Obstructive Sleep Apnea

When discussions with parents turn to disturbed sleep patterns, it can be very difficult for pediatricians to understand what is going on. Three-year-old Sam’s mother may tell me he snores like a freight train, 12-year-old Lily’s mom reports that her daughter tosses and turns all night, while five-year-old Jack’s dad is concerned because the boy seems to stop breathing at times. Fortunately for us--not to mention our young patients--there are now excellent tests which can be performed to help us understand whether these sleep habits are normal for the child or symptoms of a problem.

Below, Dr. Richard Kravitz, director of Duke’s Pediatric Sleep Laboratory, describes a common childhood sleep problem and when a sleep test may be warranted.

--Dennis Clements, MD, PhD

Dr. Kravitz

As parents, we consider nothing more important than the health and well-being of our children. We make sure they eat well, get their checkups, are immunized to prevent serious illnesses, and see a doctor when they are sick. Yet many parents are unaware that problems may occur at a time they least expect--while their children are asleep.

Obstructive sleep apnea (OSA), condition in which the airway becomes partially or completely blocked during sleep, occurs in 1 to 3 percent of otherwise healthy children. While long recognized in adults, OSA has only recently been recognized as a significant problem for children. Children frequently have symptoms that are different from those experienced by adults, and as a result, a potentially serious problem may go unrecognized and untreated.

OSA is most commonly seen in children ages 2 to 7, but it can affect infants and adolescents as well. The most common cause of OSA in children is enlarged adenoids and tonsils, though we are seeing an increasing number of cases caused by childhood obesity.

Children with OSA frequently snore and may have difficulty breathing while asleep. They may have pauses in their breathing (called apneas), which can be followed by a sudden gasping for air. Their sleep can be restless, with tossing and turning, and they may sleep in unusual or contorted positions in an attempt to open up their blocked airway. If left untreated, children are at risk for many physical as well as behavioral problems. These can include: daytime sleepiness (after snoring, the most common symptom seen in adults); excessive napping; changes in behavior; hyperactivity (especially troublesome in school); trouble concentrating in school with a decline in school performance; poor growth; the reappearance of bedwetting; and high blood pressure and other cardiac-related problems.

While observing your child when he or she sleeps is an important way of identifying a potential problem, the presence of some or all of the above listed symptoms is usually not enough to be certain that OSA is occurring. For example, snoring, a relatively common problem seen in 10 percent of otherwise healthy children, does not always mean OSA. Also, when sleep apnea is present, its severity does not always correlate with the number and degree of symptoms present--some children with mild snoring have severe OSA, while others with heavy snoring do not have OSA at all. Currently, the only way to definitively determine whether or not OSA is present is by physiologic monitoring of the child while asleep with a sleep study (also known as polysomnography).

Testing a child for OSA requires spending the night in a sleep lab, a room that is set up like a bedroom. A parent is encouraged to spend the night with their child as to make them feel comfortable and to add information as to how closely the night of observed sleep mirrors what is normally seen at home. The child is observed throughout the night by a sleep technician who further comments on the witnessed sleep. During the sleep study, we monitor the child’s brainwaves, respirations, heartbeats, and oxygen and carbon dioxide levels looking for evidence of any airway obstruction. Using computerized equipment, technicians will record the child's breathing patterns for evaluation by a doctor with expertise in sleep medicine.

If the sleep study confirms the presence of OSA, several treatment options are available, depending on the underlying cause. For example, if enlarged tonsils and/or adenoids are felt to be the problem, the child may be referred to an ear, nose, and throat (ENT) specialist to remove this excess tissue (this is the most common treatment used in children under 10 years old). If the child is overweight and this is thought to be the cause of the sleep apnea, weight loss can frequently solve the problem. Finally, the sleep specialist may recommend continuous positive airway pressure (CPAP). CPAP is a device that blows air into the child’s nose and/or mouth and helps stent open the collapsing airway. CPAP is well tolerated in children and highly effective at treating OSA not responsive to other treatments.

If your child snores, has trouble sleeping at night, is tired or hyperactive during the day, or has trouble concentrating while in school, he or she might have OSA. Tell your doctor of your concerns. Referral to a sleep specialist might be the ticket to a good night’s sleep.

Richard M. Kravitz, MD, is the director of Duke's Pediatric Sleep Laboratory and an assistant professor of pediatrics in the division of pulmonary medicine.

Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.