Obstructive sleep apnea in developmental age. A narrative review

  • Anna Lo BueEmail author
  • Adriana Salvaggio
  • Giuseppe Insalaco


Sleep is a physiological function that undergoes, at different stages of life, to considerable variations in neurophysiological and behavioral functions. The developmental age is a period characterized by a continuous process of physical and neuropsychological changes and synaptic remodeling processes that are the neurophysiological basis of brain plasticity, typical of this developmental phase, occurring mainly during sleep. In the description of obstructive sleep apnea (OSA) in children, two main points should be highlighted: its variability in different age groups, and its specificity compared with OSA in adults. The definition and criteria used for the diagnosis of OSA in adults are not applicable to OSA in developmental age. Although the adenotonsillar hypertrophy is the most common risk factor for pediatric OSA, obesity is becoming an increasingly prevalent risk factor, mostly in early childhood (6–9 years) and adolescence. OSA has been shown to affect cognitive function in children and adults. However, OSA impact on cognitive function in children is more severe since acting on the plastic brain structures can change the neuro-psychic development, learning skills, and social interactions. There is a clear difference in the definition of pathology between developmental age and adulthood according to the instrumental parameters: an AHI ≥ 5, which represents, in the pediatric age, the cut-off for a therapeutic pathway necessary to avoid a long-term effect on the child, instead, it represents in adulthood, the lower limit value for the definition of disease. This is a narrative review concerning obstructive sleep apnea in developmental age.

Conclusions: OSA is a common disorder in children and those at risk must be identified, studied, and treated promptly because untreated OSA can be responsible for cardiovascular, metabolic, and neurocognitive morbidities and may induce, sometimes, non-reversible deficits given his insistence on a period of physical and neuro-psychic development.

What is Known:

This is a review concerning Obstructive Sleep Apnea in developmental age

•Clinical manifestation, diagnostic and therapeutic criteria of sleep apnea in developmental age

What is New:

This is a “narrative” review

•This narrative review describes sleep apnea comparing and analyzing the different ages of life


Pediatric obstructive sleep apnea Children Sleep-disordered breathing Upper airway Diagnosis Treatment 



American Academy of Sleep Medicine


Apnea hypopnea index




Continuous positive airway pressure


Excessive daytime sleepiness


Home cardiorespiratory polygraphy


International Classification of Sleep Disorders


Obstructive sleep apnea


Pediatric sleep questionnaire




Respiratory disturbance index


Rapid eye movement


Respiratory effort-related arousals


Sleep disordered breathing


Sleep-related breathing disorder


Total sleep time


Authors’ Contributions

LBA conceived the study, was responsible for the collection of data and their organization, and drafted the manuscript. SA contributed to the design of the study and drafted the manuscript. IG conceived the study, contributed to the interpretation of the data, and performed a critical revision of the article. All authors actively discussed the subject, revised the paper, and provided final approval.

Funding information

This work was supported by the National Research Council of Italy, order numbers DSB.AD008.060 and DSB.AD002.054. The funders had no role in the study design, data collection, and analysis, decision to publish or preparation of the manuscript.

Compliance with ethical standards

Consent for publication

All participants gave written informed consent for personal data processing.

Competing interests

The authors declare that they have no competing interests.


