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HAVING YOUR CHILD EVALUATED FOR OBSTRUCTIVE SLEEP APNEA

If you suspect that your child has obstructive sleep apnea (OSA), you may want to consult first with your child's primary care provider (usually a pediatrician or family physician) and share your concerns. You may also choose to consult with an otolaryngologist (ear, nose, and throat specialist or ENT) or a pulmonologist (a specialist in lung problems) who deals with children. Sometimes, because of the hyperactivity, inattentiveness, aggressive behavior, irritability, and mood swings associated with pediatric OSA, a mental health provider, such as a child psychiatrist or psychologist, or a neurologist may be the first to recognize the problem. However, before seeing any specialist for an evaluation, you should check with your insurance company as you may need a referral or have to go to a specific provider.

Doctors who specialize in sleep medicine may also practice in your area. They have usually trained under other sleep specialists and/or studied sleep medicine through a residency program, continuing medical education (CME) courses, and scientific meetings. Physicians certified by the American Board of Sleep Medicine have passed standardized tests on both pediatric and adult sleep disorders. You should ask any doctor or health care provider about his/her credentials and experience, especially in dealing with children. You should be satisfied with the explanations and how it will be diagnosed and treated in your child's particular case.

In most cases, the initial evaluation for children with suspected OSA includes a complete medical history (symptoms; previous and current medical problems; operations, especially removal of the tonsils and/or adenoids; medications; and allergies), a review of any behavioral or developmental problems, a sleep history, and a physical exam (including weight and height). Blood tests, x?rays, and other specialized tests may be needed in some cases.

Based on the initial evaluation, your health care provider may suggest an overnight sleep study. A sleep study or polysomnogram can help to make a diagnosis of OSA in children and can help to judge the severity of the problem.

The recording devices used during a sleep study are similar in adults and children. These generally include an electroencephalogram (EEG) to measure brain waves and an electroculogram (EOG) to measure eye and chin movement, both to monitor the different stages of sleep; an electrocardiogram (EKG) to measure heart rate and rhythm; chest bands to measure breathing movements; and additional monitors to sense oxygen and carbon dioxide levels in the blood as well as monitors to record leg movement. None of the devices is painful and there are no needles involved, and sometimes the technician can attach the monitoring devices after the child has fallen asleep in the lab. Still the process may be a little frightening for a young child. Most sleep labs accommodate a parent's stay with the child overnight.

There are currently only a few clinics around the country that specialize specifically in pediatric sleep problems. However, many sleep study facilities (usually called sleep labs or sleep centers) perform studies on children as well as adults. Check first to make sure that the facility you use is equipped to handle children and that the sleep lab technicians are comfortable working with them. You should also ask if the doctor who will interpret the sleep study is familiar with reading pediatric sleep studies as they differ some from those of adults.

If you are not given a list of doctors and sleep testing facilities, you can find a referral from a few different sources. There is no one complete list of all such facilities, and as a non?profit organization, the American Sleep Apnea Association (ASAA) does not endorse or recommend any company, product, or health care provider. However, there is a list of sleep centers and laboratories accredited by the American Academy of Sleep Medicine (AASM) that pay their AASM membership dues. (The AASM, formerly known as the American Sleep Disorders Association or ASDA, is the professional society in the field of sleep medicine that accredits such facilities; accreditation implies adherence to a certain set of standards). The most up-to-date list of accredited member sleep centers and laboratories appears on the AASM's web site: www.aasmnet.org. You can request a list from the ASAA as well. Remember that other centers are in the process of being accredited, have chosen not to be accredited, or do not qualify for accreditation. You can also check with local hospitals and health care professionals to find a testing facility. It is technically possible to have a sleep study in the home, but home sleep studies have yet to be validated for children.

A different type of portable monitoring system has been approved by the Food and Drug Administration specifically for use in children aged five to seventeen. It can be used at home as well as in a sleep center but it does not gather some of the information that is obtained in a sleep center study. It is recommended that you check with your insurance carrier to see if they will pay for this type of study or pay for treatment based on a portable study.

OSA in children is a serious disorder that, untreated, may result in health problems as well as behavior and academic problems. Although common, OSA often goes unrecognized, but it can usually be easily treated if detected. Symptoms of pediatric OSA should not be ignored.

This piece is written for children age one or older who have not yet entered puberty and does not encompass infantile apnea or apnea of pre-maturity. As children begin to enter puberty, their symptoms--and hence the diagnosis and treatment of the disorder--become more like those of adults.

Some insurance policies specifically exclude the diagnosis and/or treatment of sleep disorders and some do not cover durable medical equipment (however, relatively few children are treated with durable medical equipment or DME; surgery is more common). Such coverage is worth considering when examining your policy and whenever thinking about changing your policy (such as during your employer's open season).

This publication is made possible through a generous grant from the R.L. Stine and Jane Stine Foundation.

As a non-profit organization, the ASAA does not endorse or recommend any company or products.

