Since the time he was just a tiny baby, our oldest son has snored. When he was still an infant, it seemed cute, and I often teased my husband that he was already taking after his Father at just a few months of age. As time passed and our son got older, I began to worry more about his snoring.
I often check on our children after they’ve fallen asleep, and I started noticing pauses in our son’s breathing. He would be snoring and take in a deep breath, only he seemed to be holding the air for as long as 20-30 seconds. Around this time, we also had been dealing with some significant behavioral changes in our son and had been referred to a developmental specialist.
The physician asked us about his sleeping habits, and after hearing about his pauses in breathing, she diagnosed him with sleep apnea. She told us that his tonsils and adenoids would need to be removed and that his lack of oxygen at night was likely contributing to the challenges we were facing with his behavior.
After his surgery, when I was making the rounds to each bedroom, I noticed something was missing from my son’s room…his snoring! Within a few nights of his surgery, the apnea had disappeared and our son was back to his usual happy (albeit a little silly) self.
What causes sleep apnea? What are the signs and symptoms? How is it treated?
Keep reading for all of the info you want to know about pediatric sleep apnea in this ultimate guide for infants, babies, and children.
Pediatric obstructive sleep apnea (OSA) is a sleep disorder that occurs when a child’s breathing is partially or completely blocked due to narrowing in the upper airways during sleep.
The main difference between OSA in children and adults is that pediatric OSA is most commonly due to enlarged tonsils and adenoids while the condition is likely (but not always) secondary to obesity in adults. Children are also more likely to exhibit behavioral side effects and adults usually complain of daytime sleepiness.
It is not uncommon for toddlers and babies to be diagnosed with OSA. Apneic spells can occur more frequently in premature infants and newborn babies. The type of apneas that take place in infants can be central, mixed, or obstructive.
Most apneas in babies are due to an immature brainstem or secondary medical conditions such as heart defects, Down Syndrome, or cleft palate. When pauses in breathing are due to developmental delays, many babies will grow out of this as they get older. Sleep apnea that occurs in toddlers is usually an early-onset of OSA, likely due to frequent illnesses that cause enlargement of the tonsils and adenoids.
It’s important not to assume your child has OSA just because they snore. While sleep apnea occurs in roughly 2% of kids, as many as 20% of healthy children snore loudly at night, according to John L. Carroll, MD., a Professor of Pediatrics at the University of Arkansas for Medical Sciences and Arkansas Children's Hospital in the Division of Pediatric Pulmonary Medicine. 
Many of the symptoms of OSA appear in the first few years of life but most cases are not diagnosed until many years later. OSA in early childhood can slow growth, but following treatment, most children show advancements in both height and weight. While every child is different, some of the most common symptoms may include:
Noisy breathing or loud snoring during sleep may be a symptom of apnea, although snoring can also occur in healthy children.
This is another symptom that can be very common in children, but can also occur due to apneic episodes.
These episodes involve screaming, flailing, and intense fear that occurs while children are still asleep.
Chronic ear infections, tonsillitis, strep throat, and swollen adenoids may all occur more frequently.
Periods of normal breathing with subsequent pauses or breath-holding can be a sign of sleep apnea.
Children may toss and turn all night long, rarely going into a deep state of sleep.
If air entry through the nose is blocked due to enlarged tonsils or adenoids, children may breathe only through the mouth.
Sleeping in abnormal conditions like with the neck arched backward could be a sign the child is trying to open the airways.
Adults are more prone to drowsiness during the daytime because of fragmented sleep. Every time they have pauses in breathing, they wake up briefly, preventing them from getting a good night’s rest. This can also be more common in teens with OSA.
Children have a higher “arousal threshold,” so they rarely wake in response to pauses in breathing. Instead, their daytime symptoms tend to occur due to “hypoxemia,” a state of lower levels of oxygen in their blood. Decreased oxygen to the brain often leads to the cognitive and behavioral symptoms that are more common with OSA in kids.
Irritability, aggression, difficulty listening, frustration, and anxiety can all be more common.
Difficulty with listening and paying attention or periods of hyperactivity occur more frequently due to low oxygenation to the brain.
Delayed growth and development can occur leading to a lack of weight gain, slow growth in height, and failure to thrive.
Children may experience problems with short and long-term memory, difficulty concentrating, poor problem-solving skills, and trouble paying attention.
It is important to speak to your child’s doctor if you are concerned about their breathing. If their physician believes there is a reason to suspect sleep apnea, they will likely refer your child to a specialist such as an ear, nose and throat doctor (ENT) or pulmonary (lung) specialist for further investigation.
