Does Your Child Snore? Snoring vs. Sleep Apnea in Kids

A parent’s guide to sorting harmless snoring from sleep apnea, and what to do about each

Plenty of children snore with a cold and stop when it clears. A child who snores most nights, cold or no cold, is a different story. As a fellowship-trained pediatric ENT in Frisco, I meet many parents who have lain awake listening to their child snore, pause, and gasp, and who want to know one thing: is this harmless, or is it hurting my child? This guide explains how to tell the difference at home, what to record for your child’s doctor, when a sleep study is needed, and what treatment looks like, from watchful waiting to surgery.

Key takeaways

• Snoring is a spectrum, from simple (“primary”) snoring to obstructive sleep apnea (OSA), where the airway repeatedly narrows or closes during sleep.
• The American Academy of Pediatrics (AAP) recommends screening every child for snoring at routine checkups.
• A one- to two-minute phone video of your child asleep is one of the most useful things you can bring to an appointment.
• Daytime clues matter: behavior and attention problems, bedwetting, morning headaches, and poor growth can all be linked to disturbed sleep.
• Not every child needs a sleep study. One is recommended before surgery for children under 2, for children with certain medical conditions, and when the diagnosis is uncertain.
• Removing the tonsils and adenoids is first-line treatment for most children with OSA and enlarged tonsils, but large trials show watchful waiting is reasonable for many children with mild disease.

Snoring, sleep-disordered breathing, and sleep apnea

Snoring is the sound of air moving through a narrowed throat during sleep. In children, the narrowing is usually caused by enlarged tonsils and adenoids. An MRI study of children who did not snore found that adenoid size increases over roughly the first seven to eight years of life and then gradually shrinks, one reason enlarged tonsils and adenoids are such a common cause of snoring in preschool and early school-age children. A large review estimated that 1.5 to 6 percent of parents say their child “always” snores, and that 1 to 4 percent of children have OSA on testing.

Tonsils and adenoids are not the only cause. Excess weight, allergies and chronic nasal blockage, a small jaw or other facial differences, low muscle tone, and conditions such as Down syndrome all raise the risk. I cover the tonsils in Are Your Child’s Large Tonsils a Problem?, the adenoids in The ABCs of Adenoids, and daytime blockage in nasal obstruction in children.

What to watch and record at night

Home video has been studied as a screening tool for sleep apnea: in one early study, a doctor’s judgment from a 30-minute home recording agreed with the formal sleep study in most children. A one- to two-minute phone clip usually shows the pattern.

How to make a useful video

• Record after your child is deeply asleep, at least an hour after bedtime. Breathing problems are often more obvious later in the night.
• Keep the sound on and use enough light to see the face and chest.
• Choose a night without a cold. Snoring only during colds is common and usually not a concern.

What to look and listen for

• Snoring three or more nights a week, the threshold the AAP lists as a warning sign
• Pauses in breathing, a few seconds of silence followed by a snort or gasp
• Labored breathing: skin pulling in between or under the ribs or at the base of the neck, or the belly rising while the chest sinks
• Unusual positions: sleeping propped up, kneeling with the bottom in the air, or with the head tipped far back, which can be a sign a child is working to keep the airway open
• Heavy sweating, restless tossing, frequent waking, and mouth breathing

Daytime clues

Children with sleep apnea are often not sleepy the way adults are. Instead, look for:

• Behavior and attention problems: hyperactivity, irritability, and learning difficulties
• Bedwetting, especially when a child who was dry at night starts wetting again
• Morning headaches and trouble waking up
• Poor growth in some children, while others are overweight
• Constant mouth breathing or a nasal voice, covered in my post on chronic mouth breathing in young children

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) tonsillectomy guideline asks clinicians to look for growth problems, poor school performance, bedwetting, asthma, and behavior problems in these children, because they may improve after treatment.

When is a sleep study needed?

An overnight sleep study (polysomnography) confirms sleep apnea and measures its severity. Sensors record breathing, oxygen levels, heart rate, and sleep stages. Nothing is painful, and in pediatric sleep labs a parent usually stays in the room.

The AAP recommends a sleep study for children who snore and have signs of sleep apnea, but many otherwise healthy children with large tonsils and a clear history are treated without one. The AAO-HNS guideline says a study should be done before surgery in:

• Children under age 2
• Children with obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses

It also advises a study when the need for surgery is uncertain, or when the size of the tonsils does not match how severe the symptoms sound. Separately, the AAP’s health supervision guidance for Down syndrome (updated 2022) recommends a sleep study by age 4 for all children with Down syndrome, whether or not they snore.

