Synopsis
Recognise paediatric obstructive sleep apnoea from nocturnal and daytime behaviour, identify high-risk syndromic and neuromuscular children, distinguish snoring from clinically significant obstruction, use polysomnography appropriately, and coordinate adenotonsillar, weight, nasal and positive-airway-pressure care.
- Ask about habitual snoring, pauses, gasping, restless sleep, unusual positions, sweating, mouth breathing and enuresis. Children often show hyperactivity, irritability and poor concentration rather than obvious daytime sleepiness.
- Examine nasal patency, tonsils, palate, jaw, neck, weight and blood pressure. Tonsil size while awake does not reliably grade sleep obstruction.
- First-line assessment is a structured sleep history, video when available and risk examination. Primary snoring without gas exchange or functional effect remains a diagnosis of exclusion.
- Reference standard: attended overnight polysomnography measuring sleep state, airflow, effort, oxygen, carbon dioxide and arousals. Use age-specific paediatric scoring; adult thresholds are inappropriate.
- Overnight oximetry can prioritise obvious moderate-to-severe disease but a normal or inconclusive result does not exclude OSA, especially in a high-risk child.
- Adenotonsillectomy is first-line anatomical treatment when significant OSA accompanies adenotonsillar hypertrophy. ENT and anaesthesia assess bleeding, respiratory and postoperative monitoring risk.
- Children under 3, severe OSA, obesity, Down syndrome, craniofacial or neuromuscular disease often need inpatient postoperative observation and specialist planning.
- Use family-centred weight support when obesity contributes; do not delay treatment of severe obstruction until weight changes.
- Intranasal corticosteroid and/or montelukast may be considered by specialists for selected mild disease or residual inflammation; counsel montelukast neuropsychiatric risk and define review.
- CPAP or bilevel support is first-line when surgery is unsuitable, obstruction persists or hypoventilation coexists. Mask fit, humidification, desensitisation and family support determine adherence.
- Treat allergic rhinitis, avoid smoke and sedating medicines, and provide school and behavioural support while definitive care proceeds.
- Repeat symptom and objective assessment after treatment in high-risk children; growth, behaviour and blood pressure are meaningful outcomes beyond snoring.
Key red flags
Witnessed prolonged apnoea, cyanosis, gasping or profound desaturation requires expedited paediatric sleep and airway assessment.
Failure to thrive in a young child or rapid obesity-related gain with hypoventilation indicates significant physiological effect.
Pulmonary hypertension, systemic hypertension, morning headache or daytime hypercapnia suggests advanced disease.
Down syndrome, craniofacial difference, achondroplasia, neuromuscular disease and mucopolysaccharidosis increase multilevel obstruction and perioperative risk.
Excessive daytime sleepiness causing dangerous episodes, school failure, severe behaviour change or developmental regression needs timely assessment.
Adenotonsillar surgery does not guarantee cure in obesity or syndromic disease; persistent symptoms require repeat objective evaluation.
Investigation priorities
Measure obstructive events, sleep disruption, gas exchange and hypoventilation across sleep stages.
Management branches
Habitual snoring, witnessed pauses or daytime impairment is reported.
- Take structured night and day history and examine airway, growth, blood pressure and risk conditions.
- Use video and oximetry for context without allowing a normal result to end high-risk assessment.
- Refer for paediatric sleep or ENT testing according to severity and comorbidity.