How common is sleep apnea in children?

Pediatric obstructive sleep apnea affects approximately 1-5 percent of children, most commonly in the 2-8 age range when tonsillar and adenoidal tissue is largest relative to airway size (American Academy of Pediatrics). It is often underdiagnosed because daytime symptoms in children look different from adults -- behavioral and attention issues rather than sleepiness.

What are the symptoms of sleep apnea in children?

Common signs include loud habitual snoring, witnessed breathing pauses or gasping, restless sleep, bedwetting beyond expected age, mouth breathing, attention or behavioral issues, hyperactivity (rather than sleepiness), poor school performance, and morning headaches. Snoring alone does not confirm OSA -- a sleep study is required for diagnosis.

Is adenotonsillectomy always recommended first?

For otherwise healthy children with enlarged tonsils and adenoids, the AAP and American Academy of Otolaryngology recommend adenotonsillectomy as first-line therapy. Surgery resolves OSA in approximately 70-80 percent of cases. Children with obesity, craniofacial issues, or Down syndrome may have residual OSA after surgery and require additional treatment.

When does a child need CPAP?

CPAP is typically prescribed for pediatric patients with persistent moderate-to-severe OSA after adenotonsillectomy, those with craniofacial abnormalities or neuromuscular conditions, children with Down syndrome and significant residual OSA, or patients in whom surgery is not appropriate. Pediatric CPAP requires pediatric sleep medicine specialty care.

Can my child have a home sleep test?

No. Both the American Academy of Pediatrics and the American Academy of Sleep Medicine recommend an in-lab polysomnogram (PSG) for diagnosing OSA in children under 18. Home sleep apnea tests are validated for adults and are not reliable in pediatric patients due to differences in normal breathing patterns and arousal thresholds.

Quick answer: most children with obstructive sleep apnea do not need CPAP. First-line treatment for pediatric OSA is adenotonsillectomy (surgical removal of the adenoids and tonsils), which resolves OSA in roughly 70-80 percent of otherwise healthy children with enlarged tonsils (American Academy of Pediatrics clinical practice guideline). CPAP is typically reserved for children with residual OSA after surgery, with craniofacial abnormalities, with Down syndrome or other comorbidities, or when surgery is not an option. Pediatric CPAP requires specialized smaller masks and close coordination with a pediatric sleep specialist for adherence support. The AAP and American Academy of Sleep Medicine recommend a polysomnogram (in-lab sleep study) -- not a home sleep test -- to diagnose OSA in children under 18 because home tests are less reliable in this population.

CPAP is the gold-standard therapy for adult patients with obstructive sleep apnea.

It is the most effective therapy, when used properly, at reducing or eliminating apnea events. CPAP therapy has been shown to prevent and even reduce the negative effects that sleep apnea can have on the body, including increased risk of death from heart problems.

We talk a lot about the use of CPAP for adults, but what about children?

It is estimated that 2-3% of children suffer from sleep apnea. Can they benefit from CPAP therapy too?

The basics of sleep apnea and CPAP therapy

Obstructive sleep apnea is the partial or complete closure of the airway during sleep that results in a reduction of airflow lasting at least 10 seconds in length before the brain signals the person to wake, usually gasping for air. The person with sleep apnea may not realize that she or he is waking dozens of times per hour, but there is significant strain on the entire body from the repeated waking, disruption to sleep cycles and reduction in oxygen (read more about the effects of sleep apnea here).

Obstructive sleep apnea is typically diagnosed with a sleep study, either in home or in a sleep center (read more about the difference between the two here) and can be treated with CPAP therapy, a device which blows pressurized air into the airway to keep it open during the night and prevent or reduce apneas (learn more about CPAP and how it works here).

Insurance coverage for CPAP

Most insurance companies will cover CPAP therapy for an adult with a diagnosis of obstructive sleep apnea when certain criteria is met:

Patient has an AHI greater than or equal to 15, or
Patient has an AHI of 5-14 with any of the following: excessive daytime sleepiness, impaired cognition, mood disorders,insomnia, treatment-resistant hypertension (persistent hypertension in a patient taking three or more antihypertensive medications), ischemic heart disease, history of stroke.

In a recent blog post, we covered what to do when a patient falls outside of the AHI requirements of some insurances, but may still benefit from the use of CPAP. You can read that post here.

What about children?

Children get selep apnea too. Read more about the signs and symptoms of sleep apnea in children here.

For the most part, any snoring or gasping for air in a child indicates a health risk. In fact, while an adult with up to five apneas per hour is considered to be normal and would NOT have a diagnosis of sleep apnea, in children, as little as one apnea per hour is sufficient for a diagnosis of sleep apnea (read more about apneas and AHI here).

Many children with sleep apnea are recommended for surgery to remove their tonsils and/or adenoids, as these are often the cause of the snoring or apnea. Unlike adults, surgical treatment for children with sleep apnea is usually successful. But there are cases when surgery does not work and other treatment is needed.

Alternatives to surgery for children with sleep apnea

There are times when surgery for a child with sleep apnea is not appropriate. Some examples are:

Surgery was attempted, but was not successful in curing obstructive sleep apnea.
Surgery is not indicated because the patient has minimal adenotonsillar tissue.
The patient's obstructive sleep apne is attibutable to another underlying cause such as craniofacial abnormality or morbid obesity.
Surgery is contraindicated

If surgery is not deemed to be an appropriate treatment, CPAP therapy can be attempted for a child under 18 years old.

What kind of sleep study does a child need to be diagnosed with OSA?

Children under 18 usually need to be diagnosed with sleep apnea from an in-center sleep study (not with at-home sleep apnea testing).

If the child has been titrated on CPAP in the sleep center, he or she may use a CPAP device that delivers a constant air pressure. Children are not typically candidates for APAP therapy (read more about the difference between CPAP and APAP here).

Is there special CPAP equipment for children?

The CPAP machine used by a child would be the same as an adult would use; however, the mask which sits on the child's face and delivers the pressurized air into the airway would be much smaller. Mask manufacturers have designed CPAP masks specifically for a child's smaller face and there are options for masks that cover the mouth and nose or only the nose (learn more about different types of CPAP masks here).

Are you concerned that your child may have a sleep disorder like sleep apnea? Contact us if you would like to schedule a consultation, sleep study or CPAP set-up.

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Request CPAP appt.

Other posts you may find interesting:

Would a Child with Sleep Apnea Need CPAP?