The treatment ladder

Watchful waiting

Two large randomized trials shape how this decision is made today.

• The Childhood Adenotonsillectomy Trial (CHAT, 2013) assigned 464 children ages 5 to 9 with sleep apnea, but without prolonged oxygen drops, to early removal of the tonsils and adenoids or to seven months of watchful waiting. Surgery did not improve formal attention and executive-function testing, but it did improve behavior, quality of life, symptoms, and sleep study results, which normalized in 79 percent of the surgery group versus 46 percent of the waiting group.
• The Pediatric Adenotonsillectomy Trial for Snoring (PATS, 2023) studied 459 children ages 3 to 12 with snoring and only mild findings on a sleep study. At 12 months, surgery again did not improve executive function or attention, but it improved behavior, sleepiness, symptoms, quality of life, and blood pressure. About 13 percent of the waiting group progressed to more significant sleep apnea, compared with about 1 percent after surgery.

For snoring or mild sleep apnea, then, waiting with regular re-checks is a legitimate choice, while surgery still offers real benefits for many children. It is a shared decision.

Medications for mild cases

• Nasal steroid sprays reduce swelling in the nose and adenoids. The AAP lists them as an option for mild sleep apnea when surgery is not appropriate, or for mild sleep apnea that remains after surgery.
• Montelukast, an oral allergy and asthma medicine, alone or with a nasal steroid, improved breathing during sleep in children with mild OSA in a 2019 meta-analysis, mostly over the short term. In 2020 the FDA added a boxed warning about serious mental health side effects, including agitation, depression, trouble sleeping, sleepwalking, and suicidal thoughts or actions. Discuss these risks before starting it, and call your doctor if you notice changes.
• Treating allergies helps when nasal blockage is allergic. See allergy testing and treatment.

Your child’s doctor will choose the product and dose based on age and weight.

Removing the tonsils and adenoids

For a child with OSA and enlarged tonsils, the AAP recommends adenotonsillectomy as first-line treatment, and the AAO-HNS recommends tonsillectomy when sleep apnea is documented on a sleep study. In some very young children whose main blockage is the adenoids, removing the adenoids alone is enough. My tonsillectomy page explains the procedure and recovery.

The AAO-HNS recommends overnight hospital monitoring after tonsillectomy for children under 3 and for those with severe sleep apnea, so the setting matters. I perform these procedures at Stonebridge Surgery Center, and at Children’s Medical Center Plano or Texas Health Hospital Frisco when hospital care is the safer choice.

Palate expanders may help selected children with a narrow upper jaw, but they do not remove enlarged tonsils or adenoids. See RPE vs. Tonsillectomy.

When sleep apnea persists after surgery

Surgery helps most children but does not cure every child. In a multicenter study of 578 children, breathing events dropped substantially after adenotonsillectomy, yet only about a quarter had complete resolution by a strict definition. Residual sleep apnea was more likely in children older than 7, children with obesity, and those with severe disease or asthma beforehand. If symptoms continue, the AAP recommends re-evaluation and, for higher-risk children, a repeat sleep study. Next steps can include CPAP (a mask that gently holds the airway open), weight management alongside other treatment, a nasal steroid for mild residual disease, and a closer look at the airway, sometimes with sleep endoscopy under anesthesia.

When snoring is an emergency

Call 911 or go to the emergency department if your child:

• Stops breathing for long periods, or turns blue or gray around the lips
• Is very hard to wake
• Struggles to breathe while awake, with pulling in at the ribs or neck
• Has noisy breathing with drooling, high fever, and a muffled voice

A baby with noisy breathing that worsens with feeding or lying on the back should be seen promptly. See Laryngomalacia: Noisy Breathing in Babies and my airway and breathing issues page.

When to see a pediatric ENT

• Snoring three or more nights a week that lasts beyond a cold
• Pauses, gasping, or labored breathing during sleep
• Behavior or attention problems, bedwetting, morning headaches, or poor growth along with snoring
• Constant mouth breathing or nasal blockage
• Snoring in a child with Down syndrome, a craniofacial or neuromuscular condition, sickle cell disease, or obesity
• Sleep symptoms that return after tonsil or adenoid surgery

More on my approach is on the sleep and breathing disorders and pediatric ENT pages.

