OSA in Children

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OSA in Children

• Katie McKie, MD
• GHSU Pediatric Pulmonology Sleep Medicine

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No Disclosures
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Objectives

• Understand the definition of OSA
• Review risk factors for pediatric OSA
• Review common symptoms of pediatric OSA
• Understand diagnosis of OSA
• Discuss management of pediatric OSA
• Review AAP guidelines for OSA

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OSA The Basics

• Definition repeated episodes of prolonged upper
  airway obstruction during sleep despite continued
  or increased respiratory effort, resulting in
  complete or partial cessation of airflow and
  disrupted sleep.
• Epidemiology 1-4 of children (documented by
  overnight sleep studies)
• Age most prevalent in ages 2-8 years
• Etiology ? UA patency, ? UA collapsibility,
  ?drive to breathe

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Risk FactorsUpper Airway Obstruction

• Adenotonsillar hypertrophy
• Allergies (chronic rhinitis)
• Craniofacial abnormalities
• GERD (pharyngeal reactive edema)
• Nasal septal deviation
• Obesity

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Risk FactorsUpper Airway Reduced Muscle Toneor
Reduced Central Ventilatory Drive

• Neuromuscular disease (muscular dystrophy, CP)
• Hypothyroidism
• Arnold-Chiari malformation
• Myelomeningocoele
• Brainstem injury or mass

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Other Risk Factors for OSA

• Specific medical conditions (Down syndrome,
  Prader Willi, achondroplasia, sickle cell
  disease, craniofacial syndromes,
  mucopolysaccharidoses)
• Environmental tobacco smoke exposure
• Family history

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Common Nighttime Symptoms of OSA

• Nightly snoring
• Apneic pauses
• Restless sleep
• Abnormal sleep position
• Mouth breathing
• Enuresis
• Increased seizure frequency in predisposed
  children
• Increase in parasomnias (sleepwalking, sleep
  terrors)

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Common Daytime Symptoms of OSA

• Mouthbreathing
• Chronic nasal congestion
• Hyponasal speech
• Morning headaches
• Excessive daytime sleepiness
• Mood changes
• ADHD-like symptoms
• Academic problems

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Evaluation for OSA

• Medical history (allergy, asthma, GERD,
  tonsillitis)
• Developmental/school history
• Family history
• Behavioral assessment
• Physical exam (growth, facial structure, signs of
  atopy, nasal passages, oropharynx, neck, heart)

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Evaluation for OSA

• Screening BEARS questionnaire
• Diagnosis Polysomnography
• Other studies to consider in specific cases
  Lateral neck film, CXR, EKG, Echo, Laryngoscopy,
  CT/MRI

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Rationale for Polysomnograpyin Pediatric OSA

• Cannot reliably distinguish OSA from primary
  snoring on the basis of history and PE
• Need to assess severity of OSA in children at
  risk for peri-operative and post-operative
  symptoms
• Provides baseline measure for children whose OSA
  may not resolve with TA alone, and who will need
  a follow-up post-operative sleep study

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the pediatric hook-up
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Diagnosis of OSA in Children

• AHI lt 1 normal
• AHI 1-5 very mild OSA
• AHI 5-10 mild OSA
• AHI 10-20 moderate OSA
• AHI gt20 severe OSA
• CO2 gt 50 mmHg for gt25 of sleep time
  hypoventilation

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Management of OSA in Children

• Adenotonsillectomy is first-line treatment
• 50 of obese children have residual OSA post TA
• Regrowth of adenoidal tissue may occur (10-15)
• Post-op complications (esp. respiratory
  compromise) are more common in children with OSA
• High risk groups children lt 3 yrs severe OSA
  associated medical conditions such as Down
  syndrome, craniofacial syndromes, morbid obesity
• Children with history of severe OSA and/or
  residual symptoms post-op should have repeat
  sleep study at least 6 weeks after TA

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Management of OSAin Children

• Other surgical interventions (turbinate
  reduction, septal repair, UPPP, maxillofacial
  surgery, tracheostomy) are rare but may be
  indicated in certain cases.
• CPAP/ BiPAP may be useful when TA is not
  indicated, if TA fails to completely resolve
  symptoms, or prior to surgery in patients with
  severe OSA
• Titration should be done every 6-12 months (or
  with significant weight changes) in children.

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Management of OSAin Children

• Weight management
• Treatment of co-morbid allergic rhinitis, GERD,
  and asthma
• Avoidance of sedating medications
• Avoidance of environmental tobacco smoke
• Oral appliances
• Positional therapy
• Supplemental oxygen therapy

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Risk Factors for Recurrence of OSA

• Obesity
• Gain velocity in BMI
• African-American race
• Persistent upper airway abnormalities (ie septal
  deviation, enlarged turbinates)
• Other medical conditions (Down syndrome,
  craniofacial syndromes, etc)

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AAP Guidelines - OSA

• All children should be screened for snoring.
• Complex, high risk patients should be referred to
  a specialist.
• patients with cardiorespiratory failure cannot
  await elective evaluation
• diagnostic evaluation is useful in discriminating
  between primary snoring and OSAS
• adenotonsillectomy is the first line of treatment
  for most children CPAP is an option for those
  who are not candidates for surgery or do not
  respond to surgery
• high-risk patients should be monitored as
  inpatients postoperatively
• patients should be reevaluated postoperatively to
  determine whether additional treatment is
  required

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Sleep Resourcesfor Pediatricians and Parents

• AAP Clinical Practice Guidelines OSA (2002)
• BEARS sleep screening questionnaire
• American Academy of Sleep Medicine
  (www.aasmnet.org)
• A Clinical Guide to Pediatric Sleep (J. Mindell
  J. Owens)
• Healthy Sleep Habits, Happy Child (M. Weissbluth)
• The SleepEasy Solution (J. Waldburger)
• Solve Your Childs Sleep Problems (R. Ferber)

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Contact Info

• Katie McKie
• GHSU Pediatric Pulmonology/ Sleep Medicine
• Office 706-721-2635
• Fax [phone]
• Email ktmckie_at_georgiahealth.edu

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Laugh, and the world laughs with you. Snore, and
you sleep alone.