Clinical assessment of obstructive sleep apnoea in children

In children, obstructive sleep apnoea typically presents with habitual snoring and observed apnoea during sleep—see Clinical features of obstructive sleep apnoea in children for other common nocturnal and daytime features. The peak incidence in children is between 2 and 7 years of age; it is less common in the first 6 months of life.

Examination usually reveals adenotonsillar hypertrophy and mouth breathing.

In contrast to adults, children with obstructive sleep apnoea frequently present with hyperactivity, behavioural problems and poor school performance; tiredness may not be present. Poor weight gain—thought to be related to increased work of breathing during sleep—can also be present.

Figure 1. Clinical features of obstructive sleep apnoea in children

Snoring or witnessed apnoeas, plus any of the following clinical features, may indicate obstructive sleep apnoea in a child.

Nocturnal symptoms or signs:

gasping
increased work of breathing
restlessness
sweating
night waking
enuresis
mouth breathing
neck extension

Daytime symptoms or signs:

mouth breathing
hyperactivity
poor attention
behavioural problems
poor school performance
daytime somnolence
tiredness

If obstructive sleep apnoea is suspected based on presentation, take a full history. In children with predisposing genetic, anatomical or developmental conditions (see Causes of obstructive sleep apnoea in children), assess for symptoms and signs of obstructive sleep apnoea routinely.

The OSA-5 questionnaire is a screening tool for obstructive sleep apnoea in children (see OSA-5 screening questionnaire for obstructive sleep apnoea in children); it has high sensitivity and good negative predictive value but low specificity. It can be a useful adjunct to clinical judgement. It is most useful to identify children unlikely to have obstructive sleep apnoea—a score below 5 makes the diagnosis unlikely. For children who score 5 or more, see here for information on treatment and referral.

Table 1. OSA-5 screening questionnaire for obstructive sleep apnoea in children
Printable table
During the past 4 weeks, how often has the child had:	None of the time	Some of the time	Most of the time	All of the time
loud snoring?	0	1	2	3
breath holding spells or pauses in breathing at night?	0	1	2	3
choking or made gasping sounds while asleep?	0	1	2	3
mouth breathing because of a blocked nose?	0	1	2	3
breathing problems during sleep that made you worried they were not getting enough air?	0	1	2	3
Total score:
A total score below 5 makes the diagnosis of obstructive sleep apnoea unlikely. A total score of 5 or higher has good sensitivity but poor specificity for moderate to severe obstructive sleep apnoea.
Note: Reproduced from Soh HJ, Rowe K, Davey MJ, Horne RSC, Nixon GM. The OSA-5: Development and validation of a brief questionnaire screening tool for obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol 2018;113:62-6. [URL] with permission from Elsevier.

Home overnight pulse oximetry showing multiple clusters of oxygen desaturation is a specific but not sensitive test for obstructive sleep apnoea in children; it can avoid the need for an overnight sleep study in up to 25% of preschool children with a suggestive history. However, a sleep study is required if overnight oximetry is normal in a child with a suggestive history.