Pediatric Sleep Apnea: When Tonsils, Adenoids, and CPAP Are the Answer

When a child snores loudly every night, stops breathing for a few seconds, or wakes up gasping for air, it’s not just noisy sleep-it’s a red flag. Pediatric obstructive sleep apnea (OSA) affects 1 to 5% of children, with the highest rates between ages 2 and 6. At this age, their tonsils and adenoids are naturally large compared to their small airways, and when they swell, they can block breathing during sleep. Left untreated, this isn’t just about tired kids-it can lead to learning problems, behavioral issues, slowed growth, and even heart strain. The good news? We know exactly what causes it, and we have clear, proven ways to fix it.

Why Tonsils and Adenoids Are the Main Culprits

Most cases of pediatric sleep apnea aren’t caused by obesity, allergies, or neurological issues-they’re caused by physical blockage. Enlarged tonsils and adenoids are responsible in 70 to 80% of cases. These are lymph tissues at the back of the throat and nose. When they grow too big, they crush the airway shut during sleep, especially when muscles relax. A child might snore, breathe through their mouth, or even pause breathing for 10 to 20 seconds at a time. Some kids wake up dozens of times a night without fully realizing it.

Doctors don’t just guess-there’s a test. A sleep study, called polysomnography, monitors brain waves, heart rhythm, oxygen levels, airflow, and chest movement. It shows exactly how many times breathing stops or slows. In severe cases, a child might have 15 to 30 interruptions per hour. That’s like being woken up every 2 to 3 minutes all night long.

What’s surprising is that even if only one tissue looks big, both tonsils and adenoids usually need to be removed. Research from the University of Chicago shows that removing just one leaves a high chance of the problem coming back. Why? Because OSA isn’t just about size-it’s about how the whole airway collapses. Removing both opens up the space as much as possible.

Adenotonsillectomy: The First-Line Treatment

The American Academy of Pediatrics says the first step for most kids with moderate to severe OSA is surgery-removing both tonsils and adenoids. This is called adenotonsillectomy. It’s one of the most common pediatric surgeries in the U.S. and Australia, with over 85% of diagnosed children starting here.

The success rate? Between 70% and 80% for kids who are otherwise healthy and have no other conditions like obesity or craniofacial differences. For these children, the surgery often cures the problem overnight. Snoring stops. Breathing improves. Energy levels rise. School performance gets better.

But it’s not without risks. About 1 to 3% of children have bleeding after surgery, and 0.5 to 1% need intensive care for breathing problems. Recovery takes 7 to 14 days. Kids need soft foods, lots of fluids, and rest. Pain is common, but there’s a newer option: partial tonsillectomy. Instead of removing the whole tonsil, surgeons take out just the part blocking the airway. This reduces pain by 30 to 40% and cuts bleeding risk by half. It’s not offered everywhere yet, but places like Yale Medicine have been using it successfully for years.

Still, surgery doesn’t always work. In 17 to 73% of cases-depending on other health factors-the apnea comes back. Why? Maybe the child has obesity, a small jaw, or muscle weakness. Or maybe the adenoids regrew. That’s when doctors look at the next option: CPAP.

CPAP for Kids: How It Works and Why It’s Hard

Continuous Positive Airway Pressure (CPAP) delivers a steady stream of air through a mask to keep the airway open. It’s not new-it’s been used for adults for decades. But for kids, it’s trickier.

The machine doesn’t need to be strong. For children, pressure is usually between 5 and 12 cm H₂O, much lower than what adults need. The mask must fit perfectly-nasal pillows, nasal masks, or full-face masks. Kids grow fast, so masks need to be refitted every 6 to 12 months. A poorly fitting mask means leaks, noise, and frustration.

Here’s the hard truth: 30 to 50% of children don’t use CPAP regularly. Why? Masks feel weird. Kids feel claustrophobic. They hate the noise. Parents struggle to get them to wear it every night. Some kids take weeks-or even months-to adjust. Specialists at Children’s National Hospital say 40 to 60% need 2 to 8 weeks of gradual training before they’ll sleep through the night with the mask on.

But when it works? CPAP is highly effective-85 to 95% of apneas disappear. It’s the go-to for kids who can’t have surgery: those with neuromuscular diseases, severe obesity, or craniofacial syndromes. It’s also the next step if surgery didn’t fix everything. Mayo Clinic says CPAP is the best option when medicines or surgery fail. And for kids with complex sleep apnea after surgery, adjusting the pressure often solves the problem within 1 to 2 weeks.

When Surgery Isn’t Enough: Alternatives and Add-Ons

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

Inhaled steroids like fluticasone (88 to 440 mcg daily) can shrink swollen tonsils and adenoids. They work slowly-3 to 6 months before you see results-but they’re safe and non-invasive. Studies show 30 to 50% improvement in mild OSA. They’re often used for kids with allergies or asthma too.

Montelukast, a daily pill used for asthma, blocks inflammation chemicals called leukotrienes that cause tissue swelling. In some kids, it reduces snoring and breathing pauses. It takes 3 to 6 months to work, but it’s a good bridge if surgery is delayed.

Rapid maxillary expansion is an orthodontic treatment. A device is placed in the mouth to slowly widen the upper jaw over 6 to 12 months. It helps kids with narrow palates-common in mouth-breathers. Success rates are 60 to 70%. It’s not a quick fix, but it can reduce the need for surgery later.

And then there’s the future: hypoglossal nerve stimulation. It’s a small device implanted in the chest that gently stimulates the tongue muscle during sleep to keep the airway open. The FDA approved it for limited pediatric use in 2022. It’s still rare, expensive, and only for severe cases that didn’t respond to anything else. But it’s a sign that treatment is evolving.

What Happens After Treatment?

Even after surgery or starting CPAP, follow-up is critical. The American Thoracic Society recommends a repeat sleep study 2 to 3 months after surgery to make sure the apnea is gone. Symptoms can return if new blockages form-like if adenoids regrow or if the child gains weight.

For CPAP users, the goal is consistency. It’s not just about the machine-it’s about routine. Put the mask on at the same time every night. Make it part of bedtime, like brushing teeth. Let your child pick the mask color or design. Celebrate small wins. A week of full use? That’s a victory.

Parents often worry about long-term effects. The good news? When treated, most children catch up developmentally. Their attention spans improve. They stop acting out. Their growth charts start climbing again. The brain, heart, and lungs begin to heal.

But untreated? That’s where the real danger lies. Chronic low oxygen and broken sleep can damage memory, learning, and emotional control. Some studies link untreated pediatric OSA to higher risks of ADHD, poor school performance, and even high blood pressure in adolescence.

What Should Parents Do Next?

If your child snores, breathes through their mouth, or seems exhausted during the day, talk to your pediatrician. Don’t wait. Ask about a sleep study. Ask if enlarged tonsils or adenoids could be the cause. Ask about surgery, CPAP, or steroid sprays.

There’s no one-size-fits-all. A 4-year-old with huge tonsils and no other issues? Surgery first. A 10-year-old with obesity and mild apnea? Try steroids and weight management. A child with Down syndrome or cerebral palsy? CPAP is likely the best long-term option.

The key is action-not waiting. Sleep apnea doesn’t go away on its own. But with the right treatment, most kids don’t just sleep better-they thrive.

Children with sleep apnea aren’t just restless-they’re fighting for air every night. The good news? We have tools that work. Whether it’s a simple surgery, a quiet mask, or a daily spray, the right treatment can turn sleepless nights into restful ones-and tired kids into bright, alert, thriving children.