Sleep-Disordered Breathing
Core concepts
Pediatric obstructive sleep apnea is most often caused by adenotonsillar hypertrophy, with obesity, craniofacial anomalies, Down syndrome, and neuromuscular disease as additional risk factors. Symptoms include snoring, mouth breathing, witnessed apneas, enuresis, morning headache, daytime sleepiness, and poor school performance. Polysomnography is the gold standard. In children, an obstructive apnea-hypopnea index greater than 1 is abnormal; severity is mild 1–5, moderate 5–10, and severe greater than 10. Adenotonsillectomy is first-line for most children with obstructive sleep apnea and adenotonsillar hypertrophy; CPAP is used for residual disease or when surgery is unsuitable. Central sleep apnea in infants is defined by pauses longer than 20 seconds or shorter pauses with desaturation or arousal.
Traps
Snoring alone does not diagnose obstructive sleep apnea. Do not apply the adult apnea-hypopnea index threshold of 5. Obesity hypoventilation can be missed. Adenotonsillectomy does not always cure obstructive sleep apnea, especially in obesity or Down syndrome. Overnight oximetry alone may miss obstructive events.
Worked example and rule of thumb
A 5-year-old with loud snoring, tonsils 3+, and new enuresis should have polysomnography; an apnea-hypopnea index of 8 indicates moderate obstructive sleep apnea, and adenotonsillectomy is first-line. Rule of thumb: in children, an obstructive apnea-hypopnea index above 1 is abnormal; do not use the adult cutoff of 5.