Obstructive sleep apnoea in an obese 5-year-old whose parents refuse surgery

First-line treatment. In a child aged 2–18 with obstructive sleep apnoea syndrome and adenotonsillar hypertrophy, adenotonsillectomy is the recommended first-line treatment. Explain why: the obstruction is structural and visible, and no medication shrinks tonsils and adenoid to a clinically reliable degree.

What to promise and not promise. Adenotonsillectomy produces a large reduction in the obstructive apnoea-hypopnoea index, improves behaviour, quality of life, enuresis and growth, and probably improves blood pressure regulation. It is not a guaranteed cure: normalisation (index below about 1–2 per hour) occurs in roughly half to two thirds of otherwise healthy children, and considerably less often in obese children, in whom persistent disease after surgery is common. Tell them this up front so that a repeat sleep study after surgery is expected rather than a surprise.

Address their concerns. Anaesthesia risk in a healthy 5-year-old is low; his asthma should be optimised preoperatively, and obesity and a high apnoea index mean he should stay overnight for monitoring rather than go home the same day. Do not dismiss their fear - explain what monitoring will be in place.

Handling the request for nasal steroid and montelukast. Intranasal corticosteroids give a modest improvement in mild disease and are reasonable while awaiting surgery or if surgery is refused, but the evidence in moderate disease is weak and neither is equivalent to surgery. Montelukast has a small additive effect, but since 2020 it carries a boxed warning for neuropsychiatric events including agitation, sleep disturbance and mood change - relevant in a child whose presenting complaint is irritability - so it should be discussed explicitly rather than prescribed casually. Offer a shared plan: start intranasal steroid, book surgery, and agree a review point. Document that the recommendation and the reasons were explained, and that the family's preference was explored rather than overridden.

Setting. Admit overnight with continuous pulse oximetry. Indications for planned admission after adenotonsillectomy include age under 3 years, severe sleep apnoea (index around 10 per hour or higher, or oxygen nadir below 80%), obesity, and comorbidity. He meets several criteria with an index of 9.2, a nadir of 82% and obesity, so same-day discharge is inappropriate. Escalate to a high-dependency bed if he has recurrent desaturations, and ensure staff trained in paediatric airway management are available overnight, since respiratory compromise typically occurs in the first postoperative night.

Analgesia. Do not prescribe codeine: it is contraindicated after adenotonsillectomy in children because ultrarapid CYP2D6 metabolisers convert it to morphine and have died. Also avoid tramadol for the same reason. Use regularly scheduled paracetamol and ibuprofen (if no contraindication), with rescue opioid only in a monitored setting at the lowest effective dose. Give intraoperative dexamethasone for oedema and postoperative nausea, and a prophylactic antiemetic. Ensure good hydration; dehydration is a common cause of readmission.

Asthma. Optimise inhaled therapy before induction, use an appropriate airway technique, and avoid trigger agents where possible; have salbutamol available.

Safety-netting. Warn about secondary haemorrhage, typically days 5–10, and give a 24-hour contact route with clear instructions to attend emergency care if there is bleeding, refusal to drink, fever, or worsening breathing. Document the codeine avoidance explicitly in the notes and on the discharge letter, as this is a recurring source of serious harm.

First, confirm the problem. Repeat overnight polysomnography rather than relying on symptoms; snoring alone is a poor predictor of residual disease, and symptom reports correlate weakly with the index. Examine the nose for adenoid regrowth, the oropharynx for residual tonsil, and assess jaw and dental arch development, nasal patency and tongue position. Ask specifically about nasal obstruction, mouth breathing, growth, school performance, enuresis and blood pressure, and record his BMI trajectory.

Explain the likely reason. Persistent disease after adenotonsillectomy is common in obese children - the adenoid and tonsil are only part of the obstruction, and fat deposition in the pharyngeal walls, a large tongue base and lingual tonsils become relatively more important.

Options. (1) Intranasal corticosteroid, with or without montelukast, is a reasonable trial with a repeat symptom review and, if available, a repeat sleep study. (2) Weight management with dietitian and family support is a genuine treatment for the disease, not a diversion, but it works slowly. (3) Continuous positive airway pressure with proper paediatric mask fitting and desensitisation; adherence in a 5-year-old is difficult but achievable with support, and the siblings sharing a bedroom is a practical barrier to address honestly. (4) Orthodontic assessment for maxillary constriction and consideration of rapid maxillary expansion in the right patient. (5) If obstruction persists and the family will consider further intervention, drug-induced sleep endoscopy can localise the level - residual adenoid, lingual tonsil, supraglottic collapse - and guide targeted surgery such as revision adenoidectomy or lingual tonsillectomy. Hypoglossal nerve stimulation is not an option at this age.

If all intervention is declined. Document the discussion, offer regular review rather than discharge, and explain in plain terms the risks of untreated disease: behavioural and learning difficulties, growth failure, raised blood pressure and cardiometabolic risk, and a small but real risk of serious respiratory events. Keep the door open without coercion.