Understanding the symptoms of sleep apnea in infants and children helps identify it early, allowing for timely diagnosis and treatment. This is crucial for parents, a basic understanding of the symptoms of sleep apnea in infants and children can help children get help as early as possible.
Sleep apnea in children primarily manifests as increased activity, accompanied by language impairment, decreased appetite, and difficulty swallowing. Non-specific behavioral difficulties, such as unusual shyness, developmental delays, rebelliousness, and aggression, are also common.
Symptoms of Sleep Apnea In Infants And Children
1.Nighttime Symptoms
The most significant symptom at night is snoring. Almost all children with OSAS snore, and most of them snore loudly. However, severe OSAS may cause no snoring or only high-pitched grunting during sleep. Snoring worsens during an upper respiratory tract infection.
OSAS, or sleep-related hypoventilation, is the most common symptom in children with OSAS. Children snore in two main forms: continuous snoring and intermittent snoring, with intermittent snoring interrupted by periods of silence that are often interrupted by loud gasps or hums.
Almost all children with obstructive sleep apnea (OSA) experience labored breathing.
The esophageal pressure range for children with sleep airway obstruction is -4.90 to -6.87 kPa. Obstructive respiratory effort manifests as intercostal, sternal, suprasternal, and supraclavicular indentations, rib margin flaring, and accessory respiratory muscle activity.
Paradoxical inspiratory chest adduction may also be observed, but this is normal in neonates, infants, and older children during REM sleep.
Obstructive sleep apnea (OSA) episodes occur periodically and can resolve on their own. During an episode, snoring suddenly ceases, and despite strained inhalation, no air enters the airways through the mouth or nose. Patients with prolonged episodes may experience cyanosis and a slow heart rate.
The recurrence of snoring indicates the cessation of the episode, the resumption of breathing, and the onset of loud puffing sounds, arousal, and changes in posture.
Most children with OSA do not have obvious obstructive symptoms. In children with moderate to severe OSA, the average frequency of obstructive episodes is 20 times/h, and the average duration of obstructive and mixed apnea is 17.3s.
The impact of OSA on sleep in children differs from that in adults. Children with OSA experience a normal amount of sleep, and those with persistent partial airway obstruction during sleep do not exhibit sleep fragmentation.
However, children with OSA often experience restless sleep at night or toss and turn in bed. Children with OSA also have abnormal sleeping postures, often manifesting as overextension of the neck, with the head sliding off the pillow or sitting up.
Among 50 children with OSA, 96% sweated profusely during sleep. Enuresis is a common manifestation of OSA in children. Several studies have shown that among children with upper airway obstruction and nocturnal enuresis, 3/4 of the patients had significant improvement in enuresis after undergoing upper airway surgery.
2.Daytime Symptoms
Morning awakening symptoms in children with OSA include open-mouth breathing, morning headaches, dry mouth, disorientation, confusion, and irritability.
School-aged children experience difficulty concentrating in class, daydreaming, fatigue, and decreased academic performance. Between 8% and 62% of children also experience excessive daytime sleepiness.
Daytime behavioral problems are common in children with OSA, mainly manifested as poor school performance, hyperactivity, intellectual disability, emotional problems, shy or withdrawn behavior, aggressive behavior, and learning problems. Many children with OSA have developmental delays.
While it’s well established that obstructive sleep apnea (OSA) in adults can impair attention, memory, alertness, and motor skills, little research has examined its impact on daytime cognitive abilities in children.
Most children with OSA have enlarged tonsils and adenoids, and the vast majority breathe through their mouths. Some also experience difficulty eating and swallowing, halitosis, and some speech impairment.
3.Associated Symptoms
Hypoxemia commonly occurs in many children with OSA. In some children with severe OSA, SaO2 may drop below 50%. In children with partial obstruction, SaO2 drops at the onset of obstruction and remains at a low level for a long time.
Hypercapnia is also a hallmark of obstructive pulmonary disease (OSA) in children. Approximately half of the cases of hypercapnia (end-tidal CO₂ > 6.0 kPa) are associated with obstructive sleep apnea (OSA) or persistent partial obstruction. Low body weight is also common in most children with obstructive pulmonary disease (OSA).
Furthermore, children with airway obstruction during sleep are more likely to experience symptoms such as gastroesophageal reflux, sudden awakenings, excessive crying, and screaming. Other studies have found that children with OSA may exhibit behavioral disturbances, such as impulsivity, defiance, or unusual shyness and social withdrawal.
