All About Infant Sleep Apnoea

According to statistics, around 7,500 children aged up to 10 are admitted to hospital each year with sleep apnoea. Of these, around two-thirds are male. This condition is common in babies who are born with low birth weight or prematurely. In this article, we’ll introduce this condition and uncover its signs, symptoms and treatment.

What is infant sleep apnoea?

Apnoea comes from Greek and means ‘suspension of breathing’. Sleep apnoea refers to a change in breathing while an infant is sleeping.

There are two types:

• Obstructive sleep apnoea (OSA): This describes when an infant’s airways narrow during sleep, reducing the amount of oxygen the child takes in. It can affect development and growth, including adverse behavioural and cognitive outcomes.
• Central sleep apnoea (CSA): This describes when the brain doesn’t send instructions to breathe. There are irregular brain signals so the child doesn’t attempt to inhale.

Apnoea on its own is used in medicine to describe breathing lapses. It is common in newborn babies but it can happen at any time in infancy, even during waking periods. A diagnosis of infant sleep apnoea is usually given when there are pauses during sleep that last 20 seconds or more. However, shorter lapses can also be diagnosed when there are other symptoms alongside them like reduced heart rate or cyanosis (a blueish tint to the skin), for example.

What happens in a child with sleep apnoea?

When we breathe, air passes into our nose and through our nasal cavity. It is warmed, moistened and filtered here before travelling down the upper respiratory tract and to the lungs. In the lungs, the oxygen in the air goes into the bloodstream to be sent around the body to where it’s needed.

When we’re asleep our muscles relax. This includes the muscles in the throat. When the muscles relax too much, there is a narrowing of the throat that makes breathing more difficult and reduces the amount of air flowing through. This is particularly true for people who have large adenoids in their nose or large tonsils in their throat. The person may have irregular breathing or snore.

If the reduced airflow causes a drop in oxygen in the blood, the body will naturally make more effort to breathe as the brain will signal to the body to restart breathing or to increase the breathing rate. This often causes the person to awaken briefly, though it’s rare this is remembered in the morning.

When breathing restarts, you’ll usually hear a snort or a gasp. The breathing returns to normal and the person resumes sleep. This may go unnoticed by the person themselves. If this is a severe problem, it can disturb how much sleep the person is getting as well as the quality of the sleep. 

What causes infant sleep apnoea?

There are several risk factors that increase a baby’s likelihood of developing infant sleep apnoea. This includes being born at less than 28 weeks’ gestation or at a low birth weight. It is rare in infants born at full term. Almost all those born before 28 weeks will develop the condition. 

It can also be caused by other illnesses and conditions. These include pertussis (whooping cough), pneumonia, bronchiolitis, cerebral malformations, seizures and congenital heart disease, among others.

Risk factors for obstructive sleep apnoea

The risk of infant obstructive sleep apnoea depends on a number of factors. Having a small airway (due to abnormalities in the face or head shape, for example) can increase the risk of obstructive sleep apnoea. Those with a cleft pallet may also have a smaller airway and thus a higher risk of obstructive sleep apnoea.

Another risk factor is reflux. Reflux is relatively common in babies and sometimes is even ‘silent’, meaning there are no obvious signs of reflux occurring. 

Neuromuscular disorders like cerebral palsy and Down syndrome also increase the risk of obstructive sleep apnoea in infants. This is due to muscle weaknesses that cause the airway to narrow or collapse during sleep. 

Obstructive sleep apnoea is also associated with passive smoking. Infants in households where there is second-hand smoke are more likely to experience obstructive sleep apnoea.

Risk factors for central sleep apnoea

In premature infants, an underdeveloped brainstem can cause central sleep apnoea. Infants are also at risk of issues that could affect the respiratory centre in the brain and thus cause central sleep apnoea. 

Risk factors specific to central sleep apnoea include:

• Infections like pertussis (whooping cough) and meningitis.
• Gastrointestinal reflux.
• Head trauma.
• Toxin exposure.
• Metabolic disorders like congenital hypothyroidism, galactosemia, phenylketonuria (PKU), sickle cell disease and cystic fibrosis.
• Down syndrome.
• Chiari malformation.

Signs of infant sleep apnoea

The main sign of infant sleep apnoea is breathing pauses. For sleep apnoea, this generally lasts 20 seconds or more and is observed by the parent or caregiver. Other signs can include:

• Snoring.
• Frequent waking.
• Sweating while asleep.
• Laboured breathing.
• Mouth breathing.
• Frequent respiratory infections.
• Trouble swallowing.
• Developmental delays.

Infants can have sleep apnoea if their pauses in breathing are less than 20 seconds long. Infants can also have some of the above signs of the condition without having sleep apnoea. This underlies the importance of getting any concerns checked out by a doctor. 

Symptoms of infant sleep apnoea

Adults who experience sleep apnoea often feel sleepy throughout the day. In infants, however, this can be difficult to spot, especially considering the amount of sleep babies and children need. A child with sleep apnoea is also likely to have behavioural problems due to poor sleep. 

If a child is being observed medically, they may show problems like a slow heartbeat or low oxygen.

Diagnosing infant sleep apnoea

Within the first 24 hours after delivery, a baby’s breathing will be monitored. Any concerns will be noted and investigated. If parents are concerned about their baby’s breathing after leaving the hospital, they will usually see a GP or paediatrician. The doctor will ask about any symptoms as well as any family history of sleep apnoea. 

