From snoring to severe obstructive sleep apnea, sleep-disordered breathing issues occur in nearly 20% of children, says Emily Boss, who was named director of pediatric otolaryngology at Johns Hopkins Children’s Center in March 2024.

There are several telltale signs of disordered breathing, Boss says: “Most commonly, children are loud snorers and they have very restless sleep. They’ll often move around like a sundial in bed, and sometimes arch their neck during sleep. Parents may notice pauses in breathing, and then the child will sometimes gasp to catch their breath.”

These breathing issues are more prevalent in children with obesity or congenital conditions such as trisomy 21. Some children experience bedwetting as a downstream result of fragmented sleep and dysregulated breathing patterns. Others may have associated difficulty maintaining focus and paying attention, or may have issues with learning and behavior.

The good news: In about a third of children affected, sleep issues resolve over time. For others, surgery may be in order. Boss and colleagues offer a number of options to help put the whole family at rest.

Surgical removal of the tonsils and adenoids (lymph tissue in the back of the nose and throat) is often performed in children to open the size of the airway and improve breathing. During a traditional tonsillectomy with adenoidectomy, surgeons remove the tonsils and their surrounding shell, or capsule. Boss and her colleagues specialize in a modified operation called powered intracapsular tonsillectomy with adenoidectomy (PITA), performing hundreds of these operations each year. During the PITA operation, Johns Hopkins surgeons remove almost all of the tonsil tissue but leave a little bit of tonsil tissue and capsule along the throat muscles.

“It generally results in easier recovery for children, less need for pain medication and a lower risk of bleeding after surgery, which is one of the more common adverse events that can happen,” says Boss. Children are monitored for about 90 minutes after these outpatient surgeries before being sent home.

The team also offers diagnostic sleep endoscopy, a minimally invasive procedure to study the airway while children are lying flat, asleep under anesthesia. The diagnostic test is helpful to pinpoint contributors to sleep-disordered breathing beyond tonsils and adenoids, such as obstructions surrounding the base of the tongue or the larynx (voice box). Additionally, the group recommends sleep studies to diagnose sleep apnea or other conditions.

Boss, who joined the Johns Hopkins faculty in 2008, has served in other leadership roles, including chief surgical quality officer for the Children’s Center. She also directs an NIH-funded study aimed at improving communication about sleep-disordered breathing between physicians and families. She and co-investigators in Seattle, Dallas and across Johns Hopkins audio record some patient encounters and interview parents about how sleep treatment options were communicated to them and how they were engaged in decisions to move forward with surgery.

“We’re learning a lot about how we can standardize our approach so that it’s more patient-centered, and so that we’re providing the right information that helps parents feel engaged and confident about treatment decisions for their children,” Boss says.