Is Apnea Normal in Children?
No, apnea is not normal in children and should always be evaluated. While brief respiratory pauses may occur in premature infants as a developmental phenomenon (apnea of prematurity), any apnea in term infants, children, or adolescents is pathologic and requires investigation for obstructive sleep apnea syndrome (OSAS) or other underlying conditions 1, 2.
Key Distinction: Apnea of Prematurity vs. Pathologic Apnea
Apnea of Prematurity (Special Case)
- Only occurs in premature infants, affecting >50% of preterm babies and nearly all infants <1000g at birth 3
- Defined as breathing pauses >20 seconds OR >10 seconds if associated with bradycardia or oxygen desaturation 3
- This is a developmental immaturity issue, not "normal" but expected in this specific population 3
- Resolves as the infant matures and is not applicable to term infants or older children 3
Pathologic Apnea in Term Infants and Children
- All children should be screened for snoring during routine health visits, as habitual snoring indicates potential OSAS 1, 4
- OSAS is characterized by complete or partial upper airway obstruction during sleep with continued respiratory efforts 5, 2
- Prevalence is 1-5% in children, with peak incidence at ages 2-5 years 2, 4
Clinical Significance and Consequences
Untreated apnea in children causes serious morbidity and mortality:
- Neurocognitive impairment and behavioral problems 4, 1
- Failure to thrive in infants 4, 6
- Cor pulmonale (right heart failure) 4, 2
- Death in severe cases 4, 1
- School failure and low academic performance 4
When to Suspect Pathologic Apnea
Red Flag Symptoms
- Habitual snoring (≥3 nights per week) 1, 7
- Witnessed apneas, gasping, or choking during sleep 1, 7
- Restless sleep or sleeping in unusual positions 7
- Daytime irritability or behavioral problems 7
- Feeding difficulties in infants 7, 6
High-Risk Physical Findings
- Adenotonsillar hypertrophy (tonsils nearly touching or touching in midline) 1, 2
- Obesity (BMI ≥95th percentile) 1, 4
- Craniofacial abnormalities (micrognathia, retrognathia, high-arched palate) 1, 7, 6
- Failure to thrive 7, 6
Diagnostic Approach
Polysomnography is the gold standard for diagnosing OSAS in children 1, 2, 6:
- OSAS is defined as apnea-hypopnea index (AHI) ≥1 event/hour 1
- Home sleep testing is not recommended in children due to inability to monitor CO₂ and high false-negative rates 1
- In-laboratory polysomnography is required for accurate diagnosis 1
Critical Pitfall to Avoid
Never assume apnea is "normal" based on age alone. The only exception is apnea of prematurity in preterm infants, which is a specific developmental condition requiring monitoring and often treatment 3. In all other children—including term infants, toddlers, and adolescents—apnea indicates pathology requiring immediate evaluation 1, 2.
Special Consideration for Infants Under 12 Months
Infants presenting with snoring or apnea require urgent subspecialist referral 7: