Sleep Apnea

Obstructive sleep apnea occurs when a child stops breathing during periods of sleep. The cessation of breathing usually occurs because of a blockage (obstruction) in the airway. Tonsils and adenoids may grow to be large relative to the size of a child's airway (passages through the nose and mouth to the windpipe and lungs). Inflamed and infected glands may grow to be larger than normal, thus, causing more blockage. The enlarged tonsils and adenoids block the airway during sleep, for a period of time. (The tonsils and adenoids are made of lymph tissue and are located at the back and to the sides of the throat.)

During episodes of blockage, the child may look as if he/she is trying to breath (the chest is moving up and down), but no air is being exchanged within the lungs. Often these episodes conclude with a period of awakening and compensation for lack of breathing. Periods of blockage occur regularly throughout the night and result in a poor, interrupted sleep pattern.

Sometimes, the inability to circulate air and oxygen in and out of the lungs results in lowered blood oxygen levels. If this pattern continues, the lungs and heart may suffer permanent damage.

Obstructive sleep apnea is most commonly found in children between three–six years of age. It occurs more commonly in children with Down syndrome.

What Causes Sleep Apnea?

In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge. Large adenoids may completely block the nasal passages and make breathing through the nose difficult or impossible.

There are many muscles in the head and neck that help to keep the airway open. When a person (child or adult) falls asleep, muscle tone tends to decrease, thus, allowing tissues to fold closer together. If the airway is partially closed (by enlarged glands) while awake, falling asleep may result in a completely closed passage.

Obesity may cause obstructive sleep apnea. While a common cause in adults, obesity is a far less common reason for obstructive sleep apnea in children. A rare cause of obstructive sleep apnea in children is a tumor or growth in the airway.

Symptoms of Sleep Apnea

The following are the most common symptoms of obstructive sleep apnea. However, each child may experience symptoms differently. Symptoms may include:

  • Loud snoring or noisy breathing during sleep
  • Periods of not breathing - although the chest wall is moving, no air or oxygen is moving through the nose and mouth into the lungs. The duration of these periods is variable and measured in seconds.
  • Mouth breathing - the passage to the nose may be completely blocked by enlarged tonsils and adenoids.
  • Restlessness during sleep (with or without periods of being awake)
  • Excessive daytime sleepiness or irritability (because the quality of sleep is poor, the child may be sleepy or irritable in the daytime)

The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

Diagnosis of Sleep Apnea

Your child's physician should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat (ENT) physician (otolaryngologist) for further evaluation. In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include:

  • Sleep history—report from parents or caretaker
  • Evaluation of the upper airway
  • Sleep study (also called polysomnography)—the standard for diagnosing obstructive sleep apnea. The test requires a high level of collaboration on the part of the child and may not be possible in younger and/or uncooperative children. The child will sleep in a specialized sleep laboratory, where a variety of testing occurs to evaluate the following:
    • Brain activity
    • Electrical activity of the heart
    • Oxygen content in the blood
    • Chest and abdominal wall movement
    • Muscle activity
    • Amount of air flowing through the nose and mouth

    During the sleep study, episodes of apnea and hypopnea will be recorded:

    • apnea the complete airway obstruction of at least 10 seconds
    • hypopnea the partial airway obstruction combined with a significant decrease in the oxygen content of the blood.

    Based on the laboratory test, sleep apnea is generally considered significant if more than 30 apnea episodes occur per night, or five or more occur per hour. Some experts define the problem as significant if a combination of five or more episodes of apnea and/or hypopnea occur per hour of sleep.

Symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Consult your child's physician for more information.

Treatment of Sleep Apnea

Specific treatment for obstructive sleep apnea will be determined by your child's physician based on:

  • Your child's age
  • Overall health and medical history
  • Cause of the condition
  • Your child's tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway blockage in children, the treatment is surgery and removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy)(link to the page on this topic). Your child's otolaryngologist will discuss the treatment options, risks, and benefits with you. This surgery requires general anesthesia. Depending on the health of the child, surgery may be performed on an outpatient basis.

If the cause of the disorder is obesity, less invasive treatments may be appropriate, including weight loss and wearing a special mask while sleeping to keep the airway open. This mask delivers continuous positive airway pressure (CPAP). The device itself is often clumsy, and it may be difficult to convince a child to wear such a mask. Surgery may be necessary.

The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway obstruction in children, the treatment is surgery and removal of the tonsils, tonsillectomy and/or adenoids, adenoidectomy. Dr. Shinhar has performed hundreds of these procedures and has developed a special technique that enables him to remove the tonsils and adenoids with minimal pain and discomfort postoperatively. This surgery requires general anesthesia and usually is performed on an outpatient basis.



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