Panel 1: Sleep Apnea in Children

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Finding Solutions, Breaking the Cycle

Panel 1

Sleep-Disordered Breathing in Children: Why, How and When to Treat

Dr. Duane Grummons, Dr. Nicholas van Buren, Dr. Jeff Schilt

Moderator: Dr. Liana Groza

Imagine for a moment a 3-year-old spiking a high fever in the middle of the night; or an 8-year-old crashing his bike; or a 12-year-old hospitalized for an inflamed appendix. These are the common scenarios that most parents tend to worry about and spend considerable effort trying to prevent, by constant monitoring of their children’s health and behavior, research, regular doctor visits and age-appropriate discussions with their family.

But despite the unprecedented focus that today's parents place on raising healthy, intelligent, emotionally and socially well-adjusted children, there are other, slower and more insidious processes that parents, teachers and health providers sometimes miss, and that may play a very significant role in how a child evolves along these developmental axes. Failing to recognize these signs in time, failing to act on them, or to follow up with the correct diagnostic tests and treatment sequence - all of these missed opportunities can affect the long-term health, cognitive and emotional well-being of a child, in ways that are often irreversible.

It is estimated that up to 27% of children are habitual snorers and that approximately 5% suffer from obstructive sleep apnea (OSA) - a condition characterized by repeated airway obstructions during sleep. The resultant disruption in sleep architecture, drop in blood oxygen saturation and increase in systemic inflammation lead to a range of health and behavioral problems that are raising increasingly more concerns among primary care physicians and specialists. As in adult OSA, these consequences range from cardiovascular disease (structural and functional cardiac abnormalities such as ventricular hypertrophy, hypertension and increased cardiac strain), to negative changes in metabolism, cognitive function and mood. Given the rate at which children’s brains develop at this age, it is critical to recognize the red flags of possible sleep-disordered breathing and intervene as soon as possible, to minimize the potential damage that this condition can inflict.

A large study by Dr. Karen Bonuck and her team showed that sleep-disordered breathing in the first five years of life is associated with 40-60% greater chance of special educational needs by age 8 (Bonuck & Rao 2012). The American Sleep Apnea Association estimates that about 25% of kids diagnosed with ADHD in fact have obstructive sleep apnea – and indeed the symptoms are typically indistinguishable between the two conditions: poor academic performance, attention difficulties, behavioral problems at school and at home, fragile mood and even depression.

The impact of sleep apnea on brain function is well known from adult studies, where the combination of hypoxemia and inflammatory damage has been shown to affect memory, concentration and mood, with untreated sleep apnea being associated with a 5-fold increase in the risk of depression and doubling the risk of Alzheimer’s dementia.

In the majority of kids, obstructive sleep apnea is due primarily to the enlarged size of the tonsils and adenoids relative to the size of the airway at this age - which is why the first line of treatment is almost always removal of the tonsils and adenoids by an Ear, Nose and Throat specialist. However, with the rapidly rising rates of obesity we have seen over the past few decades in both adults and kids, a new type of pediatric obstructive sleep apnea is emerging: the so-called "Type 2 OSA" - similar to the adult form, and with a poorer long-term response to treatment. It has also been shown (see Capdevila and Gozal, 2008) that adolescents with untreated sleep apnea have a 6-fold greater chance of developing metabolic syndrome in adulthood. The relationship between excess weight and OSA is particularly important in children, because research shows that not only are obese children less likely to fully respond to adenotonsillectomy, but that even in children without sleep-disordered breathing the systemic inflammatory markers such as hsCRP remain elevated as a result of the excess weight, and that is an independent risk factor for negative physiological changes in the brain and lower cognitive performance.

It is important to remember this distinction, both because the need for sleep re-evaluation after phase one treatment (T&A) is especially critical in this group of overweight children, and because parents need to understand that childhood obesity has implications that go well beyond appearance - affecting cardiovascular health, intellectual performance, future metabolism and even the predisposition for mood disorders such as depression.

For all these reasons, we cannot overemphasize the importance of early diagnosis and treatment of childhood sleep-disordered breathing. Our first panel conversation brings together a group of highly trained local experts with a strong focus on pediatric airway disorders, in order to highlight the common presentations of childhood sleep apnea and the ways in which parents and clinicians can work together in a timely fashion to identify, treat and monitor this condition for the optimal long-term benefit of the child. (LG)

Participants:

Dr. Duane Grummons, DDS, MSD (https://drgrummons.com/ ) is an Associate Professor of Orthodontics at The Loma Linda University Medical Center, Orthodontic Consultant and Lecturer. A clinician with 40 years of specialty practice experience, he is Board Certified in Facial Orthopedics and Orthodontics and has presented in 23 other orthodontic departments and for breathing and sleep disorders dental / medical airway conferences, as well as for radio/TV audiences. Dr. Grummons has published scientific articles, chapters, and a textbook, and lectured internationally and before most American orthodontic organizations. He is internationally recognized for his effective clinical approaches to pediatric breathing and sleep disorders, facial asymmetry, airway-focused facial orthopedics and non-extraction orthodontic treatments.

