What is the approach to managing sleep disordered breathing in children?

Approach to Sleep Disordered Breathing in Children

For otherwise healthy children with sleep disordered breathing and adenotonsillar hypertrophy, adenotonsillectomy is the first-line definitive treatment, but clinicians must recognize that success rates are highly variable—ranging from 80% in younger, normal-weight children to less than 50% in obese children—and families must be counseled that additional interventions may be necessary. 1

Initial Diagnostic Evaluation

When to Obtain Polysomnography (PSG)

Mandatory PSG before surgery: 1

• Children with obesity
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disorders
• Sickle cell disease
• Mucopolysaccharidoses

Consider PSG when: 1

• Need for surgery is uncertain
• Discordance between tonsillar size on examination and reported severity of symptoms
• Parents desire confirmation of diagnosis

PSG may be omitted: 1

• Otherwise healthy child with strong history of struggling to breathe
• Daytime symptoms present
• Enlarged tonsils on examination
• No comorbidities

Clinical Assessment Focus

Look specifically for: 1

• Tonsillar size and degree of obstruction
• Body mass index and obesity status
• Ethnicity (African American children have lower cure rates)
• Age (younger children have better outcomes)
• Severity of OSA symptoms
• Presence of chronic rhinitis or deviated nasal septum 2

Primary Treatment: Adenotonsillectomy

Expected Success Rates

Younger, normal-weight, non-African American children: 80% resolution 1, 3

Obese children: Less than 50% complete resolution 1, 3

Overall success rate (AHI <2 events/hour): 79% based on the CHAT trial 1

Complete cure rates: Only 27-40% in some populations 3

Predictors of Treatment Failure

Children at higher risk for persistent OSA after surgery: 3, 2

• Age greater than 7 years
• Obesity (50% prevalence of persistent OSA)
• Baseline severe OSA (AHI >10/hour)
• African American ethnicity
• Chronic rhinitis
• Deviated nasal septum
• Small tonsil size despite symptoms
• Underlying genetic or metabolic disorders

Perioperative Management

Communicate PSG results to anesthesiologist before surgery 1

Admit for overnight monitoring if: 1

• Age younger than 3 years
• Severe OSA on PSG (AHI ≥10 events/hour)
• Oxygen saturation nadir <80%

Management of Persistent or Recurrent OSA

Approximately 30-73% of children will have residual OSA after adenotonsillectomy, making post-operative assessment critical. 3

Post-Operative Evaluation

Obtain follow-up PSG in: 1, 3

• Children with persistent snoring or symptoms
• High-risk patients (obese, older age, severe pre-operative OSA, comorbidities)
• Those with severely abnormal preoperative PSG

Second-Line Interventions

For persistent OSA, evaluate and treat: 4, 3

1. Lingual tonsillar hypertrophy - Consider lingual tonsillectomy if identified 4

2. Weight management - Mandatory for overweight/obese children 1, 4, 3

3. CPAP therapy - For children who don't qualify for site-specific upper airway treatment 1, 4, 3

4. Medical management: 5

   • Nasal steroids for mild to moderate OSA
   • Leukotriene receptor antagonists for mild to moderate OSA
   • Treatment of chronic rhinitis

5. Orthodontic intervention - Rapid maxillary expansion if specific craniofacial features present 4, 5

6. Advanced surgical procedures - For select cases 1, 3

Special Populations

Obese children: 1

• CPAP may be reasonable alternative to surgery as first-line treatment
• Tonsillectomy often leads to weight gain, potentially worsening OSA
• Multimodal approach typically required

Children with Down syndrome or mucopolysaccharidoses: 6

• Adenotonsillectomy and CPAP appear equally effective based on limited evidence

Critical Counseling Points

Families must understand before surgery: 1

1. Enlarged tonsils are the most common but not sole cause of OSA—muscle tone plays a role 1

2. Obesity is a major independent contributor 1

3. Surgery success varies by age, weight, ethnicity, OSA severity, and medical conditions 1

4. Additional interventions may be necessary including weight loss, medications, CPAP, or further surgery 1, 3

5. OSA may persist or recur after surgery 1

Document this counseling in the medical record 1

Common Pitfalls to Avoid

• Assuming tonsillectomy will completely resolve OSA in all children 3
• Failing to obtain PSG in high-risk populations before surgery 1
• Not considering post-operative PSG in children with persistent symptoms or risk factors 1, 3
• Overlooking weight gain after tonsillectomy as a contributor to residual OSA 1
• Ignoring non-tonsillar factors (muscle tone, obesity, craniofacial anatomy) 1
• Not addressing chronic rhinitis or nasal obstruction as contributing factors 2