Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Evaluation of suspected obstructive sleep apnea in children

Shalini Paruthi, MD
Section Editor
Ronald D Chervin, MD, MS
Deputy Editor
Alison G Hoppin, MD


Obstructive sleep apnea (OSA) is characterized by episodes of complete or partial upper airway obstruction during sleep, often resulting in gas exchange abnormalities and disrupted sleep. Untreated OSA is associated with learning and behavioral problems, cardiovascular complications, and impaired growth (including failure to thrive [FTT]) [1-6]. Early diagnosis and treatment of OSA may decrease morbidity. However, diagnosis is frequently delayed [3,7]. (See "Management of obstructive sleep apnea in children", section on 'Consequences of untreated OSA'.)

The risk factors, clinical manifestations, screening, and diagnostic evaluation of children who are suspected of having OSA are reviewed here. Pathogenesis, predisposing conditions, and treatment of pediatric OSA are discussed in other topic reviews:

(See "Mechanisms and predisposing factors for sleep-related breathing disorders in children".)

(See "Management of obstructive sleep apnea in children".)

(See "Adenotonsillectomy for obstructive sleep apnea in children".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: May 2017. | This topic last updated: May 16, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 1998; 157:1098.
  2. Enright PL, Goodwin JL, Sherrill DL, et al. Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea study. Arch Pediatr Adolesc Med 2003; 157:901.
  3. Brouillette RT, Fernbach SK, Hunt CE. Obstructive sleep apnea in infants and children. J Pediatr 1982; 100:31.
  4. Nieminen P, Löppönen T, Tolonen U, et al. Growth and biochemical markers of growth in children with snoring and obstructive sleep apnea. Pediatrics 2002; 109:e55.
  5. Guilleminault C, Lee JH, Chan A. Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med 2005; 159:775.
  6. Beebe DW, Ris MD, Kramer ME, et al. The association between sleep disordered breathing, academic grades, and cognitive and behavioral functioning among overweight subjects during middle to late childhood. Sleep 2010; 33:1447.
  7. Richards W, Ferdman RM. Prolonged morbidity due to delays in the diagnosis and treatment of obstructive sleep apnea in children. Clin Pediatr (Phila) 2000; 39:103.
  8. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130:e714.
  9. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien 2014.
  10. Arens R, Marcus CL. Pathophysiology of upper airway obstruction: a developmental perspective. Sleep 2004; 27:997.
  11. Spilsbury JC, Storfer-Isser A, Rosen CL, Redline S. Remission and incidence of obstructive sleep apnea from middle childhood to late adolescence. Sleep 2015; 38:23.
  12. Hannon TS, Rofey DL, Ryan CM, et al. Relationships among obstructive sleep apnea, anthropometric measures, and neurocognitive functioning in adolescents with severe obesity. J Pediatr 2012; 160:732.
  13. Qubty WF, Mrelashvili A, Kotagal S, Lloyd RM. Comorbidities in infants with obstructive sleep apnea. J Clin Sleep Med 2014; 10:1213.
  14. Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011; 34:379.
  15. Rosen CL, Larkin EK, Kirchner HL, et al. Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. J Pediatr 2003; 142:383.
  16. Paavonen EJ, Strang-Karlsson S, Räikkönen K, et al. Very low birth weight increases risk for sleep-disordered breathing in young adulthood: the Helsinki Study of Very Low Birth Weight Adults. Pediatrics 2007; 120:778.
  17. Redline S, Tishler PV, Tosteson TD, et al. The familial aggregation of obstructive sleep apnea. Am J Respir Crit Care Med 1995; 151:682.
  18. Buxbaum SG, Elston RC, Tishler PV, Redline S. Genetics of the apnea hypopnea index in Caucasians and African Americans: I. Segregation analysis. Genet Epidemiol 2002; 22:243.
  19. Sundquist J, Li X, Friberg D, et al. Obstructive sleep apnea syndrome in siblings: an 8-year Swedish follow-up study. Sleep 2008; 31:817.
  20. Tapia IE, Shults J, Doyle LW, et al. Perinatal Risk Factors Associated with the Obstructive Sleep Apnea Syndrome in School-Aged Children Born Preterm. Sleep 2016; 39:737.
  21. Kothare SV, Rosen CL, Lloyd RM, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea. J Clin Sleep Med 2015; 11:385.
  22. Weinstock TG, Rosen CL, Marcus CL, et al. Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates. Sleep 2014; 37:261.
  23. Carroll JL, McColley SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 1995; 108:610.
  24. Guilleminault C, Korobkin R, Winkle R. A review of 50 children with obstructive sleep apnea syndrome. Lung 1981; 159:275.
