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A look at OSAS in children including an interview with Carol L Rosen, MD
Reviewed by Carol L Rosen, MD
Among the clinical syndromes that fall under the umbrella of sleep disordered breathing (SDB), obstructive sleep apnea syndrome (OSAS) that affects the upper airway is the most common and occurs in about 1% to 5% of children.1 Other more rare SDB clinical problems occur in children with brain and respiratory control deficits (central sleep apnea and/or hypoventilation disorder) or in those who have abnormalities of their spinal cord, nerves, muscles, lungs, or chest wall that interfere with sufficient breathing during sleep.
For all children with SDB, chronically disrupted sleep places them at increased risk of developing problems with attention, behavior, and learning, as well as worsening of any underlying comorbidities including obesity, asthma, or psychological distress such as anxiety or depression. Thus, early diagnosis and treatment is critical for preventing long-term morbidity.2
Given that OSAS is the most prevalent form of SDB and the one most likely to be encountered in clinical practice, this article focuses only on this type of SDB. In 2012, the American Academy of Pediatrics (AAP) published clinical practice guidelines on the diagnosis and management of childhood obstructive sleep apnea syndrome.1,3 Since the publication of those guidelines, important new findings from the Childhood Adenotonsillectomy Trial (CHAT) have been published that provide more insight into the expected benefits of adenotonsillectomy for children with mild to moderate OSAS, as well as on the natural history of milder OSAS.4
In this interview, Carol L Rosen, MD, professor of Pediatrics, J.S. Rube Endowed Chair in Pediatric Sleep Medicine, Division of Pediatric Pulmonology, Allergy/Immunology, and Sleep Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, discusses key issues of screening, diagnosing, and treating children with OSAS based on her experience and how that experience is guided primarily by the current AAP practice guideline. As a coauthor of the more recent CHAT study, she also highlights the evolution of current thinking about childhood OSAS, management options, and unanswered questions going forward.
Q: As discussed, this article focuses on children with obstructive sleep apnea. Let’s start by talking about the prevalence of pediatric OSAS.
Dr. Rosen: I just gave a talk on this subject to pediatrician colleagues and residents, so some of the answers to this question and the following will be taken from that presentation, as well as recommendations made in the most recent AAP guidelines (Table 1).1
Between 1 in 20 to 1 in 100 children suffer from OSAS, which is between 1% and 5% of children. Prevalence increases in African American children and low-income children, with further evidence showing some disparities in health outcomes and a differential response to therapy for these children. Years ago, we reported that African Americans were less likely to have undergone an adenotonsillectomy. Yet, in those who did, these children were 4 times more likely to have OSAS in the years following that surgery. In the CHAT study, African American children with OSA were less likely to normalize after surgery.4
The peak age of developing pediatric OSAS is between 2 years and 8 years, and it occurs before puberty with the same prevalence in boys and girls. Genetics play a role, with children in families with a history of OSAS at 2-fold to 4-fold increased risk of developing it. Obesity is also a risk factor for OSAS in children, but it is not as powerful a risk factor in children compared with adults. (However, obesity in the teenaged years is linked to a 5-fold risk for developing OSAS compared with nonobese teenagers.) In children, obesity is a risk factor for incomplete response to adenotonsillectomy, and if children are already overweight before adenotonsillectomy, they are at increased risk for becoming overweight after that surgery.4,5
Q: What are the causes of OSAS in children and who are most at risk?
Dr. Rosen: The number 1, 2, and 3 cause is adenotonsillar hypertrophy; that is to say, the main cause or “tip-over” for children is having enlarged tonsils and adenoids. Other less-frequent causes include craniofacial or genetic factors, neuromuscular disorders, or obesity.
So, enlarged tonsils/adenoids are commonly found in children who develop OSAS. Other risk factors include the presence of comorbidities (ie, asthma, allergies), perinatal influences (former premature babies have 3 times the risk of developing OSA),6 living in disadvantaged neighborhoods,7 and exposure to irritants such as environmental tobacco smoke,8 infectious agents, and being sleep deprived.
