What are the treatment options for sleep apnea in children?

Treatment Options for Sleep Apnea in Children

Adenotonsillectomy is the first-line treatment for pediatric obstructive sleep apnea when adenotonsillar hypertrophy is present, with CPAP reserved for persistent post-surgical OSA, contraindications to surgery, or while awaiting surgery. 1, 2

Initial Diagnostic Requirements

Before initiating treatment, all children require:

• Polysomnography (PSG) to confirm OSA diagnosis and quantify severity, as clinical symptoms alone are insufficient for treatment decisions 1, 3
• Mandatory PSG for high-risk groups: children <2 years, obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 2
• Physical examination findings suggesting OSA include tonsillar hypertrophy (Grade 3-4), adenoidal facies, micrognathia/retrognathia, high-arched palate, and obesity or failure to thrive 1

Treatment Algorithm by Clinical Scenario

First-Line Surgical Treatment

Adenotonsillectomy should be performed when:

• Adenotonsillar hypertrophy is present with confirmed OSA on PSG 1, 2
• Combined adenotonsillectomy provides superior outcomes compared to tonsillectomy alone 2
• Complete tonsillectomy is preferred over partial tonsillotomy, as residual tissue may cause persistent obstruction 2

Expected outcomes:

• Significant improvements in respiratory parameters, sleep architecture, quality of life, and behavioral outcomes 3, 2
• However, up to 40% of children may have persistent OSA post-operatively, particularly those with severe baseline OSA (oAHI >10/h), obesity (50% persistence rate), or genetic disorders like Down syndrome (50% persistence rate) 3
• Complete resolution occurs in as low as 25% of children with moderate-to-severe OSA 3

Medical Management Options

Intranasal corticosteroids:

• May be prescribed for mild OSA when adenotonsillectomy is contraindicated or for mild post-operative persistent OSA 3, 4
• Requires approximately 6 weeks of treatment with objective measurement of response 3
• Long-term efficacy is unknown; continued observation for symptom recurrence is necessary 3

Montelukast:

• Can be considered for children with mild OSA as an alternative or adjunct to intranasal steroids 4, 5

CPAP Therapy

CPAP is indicated when:

• Adenotonsillectomy is contraindicated 1
• OSA persists after adenotonsillectomy 1, 3
• Moderate-to-severe OSA is present while awaiting surgery 4
• Child is a poor surgical candidate 4

Critical CPAP considerations:

• Must be titrated in a sleep laboratory before prescribing and periodically readjusted 3
• Adherence is problematic: only 30-75% overall adherence, particularly poor in children with medical complexity 3
• Long-term use may negatively impact midface growth and dental anatomy in compliant users 3
• Requires management by experienced clinicians with pediatric CPAP expertise 3
• Behavioral modification therapy may be necessary, especially for young children or those with developmental delays 3

Weight Loss

For overweight/obese children:

• Weight loss is recommended in addition to other therapy (not as monotherapy), as it improves OSA 3, 1
• Because weight loss is slow and unreliable, other treatment modalities (adenotonsillectomy or CPAP) should be instituted concurrently 3
• Obese children may have less satisfactory adenotonsillectomy results, though many still benefit 1

Alternative Surgical Options

For persistent post-adenotonsillectomy OSA:

• The 2024 American Thoracic Society guideline addresses non-CPAP therapies including upper airway surgeries, orthodontic treatment, and medical therapy for children with surgically modifiable causes of persistent OSA 3
• Bony or soft tissue upper airway surgery is reasonable for children failing medical management or with persistent OSA following adenotonsillectomy 4

Post-Treatment Monitoring

Objective follow-up is essential:

• All high-risk children require post-operative PSG: those with obesity, severe preoperative OSA (oAHI >10/h), age <3 years, or comorbidities (Down syndrome, craniofacial abnormalities, neuromuscular disorders) 2, 3
• Repeated sleep testing is recommended for children with persisting symptoms (snoring, mouth breathing) or severely abnormal preoperative polysomnography 3
• Only 30% of children with OSA achieve remission by adulthood, contributing to the adult OSA burden 3

Critical Pitfalls to Avoid

• Never proceed to adenotonsillectomy without objective PSG documentation when the indication is sleep-disordered breathing 2
• Do not rely solely on clinical symptoms or physical examination for surgical decision-making 2
• Do not assume complete OSA resolution post-surgery in obese children, those with severe preoperative OSA, or syndromic patients 2
• Recognize that untreated OSA causes significant neurocognitive deficits, behavioral changes, poor academic performance, cardiovascular complications, and reduced quality of life 3, 1