Obstructive Sleep Apnea occurs in approximately 3% of children, and has specific medical definitions based on sleep study (polysomnogram) results. Briefly, there is a complete or partial obstruction of the upper airway for a defined period of time. The measured oxygen level in the blood may drop and carbon dioxide, a waste gas, may build up. The sleep study measures oxygen and carbon dioxide levels, breathing efforts, electrical activity in the heart and brain, movement of the limbs and other activities important to diagnosing sleep apnea and other sleep disorders. As it is not unusual for adults and children to normally experience an occasional period of apnea during sleep, the sleep study provides an objective measure of the events during sleep. This information is important, as sleep apnea can lead to disorders of the heart, lungs, and brain over time.
Snoring is the most recognized symptom that may indicate the presence of sleep apnea. Approximately 30% of children snore, so the challenge lies in determining who has medically problematic snoring. Unfortunately a parental history and physician’s examination are not very accurate in diagnosing sleep apnea. When evaluating a patient who snores, a physician, nurse practitioner, or physician’s assistant will ask a series of questions centered around a child’s general medical history and about symptoms that may accompany snoring. The medical practitioner may even request an audio or video recording of the child sleeping, so evaluate the quality of the child’s sleep.
Certain medical conditions may predispose a child to snoring and sleep apnea, and include obesity, a family history of sleep apnea, Down syndrome and other genetic or structural conditions (facial and jaw deformities), deviated nasal septum, nasal polyps, enlarged nasal turbinates, gastroesophageal reflux, and tumors or structural deformities of the lower airway. In children, the most common cause of snoring and sleep apnea is enlargement of the tonsils, adenoids, or both.
Symptoms that are indicative of sleep apnea include snoring as well as restless sleep, frequent wakening, bed wetting, witnessed apnea, struggling to breathe and gasping while asleep, daytime fatigue, behavioral issues (hyperactivity and irritability), mouth breathing, and muffled speech. Younger children may present with failure to thrive and may choke on foods of tough consistency, such as meat.
Once a history has been obtained, the medical provider will examine the child’s overall facial and body structure, look inside the nose and mouth, and possibly obtain an xray of the adenoids or place a flexible telescope into the nose to view the nasal cavity, back of the nose, and lower throat area to try and determine if there is a structural abnormality that would explain the symptoms. Although most children who snore do not have sleep apnea, surgery may be of benefit when sleep is disrupted to the extent that the child’s daytime function is affected. These children are considered to have upper airway resistance syndrome. Children with documented sleep apnea and a defined structural abnormality require medical or surgical intervention to avoid the long term negative impact on heart, lung and brain function. In both groups of children, the type of surgery is based on the severity of symptoms and the particular structural abnormalities. Many times, the tonsils, adenoids, or both are removed with improvement in the symptoms.
A sleep study, which is considered the “gold standard” for the diagnosis of sleep apnea, may be obtained prior to any intervention when the history and physical examination do not match, the child has a serious medical condition or under the age of 2 years and is at an increased risk for surgery, or the parents would prefer to forego surgery unless medically necessary. If a child does have sleep apnea, then treatment is indicated, as damage to the heart, lungs, and brain may occur. Children with sleep apnea may be referred to a sleep specialist or pulmonologist prior to surgery to discuss nonsurgical options, or following surgery if sleep apnea or other sleep disorders are still present, as they provide long term management (supplemental oxygen at night, CPAP). More extensive surgery may be an option for children with remaining sleep apnea, so the coordinated efforts of a sleep apnea surgeon and a medical sleep specialist is important.
Snoring, as a stand-alone symptom, does not justify the risk of surgery, but should be assessed by a physician experienced in treating snoring and sleep apnea. There are some medical therapies, such as treating allergies, which may improve snoring. Surgery should be reserved for symptomatic patients, as some of the surgeries required to treat sleep apnea carry a significant risk.
As always, a dialogue between the parents, the pediatrician, and the otolaryngologist is of the utmost importance in providing the most appropriate care for the child.
If you have concerns about your child, contact one of our pediatric otolaryngologists at 404-255-2033.