Obstructive sleep apnea (OSA) is a clinical entity that affects 2-3% of the child population, with important repercussions at different levels. Below, we explain what it is and where to go.
Obstructive sleep apnea syndrome is a sleep disorder characterized by prolonged partial or complete intermittent obstruction of the upper airway, which disrupts normal ventilation and sleep patterns.
It falls within the category of sleep-disordered breathing, along with simple rhoncopathy and some other less frequent entities, from which it must be distinguished by means of an exhaustive clinical history and complementary tests detailed below.
Childhood OSAS differs in some respects from adult presentation, for example, in the causal agent.
In children over the age of 2 the main cause is adenotonsillar hypertrophy. There are other less frequent causes such as obesity, which can be a causal agent regardless of age, craniofacial anomalies or neuromuscular diseases. In addition, there may be aggravating factors, such as different types of rhinitis, which can also be treated.
The main reason for consultation by parents or caregivers is snoring, defined as intense breathing noise more than 3 times/week and usually accompanied by other night and daytime symptoms.
Among the nocturnal symptoms we find increased respiratory effort, apneas or breathing pauses, restless sleep, abnormal postures, enuresis, sleep terrors or sweating.
And among the daytime symptoms are dry mouth secondary to oral respiration in those cases that associate poor nasal ventilation, hyperactivity (unlike adult) or daytime sleepiness in older children or adolescents.
All these symptoms, some of them apparently innocuous, are the reflection of a picture that has a relevant impact on many aspects of the developing child.
The importance of adequate sleep both quantitatively and qualitatively for the growth of children is well known. In those children who present OSAs, an alteration of the factors involved in normal growth released during sleep has been observed, with the consequent delay in physical growth . At a neurocognitive level there may be learning problems, decreased school performance, attention or memory deficit, hyperactivity, irritability and mood alterations due to hypoxemia during apnea pauses. A state of hypercoagulability, alterations in the nervous system, with an increase in sympathetic activity, repercussions at the metabolic level and cardiovascular alterations have also been detected, such as an increase in heart rate and an increase in cardiovascular risk if certain environmental and genetic agents converge in patients with severe OSAS.
Suspected child OSAS should be evaluated by an otolaryngologist, who will propose one treatment or another depending on the clinical entity in question.
Only a subgroup of snoring children present OSAs and it will be in this population where a closer follow up will be done, although without diminishing the importance of simple snoring, since at a physiological level it does not seem to be as innocuous as thought.
To reach a diagnosis, your otolaryngologist will take a clinical history with an exhaustive anamnesis, investigating the daytime and nighttime symptoms, duration, intensity and frequency, and then carry out a physical examination, with the aim of finding the possible causes of OSAS and aggravating factors described above.
The steps the doctor will follow in the exploration are:
- Observation of jaw position and craniofacial appearance.
- Anterior rhinoscopy: Viewing the inside of the nostrils from the outside with the aid of a rhinoscope and light, which will allow you to see signs of rhinitis and other endonasal disorders.
- Oropharynoscopy: visualization of the oral cavity and the throat also from the outside, helped by light and tongue depressor. This allows you to see size and position of the tonsils and other possible alterations, less frequent in children’s OSAs.
- If possible, a nasofibroscopy will be performed, which consists of introducing a fine camera through one or both nostrils. It is used to assess the back of the nostrils and the rhinopharynx or cavum, where adenoidal tissue is housed. Hypertrophy or enlargement of this tissue is usually the main cause of OSAS in childhood along with hypertrophy or enlarged tonsils. If this test is not possible due to lack of cooperation (which is common in children), your otolaryngologist may request an X-ray to evaluate the adenoids.
In most cases, with all of the above, a clear diagnosis is already reached and no further testing is necessary. In some doubtful cases, the doctor may consider requesting a polygraph from the pulmonary department, which consists of a test performed on the child while he or she is asleep at home (polysomnography if performed in the hospital). This assesses and counts the number and intensity of the apnea pauses, qualifying the sleep apnea based on its result as mild, moderate or severe.
At this point, your otolaryngologist will propose treatment, which will be aimed at eliminating the causative agents.
In mild cases, recent appearance or in very young children, one option is observation, correcting those aggravating factors, if any, as well as individualized hygienic dietary measures in each case: sleep hygiene, medical treatment of nasal congestion with topical nasal corticoids +/- antihistamines in cases of allergy… Sometimes the mildest cases or simple snoring can be resolved with the growth of the child.
In severe cases or in those that do not improve with conservative measures, surgical treatment will be considered if the problem is an increase in the size of adenoids and/or tonsils: adenoidectomy (if adenoidal hypertrophy is present), tonsillectomy (if tonsil hypertrophy is present) or both procedures in the same surgical act: adeno/tonsillectomy.
The surgeon removes the adenoid glands using a spoon-shaped tool (curette) through the mouth. Although there are other methodologies, these are less widespread in the child population.
There are different procedures to perform tonsillectomy or complete removal of the tonsils. In addition, size reduction without removal can be considered in selected cases, greatly reducing postoperative pain and the likelihood of bleeding. And a third option is partial removal or tonsillotomy.
For those few cases in which OSAS is not secondary to adenotonsillar hypertrophy (pneumuscular diseases, craniofacial anomalies…) or where surgery is contraindicated, CPAP can be considered as a second line of treatment, which consists of applying positive pressure to the airway using a facial device, a technique much more widespread in adult OSAS.
Your otolaryngologist will be able to advise you extensively and decide together which is the best option in each case.
If you want more information…
Snoring in children. SleepFoundation.org