Snoring and Obstructive Sleep
Apnea Syndrome
in Children
2013
Gerald M. Loughlin
Weill Cornell Medical College
Komansky Center for Child Health
New York Presbyterian Hospital
19th century original
observations…
“At night the child’s sleep is greatly
disturbed; the respirations are loud and
snorting, and there are sometimes prolonged
pauses, followed by deep, noisy inspirations.”
William Osler, 1892
Obstructive Sleep Apnea Syndrome
• A spectrum of abnormal breathing during sleep, that
in its mild form is manifested by snoring ( partial
airway obstruction) with or without gas exchange
abnormality and in its extreme form by snoring with
intermittent complete airway obstruction (apnea)
• Associated findings include increased respiratory
effort on inspiration, snoring punctuated with periods
of silence with continued respiratory efforts, resulting
in hypoxia, hypercapnia and disruption of normal
sleep patterns.
• Daytime symptoms occur as a consequence of the
abnormal breathing and/or sleep patterns.
Pathophysiology of Obstructive Sleep Apnea
Increased
Upper Airway
Resistance
Tonsils & adenoids
Obesity
Craniofacial abnormalities
Airway size
Allergy
Inflammation
OSAS
Alterations in
upper airway
control during
sleep
Other factors:
Age, Gender
Behavior
Environment
Socioeconomic status
Arousal
Genetics & Race
Passive smoking
Effects of age,
CNS dysfunction
(Primary vs. acquired)
Brainstem compression/injury
Respiratory depressants
Prevalence of OSAS in Children
10% - 12% of children
snore loudly, nightly
1-3% of children
with OSAS
Signs and Symptoms (sleep)
• Snoring
• During sleep - paradoxical inward rib cage motion –
increased work of breathing
• Apnea – obstructive and central
• Disturbed sleep (movement arousals, restlessness)
• Night sweats
• Cyanosis (not often reported)
• (?) Enuresis
• ? Increased GER/aspiration
Associated Findings – awake
• Mouth-breathing, hypo-nasal speech,
chronic nasal congestion
• Recurrent adenotonsillitis
• Excessive daytime sleepiness (unusual)
• Irritability on awakening
• Morning headaches (?)
• Behavioral and neurocognitive dysfunction
Childhood OSAS - complications
• Cardiovascular
– cor pulmonale, pulmonary hypertension
– polycythemia
– systemic diastolic hypertension
– altered cardiac function during sleep
• Failure to thrive –
– increased caloric expenditure
– decreased IGF-1 and IGFBP-3 levels
• Neurocognitive dysfunction
• Developmental delay
• Death – uncommon in children
19th century description of daytime
symptoms...
“The expression is dull, heavy, and apathetic…
In long-standing cases the child is very stupidlooking, responds slowly to questions, and may
be sullen and cross.” “Among other symptoms
may be mentioned headache, which is by no
means uncommon, general listlessness, and an
indisposition for physical or mental exertion.
The influence upon the mental
development is striking.”
William Osler, 1892
Patterns of Neuro-cognitive Dysfunction
• Infancy - Developmental delay
• Pre-school
Chronic oppositional behavior - “difficult child”
Easily fatigued, “always tired”
Lethargy / sleepiness or hyperactivity
• School age
Abnormal shyness, social withdrawal
Hyperactivity/ aggressiveness / attention
problems
Unexplained poor school performance
Decreased executive functions, visual attention,
conceptual ability and phonologic functioning
Patterns of Neuro-cognitive Dysfunction
• School Age (continued)
– Decreased executive functions, visual
attention, conceptual ability and
phonologic functioning
– Intelligence – Memory
Neurocognitive Behavioral Deficits
Children and Adolescents
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•
•
Decreased intelligence, memory, attention capacity
Decreased academic performance
Increased problematic behavior
Reports of social withdrawal, emotional lability ,
hyperactivity, conduct problems, aggressive
behavior
• Delinquency , destructive and disruptive behavior
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The association between sleep disordered breathing,
academic grades, and cognitive and behavioral functioning
among overweight subjects during middle to late
childhood. Beebe DW et al. Sleep 2010;33:1447-1456
Study of 163 overweight adolescents divided based on
AHI into 4 groups -Moderate/Severe OSA vs. mild vs.
snorers without apnea vs. non snorers
Measurements – PSG, neuropsych testing, parent and teacher
reports of grades, sleep , behavior
Findings: SDB in overwgt adolescents 10-16yrs associated with
lower grades and worse behavior: Data suggests that alterations in
academic performance arise from negative behaviors
How to make a diagnosis of OSAS?
•Direct observation – good but hard to asses severity
and to arrange
•Polysomnographt is the “gold standard.” Is it needed
in all patients?
•AAP (2002) recommends testing for OSA before T&A
- although an appropriate recommendation
is not always practical or possible
•Value of oximetry, video recordings, nap vs. overnight
study
When is intervention indicated?