Testing including evaluation of the upper airways, X-ray, and overnight sleep studies may all be used to determine the presence and extent of sleep apnea in your child. When your doctor meets with you to discuss the results, they will generally let you know how severe your child’s apnea is and what type of treatment is recommended.
Sleep apnea can have some serious complications, including high blood pressure, poor growth, and heart problems. It can also impact learning and behavior, so it is important to have it diagnosed and treated early.
In severe cases that are left untreated, there is a risk of death, albeit small. According to one study looking at morbidity and mortality in 2,998 children ages 0-19 with a diagnosis of OSA, the 5-year mortality rate was 0.7%.
Many factors play a role in the development of sleep apnea. For premature and newborn babies, it often is due to an immature central nervous system and/or respiratory system. Other risk factors can include certain developmental disabilities, musculoskeletal abnormalities, and body weight.
In older children, OSA may occur more often due to obesity, however many cases also occur in underweight kids. According to research, obese children experience changes to their respiratory systems from increased tissue mass putting pressure on their neck and lungs, narrowing the airways and inhibiting normal breathing.
Children with neuromuscular diseases are at a higher risk of developing OSA due to the weakening of muscles in the upper airway, contributing to increased resistance at night because these muscles are required to maintain an open airway.
Neurodevelopmental disabilities such as cerebral palsy can also increase the risk of OSA because of low muscle tone and various other malformations in the upper airway.
Many deformities in the cranial or musculoskeletal system can result in nasal or nasopharyngeal obstruction, blocking off the airway. Low or poor muscle tone also prevents full inhalation and exhalation, increasing the likelihood of apnea.
Sickle cell disease is present in 1 in 600 African Americans, and is a condition characterized by chronic hemolytic anemia, or the abnormal breakdown of red blood cells. There is an increased prevalence of OSA in kids with sickle cell disease, although the exact rate is uncertain with a wide variation between 5-79% in studies.
Treatments can vary based on the underlying cause. While some children may outgrow this condition, others will require treatment that may involve surgery to remove the tonsils and adenoids, correction of craniofacial abnormalities, weight loss interventions, continuous positive airway pressure (CPAP) devices.
Enlarged tonsils and adenoids are the most common causes of OSA in children, resulting in frequent infections and difficulty breathing. Surgical removal of the tonsils (tonsillectomy) and adenoids (adenoidectomy) is often recommended in this case. Sometimes, surgery to fix craniofacial malformations is also necessary.
If surgery is not effective or recommended, using a CPAP machine may be an option. This involves wearing a mask over the mouth or nose that holds the airway open by gently blowing in the air at a continuous pressure. The mask is generally worn overnight and comes in many fun kid-friendly designs.
Oral devices are an alternative to traditional CPAP masks and work by pushing the tongue and jaw forward, making the airway larger and increasing airflow. Some studies have found that oral appliances are better tolerated than CPAP machines because they are quieter, more comfortable, and portable.
Like many other conditions, there are some natural treatments and home remedies for sleep apnea that may be worth exploring. Remember that this condition can be very serious, and it is always important to speak with your child’s doctor before using any natural treatments.
Changing the diet to include more anti-inflammatory foods like fruits and vegetables can be a great step in supporting the body and respiratory system. A healthy diet is also important in cases where body weight may be contributing to OSA.
Humidifiers are used to help moisten the air, preventing dryness in the airways. Many CPAP devices have built-in humidification, but humidifiers can also be useful even when CPAP devices aren’t recommended. Certain essential oils such as lavender, marjoram, and thyme can also be added to some humidifiers and/or CPAP devices to help reduce inflammation and improve apnea.
Many allergens like dust, cigarette smoke, and pet hair can make symptoms of this condition worse. Allergens and pollutants can increase inflammation, narrowing the airways and making breathing more difficult. Opening the windows, vacuuming frequently, and using an air filtration system can also be helpful.
Sleeping in a supine position (on the back) often makes OSA worse in adults, but one study in 2002 found that it decreased symptoms in children who were overweight. Unfortunately, another study in 2017 looking at preschoolers found that sleeping on the back caused worsening of breath-holding episodes, making it difficult to say which position is recommended. Using a wedge pillow to help your child rest upright may also improve symptoms.
Sleep apnea is a serious condition that can occur in children of all ages, shapes, and sizes. If you are worried that your child may be displaying some of the signs and symptoms include snoring, restlessness, or worsening behavior, it is important to speak with their doctor for evaluation and a proper diagnosis.
With treatment, many children can recover from sleep apnea or be able to manage their symptoms using therapy like a CPAP machine. In many cases, kids can continue living normal lives despite their diagnosis, just like my son has!
 Obstructive Sleep-disordered Breathing in Children: New Controversies, New Directions, Clinics in Chest Medicine