Obstructive Sleep Apnea in
Children
Zafer Soultan,MD
Associate Professor of Pediatrics
Director, Pediatric Pulmonary and Sleep
Medicine
SUNY, Upstate Medical University
Pediatric Obstructive Sleep Apnea
- 10
+1
Weak muscles
Cross-Section of Oropharynx
Nasal
obstruction
Micro- or
retrognathia
Tonsillar
hypertrophy
Large
tongue
Pathophysiology of OSA
Structural factors
• Adenotonsillar hypertrophy
• Craniofacial abnormality
• Obesity
Neuromotor tone
• Cerebral palsy
• Genetic diseases
OSA
Other factors
• Genetic
• Hormonal
•?
Risk Factors for Residual Obstructive Sleep Apnea After Adenotonsillectomy in Children
Imanguli M; Laryngoscope 2016
Sleep Disordered Breathing
Spectrum of conditions determined by relative
amount of upper airway obstruction:
(CIRCLES DISPLAY INCREASING UPPER AIRWAY OBSTRUCTION)
o
PS - Primary snoring:
NOISY BREATHING
o
UARS - Upper airway resistance syndrome:
NOISY BREATHING + DISTURBED SLEEP
o OH - Obstructive hypoventilation:
NOISY BREATHING ± DISTURBED SLEEP +  CO2 and/or  SaO2
o
OSA - Obstructive sleep apnea:
NOISY BREATHING ± DISTURBED SLEEP +  CO2 and/or  SaO2 + ABSENCE OF
AIRFLOW
OSA Epidemiology
•
•
•
•
Habitual snoring 1.5-28%
OSA – 1% to 5%
M:F ratio approximately equal
Prevalence is higher among African
Americans, obese, AT hypertrophy,
craniofacial anomalies
Symptoms of OSA
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Frequent snoring (≥3 nights/wk)
Labored breathing
Gasps/snorting noises
Apnea
Enuresis (especially secondary)
Sleeping in a seated position or with the neck
hyperextended
Cyanosis
Headaches on awakening
Daytime sleepiness
Attention-deficit/hyperactivity disorder
Learning problems
Signs of OSA
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Underweight or overweight
Tonsillar hypertrophy
Adenoidal facies
Micrognathia/retrognathia
High-arched palate
Failure to thrive
Hypertension
Sequelae
Neuropsychological and Cognitive
Problems

Deficits in:
Learning, memory, and visuospatial skills
 Language, verbal fluency, and phonological skills
 Concept formation, analytic thinking, and verbal and
nonverbal comprehension
 School performance and mathematical abilities
 Executive functions; mental flexibility, impulse control
and working memory
There is correlation between different polysomnographic
factors and cognitive outcomes.
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Behavioral abnormalities
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Hyperactivity; in younger kids
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ADHD
Hypersomnolence
Somatization
Depression
Atypicality
Aggression, and abnormal social behaviors
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Improvement after treatment
Gozal, D. Pediatrics 1998;102:616-620
Copyright ©1998 American Academy of Pediatrics
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Neurocognitive deficits were found at baseline in SDB
children compared to controls; 10 point IQ difference
(P<.001) and similar deficits in language and executive
function.
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Adenotonsillectomy improved respiratory parameters and snoring
frequency at 6 months post surgery, neurocognitive performance
did not improve relative to controls. Kohler MJ, PLoS ONE. 2009;4(10):e7343
Phonologic processes and verbal fluency did not
improve to normal. Montgomery-Downs Eur Respir J. 2005;25(2):
336–342. Lundeborg I, Clin Linguist Phon. 2009;23(10):751–761
Conclusions by the experts
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The majority of these studies suggest that in
developing children who are dependent on
executive function, cognition, and behavioral
skills important for daily function and school
performance, treatment of childhood SDB
has benefits.
Cardiovascular dysfunction
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Subclinical left sided and right sided and
biventricular cardiac dysfunction
Correlation between the presence and
severity of OSA and elevated systolic and
diastolic BP
Effect on growth
Girls
Boys
Marcus et al. J Pediatr 1994
Soultan, Z. Arch Pediatr Adolesc Med. 1999;153:33-37.
Soultan, z. Arch Pediatr Adolesc Med. 1999;153:33-37.
Inflammation
Gozal L, J Clin Sleep Med. Author manuscript; available in PMC 2007 Apr 4.
