By Sree Roy

Many young children who have obstructive sleep apnea (OSA) travel the tried-and-true road of in-lab polysomnography for diagnosis, followed by adenotonsillectomy for therapy. This clinical pathway alleviates or fully resolves OSA in many kids. But detours have always sidelined some children from reaching effective OSA therapy, whether it’s a long wait for a sleep lab bed, adenoid regrowth, or a different challenge. 

Where previously these 2- to 7-year-olds may have reached the end of the road, today sleep specialists can access myriad diagnostic and therapy options—some earning US Food and Drug Administration (FDA) clearance or approval within just the past few years—so that even the youngest patients can get their OSA under control with relative ease.

“Think outside the box,” says Funke Afolabi-Brown, MD, FAASM, founder of The Restful Sleep Place, a concierge sleep medicine practice for children and adults. “A lot of families are out there looking for solutions that are not burdensome, so we need to stop being very rigid in our thinking. We need to try to see what’s out there and find alternative ways to make the diagnosis and treatments of sleep disorders easier for patients.”

Compared to a general practitioner, Afolabi-Brown, who is board-certified in pediatrics, pediatric pulmonology, and sleep medicine, is more specific about what she wants when referring a child for an in-lab sleep study. “I may be able to say, ‘I want you to pay attention to the limb leads,’ or ‘I want an audio or a video’ because some of those things may get missed if all you think you’re looking for is sleep apnea,” she says.

Still, the child’s in-lab study is sometimes inconclusive—perhaps because the child couldn’t tolerate the nasal cannula or was too uncomfortable to sleep much. “Or they may cry all night and get their noses extremely congested, and now you cannot record any airflow. I see that so often,” Afolabi-Brown says.

In cases where the parents or child refuse to repeat an inconclusive in-lab study—or in limited situations, such as for a neurodiverse child for whom an in-lab study is a no-go—Afolabi-Brown will offer a home sleep test (HST). The FDA has cleared several HSTs for pediatrics, including at least one within the past few years. For example, children as young as 2 years old can use a SleepImage ring (launched in 2020; its software as a medical device was FDA cleared in 2019) or a Nox T3s (the Nox T3 has been cleared in pediatrics for more than a decade).

Afolabi-Brown informs families that an HST is not considered the gold standard. But she adds, “If you are in a bind between getting nothing done and getting some data that would hopefully move the needle forward with your child’s health, I would absolutely do a home sleep test…which will at least give them some idea of how impaired [the child is]….We can leverage that, combined with the child’s symptoms, to get them the care they need.”

Others argue that pediatric HST could become a gold standard. In-lab testing is “neither a practical nor accessible as a solution for population care, nor has it been proven in clinical research to provide the value that has been promoted,” posits Solveig Magnusdottir, MD, MSc, MBA, chief medical officer at SleepImage, which markets a pediatric-sized wearable ring HST. A convenient multi-night wearable for diagnosis—that can double as a longitudinal monitoring device for therapy tracking—can be superior. 

Unlike an in-lab study where a child may get upset in a new environment, children tend to enjoy “the idea of sleeping with the ‘dream ring,’” Magnusdottir says. (A piece of tape or a glove can be placed over the ring to protect against a toddler removing it overnight.)

Families frequently pay out of pocket for HST in children, which Afolabi-Brown concedes is “unfortunate.” Still, she says, most of her patients’ families are willing to incur the cost to continue their diagnostic journey.

Adenotonsillectomy

For many young children, the firstline therapy continues to be adenotonsillectomy. However, it’s important to analyze a child’s sleep apnea holistically, says Afolabi-Brown. “Sometimes they have other risk factors,” she says. 

For example, a child could have a contributing tongue tie, allergies, or reflux. By reviewing each child’s situation, a sleep physician can “better predict whether that intervention is going to be what solves the issues or not,” she says.

CPAP therapy for children is one option that has been available for more than a decade. CPAP masks are available even in toddler sizes, but fitting these masks can be challenging.

