What are the signs and symptoms of obstructive sleep apnea in a toddler?

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Elsevier ClinicalKey Clinical Overview

Summary Manifestations suggestive of OSA are highly variable in children and adolescents and may include: Nighttime symptoms: snoring, restless sleep, witnessed apnea, nighttime awakenings, unusual positioning during sleep, enuresis Daytime symptoms: morning headaches, excessive daytime sleepiness, irritability, hyperactivity, inattentiveness, poor school performance, depressed mood, anxiety, recurrent otitis media Evidence of systemic or pulmonary hypertension Morbid obesity

Diagnosis Suspect diagnosis based on complete sleep history and physical examination Symptoms in pediatric age groups may differ somewhat than those common in adults and may include snoring, restless sleep, enuresis, morning headaches, thirst, irritability, hyperactivity, poor school performance, and behavioral problems Because persistent snoring is one of the primary symptoms of OSA, occurrence of snoring 3 or more nights per week associated with any additional potential sequelae consistent with OSA requires further evaluation for OSA Validated screening questionnaires may be used to evaluate children presenting for evaluation of possible OSA The sleep-disordered breathing section of the pediatrics sleep questionnaire (ie, PSQ-SRBD Scale) is the most widely utilized instrument to assess symptom burden in children with concern for OSA Scores greater than 0.33 have demonstrated an increased risk of elevated AHI Presumptive diagnosis of OSA May be assigned in children with consistent clinical presentation and enlarged tonsils so that treatment with adenotonsillectomy may proceed without a priori necessity for PSG Attended, overnight, in-laboratory PSG is gold standard test to confirm diagnosis in children and adolescents, when indicated

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Zur, Karen B. (2025). In Nelson Textbook of Pediatrics (pp. 2562). DOI: 10.1016/B978-0-323-88305-4.00431-4

The diagnosis of airway obstruction (seeChapter 31) can frequently be made by history and physical examination. Daytime symptoms of airway obstruction secondary to adenotonsillar hypertrophy include chronic mouth breathing, nasal obstruction, hyponasal speech, hyposmia,decreased appetite, poor school performance, hyperactivity, and, rarely, symptoms of right-sided heart failure. Nighttime symptoms consist of loud snoring, choking, gasping, frank apnea, restless sleep, abnormal sleep positions, sleep walking, night terrors, diaphoresis, enuresis, and sleep talking. Large tonsils are typically seen on examination, although the absolute size might not indicate the degree of obstruction. The size of the adenoid tissue can be demonstrated on a lateral neck radiograph or with flexible endoscopy. Other signs that can contribute to airway obstruction include the presence of a craniofacial syndrome or hypotonia. These daytime and nocturnal comorbidities should be explored in patients with enlarged tonsils and/or adenoids. Sleep studies (polysomnograms, PSG) are not routinely recommended unless significant co-morbidities exist.

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Owens, Judith A., Gueye-Ndiaye, Seyni (2025). In Nelson Textbook of Pediatrics (pp. 201). DOI: 10.1016/B978-0-323-88305-4.00031-6

The clinical manifestations of OSA may be divided into sleep-related and daytime symptoms. The most common nocturnal manifestations of OSA in children and adolescents are loud, frequent, and disruptive snoring; breathing pauses; choking or gasping arousals; restless sleep; and nocturnal diaphoresis. Many children who snore do not have OSA, but few children with OSA do not snore (caregivers may not be aware of snoring in older children and adolescents). Children, like adults, tend to have more frequent and more severe obstructive events in REM sleep and when sleeping in the supine position. Children with OSA may adopt unusual sleeping positions, keeping their necks hyperextended to maintain airway patency. Frequent arousals associated with obstruction may result in nocturnal awakenings but are more likely to cause fragmented sleep. Daytime symptoms of OSA include mouth breathing and dry mouth, chronic nasal congestion or rhinorrhea, hyponasal speech, morning headaches, difficulty swallowing, and poor appetite. Children with OSA may havesecondary enuresis,postulated to result from the disruption of the normal nocturnal pattern of atrial natriuretic peptide secretion by changes in intrathoracic pressure associated with OSA. Partial arousal parasomnias (sleepwalking and sleep terrors) may occur more frequently in children with OSA, related to the frequent associated arousals and an increased percentage of SWS. One of the most important but frequently overlooked sequelae of OSA in children is the effect on mood, behavior, learning, and academic functioning. The neurobehavioral consequences of OSA in children include daytime sleepiness with drowsiness, difficulty in morning waking, and unplanned napping or dozing off during activities, although evidence of frank hypersomnolence tends to be less common in children compared to adults with OSA (except in very obese children or those with severe disease). Mood changes include increased irritability, mood instability and emotional dysregulation, low frustration tolerance, and depression or anxiety.

The 2012 revised American Academy of Pediatrics clinical practice guidelines provide excellent information for the evaluation and management of uncomplicated childhood OSA (Table 31.5). No physical examination findings are truly pathognomonic for OSA, and most healthy children with OSA appear normal; however, certain physical examination findings may suggest OSA. Growth parameters may be abnormal (obesity, or less frequently, failure to thrive), and there may be evidence of chronic nasal obstruction (hyponasal speech, mouth breathing, septal deviation) and signs of atopic disease (i.e., “allergic shiners”). Oropharyngeal examination may reveal enlarged tonsils, excess soft tissue in the posterior pharynx, and a narrowed posterior pharyngeal space, as well as craniofacial features associated with an increased risk of obstruction including “adenoidal facies” with open mouth posture and long/asymmetric face, midface hypoplasia, retrognathia and micrognathia, forward head posture (best appreciated by inspection of the frontal and lateral facial profile), and teeth crowding, narrow arched palate, and tongue tie (short frenulum). In severe cases the child may have evidence of pulmonary hypertension, right-sided heart failure, and cor pulmonale; systemic hypertension may occur, especially in obese children. Because no combination of clinical history and physical findings can accurately predict which children with snoring have OSA, the gold standard for diagnosing OSA remains an in-lab overnightPSG.