Obstructive sleep apnea is a condition that affects breathing during sleep in both adults and children. It can have an important impact on growth, development, and behavior in affected youth. What are some of the symptoms associated with sleep apnea in children and adolescents? What unique treatments exist for these groups? Learn how to treat obstructive sleep apnea in children and teenagers, including the roles of surgery, allergy treatment, orthodontics, CPAP therapy, weight loss, and alternative options like myofunctional therapy.
What Is Pediatric Obstructive Sleep Apnea?
Obstructive sleep apnea is characterized by pauses in breathing that occur during sleep. These episodes are due to the partial or complete collapse of the upper airway, affecting tissues within the throat (like tonsils, adenoids, or the soft palate) or at the base of the tongue. It affects approximately 1 percent of children.
Sleep apnea events last at least ten seconds and are associated with either a drop in blood oxygen levels (with the saturation measurement decreasing by 3 percent), an increase in carbon dioxide levels, or an awakening that fragments sleep. Unlike in adults, where an apnea-hypopnea index (AHI) greater than five is considered abnormal, these episodes can occur just one time per hour in children and be deemed significant.
Obstructive sleep apnea is often due to facial anatomy that contributes to a blockage of the airway. It may be worsened by allergies, colds, or exposure to tobacco smoke. Sleep position, especially sleeping on the back, may also increase the occurrence. Weight gain may also have a role in children who are overweight or obese.
Symptoms and Signs of Sleep Apnea in Children
Despite the similarities to how obstructive sleep apnea occurs in adults, children also may have unique symptoms and signs of the disorder. Some of these findings include:
- witnessed pauses in breathing
- gasping or choking
- mouth breathing
- teeth grinding or clenching
- sweating at night
- restless sleep
- night terrors
- morning headaches
- daytime sleepiness
- naps in older children
- attention deficit hyperactivity disorder (ADHD)
- growth problems
Let’s review a few of these important findings and highlight how they might suggest the presence of obstructive sleep apnea.
Children should not chronically snore. Though it might seem cute, this can be a sign of difficulty breathing during sleep and should not be ignored. Mouth breathing indicates trouble breathing through the nose. This may be due to nasal congestion from a cold or chronically in the setting of allergies. Sweaty and restless sleep may be a sign of thrashing and struggling to breathe.
Sleep apnea may fragment sleep stages and lead to sleep behaviors (called parasomnias) and even bedwetting that persists beyond the normal age of resolution. Children may be sleepy during the daytime, but they more likely may become hyperactive and inattentive. Growth can also become impaired and effective treatment of sleep apnea may cause a rebound in growth and an improvement in behavior. These consequences can be avoided.
Treatments for Sleep Apnea in Children and Adolescents
Fortunately, there are effective treatment options available for this condition in children and adolescents, including:
Tonsillectomy and Adenoidectomy
This is the most common surgical treatment for children with obstructive sleep apnea. It will be performed if the doctor recognizes enlargement of the tonsils or adenoids at the back of the mouth and lining the throat. Children with enlarged tonsils may suffer from recurrent infections, complain of a sore throat, and may even have changes in their voice when the tissues are enlarged. This surgery works extremely well and the success rate is 80 percent. The procedure lasts one hour and occurs under general anesthesia. Children return to school in 1 to 2 weeks. It is performed by a general surgeon or by an ear, nose, and throat (ENT) specialist. This evaluation may require a referral from your pediatrician or sleep specialist.
Children or teenagers with allergic rhinitis (hay fever) may have congestion, a runny nose, watery or itchy eyes, or post-nasal drip. When the nose is blocked, mouth breathing is more likely to occur. This may contribute to the risk of snoring and sleep apnea. Allergies may be treated with nasal saline rinses, oral medications like montelukast (sold as the prescription Singulair), or steroid nasal sprays. Referral to an allergist can be arranged for other allergy testing or immunotherapy. Reduction of the nasal turbinates, tissues that swell with allergies and may block the nose, can be done by an ENT specialist.
Children often need braces to straighten wayward teeth, but sometimes these interventions can also improve breathing during sleep. Teenagers often visit an orthodontist, but younger children may also benefit from specific treatments. Rapid maxillary expansion may be used to widen the hard palate and the nasal passage. This is done with the placement of an adjustable brace at the roof of the mouth by an orthodontist. This treatment works best in younger children and does not work after the growth spurt ends. In older children, headgear may be used to advance forward a slowly growing jaw. This might help when retrognathia is present. As much as possible, tooth extraction should be avoided. The presence of the adult teeth will encourage normal growth of the jaw to make room for them.
Exercises of the tongue and lips may increase the muscle tone of the airway, promote nasal breathing, and reduce the risk of snoring and sleep apnea. These exercises may include sticking the tongue out, rolling it, clicking it, or pushing it toward the roof of the mouth. It may require instruction by a specialized speech therapist. Myofunctional therapy has little chance of side effects. These exercises must often be done for 45 minutes daily, however, and children may not be adherent to the recommendations. Reinforcement of good tongue positioning habits while at rest, with speech, and while eating may reduce the time required. There is some evidence that playing woodwind instruments and even the didgeridoo may also be helpful.
Continuous Positive Airway Pressure (CPAP)
CPAP therapy may be used in children or teenagers who have persistent sleep apnea despite other treatment efforts. After other interventions are made, a sleep study may be useful to reassess the condition. If it persists, CPAP can be an effective option. With CPAP, a constant flow of air is delivered through a face mask worn over the nose or nose and mouth during sleep. It is important to select a mask that does not apply too much pressure to the mid-face (nose and upper teeth) as there are reports of growth restriction. Many teenagers gradually lose interest in CPAP therapy and long-term adherence may be disrupted, especially when teenagers go off to college and sleep in dormitory environments. It can be a treatment that is returned to later as needed.
In late adolescence, surgical advancement of the upper and lower jaws can occur to open up the airway. This is indicated if a small or recessed lower jaw (micrognathia or retrognathia of the mandible) is present. This treatment is 85 percent effective. The procedure lasts 4 to 5 hours and occurs under general anesthesia. It may take 6 weeks to recover with some impairment in eating initially. It is performed by an oral and maxillofacial surgeon.
Older adolescents who have finished growing and have completed any required orthodontic work may be interested in using an oral appliance to treat sleep apnea. This is an option for mild or moderate obstructive sleep apnea. These fitted appliances are made by a dentist and adjusted over several months. When worn, the lower jaw and tongue are shifted forward, opening up the back of the airway. They can also protect teeth enamel from damage related to teeth grinding or clenching. If problems in the temporo-mandibular joint (TMJ) are present, this may not be an appropriate therapy. Due to the need to change out the device, and potential for restriction, they are not recommended for younger children who are still growing.
In children who are overweight or obese, a weight loss plan with improved nutrition and increased exercise may be indicated. These changes should be made with the supervision of a pediatrician. Gradual weight loss is a realistic goal and the amount needed will vary based on the child’s body mass index (BMI).