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Management of obstructive sleep apnea in children


Obstructive sleep apnea (OSA) is characterized by episodes of complete or partial upper airway obstruction during sleep, often resulting in gas exchange abnormalities and arousals, which disrupt sleep. The condition exists in 2 to 5 percent of children and can occur at any age . Untreated pediatric OSA is associated with behavioral and learning problems; in more severe cases, it can be associated with impaired growth (including failure to thrive) and cardiovascular complications. Early diagnosis and treatment may decrease morbidity. Treatment decisions are individualized and depend upon findings from a comprehensive evaluation, including nighttime sleep disruption, daytime dysfunction, physical examination findings, and sleep study findings.


Obstructive sleep apnea (OSA) is characterized by episodes of complete or partial upper airway obstruction during sleep, often resulting in gas exchange abnormalities and arousals that cause disrupted sleep. (See 'Introduction' above.)

Children with suspected or confirmed OSA should be referred to a specialist (eg, otolaryngology or sleep medicine) for further evaluation and planning ( algorithm 1). The decision about whether and when to initiate therapy should be made collaboratively with the caregivers once the diagnosis of OSA is confirmed by the clinical evaluation, which may include a polysomnogram (PSG) in a sleep laboratory. Important considerations include the amount of nighttime sleep disruption and daytime dysfunction, child's age, presence of adenotonsillar hypertrophy, and PSG abnormalities. Other factors influencing treatment decisions are underlying medical issues or risk factors for complicated OSA, such as a congenital syndrome, craniofacial abnormalities, neuromuscular disorders, or mucopolysaccharidosis ( table 2). (See 'Choice of therapy' above.)

Adenotonsillectomy evaluation is generally indicated for otherwise healthy children who have adenotonsillar hypertrophy (≥1+ tonsils) and OSA (eg, apnea hypopnea index [AHI] >1 in the setting of relevant clinical symptoms). (See 'Choice of therapy' above and 'Adenotonsillectomy' above.)

After the full evaluation, the decision about whether to proceed to surgery should be made collaboratively with the family, considering in particular the degree of clinical symptoms (nocturnal and daytime ( table 1)), as well as the tonsil size and OSA severity.

Risk factors in children that predict increased risk for perioperative complications following adenotonsillectomy include severe OSA on preoperative PSG or the presence of complicating factors such as obesity (especially if severe), age <3 years, • 5/2/23, 8:58 AM Management of obstructive sleep apnea in children - UpToDate 17/23 abnormal upper airway tone, congenital syndrome, or craniofacial anomalies ( table 2).

Despite adenotonsillectomy, OSA may persist or recur, especially in children with obesity. Careful clinical follow-up for signs and symptoms of OSA is advisable.

For children with OSA and minimal adenotonsillar tissue, a strong preference for a nonsurgical approach, or contraindications to adenotonsillectomy, we suggest positive airway pressure therapy (Grade 2C). This is also an option for patients who have undergone adenotonsillectomy but have residual OSA. Positive airway pressure can be delivered as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP). (See 'Positive airway pressure' above and "Continuous positive airway pressure (CPAP) for pediatric obstructive sleep apnea", section on 'Indications'.)

For patients with nonsevere OSA that has been confirmed by PSG (eg, AHI 1 to 10), watchful waiting with supportive care (continued treatment for seasonal allergies and asthma) for up to six months can be a reasonable consideration as an alternative to adenotonsillectomy. This is based on the acceptable outcomes for patients followed with watchful waiting in a randomized trial. If this approach is chosen, the child should be reevaluated within six months for worsening of clinical symptoms or reevaluated sooner if symptoms worsen. (See 'Choice of therapy' above and 'Adenotonsillectomy' above.)

For all children with OSA, efforts should be made to minimize exposure to environmental allergens or irritants such as tobacco smoke. Children who are overweight or obese should be offered support for weight loss, with the intensity depending on the child's age and degree of obesity. (See 'Adjunct therapies' above.)

Prepubertal children with OSA and a narrow palate (crossbite) and little adenotonsillar tissue are candidates for treatment with rapid maxillary expansion (RME). RME is an orthodontic technique that widens the palate and nasal passages, thereby increasing airway patency. Mandibular advancement devices (oral appliances) typically consist of a top tray and bottom tray and are used to advance the mandible and keep the tongue in an anterior position, thus increasing airway diameter. (See 'Orthodontics' above.)

Children who have severe OSA-related hypoxemia may benefit from supplemental oxygen that is administered at night until definitive therapy can be provided. When nocturnal supplemental oxygen therapy is necessary, it should be initiated during a PSG with assessment for hypercapnia. (See 'Adjunct therapies' above.)

Positional therapy may be considered for patients in whom the severity of sleepdisordered breathing varies substantially with the sleep position and other OSA treatments are not adequately effective. Positional therapy consists of positioning to avoid supine sleep by using specially designed belts or pillows or elevation of the head of the bed. (See 'Adjunct therapies' above.)


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