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OSA in Children

By Carole L. Marcus, MD

OSA is estimated to occur in 1 percent to 3 percent of otherwise healthy preschool children.1,2 The peak prevalence is at two to six years of age, but it can be seen in neonates to adolescents. It is thought to occur equally among boys and girls, and can result in significant morbidity and mortality.

ETIOLOGY
OSA in children is usually due to large tonsils and adenoids. There is no relation, however, between tonsils and adenoid size and the degree of OSA. This is probably due to the combined effects of muscle tone, pharyngeal size and adenotonsillar hypertrophy. Some children with huge tonsils are asymptomatic, whereas others with small tonsils have severe OSA. High risk groups include children with craniofacial anomalies, cerebral palsy, muscular dystrophy and Down syndrome. Children with OSA are not usually obese, but OSA does occur frequently in morbidly obese children and adolescents.

SYMPTOMS
The presence of OSA cannot be determined by history and physical examination alone. Most children present with a history of snoring and difficulty breathing during sleep. The child sleeps restlessly, and may adopt bizarre sleeping positions. Enuresis is common. The child's appearance during sleep can be so alarming that parents often continually stimulate or reposition the child throughout the night. Despite this, many parents do not volunteer a history of their child's sleep symptoms unless specifically asked.

During wakefulness, the child breathes normally. There is often a family history of snoring or OSA. Physical examination is usually normal, though the child may have an adenoidal facies, and mouthbreathing is common.

DIAGNOSIS
The American Thoracic Society recently published guidelines for pediatric polysomnography.3 In our practice, approximately 40 percent of children referred for suspected OSA have negative sleep studies. We therefore strongly recommend polysomnography in all children with suspected OSA.

Age-appropriate criteria should be used in interpreting sleep studies.4 During sleep, normal children have fewer obstructive apneas than adults, and the apneas are of shorter duration. They also have higher SaO2 values. Cortical arousals are less common, and sleep architecture is usually preserved. Some children have a pattern of persistent, partial airway obstruction associated with hypercapnia, rather than cyclic, discrete obstructive apneas, termed obstructive hypoventilation.

TREATMENT
Tonsillectomy and adenoidectomy (T&A) cures most children. Since OSA results from the upper airway components' relative size and structure rather than the tonsils' and adenoids' absolute size, both tonsils and adenoids should be removed. T&A should also be the exclusive initial OSA treatment in children with others predisposing factors.

Though considered to be minor surgery, T&A can be associated with significant complications. Therefore, snoring without OSA is not an indication for surgery. Postoperative complications in children with OSA include upper airway edema, pulmonary edema and respiratory failure, in addition to the usual risks of T&A. OSA may not resolve fully until six to eight weeks postoperatively.

Occasionally, children present with severe OSA requiring emergency hospital admission. Sedative drugs may aggravate OSA, thus should be avoided. Supplemental oxygen should not be administered without simultaneous monitoring of PCO2, as it may precipitate respiratory failure. Nasopharyngeal tubes can be placed to bypass the obstruction pending definitive treatment, but vigilant nursing is necessary, as the tubes frequently clog with mucus.

While the FDA has not approved a CPAP machine specifically for children, it is commonly prescribed because CPAP delivered by nasal mask can be used effectively in the population. Care must be used in choosing an appropriate mask size. We have found that most children under the care of experienced practitioners will tolerate CPAP well, if they have motivated families. CPAP requirements vary with age and upper airway structure growth, so sleep studies should be repeated every six to 12 months.

Obese patients should be encouraged to lose weight. In patients with craniofacial anomalies, specific surgery can sometimes be performed. Lip-tongue adhesion procedures, for example can help patients with Pierre Robin sequence. Some patients benefit from UVPP. These days, tracteostomy is rarely required.

PROGNOSIS
Most children experience a dramatic resolution of their symptoms following T&A, though the natural course and long-term prognosis of pediatric OSA are not known. It is possible that children with treated OSA are at risk for recurrence during adulthood.

References

   1. Ali NJ, Pitson DJ, Strading JR. Snoring, sleep disturbance and behaviour in 4 to 5 years olds. Arch Dis Child. 1993; 68:360-366. Back to text
   2. Gislason T, Benediktsdottir. Snoring, apneic episodes and nocturnal hypoxemia among children 6 months to 6 years old. CHEST. 1995;107:963-966 Back to text
   3. American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med. 1996; 153:866-878. Back to text
   4. Marcus CL, Omlin KJ, Basinski DJ, et al. Normal polysomnographic values for children and adolescents. AM Rev Resp Dis. 1992; 146:1235-1239. Back to text

Dr. Marcus is medical director of the pediatric sleep laboratory at The John Hopkins Pediatric Sleep and Breathing Disorders Center, and a member of the ASAA Medical and Research Advisory Committee.

The ASAA can help you help your patients. For brochures, reprints of their newsletters and other informational materials, write to them at 1425 K St. NW Ste. 302, Washington, DC 20005 (202) 293-3650

Sleep Tracks, Advance for Managers of Respiratory Care, September, 1996.