Paediatric obstructive sleep apnoea (POSA) is a breathing disorder caused by repetitive episodes of upper airway obstruction during sleep, which result in the disturbance of normal respiratory and sleep patterns. It is one of a group of sleep disorders, termed sleep disordered breathing (SDB), which have been shown to negatively impact a child’s quality of life: in particular, there are physical, developmental, and cognitive consequences, if left untreated.
The prevalence of paediatric SDB is up to 6% in children of all ages. Both girls and boys are equally affected before puberty, with the peak incidence of POSA occurring at the age of 2-8 years, during which tonsillar and/or adenoidal hypertrophy is common. With increasing societal affluence and the resultant rising prevalence of obesity, there is now a second peak incidence in children aged above eight years of age.
The most common presenting complaint is snoring, mouth breathing and sleep disturbances. Concerned parents may notice apnoea or choking episodes and increased respiratory effort with retractions or paradoxical movement of the chest and abdomen. There are frequent night-time awakenings, enuresis and awakening unrefreshed in the mornings. Furthermore, as the day progresses, such children may present with hyperactivity, poor school performance or conduct disorders.
Clinical assessment requires assessing both the size of the tonsils and adenoids as well as establishing if the child has nasal obstruction. Allergic rhinitis is also prevalent in the general population, and it can compound the problem in the child with POSA.
Children with certain medical conditions are also more likely to have POSA, particularly those associated with muscle weakness, hypotonia, craniofacial abnormalities including micrognathia, previous upper airway surgery including repair of cleft palate, and syndromes such as Down syndrome or Achondroplasia.
The clinical findings alone are poor predictors of the severity of POSA. Studies have also shown that there is no correlation between the intensity of snoring and severity of POSA. A normal physical examination does not exclude POSA, and conversely, not all children with large tonsils have POSA.
Thus, a sleep study (polysomnography) may be needed to aid in the diagnosis of POSA for those children with the aforementioned medical conditions, or if there is dissent between the parents. A recent meta-analysis has shown that the use of paediatric sleep questionnaire together with pulse oximetry is also effective for early detection of POSA.
The first-line surgical treatment in children is Adenotonsillectomy. Often, this results in a marked improvement, however, studies have shown that about 15-20% of these children still have persistent POSA or a recurrence of symptoms.
Treatment failure can result from obstruction at multiple levels, beyond enlarged tonsils and adenoids. These areas of narrowing in the nasal, retropalatal and retroglossal regions occurs more frequently in children with craniofacial abnormalities, Down syndrome and obese children, but it can also occur in otherwise normal children. These cases can be assessed by Sleep nasendoscopy and CINE MRI. Newer surgical modalities to include powered endoscopic inferior turbinoplasties and tongue base reduction procedures.
Despite treatment, POSA may recur (or persist), especially in children with the underlying risk factors mentioned above. GPs play an important co-management role in the follow-up and screening for recurrent/residual POSA.
As POSA has been shown to negatively impact quality of life, if left untreated, in the long term it can predispose the child to chronic problems such as heart disease and hypertension in adulthood. Therefore, early detection and intervention will reduce the morbidities associated with POSA, improve school performance, and reduce healthcare costs.
Key messages
- Sleep disturbed breathing issues in children may lead to physical, developmental, and cognitive consequences if untreated
- The three most common risk factors for POSA in children are tonsillar and/or adenoidal hypertrophy and obesity
- The most common surgical treatment for POSA in children is Adenotonsillectomy.
Author competing interests – nil