Sleep Disordered Breathing (SDB) in Children Bergen County School Nurses Association November 18, 2013

1. Sleep Disordered Breathing (SDB) in ChildrenBergen County School Nurses AssociationNovember 18, 2013 Lee D. Eisenberg M.D., M.P.H., F.A.C.S. ENT and Allergy Associates, LLP Englewood, NJ

2. Definition: Breathing difficulties during sleep • 10% of Children snore regularly • 2-4% have obstructive sleep apnea SDB in Children

3. Sleep disordered breathing (SDB) is characterized by an abnormal respiratory pattern during sleep, and includes snoring, mouth breathing, and pauses in breathing. • SDB encompasses a spectrum of disorders that increase in severity from snoring to obstructive sleep apnea. • Obstructive sleep apnea is diagnosed when SDB is accompanied by an abnormal PSG with obstructive events SDB-Definition

4. Obesity • Enlarged Tonsils and Adenoids • Down’s Syndrome • Other Craniofacial Disorders (Treacher-Collins) • Neuromuscular Disorders (i.e. Cerebral Palsy) • Sickle Cell Disease SBD: Risk Factors

5. • Appearance • Weight • Body Mass Index • Body Mass Index percentile for Age Different Criteria than adults How do you determine if a child is Obese

6. • BMI: indirect measure of body fat ▪ BMI for age: sex and age specific values • BMI % for age: indicates the relative position of the child's BMI number among children of same sex and age: Obese > 95% Indirect measure of excess fat and may need to confirm by measuring skin fold thickness Obesity

7. Similar idea as for height and weight for age. • Age 4 years 10 months, 40 inches, 50 pounds: • BMI 22.0 (>=97%) • Age 5 years 10 months, 44 inches, 50 pounds: • BMI 18.2 (90-94%) BMI Percentage

8. Snoring • Daytime fatigue • Hyperactivity • Audible Breathing (The Darth Vader sound) • Restless Sleep Symptoms of Sleep Disordered Breathing

9. Chronic Mouth Breathing • Gasping (arousals) • Enuresis • Sleep in an odd position • Extended neck • Head over the bed Symptoms of Sleep Disordered Breathing

10. Growth Retardation • Poor School Performance • Behavioral Problems • Irritability • Decreased Quality of Life • Occasionally ADHD Symptoms of Sleep Disordered BreathingCo-Morbid Conditions-Common

11. Systemic Hypertension • Pulmonary Hypertension • Right Heart Failure: now rare Symptoms of Sleep Disordered BreathingCo-Morbid Conditions-Uncommon

12. History and Physical Alone • Adenoidal Facies • Tonsil hypertrophy • Audio or Visual Recording • Evidence of struggling while breathing • Sleep Study • Overnight oxygen recording Diagnosis of SDB/OSA

13. Adenoidal Facies

14. Tonsil Hypertrophy

15. Adenoidal Hypertrophy endoscopic view

16. Not all children need PSG before surgery • After surgery in children with persistent symptoms • After surgery in all children in whom PSG is strongly recommended PolysomnographyWhen

17. Obesity • Down’s Children • Other Craniofacial Anomalies • Children with Sickle Cell Disease • Neuromuscular disorder (i.e. Cerebral Palsy) • When the symptoms do not match the physical exam PolysomnographyWho?

18. Not everyone agrees but if the following, OSA: • Apnea Hypopnea Index (AHI) >1 • Pulse oximetry levels <92% • There may be significant hypoxemia despite a low AHI • Low Oxygen saturation levels can negatively effect school performance PolysomnographyInterpretation

19. Standard is Adenotonsillectomy • Weight loss and exercise if indicated • CPAP • High Flow Nasal oxygen if CPAP not tolerated in special circumstances SDB Treatment

