Consider that patients with snoring may have obstructive sleep apnea syndrome (OSAS)

Consider that patients with snoring may have obstructive sleep apnea syndrome (OSAS): Excerpt from Avoiding Common Pediatric Errors

Author: Sarika Joshi, MD

What to Do - Interpret the Data

OSAS is an underrecognized but clinically important respiratory disorder in children. OSAS is characterized by intermittent, complete, or partial upper airway obstruction during sleep, sometimes with associated hypoxemia or carbon dioxide retention. In children, the prevalence of OSAS is 1% to 3%, with the peak incidence in preschool-aged children.

The most common symptom of OSAS in children is snoring. Snoring affects 7% to 9% of children younger than age 10. Unfortunately, there is no reliable screening test to differentiate primary snoring from OSAS. Other symptoms consistent with OSAS include restless sleep; difficulty with or irritability upon awakening; mouth breathing; and behavioral problems, such as hyperactivity and aggression. In severe cases, untreated OSAS can lead to learning difficulties, developmental delay, failure to thrive, pulmonary hypertension, cor pulmonale, and congestive heart failure. According to the American Academy of Pediatrics' practice guidelines for OSAS, pediatricians should consider the possibility of OSAS in any child presenting with snoring. If other signs or symptoms of OSAS are also present, further investigation should be undertaken. The usual etiologies of OSAS can be divided into anatomic versus functional problems, all of which result in airway occlusion, narrowing, or collapse. Anatomic causes include both bony and soft tissue abnormalities. Many genetic syndromes are associated with craniofacial anomalies, such as micrognathia (e.g., Pierre Robin sequence, Treacher Collins syndrome), midface hypoplasia and deformities of the skull base (e.g., Down syndrome, Pfeiffer syndrome).

Adenotonsillar hypertrophy is a soft tissue abnormality, with a peak incidence in children ages 3 to 8 years old, and it is the most common anatomic cause of OSAS in children. Laryngomalacia and severe allergic rhinitis causing nasal obstruction are other soft tissue anomalies that can result in OSAS. Obesity causes increased fat deposition in the soft tissues of the upper airway. As the rates of childhood obesity in the developed world continue to climb, it is important for pediatricians to remember that obesity is a significant risk factor for OSAS. Neuromuscular diseases leading to generalized hypotonia or muscular incoordination are functional etiologies of OSAS in children. These include muscular dystrophy and cerebral palsy.

PolysomnographyisthegoldstandardforthediagnosisofOSASinchildren. The American Thoracic Society recommends obtaining a polysomnogram in the following situations: (a) to differentiate primary snoring from OSAS, (b) to evaluate a child with pathologic sleep patterns (e.g., difficulty with or irritability upon awakening), (c) to confirm suspected OSAS prior to surgical referral, (d) to evaluate the risk for respiratory complications prior to surgeries of the upper airway, (e) to evaluate children with laryngomalacia or cor pulmonale, (f) to evaluate obese children with signs or symptoms concerning for OSAS, (g) to evaluate children with sickle cell disease (due to the risk of vascular occlusion with intermittent hypoxemia during sleep), (h) to evaluate recurrent snoring postadenotonsillectomy, and (i) to titrate ongoing OSAS treatment with continuous positive airway pressure (CPAP).

TreatmentforOSASdependsontheetiology.Adenotonsillectomyiscurative in >75% of children with adenotonsillar hypertrophy. There are many other surgeries to treat craniofacial anomalies. In obese children, weight loss should be recommended but should not delay the initiation of other therapies. Treatment with CPAP or bilevel positive airway pressure (BiPAP) is appropriate when surgery is unsuccessful or not indicated, or when symptoms persist after surgery. In summary, OSAS is a significant respiratory disorder of children, and failure to diagnose it can lead to considerable morbidity. At-risk groups include obese children, or children with adenotonsillar hypertrophy, craniofacial anomalies, and neuromuscular disorders. Diagnosis relies on polysomnography, and treatment options include surgery, CPAP, or BiPAP.

Suggested Readings

American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med. 1996;153:866–878.
Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704–712.
Sulit LG, Storfer-Isser A, Rosen CL, et al. Associations of obesity, sleep-disordered breathing and wheezing in children. Am J Respir Crit Care Med. 2005;171:659–664.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Sleep Apnea—Obstructive Sleep Apnea Syndrome (The 5-Minute Pediatric Consult)

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