Part 26 - The Evaluation of Sleep Apnea in Children

The Evaluation of Sleep Apnea in Children

Children whose caregivers believe they may have sleep apnea can be evaluated by a pediatric sleep specialist. Because home sleep apnea testing is not approved for use in children, this could require an overnight sleep study at a sleep center.

Sleep apnea can have serious, long-lasting consequences on mental and physical development. It's important to talk to your child's pediatrician or a pediatric sleep specialist if you have reason to believe that your child may be experiencing sleep apnea.

When considering the potential predisposing factors for children to develop sleep apnea, these can be subdivided into several major categories.

Enlarged Tonsils and Adenoids

Perhaps the single most common contribution to sleep apnea in children relates to a narrowing of the anatomy of the upper airway. The tissues at the back of the mouth and throat called tonsils and adenoids are likely suspects. Just because enlargement of these tissues is present does not mean a child will have sleep apnea. However, those children with sleep apnea who have enlarged tonsils and adenoids may be significantly helped by removing them. Approximately 10% of children do not improve after surgery, and they may have other factors contributing to their condition.


Obesity among children is increasing, and it may have a greater role in causing sleep apnea as these trends continue. As the amount of fat lining the airway grows, it may lead to crowding and narrowing within the airway. Alternatively, extra weight outside of the airway may apply pressure and lead to the airway collapse, resulting in apnea events.

Craniofacial Abnormalities

There are several abnormalities of the head or face (called craniofacial abnormalities) that may lead to an increased risk of developing sleep apnea. Conditions that decrease the size of the nose, mouth, and throat may lead to a collapse of the airway during sleep. For example, an enlarged tongue (called macroglossia) may contribute. Other conditions include:

• Midfacial hypoplasia (underdevelopment of the nose and central face)

Retrognathia or micrognathia (a recessed or small jaw)

Mandibular retrognathia is the condition of having a visibly recessed chin and overbite. It is a common condition that can affect more than just a person's self-image. In some cases, it can lead to:

• Jaw misalignment

• Eating pain

• Orthodontic problems

• Sleep disorders

Retrognathia Symptoms

Retrognathia is when the lower jaw (mandible) is set back from the upper jaw (maxilla). It doesn't necessarily mean that the mandible is small, just that it appears recessed when the face is viewed in profile.

Retrognathia is often referred to as an "overbite." The feature is not considered abnormal or unattractive and is generally proportionate to the rest of the face.

When the jawbone is abnormally small and out of proportion to the face, the person is said to have micrognathia, a condition that can cause serious health concerns, including difficulty breathing and feeding.


The anatomical structure of the face is based, at least in part, on a person's genetics. So, people with retrognathia will often have a jaw structure similar to that of other family members. (Burnett herself referred to her overbite as the "Burnett family lip.")

Rare genetic conditions also can cause severe malformations of the jaw, including Pierre-Robin sequence, a disorder characterized by an abnormally small mandible and associated breathing problems.

Facial trauma in early childhood development can also cause jaw displacement, often resulting in an asymmetrical, "set back" appearance.


Retrognathia may cause problems from as early as birth, with some babies unable to adequately to properly latch onto a nipple when feeding.

As the person gets older, misalignment of the teeth may affect the ability to bite or chew food, If the lower jaw is smaller, the teeth may also become crowded or irregularly positioned.

These features can contribute to a disorder known as temporomandibular joint disorder (TMJ), an often painful condition characterized by muscle spasms and tension in the jaw. Retrognathia can also cause disrupted breathing, especially during sleep or when lying on one's back.

Snoring and sleep apnea are not uncommon in people with retrognathia, caused when the recessed position of the jaw allows the tongue to slip back toward the airway. This can lead to abnormal gaps in breathing as well as gasping and choking.

• Narrow maxillary arch (the top of the mouth)

Children with Down's syndrome are at particularly high risk for developing these problems.


There are a group of rare disorders called mucopolysaccharidoses, or mucolipidoses, that may put children at increased risk of sleep apnea. This occurs because of the tissues in the upper airway accumulating large molecules and swelling in size. There are typically associated developmental abnormalities that are identified at birth or in early childhood, so most parents will be aware that their child has this condition.

Neuromuscular Factors

Loss of the control of the musculature of the upper airway may also lead to sleep apnea. A change in muscle tone (called hypotonia if it is low, or hypertonia if it is high) may contribute. Compression of the brainstem (as may occur in Arnold Chiari malformations or in tumors) may lead to sleep apnea. There are some developmental abnormalities, such as Down syndrome, that lead to a high risk for the condition. In general, other problems will be identified beyond the sleep apnea to suggest the risk of more serious conditions.

Any sleep disorder that disrupts deep sleep may decrease growth hormone secretion. Moreover, simply not getting enough sleep could have the same effects. Fortunately, children whose sleep apnea is treated undergo a rebound growth spurt. Many will recover to their prior growth trajectory, moving back to their prior percentiles. This suggests that addressing the other conditions that undermine sleep quality, such as restless legs syndrome, may likewise be beneficial.

Sleep Deprivation, Failure to Meet Sleep Needs, and Obesity

The risk of sleep deprivation causing obesity has been well studied in adults. Although the mechanism is not fully understood, it may relate to hormonal changes or effects on normal metabolism. A similar association appears to exist in children. When children don't get enough sleep at night to meet their age-based sleep needs, they are at risk of undermining their overall health.

Over the past 20 years, many independent studies of more than 50,000 children support the fact that sleep deprivation appears to be associated with an increased risk of obesity. In 2002, a study of 8,274 Japanese children who were 6-7 years old showed that fewer hours of sleep increased the risk of childhood obesity.

These consequences appear to persist beyond the period of sleep disruption. In 2005, a study showed that sleep deprivation at age 30 months predicted obesity at age 7 years. The researchers hypothesize that sleep disruption may cause permanent damage to the area of the brain called the hypothalamus, which is responsible for regulating appetite and energy expenditure.

The risks of untreated sleep disorders should prompt careful attention by parents to any signs that their child is not getting enough quality sleep. If you suspect a problem, you should speak with your pediatrician. A careful evaluation may offer some reassurance, and when treatment is indicated, it may help your child to grow and thrive.

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