20. Risk Factors for Postoperative Respiratory Complications • in Children With OSAS Undergoing Adenotonsillectomy • Age younger than 3 years • Severe OSAS on polysomnography (AHI>10 or Oxygen Saturation below 85%) • Cardiac complications of OSAS (e.g., right ventricular • hypertrophy) • Failure to thrive • Obesity • Prematurity • Recent respiratory infection • Craniofacial anomalies • Neuromuscular disorders Risk Factors for Postoperative Respiratory Complicationsin Children With OSAS Undergoing AdenotonsillectomyAAP Practice Guideline: OSA in ChildrenPediatrics 2002;109;704

21. Down’s children • Other Craniofacial disorders • Neuromuscular disorders • AHI>10 or Oxygen Saturation =<85% • Obese child • Under the age of 2 (possibly age 3) T&AWho should stay overnight?

22. Perioperative anesthetic issues • Post operative hemorrhage (2-5%) • Dehydration • Respiratory Suppression (acetaminophen with codeine-FDA black box warning) • Post operative death-most commonly related to respiratory suppression T&A: The “easy” but dangerous procedure

23. Age > 7 years Obesity - BMI % > 95% Presence of Asthma Preop PSG with AHI > 10 events an hour Bhattacharjee R Am JResp C 2010 Predictors of Failure After T&A

24. Study by Marcus et al: A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea Downloaded from nejm.org on June 12, 2013. • “Children with obstructive sleep apnea who had a common surgery to remove their adenoids and tonsils showed notable improvements in behavior, quality of life and other symptoms compared to those treated with "watchful waiting" and supportive care. However, there was no difference between both groups in attention and executive functioning, as measured by formal neuropsychological tests.” Does Every Child with SDB Need Surgery?

25. There were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Study by Marcus et al: A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea Downloaded from nejm.org on June 12, 2013.

26. If SDB are mild or intermittent, academic performance and behavior is not an issue, the tonsils are small or the child is near puberty (tonsils and adenoid often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated only if symptoms worsen. Fact Sheet: Pediatric Sleep Disordered Breathing/Obstructive Sleep Apnea. American Academy of Otolaryngology/Head and Neck Surgery, Inc. Updated 11/15/11 Does Every Child with SDB Need Surgery?

27. The bottom line: • There is no urgency for surgery in those children with mild symptoms, but their quality of life, and therefore their parents or caregivers, may be adversely affected Does Every Child with SDB Need Surgery?

28. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea SyndromeAmerican Academy of PediatricsPediatrics 2002;109;704This guideline specifically excludesinfants younger than 1 year, patients withcentral apnea or hypoventilation syndromes, and patientswith OSAS associated with other medical disorders,including but not limited to Down syndrome,craniofacial anomalies, neuromuscular disease (includingcerebral palsy), chronic lung disease, sicklecell disease, metabolic disease, or laryngomalacia.

29. 1) all children should be screened for snoring; 2) complex high-risk patients should be referred to a specialist; 3) patients with cardiorespiratory failure cannot await elective evaluation; 4) diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography; Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea SyndromeAmerican Academy of Pediatrics

30. 5) adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery; 6) high-risk patients should be monitored as inpatients Postoperatively; 7) patients should be reevaluated postoperatively to determine whether additional treatment is required. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea SyndromeAmerican Academy of Pediatrics

31. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome: American Academy of Pediatrics, Pediatrics 2002;109;70 • Polysomnography for Sleep Disordered Breathing in Children Prior to Tonsillectomy: American Academy of Otolaryngology-Head and Neck Surgery-Clinical Practice Guideline http://www.entnet.org/guide_lines/Polysomnography.cfm • Tonsillectomy in Children: American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guideline http://www.entnet.org/guide_lines/Tonsillectomy.cfm • A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea: Marcus, C et.al. NEJM, Published May 21, 2013. Accessed June 12, 2013 • Surgery on Adenoid and Tonsils Improves Outcomes in Children with Obstructive Sleep Apnea: National Sleep Foundation (Summary of Marcus Article) Accessed November 9, 2013 References

32. Questions