Inflammation
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Increased glucocorticoid and leukotriene
receptors in adenotonsillar tissue from
children who had OSAS compared with
tissue from children who experienced chronic
throat infections. Khalyfa A et al, Goldbart AD et al
Diagnosis; just ask and verify
Pediatric Sleep Questionnaire
Patient Name: ____________________________________________________________
Date of Birth: ____________________________________________________________
Yes
No
While sleeping does your child…
Snore more than half the time?
Always snore?
Snore loudly?
Have “heavy” or loud breathing?
Have trouble breathing or struggle to breathe?
Have you ever…
Seen your child stop breathing during the night?
Does your child….
Tend to breathe through the mouth during the day?
Have a dry mouth on waking up in the morning?
Occasionally wet the bed?
Wake up feeling un-refreshed in the morning?
Have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child up in the morning?
Does your child wake up with headaches in the morning?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?
This child often…
Does not seem to listen when spoken to directly
Has difficulty organizing tasks
Is easily distracted by extraneous stimuli
Fidgets with hands or feet or squirms in seat
Is “on the go” or often acts as if “driven by a motor”
Interrupts or intrudes on others (e.g. butts into conversations or games)
Sensitivity 78-85 %
Specificity 72-87%
Total Number of “Yes” Responses
_____________
If eight or more statements are answered “yes”, consider referring for sleep evaluation
CHERVINE ET AL, PEDIATRIC SLEEP QUESTIONNAIRE: VALIDITY AND RELIABILITY OF SCALES FOR SLEEP DISORDERED BREATHING,
SNORING, SLEEPINESS, AND BEHAVIORAL PROBLEMS, SLEEP MEDICINE 2000;1:21-32
Don’t
Know
Diagnosis
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Nocturnal oximetry
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Sensitivity 67%, and specificity 60% for moderate
OSA AHI > 5. Kirk et al.
Good correlation with PSG, but 80% of the 223
children had normal, inconclusive, or technically
unsatisfactory oximetry. Brouillette et al
Home sleep study; abbreviated form. Promising for
school-aged children and for AHI >5
Pediatric Polysomnography
EEG
EOG
Nasal EtCO2
Nasal Oral Airflow
Chin EMG (2)
Microphone
Sao2
EKG
Tech Observer
Video Camera
Respiratory Effort
Documents arousals,
parasomnias, abnormal
sleeping position, and attends
to any technical problem
Leg EMG (2)
Record behavior
Courtesy of Dr. Carol Rosen
Obstructive Sleep Apnea
OBSTRUCTIVE APNEA
OBSTRUCTIVE APNEA
HYPOXEMIA FOLLOWING APNEIC EPISODE
Obstructive Hypoventilation
PARADOXICAL RIB-CAGE MOTION
HYPERCAPNIA
Pediatric Polysomnography
Role of Polysomnography
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Differentiate OSA from primary snoring
Define severity of OSAS
Differential diagnosis
Evaluate success of treatment
Treatments:
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Adenotonsilletcomy, Partial tonsillectomy
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Pain and poor oral intake
Bleeding, infection, anesthetic complications,
respiratory decompensation, velopharyngeal
incompetence, subglottic stenosis, obesity, and,
rarely, death.
In-patient observation: age <3 years, severe
OSAS, presence of cardiac complications,
failure to thrive, obesity, and presence of
upper respiratory tract infection (URI).
Does it work?
Persistence of OSA after AT
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OSA (AHI >1) persistence 19%-73%, AHI
≥5/hour 13%-29%.
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Obesity: 51% AHI ≥5/hour; OR of persistent
OSAS in 3.21 to 4.7.
Severe OSA
Very young and older children > 7 years
independent of obesity
Coexisting asthma, and family history
Likely in children with craniofacial anomalies,
Down syndrome, and neuromuscular disease
Cure, improve with residual OSA after AT
AHI: Pre AT 21.4 (2.3–147.5), post 1.5 (0–20.0) p <.001
The prevalence of residual OSA for AHI >1 criteria (72%), and
AHI >2 was 38%
Risk Factors for Residual Obstructive Sleep Apnea After Adenotonsillectomy in Children
Imanguli M; Laryngoscope 2016
Conclusions by the experts
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AT is the most effective surgical therapy for pediatric patients,
leading to an improvement in polysomnographic parameters in the
vast majority of patients
Significant proportion of patients are left with persistent OSAS after
AT.
