Pediatric Sleep Apnea: Tonsils, Adenoids, and CPAP Explained

When a child snores loudly, stops breathing for a few seconds during sleep, or wakes up gasping, it’s not just noisy nights-it could be pediatric sleep apnea. This isn’t just about tired kids. Untreated, it can affect their focus in school, growth, heart health, and even behavior. The most common cause? Enlarged tonsils and adenoids. For many children, removing them is the fix. But when that doesn’t work-or isn’t safe-CPAP becomes the next step.

What Exactly Is Pediatric Sleep Apnea?

Pediatric obstructive sleep apnea (OSA) happens when a child’s airway gets blocked during sleep. It’s not rare. About 1 to 5 out of every 100 children have it, especially between ages 2 and 6, when their tonsils and adenoids are biggest compared to their small airways. These tissues, meant to trap germs, can grow too large and physically block airflow. Each time the airway closes, the child struggles to breathe. Their body wakes them up just enough to restart breathing-often without them remembering it. This can happen 15 to 30 times an hour.

Doctors call this sleep fragmentation. It’s not just about being tired. It disrupts deep sleep needed for brain development, memory, and emotional regulation. Over time, it can lead to attention problems, learning delays, bedwetting, and even high blood pressure. That’s why it’s not something to ignore.

Why Tonsils and Adenoids Are the Main Culprits

Tonsils sit at the back of the throat. Adenoids are higher up, behind the nose. Together, they form a ring of lymphoid tissue that helps fight infections. But in many kids, they swell up-sometimes from repeated colds, allergies, or just natural growth patterns-and start crowding the airway.

It’s not just size. The shape matters too. Some kids have narrow airways to begin with, so even modest enlargement causes problems. Research shows that in healthy children with no other conditions, removing both tonsils and adenoids together (called adenotonsillectomy) resolves sleep apnea in 70 to 80% of cases. That’s why the American Academy of Pediatrics recommends it as the first treatment for moderate to severe OSA in kids without other health issues.

But here’s something important: removing just one doesn’t always work. Studies show that if only the tonsils are taken out, or only the adenoids, the sleep apnea often comes back. That’s because both tissues contribute to the blockage. Experts like Dr. David Gozal from the University of Chicago stress that treating OSA means opening the airway as much as possible-and that means removing both.

What Happens During Adenotonsillectomy?

The surgery is done under general anesthesia and usually takes less than an hour. Most kids go home the same day. Recovery takes about 7 to 14 days. During that time, they need soft foods, lots of fluids, and rest. Pain is common, especially in the first few days, but most children bounce back quickly.

There’s a newer technique called partial tonsillectomy-where only part of the tonsil is removed. It’s not available everywhere, but places like Yale Medicine use it because it cuts recovery time by about 30% and reduces bleeding risk by nearly half. It’s especially helpful for kids who are prone to complications or need to get back to school faster.

Still, surgery isn’t risk-free. About 1 to 3% of kids experience bleeding after surgery. A smaller number-around 0.5 to 1%-may have breathing problems that need intensive care. That’s why doctors watch them closely overnight. And even after a successful surgery, follow-up sleep studies are recommended 2 to 3 months later to make sure the apnea is truly gone.

When CPAP Is the Better Choice

Not every child is a good candidate for surgery. If a child has obesity, a craniofacial disorder, a neuromuscular disease, or very small tonsils, removing them won’t fix the problem. That’s where CPAP comes in.

CPAP stands for continuous positive airway pressure. It’s a machine that blows gentle, steady air through a mask worn over the nose or face during sleep. This keeps the airway open, preventing those pauses in breathing. For kids who need it, CPAP works in 85 to 95% of cases-when used correctly.

But here’s the catch: kids don’t always wear it. Studies show 30 to 50% of children struggle with adherence. Masks can feel claustrophobic. The noise of the machine is scary. The tubing gets tangled. And as kids grow, the mask doesn’t fit anymore-so it leaks, and the treatment stops working.

That’s why pediatric CPAP isn’t like adult CPAP. Specialized masks designed for children’s smaller faces are essential. Many hospitals have teams that help families adjust-trying different mask types, adjusting pressure settings, and even using reward charts to encourage nightly use. Pressure levels for kids are lower than for adults-usually between 5 and 12 cm H₂O-and must be fine-tuned during a sleep study.

CPAP is also used when surgery doesn’t fully fix the problem. About 15 to 20% of kids still have sleep apnea after adenotonsillectomy. For them, CPAP isn’t a backup-it’s the next step to protect their health.

Other Treatments You Might Not Know About

Not every child needs surgery or CPAP right away. For mild cases, doctors may try other options first.

Inhaled corticosteroids-like fluticasone nasal spray-are sometimes used to shrink swollen adenoids. They work slowly, over 3 to 6 months, and can improve symptoms in 30 to 50% of mild cases. But they’re not a cure. If symptoms return after stopping, the treatment may need to restart.

Rapid maxillary expansion is an orthodontic device that widens the upper jaw over 6 to 12 months. It helps kids whose narrow palate contributes to airway crowding. Success rates are around 60 to 70%, but it’s only helpful if the problem is structural, not just from enlarged tonsils.

Montelukast, a daily pill usually used for asthma, is being studied for sleep apnea. It blocks inflammatory chemicals called leukotrienes that may cause tonsil swelling. Early results show it can reduce symptoms in mild cases, but it takes months to work and isn’t approved for this use in all countries.

And then there’s hypoglossal nerve stimulation-a newer option approved for select pediatric cases since 2022. A small device implanted in the chest stimulates the tongue muscle to keep the airway open. It’s used only in severe cases where other treatments failed, and only at specialized centers.

What Parents Should Watch For

You don’t need a sleep study to suspect sleep apnea. Look for these signs:

• Loud, regular snoring-more than three nights a week
• Pauses in breathing during sleep
• Gasping, choking, or snorting noises
• Restless sleep, sleeping in odd positions (neck stretched back)
• Daytime sleepiness, irritability, or trouble concentrating
• Bedwetting after being dry for months
• Poor growth or weight gain

If you see two or more of these, talk to your pediatrician. They’ll likely refer you to a sleep specialist. The gold standard test is a polysomnography-a sleep study that tracks brain waves, oxygen levels, heart rate, breathing patterns, and muscle movements. It’s the only way to confirm OSA and decide on the right treatment.

Long-Term Outlook

Most kids who get treated for sleep apnea do well. After adenotonsillectomy, many see big improvements in behavior, school performance, and energy levels within weeks. Kids on CPAP often show similar gains once they adapt to the mask.

But sleep apnea can come back. If a child gains weight, develops allergies, or grows into a new facial structure, the airway can narrow again. That’s why ongoing monitoring matters. Follow-up visits, even years later, are important.

What’s clear now is that pediatric sleep apnea isn’t just a breathing problem. It’s a developmental one. Treating it early can change a child’s trajectory-helping them sleep better, learn better, and grow stronger.