Snoring is very common, affecting about around 10-30% of young children. When habitual (three or more nights per week) or with observed apnoea, this needs further evaluation for OSA.
OSA is common in children of all ages particularly in school-aged children where adenotonsillar hypertrophy peaks. Children who snore and have risks such as obesity, comorbidities such as hypertension or poor asthma control benefit from further assessment. There are distinct differences to adult OSA as outlined in the table.
Nocturnal symptoms include gasping (albeit harder to recognise in children), sleepwalking, enuresis, unrefreshing sleep despite adequate duration or excessive sweating. Daytime symptoms include poor school functioning, ADHD-like behaviour and other disruptive behaviours. Epworth score and non-attended sleep tests used in adults are not generally validated or used.
Whilst the long-term cardiovascular and metabolic morbidities consequent to adult OSA are well depicted, such consequences in children are not really known.
In cases of mild OSA, anti-inflammatory therapy such as nasal steroids have proven efficacy and the mainstay. Early reports suggested very high efficacy (>85%) from adenotonsillectomy, however, the contemporary data has revealed cure rates are much lower especially with more obese children. CPAP has well proven benefits in children with adherence rates similar to adults. Dental therapies have an emerging role.
Parasomnias
Many children will experience one form of parasomnia, often in the non-REM category. These include sleepwalking, confusional arousals and night terrors. They share many similarities often with a familial history and arising in the first half of the evening. They usually arise from partial awakening from deep (usually stage 3) sleep.
Night terrors peak around 5-7 years and are different to terrifying nightmares in that there is very poor recall of the event the next day and the child appears to not be fully awake with limited cognition during events (as with sleepwalking).
A piercing scream marks the beginning of the partial arousal, followed by cries or vocalisation of marked distress. The child appears petrified, with unfocused eyes, intense sweating, heart racing and might jump out of bed and run around with potential injury resulting. These events typically end abruptly, usually within five minutes.
Differentiating with nocturnal seizures or REM, parasomnias may be a challenge. Video documentation at home can be helpful.
Management includes injury minimisation measures, with adjustment in the home environment especially securing windows, stairs and doors. It is imperative to reassure parents that this is not representing a primary psychological problem and tends to diminish and almost always resolve as the child gets older.
Parents are advised to not try and awaken the child because this can result in more frequent events in the evening and sometimes cause an outburst and confusional awakening with distress. They should be encouraged to let the event run its course, gently guide the child back to bed with minimal intervention other than injury prevention.
Avoiding triggers such as sleep deprivation, attention to good sleep routines, reducing bedroom disturbances such as noises and pets is advised. Some medications such as SSRIs can provoke these parasomnias. Addressing any stress and sleep pathology such as sleep apnoea is also relevant.
In severe and frequent cases, a more systematic behavioural approach, programmed awakenings and a referral may be needed. In a small fraction, medications such as clonazepam are useful adjuncts to the above.
Key messages
- OSA is common in children but quite different clinically to adult OSA
- Conservative and surgical treatments have a primary role
- Parasomnias generally resolve and lifestyle measures are first line.
Author competing interests – nil