From my research and practice

Two systematic reviews and meta-analyses I co-authored bear on this topic. The first, in the Journal of Laryngology & Otology in 2016 (Reckley, Song, Chang, Cable, Certal, Camacho), pooled studies of adenoidectomy alone for sleep apnea in children. Only three studies with 47 children qualified; breathing events during sleep fell substantially, most in infants under 12 months, but the evidence base was too small to be definitive. The second, in the International Journal of Pediatric Otorhinolaryngology in 2016 (Song, Tolisano, Cable, Camacho), pooled 19 prospective studies and found developmental and IQ scores improved after adenotonsillectomy, especially in preschoolers, although only three studies included that age group. Because the randomized trials above found no difference in formal attention testing in school-age children, I talk with families about sleep, behavior, and quality of life rather than promising better test scores. These papers are on my publications and research page.

Frequently asked questions

Is it normal for children to snore?

Occasional snoring during a cold or allergy flare is common and usually harmless. Snoring three or more nights a week, or snoring with pauses, gasps, or labored breathing, is not normal and should be mentioned to your child’s doctor.

How can I tell if my child has sleep apnea instead of just snoring?

Watch for pauses followed by a snort or gasp, pulling in at the ribs or neck, restless sleep, sweating, and odd sleep positions, along with daytime behavior problems, bedwetting, or morning headaches. A short phone video is very helpful. Only a sleep study confirms sleep apnea and measures its severity.

Does my child need a sleep study before tonsil surgery?

Not always. The AAO-HNS recommends one before surgery for children under 2 and for children with obesity, Down syndrome, craniofacial differences, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. A study is also advised when the diagnosis or need for surgery is uncertain.

Will my child outgrow snoring?

Some children do, because tonsils and adenoids usually shrink after early childhood. In the PATS trial, many children with snoring and mild sleep apnea improved without surgery, but about 13 percent of those who waited developed more significant sleep apnea within a year, so regular re-checks matter.

Does removing the tonsils and adenoids always cure sleep apnea?

No. Surgery helps most children, and sleep studies normalized in 79 percent of the surgery group in the CHAT trial. Sleep apnea is more likely to persist in older children, children with obesity, and those with severe disease, and some need further treatment such as CPAP.

References

1. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576–584. doi:10.1542/peds.2012-1671
2. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019;160(1 Suppl):S1–S42. doi:10.1177/0194599818801757
3. Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366–2376. doi:10.1056/NEJMoa1215881
4. Redline S, Cook K, Chervin RD, et al. Adenotonsillectomy for snoring and mild sleep apnea in children: a randomized clinical trial. JAMA. 2023;330(21):2084–2095. doi:10.1001/jama.2023.22114
5. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):242–252. doi:10.1513/pats.200708-135MG
6. Papaioannou G, Kambas I, Tsaoussoglou M, et al. Age-dependent changes in the size of adenotonsillar tissue in childhood: implications for sleep-disordered breathing. J Pediatr. 2013;162(2):269–274. doi:10.1016/j.jpeds.2012.07.041
7. Sivan Y, Kornecki A, Schonfeld T. Screening obstructive sleep apnoea syndrome by home videotape recording in children. Eur Respir J. 1996;9(10):2127–2131. doi:10.1183/09031936.96.09102127
8. Bull MJ, Trotter T, Santoro SL, Christensen C, Grout RW; Council on Genetics. Health supervision for children and adolescents with Down syndrome. Pediatrics. 2022;149(5):e2022057010. doi:10.1542/peds.2022-057010
9. Liming BJ, Ryan M, Mack D, Ahmad I, Camacho M. Montelukast and nasal corticosteroids to treat pediatric obstructive sleep apnea: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2019;160(4):594–602. doi:10.1177/0194599818815683
10. US Food and Drug Administration. FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair). Drug Safety Communication; March 4, 2020. fda.gov
11. Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010;182(5):676–683. doi:10.1164/rccm.200912-1930OC
12. Reckley LK, Song SA, Chang ET, Cable BB, Certal V, Camacho M. Adenoidectomy can improve obstructive sleep apnoea in young children: systematic review and meta-analysis. J Laryngol Otol. 2016;130(11):990–994. doi:10.1017/S0022215116008938
13. Song SA, Tolisano AM, Cable BB, Camacho M. Neurocognitive outcomes after pediatric adenotonsillectomy for obstructive sleep apnea: a systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2016;83:205–210. doi:10.1016/j.ijporl.2016.02.011

If your child snores most nights or you have noticed pauses or gasping during sleep, I’m happy to take a look. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.