En
Français
Nederlands
Deutsch
Español
Italiano
Sleep Apnea in Children: Symptoms, Causes and Treatments
Sleep apnoea is not an adults-only condition. It also affects children, often in a different way and with symptoms that can go unrecognised or be mistaken for other disorders. An early diagnosis matters, because it prevents consequences on growth, cognitive development and learning.
A widely under-diagnosed condition in children
The prevalence of obstructive sleep apnoea in children is estimated at 1 to 5 % of the paediatric population by the American Academy of Pediatrics, with a peak between ages 2 and 8. Unlike adults, paediatric apnoea often has an identifiable anatomical cause, mainly enlarged tonsils and adenoids. It can therefore be treated definitively in many cases.
Symptoms very different from adults
One of the main challenges of paediatric diagnosis is that a child's symptoms differ considerably from an adult's. Where an adult is sleepy during the day, a child often reacts the other way round, with hyperactivity and restlessness.
Nighttime symptoms:
- Regular, loud snoring - the main sign, present in most children with apnoea
- Breathing pauses observed by the parents
- Mouth breathing at night and an open mouth during sleep
- Unusual sleeping positions - the child often sleeps with the head tilted far back (hyperextension) to open the airway
- Excessive night sweating
- Bedwetting - often overlooked as a sign of apnoea in children. The negative chest pressure during apnoeas stimulates the release of atrial natriuretic peptide (ANP), which increases urine production
- Frequent awakenings and restless nights
- Parasomnias (night terrors, sleepwalking) - more common in children with apnoea
Daytime symptoms:
- Hyperactivity and restlessness - paradoxical but very characteristic. A child with apnoea is often over-excited rather than sleepy.
- School difficulties - problems with concentration, memory and learning, which can be mistaken for ADHD or for learning disorders
- Irritability and mood swings
- Mouth breathing during the day
- Nasal voice
- Swallowing difficulties (enlarged tonsils)
- Growth delay in some cases, as deep sleep is essential to the secretion of growth hormone
Severity thresholds in children
The AHI and AHIO thresholds are very different in children and in adults.
| AHIO (child < 16 years) | Interpretation |
|---|---|
| < 1 /hour | Normal |
| 1 to 5 /hour | Mild apnoea - monitoring and ENT assessment recommended |
| 5 to 10 /hour | Moderate apnoea - treatment recommended |
| > 10 /hour | Severe apnoea - urgent treatment |
An AHIO of 1 or more per hour in a child under 16 is considered abnormal and calls for a medical assessment. That threshold is far lower than in adults, where the limit of normality is below 5 per hour.
Causes of sleep apnea in children
Anatomical causes (the most frequent):
- Enlarged tonsils: this is the leading cause of paediatric apnoea. Bulky tonsils narrow the pharynx. The enlargement is common between ages 2 and 8.
- Enlarged adenoids: often associated with enlarged tonsils. The adenoids block the back of the nasal passages and force mouth breathing.
- Maxillofacial malformations: a set-back jaw (retrognathia), a narrow palate, macroglossia (an oversized tongue).
- Childhood obesity: a growing risk factor in children, through mechanisms similar to those in adults.
Other factors:
- Down syndrome (trisomy 21)
- Neuromuscular diseases
- Repaired cleft palate
- Chronic allergies
How is apnoea diagnosed in a child?
The diagnosis of paediatric apnoea rests on three things:
- The interview with the parents: a detailed description of the night-time symptoms (snoring, pauses, sleeping positions). Parents are the first witnesses.
- The clinical examination: the paediatrician or the ENT specialist assesses the size of the tonsils and adenoids and the shape of the jaw and face.
- Paediatric polysomnography: the reference test in children. Unlike in adults, ambulatory polygraphy is used less in children because reading the data calls for specific paediatric expertise. A PSG in a paediatric sleep centre remains the reference examination.
Treatments for pediatric sleep apnea
Surgery: first-line treatment in most cases
In children, first-line treatment is most often surgical:
- Adeno-tonsillectomy (removal of the tonsils and adenoids): an effective and well-tolerated procedure. In the randomised CHAT trial (New England Journal of Medicine, 2013), polysomnography returned to normal in 79 % of the children who had surgery, against 46 % under watchful waiting. It is the most effective treatment for apnoea caused by enlarged tonsils.
- Adenoidectomy alone: when the obstruction comes mainly from the adenoids.
