Saturday, February 24, 2024

Childhood Sleep Apnea

Practice Essentials

Obstructive sleep apnea (OSA) in children is characterized by episodic upper airway obstruction that occurs during sleep. The airway obstruction may be complete or partial.

Signs and symptoms

The clinical presentation of a child with obstructive sleep apnea (OSA) is nonspecific and requires increased awareness by the primary care physician. OSA symptoms in children can include the following:

Abnormal breathing during sleep

Frequent awakenings or restlessness

Frequent nightmares

Enuresis

Difficulty awakening

Excessive daytime sleepiness

Hyperactivity/behavior problems

Daytime mouth breathing

Poor or irregular sleep patterns

Complications of OSA in children can generally be divided into the 4 following immediate consequences of upper airway obstruction during sleep:

Sleep fragmentation

Increased work of breathing

Alveolar hypoventilation

Intermittent hypoxemia

See Clinical Presentation for more detail.

Diagnosis

Currently, the only available tool for definitive diagnosis of OSA is an overnight polysomnographic evaluation in the sleep laboratory (see the image below). Ideally, polysomnography should be performed overnight and during the patient’s usual bedtime.

Example of an obstructive apnea and an obstructive

Example of an obstructive apnea and an obstructive hypopnea recorded during polysomnography.

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Polysomnography provides the following measures:

Sleep state (≥2 EEG leads)

Electrooculogram (right and left)

Submental electromyelogram (EMG)

Airflow at nose and mouth (thermistor, capnography, or mask and pneumotachygraph)

Chest and abdominal wall motion (impedance or inductance plethysmography)

Electrocardiogram (preferably with R-R interval derivation technology)

Pulse oximetry (including a pulse waveform channel)

End-tidal carbon dioxide (sidestream or mainstream infrared sensor)

Video camera monitor with sound montage (analog or digital)

Transcutaneous oxygen and carbon dioxide tensions (in infants and children < 8 y)

Polysomnographic normal standards differ between children and adults. In the pediatric age range, abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of ET CO2 measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.

See Workup for more detail.

Management

Surgical intervention

Although OSA has multiple etiologies in children, once the diagnosis has been established and its severity assessed, adenotonsillectomy is usually the first line of treatment. Tonsillotomy, rather than tonsillectomy, has been recently advocated as equally effective with less postoperative morbidity.

Adenotonsillectomy should be implemented along with weight normalization in obese children. Caloric intake limitation and dietary counseling are necessary if obesity complicates OSA. Children and adolescents with significant sleep apnea should avoid eating large amounts just before bedtime.

Continuous positive airway pressure

CPAP is the mainstay of therapy for most adults with OSA, as well as a large number of children and adolescents. However, it is often difficult for children to adhere to the therapy regimen.

CPAP devices can be uncomfortable and inappropriately fitting masks can leak, leading to the development of pressure sores on the bridge of the nose. Air leaks can also irritate the conjunctiva, causing increased lacrimation and eye discomfort. Also, midfacial hypoplasia may develop with long-term use, particularly in children with neuromuscular weakness.

See Treatment and Medication for more detail.

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