Obstructive Sleep Apnea Syndrome in Children

Riva Tauman; David Gozal


Expert Rev Resp Med. 2011;5(3):425-440. 

In This Article

Abstract and Introduction


The clinical syndrome of obstructive sleep apnea (OSAS) in children is a distinct, yet somewhat overlapping disorder with the condition that occurs in adults, such that the clinical manifestations, polysomnographic findings, diagnostic criteria and treatment approaches need to be considered in an age-specific manner. Childhood OSAS has now become widely recognized as a frequent disorder and as a major public health problem. Pediatric OSAS, particularly when obesity is concurrently present, is associated with substantial end-organ morbidities and increased healthcare utilization. Although adenotonsillectomy (T&A) remains the first line of treatment, evidence in recent years suggests that the outcomes of this surgical procedure may not be as favorable as expected, such that post-T&A polysomnographic evaluation may be needed, especially in high-risk patient groups. In addition, incorporation of nonsurgical approaches for milder forms of the disorder and for residual OSAS after T&A is now being investigated.


During the past decade the childhood obstructive sleep apnea syndrome (OSAS) has become widely recognized as a frequent disorder with potentially serious clinical implications and has emerged as a major public health problem. Considerable insights have been gained into the recognition of OSAS-associated morbidities and into the underlying mechanisms by which these complications develop.

It is clear that the classic syndrome of obstructive sleep apnea in children is a distinct disorder from the condition that occurs in adults, in particular with respect to clinical manifestations, polysomnographic findings and diagnostic criteria, and treatment approaches.

Obstructive sleep apnea syndrome in children is characterized by recurrent events of partial or complete upper airway obstruction during sleep, resulting in disruption of normal gas exchange (intermittent hypoxia and hypercapnia) and sleep fragmentation.[1] The clinical spectrum of obstructive sleep-disordered breathing (SDB) includes OSAS at one end of the spectrum, upper airway resistance syndrome (traditionally associated with globally rather normal oxygenation patterns, but evidence for increased respiratory-related arousals, i.e., sleep fragmentation), and primary or habitual snoring at the low end of this spectrum. In other words, primary snoring, which is defined as the presence of habitual snoring in the absence of apneas, gas exchange abnormalities and/or disruption of sleep architecture, is very frequent in children, and represents a relatively more benign, albeit noninnocuous manifestation of increased upper airway resistance during sleep.

The spectrum of SDB occurs in children of all ages, from neonates to adolescents. Snoring, the hallmark indicator of increased upper airway resistance during sleep, is a frequent symptom during childhood, being reported in up to 27% of children affected occasionally, and 7–12% reporting habitual snoring, that is, loud snoring recognized by parents three times or more per week.[2–8] The prevalence of OSAS is estimated at 2–3% of all children when using more stringent diagnostic criteria.[3,4]

Symptoms of OSAS in children are often subtle and therefore not always immediately recognized by the parents. The usual nighttime symptoms and signs of OSAS in children include snoring, noisy breathing, snorting episodes, paradoxical chest and abdominal motion, retractions, witnessed apnea, labored breathing, cyanosis, sweating, recurring nightmares, and restless sleep. Children with severe nasal obstruction may open their mouths and hyperextend their necks to breathe, minimizing snoring noises. Daytime symptoms can include mouth breathing, difficulty in waking up, moodiness, morning headaches, nasal obstruction, daytime sleepiness, hyperactivity and cognitive problems. More severe cases of OSAS may be associated with pulmonary hypertension and cor pulmonale, systemic hypertension, failure to thrive and developmental delay.

In this article, we will examine our current understanding of the pathophysiology of OSAS in children, the important and evolving role of obesity in the pathogenesis of OSAS in children, the end-organ morbidities associated with pediatric OSAS, and the therapies currently available for the disorder.


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