Sleep disordered breathing / Obstructive sleep apnoea (OSA) (Paediatric Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • North NHS Highland only
  • Primary and Secondary Care
  • Children only

  1. History Taking

Suspect OSA if the following symptoms are present:

    • Snoring with apnoea
    • Loud inspiratory gasps
    • Breathing effort (chest retractions, mouth breathing, head extended)
    • Choking/gagging in sleep
    • Odd sleep positions or restless sleep
    • Daytime impacts: tiredness, concentration issues, behaviour challenges
    • Other signs: morning headaches, poor growth, worsening epilepsy

  1. Clinical Examination

Minimum Data set to include

    • Nasal obstruction?
    • Enlarged tonsils?
    • Syndromic appearance, or a known syndrome

  1. Red Flags (Urgent Referral if Any Present)

Check for red flags:

    • Extreme Obesity (BMI >3.5th centile for age)  (see definition table below)*
    • Age <2 years
    • Head extended while sleeping
    • Severe daytime sleepiness impacting daily activities
    • Signs of right heart strain (e.g., cyanosis, breathlessness)

  1. Who to refer to

ENT:

    • Children with upper airway obstruction from tonsils / adenoids should be referred to ENT

Refer to Medical Paediatrics if:

    • No obvious upper airway obstruction from tonsils / adenoids
    • Severe Obesity  ( please include height/weight/BMI).
    • Significant comorbidities (e.g., congenital heart disease, Down's syndrome, neurodisabilities, craniofacial anomalies, hypotonia, genetic disorders, mucopolysacharidosis).

  1. What to Include in the Referral

  • ALL referrals should include: relevant history, clinical examination and red flags as above
  • Request parents to capture video clips with audio: Include head and chest of child during sleep, save in a folder on their smart device, ready to be shown if a hospital appointment is offered.

  1. Hospital Management for suspected Severe OSA based on clinical concerns and or highly abnormal sleep study.

  • Admit urgently to the Children Ward. Shared care with Paediatric team
  • ENT consultant to Paediatric consultant discussion
  • Perform urgent inpatient sleep study if not already done
  • Liaise with tertiary ENT / Respiratory centres (Edinburgh / Glasgow).

Post-adenotonsillectomy OSA; If children re-present

Follow the same principles above

Assessment:

  • Evidence of nasal obstruction or tonsillar enlargement?
    • Yes: ENT to Consider redo surgery.
    • No: ENT/GP to refer to paediatrics.

Paediatric Management:

  • Urgent sleep study and outpatient clinic.
    • Liaise with Tertiary Respiratory centres if needed.

Guidance for parents

Extreme obesity definitions for different ages

Extreme obesity BMI >3.5sd ie BMI (kg/m2) over the following:

 Boys Girls
2 yrs 22.7 22.7
5 yrs 22 23.5
10 yrs 32 33
15 yrs 38 38
18 yrs 40 40

Abbrevations

  • BMI: body mass index
  • ENT: ear, nose and throat
  • OSA: Obstructive sleep apnoea

Editorial Information

Last reviewed: 28/08/2025

Next review date: 31/08/2028

Author(s): Paediatrics.

Version: 1

Approved By: TAM Subgroup of the ADTC

Reviewer name(s): Dr D Goudie, Consultant Paediatrician, Dr A Cain, Consultant, ENT .

Document Id: TAM706