Sleep techs can get assistance selecting the right size from new virtual mask fitting solutions. 

For example, SleepGlad’s fitting platform includes SleepNet’s MiniMe pediatric line, offering two nasal mask options for children ages 2 to 12 years. The sizes are designed with “a little bit of wiggle room” since children grow rapidly, says Troy Nielsen, director of national sales at SleepNet. 

This flexibility is achieved in part through its Custom Fit Technology, which uses a pliable material that responds to gentle manipulation and accommodates changes in weight and facial asymmetry. “You can actually bend it, mold it, and shape it to the patient’s face,” Nielsen says. The pediatric masks also include a medical-grade silicone gel, dubbed AIR°gel, that conforms to the contours of a child’s face to create a better seal.

Other brands of FDA-cleared masks for children include those by ResMed, Philips, and Circadiance.

The pediatric sleep CPAP mask market has grown since the MiniMe and MiniMe 2 were launched (in 2009 and 2013, respectively). “We have seen significant, sustained attention being put onto pediatrics now, both in the home area as well as in the acute for pediatrics,” Nielsen says.

Orthodontic Appliance for Sleep Apnea

A newly FDA-cleared option for children ages 6 to 17 years old is an orthodontic oral appliance for OSA—different from a mandibular advancement device—which received clearance in September 2024, following an earlier clearance for adults.

The appliance, the Vivos DNA, is cleared to reduce nighttime snoring and treat moderate and severe OSA in children who snore and/or have moderate or severe OSA and need orthodontic treatment. It allows for six degrees of customization, including anteroposterior and transverse adjustments, as well as adjustments to the vertical dimension of occlusion. It aims to expand the nasal airway through jaw expansion and mid-facial redevelopment, potentially permanently improving the oropharyngeal airway, increasing nasal cavity volume, and reducing apneas and hypopneas. 

Perhaps the biggest advantage of Vivos DNA is that it is only needed, on average, for less than 10 months—when a follow-up sleep study could show that the child’s OSA has resolved. “Are we going to manage this disease over a lifetime, which is what CPAP and mandibular advancement do, or are we going to try to rehabilitate that airway?” says R. Kirk Huntsman, chairman and CEO of Vivos. “Our approach is to try to rehabilitate the airway. We do that by manipulating the tissues of the oral cavity, which are directly tied to the airway that sits right behind it.”

For children too young for a DNA appliance, Vivos Guides, a class one orthodontic appliance, can be given to toddlers as young as 3 years old to guide the growth and development of dental arches and facilitate proper occlusion and positioning of the jaws. Vivos Guides are not FDA-cleared for OSA treatment, but they can sometimes fix the anatomy behind sleep-disordered breathing. “When the kid has one of these devices in their mouth, they have to breathe through their nose,” Huntsman adds. 

Vivos Guides are most effective before a child hits puberty, according to Huntsman, which emphasizes the importance of early screening for craniofacial issues linked to OSA. “Everything after puberty becomes more difficult,” he says.

Could Sleep Be Added to Pediatric Preventative Care?

Magnusdottir echoes the idea that sleep health should be assessed early and regularly. “If sleep quality is as important as believed, why not put more emphasis on evaluating sleep quality in routine pediatric care and use ‘sleep charts’ in a similar way as ‘growth charts’ are utilized today to identify if the child is deviating from their baseline in height and/or weight?” she asks.

She thinks sleep testing should be incorporated into routine care starting at about 2 years old. That approach would “take sleep out of the silo of sleep apnea testing for diagnosis after symptoms have presented themselves,” she says. “Approaching sleep care as part of routine care for preventative purposes would likely improve pediatric health outcomes, their quality of life, and over time contribute to improved population health and lower healthcare costs.”

New pediatric diagnostic and therapy devices have been brought to market in the past few years. Perhaps in a few more, the technology to seamlessly integrate sleep care into wellness visits will become a reality.

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