  25. Ali NJ, Pitson DJ, Stradling JR. Snoring, sleep disturbance, and behaviour in 4-5 year olds. Arch Dis Child 1993; 68:360.
  26. Gislason T, Benediktsdóttir B. Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old. An epidemiologic study of lower limit of prevalence. Chest 1995; 107:963.
  27. Redline S, Tishler PV, Schluchter M, et al. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med 1999; 159:1527.
  28. Li AM, Au CT, So HK, et al. Prevalence and risk factors of habitual snoring in primary school children. Chest 2010; 138:519.
  29. Rosen CL, Storfer-Isser A, Taylor HG, et al. Increased behavioral morbidity in school-aged children with sleep-disordered breathing. Pediatrics 2004; 114:1640.
  30. Goh DY, Galster P, Marcus CL. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir Crit Care Med 2000; 162:682.
  31. Frank Y, Kravath RE, Pollak CP, Weitzman ED. Obstructive sleep apnea and its therapy: clinical and polysomnographic manifestations. Pediatrics 1983; 71:737.
  32. Rosen CL. Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children. Pediatr Pulmonol 1999; 27:403.
  33. Chervin RD, Archbold KH, Dillon JE, et al. Inattention, hyperactivity, and symptoms of sleep-disordered breathing. Pediatrics 2002; 109:449.
  34. Suratt PM, Barth JT, Diamond R, et al. Reduced time in bed and obstructive sleep-disordered breathing in children are associated with cognitive impairment. Pediatrics 2007; 119:320.
  35. Rudnick EF, Mitchell RB. Behavior and obstructive sleep apnea in children: is obesity a factor? Laryngoscope 2007; 117:1463.
  36. Beebe DW. Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review. Sleep 2006; 29:1115.
  37. Beebe DW, Rausch J, Byars KC, et al. Persistent snoring in preschool children: predictors and behavioral and developmental correlates. Pediatrics 2012; 130:382.
  38. Perfect MM, Archbold K, Goodwin JL, et al. Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing. Sleep 2013; 36:517.
  39. O'Brien LM, Holbrook CR, Mervis CB, et al. Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention-deficit/hyperactivity disorder. Pediatrics 2003; 111:554.
  40. Stradling JR, Thomas G, Warley AR, et al. Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children. Lancet 1990; 335:249.
  41. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics 1998; 102:616.
  42. Ali NJ, Pitson D, Stradling JR. Natural history of snoring and related behaviour problems between the ages of 4 and 7 years. Arch Dis Child 1994; 71:74.
  43. Huang YS, Guilleminault C, Li HY, et al. Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study. Sleep Med 2007; 8:18.
  44. Mitchell RB, Kelly J. Child behavior after adenotonsillectomy for obstructive sleep apnea syndrome. Laryngoscope 2005; 115:2051.
  45. Mitchell RB, Kelly J. Behavioral changes in children with mild sleep-disordered breathing or obstructive sleep apnea after adenotonsillectomy. Laryngoscope 2007; 117:1685.
  46. Wei JL, Mayo MS, Smith HJ, et al. Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing. Arch Otolaryngol Head Neck Surg 2007; 133:974.
  47. Garetz SL. Behavior, cognition, and quality of life after adenotonsillectomy for pediatric sleep-disordered breathing: summary of the literature. Otolaryngol Head Neck Surg 2008; 138:S19.
  48. Chervin RD, Ruzicka DL, Giordani BJ, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 2006; 117:e769.
  49. Marcus CL, Curtis S, Koerner CB, et al. Evaluation of pulmonary function and polysomnography in obese children and adolescents. Pediatr Pulmonol 1996; 21:176.
  50. Williams EF 3rd, Woo P, Miller R, Kellman RM. The effects of adenotonsillectomy on growth in young children. Otolaryngol Head Neck Surg 1991; 104:509.
  51. Katz ES, Moore RH, Rosen CL, et al. Growth after adenotonsillectomy for obstructive sleep apnea: an RCT. Pediatrics 2014; 134:282.
  52. Soultan Z, Wadowski S, Rao M, Kravath RE. Effect of treating obstructive sleep apnea by tonsillectomy and/or adenoidectomy on obesity in children. Arch Pediatr Adolesc Med 1999; 153:33.
  53. Hashemian F, Farahani F, Sanatkar M. Changes in growth pattern after adenotonsillectomy in children under 12 years old. Acta Med Iran 2010; 48:316.
