Childhood Sleep Apnea Differential Diagnoses

Updated: Feb 13, 2019
  • Author: Mary E Cataletto, MD; Chief Editor: Denise Serebrisky, MD  more...
  • Print

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