#104: Snoring is Never Boring: Pediatric Obstructive Sleep Apnea

February 28, 2024 | By Sam Masur

Audio

Summary:

You won’t want to sleep through this eye opening review of Pediatric Obstructive Sleep Apnea with our guest, Dr. Ignacio Tapia. He is the Chief of the Division of Pediatric Pulmonology and Batchelor professor of Cystic Fibrosis and Pediatric Pulmonology at the University of Miami.He is board certified in General Pediatrics, Pediatric Pulmonology and Sleep Medicine. His main research interests are the pathophysiology of the Obstructive Sleep Apnea Syndrome (OSAS) in children, clinical trials focusing on treatment of OSAS in children, health disparities in pediatric sleep, and the consequences of OSAS in individuals with Down syndrome. He teaches us about risk factors, screening, diagnosis, and treatment of pediatric OSA.

Pediatric OSA Pearls

1. Children with Pediatric OSA can present as irritable rather than sleepy 
2. The AHI is key in understanding severity of disease, but remember to look at the length of events and nadir of saturation 
3. Children with mild OSA can benefit from watchful waiting

Pediatric OSA Notes

Presentation of Pediatric OSA 

Children can present with classic symptoms like snoring, mouth breathing, apneas and gasping for air while sleeping. School age children may have problems with executive functioning that can overlap with ADHD like symptoms (Yossef 2011, Brien 2003). It is important to note that families may report more irritability in children versus sleepiness seen in adolescents or adults. 

Defining Pediatric OSA and Etiology

Pediatric Obstructive Sleep Apnea occurs because of increased resistance in the upper airway that leads to either partial or complete obstruction in the airway. Reasons for increased resistance / obstruction include anatomy (large adenoids, large tongue, obesity), genetic disorders (abnormal facies like mid facial hypoplasia) and neuromuscular issues (Gouthru 2023). