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Posted by Greg Harper on March 12, 1998 at 21:00:51:In Reply to: Sleep Apnea?? for a 3 year old??? posted by R. E. Miller on March 08, 1998 at 20:16:29:
Dear Mr/Mrs Miller:
I have put togather some information about OSA in children. Hope it helps. Good luck with your appointment.
Sincerely,
Greg Harper, RRT, RCP
Obstructive sleep apnea is estimated to occur in 1% to 3 % of otherwise healthy preschool children. The peak prevalence is at two to six years of age, but can be seen in any age from neonates to adolescents. It is thought to occur equally among boys and girls,and can result in significant problems socially and with school work. The health related problems can also be very serious.OSA in children is usually due to large tonsils and adenoids. The airway obstruction can be complete or partial during sleep. The obstruction that occurs during sleep can cause decreases in blood oxygen levels and increases in blood carbon dioxide levels. There is no relationship between tonsil and adenoid size and the severity of OSA. This is probably due to the combined effects of muscle tone, throat (pharyngeal) size and adenotonsillar overgrowth (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’s Syndrome.
Children with OSA are usually not obese, but OSA does occur frequently in morbidly obese children and adolescents.
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. Other nighttime symptoms may include; strained or abnormal chest wall movement, sweating and “loud” breathing. The child sleeps restlessly, and may adopt bizarre sleeping positions, with positions that often involve extending the neck. This extention of the neck, the “sniffing position”, naturally creates the largest airway diameter for the sleeping child. They may also sleep in the kneeling knee-chest position. Bedwetting (enuresis) is reported with variable frequency. Sudden awakenings may occur with crying, screaming, moaning, or changes in body position. Some children will awaken with intense anxiety. The child’s appearance during sleep can be so alarming that parents often continuously stimulate or reposition the child throughout the night. Despite this, many parents do not volunteer a history of their child’s sleeping symptoms unless
specifically asked.During wakefulness, the child breathes normally in most cases. Symptoms reported upon awakening include dry mouth, grogginess, disorientation, irritability, confusion, and headache.
The most confounding and paradoxical feature in children with OSA is that excessive daytime sleepiness (EDS) is not a major factor. It is easy to spot an adult who is excessively sleepy...it’s not always so easy with children. It is unusual for EDS to be the main presenting symptom (9% to 13% of cases).
There is little controlled data about daytime behavior with OSA in children. In a small study of eight patients (Guilleminault 1976) there was reported to be a high incidence of impaired school performance, hyperactivity, decreased intellectual performance, and emotional problems in children with OSA. There are also case reports of developmental delay in children with OSA. Adults with OSA have been shown to have impaired
cognitive functioning during the day with impaired attention span, concentration, memory, vigilance, and motor skills. Since children with OSA also suffer moderate-to-severe low blood oxygen levels when sleeping, it is likely that their daytime cognitive function is also impaired.One of the main associated features of childhood-type OSA is impaired body growth.
Growth hormone release occurs during sleep, specifically slow-wave or delta sleep, and
sleep fragmentation has been shown to impair growth hormone release. However, sleep fragmentation can be minimal in children with OSA, so the exact relationship between growth and sleep still needs to be determined.There is often a family history of snoring or OSA. Physical examination is usually normal, though the child may have a dull lethargic appearance with an open mouth. Mouthbreathing is common.
About 40% of children referred for suspected OSA have negative sleep studies. Polysomnography is strongly recommended in all children with suspected OSA.
Age-appropriate criteria should be used in interpreting sleep studies. During sleep,
normally children have fewer obstructive apneas than adults, and the apneas are of shorter duration. They may also have higher SaO2 values. Cortical arousals are less common and sleep architecture is usually preserved. Some children have a persistent, partial airway obstruction associated with high carbon dioxide levels (hypercapnea), rather than cyclic, discrete obstructive apneas, termed obstructive hypoventilation.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 the tonsils and adenoids should be removed. T&A should also be the exclusive initial treatment for OSA without other predisposing factors.
Though considered to be minor surgery, T&A can be associated with significant complications. Post operative complication 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 fully 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.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 this population. Care must be taken in choosing an appropriate mask size. CPAP requirements vary with age and upper airway structure growth, so sleep studies should be repeated every six to 12 months.
Most children experience a dramatic resolution of their symptoms following T&A, though the long-term prognosis of pediatric OSA is not known. It is possible that children with treated OSA are at risk for recurrence during adulthood.
There is still a great deal of information that needs to be obtained concerning sleep disorders in adults and children. The true study and impact of sleep disorders is in it’s infancy, having
only received much scientific attention since the late 1960’s. Thus, there is even a greater
amount of information that needs to be determined in children. More research is clearly needed in this area. Childhood disease can be similar to adult disease in some cases...other times it is not. Research in childhood diseases usually lags behind research in adult diseases. Hopefully, someday we will all be able to sleep better.
Ferber R, Kryger M, (eds): Principles and Practice of Sleep Medicine in the Child,
Philadelphia, WB Saunders, 1995Marcus C: Sleep Notes - OSA in Children, Advance Newsmagazine for Respiratory Care
Practitioners, September 1996
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