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Snoring and Obstructive Sleep Apnoea in Children


This guideline applies to children and young people aged 15 years and younger.

 

Introduction

Snoring is common in children, affecting 4-5% of 5-year-olds. It is usually due to adenotonsillar hypertrophy. Adenoids tend to grow from birth, reaching the largest size when the child is 3-5yr old, before slowly shrinking away by adulthood1. Therefore, snoring symptoms tend to resolve as the child grows. Snoring often has no significant impact on health, but in severe cases can be associated with sleep apnoea.

 

Red Flag Features

Obstructive airway symptoms and signs not attributable to adenotonsillar hypertrophy e.g. stridor.

 

Key Features of Assessment

Simple snoring

  • Common
  • Often no significant impact on health
  • Usually exacerbated by concurrent URTI or nasal obstruction/congestion

Obstructive Sleep Apnoea (OSA)

  • Observed episodes of apnoea, often followed by a gasp, snort or choking sound
  • Sometimes restlessness, laboured breathing or sudden arousal from sleep
  • These episodes occur throughout the night, every night (not just with URTIs), are often associated with snoring (but not always) and may be associated with behavioural problems, irritability, reduced concentration, reduced school performance and, in severe cases, faltering growth

Differential diagnosis of stridor (not exhaustive)

  • Foreign body: sudden onset stridor in an otherwise well child.
  • Croup: stridor in the context of an unwell child with barking cough, fever, working hard to breathe.
  • Epiglottis / supraglottitis: toxic child with stridor, drooling, laboured breathing, high fever, unvaccinated. Do not attempt to examine the throat with a tongue depressor as this could induce laryngospasm.
  • Anaphylaxis: stridor, wheeze, breathlessness, hypotension, tachycardia, rash, suspected trigger.

 

Management

In the context of a well child without any red flag features:

  1. In most cases, reassurance and education will be all that is required. Provide patient information, including explanation on likely cause of and natural history of simple snoring in children.
     
  2. When apnoeic episodes are:
  • transient or limited to URTIs, reassure and explain that referral is not necessary as surgery would not work, and is therefore not appropriate in these instances.
     
  • persistent, associated with behavioural problems and/or faltering growth, refer to secondary care.

Where possible, get parents to video record the apnoeic episodes causing concern.

 

Advice and Guidance

If diagnostic uncertainty, consider seeking ENT Advice and Guidance.

 

Referral

Same-day care

Arrange assessment via discussion with Paediatrics first on-call for:

  • Patients with obstructive airway symptoms or signs not attributable to adenotonsillar hypertrophy e.g. stridor.

Use clinical judgement to determine whether to call 999 and/or initiate treatment in the case of suspected life-threatening causes of stridor i.e. epiglottitis, anaphylaxis, foreign body, severe croup etc.

 

Paediatric ENT (Neck and Throat) Referral

  • Suspected OSA in children, for consideration of adenotonsillectomy (this procedure is usually curative in children).

 

General Paediatric Referral

  • Snoring children with wider health concerns, e.g. congenital or developmental disorder faltering growth and/or obesity.

 

Supporting Information

For professionals:

NICE CKS – Obstructive Sleep Apnoea Syndrome

For patients:

ENT UK – Snoring and Sleep Apnoea

 

References

  1. Kernow CCG commissioning policies – snoring in the absence of obstructive sleep apnoea

 

Page Review Information

Review date

05/04/2024

Next review date

05/04/2026

GP speciality lead

Dr Laura Vines

Contributors

Ms Aileen Lambert, Consultant ENT Surgeon

Mr Neil Tan, Consultant ENT Surgeon

                                                                                     

Criteria for Adenoidectomy