After an adeno-tonsillectomy, a follow-up polysomnography is often recommended to confirm the cure, especially in children who are obese or who had severe apnoea before surgery.
Orthodontic treatments
- Palatal expansion: an orthodontic device that widens the palate to improve the nasal passage. It can significantly reduce apnoea in children with a narrow palate.
- Treatment of maxillofacial malformations: orthognathic surgery for severe retrognathia.
Pediatric CPAP
CPAP is used in children when surgery is not enough or is not possible. The typical situations are:
- Apnoea that persists after an adeno-tonsillectomy
- A contraindication to surgery
- Apnoea linked to obesity with no traceable anatomical cause
- Neuromuscular diseases or genetic syndromes
Paediatric CPAP calls for a mask suited to the child's face and for close follow-up. Children generally adapt well when the introduction is gradual and supported.
Lifestyle measures
- Management of childhood obesity
- Treatment of chronic allergies (rhinitis, asthma)
- Orofacial myofunctional therapy, which can improve muscle tone
Consequences of untreated apnea in children
- Growth delay: deep sleep is essential to the secretion of growth hormone. Apnoea fragments deep sleep and can slow growth.
- Cognitive and school difficulties: studies show that untreated children with apnoea perform below their peers at school. The deficits affect attention, memory and executive functions, and they often improve after treatment.
- Behavioural problems: hyperactivity, ADHD-like behaviour, aggressiveness.
- Maxillofacial development: chronic mouth breathing caused by nasal obstruction can change the growth of the face (adenoid facies, high-arched palate).
- High blood pressure: even in children, severe apnoea can cause hypertension.
VivaRespire and pediatric CPAP
If your child needs a CPAP, VivaRespire can help you choose the equipment. The INAMI/RIZIV convention can also apply to children under certain conditions. For all the details: CPAP reimbursement in Belgium.
Browse our CPAP masks and CPAP devices.
Frequently asked questions about sleep apnea in children
Sleep apnea can be diagnosed from early childhood, with a prevalence peak between 2 and 8 years, when the tonsils and adenoids are at their largest. Infants can also have breathing disorders but these require specific paediatric management. Pediatric polysomnography remains the reference test to confirm diagnosis. Consult a paediatrician or ENT specialist to assess your child's individual situation.
Symptoms differ from adults. Night: regular snoring, breathing pauses, mouth breathing, head-extended sleep position, excessive sweating, bedwetting, parasomnias. Day: hyperactivity and agitation (paradoxical but very characteristic), school difficulties, irritability, nasal voice, possible growth delay. Where adults are sleepy, children are often over-excited - a common diagnostic trap leading to confusion between apnea and ADHD.
Yes, and it is one of the best-known diagnostic pitfalls. In children, sleep fragmentation from apnea does not cause sleepiness but hyperactivity, agitation and concentration difficulties that resemble ADHD. Before diagnosing ADHD in a child who snores regularly and sleeps with mouth open, it is essential to rule out sleep apnea. Treating apnea often significantly improves behavioural symptoms.
In most cases yes. Adeno-tonsillectomy (removal of tonsils and adenoids) normalises polysomnography in 79% of children who have surgery, against 46% under watchful waiting, in the randomised CHAT trial (New England Journal of Medicine, 2013). It is the first-line treatment in children. A post-operative polysomnography is often recommended, especially in obese children or those with severe preoperative apnea, as residual apnea may persist and warrant pediatric CPAP.
Yes, but pediatric CPAP is rarely the first-line treatment. It is used in cases of persistent apnea after surgery, surgical contraindication, obesity-related apnea, or neuromuscular disease. Pediatric CPAP requires a mask adapted to the child's morphology, gradual introduction and close follow-up by a paediatric sleep centre. Children generally adapt well when the team and family are actively involved.
Early improvements in behaviour and attention can appear within 3 to 6 months of effective treatment (surgery or CPAP). Academic gains are often measurable from the following term. Studies show that treated apneic children catch up significantly in attention, memory and executive functions. The earlier treatment starts, the greater the cognitive benefit - which justifies rapid screening for any unexplained regular snoring.
More precisely, untreated pediatric apnea can mimic or worsen ADHD-like symptoms (inattention, hyperactivity). A landmark study found that inattention and hyperactivity symptoms are more common in children who snore and show signs of sleep-disordered breathing (Chervin et al., Pediatrics 2002). This does not mean all ADHD is caused by apnea, but it does mean it is essential to test sleep before making an ADHD diagnosis. Consult a paediatric sleep specialist to assess your child.