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 rare. About 1 in 20 kids between ages 2 and 6 have it. And more often than not, the cause is simple: enlarged tonsils and adenoids blocking their airway. For many families, the path forward isn’t complicated-but it does require knowing what options exist, what works best, and what to expect next.

Why Tonsils and Adenoids Are the Main Culprits

In young children, tonsils and adenoids are naturally larger relative to the size of their airways. By age 4, these lymphoid tissues peak in size. That’s why sleep apnea hits hardest between ages 2 and 6. When these tissues swell-often from repeated infections or chronic inflammation-they crowd the back of the throat. Breathing becomes a struggle. Each time the child inhales, the airway collapses partially or fully, cutting off oxygen for a few seconds. The brain wakes them up just enough to restart breathing, but not enough for real rest.

This cycle repeats dozens of times a night. Mayo Clinic data shows kids with severe cases can stop breathing 15 to 30 times per hour. That’s not just tiredness. It’s brain stress. Poor sleep messes with attention, memory, and learning. It can slow growth, raise blood pressure, and even lead to heart strain over time.

Doctors don’t guess. They test. A polysomnography-also called a sleep study-is the gold standard. It tracks brain waves, oxygen levels, heart rhythm, breathing effort, and airflow. It’s the only way to confirm sleep apnea and measure how bad it is. No home monitor or phone app can replace it.

Adenotonsillectomy: The First-Line Treatment

If a child has enlarged tonsils and adenoids and no other major health issues, surgery is the first step. Removing both the tonsils and adenoids together-called adenotonsillectomy-is the most common treatment. The American Academy of Pediatrics updated its guidelines in 2023 to make this clear: if the airway blockage is from tissue, cut it out.

Success rates? Between 70% and 80% in otherwise healthy kids. That means most kids stop snoring, sleep through the night, and feel better during the day. Yale Medicine reports that when tonsils are grade 3 or 4 on the sizing scale (meaning they’re touching or nearly touching each other in the throat), surgery is almost always effective.

But it’s not perfect. About 20% to 30% of kids still have symptoms after surgery. Why? Sometimes the problem isn’t just tissue. It’s also jaw structure, muscle tone, or obesity. In those cases, the airway may still collapse even without big tonsils.

There’s also a newer surgical option: partial tonsillectomy. Instead of removing all the tonsil tissue, surgeons leave a thin layer. This reduces pain, lowers bleeding risk by about half, and shortens recovery by 30%. But it’s only available at a few specialized centers. Most hospitals still do full removal.

Recovery takes 7 to 14 days. Kids need soft foods, lots of fluids, and quiet time. Pain is normal. So is bad breath. But if a child starts vomiting blood, has trouble breathing, or won’t drink for more than 12 hours, call the doctor right away. Post-op bleeding happens in 1% to 3% of cases.

When CPAP Becomes the Answer

Not every child is a candidate for surgery. If a child has Down syndrome, cerebral palsy, obesity, or a rare craniofacial disorder, removing tonsils 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 nose and mouth-while the child sleeps. The air keeps the throat open. No collapse. No pauses. No oxygen drops.

It’s not a cure. It’s a management tool. But it works. When fitted and set correctly, CPAP eliminates apneas in 85% to 95% of cases. That’s better than surgery for kids with complex conditions. UChicago Medicine calls it essential for children with neurological issues, severe OSA, or those who’ve had surgery but still struggle to breathe at night.

The catch? Getting kids to wear it.

Children’s National Hospital says 30% to 50% of kids refuse or quit using CPAP. Masks feel strange. They itch. They leak. Kids feel trapped. Some panic when they can’t breathe freely. It takes weeks to adjust. Many need help from sleep specialists who specialize in pediatrics-adult CPAP masks won’t fit a 4-year-old’s face.

Pressure settings matter too. Kids need lower pressure than adults-usually between 5 and 12 cm H₂O. That’s determined during a separate titration sleep study. Too little? Apneas return. Too much? It hurts. It’s a balance. And because kids grow fast, masks need to be refitted every 6 to 12 months.

Parents often worry about long-term use. But CPAP isn’t forever. Many kids outgrow their airway issues by puberty. Others use it until they’re ready for other treatments, like orthodontic expansion or, in rare cases, nerve stimulation devices.

Other Options You Should Know About

Surgery and CPAP aren’t the only tools. For mild cases or when parents want to avoid surgery, doctors may suggest alternatives.

Inhaled corticosteroids like fluticasone (88-440 mcg daily) can shrink swollen tonsils and adenoids over time. It takes 3 to 6 months to see results. Success rates? Around 30% to 50% improvement in mild cases. It’s not a magic fix, but for kids with allergies or asthma, it can help enough to delay or avoid surgery.

Rapid maxillary expansion is an orthodontic device that widens the upper jaw. It’s used when the palate is too narrow, forcing the tongue into the airway. It’s worn for 6 to 12 months. Success rates are 60% to 70% in kids with clear jaw structure issues. It’s often paired with other treatments.

Montelukast, a daily pill used for asthma, is sometimes prescribed off-label. It blocks inflammatory chemicals that make tonsils swell. Studies show it can reduce symptoms in mild OSA, but again, it takes months. It’s not FDA-approved for sleep apnea, but some pediatric sleep specialists use it when surgery isn’t an option.

There’s also emerging tech: hypoglossal nerve stimulation. Approved by the FDA for limited pediatric use in 2022, it’s a tiny implant that stimulates the tongue muscle during sleep to keep it from blocking the airway. It’s only for severe cases where CPAP and surgery have failed. Very few centers offer it. Cost is high. But it’s a future option.

What Happens After Treatment?

Treatment doesn’t end when the surgery is done or the CPAP machine is handed over. Follow-up is critical.

The American Thoracic Society recommends a repeat sleep study 2 to 3 months after adenotonsillectomy. Why? Because sometimes the apnea comes back. New tissue growth, weight gain, or undiagnosed structural issues can cause recurrence. Cleveland Clinic warns: “Symptoms may return if your child develops a new blockage.”

For CPAP users, follow-up means checking mask fit, pressure settings, and adherence. Most kids need 2 to 8 weeks to adjust. If they’re still fighting the mask after a month, don’t give up. Talk to the sleep team. Try a different mask. Adjust the pressure. Use rewards, routines, and patience. Many families succeed with consistent support.

And if nothing works? That’s when specialists dig deeper. Could it be obesity? A neuromuscular disorder? A rare genetic syndrome? That’s when genetic testing, full-body imaging, or metabolic panels come into play.

What Parents Should Do Now

If you suspect your child has sleep apnea-loud snoring, gasping, mouth breathing, daytime fatigue, poor school performance-don’t wait. Talk to your pediatrician. Ask for a referral to a pediatric sleep specialist.

Don’t assume it’s just “growing pains.” Sleep apnea in kids is treatable. But untreated, it can affect learning, behavior, and long-term health.

Be ready to ask:

• Are the tonsils and adenoids enlarged enough to cause this?
• Has a sleep study been done?
• Is surgery the best first step-or should we try medication or CPAP?
• What are the risks and success rates for each option?
• What happens if we don’t treat this?

There’s no one-size-fits-all answer. But there is a clear path: diagnose, choose, follow up. Most kids get better. Many thrive after treatment. And the earlier you act, the better the outcome.