  54. Roemmich JN, Barkley JE, D'Andrea L, et al. Increases in overweight after adenotonsillectomy in overweight children with obstructive sleep-disordered breathing are associated with decreases in motor activity and hyperactivity. Pediatrics 2006; 117:e200.
  55. Lewis TL, Johnson RF, Choi J, Mitchell RB. Weight gain after adenotonsillectomy: a case control study. Otolaryngol Head Neck Surg 2015; 152:734.
  56. Li AM, Au CT, Sung RY, et al. Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study. Thorax 2008; 63:803.
  57. Tal A, Leiberman A, Margulis G, Sofer S. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonol 1988; 4:139.
  58. Ross RD, Daniels SR, Loggie JM, et al. Sleep apnea-associated hypertension and reversible left ventricular hypertrophy. J Pediatr 1987; 111:253.
  59. Hodges S, Wailoo MP. Tonsillar enlargement and failure to thrive. Br Med J (Clin Res Ed) 1987; 295:541.
  60. Chan JY, Li AM, Au CT, et al. Cardiac remodelling and dysfunction in children with obstructive sleep apnoea: a community based study. Thorax 2009; 64:233.
  61. Nisbet LC, Nixon GM, Yiallourou SR, et al. Sleep-disordered breathing does not affect nocturnal dipping, as assessed by pulse transit time, in preschool children: evidence for early intervention to prevent adverse cardiovascular effects? Sleep Med 2014; 15:464.
  62. Horne RS, Yang JS, Walter LM, et al. Nocturnal dipping is preserved in children with sleep disordered breathing regardless of its severity. Pediatr Pulmonol 2013; 48:1127.
  63. Quante M, Wang R, Weng J, et al. The Effect of Adenotonsillectomy for Childhood Sleep Apnea on Cardiometabolic Measures. Sleep 2015; 38:1395.
  64. Nisbet LC, Yiallourou SR, Biggs SN, et al. Preschool children with obstructive sleep apnea: the beginnings of elevated blood pressure? Sleep 2013; 36:1219.
  65. Gozal D, Kheirandish-Gozal L, Serpero LD, et al. Obstructive sleep apnea and endothelial function in school-aged nonobese children: effect of adenotonsillectomy. Circulation 2007; 116:2307.
  66. Duman D, Naiboglu B, Esen HS, et al. Impaired right ventricular function in adenotonsillar hypertrophy. Int J Cardiovasc Imaging 2008; 24:261.
  67. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130:576.
  68. Leach J, Olson J, Hermann J, Manning S. Polysomnographic and clinical findings in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992; 118:741.
  69. Marcus CL. Sleep-disordered breathing in children. Am J Respir Crit Care Med 2001; 164:16.
  70. McColley SA, Carroll JL, Curtis S, et al. High prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apnea. Chest 1997; 111:170.
  71. Silvestri JM, Weese-Mayer DE, Bass MT, et al. Polysomnography in obese children with a history of sleep-associated breathing disorders. Pediatr Pulmonol 1993; 16:124.
  72. Friedman M, Tanyeri H, La Rosa M, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope 1999; 109:1901.
  73. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep 2006; 29:903.
  74. Wang RC, Elkins TP, Keech D, et al. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg 1998; 118:69.
  75. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg 1995; 121:525.
  76. Dreher A, de la Chaux R, Klemens C, et al. Correlation between otorhinolaryngologic evaluation and severity of obstructive sleep apnea syndrome in snorers. Arch Otolaryngol Head Neck Surg 2005; 131:95.
  77. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 145:S1.
  78. Canet E, Gaultier C, D'Allest AM, Dehan M. Effects of sleep deprivation on respiratory events during sleep in healthy infants. J Appl Physiol (1985) 1989; 66:1158.
  79. Hershenson M, Brouillette RT, Olsen E, Hunt CE. The effect of chloral hydrate on genioglossus and diaphragmatic activity. Pediatr Res 1984; 18:516.
  80. Katz ES, Greene MG, Carson KA, et al. Night-to-night variability of polysomnography in children with suspected obstructive sleep apnea. J Pediatr 2002; 140:589.
  81. Verhulst SL, Schrauwen N, De Backer WA, Desager KN. First night effect for polysomnographic data in children and adolescents with suspected sleep disordered breathing. Arch Dis Child 2006; 91:233.
  82. Berry RB, Brooks R, Gamaldo CE, et al for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.4, www.aasmnet.org, American Academy of Sleep Medicine, Darien, IL 2017.
  83. Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2007; 3:737.
  84. Goodwin JL, Enright PL, Kaemingk KL, et al. Feasibility of using unattended polysomnography in children for research--report of the Tucson Children's Assessment of Sleep Apnea study (TuCASA). Sleep 2001; 24:937.
