Up to one in 10 children have sleep-disordered breathing, a catch-all term for breathing disorders that occur while you sleep, which includes obstructive sleep apnoea (OSA) and snoring. However, as we’ll now explore, the signs, causes and treatments in children vary from what you’d expect to see in adults with the condition.
The series of events that occur during obstructive sleep apnoea is the same in children and adults. It starts with the upper airway becoming partially or completely blocked while your child sleeps. This causes their breathing to stop and start multiple times during the night.
The periods of time when they stop breathing are called apnoeic episodes or apnoeas. Mild cases of sleep apnoea cause at least five apnoeas for every hour of sleep but in severe cases, this can rise to 30 or more. During these apnoeas, their chest muscles and diaphragm work harder to open up the blocked airway and pull air into their lungs.
Apnoeas reduce the oxygen levels in their blood, which is sensed by their brain and triggers them to wake up. However, your child may not fully wake up. In fact, they most likely won’t be aware that they’re slightly waking repeatedly through the night, potentially hundreds of times every night.
Although your child may not be aware of their wakefulness at night, their body will feel the effects, with noticeable consequences for their health, wellbeing and development. In very severe cases of sleep apnoea in children, it can affect their heart and growth. This makes it all the more important to see your doctor if you’re concerned that your child may have a sleeping disorder.
Snoring alone doesn’t mean your child has sleep apnoea. Sleep apnoea involves a combination of symptoms, of which snoring is just one.
If you’re concerned, watch them while they’re sleeping and look out for pauses in their breathing, snorts or gasps. Typically, if your child has sleep apnoea, they’ll snore and then pause as their breathing stops. This silent pause may last for around 10 seconds or more. It will be followed by an audible catch-up breath or gasp.
Other signs while they sleep include heavy or noisy breathing, restlessness, unusual sleep positions, bedwetting and sweating as their chest muscles and diaphragm work harder to breathe normally.
You may also find it difficult to wake them up in the morning and notice behavioural and concentration problems, which at school, may be interpreted as learning difficulties. Unlike adults, children may not seem drowsy or tired but instead become hyperactive — some studies show that around half of all children with Attention Deficit Disorder (ADD) have sleep apnoea.
In children, sleep apnoea is usually caused by enlarged tonsils or adenoids. Your tonsils are two small, soft glands that sit at the back of your throat and bulge out slightly; in between them is a dangling part called the uvula. Your adenoids sit at the back of your nose and so can’t be seen. Both the tonsils and adenoids help fight infection but are not required for a healthy immune system, as there are several other glands in the throat that perform the same role.
Enlarged tonsils and adenoids very rarely cause sleep apnoea in adults, as the tonsils and adenoids shrink in adulthood. In contrast, being overweight or obese is a major cause of sleep apnoea in adults; between 60–90% of all adults with sleep apnoea are overweight. However, notably in children, being overweight only plays a small role in sleep apnoea.
Other causes of sleep apnoea in children include abnormalities in the shape of their face or head, known medically as craniofacial disorders.
If you’re concerned that your child has sleep apnoea, see your GP and tell them about the signs and symptoms you’ve noticed. It is also helpful to record a video of your child sleeping to show your GP.
They may refer you to an Ear, Nose and Throat (ENT) consultant who will perform a physical examination to check your child’s nose and throat. This can help determine if something other than enlarged adenoids and tonsils is causing a blockage in your child’s upper airways, such as allergies that cause congestion. Rarely the sleep apnoea is caused by a problem in the brain.
Your ENT consultant may occasionally suggest a sleep study when the diagnosis is unclear. This can be carried out at home using a special sleep apnoea device. The sleep study alone is not a foolproof method for detecting sleep apnoea. However, together with your child’s other symptoms, these results can give your doctor enough information to make a diagnosis.
If your child gets a diagnosis of obstructive sleep apnoea, treatment will depend on the underlying cause. If the cause is enlarged adenoids or tonsils, as is most often the case, this will involve surgery to remove the enlarged tissues.