  1. 1.
    Tononi G, Cirelli C (2006) Sleep function and synaptic homeostasis. Sleep Med Rev 10:49–62PubMedCrossRefGoogle Scholar
  2. 2.
    Bruni O (2000) Principi di medicina del sonno in età evolutiva. Mediserve editoreGoogle Scholar
  3. 3.
    American Academy of Sleep Medicine (2014) International classification of sleep disorders. 3rd ed. American Academy of Sleep Medicine, DarienGoogle Scholar
  4. 4.
    Villa MP, Brunetti L, Bruni O, Cirignotta F, Cozza P, Donzelli G, Ferini Strambi L, Levrini L, Mondini S, Nespoli L, Nosetti L, Pagani J, Zucconi M, Gruppo di Studio Interdisciplinare Disturbi Respiratori nel Sonno (2004) Guidelines for the diagnosis of childhood obstructive sleep apnea syndrome. Minerva Pediatr 56:239–253PubMedGoogle Scholar
  5. 5.
    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235PubMedCrossRefGoogle Scholar
  6. 6.
    Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, Mooser V, Preisig M, Malhotra A, Waeber G, Vollenweider P, Tafti M, Haba-Rubio J (2015) Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 3:310–318PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Alsubie HS, BaHamm AS (2016) Obstructive sleep apnoea: children are not little adults. Paediatr Respir RevGoogle Scholar
  8. 8.
    Chang SJ, Chae KY (2010) Obstructive sleep apnea syndrome in children: epidemiology, pathophysiology, diagnosis and sequelae. Korean J Pediatr 53:863–871PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM, American Academy of Sleep Medicine, American Academy of sleep medicine (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 8:597–619PubMedPubMedCentralGoogle Scholar
  10. 10.
    Reuter S, Moser C, Baack M (2014) Respiratory distress in the newborn. Pediatr Rev 35(10):417–429PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Dotan R, Mitchell C, Cohen R et al (2012) Child-adult differences in muscle activation - a review. Pediatr Exerc Sci 24:47–49CrossRefGoogle Scholar
  12. 12.
    Goh DY, Galster P, Marcus CL (2000) Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir Crit Care Med 162:682–686PubMedCrossRefGoogle Scholar
  13. 13.
    Charbonneau M, Marin JM, Olha A, Kimoff RJ, Levy RD, Cosio MG (1994) Changes in obstructive sleep apnea characteristics through the night. Chest 106:1695–1701PubMedCrossRefGoogle Scholar
  14. 14.
    Marcus CL, Lutz J, Carroll JL, Bamford O (1998) Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. J Appl Physiol 84:1926–1936PubMedCrossRefGoogle Scholar
  15. 15.
    Marcus CL, Bamford O, Bamford O, Lutz J (1999) Response to inspiratory resistive loading during sleep in normal children and children with obstructive apnea. J Appl Physiol 87:1448–1454PubMedCrossRefGoogle Scholar
  16. 16.
    Katz ES, White DP (2004) Genioglossus activity during sleep in normal control subjects and children with obstructive sleep apnea. Am J Respir Crit Care Med 170:553–560PubMedCrossRefGoogle Scholar
  17. 17.
    Liu Y, Su C, Liu R, et al. (2010) NREM-AHI greater than REM-AHI versus REM-AHI greater than NREM-AHI in patients with obstructive sleep apnea: clinical and polysomnographic features. Sleep BreathGoogle Scholar
  18. 18.
    Spruyt K, Gozal D (2012) REM and NREM sleep-state distribution of respiratory events in habitually snoring school-aged community children. Sleep Med 13:178–184PubMedCrossRefGoogle Scholar
  19. 19.
    Chan KC, Au CT, Hui LL, Ng SK, Wing YK, Li AM (2019 Jul) How OSA evolves from childhood to young adulthood: natural history from a 10-year follow-up study. Chest 156(1):120–130PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Lam Y, Chan EYT, Ng DK, Chan CH, Cheung JM, Leung SY, Chow PY, Kwok KL (2006) The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest 130:1751–1756PubMedCrossRefGoogle Scholar
  21. 21.
    Choi JH, Kim EJ, Choi J et al (2010) Obstructive sleep apnea syndrome: a child is not just a small adult. Ann Otol Rhinol Laryngol 119:656–661PubMedCrossRefGoogle Scholar
  22. 22.
    Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D (2008) Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proc Am Thorac Soc 5:274–282PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Aboussouan LS, Mireles-Cabodevila E (2017) Sleep-disordered breathing in neuromuscular disease: diagnostic and therapeutic challenges. Chest 152:880–892PubMedCrossRefGoogle Scholar
  24. 24.
    Ferré Á, Poca MA, de la Calzada MD, et al. (2017) Sleep-related breathing disorders in Chiari malformation type 1: a prospective study of 90 patients. Sleep 1; 40(6)Google Scholar
  25. 25.
    Kamal M, Tamana SK, Smithson L, Ding L, Lau A, Chikuma J, Mariasine J, Lefebvre DL, Subbarao P, Becker AB, Turvey SE, Sears MR, Canadian Healthy Infant Longitudinal Development (CHILD) Study Investigators, Pei J, Mandhane PJ (2018) Phenotypes of sleep-disordered breathing symptoms to two years of age based on age of onset and duration of symptoms. Sleep Med 48:93–100PubMedCrossRefGoogle Scholar
