CSA, the person stops breathing or exhibits shallow breathing. Their chest also does not rise or fall because there is no effort to breathe.  There is no physical blockage to breathing, so the person does not experience snoring or gasping.


OSA vs. CSA

The main difference between the two apneas is:  

Characteristic

OSA

CSA

Cause of Apnea

Physical Blockage

Brain Signals

Snoring

Yes, in most cases

No 



3. Complex Sleep Apnea Syndrome

This is a combination of obstructive sleep apnea and central sleep apnea. One study revealed that complex sleep apnea syndrome is not a disease, and another emphasized the need for more clinical studies regarding the subject.

While not as common as OSA and CSA, mixed sleep apnea still affects some children. It often begins as obstructive sleep apnea and gets treated as such, according to Merck Manual.  

What Are Signs and Symptoms of Sleep Apnea in Children?

Children with sleep apnea can exhibit the following signs and symptoms.  

At night or bedtime they may:

  • Snore loudly and regularly
  • Pause, gasp, snort, and stop breathing during sleep
  • Show actual difficulty in breathing 
  • Feel restless and sleep in strange positions
  • Experience night terrors with episodes of screaming, shouting, flailing, etc.
  • Sweat heavily 
  • Wet the bed

During the day or in general, they may:

  • Show difficulty in waking up in the morning or ask for more time to sleep in 
  • Experience morning headaches
  • Be hyperactive 
  • Be irritable, agitated, and cranky
  • Have social and behavioral problems at school
  • Be sleepy or fall asleep during the day
  • Breathe through the mouth regularly (It becomes a habit because of the nasal obstruction)
  • Have a nasal voice  

Children with obstructive sleep apnea can exhibit symptoms similar to adults, like snoring and noisy breathing. It can also be that the disorder works differently across age groups, whereby adults can experience daytime sleepiness and childhood behavioral problems, according to the Mayo Clinic.


What Causes Pediatric Sleep Apnea?

The most widely known causes of obstructive sleep apnea among children are:

  • Adenotonsillar hypertrophy. As noted above, this is a common cause of OSA among children. Tonsils are lymphatic tissues located at the back of the throat. Adenoids are a kind of tonsil found at the roof of the pharynx and behind the nose. The enlargement may be due to infections or allergies, although some occur for no reason. As the enlarged tonsils or adenoids block the airways, the child has difficulty breathing and swallowing. Indeed, noisy breathing and restlessness are signs of adenoid or tonsil enlargement and therefore of sleep apnea, too. 
  • Obesity. This is a common cause of sleep apnea in adults and can also be the case in children. A 2013 study revealed a link between children who are obese and the high likelihood of OSA.  
  • Craniofacial anomalies:  This is a common cause of sleep apnea among infants. Children with inborn anomalies in the skull and head may be predisposed to OSA, according to this study. Examples of craniofacial abnormalities associated with OSA are cleft lip palate, undersized or smaller than usual lower jaw (mandible), and larger tongues (macroglossia).

What Are the Risk Factors for Sleep Apnea in Children?

A child may have a higher risk of developing sleep apnea or have a high predisposition toward obstructive sleep apnea when the following factors are present:

  • Family history (sleep apnea can be inherited)
  • Obesity 
  • Skull and head abnormalities    
  • Less muscle tone associated with neuromuscular diseases, Down syndrome, and cerebral palsy 
  • Genetic syndromes like Down syndrome and Prader-Willi syndrome  
  • Sickle cell disease (SCD) 
  • Born preterm 

Low Birth Weight and Related Issues

Small for gestational age (SAG) is a term used for babies who are smaller than those born with the usual number of weeks for pregnancy or due to problems that occur during pregnancy. 

A study in 2012 investigated the relationship between early childhood, sleep apnea, preterm birth, and SAG among children aged 2.5 to 6 years. It was found that:

  • Sleep apnea diagnosis is more prevalent in children born preterm
  • Children born small for gestational age did not show a high risk of sleep apnea.

On the subject of weight, being overweight can be a risk factor for sleep apnea, while being underweight can be a surprising sign of the disorder. 

Slow-wave sleep (SWS) or deep sleep is stage three of sleep when the body undergoes recuperation.   As part of the healing process, it secretes growth hormones. Sleep affects the release of GH, and disruptions caused by sleep apnea can adversely affect the child’s height and weight. 


What Are the Complications of Sleep Apnea? 


Sleep apnea may increase a child’s risk of certain diseases. Pediatric OSA may contribute to the following conditions: 

  • Failure to thrive
  • Long-term learning disabilities 
  • High blood pressure
  • Heart disease 
  • Type 2 diabetes
  • Death

As the World Health Organization has stated, OSA is not a life-threatening condition itself, but it can lead to serious problems or complications if left untreated.   

How Is Sleep Apnea in Children Diagnosed?


Is your child habitually snoring or showing breathing problems while sleeping? 

Talk to the doctor, who will: 

  • Ask for your child’s medical history, which you can gather beforehand to make it as detailed as possible. You can also take a video of your child while sleeping and present it to the doctor. 
  • Conduct a physical examination on the patient to check for enlarged tonsils, narrowed or swollen airway, and jaw size and structure, among other things. 
  • Refer your child to a specialist (sleep medicine; ear, nose, and throat; or orthodontist) or a sleep study center.  

Polysomnography is a kind of sleep study that involves an overnight stay at a sleep laboratory or which can be performed at home with a sleep apnea test kit. The somnograph will record or monitor your child’s brain and body activities during sleep, including:

  • Brain waves
  • Oxygen levels in the blood 
  • Heart rate
  • Eye movements 
  • Body movements
  • Snoring 
  • Breathing patterns

What Is the Treatment for Children with Sleep Apnea?


