We've all heard of sleep apnea, but did you know that there are different kinds? Estimates show that approximately 2% of children in the U.S. are affected by a type called obstructive sleep apnea syndrome or OSAS. Do you know the symptoms? If you have children, or work with them, read on...
What is OSAS?
Pediatric OSAS occurs when a child's airway is partially blocked due to abnormally large tonsils and/or adenoids. Because the peak age for obstructive sleep apnea coincides with that of a critical period for brain development, delayed diagnosis and treatment of obstructive sleep apnea possibly imposes a greater burden on vulnerable brain structures and ultimately hampers the overall neurocognitive potential of children with obstructive sleep apnea. Neurobehavioral disturbances and diminished learning capabilities, stunted growth, altered respiratory load response patterns, and pulmonary hypertension are major consequences of obstructive sleep apnea in childhood. Early diagnosis and prevention of such morbidities are fundamental aspects of adequate pediatric care in the community. [1]
Symptoms
When looking at childhood OSAS, one must not only consider symptoms of sleep disordered breathing itself, but also the obvious signs of an actual obstruction. In a child with OSAS, you may witness some or all of the following:
- Snoring at night
- Pauses in breathing at night (sometimes lasting for 8-10 seconds)
- "Snoring" while awake
- Odd sleeping positions, sometimes with the head tilted way back
- Sweating during sleep
- Behavioral problems, especially upon waking in the morning
- Restless sleep
- Nighttime mouth breathing
- Daytime mouth breathing
- Cognitive impairment
- Enlarged tonsils and/or adenoids
- Reluctance to eat
- Refusal to eat certain foods
- Requiring extended time to finish meal
- Insisting on very small bites of food
- Choking
Mortality/Morbidity
Sleep fragmentation in adults affects neuropsychological and cognitive performance. No evidence suggests such impairments are absent in children, and such deleterious effects may be worse, given that the child's brain is undergoing active developmental changes. Reports of decreased intellectual function in children with tonsillar and adenoidal hypertrophy date from 1889 when Hill reported on "some causes of backwardness and stupidity in children." Schooling problems have been repeatedly reported in case studies of children with obstructive sleep apnea and, in fact, may underlie more extensive behavioral disturbances, such as restlessness, aggressive behavior, excessive daytime sleepiness, and poor test performances.The neurocognitive and behavioral consequences of disrupted sleep architecture and hypoxemia caused by sleep-disordered breathing in children with obstructive sleep apnea have only recently been defined by appropriate scientific methodology in the pediatric population. However, some studies have documented that children with sleep disorders tend to have behavioral problems similar to those observed in children with attention deficit hyperactivity disorder (ADHD). A survey study of 782 children recently documented daytime sleepiness, hyperactivity, and aggressive behavior in children who snore. Inverse correlations between memory and learning performance and the severity of obstructive sleep apnea were also found, and other studies have clearly demonstrated significant improvements in school performance after treatment of obstructive sleep apnea.
In a study of 19 preschool-aged children with obstructive sleep apnea, prior to tonsillectomy and adenoidectomy (T&A), cognitive scores were significantly lower in children with obstructive sleep apnea versus control subjects. Following T&A, the scores of the children with obstructive sleep apnea improved compared with preoperative scores and did not differ from those of the matched controls. This underscores the importance of diagnosis and treatment, insofar as the cognitive impairments of children, unlike adults, take place in the developing brain.
Sleep deprivation, sleep disruption, and intermittent hypoxia independently may be sufficient to cause daytime effects in vulnerable children. Preliminary evidence suggests that, if left untreated, sleep-disordered breathing may impose long-term decrements in academic performance and the combination of 2 or more of these factors can result in particularly impaired daytime functioning.
Although empirical awareness of the deleterious consequences of obstructive sleep apnea on neurocognitive function and behavior is well established, the scientific foundation for the causal mechanisms underlying such detrimental effect on intellectual function has yet to be determined. This endeavor is currently a major focus of research programs.
Because the peak age for obstructive sleep apnea coincides with that of a critical period for brain development, delayed diagnosis and treatment of obstructive sleep apnea possibly imposes a greater burden on vulnerable brain structures and ultimately hampers the overall neurocognitive potential of children with obstructive sleep apnea.[1]
In conclusion, parents need to be aware of the symptoms of OSAS. If you have children and their pediatrician hasn't asked you if you've seen symptoms of OSAS during a general check-up, please bring it up during your next visit. Our children cannot afford for it to be undiagnosed.
