Could your child have sleep apnea?

Obstructive sleep apnea (OSA) affects 2-5% of children, with peak prevalence between ages 2-6 years. This coincides with the age at which adenoids and tonsils are proportionally largest relative to airway size. Habitual snoring is present in 1.5-6% of children. Despite its prevalence, paediatric OSA is frequently undiagnosed because parents do not recognise snoring as a medical concern, and daytime symptoms are often attributed to other causes. Source: Lumeng and Chervin (2008).

Nighttime symptoms include: habitual snoring (most nights), loud or laboured breathing during sleep, witnessed pauses in breathing, mouth breathing, restless sleep, and bedwetting. Daytime symptoms include: excessive sleepiness or difficulty waking, morning headaches, difficulty concentrating, hyperactivity, irritability, and poor school performance. In younger children, failure to thrive or slow growth can be a sign. Notably, children with OSA are more likely to present with hyperactivity than the sleepiness seen in adults. Source: Marcus et al. (2012), AAP Clinical Practice Guideline.

The PSQ is a 22-item parent-completed screening questionnaire developed by Dr. Ronald Chervin and colleagues in 2000. It assesses three domains: snoring and breathing during sleep (8 items), daytime sleepiness (4 items), and behaviour (6 items), plus additional items. Each item is answered Yes or No. The score is the proportion of "yes" responses. A score above 0.33 is considered a positive screen, with 81% sensitivity and 87% specificity for detecting OSA. Source: Chervin et al. (2000), Sleep Medicine.

The gold standard for diagnosing paediatric OSA is overnight polysomnography (PSG), a sleep study conducted in a laboratory setting. PSG measures brain activity, eye movement, muscle tone, heart rate, oxygen levels, airflow, and respiratory effort during sleep. An Apnea-Hypopnea Index (AHI) of 1 or more events per hour is considered abnormal in children (compared to 5+ in adults). Mild OSA is AHI 1-5, moderate is 5-10, and severe is above 10. Referral to a paediatric sleep specialist or ENT is the typical pathway. Source: Marcus et al. (2012).

Yes. Sleep fragmentation from apnea events disrupts restorative sleep, and in children the daytime consequence is often hyperactivity and inattention rather than overt sleepiness. Multiple studies show that children with untreated OSA score significantly higher on ADHD symptom scales, and treatment (typically adenotonsillectomy) can reduce or resolve these behavioural symptoms. Chervin et al. (2000) included behavioural items in the PSQ specifically because of this overlap. This does not mean every child with ADHD has sleep apnea, but screening for sleep-disordered breathing is recommended when ADHD is being evaluated. Source: Marcus et al. (2012).

Adenotonsillectomy (surgical removal of adenoids and tonsils) is the first-line treatment for most children with OSA and achieves complete resolution in approximately 70-80% of non-obese children. Residual OSA can persist after surgery, particularly in obese children, children with severe pre-operative OSA, and those with craniofacial abnormalities. Post-operative polysomnography is recommended for high-risk groups. For children who are not surgical candidates, CPAP is an effective alternative, though adherence can be challenging in younger children. Source: Bhattacharjee et al. (2010).

Occasional snoring during a cold is normal at any age. Habitual snoring, defined as snoring on most nights, is never considered "normal" in children and warrants evaluation at any age. The AAP recommends that paediatricians screen for snoring at every well-child visit. If your child snores most nights and also shows daytime symptoms (mouth breathing, restlessness, hyperactivity, difficulty concentrating, morning headaches), the combination significantly increases the likelihood of OSA. The peak age for OSA is 2-6 years, but it can occur at any age. Source: Marcus et al. (2012); NICE CKS.

Untreated paediatric OSA can lead to a range of consequences. Cognitive effects include poor academic performance, reduced attention, and lower scores on some cognitive tests. Behavioural effects include hyperactivity, aggression, and mood instability. Cardiovascular effects include elevated blood pressure and, in severe cases, right-sided heart strain. Growth effects include failure to thrive, as disrupted sleep impairs growth hormone secretion. The good news is that most of these effects are reversible with treatment, particularly when addressed early. Source: Marcus et al. (2012); Bhattacharjee et al. (2010).