• In 2013 – Snoring can no longer be considered
normal. It is equivalent to stridor and wheeze, as a
sign of airway obstruction
• Need to be certain that what is being described is
actually snoring
• Therapy indicated in snoring child who presents
with typical symptoms/complications of OSAS
• Medical management ( including weight loss) can
be considered for mild to moderate cases
• T&A – most common surgical option
• Results post T&A are inconsistent – abnormal sleep
study may persist in as many as 40%
Treatment of obstructive SDB in
children
Surgical treatment for OSAS
Adenotonsillectomy (? Role for recently
described intracapsular procedure)
Uvulopalatopharyngoplasty (UPPP) – not
for children
Tracheostomy (rarely used now for OSAS)
Craniofacial reconstruction
Miscellaneous (brainstem decompression
surgery in achondroplasia and Chiari
malformation)
Non surgical Interventions
Rx of upper respiratory allergies/inflammation
•Leukotriene antagonists
• Nasal steroids
Weight loss for obese children
Nasal airway (short term)
Oral appliances (?)
Nasal strips (?)
“Follow up essential regardless treatment plan”
Long-term Implications of
Childhood OSAS
• May predict who is at risk as adults
– “As the twig is bent, the tree inclines”
• If untreated - may have profound effects on
neurocognitive and cardiovascular function
in adults
In adults
• Risk factor for hypertension
• ? sudden death during sleep
• ? myocardial infarction, ? Stroke
Allergy/Immunology – upper airway inflammation
Anesthesiology – pre and intra-operative airway management
Cardiology – cor pulmonale, ventricular dysfunction, hypertension
Critical Care – post–op management (pulmonary edema, airway obstruction)
Developmental and General Pediatrics – developmental delay, FTT, enuresis
Endocrine – obesity, growth problems, puberty
Gastroenterology –possible increase in GER
Genetics – increased risk in African –Americans, gender issues
Hematology – differential diagnosis of polycythemia
Infectious Disease – recurrent adenotonsillitis
Neonatology – increased risk in former premature infants
Nephrology – hypertension, enuresis
Neurology – neuro-cognitive problems, school problems
Neuro-radiology – functional MRI
Neurosurgery – brainstem compression syndromes
Otolaryngology – most common indication for T&A
Orthopediatics – fractures from falling out of bed
Outcomes and Health Services Research – data needed on natural history,
approach to diagnosis and therapy, who to treat and how
Pulmonary – abnormal respiration and gas exchange
Sleep Medicine – perhaps most common & severe sleep disorder in children
Urology – enuresis
Suggested Reading
Marcus Cl. Sleep-disordered Breathing in Children. Am J Resp Crit
Care Med 2001; 164:16-30
Clinical Practice Guideline: Diagnosis and Management of
Childhood Obstructive Sleep Apnea Syndrome. 2002; 109 704-712.
Beebe DW, et.al. The association between sleep disordered breathing,
academic grades,and cognitive and behavioral functioning among
overweight subjects during middle to late childhood. Sleep
2010;33:1447-1456.
Redline S Amin R et.al. The Childhood Adenotonsillectomy Trial
(CHAT): Rationale, Design, and Challenges of a Randomized
Controlled Trial Evaluating a Standard Surgical Procedure in a
Pediatric Population. Sleep 2011; 34: 1509-1517.
Macey PM, et.al. Brain Morphology Associated with Obstructive
Sleep Apnea. AJRRCM 166: 1382, 2002
Weissbluth M, et.al. Signs of airway obstruction during sleep and
behavioral, developmental and academic problems. J Dev Behav
Pediatr 1983; 4:119-121.
Urschitz MS, et. al. Snoring, intermittent hypoxia and academic
performance in primary school children. Pediatrics 2004; 114:10411048.
Gozal D, Pope D. Sleep disordered breathing and school
performance in children. Pediatrics 1998; 102: 616-620.
Ali NJ, et al. Snoring, sleep disturbance and behavior in 4-5 year
olds. Arch Dis Child 1993;68:360-68.
Neuropsychological and psychological function in children
with a history of snoring or behavioral sleep problems.
S. Blunden et al. J Pediatr 146:780-786, 2005.
Bonuck K, et.al. Sleep-disordered breathing in a populationbased cohort: Behavioral Outcomes at 4 and 7 years.
Pediatrics 2102; 129:1-9.
Redline S, et.al.The Childhood Adenotonsillectomy Trial
(CHAT): Arationale design, and challenges of a Randomized
Controlled Trial Eva;uating a Standard Surgical Procedure in a
Pediatric Population. Sleep 2011; 34:1509-1517.
Dillon JE, et.al. DSM-IV Diagnoses and Obstructive Sleep
Apnea in Children Before and 1 year after Adenotonsillectomy
J Am Acad Child Adolesc Psychiatry 2007; 46: 1425-1436.