Treatment of obstructive sleep apnoea in children
Overview
Children with features of obstructive sleep apnoea (see Clinical features of obstructive sleep apnoea in children) who are younger than 2 years or have risk factors such as craniofacial abnormalities or Down syndrome should always be referred to a paediatrician with expertise in sleep, or an ear, nose and throat surgeon.
For children 2 years or older with no risk factors, consider referral to an ear, nose and throat surgeon for surgical management if the child has adenotonsillar hypertrophy. If the child does not have adenotonsillar hypertrophy, consider a trial of drug therapy instead of, or while awaiting, specialist referral.
Other interventions for obstructive sleep apnoea in children include noninvasive ventilation (usually continuous positive airway pressure [CPAP]) or craniofacial surgery.
Poorly controlled asthma can worsen obstructive sleep apnoea, and obstructive sleep apnoea can worsen asthma. Optimise management of both conditions in children with coexisting disease. See Asthma maintenance management in children for details about managing asthma in children.
Drug therapy
Consider a trial of drug therapy instead of specialist referral, or while awaiting specialist referral, for children 2 years or older who do not have risk factors (such as craniofacial abnormalities or Down syndrome). Some children experience complete resolution of symptoms with drug therapy and do not require further investigation or referral. Drug therapy may be particularly useful in children with coexisting allergic rhinitis.
Intranasal corticosteroids can reduce nasal obstruction and symptoms of obstructive sleep apnoea. Instruct patients on how to use nasal sprays correctly to minimise drug deposition onto the nasal septum; see Patient instructions for using a nasal spray. Use:
1 fluticasone furoate 27.5 micrograms per spray, 1 or 2 sprays into each nostril, once daily obstructive sleep apnoea (child) fluticasone furoate
OR
1 mometasone 50 micrograms per spray, 1 spray into each nostril, once daily. obstructive sleep apnoea (child) mometasone
Review drug therapy after 4 to 6 weeks. If the child has a good response, continue therapy until symptoms resolve. The optimal duration of treatment has not been studied. Therapy can be restarted if symptoms recur after stopping.
If the child does not respond to intranasal corticosteroid therapy, refer to a paediatric respiratory or sleep physician for assessment, including consideration of a sleep study1 and surgical management. Consider using combination therapy with an intranasal corticosteroid and montelukast or an oral antihistamine, at the same dosages used for allergic rhinitis, while awaiting referral.
Surgical management
Adenotonsillectomy is curative in up to 90% of children with obstructive sleep apnoea in the absence of underlying medical problems.
Consider referring children with features of obstructive sleep apnoea (see Clinical features of obstructive sleep apnoea in children) and marked adenotonsillar hypertrophy to an ear, nose and throat surgeon for adenotonsillectomy. Drug therapy can be trialled while awaiting referral.
Adenotonsillectomy can also be considered in children without marked adenotonsillar hypertrophy who do not respond to drug therapy.
If symptoms of obstructive sleep apnoea persist after an adenotonsillectomy, refer the child to a paediatrician with expertise in respiratory or sleep medicine for consideration of a sleep study.2