  85. Marcus CL, Traylor J, Biggs SN, et al. Feasibility of comprehensive, unattended ambulatory polysomnography in school-aged children. J Clin Sleep Med 2014; 10:913.
  86. Zucconi M, Calori G, Castronovo V, Ferini-Strambi L. Respiratory monitoring by means of an unattended device in children with suspected uncomplicated obstructive sleep apnea: a validation study. Chest 2003; 124:602.
  87. Poels PJ, Schilder AG, van den Berg S, et al. Evaluation of a new device for home cardiorespiratory recording in children. Arch Otolaryngol Head Neck Surg 2003; 129:1281.
  88. Marcus CL, Keens TG, Ward SL. Comparison of nap and overnight polysomnography in children. Pediatr Pulmonol 1992; 13:16.
  89. Saeed MM, Keens TG, Stabile MW, et al. Should children with suspected obstructive sleep apnea syndrome and normal nap sleep studies have overnight sleep studies? Chest 2000; 118:360.
  90. Kaditis A, Kheirandish-Gozal L, Gozal D. Pediatric OSAS: Oximetry can provide answers when polysomnography is not available. Sleep Med Rev 2016; 27:96.
  91. Garde A, Dehkordi P, Karlen W, et al. Development of a screening tool for sleep disordered breathing in children using the phone Oximeter™. PLoS One 2014; 9:e112959.
  92. Brouillette RT, Morielli A, Leimanis A, et al. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics 2000; 105:405.
  93. Lamm C, Mandeli J, Kattan M. Evaluation of home audiotapes as an abbreviated test for obstructive sleep apnea syndrome (OSAS) in children. Pediatr Pulmonol 1999; 27:267.
  94. Goldstein NA, Sculerati N, Walsleben JA, et al. Clinical diagnosis of pediatric obstructive sleep apnea validated by polysomnography. Otolaryngol Head Neck Surg 1994; 111:611.
  95. Sivan Y, Kornecki A, Schonfeld T. Screening obstructive sleep apnoea syndrome by home videotape recording in children. Eur Respir J 1996; 9:2127.
  96. Sleep-Related Breathing Disorder Scale (SRBD Scale), from Pediatric Sleep Questionnaire, to Identify Symptoms of Obstructive Sleep Apnea in Children. Available at: http://inventions.umich.edu/technologies/3773_sleep-related-breathing-disorder-scale-srbd-scale-from-pediatric-sleep-questionnaire-to-identify-symptoms-of-obstructive-sleep-apnea-in-children (Accessed on December 22, 2016).
  97. Rosen CL, Wang R, Taylor HG, et al. Utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome. Pediatrics 2015; 135:e662.
  98. Chervin RD, Weatherly RA, Garetz SL, et al. Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg 2007; 133:216.
  99. Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med 2000; 1:21.
  100. Ehsan Z, Kercsmar CM, Collins J, Simakajornboon N. Validation of the pediatric sleep questionnaire in children with asthma. Pediatr Pulmonol 2017; 52:382.
  101. Chervin RD, Weatherly RA, Ruzicka DL, et al. Subjective sleepiness and polysomnographic correlates in children scheduled for adenotonsillectomy vs other surgical care. Sleep 2006; 29:495.
  102. Kadmon G, Chung SA, Shapiro CM. I'M SLEEPY: a short pediatric sleep apnea questionnaire. Int J Pediatr Otorhinolaryngol 2014; 78:2116.
  103. Melendres MC, Lutz JM, Rubin ED, Marcus CL. Daytime sleepiness and hyperactivity in children with suspected sleep-disordered breathing. Pediatrics 2004; 114:768.
  104. Slaats MA, Van Hoorenbeeck K, Van Eyck A, et al. Upper airway imaging in pediatric obstructive sleep apnea syndrome. Sleep Med Rev 2015; 21:59.
  105. Francis A, Eltaki K, Bash T, et al. The safety of preoperative sedation in children with sleep-disordered breathing. Int J Pediatr Otorhinolaryngol 2006; 70:1517.
  106. Brown KA, Morin I, Hickey C, et al. Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative respiratory morbidity. Anesthesiology 2003; 99:586.
  107. Boudewyns A, Van de Heyning P, Verhulst S. Central apneas in children with obstructive sleep apnea syndrome: prevalence and effect of upper airway surgery. Sleep Med 2016; 25:93.
  108. Sedky K, Bennett DS, Carvalho KS. Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: a meta-analysis. Sleep Med Rev 2014; 18:349.