Finally, children with specific medical conditions are at increased risk, including those with Down syndrome, Prader-Willi syndrome, achondroplasia, Pierre Robin anomalad, sickle cell anemia,9 craniosynostosis, spina bifida, and Hunter disease.
Q: What are the signs and symptoms of OSAS in children?
Dr. Rosen: The most common symptom of OSAS in children is snoring. That is why I often use the description “snoring and obstructive sleep apnea” when referring to OSAS in children. About 10% of children habitually snore, that is, snore more than 3 nights a week, but not all children have OSAS.
The AAP guidelines provide a list of additional signs and symptoms1 of OSAS beyond just snoring (Table 2). When taking a history of a child, it can be challenging to recognize OSAS because parents may not report some of the most common symptoms, such as snoring, difficult breathing, observed apnea and arousals, and any changes in daytime sleepiness. The clinical evaluation during wakefulness (history and physical examination) has only a 50-50 chance for predicting OSAS. Some children have lots of symptoms and enlarged tonsils, but only minimal findings when an overnight diagnostic test is performed. On the other hand, some children may have minimal symptoms and mildly enlarged tonsils, but will show significant OSAS when overnight diagnostic testing is performed.
Q: What are the current recommendations for screening and diagnosis?
Dr. Rosen: As highlighted in the guidelines (Table 1, Statement 1),1 clinicians should screen all children at every health encounter for snoring because snoring is the most common symptom. If the child snores, then the pediatrician should “do more,” checking into other potentially OSAS-related signs and symptoms and family history of OSAS. The Sleep-Related Breathing Disorders Scale of the Pediatric Sleep Questionnaire (PSQ), by Chervin and colleagues, is a well-validated symptom inventory and popular screening tool.10
It should be noted, however, that the PSQ is not perfect at correctly identifying OSAS. In the CHAT study, this screening tool was “positive” in about 75% of snoring children who had OSAS diagnosed by overnight sleep study.4
For diagnosing OSAS in children, the AAP guideline provides a couple of options (Table 1, Statement 2A and 2B)1. For children who snore on a regular basis or present with signs/symptoms of OSAS (Table 2),1 the guidelines recommend a sleep study (which measures the severity of sleep apnea by using the apnea hypopnea index [AHI] measure) or referring the child to a specialist (such as a sleep specialist or otolaryngologist) for more extensive evaluation. Alternatively, clinicians can order tests other than a sleep study (Table 1, Statement 2B).1
There are a couple of challenges to diagnosis. Tonsil size does not predict OSAS severity and there is poor correlation between snoring, the AHI measured on the sleep study and daytime dysfunction. Some children may have a lot of daytime problems believed to be related to OSAS, but only low AHI during overnight testing. Other children with a high AHI may have only minimal daytime problems.
Q: Does OSAS affect children differently than adults? If so, how?
Dr. Rosen: Yes, there are several differences. In adults, OSAS is much more common in men than women. In children before puberty, there’s no difference in prevalence between girls and boys. In adults, the peak age for OSAS is midlife, whereas in children it peaks between ages 2 years and 8 years. The presenting symptoms also differ in that for children the main complaints are snoring and behavioral or learning problems, whereas for adults the chief complaint is daytime sleepiness.
There are also different patterns of breathing. Adults have more specific discreet airway collapses, whereas children are more likely to have partial collapses because they are better at keeping their airway open than adults. This may explain why children don’t necessarily have as much daytime sleepiness as adults because they are better at staying asleep during their partial airway collapse compared with adults who regularly wake up when their airways collapse completely. However, the clinical picture of obese children with OSAS may be more similar to adults with OSAS.
Q: What is the standard treatment for OSAS in children?
Dr. Rosen: Unlike the use of continuous positive airway pressure (CPAP), which is the standard treatment for adults with OSAS, the standard first-line treatment for children with enlarged tonsils and adenoids is adenotonsillectomy that has about an 80% cure rate (Table 1, Statement 3)1. If the child already has had an adenotonsillectomy, then CPAP is the next line of therapy and can be effective. However, implementation and adherence are problematic, especially in children with limited ability to cooperate or in teenagers who are oppositional. Parent supervision and commitment are key. Although nonsurgical CPAP can be an alternative treatment in children with enlarged tonsils and adenoids, it is much harder to deliver and tolerate than effective CPAP therapy when the tonsils and adenoids are blocking the upper airway.