The following options treat sleep apnea in children, based on the somnograph and applicable diagnostic tests. 

Surgery

Adenotonsillectomy (AT) is the first surgery option for children with OSA and one of the most common surgeries performed in these cases. The procedure involves the removal of adenoids and tonsils of children. One may opt to remove tonsils alone (tonsillectomy) or adenoids (adenoidectomy). 

According to The American Thoracic Society, the improvement of symptoms in OSA is expected after AT. This research, for example, showed an increase in slow-wave activity in children with OSA who underwent surgery than those who had untreated OSA. 

Another study, however, noted that sleep apnea could persist after the removal of the tonsils and adenoids. That’s why the child may need to undergo another sleep study after AT and other treatments like CPAP therapy.

Continuous Positive Airway Pressure (CPAP)

CPAP is a non-surgical therapy for children with OSA, and is the second-most common treatment, after surgery. 

It therapy involves the use of a device to deliver air to patients with obstructive sleep apnea and other sleep-related breathing problems. Continuous yet mild air pressure keeps the upper airways open, preventing any pauses or stops in breathing while sleeping. This way, your child can breathe in and out with ease.

CPAP consists of a mask (worn over the nose only or both the nose and mouth), a tube that connects this mask to a machine, and the machine itself.  Pediatric CPAP masks for children can be uncomfortable at first, so you may need to employ a gradual desensitization process as recommended by the Children’s Hospital of Philadelphia.

Oral/Dental Appliances

Orthopedic appliances are considered a third option after surgery and CPAP for kids. This paper, for example, noted that oral appliances might be an  auxiliary treatment for children who have craniofacial anomalies and who are at risk of obstructive sleep apnea.

Oral or dental devices are classified into two groups:

  • A mandibular advancement device (MAD) modifies the position of the jaw and tongue such that they are pushed slightly forward. This prevents the throat muscles from collapsing. Mandibular advancement devices look like mouthguards and orthodontic braces and are recommended for simple snoring or mild to moderate sleep apnea.
  • A tongue-retaining device is a mouthpiece with a tube to hold the tongue in place. The device pushes the tongue forward so it won’t obstruct the upper airway. 

Consult with a dentist or orthodontist who has training in sleep medicine and experience in fitting these oral appliances in children.  

Lifestyle Changes

These home remedies and lifestyle modifications may help treat or prevent sleep apnea:   

  • Indoor Air Quality: Reduce your kid’s exposure to pollutants inside the home, which can irritate the nose and throat. Smoking, asbestos, and excess moisture are among pollutant sources commonly found at home.  
  • Weight Loss Programs: With obesity presenting a risk factor for sleep apnea, work with a dietitian on an effective plan to control your child’s weight. You can also set a good example by living a healthy lifestyle. 
  • A Sleep-Conducive Bedroom: A cold and dark room with a comfortable mattress and pillows may invite a restful sleep for your child. Discourage them from watching TV or using electronic devices around bedtime. 
  • Body Position: It’s generally believed that sleeping on one’s back results in or worsens sleep apnea. This paper, however, reported that children with OSA breathed best in the supine position. Observe the sleeping position of your child; it might help to put pillows on their side or back.  

The bottom line: children can have sleep apnea. The outward signs of sleep apnea may vary from child to child, but it affects the quality of their life with poor school performance, a major consequence of pediatric OSA.  

However, sleep apnea is curable with some of the treatment options laid out here. Going to a doctor at the onset or early stages of sleep apnea is your first line of defense when it comes to treating this potentially harmful condition in your child. 


References

Web Content

American Academy of Sleep Medicine. n.d. “Sleep Apnea—Symptoms & Risk Factors.” Last updated June 22, 2016.  http://sleepeducation.org/essentials-in-sleep/sleep-apnea/symptoms-risk-factors

American Thoracic Society. Obstructive Sleep Apnea in Children.” Accessed February 7, 2020.  https://www.thoracic.org/patients/patient-resources/resources/osa-in-children.pdf

Kondamudi, Noah P. and Andrew S. Wilt. “Infant Apnea. Last updated January 9, 2020.  https://www.ncbi.nlm.nih.gov/books/NBK441969/

Mayo Clinic. 2018. “Pediatric Obstructive Sleep Apnea.” Accessed February 7, 2020. 

Mayo Clinic. 2018. ”Sleep Apnea.” Accessed February 7, 2020.  https://www.mayoclinic.org/diseases-conditions/sleep-apnea/symptoms-causes/syc-20377631

National Heart, Lung, and Blood Institute. n.d. “Sleep Apnea.” Accessed February 7, 2020.  https://www.nhlbi.nih.gov/health-topics/sleep-apnea

Sleep Foundation. n.d. “Sleep Apnea.” Accessed February 7, 2020.    https://www.sleepfoundation.org/sleep-apnea

WebMD. n.d. “Sleep Apnea.” Last reviewed September 18, 2018.   https://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea

Journal Articles 

Wang, Juan, Yan Wang, Jing Feng, Bao-yuan Chen, and Jie Cao. 2013. “Complex Sleep Apnea Syndrome.” Patient Preference and Adherence 7: 633–641  https://doi.org/10.2147/PPA.S46626

Lumeng, Julie C. and Ronald D. Chervin. 2008. “Epidemiology of Pediatric Obstructive Sleep Apnea.” Proceedings of the American Thoracic Society 5(2): 242–252  https://doi.org/10.1513/pats.200708-135MG