If your child snores, sleeps with his or her mouth open, has a poor attention span and/or behavioral issues, obstructive sleep apnea may be the problem.

Most children don’t snore, so if your child does, consider asking your doctor whether there might be a problem. At least 2 to 3% of children are believed to have sleep apnea, with the disorder believed to be as high as 10 to 20% in children who habitually snore. Sleep apnea is a condition in which the muscles at the back of the throat intermittently relax too much, partially or completely blocking the airway. This means the child’s breathing may be starting and stopping during sleep. These breathing interruptions, which typically last 10 to 20 seconds, may happen anywhere from five to more than 30 times in one hour.

Every time your child stops breathing, even briefly, the brain awakens slightly. Consequently, their quality of sleep is extremely poor, which can make your child tired and cranky during the day. This can lead to other health problems, including poor growth.

Fortunately, pediatric obstructive sleep apnea, or OSA, is treatable. If the problem is the result of enlarged tonsils or adenoids, a simple surgery to remove either or both provides a cure. Other times, your child may need to wear a specialized medical device while they sleep. 

Sleep apnea is characterized by pauses in breathing during sleep. The pauses may be infrequent or every couple of minutes or even more often. Breathing between pauses is also shallow. After a pause, normal breathing resumes but is sometimes accompanied by a loud snort or a choking sound.

There are several types of sleep apnea, but the most common is obstructive sleep apnea, which occurs more frequently than you might think. “Obstructive sleep apnea affects 3 to 6 percent of children and is associated with repetitive narrowing of the airways, which is the breathing tube from the mouth and the nose down to the lungs,” explains Yale Medicine's Craig A. Canapari, MD, director of the Pediatric Sleep Medicine Program. “This can happen multiple times in the night, and results in significant sleep disruption. A common consequence is problems paying attention the next day. Some children might also be sleepy, while others will be hyperactive."  

While pediatric obstructive apnea is similar to the adult kind of obstructive sleep apnea, there are a few differences. For instance, children typically experience a partially narrowed airway, whereas for adults, the airway is usually completely blocked.

Symptoms of pediatric obstructive sleep apnea include: 

• Snoring, often with pauses, snorts or gasps between breaths
• Heavy breathing while sleeping
• Extremely restless sleep
• Bedwetting (especially if a child previously stayed dry at night)
• Daytime sleepiness or behavioral problems

Obesity is a common factor associated with obstructive sleep apnea in adults. In children, however, the most common cause of the problem is enlarged tonsils and adenoids.

Thirty years ago, approximately 90 percent of tonsillectomies in children were done for recurrent tonsillitis infections. That has changed dramatically—today, just 20 percent of these surgeries are done for infections, with 80 percent performed as treatment for pediatric obstructive sleep apnea. according to the American Academy of Otolaryngology-Head and Neck Surgery. 

Additional causes of obstructive sleep apnea in children include "low airway tone as in cerebral palsy or Down syndrome," Dr. Canapari notes.

If your child has trouble sleeping or gets frequent throat infections, such as strep throat, your pediatrician may suggest seeing a pediatric sleep specialist or an ear, nose and throat doctor.

In addition to taking a thorough medical history and conducting a physical examination, your child’s doctor may order several tests to diagnose pediatric obstructive sleep apnea.

Tests may include:

• Polysomnogram (overnight sleep study):During a sleep study (available at our specialized pediatric sleep labs at Yale New Haven Children’s Hospital and at Bridgeport Hospital), sensors are placed on your child’s neck, chest and other parts of the body to record brain wave activity, breathing patterns, snoring, oxygen levels, heart rate and muscle activity. They are not uncomfortable. Children can sleep normally wearing these sensors.  
• Oximetry: In some cases, a child’s physician may feel confident in the diagnosis of pediatric obstructive sleep apnea and not require an overnight study. If this is the case, you may be able to do a home version of a sleep study, taking an overnight recording of oxygen levels in your home. (Note: If the diagnosis is inconclusive, your child may need to do the overnight study.)
• Electrocardiogram: For this test, sensor patches with electrodes measure the electrical impulses given off by your child's heart. This test may be required because OSA sometimes affects the cardiovascular system. 

If your child has obstructive sleep apnea, your physician may recommend removal of the tonsils (tonsillectomy) or adenoids (adenoidectomy), or both. At Yale Medicine, our ear, nose and throat surgeons offer a partial tonsillectomy, a procedure that allows for a quicker recovery and fewer complications. This technique is not widely performed elsewhere. Removing the tonsils and/or adenoids should open up your child’s airway and eliminate OSA.

If the tonsils and/or adenoids are removed, your child may need another sleep study if the apnea was severe or if symptoms persist, Dr. Canapari says. "Our colleagues in ENT may also perform an examination of the airways during sleep (a sleep endoscopy) to determine what the next steps may be. And we may try CPAP if needed," he says.

If the tonsils or adenoids are not the problem, continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) may help while your child sleeps. These small machines gently blow air through a tube and mask attached to your child's nose, or nose and mouth, thereby keeping their airways from collapsing at night.

“Though it sounds pretty intimidating to children to sleep with a snorkel on their face at night, it is quite effective and we’ve had good success implementing this even with young children,” says Dr. Canapari. 

Weight loss, Dr. Canapari adds, will be helpful in children who are overweight or obese. If the tonsils and/or adenoids are not causing the sleep apnea, other factors may be soft tissue in other parts of the airway, including at the base of the tongue or in the nose. "These can be removed surgically," Dr. Canapari says. "Weight loss and allergy treatment can also help." 

At Yale Medicine, you will find pediatric specialists in both sleep medicine and otolaryngology. Plus, few places in the state have pediatric-only sleep laboratories, and Yale has two: one at Yale New Haven Children’s Hospital and the other at Bridgeport Hospital. An overnight sleep study is often key to diagnosing your child’s obstructive sleep apnea.

Additionally, our sub-specialized pediatricians are actively involved in sleep research, including ways to improve the treatment of children who have obstructive sleep apnea and need to sleep with a mask. We work closely with our colleagues across multiple specialties to ensure that every child is receiving the best care that will help solve his or her issues with obstructive sleep apnea, or any other problem.