Dr. Nicholas Van Buren, M.D., is a board-certified physician in otolaryngology and head and neck surgery working at Spokane Valley Ear, Nose, and Throat. His special interests include surgery of the ear, endoscopic sinus surgery, thyroid surgery, sleep apnea and pediatric ENT. He is a member of the American Academy of Otolaryngology-Head and Neck Surgery.

Dr. Jeff Schilt, DNP ARNP is a nurse practitioner and pediatric primary care provider practicing at Mt. Spokane Pediatrics in Spokane, WA. He is passionate about providing medical care to children in a family-centered environment that meets their unique needs. Jeff is also experienced in diagnosing and treating behavioral disorders such as ADHD and is certified as a pediatric primary care mental health specialist (PMHS).

Dr. Liana Groza, DDS FAGD is a Diplomate of the American Board of Dental Sleep Medicine, the coordinator of the Spokane Regional Sleep Apnea Network and the owner of Spokane Sleep Apnea Dentistry. A clinician with over 20 years experience, Dr Groza is a Fellow of the Academy of General Dentistry and a member of the American Academies of Sleep Medicine and Dental Sleep Medicine. Her current practice focuses exclusively on the treatment of adults with obstructive sleep apnea and CPAP intolerance, through medically-covered dental appliance and various combination therapies.

1. What is the best age to start watching your child for signs of sleep-disordered breathing?

NVB: Sleep disordered breathing can occur at all ages. I suggest parents and providers be on the lookout for signs of obstructed breathing at night from birth. It is important to be aware of the problem and know what to look for. Though it can occur at any age, it is most common in the pre-school age children.

DG: As soon as symptoms are recognized in clinical screening, and Pediatric Screening Questionnaire is completed by the parent. Research is now showing these facial jaw mismatches in utero, which lead to pediatric airway / breathing problems in the early years after birth. Certainly, by age 2 a simple screening with snoring and breathing assessment can and should be done.

2. What are some of the signs and symptoms that should alert parents about the possibility of an airway disorder?

DG: Mouth-breathing, noisy and restless sleep patterns and conditions, gasping or choking sounds during sleep, snoring, bedding in disarray due to thrashing around during sleep, etc. Simply ask the parents: does your child fall asleep easily; does your child stay asleep during the night (frequent awakenings or sleepwalking), and does your child wake up feeling rested? After a certain age, the persistence of enuresis becomes a clue. Dental arches are often too narrow, teeth may be crowded or mismatched, profile of upper and lower jaws may be mismatched. Speech and swallowing dysfunction may also be evident.

NVB: At night they should look for the following signs: snoring, restless sleep, observed pauses in breathing, labored breathing, irregular sleeping positions, mouth breathing, gasping, frequent awakenings, obesity, and bedwetting. They should observe for the following symptoms: difficult to awake, poor morning behavior, attention deficit issues, behavior problems, daytime fatigue and learning problems.

JS: Parents who observe concerning signs and symptoms may want to seek further evaluation for their child. These could include cyanosis, irregular breathing, retractions with breathing, wheezing, fatigue, irregular sleep patterns, snoring, and behavioral problems such as trouble focusing.

3. When checking children’s teeth, what observations should lead dentists to inquire about sleep, fatigue or behavioral problems?

DG: Notice that dental arches appear narrow or V-shaped; upper jaw may be high in the center; primary teeth may not show generalized spacing between teeth (baby teeth are not supposed to be close together; rather they should be widely spread out to help provide the space needed in the future for permanent teeth to fit in as jaws continue growth and development); tongue unable to fit in properly between arches of teeth (arches too narrow, or tongue size too large to fit, or other reasons); lingual frenum under tongue is small, short and low into floor of mouth so tongue can’t elevate freely; with mouth open, can the tongue reach and touch up behind upper front teeth area; can tongue freely stick out / extend from mouth indicating full range of movement freedom; front teeth in open bite arrangement; observe speech sounds and consonants (count from 65-75 or so and observe speech and “s” sounds; observe swallowing (take sip of water): do lips stay relaxed as muscles activate the swallow, or does the peri-oral musculature flex and show mentalis strain in the act of swallowing; at rest, are the lips relaxed and closed, or is the mouth drooped open in order to mouth-breathe; does the tongue appear to rest on top of the lower side teeth rather than fitting within the lower arch of teeth; with the lips sealed together, can the child breathe through the nostrils, and can they breathe in with lips sealed and one nostril held closed (repeat for each side of nose); does the upper arch of teeth appear narrower on the sides than the lower arch of teeth (no cross-bites of back teeth); are lower back teeth so narrow that they are fitting narrowly and within the upper arch – in cross-bite with lower arch of teeth totally narrow and leaning in toward tongue when compared to upper; and more.