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13-29% in low-risk population for AHI ≥5/hour
73% when including obese children and adolescents and a conservative AHI
≥1/hour.
Children at highest risk of persistent OSAS are those who are obese
and those with a high preoperative AHI, especially those with an AHI
≥20/hour, as well as children >7 years of age.
Positive Airway Pressure
Positive airway pressure
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Indications: persistent OSAS after AT, usually
in obesity or craniofacial anomalies, and
when surgery is contraindicated
Effective in resolving symptoms and
polysomnographic abnormalities
Adherence?
Special Considerations for CPAP in
Children
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Need wide variety of mask sizes and styles to
fit children
Compliance may be enhanced by behavioral
techniques
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Empowerment
Positive reinforcement
Desensitization
Role modeling
Medications
Intranasal steroids may be considered for treatment of mild OSA; AHI <5/hour
Sleep Med. 2007 Mar;8(2):128-34. Epub 2007 Jan 18.
Rapid maxillary expansion in children
with obstructive sleep apnea syndrome:
12-month follow-up.
Villa et all
The Childhood Adenotonsillectomy Trial
(CHAT)
Conclusions by the CHAT
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As compared with a strategy of watchful waiting, surgical treatment for the
obstructive sleep apnea syndrome in school-age children did not
significantly improve attention or executive function as measured by
neuropsychological testing but did reduce symptoms and improve
secondary outcomes of behavior, quality of life, and polysomnographic
findings, thus providing evidence of beneficial effects of early
adenotonsillectomy. (Funded by the National Institutes of Health; CHAT
ClinicalTrials.gov number, NCT00560859.)
Nothing is a medicine too (normalization of polysomnographic findings in 46% (79%
after AT), but only for certain patients!
“Normalization of polysomnographic findings in a large number of children in
the watchful-waiting group and an absence of significant cognitive decline in
this group indicate that medical management and reassessment after a
period of observation may be a valid therapeutic option”
Pediatrics. 1977 Jun;59(6):865-71.
Hypoventilation during sleep in children who have lymphoid airway
obstruction treated by nasopharyngeal tube and T and A.
Kravath RE, Pollak CP, Borowiecki B.
Abstract
Three children with sleep apnea, alveolar hypoventilation, apparent mental
retardation, and poor growth associated with chronically enlarged tonsils and
adenoids were treated with the use of a nasopharyngeal tube followed by
tonsillectomy and adenoidectomy. The effectiveness of this therapy was
documented by polygraphic recording of sleep stages and respirations, and by
correlation with serial arterial blood gases and pH. The nasopharyngeal tube was
well tolerated, easy to use, and effective in diagnosis and treatment. We suggest
that its use be further evaluated in patients with obstructive apnea.
PMID: 865938 [PubMed - indexed for MEDLINE]
Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/Journals/JASA/931422/ on 04/09/2016
Kravath’ method
We end with the AAP recommendations
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Inquire about snoring, and if positive do thorough evaluation.
Polysomnogram (PSG), or referral to a sleep specialist or
otolaryngologist
If PSG is not available; nocturnal video recording, nocturnal
oximetry, daytime nap PSG, or ambulatory PSG.
Adenotonsillectomy (AT)
Monitor high-risk patients after AT
Reassess all patients with OSAS for persisting signs and
symptoms after therapy
Reevaluate high-risk patients for persistent OSAS after AT
CPAP
Weight loss
AAP recommendations cont.
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Topical intranasal corticosteroids for children
with mild OSAS in whom adenotonsillectomy
is contraindicated or for children with mild
post-operative OSAS
Not AAP recommendation, do nothing?
Conclusion
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We should not overlook OSA, because it
does have serious consequences
Early diagnosis and treatment of may
improve a child’s long-term cognitive and
social potential and school performance.
The source and useful resource

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome Carole L.
Marcus, Lee Jay Brooks, Kari A. Draper, David Gozal, Ann Carol Halbower, Jacqueline Jones,
Michael S. Schechter, Stephen Howard Sheldon, Karen Spruyt, Sally Davidson Ward, Christopher
Lehmann and Richard N. Shiffman Pediatrics 2012;130;576; originally published online August
27, 2012;
DOI: 10.1542/peds.2012-1671; The online version of this article, along with updated information
and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/130/3/576.full.html