Removal of the tonsils is called a tonsillectomy, removal of the adenoids is called an adenoidectomy, and removal of both is called an adenotonsillectomy. Whichever procedure your child has, no cuts are made on the outside so your child will not have any visible scars.
Although the adenoids and tonsils help fight infection, their removal will not affect your child’s immune system or put them at greater risk of infections. This is because there are other tissues in the head and neck that can effectively fight infection too.
The removal of enlarged tonsils and/or adenoids is highly effective at resolving obstructive sleep apnoea in children. However, if your child has central sleep apnoea, removing these tissues will not help.
Central sleep apnoea is a far less common type of sleep apnoea, which is not caused by a temporary blockage of the airways. Instead, it is caused by a problem with the brain’s ability to sense oxygen levels in the blood and direct the muscles that control breathing. Treatments for central sleep apnoea include medication, breathing assistance devices and sometimes surgery. Often central sleep apnoea gets better on its own as your child gets older.
Traditionally, the adenoids and tonsils are removed by cutting or scraping them out. However, in the last 10 years, a newer surgical technique called coblation has become increasingly popular and is now considered the safest way to remove tonsils and adenoids in children. Performing this technique requires specialist training, so you should always ask your ENT surgeon whether or not they offer this technique.
Coblation uses a wand that transmits radiofrequency waves through a salty solution. This creates a plasma field that evaporates any tissue it comes into contact with. The technique allows the surgeon to shave the tissues to a minimum (intracapsular technique) or remove them completely (extracapsular technique).
Compared with traditional surgery to remove tonsils and adenoids, coblation causes less pain and bleeding during and after surgery. The recovery time is also faster if the intracapsular coblation technique is used. This is because coblation avoids damage to the muscles lying under the tonsils and adenoids. These muscles contain many blood vessels and nerves and consequently, damage to them, which is more likely to occur during traditional surgery, causes more pain and bleeding.
However, coblation is not suitable for all children with sleep apnoea. It may not be appropriate if your child has recurrent tonsillitis.
Both coblation and traditional surgery are carried out under general anaesthetic.
Every surgery comes with risks. Your ENT surgeon will explain the specific risks associated with surgery to remove your child’s tonsils and/or adenoids.
The main risks include bleeding, infection and damage to the lips or teeth. Excessive bleeding may occur during the surgery or any time up to two weeks after surgery. Around one in every 100 children who have their adenoids or tonsils removed will need to go back into surgery to stop persistent bleeding. Infection after surgery can be treated with a course of antibiotics.
If your child has a loose tooth, this may become looser as your surgeon will need to place a mouth gag to keep their mouth open. The use of a mouth gag may also slightly bruise their lips.
In a small number of cases, after surgery to remove the adenoids, drink may come out through your child’s nose. This is because the adenoids block the back of the nose and stop food and drink from passing up through here. It may take a few weeks for the muscles in your child’s throat to close this gap off.
After surgery to remove your child’s tonsils or adenoids, a little discomfort is normal, similar to having a sore throat. This can usually be managed by taking over-the-counter painkillers, such as children’s paracetamol and ibuprofen. Children can usually start eating and drinking again an hour or two after waking up from their surgery.
The time needed to fully recover will depend on whether your child has traditional surgery or coblation — coblation is the gold standard for treating sleep apnoea in children. If your child has traditional surgery, they will need to take two weeks off school but with coblation, they can often return to school after a week to 10 days.
Mr Anand Kasbekar is a Consultant Ear, Nose and Throat Surgeon at Spire Nottingham Hospital and at Nottingham University Hospitals NHS Trust. He specialises in children and adult ear and hearing problems, tonsils and adenoids, balance, dizziness and snoring, as well as nasal, sinus and allergy treatments. He is also an Honorary Assistant Professor at the University of Nottingham. In addition to his clinical responsibilities, he runs training courses for ENT doctors, teaches on various national ENT courses and is in charge of ENT training in the East Midlands Region. Visit Mr Kasbekar's website.