Ron Mitchell, M.D. Answers Questions On: Children with Obstructive Sleep Apnea (OSA)

All children who have OSA will snore and have periods of gasping for air. In younger kids, it’s usually a parent who spots the problem. These children are generally snoring and restless; they may travel around the bed as they sleep, as they’re trying to find a more comfortable position. But when the child is old enough to sleep in a separate room from the parents, it can be harder for the parents to notice it. It’s not unusual for parents to bring their child to a doctor after the child went to stay with a grandparent: the grandparent watched the kid more closely and was horrified by how loudly he or she snored or how many times the child stopped breathing at night.

The first thing we do with most of these kids is consider getting a sleep study. Not all children need a sleep study. Generally, if the tonsils and adenoids are big, we remove them. If they continue to have problems, and they have any evidence of malocclusion [misaligned teeth], we will refer them to an orthodontist. If we feel that the majority of the problem is related to the child being overweight, we would get him or her to be evaluated at the COACH Clinic, the weight-reduction service at Children’s. If we feel there are other issues, we will direct these kids according to what the underlying problem is.

Then there is the question of what to do about the children who have had their tonsils and adenoids removed but who still have OSA. With them, the challenge is much more complex. Those kids mostly suffer from obesity, Down syndrome, craniofacial problems, neuromuscular disorders, and so on. We use medical management of these kids with nighttime breathing support, as well as more extensive surgery to reshape the palate, reduce the bulk of the tongue base, and other airway procedures.

Obviously we don’t want to do surgery that may be temporarily effective only to find that it’s reversed by an increase in weight in these kids. So it’s very much a multidisciplinary approach involving sleep medicine, weight reduction, and surgery. We manage each patient individually and decide on the  the best option for the child.

Most kids with OSA have a mild to moderate sleep disorder, and it usually manifests itself in behavioral problems during the day. They may have attention problems, trouble concentrating, or hyperactivity. Some children may be considered for medication for hyperactivity when the underlying problem is actually poor sleep. That’s a big difference between adults and children: Adults who don’t sleep usually have daytime sleepiness, whereas children who don’t sleep, as many parents know, become hyperactive. They can have problems at home, in day care or preschool, or with hyperactivity at school. School performance is decreased in kids who have OSA.

Severe sleep apnea can have cardiopulmonary consequences in kids, including conditions such as right-sided cardiac hypertrophy or heart failure, even pulmonary hypertension (high blood pressure in the lungs). This can be a particular problem in kids with Down syndrome, who are already prone to obesity and pulmonary hypertension, independent of sleep apnea. So keeping their weight under control and their cardiac function good is a challenge.

In younger children, tonsillectomy and adenoidectomy are one and the same procedure, and may be called an adenotonsillectomy. As children get older, sometimes their adenoids shrink down in size considerably, and they might just need a tonsillectomy.

The procedure itself lasts 30 minutes to one hour. The child is put to sleep under general anesthetic, and the operation is all done through the mouth. Modern instruments have made it much quicker and involve less bleeding. There can be problems like dehydration because of throat pain, and the challenge is to keep the child pain-free as much as we can and keep them drinking. Somewhere between 1 percent and 5 percent of children will actually have some bleeding after a tonsillectomy, and some need to go back to the operating room for cautery if the bleeding persists.

Tonsillectomies have been done for thousands of years, literally. Historically, tonsillectomies were done for recurrent strep throat; the concern was that children may end up with complications like rheumatic fever as a result of strep exposure. In the 1950s to early ‘70s it was a much more common procedure than it is now – many doctors felt that the indication for a tonsillectomy was simply the presence of tonsils. Then there was an outcry about unnecessary tonsillectomies, and the number of them went down by three-quarters by the end of the 1980s. With better usage of antibiotics, the number of kids who have tonsillectomies for recurrent strep throat has gone down quite a bit, as well.

More recently, tonsillectomies have increased – not to their 1960s or ‘70s level, but currently we are performing about half a million tonsillectomies per year in the United States, the majority of them for sleep disorders.

Clinical Practice Guideline: Tonsillectomy in Children (1.4 MB PDF)