NVB: Tonsillar hypertrophy (> 2+), mouth breathing, bad breath, nasal obstruction and narrow oropharyngeal airway should lead them to ask about sleep disordered breathing issues. All providers should be aware of the increasing problems with pediatric obesity. Large BMI and larger waistline in kids are risk factors for sleep disordered breathing.

4. Are there speech problems associated with sleep apnea in children? If so, what is the connection between airway obstruction, dental arch abnormalities and speech pathologies?

DG: See answers to number 3 above. In addition, the tongue has to fit within the dental arches, so when the arches are too narrow to properly accommodate for tongue size, then it is commonly observed that the tongue may be projecting forward between the upper and lower front teeth (tongue-thrust) in efforts to keep the tongue away from the pharyngeal airspace, and/or the tongue may fall back or posture further back in the mouth and occupy airway space and require increased respiratory effort with turbulence to sufficiently breathe / inspire with each breath. The soft palate / uvula length, and adenotonsillar mass influence available airway and tongue space. Speech and swallow efforts and clinical assessment should routinely be done in screening intake and repeat care visits. Are there any neurologic reasons? Any syndromes? Video recordings of speech are very useful for documentation, communication with family / colleagues, and for assessing progress and therapies benefits.

NVB: There can be speech related issues associated with sleep apnea. The consequences of sleep apnea can lead to cognitive and behavioral learning problems that could lead to speech issues. The most common type of obstruction in pediatric OSA is related to adenotonsillar hypertrophy. This can also lead to muffled speech from a crowded oropharynx and can lead to hyponasal speech because of blocked nasopharyngeal airway.

5. Should schools screen for airway disorders, just like they screen for vision and speech problems? If so, what is the most vulnerable age when this should be done?

DG: Yes. Ages 3, 4 or 5 as kids begin pre-K schooling. Teachers and parents can be taught and informed about screening young children for these breathing and sleep disorders, with emphasis upon prevention of worsening sleep related problems.

NVB: Primary care providers are advised to ask about snoring at each well child visit. They should be aware of other signs and symptoms of pediatric OSA. There needs to be increase awareness of pediatric OSA among the school staff. Teachers need to be aware of daytime fatigue, learning disabilities, attention issues that could be from OSA. Nurses, speech therapists, psychologists, administration need to be aware of these issues and have a system in place to have children/parents referred to proper health professionals.

6. Are there pediatric screening questionnaires or other tools that teachers, parents and primary care providers can use?

NVB: There are a number of questionnaires. The PSQ is the most studied evaluation for sleep disordered breathing. There is a one page SRDB scale within this questionnaire that has been modified to use in clinical setting for OSA. This would be a great use in the PCP, ENT, sleep dentist, and sleep physician clinics. The “IM SLEEPY” questionnaire is great for pediatricians and a version for parents is available as well.

DG: HSQ or PSQ’s, BEARS questionnaire, Grummons PQ, “I’M SLEEPY” PQ, and more.

(See PEDIATRIC SLEEP SCREENING TOOLS for links to questionnaires at the end of this discussion).

7. What diagnostic options do parents have if they suspect that their child might suffer from sleep apnea? What type of specialist should they seek?

NVB: They should be referred to a health professional that specializes in pediatric OSA. An otolaryngologist, sleep dental specialist, pediatric pulmonologist and sleep medicine physician may obtain the history and perform the exam to evaluate the problem. A sleep study is the gold standard to diagnose this condition. Depending on the history and exam, not every patient requires a sleep study before treatment. Each case is unique and the diagnostic tests and treatments are specific for the patient. High risk patients should always be referred to a sleep specialist and should obtain a sleep study. An upper airway endoscopy is an important diagnostic tool to evaluate for nasal obstruction, adenoid hypertrophy, and other areas of obstruction in addition to tonsillar obstruction. This study can be done awake or with sedation to mimic the effects of typical obstruction during sleep.

JS: Typically, the first step parents should take is to see their primary care provider to assess the child’s symptoms and evaluate whether or not the child is functioning normally. If the child is experiencing abnormal symptoms potentially associated with sleep apnea, the primary care provider can refer them to the appropriate specialist which may include an otolaryngologist or a pediatric pulmonologist.

