Parents often describe the same pattern: Their child snores when sleeping on their back, and the snoring eases when they change positions. Until recently, little research had explored how common positional obstructive sleep apnea (pOSA) is in children and what treatment works best.
Researchers at Children’s Health℠ set out to answer those questions. The team was led by Seckin O. Ulualp, M.D. and Ron B. Mitchell, M.D., Pediatric Otolaryngologists at Children’s Health and Professors at UT Southwestern. They reviewed sleep study data from 1,167 children undergoing adenotonsillectomy to treat OSA.
“What we found was striking,” Dr. Ulualp says. “Positional OSA is common in children, and it resolves after adenotonsillectomy, in most cases. That makes surgery a strong first-line option for these children.”
Their study, published in Laryngoscope Investigative Otolaryngology in March 2025, is one of the largest efforts to measure how often pOSA occurs and how well adenotonsillectomy resolves it. The manuscript received the Triological Society’s Thesis: With Distinction Award, and Dr. Ulualp will present the work at the society’s national 2026 Combined Sections Meeting.
Why early detection of positional OSA is important
Early diagnosis of pediatric OSA is important because OSA affects children’s behavior, learning, growth and overall quality of life. Part of that early recognition involves understanding the different ways OSA can appear, including when symptoms shift with sleep position. And pOSA is a subtype in which breathing problems occur in certain sleep positions, typically on the back. Yet when parents report their child’s positional symptoms, they may not always cue providers to look deeper.
Recognizing positional OSA: Diagnostic implications for clinicians
The research helps translate parents’ observations into actionable clinical information.
The team found that positional involvement is more common than previously believed in children undergoing adenotonsillectomy for OSA.
The study also revealed that positional involvement was not tied to OSA severity: Children with mild, moderate and severe OSA had similar rates of pOSA.
For providers, these findings show sleep-position patterns as an important part of the diagnostic picture, rather than an incidental detail. Positional symptoms should prompt providers to evaluate for OSA and refer children sooner for sleep studies.
“Knowing the positional component gives providers more context,” says Dr. Mitchell. “It helps in deciding when a child may benefit from further evaluation and surgery.”
Key findings: Adenotonsillectomy resolves positional OSA in most children
The study showed that pOSA occurred in 28% of children undergoing adenotonsillectomy to treat OSA. The investigators also found that adenotonsillectomy resolved pOSA in 76% of these children, providing evidence of surgery as a strong, first-line option.
Dr. Mitchell notes that many families first want to try positional therapy, which uses pillows or other devices to keep children on their side during sleep. However, it’s unclear how long children may need positional therapy or how well it works. “Our findings show that adenotonsillectomy offers much more predictable improvement for children with pOSA,” Dr. Ulualp says.
Clinical guidance: When to evaluate and refer children with positional OSA
Positional symptoms can offer useful clues when evaluating a child with disrupted sleep. The study findings give providers clearer direction on what to watch for and when referral is appropriate.
Pay attention to positional symptoms. When parents report loud snoring, breathing pauses or increased breathing effort when a child sleeps on their back, ask how often and for how long these changes have been occurring.
Use a three-month threshold. Refer children for ENT evaluation when nighttime symptoms (snoring, mouth breathing, witnessed apneas, restless sleep) or daytime symptoms (attention and concentration difficulties, hyperactivity, excessive tiredness) last three months or longer.
Refer directly for specialty evaluation. Positional therapy and other nonsurgical strategies vary in effectiveness. The study supports sending children for ENT assessment to determine whether surgery may help.
Help families weigh treatment options. The study shows that adenotonsillectomy provides more reliable improvement than nonsurgical strategies. Explaining this point to families helps them make a more informed decision.
“When sleep problems change with position, those symptoms shouldn’t be underestimated,” Dr. Ulualp says. “Early referral to ENT or sleep medicine can help children get the care they need.”
Advancing pediatric OSA care through large-scale clinical research
Children’s Health and UT Southwestern are home to one of the nation’s largest programs for pediatric sleep apnea research and patient care. The system’s large, diverse patient population and high-volume sleep center make it uniquely positioned to conduct meaningful studies like this one.
The ENT and Sleep Medicine teams collaborate on institutional, national and international studies, including NIH-funded research. Their work has helped establish new treatment pathways, such as upper airway stimulation for children with Down syndrome.
As part of their ongoing research, the investigators are planning studies to understand why pOSA persists in some children and which therapies may be most effective for them.
“This study is one part of a broader effort to better understand pediatric OSA from every angle,” says Dr. Mitchell. “We’re committed to advancing knowledge and translating our work into better sleep and better daily life for children.”
Learn more about ENT and pediatric OSA care at Children’s Health.
