Academic struggles, emotional outbursts, and a sudden inability to focus usually send pediatricians hunting for a behavioral diagnosis.

But Binal Kancherla, MD, medical director at the Children’s Sleep Center at Texas Children’s Hospital in Houston, sees another possibility: the child may have obstructive sleep apnea (OSA)

“It is common to see children referred for behavioral or academic concerns who ultimately have significant sleep-disordered breathing,” said Kancherla, chair of the Section on Pediatric Pulmonary and Sleep Medicine at the American Academy of Pediatrics.

For years, OSA has been recognized primarily as a disorder of snoring, disrupted sleep, and airway obstruction.

But research suggests the effects of repeated nighttime oxygen drops and fragmented sleep in children may extend beyond the nighttime hours, potentially influencing developing brain networks involved in attention, executive function, and learning.

Studies using structural MRI have identified reduced gray matter volume and cortical thinning in children with OSA compared with their peers. More recent functional imaging studies have pointed toward specific brain networks affected by OSA, involved in executive function, memory consolidation, and emotional regulation.

Kin Yuen, MD, a sleep medicine specialist at University of California, San Francisco, said these emerging findings are not yet a reason to order brain imaging for every child with sleep-disordered breathing. Instead, they should prompt clinicians to reconsider how sleep loss can contribute to the cognitive and behavioral changes in some children.

“The theory is, pending larger studies, that hypoxemia from untreated pediatric OSA is affecting the proper development of these regions and interfere with learning, emotional imprinting of experiences, and developing empathy for others,” Yuen said.

But experts caution that the MRI findings do not mean every child with OSA has measurable brain injury or that brain imaging should become part of routine evaluation.

When Sleep Problems Look Like Behavior Problems

Clinicians should ask caregivers if their child is experiencing symptoms of OSA, including habitual snoring, breathing pauses, restless sleep, mouth breathing, enlarged tonsils, difficulty waking in the morning, and daytime behavioral changes.

But one of the challenges for pediatricians is the symptoms of OSA often overlap with other childhood comorbidities.

Children with untreated OSA may appear inattentive, impulsive, irritable, or emotionally dysregulated. Those symptoms can resemble attention-deficit/ hyperactivity disorder and may lead families and clinicians down a behavioral evaluation pathway before sleep is considered, Kancherla said.

Yuen said pediatricians and caregivers should pay attention to changes from a child’s baseline.

“If the child is normally able to follow directions, remain calm with challenges, but [suddenly] acutely lacks emotional regulation or even throws a tantrum, shuts off, then the parent or caregiver should inquire further,” she said.

For adolescents, social changes such as self-isolating or having difficulty with friends may be red flags.

Observations from teachers can also be useful because they provide insights into a child’s daily functioning.

“Is the child having difficulty paying attention in school? Have teachers reported problems with focus, organization, or memory? Has academic performance changed? Are there concerns about impulsivity or irritability?” Kancherla said.

Screening and Treatment Without Imaging

Routine brain imaging is not realistic for most children with OSA, leaving clinicians with a practical question of how to identify children who may be experiencing cognitive or behavioral effects.

Kancherla said the focus should be on identifying functional changes rather than trying to detect structural brain differences.

Validated screening tools created for adults, including sleep questionnaires and behavioral assessments, may help pediatricians track symptoms over time.

“The pediatric Epworth score, though not ideal, can at least assess how sleepy the child is,” she said. “If over 10/24, then the parent should evaluate what may be causing the daytime sleepiness.”

Experts said treatment may improve some of the behavioral issues.

Adenotonsillectomy, which removes enlarged tonsils and adenoids that can obstruct the airway, remains one of the most common treatments for pediatric OSA. Studies have shown improvements in behavior, attention, and quality of life after treatment, Kancherla said.

Children treated with continuous positive airway pressure may also experience improvements in daytime functioning and neurobehavioral symptoms when used consistently, she said.

But treatment is not necessarily a one-time solution. Clinicians should continue to monitor children, especially if symptoms return or risk factors change. As children grow, changes in airway anatomy, jaw structure, weight, hormones, and environment can influence whether OSA resolves or persists.

These factors “influence whether there is adequate space for the tongue, teeth, and nasal structures to fit adequately,” Yuen said.

Some children may also need continued monitoring because of additional risk factors, including genetic syndromes, neurodevelopmental conditions, or other sleep disorders, such as restless legs syndrome or periodic limb movements.

“Continual monitoring is the key even amongst those that qualify and have received adenotonsillectomy or have undergone jaw expansions with orthodontists,” she said.

Kancherla reported serving as a consultant for Avadel Pharmaceuticals. Yuen reported having no relevant disclosures.

Lara Salahi is a health journalist based in Boston.