If infant sleep apnoea is suspected, there might be tests. These include:

• A physical examination: Doctors understand that symptoms won’t necessarily be present when the infant is examined.
• Polysomnography: Polysomnography is a sleep study and is the main diagnostic tool for infant sleep apnoea. It can detail what is going on, including the type of sleep apnoea present. Polysomnography tests can also be carried out periodically to monitor an infant’s response to any treatment for their condition. The sleep study will chart the brainwaves, breathing and heart rate during sleep. Any movements made by the child will also be noted. For these tests, the child will need to stay overnight but a parent or guardian is usually allowed to stay with them.
• Endoscopy of the airway: A doctor might carry out an endoscopy (a tube with a camera inserted into the airway) to see if there are any indications as to what could be causing the sleep apnoea. If it is obstructive sleep apnoea, they will also be able to gauge how serious the condition is.
• Imaging tests: Doctors may order imaging tests like CT (computed tomography) scans and X-rays to see the upper airway anatomy.

The impact of infant sleep apnoea

Babies and children need sleep for their development and growth. Sleep apnoea can prevent infants from getting enough sleep for optimal development. Even if they seem to be getting enough sleep, it might be poor quality sleep, which can have an impact too. 

If sleep apnoea is not noticed or goes untreated, it can cause problems in childhood or even in adulthood. These problems are caused by sleep deprivation. Young children with poor sleep can demonstrate poor behaviour like aggressiveness or hyperactivity. Older children will likely behave more like adults and be tired during the day. It might be difficult for them to concentrate. They may also wake up feeling unhappy or with a headache, and they might also refuse breakfast. In the long term, a child might have poor weight gain or poor growth. 

A child with obstructive sleep apnoea that isn’t treated has an increased risk of developing conditions like prediabetes, high cholesterol and high blood pressure. 

Treatment for infant sleep apnoea

Depending on the type of sleep apnoea (obstructive or central), the treatment will be on a case-by-case basis. 

The treatment prescribed will depend on different factors like the presence of any other medical conditions or how severe the symptoms are. Infants that are preterm often grow out of sleep apnoea by the time they reach 4 weeks after their original due date. Problems may linger for infants that were born before 28 weeks. 

If symptoms don’t improve naturally, there may be other treatments or care required. Most children with infant sleep apnoea don’t have long-term problems with it. As children grow, their airways widen and so most grow out of the condition without intervention.

If OSA is confirmed, then surgery may be performed to remove the tonsils or adenoids that might be causing the obstruction. If problems persist, a child might be required to wear a mask during sleep for positive airway pressure therapy. The treatments will be either CPAP (Continuous Positive Airway Pressure) or BiPAP (Bi-Level Positive Airway Pressure).

Medicines used to treat sleep apnoea

For mild cases of sleep apnoea, medicines might be given. These include topical nasal steroids like fluticasone and budesonide.

CPAP

When on CPAP, a child will wear a mask that provides a constant pressure while they sleep. This is usually a first choice for anyone needing treatment. It gives the user a continuous flow of air at a specific pressure. The pressure remains for both inhalation and exhalation, which forces the airways to stay open so sleep isn’t interrupted. 

Most CPAP masks cover the full face (nose and mouth) while others are just on the nose. There are drawbacks to using CPAP with infants too. It can, for example, lead to oral feeding delays, gastric distention, chronic lung disease, or nasal damage. 

BiPAP

BiPAP is similar to CPAP but the pressure of air is different for exhalation, which makes it easier to breathe out. BiPAP is generally used for more severe cases of sleep apnoea. It is also used for central sleep apnoea for when CPAP isn’t enough.

Oral appliances

Sometimes dental devices that expand the palate or nasal passages might be provided. These are designed to keep the airway open.

Easing symptoms at home

Parents can help to ease symptoms of sleep apnoea by reducing allergens and airway irritants in the home. Things like air fresheners, strong cleaning products and tobacco smoke will exacerbate the symptoms. In older children, obesity can be a contributing factor too. If this is the case, a health professional might work with parents or guardians to reduce weight.

Risks of infant sleep apnoea

The most likely candidates for infant sleep apnoea are small preterm infants and micro preemies (those born before 26 weeks’ gestation or weighing less than 750g). It tends to materialise within the first week of life but usually from day two onwards. Medical problems like acid reflux, anaemia, infection, seizures, neurological problems, lung disease and metabolic disorders also make the condition worse as do certain medications and anaesthesia.

There are a small number of cases of children who have apnoea symptoms that go on to die from sudden infant death syndrome (SIDS). However, it’s worth noting that infant sleep apnoea is not considered to be a risk factor for SIDS.

Final thoughts on infant sleep apnoea

Infant sleep apnoea is a sleep-related breathing condition. It is categorised by pauses in breathing either by a physical problem with the airway (obstructive sleep apnoea) or an interference or problem with brain signals (central sleep apnoea). It is rare in babies born at full term but is more common in those who are born earlier or at a low birth weight. Whether you’re navigating a new diagnosis of infant sleep apnoea or are worried about your child having it, the best thing to do is speak to a health professional for advice. Good sleep is one of a baby’s basic needs so it’s important to get help if there’s a problem.