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

When a child snores loudly every night, stops breathing for a few seconds during sleep, or wakes up gasping for air, it’s not just noisy sleep-it’s a red flag. Pediatric obstructive sleep apnea affects 1 to 5% of children, with the highest rates between ages 2 and 6. At this age, their tonsils and adenoids are often large compared to their small airways, making blockages common. Left untreated, this isn’t just about tired mornings. It can lead to learning problems, behavioral issues, slow growth, and even heart strain over time.

What Causes Sleep Apnea in Kids?

The main culprit in most children is enlarged tonsils and adenoids. These are lymph tissues at the back of the throat and nose that help fight infection. But when they grow too big-often after repeated colds or allergies-they physically block the airway during sleep. Unlike adults, where obesity is the top cause, kids usually have this structural issue. The airway collapses because there’s simply not enough room for air to flow freely.

Doctors use a sleep study, called polysomnography, to confirm the diagnosis. This test tracks brain waves, heart rhythm, oxygen levels, breathing effort, and airflow-all while the child sleeps. A child with moderate to severe sleep apnea might stop breathing 15 to 30 times per hour. That’s not occasional snoring. That’s a medical condition that needs action.

Adenotonsillectomy: The First-Line Treatment

If your child has enlarged tonsils and adenoids and no other major health issues, surgery to remove them-called adenotonsillectomy-is the standard first step. The American Academy of Pediatrics recommends this as the go-to treatment for most kids with moderate to severe sleep apnea. Studies show it works in 70 to 80% of cases when the tonsils and adenoids are the only problem.

It’s not a minor procedure. It’s done under general anesthesia, and recovery takes about a week to two weeks. Kids need soft foods and plenty of rest. Some parents worry about pain or bleeding, and yes, there are risks: about 1 to 3% experience post-surgery bleeding, and 0.5 to 1% may need intensive care for breathing problems. But for most children, the benefits far outweigh the risks.

There’s also a newer option: partial tonsillectomy. Instead of removing the entire tonsil, surgeons remove just the bulk that’s blocking the airway. This technique, used at places like Yale Medicine, cuts recovery time by about 30% and reduces bleeding risk by nearly half. It’s not available everywhere yet, but it’s gaining traction in pediatric sleep centers.

Important note: both tonsils and adenoids should be removed together, even if one looks bigger. Removing just one leaves the other to keep blocking the airway. Studies show OSA often comes back if only one is taken out.

When CPAP Is the Better Choice

Not every child is a good candidate for surgery. If your child has:

• Neuromuscular disorders like cerebral palsy
• Craniofacial abnormalities such as Down syndrome
• Severe obesity (BMI above the 95th percentile)
• Small tonsils but persistent breathing issues
• OSA that returned after surgery

Then CPAP (continuous positive airway pressure) becomes the top option. CPAP uses a small machine that pushes air through a mask worn at night. The air pressure keeps the airway open so breathing doesn’t stop. For kids, the pressure is usually set between 5 and 12 cm H2O-calibrated during a special sleep study to find the lowest effective dose.

CPAP is highly effective-85 to 95% of kids see their apneas disappear when they use it consistently. But here’s the catch: getting a child to wear it every night is hard. About 30 to 50% of kids struggle with adherence. The mask can feel claustrophobic. It may leak. It can irritate the skin. Some kids hate the noise. Others just won’t tolerate it.

The key to success? Custom fit. Pediatric masks are smaller, softer, and come in different styles-nasal pillows, full face, or just over the nose. They need to be replaced every 6 to 12 months as the child grows. A good sleep specialist will work with you to find the right mask and help your child get used to it over 2 to 8 weeks. Refitting as they grow is not optional-it’s essential.

Other Options: Steroids, Expansions, and Medications

For mild cases, or if you’re waiting for surgery or trying to avoid it, there are alternatives.

Inhaled corticosteroids-like fluticasone sprayed into the nose-can shrink swollen tonsils and adenoids over 3 to 6 months. They’re not a cure, but they can reduce symptoms enough to delay or avoid surgery in some kids. Doses are low and safe for long-term use in children.

Rapid maxillary expansion is an orthodontic treatment that widens the upper jaw using a device worn for 6 to 12 months. It helps kids whose narrow palate contributes to airway crowding. Success rates are 60 to 70% in those with the right anatomy.

Montelukast, a daily pill used for asthma and allergies, is sometimes prescribed off-label. It blocks inflammatory chemicals that make tonsils swell. Studies show it helps in about 30 to 50% of mild cases, but it takes months to work. It’s not a replacement for surgery in severe cases.

What Happens After Treatment?

Even after surgery or starting CPAP, follow-up matters. The American Thoracic Society says kids with severe OSA should have another sleep study 2 to 3 months after surgery to make sure the airway is truly open. Symptoms can return if new blockages form-like from allergies, weight gain, or regrowth of tissue.

For CPAP users, pressure settings may need adjusting as the child grows. A mask that fit perfectly last year might be too tight or too loose now. Most issues can be fixed with a simple clinic visit and a pressure tweak.

And if CPAP doesn’t fully fix the problem? Newer options are emerging. In 2022, the FDA approved hypoglossal nerve stimulation for select pediatric cases-tiny implants that gently move the tongue forward during sleep to keep the airway open. It’s still rare and only for children who don’t respond to other treatments.

What Parents Should Watch For

Keep an eye out for these signs:

• Loud, regular snoring (not just occasional)
• Pauses in breathing during sleep
• Gasping, choking, or snorting noises
• Restless sleep, sleeping in odd positions
• Daytime sleepiness, irritability, or trouble concentrating
• Mouth breathing, dry mouth, or frequent bedwetting

If you notice two or more of these, talk to your pediatrician. Don’t wait. Early treatment prevents long-term damage to the brain, heart, and learning ability.

Final Thoughts: No One-Size-Fits-All

There’s no single answer for every child with sleep apnea. For most, removing tonsils and adenoids is the fastest, most effective solution. For others-especially those with complex health needs-CPAP is the lifeline. Some benefit from steroids or orthodontic devices. The goal isn’t just to stop the snoring. It’s to restore deep, restful sleep so your child can grow, learn, and thrive.

The best path starts with a sleep study. From there, your pediatric sleep specialist will help you weigh risks, benefits, and your child’s unique needs. Don’t assume it’s just a phase. Sleep matters-more than you think.