May 2014 

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Evaluation of Sleep Disordered Breathing in Children
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Dear Colleague,     

 

 I hope you are finding our ENT E-Updates useful in your practice, and please share them with your colleagues. In this issue Christopher M. Discolo, M.D., MSCR discusses best practices for evaluating children with sleep disordered breathing.

More information on Dr. Discolo follows the article below and is on our website. As always, we encourage your feedback or questions about the E-Udate articles, your patients, or any other ENT issue. Write to us at [email protected] and please forward this E-Update to all who may be interested.

Many thanks for your continued interest and support. 
 

 

Paul R. Lambert, MD

Professor and Chair

Christopher M. Discolo, M.D., MSCR - Assistant Professor, MUSC
Evaluation of Sleep Disordered Breathing in Children     

Although obstructive sleep apnea (OSA) was described in medical literature dating back to the 1700s, it wasn't until the mid-1970s that the disease was first reported in children. Our knowledge about the pathophysiology and treatment of sleep disordered breathing (SDB) has expanded greatly over the last 30 years; however gaps remain in the understanding and evidence that guides our evaluations and treatments of these children.

 

Sleep disordered breathing is characterized by abnormal respiratory patterns during sleep. It generally refers to the spectrum of disease that encompasses snoring on one end and OSA on the other. The use of polysomnography in population based pediatric studies estimates that the prevalence of OSA ranges from 1.2% to 5.7% while that of SDB is somewhere around 10%-12%. Several factors may increase a child's risk of developing OSA. These include craniofacial deformity, obesity, genetic syndrome, neurologic disease, metabolic disease and ethnicity with African-American children at higher risk compared to Caucasian children.

 

Untreated OSA in children has been demonstrated to have significant negative sequelae. OSA has several deleterious effects on the cognitive function of children. Almost all studies looking at neuropsychiatric and cognitive outcomes have supported this theory. Children with OSA have been shown to have lower general intelligence, impaired learning and memory, decreased visual and auditory retention and impaired language skills. Studies have shown improvement in these domains following treatment via adenotonsillectomy.

 

 

Behavioral problems are also common in children with SDB/OSA, with hyperactivity being one of the most prevalent findings in addition to oppositional behaviors and aggression. These domains also tend to improve following treatment of SDB/OSA.

Although perhaps more commonly seen in adults, the cardiopulmonary complications of SDB/OSA have been described in the pediatric population as well. These include both right and left ventricular dysfunction, blood pressure elevations and an increased risk for pulmonary complications following surgery. These significant consequences on the health and quality of life of children mandate appropriate work up and treatment of suspected SDB/OSA.

 

A thorough history and physical examination are the cornerstones of medical practice. Unfortunately, when it comes to pediatric sleep disturbance, the results of studies looking at the ability to predict OSA using these basic skills have been less than encouraging. A large study involving over 400 children found that clinical symptoms, either alone or in combination, were poor predictors of OSA based on overnight polysomnography. Other smaller studies have found some value in parental reports of witnessed apnea or other difficulties in breathing but none of these were able to accurately predict the presence of OSA.

 

Several surveys have been developed in an effort to efficiently screen for OSA. These have also met with mixed results. The pediatric sleep questionnaire (PSQ) has shown good sensitivity (78%) and specificity (72%) when compared to sleep study results. Polysomnography should be obtained to follow up on positive screening questionnaires.

 

The current gold standard test to diagnose OSA in children is an attended, in-laboratory, overnight polysomnogram. Since treatments are generally based on these results, the reliability of the test is crucial. In the adult literature, there is good evidence of what's known as the first night effect where subjects do not sleep as well during the first night of testing. This phenomenon can alter sleep efficiency/architecture and is felt to generally underestimate the severity of OSA. Fortunately, pediatric studies have shown that this first night effect plays a much-reduced role in the quality of a single overnight study.

 

In recent years, the home sleep study has become increasingly popular in adults and is approved for use in this population. There is currently limited data on the use of this technology in pediatric patients and, because of this, it is not recommended that these tests be utilized. Part of this issue is related to the age at which this testing would be feasible. Studies looking at children over the age of 8 years have shown some promise in that the home studies correlated fairly well with a full channel polysomnogram. In younger children there was a much poorer predictive value of this testing calling into question the utility of home sleep studies in younger children. Increasing the number of variables measured during a home sleep study will likely improve its accuracy but also may make the test more difficult to administer and obtain consistent quality. More research needs to be done to better elucidate the role that home sleep studies will ultimately play in the management of pediatric SDB.

 

In 2011, the American Academy of Otolaryngology - Head and Neck Surgery published a clinical practice guideline to provide otolaryngologists with evidence-based recommendations for the use of polysomnography in children. The guideline statement defines several reasons why obtaining a sleep study in certain high-risk pediatric populations is beneficial prior to consideration of surgery (Table 1). The guideline goes on to recommend obtaining a sleep study in pediatric patients with any of the following conditions: obesity, craniofacial abnormalities, sickle cell disease, mucopolysaccharidoses, neuromuscular disorders or Down syndrome. History and physical exam have been shown to be poor predictors of OSA severity and thus the risk of respiratory complications postoperatively. Because of this, history and physical exam should not be used as the sole diagnostic criteria in these populations of children who, due to their comorbid medical conditions, are at higher risk for complications. The guidelines also suggest that the clinician advocate for a sleep study when the need for surgery is uncertain or when there is significant discordance between the physical exam findings and the reported severity of SDB symptoms.

As more and more surgeries are being performed in outpatient surgical centers, it is imperative that children are admitted appropriately following surgical treatment of OSA. The guideline advocates admission for overnight observation in children with OSA who are under the age of 3 or who have severe OSA (apnea-hypopnea index of 10 or more events/hour, oxygen saturation nadir < 80%, or both). These children are at increased risk for respiratory complications following surgery including the need for supplemental oxygen, positive pressure therapy or even reintubation.

Pediatric sleep disordered breathing is a common problem in children which can have significant effects on quality of life and general overall health. Overnight in-laboratory polysomnography remains the gold standard diagnostic tool in our armamentarium. Appropriate use of testing and proper post-operative management protocols help minimize complications associated with OSA in children.

 

 

Table 1: Role of Sleep Studies in High-Risk Populations*

Role of Sleep Study

- Avoid unnecessary or ineffective surgery in children who may have primarily nonobstructive events

 

- Confirm presence of sleep apnea

 

- Define severity of sleep apnea to assist in preoperative planning

 

- Document preoperative severity and provide baseline for comparison after surgery

 

* Adapted from Roland PS, et al. Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children. Otolaryngology - Head and Neck Surgery, 2011  

  

  

Christopher M. Discolo , M.D., MSCR

Medical University of South Carolina
About Dr. Discolo... 
  Christopher M. Discolo, MD

Christopher M. Discolo , M.D., MSCR

 Assistant Professor; Medical Director, Craniofacial Anomalies &
Cleft Palate Team 
M.D. / MSCR: State University of New York Health Science Center at Brooklyn / MUSC
Residency: The Cleveland Clinic
Fellowship: University of Minnesota

Special interest: Cleft lip/palate and other craniofacial syndromes; Complex airway/swallowing disease; Head and neck masses; Distraction osteogenesis 

 

Medical University of South Carolina Department of Otolaryngology - Head & Neck Surgery

135 Rutledge Avenue, MSC 550, Charleston, SC 29425|Phone: 843.792.8299|Website: ENT.musc.edu|� 2014