Please check back often, as this page will undergo periodic updates. Also, please see links for additional information on our resource page which will be posted soon.
September 8, 2011
Recently, I came upon this publication regarding pediatric sleep apnea on medscape. I wanted to share it because it lists some of the morbidities associated with this condition.
Excerpt regarding the prognosis (emphasis in bold italics is mine):
Prognosis
Major morbidities associated with childhood obstructive sleep apnea include failure to thrive, difficulty concentrating and/or developmental delay, behavioral problems, hypertension, pulmonary hypertension, and, ultimately, cor pulmonale. Some pulmonologists theorize that chronic upper airway obstruction with labored breathing may result in the development of a pectus excavatum deformation in a compliant immature chest wall. Concomitant gastroesophageal reflux is likely to be exacerbated by obstructive sleep apnea.
Children with obstructive sleep apnea syndrome, as well as children with a history of loud habitual snoring, appear to be at risk for developing deficits of executive function. According to the model by Beebe and Gozal, sleep fragmentation, intermittent hypoxemia, and hypercapnia contribute to dysfunction in the prefrontal areas of the brain.[5] Executive functions include behavioral inhibition, regulation of affect and arousal, ability to analyze and synthesize, and memory. Executive dysfunction interferes with cognitive abilities and learning.
Obesity-related hypoventilation, commonly known as the pickwickian syndrome, occurs in some children who have obesity and obstructive sleep apnea. These individuals respond abnormally to both hypercapnic and hypoxemic stimuli to breathe; they have repetitive obstructive events with sleep and marked daytime sleepiness, daytime hypoventilation, and hypercapnia.
The incidence of cor pulmonale and death due to obstructive sleep apnea is unknown. Once pulmonary hypertension has developed, it is usually reversible if the underlying obstructive sleep apnea is effectively treated.
Children with severe obstructive sleep apnea may develop postobstructive pulmonary edema within a few hours of surgery undertaken to relieve upper airway obstruction. Furthermore, such patients are at risk for postoperative respiratory compromise, which is characterized by severe upper airway obstruction and may require endotracheal intubation or the use of noninvasive respiratory support such as continuous positive airway pressure via a nasal mask.
Prognosis after surgery
Surgical treatment of severe obstructive sleep apnea warrants an overnight observation, especially if the child is younger than 3 years or has concomitant cardiopulmonary disease, morbid obesity, hypotonia, or craniofacial anomalies.
The major determinants of surgical outcome include the apnea hypopnea index (AHI) and obesity at the time of diagnosis. The AHI is the total number of apneas and hypopneas that occur divided by the total duration of sleep in hours. An AHI of 1 or less is considered to be normal by pediatric standards. An AHI of 1-5 is very mildly increased, 5-10 is mildly increased, 10-20 is moderately increased, and greater than 20 is severely abnormal.
In children with enlarged tonsils and adenoids that lead to obstructive sleep apnea, an adenotonsillectomy usually results in complete cure, although no definitive studies have clearly demonstrated this issue.
The outcome of patients who require extensive surgical management obviously depends on the severity of the condition that leads to upper airway compromise. With the emergence of noninvasive ventilation as an alternative option for these children, upper airway obstruction during sleep can be conservatively and successfully managed in most children.
In children with failure to thrive (FTT), treatment of obstructive sleep apnea leads to resolution of the somatic growth disturbance. Similarly, pulmonary hypertension resolves. Although major improvements in neurobehavioral outcomes are expected, data are currently insufficient to support a complete recovery in some of the cognitive abilities affected by obstructive sleep apnea.
Tauman et al reported that only 25% of children treated for obstructive sleep apnea with adenotonsillectomy had complete postoperative normalization of symptoms.[6]
The areas of this publication that I have emphasized, show how some of the symptoms of OSAS mimic those of ADHD. If you know a young child who has been diagnosed with, or is suspected to have, ADHD (or a general developmental delay), please check to see if they may also have the physical symptoms of OSAS listed above. There is no doubt that some of these kids with apnea are overlooked, go undiagnosed and consequently have a label slapped on them when they get to elementary school. If it is OSAS, and is corrected soon enough, then this type of scenario could quite possibly be avioidable.
