Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Updates on Pediatric Sleep-Disordered Breathing

  Sleep-disordered breathing in children ranges from habitual snoring and increased airway resistance to obstructive sleep apnoea (OSA). It can disturb sleep architecture, oxygenation, behaviour, learning, growth and cardiovascular health. Current practice places greater emphasis on recognising the condition early, including in children who do not fit the traditional image of a child with enlarged tonsils.

  For Australian families, assessment and treatment must account for geography, public hospital waiting lists, private sleep laboratories, Medicare access and the cost of equipment. Children in Sydney, Melbourne and Brisbane may have several referral pathways, while families in regional Western Australia, the Northern Territory or Far North Queensland can face long travel for paediatric respiratory services.

  Recognising The Wider Clinical Picture

  Loud snoring remains an important warning sign, particularly when it occurs most nights. Other symptoms can include mouth breathing, restless sleep, unusual sleeping positions, morning headaches, enuresis, daytime irritability, poor concentration and hyperactivity. Younger children may appear overactive rather than sleepy, making the condition easy to miss in childcare or school settings.

  Risk is increased by adenotonsillar enlargement, obesity, craniofacial conditions, Down syndrome, neuromuscular disorders, allergic rhinitis and nasal obstruction. Clinicians are also paying closer attention to children with recurrent wheeze, chronic nasal congestion and orthodontic or facial growth concerns. A normal-looking child can still have clinically significant airway obstruction during sleep.

  Improving Diagnosis Beyond Symptoms

  History and physical examination help determine risk but cannot reliably exclude OSA. Overnight polysomnography remains the reference investigation because it measures airflow, respiratory effort, oxygen saturation, carbon dioxide, sleep stages and arousals. The apnoea–hypopnoea index is useful, although it should be interpreted alongside symptoms, gas exchange and the child’s overall health.

  Home-based sleep studies and overnight oximetry may be useful in selected settings, especially where laboratory access is limited. They can support triage, but a normal oximetry result does not rule out milder obstruction or arousal-related disease. Australian services increasingly use telehealth for preliminary review and follow-up, while complex cases still require face-to-face paediatric assessment.

  The Role Of Adenoids, Tonsils And Nasal Health

  Adenotonsillectomy remains a common first-line treatment when enlarged tonsils and adenoids are contributing to obstructive breathing. The decision should reflect symptom burden, sleep study findings, comorbidities, surgical risk and family preferences. Children with severe OSA, significant oxygen desaturation or relevant medical conditions may need enhanced perioperative monitoring.

  Nasal obstruction also deserves active treatment. Allergic rhinitis, chronic sinus symptoms and turbinate enlargement can increase upper-airway resistance. Saline irrigation, allergen control and prescribed intranasal corticosteroids may help selected children, although medication should be used according to age, diagnosis and clinical guidance. Persistent mouth breathing after surgery warrants reassessment rather than simple reassurance.

  Persistent Symptoms After Surgery

  Surgery improves breathing for many children, but residual OSA is common in those with obesity, Down syndrome, craniofacial differences, severe baseline disease or ongoing nasal obstruction. Follow-up should be guided by symptoms and risk factors. Repeating a sleep study is particularly important when snoring persists, behaviour remains impaired or the child has substantial comorbidity.

  Continuous positive airway pressure (CPAP) or bilevel support may be appropriate when obstruction remains or surgery is unsuitable. Successful use depends on mask fit, humidification, gradual desensitisation and family coaching. Children often need practical routines that fit school nights, travel and shared bedrooms. Equipment review is essential as the child grows.

  Weight, Growth And Daily Habits

  Childhood overweight and obesity can worsen airway narrowing and increase the likelihood of persistent disease. Weight management should be framed around sleep, energy, movement and family wellbeing rather than blame. A balanced approach may include regular meals, reduced sugary drinks, daily activity and support from a paediatric dietitian or general practitioner.

  Australian routines can complicate sleep health. Evening screen use, late sporting commitments and long commutes in outer Melbourne or Western Sydney may delay bedtime. In hot regions such as Darwin and Townsville, bedroom temperature and nasal congestion can also affect sleep comfort. Consistent sleep schedules, a dark quiet room and reduced device use before bed are practical parts of respiratory care.

  Equity, Access And Safe Information Sharing

  Access differs sharply between metropolitan and rural communities. Families in Perth may need to travel hundreds of kilometres from regional areas, while children in remote Aboriginal and Torres Strait Islander communities may require coordinated outreach, transport assistance and culturally safe care. Interpreters and Aboriginal health workers can improve communication, trust and continuity.

  Cost is another consideration. Private sleep studies, CPAP equipment, masks and specialist appointments may create financial pressure, even when some services are Medicare-supported. Families should receive clear information about likely expenses and equipment options. Clinics must also handle sleep recordings, school reports and genetic or developmental information in line with the Australian Privacy Principles and appropriate consent requirements.

  Recommendations For Clinical Practice

  A practical management pathway should combine careful screening, objective testing and ongoing review:

  • Ask about snoring, witnessed pauses, mouth breathing, sleep position, morning symptoms and daytime behaviour.
  • Examine nasal airflow, tonsils, adenoidal features, facial growth, weight and relevant neurological or developmental conditions.
  • Use polysomnography when symptoms are significant, risk is high, the diagnosis is uncertain or treatment response needs checking.
  • Treat allergic rhinitis and nasal obstruction where clinically appropriate, with clear instructions about prescribed medicines.
  • Arrange timely review after adenotonsillectomy, especially for children with obesity, Down syndrome, craniofacial conditions or severe preoperative OSA.
  • Support CPAP acclimatisation through child-friendly education, mask fitting, humidification and equipment troubleshooting.
  • Build referral plans that account for rural travel, Aboriginal and Torres Strait Islander health needs, interpreter access and family costs.

  The most useful update is a shift from treating snoring as a minor childhood habit to viewing disrupted breathing as a potentially important health condition. In practice, every child with persistent snoring or concerning sleep symptoms should receive structured assessment, an evidence-based plan and follow-up that confirms whether sleep quality and breathing have genuinely improved.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)