DG: Sleep doctors or sleep dentists locally, A.W.A.K.E. network providers, or ask them for referrals to medical / dental / myofunctional / speech providers; also teachers can capably provide screening evaluations and/or cross-referral to providers who are actually knowledgeable and interested in treating OSA and sleep disordered breathing (SDB) patients.

8. What are the typical treatment options for a pre-teen child diagnosed with sleep apnea?

DG: Begin with clinical evaluation and sleep diagnostics, for children typically an in-lab overnight sleep study which includes the important EEG information. This leads to identification and specification of the problem(s), and then the appropriate therapies for each. The treatment must match the problem basis. If obstructive sleep apnea is diagnosed, then the causes of the airway obstruction must be determined. Is there adenoidal / tonsillar hypertrophy with obstruction of airway? Nasal mucosal inflammation or middle turbinate hypertrophy? Environmental allergens or food/ chemical-related reasons for nasal airway inflammatory responses with mucosal hypertrophy affecting the airflow? Are upper nasal airway tract structural problems (nasal septum, inferior or middle turbinates, soft tissue septum collapse, and/or chronic inflammation of nasal mucosa, etc.) the culprit? These issues typically require a referral to the ENT specialist and/or allergist.

On the other hand, the clinician may observe structural transverse facial / jaws morphologic narrowness and width problems - which require facial orthopedic expansion and growth modification; or lower jaw posturing posteriorly with the tongue encroaching upon the airway, in which case functional jaw forward-positioning and growth modification are indicated.

The most common interventions in children suffering from obstructive sleep apnea include surgical removal of tonsils and adenoids, PAP mask therapy and/or facial orthopedics to contribute to airway and sleep optimization. Another important aspect of the therapy includes the management of allergies and excess weight, as both of these problems represent important risk factors for OSA.

NVB: The treatment for sleep apnea in a pre-teen is determinate on the area of obstruction. A pre-teen may benefit from exercise and nutrition education to reduce BMI and waistline. Starting PAP therapy may be an option. Surgery to improve areas of anatomical obstruction is an important option.

9. Is there an ideal treatment window for pediatric sleep apnea? What happens if parents and providers miss this window?

NVB: Pediatric patients should be screened for concerns for OSA at every pediatric well visit and parents need to be observing for this issue. Early treatment will avoid long term effects of poor learning, poor behavior, cardiovascular risks, and respiratory risks. Parents and providers can seek help at any time and it’s not too late to take action and provide needed health benefits for these kids.

DG: It is ideal to prevent or moderate the problem with early recognition and intervention. Diagnose and treat as early as it can be recognized. If missed, once the condition is recognized and diagnosed, and its causes identified, then actively pursue the therapies which match and address the problems.

10. Should children treated with adenotonsillectomy for sleep apnea be followed up and re-evaluated/re-tested? If so, at what time intervals? What other interventions may be necessary?

NVB: All kids undergoing T&A for OSA should be followed up to review sleep quality. High risk patients will need repeat sleep studies after T&A. I usually wait 3-4 months after T&A to repeat the sleep study. I do not typically repeat the sleep study in a low-medium risk patient who underwent T&A.but I will ask about changes in sleep. If there is improvement in sleep and symptoms then I ask parents/ PCP to continue to monitor the child. If no improvement is noted, then we need to consider other areas of obstruction that could be contributing to sleep-disordered breathing.

JS: Yes, children should receive follow-up after the procedure. The parents should see the child’s surgeon or sleep physician for timely follow-up care and potential sleep study re-evaluation.

DG: Absolutely, yes. The literature makes it clear that there are often more problems than what the T and A surgery resolves. There are multiple other possible nasal airway, jaw orthopedic, breathing/ speech/ swallowing risk factors. Nutrition/ dietary, environmental, chemical irritants, etc are all co-factors; and sleep fragmentation may occur from other sleep conditions as well, which is why it is important to work with a board-certified sleep specialist.

11. What is the benefit of a multidisciplinary team approach in screening and treating children with sleep-disordered breathing? Are there such examples of successful pediatric programs around the country?

NVB: There is a huge benefit in working with a team approach. Each specialist has their own knowledge, expertise, and technical skills that can aid in accurate diagnosis and improve outcomes of treatment. The areas overlap and it is important to have the team working together and communicating for the patient.

DG: This is critical to optimizing treatment outcomes. Pediatric sleep disorders teams still need to be established in most areas of the country. Lurie Children’s (Chicago), Boston Children’s and LeBonner Children’s (Memphis) are good models in place so far.