Other treatments for specific children may include dental/orthodontic devices, specialized aggressive surgeries, positional therapy, or weight loss.
Q: When should a pediatrician refer a child with OSAS to a sleep specialist?
Dr. Rosen: That is clearly stated in the guidelines (Table 1, Statements 1 and 2).1 The guidelines recommend referral to a specialist in sleep and breathing in children. This individual may be a sleep medicine specialist or other specialist, including otolaryngologists.
Q: What would you further highlight as important for pediatricians to know about OSAS in children?
Dr. Rosen: I would highlight the CHAT study, which was a randomized, controlled trial in which children with mild-to-moderate OSAS were randomized to surgery or watchful waiting and supportive care. After 7 months following surgery or watchful waiting, the children were reassessed for OSAS.
The study found no differences between the 2 groups in terms of the primary outcome, which looked at attention/executive and cognitive functioning.5 Children who did undergo surgery, however, reported significant improvements in global behaviors, generic and disease-specific quality of life, and symptoms of OSAS such as snoring and sleepiness. In the early surgery group, most of these children (79%) also had a normal polysomnography 6 months later compared with only 46% of the kids in the watchful waiting group.
In the surgery group, finding a normal sleep study 6 months later is similar to previous studies suggesting an 80% to 85% “cure rate” for OSAS after surgery. On the other hand, the finding that almost one-half of the children who did not have surgery had a normal sleep study 7 months later was somewhat of a surprise. Children with milder OSAS and less obesity, and who were non-African American, were more likely to “normalize” their sleep studies. However, normalization of the sleep study doesn’t mean that symptoms got better.11 Nevertheless, watchful waiting may be a reasonable management option in children with milder OSAS and fewer symptoms.
However, there are still many unanswered questions about what the best practices are with regard to how to best treat children who snore. The interesting thing about the CHAT study is that nearly half the children who met criteria for study participation (ie, candidates for surgery) based on clinical assessments that indicated OSAS, actually had normal sleep studies without OSAS, and therefore were not eligible for enrollment in the CHAT study.
The National Institutes of Health (NIH) is sponsoring a new multisite clinical trial called the Pediatric Adenotonsillectomy for Snoring (PATS) trial that begins this spring. The trial will look at children with mild SDB (that is, children who snore but don’t have OSAS) and examine whether tonsillectomy and adenoectomy will change outcomes in this group. It will assess the effect of early adenotonsillectomy on behavior, vigilance, OSAS symptoms and quality of life, and healthcare use. It will also identify factors that moderate a child’s response to surgery, including age, race, asthma, tobacco exposure, and socioeconomic status.
1. Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576-584.
2. Halbower AC, McGinley BM, Smith PL. Treatment alternatives for sleep-disordered breathing in the pediatric population. Curr Opin Pulm Med. 2008;14(6):551-558.
3. Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Technical report: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714-e755.
4. Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376.
5. Katz ES, Moore RH, Rosen CL, et al. Growth after adenotonsillectomy for obstructive sleep apnea: an RCT. Pediatrics. 2014;134(2):282-289.
6. Rosen CL, Larkin EK, Kirchner HL, et al. Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. J Pediatr. 2003;142(4):383-389.
7. Spilsbury JC, Storfer-Isser A, Kirchner HL, et al. Neighborhood disadvantage as a risk factor for pediatric obstructive sleep apnea. J Pediatr. 2006;149(3):342-347.
8. Weinstock TG, Rosen CL, Marcus CL, et al. Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates. Sleep. 2014;37(2):261-269.
9. Rosen CL, Debaun MR, Strunk RC, et al. Obstructive sleep apnea and sickle cell anemia. Pediatrics. 2014;134(2):273-281.
10. Chervin RD, Hedger K, Dillion JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000;1(1):21-32.
11. Chervin RD, Ellenberg SS, Hou X, et al. Prognosis for spontaneous resolution of OSA in children. Chest. 2015;148(5):1204-1213.
Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has more than 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.