Noninvasive PAP supports respiratory function in children with an array of diseases. However, effective therapy requires a well-fitting interface.
Interface selection depends on patient age, facial anatomy, and comfort, as well as available headgear. Nasal masks are used most commonly in children, although other options include oronasal masks, full-face masks, nasal pillows, and nasal prongs.1–2 Identifying an appropriately fitting interface is a major challenge in children. While the number of styles and sizes of pediatric interfaces has grown over the past decade, choices are relatively few, especially in young children. Furthermore, craniofacial anomalies (like Pfeiffer syndrome) are often associated with disproportionate facial and head sizes. Finding well-fitting headgear and masks for these children is therefore difficult.
The presence of mouth breathing does not necessarily require use of an oronasal mask. Nasal CPAP actually decreases mouth opening in patients with OSA by preventing pharyngeal collapse.2 Furthermore, oronasal CPAP can worsen airway collapsibility and adherence compared with nasal mask use.3–4 Oronasal masks are generally not recommended for young children and in those with developmental disabilities because of the aspiration risk with emesis, but they may be considered in specific circumstances with appropriate monitoring.
Pressure injury is the most common interface-related complication. These injuries initially present as nonblanching erythema and affect 20% to 50% of children using chronic PAP.5–6 Infants—especially preterm—are at higher risk due to fragile skin. In one study of 253 children using PAP, most pressure injuries occurred on the nasal bridge or cheeks.7 Mask leak was a risk factor, possibly reflecting poor mask fit or excessively tightened headgear.7
Risk-reduction strategies include alternating interfaces with different contact points, using barrier dressings, and limiting the number of hours per day of PAP usage, if feasible. Headgear straps should not be excessively tight; many apply the “two-finger rule,” whereby one finger should fit underneath the headgear strap on each side of the face.8 Using nasal bridge-sparing interfaces like nasal pillows or prongs can help prevent injuries as well. One study found that skin injury rates fell over time, underscoring the importance of early intervention.6
Nasal symptoms (dryness, epistaxis, nasal congestion) occur in up to 40% of children using PAP, and obesity is a risk factor for the persistence of such symptoms.6,8 Heated humidification usually resolves symptoms and can improve adherence.8 During viral upper respiratory tract infections, delivery of PAP via a nasal mask may be challenging; a short course of nasal decongestant, such as oxymetazoline, can help. If nasal congestion persists, nasal corticosteroids or saline spray can be considered.8-9
Midface hypoplasia, manifesting as facial flattening and maxillary retrusion, is a troubling side effect of long-term PAP therapy. Children are at increased risk for this complication because of active growth and remodeling of the pediatric facial skeleton. In one study, daily use of PAP for more than 10 hours (OR 6.3, P = .02) and diagnoses of OSA or neuromuscular disease were risk factors (OR 18, P = .007).5 In a recent study involving 507 children, midface hypoplasia was relatively rare (< 5%), with younger age at PAP initiation being a significant risk factor.6 Limiting the amount of PAP time may reduce the risk or severity of midface hypoplasia.10 The relationship between maximum PAP pressure and midface hypoplasia is unclear.7
Gastrointestinal (GI) side effects of PAP include aerophagia, gastric distension, and gastroesophageal reflux.6 While the exact pressure at which gastric insufflation occurs in children is unclear, using the lowest effective PAP is generally advisable to reduce the risk of GI side effects. In children receiving BiPAP, patient-ventilator asynchrony can also worsen GI side effects.11
Even when interfaces are well-fitted, children often require desensitization to their use, especially if developmental delay or significant PAP-related anxiety is present.8 Allowing the child to acclimate to the mask in a positive environment without delivery of PAP is often beneficial.
The limited repertoire of pediatric interfaces requires novel approaches to enhance PAP use and limit side effects. Recently, investigators have explored 3-D printing customized masks for children.12 In young children, use of pediatric nasal prong systems to deliver PAP could be a useful strategy. Finally, improvisation to adapt the fit of the mask or headgear to the patient’s craniofacial structure can prove to be helpful.
References
1. Dosso M, Griffon L, Vedrenne-Cloquet M, Poirault C, Fauroux B, Khirani S. CPAP/NIV interfaces for children according to age. Sleep Breath. 2025;30(1):11. doi:10.1007/s11325-025-03561-3
2. BaHammam AS, Singh T, George S, Acosta KL, Barataman K, Gacuan DE. Choosing the right interface for positive airway pressure therapy in patients with obstructive sleep apnea. Sleep Breath. 2017;21(3):569-575. doi:10.1007/s11325-017-1490-9
3. Landry SA, Mann DL, Beare R, et al. Oronasal vs nasal masks: the impact of mask type on CPAP requirement, pharyngeal critical closing pressure (Pcrit), and upper airway cross-sectional areas in patients with OSA. Chest. 2023;164(3):747-756. doi:10.1016/j.chest.2023.03.025
4. Borel JC, Tamisier R, Dias-Domingos S, et al. Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One. 2013;8(5):e64382. doi:10.1371/journal.pone.0064382
5. Fauroux B, Lavis JF, Nicot F, et al. Facial side effects during noninvasive positive pressure ventilation in children. Intensive Care Med. 2005;31(7):965-969. doi:10.1007/s00134-005-2669-2
6. Bedi PK, DeHaan K, Ofosu D, Olmstead D, MacLean JE, Castro-Codesal M. Predictors of NIV-related adverse events in children using long-term noninvasive ventilation. Pediatr Pulmonol. 2023;58(12):3549-3559. doi:10.1002/ppul.26689
7. Lauderbaugh DL, Bhattacharjee R, Proudfoot J, et al. Noninvasive ventilation device-related pressure injury in a children’s hospital. Respir Care. 2019;64(12):1455-1460. doi:10.4187/respcare.06784
8. Castro-Codesal ML, Olmstead DL, MacLean JE. Mask interfaces for home non-invasive ventilation in infants and children. Paediatr Respir Rev. 2019;32:66-72. doi:10.1016/j.prrv.2019.03.004
9. Khirani S, Ducrot V. Mask interfaces and devices for home noninvasive ventilation in children. Pediatr Pulmonol. 2024;59(6):1528-1540. doi:10.1002/ppul.26984
10. Roberts SD, Kapadia H, Greenlee G, Chen ML. Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions. J Clin Sleep Med. 2016;12(4):469-475. doi:10.5664/jcsm.5668
11. Amaddeo A, Frapin A, Fauroux B. Long-term non-invasive ventilation in children. Lancet Respir Med. 2016;4(12):999-1008. doi:10.1016/S2213-2600(16)30151-5
12. Pigmans R, Smith JM, Markhorst DG, et al. Current advances and gaps in knowledge on personalizing masks for noninvasive respiratory support. Respir Care. 2024;69(9):1201-1211. doi:10.4187/respcare.11886
