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Snoring and Obstructive Sleep Apnea Syndrome in Children 2013 Gerald M. Loughlin Weill Cornell Medical College Komansky Center for Child Health New York Presbyterian Hospital. 19th century original observations….

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Snoring and Obstructive Sleep Apnea Syndromein Children2013Gerald M. LoughlinWeill Cornell Medical CollegeKomansky Center for Child HealthNew York Presbyterian Hospital

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19th century original observations…

“At night the child’s sleep is greatly disturbed; the respirations are loud and snorting, and there are sometimes prolonged pauses, followed by deep, noisy inspirations.”

William Osler, 1892

obstructive sleep apnea syndrome
Obstructive Sleep Apnea Syndrome
  • A spectrum of abnormal breathing during sleep, that in its mild form is manifested by snoring ( partial airway obstruction) with or without gas exchange abnormality and in its extreme form by snoring with intermittent complete airway obstruction (apnea)
  • Associated findings include increased respiratory effort on inspiration, snoring punctuated with periods of silence with continued respiratory efforts, resulting in hypoxia, hypercapnia and disruption of normal sleep patterns.
  • Daytime symptoms occur as a consequence of the abnormal breathing and/or sleep patterns.
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Pathophysiology of Obstructive Sleep Apnea

Increased

Upper Airway

Resistance

Alterations in

upper airway

control during

sleep

OSAS

Tonsils & adenoids

Obesity

Craniofacial abnormalities

Airway size

Allergy

Inflammation

Other factors:

Age, Gender

Behavior

Environment

Socioeconomic status

Arousal

Genetics & Race

Passive smoking

  • Effects of age,
  • CNS dysfunction
  • (Primary vs. acquired)
  • Brainstem compression/injury
  • Respiratory depressants
prevalence of osas in children
Prevalence of OSAS in Children

10% - 12% of children snore loudly, nightly

1-3% of children

with OSAS

signs and symptoms sleep
Signs and Symptoms (sleep)
  • Snoring
  • During sleep - paradoxical inward rib cage motion – increased work of breathing
  • Apnea – obstructive and central
  • Disturbed sleep (movement arousals, restlessness)
  • Night sweats
  • Cyanosis (not often reported)
  • (?) Enuresis
  • ? Increased GER/aspiration
associated findings awake
Associated Findings – awake
  • Mouth-breathing, hypo-nasal speech, chronic nasal congestion
  • Recurrent adenotonsillitis
  • Excessive daytime sleepiness (unusual)
  • Irritability on awakening
  • Morning headaches (?)
  • Behavioral and neurocognitive dysfunction
childhood osas complications
Childhood OSAS - complications
  • Cardiovascular
    • cor pulmonale, pulmonary hypertension
    • polycythemia
    • systemic diastolic hypertension
    • altered cardiac function during sleep
  • Failure to thrive –
    • increased caloric expenditure
    • decreased IGF-1 and IGFBP-3 levels
  • Neurocognitive dysfunction
  • Developmental delay
  • Death – uncommon in children
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19th century description of daytime symptoms...

“The expression is dull, heavy, and apathetic… In long-standing cases the child is very stupid-looking, responds slowly to questions, and may be sullen and cross.”“Among other symptoms may be mentioned headache, which is by no means uncommon, general listlessness, and an indisposition for physical or mental exertion. The influence upon the mental development is striking.”

William Osler, 1892

patterns of neuro cognitive dysfunction
Patterns of Neuro-cognitive Dysfunction
  • Infancy - Developmental delay
  • Pre-school

Chronic oppositional behavior - “difficult child”

Easily fatigued, “always tired”

Lethargy / sleepiness or hyperactivity

  • School age

Abnormal shyness, social withdrawal

Hyperactivity/ aggressiveness / attention problems

Unexplained poor school performance

Decreased executive functions, visual attention, conceptual ability and phonologic functioning

patterns of neuro cognitive dysfunction1
Patterns of Neuro-cognitive Dysfunction
  • School Age (continued)
    • Decreased executive functions, visual attention, conceptual ability and phonologic functioning
    • Intelligence -
    • Memory
neurocognitive behavioral deficits children and adolescents
Neurocognitive Behavioral Deficits Children and Adolescents
  • Decreased intelligence, memory, attention capacity
  • Decreased academic performance
  • Increased problematic behavior
  • Reports of social withdrawal, emotional lability , hyperactivity, conduct problems, aggressive behavior
  • Delinquency , destructive and disruptive behavior
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*

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The association between sleep disordered breathing, academic grades, and cognitive and behavioral functioning among overweight subjects during middle to late childhood. Beebe DW et al. Sleep 2010;33:1447-1456

Study of 163 overweight adolescents divided based on AHI into 4 groups -Moderate/Severe OSA vs. mild vs. snorers without apnea vs. non snorers

Measurements – PSG, neuropsych testing, parent and teacher reports of grades, sleep , behavior

Findings: SDB in overwgt adolescents 10-16yrs associated with lower grades and worse behavior: Data suggests that alterations in academic performance arise from negative behaviors

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How to make a diagnosis of OSAS?

