Osteopathic Evaluation for Sleep Apnea In Children

Brought to you by Creative Healing for Youth in Pain's Parenting Blog

Dr. Sylvia Orozco Silberman DO, MS
May 27, 2024 / 7 mins read

Sleep apnea is not a condition we consider much in kids, but we should.

When should we suspect it?

Who do we go to for evaluation?

Why is it important to recognize it, and how does it affect the overall expression of health?

Think about your child’s sleep habits from childhood until the teenage years. Did/do they:

  • Snore?
  • Grind their teeth?
  • Breathe through their mouth?
  • Have a dry throat in the morning?
  • Have dry lips in the morning?
  • Have night sweats?
  • Have sweaty palms or feet?
  • Toss and turn a lot?
  • Have sleep disturbances?
  • Have morning headaches?
  • Wet the bed?
  • Experience daytime sleepiness?
  • Experience neurocognitive effects, ADHD, and/or behavioral issues?
  • Have enlarged adenoids and/or tonsils?
  • Have dark rings under their eyes?
  • Have recurrent upper respiratory infections?
  • Have poor dentition (cavities)?

The Nose
If your child has any or some of these symptoms, the first line of inquiry should be determining what may obstruct their airway. Check the nose. Do they have allergies? Is there a pet in the home? Is there congested tissue that may obstruct the nasal passages (aka airway)? Do they eat with their mouth open? Do they sound “nasally” when speaking? Can they talk with complete sentences without gasping for snippets of air?

Tools to help are:

  1. Lessen the dust and pet dander.

  2. Keep the blinds, curtains, and/or fan clean.

  3. Avoid carpets in the room.

  4. Clean their bed sheets every 1-2 weeks to lessen allergens.

  5. Check the material of their pajamas.

  6. Check the material of their pillows and sheets.

  7. Use nasal saline rinses with a neti pot or nasal spray before bed to clear the nasal passages.

  8. For those who live in colder climates: When the heat is turned on in the winter, a clean humidifier to moisten the nasal passages is excellent.

Breathing through the nose is vital for regulating the vitality of our health and the balance and functioning of our autonomic nervous system, which in turn affects our immune system, cardiovascular health, digestion, attention, mood, and much more.

If you are unfamiliar with Buteyko Breathing, it is an incredible resource and perspective on the importance of nasal breathing. Understanding nasal breathing begins with its anatomical and physiological importance but also explores the breath itself. If one is nasal breathing, it does not necessarily mean one is breathing optimally. Nasal breathing is just the first step.

The Tongue
Once the nasal airway is eliminated as a variable for possible obstruction, we should look at tongue function. Is the tongue floppy and compressing into the airway passage in the throat at night? The tongue is this incredible part of our anatomy that has been the most underappreciated or misunderstood.

At rest, the tongue should always reside on the roof of the mouth. The tongue is an extension of our brain and is the key player in forming the structure of our palate (aka airway). It also neurologically integrates our nervous system.

The tongue is a key player in our survival. Before formula was an option, breastfeeding was a key and vital function. Breastfeeding allows a child to exercise the tongue’s function and optimize the shaping of the airway structure. The tongue function is vital for swallowing, chewing, eating, and speaking—activities we take part in all day long. If its function is off, it can limit the vital functioning of our physiology.


  1. Rest posture: Is your child’s tongue at the roof of the mouth at rest?

  2. Swallowing: Can your child swallow with their cheeks held apart? Without blinking?

  3. Chewing: Can your child eat with their mouth closed, moving a bolus of food cleanly and with coordination from the left back molars to the right back molars?

  4. Does your child’s tongue stick out when doing certain activities?

  5. Does your child chew on their tongue while doing certain activities, like climbing stairs or drawing?

  6. Was your child breastfed? If so, did they have difficulties breastfeeding?

  7. Was/is your child a messy eater?

  8. Was/is your child a picky eater? Do they have texture issues?

If tongue activity is dysfunctional or not optimized, a myofunctional therapist is an incredible resource. They are usually either a sleep-language pathologist or dental hygienist who received extra training in evaluating and treating improper tongue function. Most also have training in breathing tools.

Because the tongue’s function highly determines the shape and structure of the palate, evaluating one always goes hand in hand with the other. The question is, with the strengthening of tongue function, is there still obstruction of airway passages? If so, a thoughtful airway dentist is highly recommended for evaluation. Could genetics or improper tongue function and chewing in childhood have affected the growth and development of the facial structures and airway capacity?


  1. Does your child’s tongue have bite marks on it?
  2. Is their palate high and narrow?
  3. Do you see less than six teeth when your child smiles?
  4. Can you see the back of your child’s throat when they stick out their tongue and say, “Ah?”
  5. Does your child have speech issues?

These are preliminary tools for thinking about the effects of nasal breathing, tongue function, and palate structure and their influences on and causes of obstructive sleep apnea.

From an Osteopathic Hands-On Evaluation
Besides evaluating the oral cavity, osteopaths understand the influences of various other functions of the body that influence breath, tongue function, and sleep:

Cranial Nerve XII influences the functioning of the tongue. This nerve extends from the brainstem's medulla to its output through the occipital bone (in the back of the cranium) and into the tongue muscles. Therefore, its motions and/or restrictions should be assessed. Osteopaths evaluate the cranium's motion to assess if any strain, restriction, or compression impairing the function of the nerve’s innervation to the tongue, which could have occurred during birth, trauma/injury, or traditional orthodontic care.

The diaphragm is key in breathing, airway function, immune functioning, autonomic nervous system regulation, and digestion. During REM sleep, all body muscles are paralyzed except the diaphragm. Therefore, its capacity to move optimally during sleep is critical to vital sleep. Osteopaths evaluate the nerves coming from the neck, which innervate the diaphragm. The diaphragm connects to the ribs and the thoracic and lumbar spine. Fascial connections to the diaphragm are influenced by the tongue, sternum, pelvis, and much more.

These examples illustrate the beautiful complexity and interwoven effects of the whole body’s connections. A hands-on osteopathic evaluation and perspective help diagnose the root causes of dysfunctional breathing, airways, and sleep.

Lastly, if any of the conditions or patterns listed above raise concerns about sleep apnea in your child, the gold standard for diagnosing sleep apnea is to have a sleep study (polysomnography). Your next step should be to find a sleep doctor or pulmonologist who can evaluate the study.

Recommended Reading to Learn More

  1. Breath: The New Science of a Lost Art, by James Nestor

  2. The Alf Approach: Changing the Face of Orthodontics, by Dr. Tasha Turzo, DO

  3. ButeykoClinic.com

  4. “Role of Mouth Breathing In the Misdiagnosis of ADHD” (https://myacare.com/blog/role-of-mouth-breathing-in-the-misdiagnosis-of-adhd)