Sleep Apnea in Infants/Toddlers


Infants and Pre-Schoolers

Age 0-6

  • When a baby is born, they are not breathing. Everyone has seen the movie scene where the doctor delivers the baby and the first thing is does is give it a whack on the behind! This initiates a crying response forcing the baby to suck air into their lungs for their first ever breathe of air. We assume from that point on, the baby will breathe normally and that is usually the last thought most parents have regarding breathing until the child gets their first cold.

The breathing reflex on a newborn is actually not fully formed until they start breathing and it is quite normal for newborns to “forget” to breathe for a few seconds and then restart. This is termed “periodic breathing” and can last 5-10 seconds. It occurs usually during sleep (which newborns do a lot of). Eventually they get it right and their breathing stabilizes, usually within the first few weeks. It is perfectly normal for newborns to breathe irregularly and is not a reason for concern.

Time for concern in newborns is if their breathing stops for longer stretches of time or turns blue. This is a medical emergency if it occurs.

Obstructive Sleep Apnea occurs in 1-2% of children over 12 months. With older children the symptoms associated with OSA are easily confused with ADHD (Attention Deficit Hyperactivity Disorder) and occurs in much high numbers. The most common symptoms of OSA in young children is:

Night time symptoms:

  • Snoring
  • Breathing through the mouth
  • Pauses in breathing (apnea events)
  • Frequent urinating at night or bedwetting
  • Tooth grinding
  • Head banging in their crib or bed
  • Talking in their sleep
  • Sleep walking
  • Restless sleeping
  • Sleep avoidance/resistance

Daytime symptoms:

  • Excessive sleepiness or hyperactivity
  • Learning and concentration problems
  • Behavioral problems including paying attention or aggressive behavior
  • Failure to thrive, underweight, short stature
  • Tooth grinding, sometimes to the point of wearing the teeth down flat
  • Poor coordination, clumsy

The Most Common Cause of OSA and UARS in Young Children is enlarged tonsils and adenoids that restrict airflow. Allergies can cause hypertrophy or enlargement of these tissues or they may just be congenitally large. Surgically removing the enlarged tonsils and adenoids has about an 80% chance of curing the apnea. In some cases they may grow back and the OSA may return. These cases may require a 2nd surgery to correct this. There is a classification system for the size of tonsils that can be used on even very young children. A a rule, the larger the tonsils and adenoids, the greater the risk of OSA or UARS.

Tonsil Classification

Tongue posture is also a significant contributor. At rest , the forward 1/3 of the tongue should be resting in the front palate, behind the upper incisors. The tongue is very important in the development of the size and shape of the upper jaw in children. If it positions in the palate at rest, the palate develops normally. If, however, it is positioned low in the mouth, the palate does not develop and becomes very narrow due to the inward pressure of the cheeks. Mouth breathing children all have abnormal tongue posture (low, in the floor of the mouth) as they would not be able to mouth breath if the tongue was in its normal position up and forward.

Congenitally small lower jaws or narrow upper jaws can also cause OSA in young children. All babies look like they have a small lower jaw but by 4-5 months it should match up with the upper jaw reasonably well and nose breathing should be the primary form of breathing. If the child is a dependent mouth breather there are significant problems associated with this:

  • Increase in airborne illnesses as the viruses are inhaled directly into the lungs as opposed to being filtered in the nose.
  • Once the primary teeth have erupted (the incisors are usually the 1st to come in), mouth breathing causes drying of the teeth and increases the risk of tooth decay in them.
  • The child’s posture is affected: they exhibit forward head posture and rolled shoulders. They lift their chin and head slightly and the mandible is held in a retruded positioning (back towards the ears).
  • The tongue rests in the floor of the mouth instead of in the roof of the mouth (this allows air to enter through the mouth)
  • They often develop a reverse swallowing pattern whereby their tongue protrudes forward between or just behind the front teeth. This is also called a tongue thrust swallow. Normally the forward 1/3 of the tongue should touch the palate just behind the incisors when swallowing.

Oral Habits such as thumb and finger sucking causes narrowing of the palate and forces the tongue down into the reverse swallowing position. If allowed to persists past age 7, treatment should be initiated to stop it (finger splints that prevent sucking, oral “cribs” to block thumb or finger entry etc.). Untreated oral habits set up the stage for the development of OSA in this group of children as well as the need for costly orthodontic treatment later in life.

The height of the lower face is also contributory to OSA. Children with deep over bites tend to have short lower face heights which reduces the space available for the tongue. If the tongue is crowded, it has only one place to go…BACK! This assists in blocking the child’s airway and results in obstructed breathing.

A long soft palate in a child is another significant sign. The Mallampati scoring system rates the length of huge soft palate.  As a rule, the higher the score the higher the risk of an airway obstruction.

Soft Tissue Length Classification

Combined with large tonsils, a long soft palate can be very serious. Add a large tongue and the child will not be able to breath well, even while awake. These children tend to be noisy breathers and noisy eaters.

Sleep Bruxism:

Research has shown that children have the highest incidence of sleep bruxism, at 17%. If severe, this can cause ear pain in the absence of infection. If the child also has a deep overbite, often tubes will be placed in their ears to relive pressure and ear pain. If they also suffer from sleep bruxism, these tubes will often pop out from the pressure of the grinding on the TMJ or jaw joint, which is just ahead of the ear canal.


Until the child reaches an age where the 1st permanent molars and all 8 incisors are in place, Phase 1 or early orthodontic treatment cannot be done. This usually occurs between the ages of 7 and 9 for most kids. This includes expansion appliances, ALF appliances, and craniosacral treatments to widen the palate. Don’t forget that the roof of the mouth is the floor of the nose!

Expansion Appliance                 A.L.F. Appliance           Twin Block Appliance

Saggital Appliance

A.L.F. Appliance

Twin Block Appliance

Next: Children 6-12