  • Direct observation – good but hard to asses severity and to arrange
  • Polysomnographt is the “gold standard.” Is it needed in all patients?
  • AAP (2002) recommends testing for OSA before T&A
  • - although an appropriate recommendation
  • is not always practical or possible
  • Value of oximetry, video recordings, nap vs. overnight study
when is intervention indicated
When is intervention indicated?
  • In 2013 – Snoring can no longer be considered normal. It is equivalent to stridor and wheeze, as a sign of airway obstruction
  • Need to be certain that what is being described is actually snoring
  • Therapy indicated in snoring child who presents with typical symptoms/complications of OSAS
  • Medical management ( including weight loss) can be considered for mild to moderate cases
  • T&A – most common surgical option
  • Results post T&A are inconsistent – abnormal sleep study may persist in as many as 40%
treatment of obstructive sdb in children
Treatment of obstructive SDB in children

Surgical treatment for OSAS

  • Adenotonsillectomy (? Role for recently described intracapsular procedure)
  • Uvulopalatopharyngoplasty (UPPP) – not for children
  • Tracheostomy (rarely used now for OSAS)
  • Craniofacial reconstruction
  • Miscellaneous (brainstem decompression surgery in achondroplasia and Chiari malformation)
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Non surgical Interventions

  • Rx of upper respiratory allergies/inflammation
  • Leukotriene antagonists
  • Nasal steroids
  • Weight loss for obese children
  • Nasal airway (short term)
  • Oral appliances (?)
  • Nasal strips (?)
  • “Follow up essential regardless treatment plan”
long term implications of childhood osas
Long-term Implications of Childhood OSAS
  • May predict who is at risk as adults
    • “As the twig is bent, the tree inclines”
  • If untreated - may have profound effects on neurocognitive and cardiovascular function in adults

In adults

  • Risk factor for hypertension
  • ? sudden death during sleep
  • ? myocardial infarction, ? Stroke
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Allergy/Immunology – upper airway inflammation

Anesthesiology – pre and intra-operative airway management

Cardiology – cor pulmonale, ventricular dysfunction, hypertension

Critical Care – post–op management (pulmonary edema, airway obstruction)

Developmental and General Pediatrics – developmental delay, FTT, enuresis

Endocrine – obesity, growth problems, puberty

Gastroenterology –possible increase in GER

Genetics – increased risk in African –Americans, gender issues

Hematology – differential diagnosis ofpolycythemia

Infectious Disease – recurrent adenotonsillitis

Neonatology – increased risk in former premature infants

Nephrology – hypertension, enuresis

Neurology – neuro-cognitive problems, school problems

Neuro-radiology – functional MRI

Neurosurgery – brainstem compression syndromes

Otolaryngology – most common indication for T&A

Orthopediatics – fractures from falling out of bed

Outcomes and Health Services Research – data needed on natural history, approach to diagnosis and therapy, who to treat and how

Pulmonary – abnormal respiration and gas exchange

Sleep Medicine – perhaps most common & severe sleep disorder in children

Urology – enuresis

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Suggested Reading

Marcus Cl. Sleep-disordered Breathing in Children. Am J Resp Crit Care Med 2001; 164:16-30

Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. 2002; 109 704-712.

Beebe DW, et.al. Theassociation between sleep disordered breathing, academic grades,and cognitive and behavioral functioning among overweight subjects during middle to late childhood. Sleep 2010;33:1447-1456.

Redline S Amin R et.al. The Childhood Adenotonsillectomy Trial (CHAT): Rationale, Design, and Challenges of a Randomized Controlled Trial Evaluating a Standard Surgical Procedure in a Pediatric Population. Sleep 2011; 34: 1509-1517.

.

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Macey PM, et.al. Brain Morphology Associated with Obstructive Sleep Apnea. AJRRCM 166: 1382, 2002

Weissbluth M, et.al. Signs of airway obstruction during sleep and behavioral, developmental and academic problems. J Dev Behav Pediatr 1983; 4:119-121.

Urschitz MS, et. al. Snoring, intermittent hypoxia and academic performance in primary school children. Pediatrics 2004; 114:1041-1048.

Gozal D, Pope D. Sleep disordered breathing and school performance in children. Pediatrics 1998; 102: 616-620.

Ali NJ, et al. Snoring, sleep disturbance and behavior in 4-5 year olds. Arch Dis Child 1993;68:360-68.

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Neuropsychological and psychological function in children with a history of snoring or behavioral sleep problems. S. Blunden et al. J Pediatr 146:780-786, 2005.

Bonuck K, et.al. Sleep-disordered breathing in a population-based cohort: Behavioral Outcomes at 4 and 7 years. Pediatrics 2102; 129:1-9.

Redline S, et.al.The Childhood Adenotonsillectomy Trial (CHAT): Arationale design, and challenges of a Randomized Controlled Trial Eva;uating a Standard Surgical Procedure in a Pediatric Population. Sleep 2011; 34:1509-1517.

Dillon JE, et.al. DSM-IV Diagnoses and Obstructive Sleep Apnea in Children Before and 1 year after Adenotonsillectomy

J Am Acad Child Adolesc Psychiatry 2007; 46: 1425-1436.