4.Physical Signs
Key symptoms include dyspnea, nasal flaring, intercostal and supraclavicular retractions, and paradoxical chest and abdominal movements during inspiration.
Parents may notice that their child refuses to cover himself with a blanket at night, sweats at night, and experiences respiratory arrest followed by gasping. The typical sleeping position is prone, with the head turned to one side, the neck hyperextended with the mouth open, and the knees flexed to the chest.
Some craniofacial features often suggest the presence of sleep apnea, such as triangular mandible, steep mandibular plane, retrognathic mandible, long face, high hard palate and/or long soft palate.
Diagnosis Of Sleep Apnea In Infants And Children
1.Main Diagnostic Basis
1.1 Polysomnography (PSG) results
Key indicator: Obstructive apnea-hypopnea index (OAHI) ≥ 1 event/hour (i.e., ≥ 1 obstructive apnea + hypopnea event per hour of sleep) or AHI ≥ 5 events/hour (if obstructive or central sleep cannot be distinguished).
Supplementary indicators: Decreased nocturnal oxygen saturation (e.g., lowest oxygen saturation ≤ 92% or duration below 90% for ≥ 1% of total sleep time);
Disrupted sleep architecture (e.g., frequent arousals, fragmented sleep).
1.2 Typical Symptoms And Signs
Nocturnal manifestations: snoring (≥3 nights/week), apnea, mouth breathing, night sweats, and restless sleep.
Daytime manifestations: inattention, hyperactivity, morning headaches, and growth retardation.
Physical signs: enlarged tonsils or adenoids, maxillofacial deformities (e.g., micrognathia), and obesity (BMI ≥ 95th percentile for age).
2.Key Points For Diagnosis By Age
Infants and young children (<1 year old) are mainly diagnosed with central apnea, which requires a comprehensive assessment based on feeding difficulties, developmental delay, and PSG results.
In children over one year old, obstructive sleep apnea is the most common cause, with emphasis on adenoid/tonsillar hypertrophy and maxillofacial structural abnormalities. Obese children should be aware of the possibility of concurrent central sleep apnea.
3.Differential Diagnosis
Simple snoring: Snoring alone, with PSG showing OAHI <1 event/hour, and no hypoxia or sleep architecture abnormalities.
Central sleep apnea: PSG shows predominantly central respiratory events, requiring investigation for neurologic or metabolic disorders.
Other conditions: Asthma, allergic rhinitis, gastroesophageal reflux, etc. may exacerbate symptoms and require concurrent evaluation.
Treatment Of Sleep Apnea In Infants And Children
Sleep apnea syndrome in children can be treated by adjusting sleeping position, controlling weight, using nasal hormones, wearing oral braces, and surgical treatment etc.
1.Adjust Your Sleeping Position
Sleeping on your back may worsen airway obstruction, so sleeping on your side or prone is recommended. A dedicated pediatric position-fixing pillow can be used to prevent excessive neck flexion.
For mild obstructive sleep apnea, changing body position can reduce the apnea-hypopnea index. Keep the bed flat and avoid soft bedding covering the mouth and nose.
2.Control Your Weight
Overweight children with fat accumulation in the neck can compress their airways. Losing 5%-10% of body weight can improve symptoms. It’s recommended to maintain 60 minutes of moderate to high-intensity exercise daily and reduce high-sugar, high-fat diets.
Parents should regularly monitor their body mass index percentiles. Those with metabolic syndrome should consult a nutritionist to develop a dietary plan.
3.Nasal Hormones
Mometasone furoate nasal spray and fluticasone propionate nasal spray can reduce nasal mucosal edema and are suitable for children with allergic rhinitis and mild obstruction. Continuous use for more than four weeks can reduce adenoid size.
However, be wary of side effects such as epistaxis and growth suppression. Monthly assessment of height growth is recommended during medication use.
4.Oral Braces
Mandibular advancement appliances expand the pharyngeal cavity by advancing the mandible. They are suitable for school-age children with jaw abnormalities who are not candidates for surgery.
A personalized device is required by a dental specialist and should be worn for 8-10 hours each night. Temporomandibular joint discomfort may occur initially, requiring muscle function training.
5.Surgical Treatment
Adenotonsillectomy is effective in up to 80% of children with moderate to severe disease. Using a low-temperature plasma scalpel under general anesthesia can reduce bleeding.
Patients with craniofacial deformities may require orthognathic surgery, and polysomnography is required postoperatively to assess efficacy.
Surgery may be associated with complications such as postoperative bleeding and velopharyngeal insufficiency, typically manifesting as bleeding from the wound and coughing when drinking water.
