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Sleep apnoea in children and adenotonsillectomy
In a child the commonest cause of obstructive sleep apnoea is enlarged tonsils and adenoids, and the first treatment is removing them; a sleep study before surgery is needed only in risk groups or when the picture is unclear, and high-risk children stay for overnight monitoring after surgery.
Why it matters in the exam
The peak is at age 2 to 8 years. The leading symptom is habitual snoring, with breathing pauses, restless sleep, bedwetting, and in the daytime — hyperactivity, attention problems and learning difficulty, sometimes FTT. Under AAO-HNS 2019, a sleep study (PSG) before tonsillectomy is advised in a child under age 2, with obesity, Down syndrome, craniofacial anomalies, neuromuscular disease, sickle cell disease and mucopolysaccharidoses, or when complaints and examination disagree. In children an AHI of 1 or more is abnormal: 1 to 5 — mild, 5 to 10 — moderate, 10 or more — severe.
The CHAT trial (2013) showed that adenotonsillectomy improves behaviour, quality of life and sleep study findings; normalisation of the sleep study within 7 months was about 79% versus about 46% with waiting. In mild disease an intranasal steroid and montelukast can be tried. Residual apnoea after surgery is commoner with obesity, severe disease and Down syndrome — where CPAP is an option. Indications for tonsillectomy for recurrent throat infection (Paradise criteria): 7 episodes in one year, 5 per year for two years, or 3 per year for 3 years, documented with fever, nodes, exudate or a positive streptococcal culture.
After surgery, admit for monitoring a child under age 3, a child with severe apnoea (AHI 10 or more or a nadir saturation below 80%), or a child with comorbidities. A single intraoperative dose of dexamethasone is advised; ibuprofen and paracetamol are allowed; codeine is forbidden under age 12; routine antibiotics are not advised. Primary bleeding appears within 24 hours, and secondary bleeding usually on day 5 to 10, in about 2% to 5%. Before adenoidectomy, look for a submucous cleft palate (bifid uvula, palatal notch, translucent midline), because removal can cause velopharyngeal insufficiency; in a child with Down syndrome take care with neck movement because of atlanto-axial instability.
Key points
- Enlarged tonsils — the common cause.
- PSG only in risk groups.
- AHI of 1 or more is abnormal in a child.
- Adenotonsillectomy — first line.
- Overnight monitoring: under age 3 and severe apnoea.
Summary table
| Topic | Criterion | Decision |
|---|---|---|
| PSG before surgery | Under age 2, obesity, Down, anomalies, neuromuscular disease | Perform a sleep study |
| Severity in children | AHI 1 to 5, 5 to 10, 10 or more | Mild, moderate, severe |
| First line | Enlarged tonsils with apnoea | Adenotonsillectomy |
| Mild disease | Low AHI, moderate tonsils | Intranasal steroid and montelukast |
| Recurrent infections (Paradise) | 7 in a year, 5 a year for two years, 3 a year for 3 years | Tonsillectomy |
| Overnight monitoring | Under age 3, AHI 10 or more, saturation below 80% | Admission after surgery |
A free exam question
מהו הגיל האופייני להופעה של PFAPA ? (Periodic Fever With Aphthous Ulcers, Pharyngitis, and Adenopathy) (the question as examined, in Hebrew)
- א. 5-7 שנים
- ב. 8-10 שנים
- ג. 11-13 שנים
- ד. 2-5 שנים
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Sources
- AAO-HNS Clinical Practice Guideline: Tonsillectomy in Children (Update), 2019 — Indications, polysomnography and perioperative care
- AAP Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome, 2012 — Adenotonsillectomy and CPAP
- Marcus CL et al. A randomized trial of adenotonsillectomy for childhood sleep apnea (CHAT, NEJM), 2013 — Main results
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.
See also: Obstructive sleep apnoea in adults: diagnosis and surgery