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Childhood Sleep Apnea Differential Diagnoses

  • Author: Mary E Cataletto, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
Updated: Apr 21, 2016

Diagnostic Considerations

Obstructive sleep apnea (OSA) must be differentiated from simple snoring, which is a vibratory inspiratory noise that is usually not accompanied by oxygen desaturation, hypercapnia, or sleep disruption. Overnight polysomnography can be performed to differentiate pronounced snoring from true obstructive sleep apnea in the pediatric age group.

Go to Upper Airway Evaluation in Snoring and Obstructive Sleep Apnea for complete information on this topic.

Daytime somnolence

Daytime somnolence is a common complaint among individuals with obstructive sleep apnea. For teens and adults, this may be the presenting concern that brings them to medical attention. However, keep in mind that not all children with excessive daytime somnolence have obstructive sleep apnea. Sleepiness during the day may be due to numerous factors in addition to sleep apnea. Many children are sleepy during the day simply because their parents do not have a clear idea as to how much sleep a child actually requires.

Chaotic sleep schedules with inconsistent bedtimes and rise times and with limited time allowed for sleep are major causes of daytime sleepiness and lassitude. Any evaluation for suspected sleep apnea must include a careful history with inquiries about sleep times, bedtime routines, and a description of the sleeping environment. Parents should be asked to complete a sleep diary for 1-2 weeks to evaluate whether a child is sleeping enough.


Narcolepsy is a disease characterized by irresistible sleeping attacks that occur intermittently throughout the day. It is included in the differential diagnosis of excessive daytime sleepiness. Patients with narcolepsy are tired throughout the day; thus, the disorder can be confused with obstructive sleep apnea syndrome. A history of episodic sleep-onset paralysis, hypnagogic (sleep-onset) hallucinations, or daytime memory lapses with automatic behaviors may help differentiate between narcolepsy and obstructive sleep apnea. Sleep paralysis is a frightening experience that lasts from a few seconds to several minutes, during which an individual can breathe and move the eyes but otherwise cannot speak or move.

Hypnagogic hallucinations

Hypnagogic hallucinations are vivid lifelike dreams that occur just as one begins to fall asleep. These hallucinations often involve an awareness of another person or an animal in the room, bright colors, or unusual shapes. Often, other senses are involved during the experience, including touch, smell, and hearing. Older patients with narcolepsy may experience cataplexy, or the sudden brief loss of muscular tone without loss of consciousness. Multiple sleep latency testing (MSLT) following overnight polysomnography is necessary to confirm a diagnosis of narcolepsy and differentiate this from obstructive sleep apnea.

Nocturnal gastroesophageal reflux

Nocturnal gastroesophageal reflux may result in nocturnal restlessness, choking episodes during sleep, frequent awakenings, and labored breathing that resemble symptoms of obstructive sleep apnea syndrome.

Other disorders

Periodic limb movement disorder, nocturnal seizures, rhythmic movement disorder, and various parasomnias can be differentiated from obstructive sleep apnea on the basis of polysomnography.

Differential Diagnoses

Contributor Information and Disclosures

Mary E Cataletto, MD Professor of Clinical Pediatrics, State University of New York at Stony Brook

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians

Disclosure: Nothing to disclose.


Timothy D Murphy, MD Consulting and Attending Staff, Pediatric Pulmonary and Sleep Medicine, Mary Bridge Children's Hospital

Timothy D Murphy, MD is a member of the following medical societies: American Thoracic Society, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Andrew J Lipton, MD MPH and TM, Staff Pediatric Pulmonologist, Assistant Professor of Pediatrics, Department of Pediatrics, Walter Reed Army Medical Center

Andrew J Lipton, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children's Hospital, Rush University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Additional Contributors

Susanna A McColley, MD Professor of Pediatrics, Northwestern University, The Feinberg School of Medicine; Director of Cystic Fibrosis Center, Head, Division of Pulmonary Medicine, Children's Memorial Medical Center of Chicago

Susanna A McColley, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Sleep Disorders Association, American Thoracic Society

Disclosure: Received honoraria from Genentech for speaking and teaching; Received honoraria from Genentech for consulting; Partner received consulting fee from Boston Scientific for consulting; Received honoraria from Gilead for speaking and teaching; Received consulting fee from Caremark for consulting; Received honoraria from Vertex Pharmaceuticals for speaking and teaching.


Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

David Gozal, MD Vice-Chairman of Research and Director, Comprehensive Sleep Medicine Center, Kosair Children's Hospital; Professor, Department of Pediatrics, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Michael Steffan, MD Director of Pediatric Sleep Center, Department of Pediatrics, Department of Pediatrics, Children's Medical Center; Associate Professor, Wright State University School of Medicine

Disclosure: Nothing to disclose.

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Palate appearance following uvulopalatopharyngoplasty (UPPP) surgery.
Example of an obstructive apnea and an obstructive hypopnea recorded during polysomnography.
Medical complications associated with obstructive sleep apnea in children.
Compressed overnight polysomnography tracing of a 6-year-old boy who snores, showing multiple events of obstructive apnea (green-shaded areas) associated with oxyhemoglobin desaturation (yellow-shaded areas) and EEG arousals (red-shaded areas).
Parameters monitored during an overnight pediatric sleep study.
Normal parameters for sleep gas exchange and gas exchange in children.
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