Obstructive sleep apnoea (OSA – KIDS)

upper airway dysfunction causing complete or partial airway obstruction during sleep leading to decreased oxygen saturation or arousals from sleep.

Peaks in pre-school years

• pediatric OSA peaks between 2- 8 years of age due to the increased growth of tonsils and adenoids relative to the size of the upper airway in this age group.

often not complete apnoea, but hypopnoea

Snoring is cardinal symptom

• about 15 to 20 per cent of children snore
• OSA is less common, and only affects about 1-3% of children

Risks

• Enlarged tonsils and adenoids most common cause.
• obesity
• Allergic rhinitis
• Medical conditions 
  • Muscle weakness
  • Hypotonia
  • craniofacial abnormalitites
  • microganthia
  • airway surgery
  • cleft palate repair
  • down syndrome
  • achrondoplasia

Consequences

• Increase in BP
• Increased ventricular wall thickness
• Increases risk of lifelong hypertension
• Impairment memory, attention, learning, behaviour

Key differences between adults and children in the clinical features of OSA

Adults	Children
Alternating snoring with obstructive apnoeas	Continuous snoring – episodic reduction in flow (hypopnoea) without obstructive apnoea is most common
Daytime sleepiness is a cardinal feature	Daytime sleepiness is uncommon
Obesity is common	Most children are normal weight, although failure to thrive may occur in severe cases and obesity increases the risk
Male predominance	No prevalence difference by gender

 

Clinical

• Snoring 
  • Often continuous, not necessarily with apnoeas
  • during sleep present ≥3 nights/week
• Difficulty breathing while asleep 
  • increased effort of breathing
  • choking
  • gasping
  • snorting during sleep
• daytime mouth breathing
• witnessed apneas
  • parent describes cessation of airflow with clear ongoing breathing effort
• frequent night time awakenings
• secondary nocturnal enuresis
• disrupted sleep can lead to behavioral issues
  • Wakes tired and grumpy
  • hyperactivity
  • irritability
  • even aggression
• Daytime sleepiness is not common

Examine

• Groth
• Craniofacial
• Nasal airflow
• Tongue, pharynx, palate, uvula, tonsils
• Right ventricular hypertrophy

Investigation

• Consider sleep study – often guided by ENT
• Assess adenoids with XR or nasoendoscopy

Treatment

• Surgical removal T+A’s
• Anti-inflammatory treatments
  • Useful nasal obstruction, mild OSA
  • Mometasone or fluticasone – one spray each nostril daily
• Dental therapies
• CPAP

 

Differential Diagnosis

1. Allergic rhinitis
   • Not all snoring is OSA, which should be discussed with the parents at the time of the initial evaluation, and nasal congestion should be treated.
2. Attention deficit hyperactivity disorder (ADHD) 
   • Pediatric OSA can be mistaken for behavioral problems because it frequently manifests as hyperactivity and difficulty with focus and attention in children.
3. Developmental delay 
   • OSA can lead to learning difficulties due to compromised focus and attention and sometimes be mistaken for a developmental delay.
4. Gastroesophageal reflux
   • When reflux occurs at night, it can cause a brief pause in breathing that may be mistaken for OSA. The two are not, however, mutually exclusive and reflux can increase the risk of OSA by worsening adenotonsillar hypertrophy.
5. Nocturnal enuresis 
   • Primary nocturnal enuresis is rarely associated with OSA, but secondary nocturnal enuresis should prompt screening for other symptoms of OSA. 
6. Morning headaches 
   • These can be a consequence of carbon dioxide retention overnight, but the patient should also be screened for more concerning qualities of the headaches (waking them from sleep at night, worse when lying supine, etc.) that may require imaging or further evaluation. A typical headache from OSA is dull and generally goes away on its own shortly after getting out of bed without using medication or caffeine. 
7. Parasomnias 
   • OSA can increase the occurrence of sleepwalking, night terrors, and confusional arousals but may also be unrelated. 
8. Narcolepsy 
   • OSA usually does not present as excessive daytime sleepiness in younger children. Patients frequently falling asleep during the day after five years of age should prompt screening questions for narcolepsy.

 

The only definitive way to distinguish between OSA and any of these is polysomnography.