Obstructive Sleep Apnoea and Sleep Disordered Breathing in Children

Obstructive Sleep Apnoea and Sleep Disordered Breathing in Children

The signs your child may be suffering from OSA/SDB include:

  • Loud snoring, every night – even when well.
    We all snore when we have a cold or flu, and some mild snoring occasionally (especially when your little one is very tired) is normal. However, loud snoring (can be heard outside their room) every-night, even when well is not normal.
  • Laborious breathing: the child looks like they are “working hard” to breathe. There can be some in-drawing of the chest when breathing, they are often sweaty/hot to touch, and posturing their neck backwards with mouth open to try and open their airway.
  • Pauses in breathing or gasping/choking: these episodes can be scary! In the more severe forms of OSA the pauses can be long and worrying. Breathing pauses are normally associated with a choking/gasping event before the child partially wakes up and changes position.
    (Children with OSA/SDB are often extremely restless – thrashing around in bed and ending up-side down with sheets/blankets all over the place).
  • Waking up tired and irritable despite long sleep: Children with OSA/SDB are not getting the refreshing sleep they need to rest, and grow. The constant waking from apnoea episodes means sleep is fragmented – they wake tired, irritable and restless.
  • Behavioural troubles/troubles concentrating: OSA/SDB is well documented in leading to externalising behaviours (aggression, hyperactivity) and internalising behaviours (depression type traits) in some children. Some of the features are similar to an Attention-Deficit Hyperactivity Disorder (ADHD) pattern.

Children with untreated OSA/SDB may have issues concentrating, and therefore problems with learning and development.

Other more subtle signs associated with OSA/SDB in children:

  • Growth restriction: whilst there are many medical causes for growth restriction in children (and some kids are just small, particularly if parents are smaller stature) – OSA/SDB may be contributing. Sleep is used by children for rest, and growth. Normally the calories from food are used to facilitate growth, but if they are being utilised on breathing/overcoming airway obstruction while asleep growth can be compromised. The deep phases of sleep are when Growth Hormone and other developmental processes – these are compromised in OSA/SDB.
  • Bed wetting: OSA/SDB is linked to bed-wetting in children, particularly those who previously had control of bed-wetting – who have regressed and started to wet the bed again.
  • Teeth Grinding: some children who grind their teeth (bruxism) will also have features of OSA/SDB. This may be identified by your dentist.

Diagnosis of OSA/SDB in children

We rely mostly on the history and concern of the parents/carers as well as what we find on examination to diagnose OSA/SDB in children.

Any video footage of your child sleeping that you are happy to share with us can greatly add the information gathering process! We encourage you to take a short video of your child sleeping/snoring on a typical night and bring to your consultation.

We generally do NOT send children for a diagnostic sleep study, unless there are exceptional circumstances including:

  • The child is very young (less than 2 years old)
  • Complex medical history (previous surgeries to the airway – including adenotonsillectomy, cranio-facial syndromes, significant obesity, neuromuscular disorders)
  • The severity of symptoms does not match the findings of the examination
  • Sometimes as parents, we feel better knowing that there IS some OSA on a sleep study before committing to treatment. This can be discussed and arranged.

We can further discuss the role of diagnostic sleep studies in children at your consultation.

Treatment of OSA in children

The pathway of management for your child can be discussed at length in your consultation.
There are non-surgical and surgical options; and you may elect either pathway depending on your overall concern and preference.

Non-Surgical Options

  • Watch and wait: if symptoms are mild, and concern is low this can be a valid option. As your child grows, the airway may expand to a level that is no longer troublesome however this is not always the case
  • Treat nasal allergies/other sinonasal conditions
  • CPAP mask: may be fitted by Paediatric Sleep Physician, these are not normally well tolerated by children but will overcome obstruction if surgery is not an option

Surgery

The primary treatment for children with OSA/SDB is surgical removal of the tonsils and adenoids – TONSILLECTOMY AND ADENOIDECTOMY.

We know from our scientific data, that this operation will cure OSA/SDB in the large majority of children (approximately 90%). In those where it does not rectify the problem, there is often something else affecting the airway – and this can be further investigated.

In some circumstances a procedure to the “turbinates” (shelves of tissue that react to allergens) inside the nose may be needed, but this would be in addition to tonsillectomy and adenoidectomy in the same procedure.

If there is any query regarding other areas of the airway causing collapse and OSA/SDB we may discuss performing Drug Induced Sleep Endoscopy (DISE) with you.

In this procedure, we bring your child into hospital operating theatre and our Anaesthetist gives them a small amount of sedation to get them off to sleep/snoring.

Whilst asleep we use a thin, fibreoptic telescope to look down the airway and document any areas of collapse or vibration that might be contributing to the problem. Common problem areas include the tonsil at the base of tongue (lingual tonsil) and “floppy” structures around the voice box (laryngomalacia).

We occasionally recommend DISE to be undertaken at the same time as tonsillectomy and adenoidectomy.

We can discuss Tonsillectomy and Adenoidectomy for your child in detail at our consultation, but some general information is as follows:

  • The operation is done under General Anaesthetic (your child is completely asleep under the watchful eye of our skilled Anaesthetists for the duration of the operation)
  • The operation itself takes around 30 mins, but from the time you leave your child with us in the operating room until the time you can see your child in recovery is approximately 1 hour.
  • It involves a one-night stay in hospital (one parent or carer can stay the night)
  • There is no restriction on what they can eat and drink after the operation – they will tend to want to stick to softer, colder things (ice cream, jelly) – but if they feel like normal food… go for it!
    Getting the operation done is the easy bit – the recovery is the hard part….
  • It is sore. Unfortunately it is a painful operation, but the kids generally do pretty well (nothing like the pain of tonsillectomy in adults). We will discuss our pain relief regime and what to expect with you.
  • There is small chance of bleeding afterwards. We will discuss what to do if this happens.
  • They will need 2 weeks off school/day-care with someone caring for them at all times. During this period we ask you stay within 30 mins of a major hospital (that has ENT Surgery cover)

As a parent, Mr Hayward understands the stress of committing your child to an operation – we can go through any concerns, expectations and questions in detail during consultations.

My child has previously had Tonsillectomy and Adenoidectomy but is still having features of OSA/SDB

In the rare instances where Tonsillectomy and Adenoidectomy fails to fix the OSA/SDB – other causes must be considered.

In addition to a sleep study, performing Drug Induced Sleep Endoscopy (DISE) can be incredibly useful (see above).

Using DISE, if we can identify an area of collapse warranting treatment – we will discuss this with you at length, and formulate a management plan.

If you have any concerns regarding your little one(s) and OSA/SDB – please contact us to schedule an appointment.