12. How might sleep-disordered breathing manifest itself in adolescents, as opposed to young children? Are there TMJ or chronic allergy complaints that should prompt parents to seek a diagnostic test?

NVB: Teenagers are big kids or small adults. I have seen teenagers manifest with adult and child like signs and symptoms. Allergies and nasal obstruction should always be considered. Dental or TMJ issues should be evaluated and considered related to possible pediatric OSA issue.

DG: All children should be screened for allergy and TMD potential co-factors. Most patients have multiple co-factors leading to obstructive sleep apnea, rather than a singular cause. Younger children more commonly exhibit food or environmental allergens or intolerance; fortunately the percentage of children with TMJ / myofascial or headache problems is much lower. However, we must not miss any of these potential factors in our examination, questioning process or phases of care.

13. Can you discuss the connection between pediatric sleep apnea and a diagnosis of ADHD? What steps should parents follow if they suspect their ADHD child may also have a sleep airway problem?

JS: Undiagnosed sleep apnea in children may lead to a chronic lack of sleep, resulting in the potential for behavioral problems which may mimic disorders such as ADHD. Parents should discuss with their primary care provider the potential for a sleep disorder and evaluate whether any symptoms are present which could indicate such an underlying problem.

NVB: Poor sleep can result from frequent awakenings related to recurrent airway obstruction at night. This sleep disruption and subsequent decrease in oxygen saturation leads to cognitive and behavioral issues in children. This is often manifested through symptoms that are very similar to ADHD. Parents should seek help from their pediatrician and ask to refer them to a health professional who evaluates and treats pediatric OSA

DG: This is more correctly being described as ADD now, and there are indications that it may be partly related to the brain stimulation effects of electronic devices and sleep fragmentation. The sleep study findings are essential in order to determine whether OSA is a contributor to the ADD signs and symptoms - and if so, this should be discussed with the PCP or specialist treating the child's ADD. The neurologist and/or clinical psychologist and/or nutritionist hopefully can lead the way with help for children with ADD.

RESOURCES

GUIDELINES AND KEY PAPERS:

*** 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://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.334.1315&rep=rep1&type=pdf

***Bonuck, Karen, Trupti Rao, and Linzhi Xu. "Pediatric sleep disorders and special educational need at 8 years: a population-based cohort study." Pediatrics 130.4 (2012): 634-642.

http://pediatrics.aappublications.org/content/130/4/634.short

*** Bonuck, K., Freeman, K., Chervin, R. D., & Xu, L. (2012). Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics, 129(4), e857-65.

http://europepmc.org/articles/pmc3313633

*** Marcus CL, Brooks LJ, Davidson S, et al. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2012. 130(3): p. 576–584

http://pediatrics.aappublications.org/content/130/3/e714.long

American Sleep apnea Association – Children’s Sleep Apnea

https://www.sleepapnea.org/treat/childrens-sleep-apnea/

Huynh, NT, Desplats E, Almeida, FR. Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis. Sleep Medicine Reviews. 25 (2016) p. 84-94.

http://www.smrv-journal.com/article/S1087-0792(15)00029-5/pdf

Tapia IE and Marcus CL. Newer treatment modalities for pediatric obstructive sleep apnea. Paediatric Respiratory Reviews. 2013. 14(3): p. 199–203

http://www.prrjournal.com/article/S1526-0542(12)00038-3/fulltext

Guilleminault, C. (2013). Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Frontiers in neurology, 3, 184.

https://www.frontiersin.org/articles/10.3389/fneur.2012.00184/full

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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4467532/

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/

CLINICAL TOOLS:

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

Print out SLEEP DISORDERS YOUTH FACT SHEET by clicking HERE

PEDIATRIC SLEEP SCREENING TOOLS:

Chervin, Ronald D., et al. "Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems." Sleep medicine 1.1 (2000): 21-32.

https://pdfs.semanticscholar.org/092c/37f0ef50650f691b7fbf1d8073486b4d6334.pdf

Kadmon, G., S. A. Chung, and C. M. Shapiro. "I'M SLEEPY: a short pediatric sleep apnea questionnaire." International journal of pediatric otorhinolaryngology 78.12 (2014): 2116.

https://www.ncbi.nlm.nih.gov/pubmed/25305064

BEARS SLEEP SCREENING ALGORITHM

https://depts.washington.edu/dbpeds/Screening%20Tools/BEARSsleep.doc

CHILDREN’S SLEEP HABITS QUESTIONNAIRE

http://njaap.org/wp-content/uploads/2016/04/Childrens-Sleep-Habits-Questionnaire.pdf

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

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.