  26. 26.
    Melendres MC, Lutz JM, Rubin ED, Marcus CL (2004) Daytime sleepiness and hyperactivity in children with suspected sleep-disordered breathing. Pediatrics 114:768–775PubMedCrossRefGoogle Scholar
  27. 27.
    Bucks RS, Olaithe M, Eastwood P (2013) Neurocognitive function in obstructive sleep apnoea: a meta-review. Respirology 18:61–70PubMedCrossRefGoogle Scholar
  28. 28.
    Beebe DW, Gozal D (2002) Obstructive sleep apnea and the prefrontal cortex: towards a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioral deficits. J Sleep Res 11:1–16PubMedCrossRefGoogle Scholar
  29. 29.
    Redline S, Storfer-Isser A, Rosen CL, Johnson NL, Kirchner HL, Emancipator J, Kibler AM (2007) Association between metabolic syndrome and sleep-disordered breathing in adolescents. Am J Respir Crit Care Med 176:401–408PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Vlahandonis A, Yiallourou SR, Sands SA, Nixon GM, Davey MJ, Walter LM, Horne RS (2014) Long-term changes in heart rate variability in elementary school-aged children with sleep-disordered breathing. Sleep Med 15:76–82PubMedCrossRefGoogle Scholar
  31. 31.
    Amin RS, Kimball TR, Kalra M, Jeffries JL, Carroll JL, Bean JA, Witt SA, Glascock BJ, Daniels SR (2005) Left ventricular function in children with sleep-disordered breathing. Am J Cardiol 95:801–804PubMedCrossRefGoogle Scholar
  32. 32.
    Bhattacharjee R, Kheirandish-Gozal L, Pillar G, Gozal D (2009) Cardiovascular complications of obstructive sleep apnea syndrome: evidence from children. Prog Cardiovasc Dis 51:416–433PubMedCrossRefGoogle Scholar
  33. 33.
    Bonuck KA, Freeman K, Henderson J (2009) Growth and growth biomarker changes after adenotonsillectomy: systematic review and meta-analysis. Arch Dis Child 94:83–91PubMedCrossRefGoogle Scholar
  34. 34.
    Ilarslan NEC, Gunay F, Haskologlu ZS, Bal SK, Tezcaner ZC, Kirsaclioglu CT, Firat S, Altuntas C, Ciftci B, Ozgursoy OB, Cobanoglu N (2019) Evaluation of children with chronic cough including obstructive sleep apnea: a single-center experience. Eur J Pediatr 178(2):189–197PubMedCrossRefGoogle Scholar
  35. 35.
    Guilleminault C, Lee JH, Chan A (2005) Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med 159:775–785PubMedCrossRefGoogle Scholar
  36. 36.
    Marcus CL, Brooks LJ, Draper KA et al (2012) American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130:576–584PubMedCrossRefGoogle Scholar
  37. 37.
    Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM (1995) Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 108:610–618PubMedCrossRefGoogle Scholar
  38. 38.
    Kaditis A, Kheirandish-Gozal L, Gozal D (2016) Pediatric OSAS: oximetry can provide answers when polysomnography is not available. Sleep Med Rev 27:96–105PubMedCrossRefGoogle Scholar
  39. 39.
    Alonso-Álvarez ML, Terán-Santos J, Ordax Carbajo E, Cordero-Guevara JA, Navazo-Egüia AI, Kheirandish-Gozal L, Gozal D (2015) Reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children. Chest 147:1020–1028PubMedCrossRefGoogle Scholar
  40. 40.
    Tan HL, Gozal D, Ramirez HM, Bandla HP, Kheirandish-Gozal L (2014) Overnight polysomnography versus respiratory polygraphy in the diagnosis of pediatric obstructive sleep apnea. Sleep 37:255–260PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Kaditis AG, Alonso Alvarez ML, Boudewyns A, Alexopoulos EI, Ersu R, Joosten K, Larramona H, Miano S, Narang I, Trang H, Tsaoussoglou M, Vandenbussche N, Villa MP, van Waardenburg D, Weber S, Verhulst S (2016) Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J 47:69–94PubMedCrossRefGoogle Scholar
  42. 42.
    Li Z, Celestin J, Lockey RF (2016) Pediatric sleep apnea syndrome: an update. J Allergy Clin Immunol Pract 4:852–861PubMedCrossRefGoogle Scholar
  43. 43.
    Torretta S, Rosazza C, Pace ME, Iofrida E, Marchisio P (2017) Impact of adenotonsillectomy on pediatric quality of life: review of the literature. Ital J Pediatr 43(1):107PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Dehlink E, Tan HL (2016) Update on paediatric obstructive sleep apnoea. J Thorac Dis 8:224–235PubMedPubMedCentralGoogle Scholar
  45. 45.
    Venekamp RP, Chandrasekharan D, Abel F, Blackshaw H, Kreis IA, Evans H, Schilder AG (2017) Research into childhood obstructive sleep-disordered breathing: a systematic review. CHEST 152:51–57PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  • Anna Lo Bue
    • 1
    Email author
  • Adriana Salvaggio
    • 1
  • Giuseppe Insalaco
    • 1
  1. 1.National Research Council of ItalyInstitute for Biomedical Research and InnovationPalermoItaly

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