As we explained in previous blogs, as opposed to adults where OSA is most often related to being overweight, in otherwise healthy kids the most common cause of OSA is enlarged tonsils and adenoids (glands located at the exit of the nose canal as it enters the throat). This being the case, the most effective treatment of children with OSA is the surgical removal of the tonsils and adenoids (called adenotonsillectomy or AT). This procedure generally improves the sleep apnea and the associated symptoms and is considered the “first-line” of treatment.
Initially, this surgery was felt to be so effective that it cured almost 90% of children with OSA. However, more recent studies in the medical literature show that up to one third of the children who had AT did not respond as well as originally believed. A relatively recent research trial showed that children with persistent sleep apnea even after AT who were treated with medications that lower inflammation, such as steroid nasal sprays (e.g. Rhinocort, and others) and monteleukast (Singulair) had a significant improvement in their sleep apnea. The inflammation that is being treated is probably a result of allergies and the frequent viruses that children develop, and are also probably the cause of the enlarged tonsils and adenoids in the first place. These medicines do not play a significant role before AT, just as a back-up after the surgery if mild OSA still persists.
Continuous positive airway pressure or CPAP plays in a much smaller role in treatment of OSA in kids compared to adults (please refer to previous blogs on CPAP). As opposed to AT which is a one-time procedure offering a cure of the problem, CPAP needs to be used every night and is not a “cure”, but rather fixes the problem of the repetitive airway collapse by keeping it open only when it is being used. We have already discussed the difficulty that adults have in adjusting to nightly CPAP use, a problem which is amplified in children. It also requires close medical follow-up because as the child grows there may be the need for higher pressures or different masks. Due to these issues, CPAP is reserved for those cases that surgery can not be performed or is refused, those children who have “adult-like” sleep apnea related to obesity or other facial deformities, and when there is persistent OSA despite AT and use of anti-inflammatory medications. With all the news we have been hearing about the epidemic of obesity among children, there is a growing concern that more kids will need to be placed on CPAP in the near future.
Just to summarize the information we covered on pediatric OSA: