Treat it and beat it: How to Treat Obstructive Sleep Apnea in Children
- ZZZPack
- Jul 21, 2019
- 4 min read
Pediatric Obstructive Sleep Apnea if left untreated can have all sorts of long term consequences on neurologic development and cardiopulmonary health. Earlier we talked about what Obstructive Sleep Apnea is in kids, now let's discuss how to treat it.
1. Adenotonsillectomy
The #1 risk factor is enlargement of the tonsils and adenoids. Those pediatric upper airways are small, and removing the increased tissue can really make a difference.
You want to make sure that a referral to an Otolaryngologist (ENT) who specializes in pediatrics is made.
Typically if the child has OSA and has enlarged tonsils, surgery is considered.
If the child does not have enlarged tonsils but is obese or has other co-morbidities, adenotonsillectomy can still be considered to optimize the space in the upper airway.
2. Watchful Waiting for 6 months, then Adenotonsillectomy
If the child's OSA is not severe and the child does not have any other comorbidities, it's okay to see how they do after 6 months, and avoid a surgery.
The Childhood Adenotonsillectomy Trial (CHAT) determined that the kids who had surgery earlier did not have better attention or executive functioning scores on neuropsych testing. Obviously more kids who had surgery right away had greater success with resolving OSA faster both clinically and on PSG.
So then...don't wait?
Well it's up to you. Subjectively, there was improvement in behavior, and quality of life. So waiting for 6 months is okay as long as the sleep apnea is mild and there are no other comorbidities associated with the OSA. But there is some subjective benefit to earlier surgery.
3. Positive Airway Pressure
Yes, that means CPAP and BPAP! This treatment is non-surgical and effective in children. It provides the amount of pressure needed to keep the airway open (Pcrit) and prevents symptoms of obstructive sleep apnea.
Usually it is not started in children less than 6 years old, but it can be. Depends on the patient.
Things to consider are risk for mid-face hypoplasia, those kids' bones are still developing, and applying PAP may affect bone development.
Also, not all children are able to tolerate PAP and the masks.
CPAP desensitization is always an option too in this case, and is great for helping some children to get used to having a mask and positive airway pressure!
This is usually done by a psychologist who specializes in PAP desensitization.
4. Rapid Maxillary Expansion
What is this? Basically the palate is expanded, and this is an option for kids with narrow palate (typically high-arched palate). It's a strategy used in (mainly) pre-pubertal children, and it widens the palate and nasal passages.
How does it work? An expansion of 0.5mm to 1mm occurs each day until the posterior cross bite is resolved.
There is a key that gets turned every day in the middle of the expander, and that pushes the arms outward.
This takes anywhere between 3-6 months typically. During this time period, bone is able to fill in this expanded area.
Patients also get a retainer to keep the teeth in place after the expansion is over. It's very important that an orthodontist who is experienced in Pediatric Sleep is performs this procedure!
5. Allergy Control
This involves use of inhaled nasal corticosteroids, and other medications like Claritin, Singulair, and Zyrtec.
Controlling those allergies reduces the space that enlarged turbinates take up in the nasal passages, and can be helpful in the treatment of especially mild OSA.
Every little bit helps!
6. Other Therapies
Oxygen therapy- Does this treat obstruction per se ? No. Does it treat the symptoms of OSA. Yes, absolutely. Much of the cardiovascular effect of OSA is due to repeated oxygen desaturation. So until a child is able to tolerate PAP, or has some other intervention that treats the OSA, this is a great option!!!
Tracheostomy- This literally keeps the airway open, and is oftentimes a necessary procedure. This may be needed in children with tracheal stenosis, tracheomalacia, and other upper airway anomalies.
Weight Loss- Very helpful in kids with obesity, and can make a big difference in eliminating or reducing the severity of OSA.
Avoidance of Tobacco Exposure- This can irritate the airways, and worsen OSA.
Treatment of GERD- Untreated GERD can cause upper airway edema and laryngospasm, thus worsening OSA.
Positional Therapy- OSA is typically worse in the supine position, so staying off the back can be helpful. Some kids even self-treat themselves by preferring to sleep in an armchair until they are diagnosed and treated. Other kids may sleep in strange positions such as having their neck arched.
There you have it! More to come on other disorders that can present with OSA such as behavioral insomnia of childhood and RLS.
References:
1. Paruthi S. Management of Obstructive Sleep Apnea in Children. Chervin RD, ed. UpToDate. UpToDate Inc. https://www.uptodate.com(Accessed on July 19, 2019.)
2. Diagram of the palatine tonsils from U.S. National Cancer Institute web site http://training.seer.cancer.gov/module_anatomy/unit8_2_lymph_compo2_tonsils.html, Uploaded on 18 December 2004 from U.S. National Cancer Institute training web site
3. Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, Mitchell RB, Amin R, Katz ES, Arens R, Paruthi S, Muzumdar H, Gozal D, Thomas NH, Ware J, Beebe D, Snyder K, Elden L, Sprecher RC, Willging P, Jones D, Bent JP, Hoban T, Chervin RD, Ellenberg SS, Redline S, Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366. Epub 2013 May 21
4. Philips Respironics Wisp Pediatric CPAP Nasal Mask image obtained from
5. Hyrax rapid palatal expander in a child, used to increase the width of the upper jaw. Ian Furst (Mar 28 2019) https://en.wikipedia.org/wiki/Palatal_expansion#/media/File:Hyrax_rapid_palatal_expander.png
6. FDA Allergy Relief for your Child. https://www.fda.gov/consumers/consumer-updates/allergy-relief-your-child
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