PEDIATRIC SLEEP APNEA

The presentation of obstructive sleep apnea in children differs from adult OSA in several key respects. Unlike adults, children with sleep disordered breathing may demonstrate hyperactivity and behavioral problems, symptoms which are sometimes mistaken for Attention Deficit Hyperactivity Disorder (ADHD). According to the American Sleep Apnea Association, as many as 25% of children diagnosed with ADHD may in fact have Obstructive Sleep Apnea, with their behavior being a consequence of chronically fragmented sleep.

SIGNS AND SYMPTOMS OF PEDIATRIC OSA:

SCREENING AND DIAGNOSIS

Parents who notice any of the signs or symptoms listed here are encouraged to seek a consultation with their child's primary care provider. A referral to a certified sleep physician is typically the next step, as definitive diagnosis can only be made on the basis of a sleep test. Other providers who may be involved in the evaluation and treatment process include ENT specialists and orthodontists. In addition to health history, physical examination and sleep testing, new imaging technology such as Cone Beam Computed Tomography (CBCT) may be used to obtain valuable information about the size of the airway and the nature or location of the obstructions. This information is essential in determining the best course of treatment.

· noisy, irregular breathing or snoring during sleep; this may occur without apnea or deep oxygen desaturations, but still be characterized by significant respiratory effort and frequent arousals due to this effort. 3.2 to 12.1 % of children habitually snore, while the prevalence of OSA in children ranges from 0.7% to 10.3%

· chronic mouthbreathing

· witnessed gasping/ apnea

· choking

· irregular and frequent body position changes

· recurrent ear/ sinus/ throat infections

· excessive daytime sleepiness (less common, often with severe OSA)

· rib cage retraction and rib flaring as a result of the respiratory effort

· irritability, restlessness or hyperactivity (more common)

· behavioral, social or academic problems

· halitosis

· bedwetting

· poor weight gain

· bruxism

HEALTH CONSEQUENCES

Children with sleep disordered breathing have an increased likelihood of learning problems and an almost 3-fold increased risk of neurobehavioral problems. Impaired growth, increased blood pressure (even in primary snoring) and cardiac abnormalities have also been associated with pediatric sleep disordered breathing, therefore it is important that all children who snore or exhibit some of the other signs listed above be screened and/ or tested for SDB. There is also a high prevalence of malocclusion in children with OSA and adenotonsillar hypertrophy (open bite, cross bite) as a result of chronic mouth breathing, so an orthodontic evaluation should be considered once a diagnosis of OSA is made, in order to determine the need and optimal timing for orthodontic correction.

TREATMENT OPTIONS

Since enlarged lymphatic tissues (relative to the size of the airway) is the most common cause of the obstruction, adenotonsillectomy is the typical first-line treatment, and may be curative in itself. Additional treatments may include orthodontic rapid palatal expansion to widen a constricted palate, make room for the tongue and teeth and enlarge the nasal airway, or surgical corrections of craniofacial abnormalities.

Other adjunctive treatments that may be considered in some cases include the medical management of nasal allergies, encouraging side sleeping with the use of positional devices or pillows, and a weight control program.

VIDEOS

Sleep Disorders in Children / CLEVELAND CLINIC

https://www.youtube.com/watch?v=GwKPf5Gim8E

Finding Connor Deegan / AAPMD

https://www.youtube.com/watch?v=Sk5qsmRyVcE&t=43

Dr. Duane Grummons: Airway Focused Orthodontics

To see presentation click this link: https://vimeo.com/channels/1129113

Orthodontic pioneer, Duane Grummons, challenges us to look at orthodontics in a different way. This discussion highlights how we have failed to put into practice information that has been available to us for decades. Maybe it's time for us to catch up.

_____________________________________________________________

Robert A. Schoumacher, MD

Professor of Pediatrics & Otolaryngology

Director of LeBonheur Pediatric and Adolescent

Sleep Disorders Center

University of Tennessee Health Science Center

FOR PEDIATRICIANS: How to start the conversation at well-child visits

click HERE or download PDF

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Print out Sleep Disorders youth fact sheet by clicking on the link or downloading PDF file below.

Print out PEDIATRIC SLEEP SCREENING TOOL - “BEARS” (AGES 2-18 YEARS) by clicking on the link or downloading PDF file below.

References:

Capdevila, Oscar Sans, et al. "Pediatric obstructive sleep apnea: complications, management, and long-term outcomes." Proceedings of the American Thoracic Society 5.2 (2008): 274-282.

http://www.researchgate.net/profile/David_Gozal2/publication/5602603_Pediatric_obstructive_sleep_apnea_complications_management_and_long-term_outcomes/links/00b4952617e2939b23000000.pdf

Koren, Dorit, Katie L. O’Sullivan, and Babak Mokhlesi. "Metabolic and glycemic sequelae of sleep disturbances in children and adults." Current diabetes reports15.1 (2015): 1-10.

http://www.researchgate.net/profile/Dorit_Koren2/publication/268336495_Metabolic_and_Glycemic_Sequelae_of_Sleep_Disturbances_in_Children_and_Adults/links/54bd2d3c0cf27c8f2814b077.pdf

Estrada, Elizabeth, et al. "Children's Hospital Association Consensus Statements for Comorbidities of Childhood Obesity." Childhood Obesity 10.4 (2014): 304-317.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120655/

Karen Bonuck, Katherine Freeman, Ronald D. Chervin and Linzhi Xu. Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years. Pediatrics; originally published online March 5, 2012;

http://pediatrics.aappublications.org/content/early/2012/02/29/peds.2011-1402

Youssef, Nagy A., et al. "Is obstructive sleep apnea associated with ADHD."Ann Clin Psychiatry 23.3 (2011): 213-224.

https://www.aacp.com/pdf%2F0811%2F0811ACP_Youssef.pdf

ADHD or Sleep Disorder: Are We Getting It Wrong?

https://www.psychologytoday.com/blog/sleep-newzzz/201305/adhd-or-sleep-disorder-are-we-getting-it-wrong