How is obstructive sleep apnea (OSA) diagnosed and treated in children?

Diagnosis and Management of Obstructive Sleep Apnea in Children

Polysomnography is the gold standard for diagnosing obstructive sleep apnea syndrome (OSAS) in children, and adenotonsillectomy is the first-line treatment for children with adenotonsillar hypertrophy. 1

Diagnostic Approach

Screening and Initial Evaluation

• All children should be screened for snoring during routine health maintenance visits 1
• OSAS is unlikely in children without habitual snoring 1
• When snoring is present, a more detailed evaluation should follow, looking for:
  • Labored breathing during sleep 1
  • Gasping/snorting noises or observed episodes of apnea 1
  • Secondary sleep enuresis 1
  • Sleeping in seated position or with neck hyperextended 1
  • Daytime sleepiness or attention/learning problems 1

Physical Examination

• Key physical findings that suggest OSAS include:
  • Tonsillar hypertrophy 1
  • Adenoidal facies 1
  • Micrognathia/retrognathia 1
  • High-arched palate 1
  • Obesity or failure to thrive 1

Diagnostic Testing

• Polysomnography (PSG) is the diagnostic method of choice for children with symptoms/signs of OSAS 1
• PSG is the only test that quantifies sleep and ventilatory abnormalities 1
• Home sleep apnea tests (HSATs) are not recommended for diagnosis of OSA in children 1
• Alternative screening techniques (videotaping, audiotaping, nocturnal pulse oximetry, daytime nap polysomnography) have high false-negative rates and don't assess disease severity 1
• If alternative tests are negative but clinical suspicion remains high, full polysomnography should be performed 1

Diagnostic Limitations

• History and physical examination alone have been shown to be poor in differentiating between primary snoring and OSAS 1, 2
• Clinical assessment is sensitive (92.3%) but not specific (29.4%) compared to polysomnography 2
• The shortage of pediatric sleep laboratories may limit access to polysomnography in some regions 1

Treatment Approach

First-Line Treatment

• Adenotonsillectomy is the recommended first-line treatment for children with OSAS who have adenotonsillar hypertrophy 1
• Both adenoids and tonsils should typically be removed, as residual lymphoid tissue may contribute to persistent obstruction 1
• Postoperative polysomnography typically shows major decrease in obstructive events, though some may persist 1

High-Risk Patients

• High-risk patients should be monitored as inpatients postoperatively with continuous pulse oximetry 1
• Risk factors for postoperative complications include:
  • Age younger than 3 years 1
  • Severe OSAS on polysomnography (lowest oxygen saturation <80% or AHI ≥24/h) 1
  • Cardiac complications 1
  • Failure to thrive or obesity 1
  • Craniofacial anomalies or neuromuscular disorders 1

Alternative and Adjunctive Treatments

• Continuous positive airway pressure (CPAP) is recommended when:
  • Adenotonsillectomy is contraindicated 1
  • OSAS persists after surgery 1, 3
• Weight loss is recommended in addition to other therapy for overweight/obese patients 1
• Intranasal corticosteroids may be an option for:
  • Children with mild OSAS where adenotonsillectomy is contraindicated 1
  • Mild postoperative OSAS 1

Post-Treatment Follow-up

• All patients should be reevaluated after treatment to determine if further intervention is needed 1
• Objective testing (polysomnography) should be performed in:
  • High-risk patients 1
  • Patients with persistent symptoms/signs of OSAS after therapy 1
  • Patients with complex medical comorbidities 3

Special Considerations

Obese Children

• Obese children may have less satisfactory results with adenotonsillectomy, though many will still benefit 1
• Clinical judgment is required to determine benefits of adenotonsillectomy compared with other treatments in obese children 1
• These patients often require additional evaluation and management for multiple levels of airway obstruction 3

Complex Patients

• Children with craniofacial anomalies, neuromuscular disease, or other complex conditions require referral to appropriate subspecialists 1, 3
• These patients often have multiple levels of airway obstruction and may require additional evaluation and management beyond standard approaches 3