This condition, due to obstruction of the upper airway (nose/adenoids and tonsils), has varying degrees of severity from mild snoring through to severe obstruction with growth failure and cardiac complaints. About 10% of all children snore, but only about 3% have obstructive sleep disorder.

The obstruction to the air passages can be due to either blockage of the nose, enlarged adenoids or enlarged tonsils, or a combination of all of these. In addition, children with other conditions such as Down Syndrome, Cerebral Palsy or Cranio-facial abnormality may have an increased susceptibility to this condition due to either lax or floppy tissues or narrow breathing passages.

OSD can affect children within the first days of life, or present later in life with enlarged tonsils and adenoids, particularly in allergic children.

SYMPTOMS AND SIGNS OF OSD

The following symptoms and signs of Obstructive Sleep Disorder in children is presented in order of frequency. The more severe symptoms relate to children who stop breathing (obstructive sleep apnoea) for 5 – 10 seconds or more, are restless at night, and have periods of cyanosis (blue tinge around the lips).

- Snoring
- Chronic mouth breathing
- Periods of apnoea (breath holding)
- Sweating
- Restless sleep
- Frequent wakening
- Sleep walking/night terrors
- Sleeping in unusual positions e.g. head arched back
- Frequent need of afternoon sleep (if over 4 years)
- Tired and grumpy in the mornings
- Difficulty swallowing meat
- Overweight/Growth Retardation
- Underweight for age
- Bed wetting
- Cyanosis
- Hyperactive during the day/ADHD
- Learning Difficulties/Concentration Problems
- Behavioural Problems

If you observe your child breathing whilst asleep about one hour after they have settled at night, you will be able to note whether your child has these symptoms and signs.

Some children with many of the symptoms and signs in the above list need a normal sleep study where they are observed overnight and monitored for the severity of their OSD in a hospital.

Enlarged Tonsils

TREATMENT OF OSD

This depends on the source of the problem. It occasionally will respond to treatment of the nasal blockage by a steroid nasal spray, but often with a congested allergic nose there are enlarged adenoids and tonsils which require surgery as well.

If these OSD children require adenoidectomy or tonsillectomy and cautery of the turbinates, they are usually monitored postoperatively with an oximeter (oxygen level meter on the finger or toe) to ensure they do not have breathing problems postoperatively. These children are more sensitive to narcotics such as Pethidine and to sedative agents such as Phenergan or Vallergan and these agents, if used, are often given in reduced amounts.

In Paediatric hospitals throughout the world, OSD is the commonest reason to perform tonsillectomy and adenoidectomy, rather than recurrent tonsillitis. Parents are often concerned that removal of the tonsils and adenoids will reduce the child’s ability to fight infections. There is no evidence to suggest the removal of the tonsils and adenoids after the age of 3 years causes any change in the child’s immunity. If the child is under 3 years and required surgery for OSD, the necessity for the surgery outweighs any concern about the child’s immunity.
Not every snoring child should undergo a tonsillectomy and adenoidectomy. All procedures have their risks and benefits. Your doctor will decide if your child’s problem is severe enough to warrant surgery.

Further Reading

In some cases if your observations indicate that your child has quite significant obstructive sleep apnoea or in cases where we are not 100% certain for the severity we may obtain a sleep study with a paediatric sleep medicine expert. These are either done at Princess Margaret Hospital for Children or St John of God Subiaco utilizing one of the paediatric sleep medicine experts after consultation with them. Sleep studies or polysomnography is the “gold standard” for seeing whether or not a child has significant obstructive sleep disorder and if in fact in the more severe cases a child might require special nurses postoperatively (usually tonsillectomy or adenoidectomy) or in uncommon circumstances an intensive care ward at Princess Margaret Hospital particularly in children with co-morbidities such as cerebral palsy, Down Syndrome or other neuralgic conditions.

In some cases the airway obstruction causing obstructive sleep disorder and apnoea is quite obvious and rather than wait several months for the sleep study to be performed we go ahead with the surgical intervention. There are also instances where the child may not have all the classical features of obstructive sleep disorder but have quality of life issues such as being unable to swallow solids such as meat apple peel and similar food causing gagging, vomiting or even failure to thrive. For further more detailed information on obstructive sleep disorder I would direct you towards the attached website of the Joint Committee of the Paediatric Section of the Royal Australasian College of Paediatrics and the Committee from the Australian Society of Otolaryngology Head and Neck Surgery with the position statement on tonsillectomy. Professor Coates was a member of this Committee

Monitoring Your Child’s Obstructive Sleep Disorder

Obstructive sleep disorder involves a group of symptoms that are indicated below.

The most important of these are:
- Snoring
- Struggling to breathe
- Periods of stopping breathing during sleep termed Apnoea.

In order to establish how significant this condition is in your child it is very worth while if you do a sleep study observation yourself at home. Ideally this is at 4am in the morning but for practical purposes an hour after the child falls asleep is appropriate. The symptoms are noted as both Daytime and Nighttime symptoms and signs with a tick box for your observations, which you can print out, and either email or bring to your child’s consultation.

Apnoea is a period when a child is snoring and then goes quiet and holds their breathe with a period of obstruction and struggling to breathe followed by an inspiratory gasp. It is very useful to time the period of this apnoea. The child may not snore every night but it is certainly worthwhile over the period of observation to see whether the child’s snoring is mild normally and significantly worse with upper respiratory tract infections as this obviously has an impact on their management.

Links

ASOHNS/RACP