Obstructive Sleep Apnoea in Children
On average, a child spends almost half of his or her time sleeping. The quality of sleep plays an important role in children's development. That is why children who suffer from respiratory disorders such as obstructive sleep apnoea (OSA) demands the careful care and attention of sleep physicians and specialists who take a special interest in the field of sleep disordered breathing (SDB).
OSA occurs when the muscles around the airway relax causing the airway passage to be intermittently blocked during sleep. In clinical terms, sleep apnoea is present when the pauses in breathing lasts 10 seconds or more during sleep. When children have difficulty breathing when they are asleep due to OSA, the sleep disorder not only robs them of the restful sleep they need, it can also impair their health and lead to negative consequences.
OSA in children is a relatively prevalent condition that may have long-term implications extending well into adulthood. Among the physicians involved in the treatment of childhood OSA, dentists may serve best as “gatekeepers”, given they are most likely to identify children with adenotonsillar hypertrophy – the most common cause of obstructive sleep apnoea.1
Does your child snore?
Snoring is one of the most common symptoms of OSA among children. While it is not unusual for children to snore occasionally, there are those who snore on most nights. Snoring is caused by the vibration of tissues in the throat when there is a partial blockage of air passing through the back of the mouth. This opening and closing of the air passage produces the vibrating sound when the child sleeps – the loudness depending on the amount of air passing through and how fast the throat tissues are vibrating.
Snoring is not necessarily associated with obstructive sleep apnoea syndrome (OSAS). However, loud and regular snoring may be a symptom of sleep apnoea or other issues including a stuffy nose, allergy or respiratory infection. If your child’s snoring is accompanied by gasping or pauses in breathing, it may suggest a narrowed or obstructed airway symptomatic of OSAS.
Causes and symptoms of childhood OSA
It is estimated that between 3-12 per cent of children snore, while OSA affects 1-10 per cent.2 Prevalent contributing factors to children who suffer from sleep apnoea include: Obesity, asthma, nasal allergies, abnormality in facial physical structure (such as the jaws) as well as medical or neurological conditions.
One of the most common problems associated with childhood OSA is large tonsils and adenoids. Children’s tonsils and adenoids, in relation to the size of their throat, may be rather large. As such, these outsized lymphoid tissues may partially block the airway and cause difficulty in breathing when they sleep.
Untreated sleep apnoea affects more than just the child’s nocturnal breathing. Children who snore loudly or sleep poorly are more likely to have learning problems, difficulty paying attention in school and be hyperactive.3
Here are some of the symptoms that children with OSA may exhibit:
- Loud and persistent snoring
- Gasps, snorts and pauses in breathing when sleeping
- Abnormal sleeping positions
- Listless, irritable, agitated and even aggressive
- Daytime sleepiness
- Mouth breathing
- Difficulty waking up in the morning
- Sweat profusely during the night
- Morning headaches
- Nasal voice due to frequent blocked nose
- Restless sleep
- Bed-wetting (enuresis)
- Issues with swallowing (due to enlarged tonsils)
Childhood OSA treatment options
Depending on the causes and severity of the sleep apnoea condition, there are several options available for the management of OSA in children.
In cases when the patient presents with normal craniofacial features and uncomplicated medical status, adenotonsillectomy (surgical removal of tonsils and adenoids) is generally accepted as the standard treatment for childhood OSA. The procedure has a success rate of approximately 83 per cent, although the figure may be lower for obese children with OSA or children with severe OSA.1 Nevertheless, the surgical procedure cures sleep apnoea in the majority of paediatric cases.
CPAP (Continuous positive airway pressure)
While continuous positive airway pressure (CPAP) is the first-line therapy for adult sleep apnoea patients, it is a second-line therapy for children with OSA. CPAP is generally recommended for children with OSA when adenotonsillectomy is contraindicated or has failed.
CPAP therapy includes the use of a portable unit attached via tube to a mask that the patient wears on their mouth and nose. CPAP provides positive airway pressure to relieve upper airway obstruction during sleep. The air pressure is used to open the throat muscles as well as the air passage so that the patient is allowed to breathe normally while asleep.
Despite its efficacy, CPAP is not for everyone as some patients have problems complying with the therapy. It is estimated that 20 per cent of children find CPAP difficult to tolerate.2 Due to the rapid growth of children, the mask must be adjusted at least every 6 months, hence requiring frequent follow-up visits.2
Diet and Medication
Weight loss and healthy diet programs are frequently recommended for obese children with OSA. If mild or residual OSA is present after surgery, antibiotic medications or topical intranasal application of corticosteroids and/or other anti-inflammatory therapy may be considered.
Oral Appliance Therapy
Oral appliances are frequently recommended as a first-line treatment for adult patients with mild-to-moderate OSA and second-line treatment for adult patients with severe OSA. Oral appliance therapy has emerged as a popular alternative therapy to surgery and patients who fail to comply with CPAP treatment.
The use of oral appliance has involved dentists in the treatment of both adults and children that have been diagnosed with OSA. Dental devices or sleep apnoea mouthpieces help to move your child's bottom jaw and tongue forward so as to keep his or her upper airway open. Only some children benefit from oral appliance therapy.
How dentists can help?
Dentists are becoming increasingly aware of sleep apnoea in adults, and are in a vantage position to identify children with adenotonsillar hypertrophy. They play an important “gatekeeping” role by informing the family physician and parents about the risks of OSA. The involvement of dentists in the diagnostic and treatment process can contribute enormously to the health of OSA patients.
Does your child have OSA?
If you suspect that your child may have OSAS symptoms, you may wish to speak to your doctor about it. Your child may then be referred to a sleep specialist or asked to go for an overnight sleep study. The study will monitor the child’s breathing, heartbeat, brain waves and body movements to provide a diagnosis. The sleep specialists will review the records of the study, also known as a polysomnograph, and determine whether your child has sleep apnoea, primary snoring or other issues. They would also be able to prescribe an appropriate treatment if and when necessary.
- "Role of Oral Health Professional in Paediatric Obstructive Sleep Apnoea." NCBI. Accessed December 23, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304178/.
- "Obstructive Sleep Apnoea in Children." American Family Physician. March 1, 2004. http://www.aafp.org/afp/2004/0301/p1147.html.
- "Snoring in Children." National Sleep Foundation. Accessed December 23, 2015. https://sleepfoundation.org/sleep-news/snoring-children.