Overview of evaluation and initial management of obstructive sleep apnea in children

OSA: obstructive sleep apnea; URI: upper respiratory tract infection; ENT: ears, nose, and throat; PSG: polysomnography; AHI: apnea-hypopnea index; CPAP: continuous positive airway pressure; ADHD: attention deficit hyperactivity disorder.

* Nocturnal symptoms and signs of OSA may include habitual or loud snoring, mouth-breathing, observed or witnessed pauses in breathing, sleepwalking, enuresis, or excessive sweating during sleep. Daytime symptoms include poor school functioning or other behavioral concerns such as ADHD, ADHD-like behavior, other disruptive behavior, or sleepiness. Risk factors for OSA include obesity, Down syndrome or other syndrome, craniofacial anomalies, and neuromuscular disorders.

¶ Refer to the UpToDate topic on management of OSA in children regarding selection of patients for intranasal steroids, leukotriene modifiers, or rapid maxillary expansion.

Δ For patients with mild to moderate OSA that has been confirmed by PSG, watchful waiting for up to 6 months is a reasonable consideration, as an alternative to adenotonsillectomy or CPAP treatment.

◊ Positional therapy may be considered when a child or adolescent cannot be treated by other means and if positioning substantially improves the OSA.

§ An adjuvant surgical procedure may be performed as primary therapy for children with multilevel OSA, typically in those with complex medical conditions such as Down syndrome, craniofacial abnormality, mucopolysaccharidosis, or a neuromuscular disorder. Adjuvant surgery also may be indicated as a secondary intervention in children with residual OSA after adenotonsillectomy. Refer to UpToDate content on adenotonsillectomy for OSA in children.

¥ The approach to reassessment depends on the patient's presenting symptoms and severity of OSA. Patients with severe OSA (eg, significant symptoms or AHI >10) who undergo adenotonsillectomy usually should be reevaluated clinically within 1 to 2 months after surgery and with a PSG in 3 to 12 months. Patients with mild or moderate OSA prior to adenotonsillectomy may be followed clinically if their presenting symptoms have improved. Reevaluation after treatment is also indicated for patients with progressive obesity. Patients managed with CPAP should be followed clinically by the prescribing clinician, with follow-up PSG as indicated.

‡ At the time of follow-up, the determination of whether the residual OSA is "clinically significant" depends upon a global assessment by the specialist, including clinical symptoms and risk factors, and multiple variables from the PSG. Clinical decisions should not be based upon the AHI result alone. However, most patients with AHI >10 and some patients with AHI >1 have clinically significant OSA, if this is compatible with other clinical findings.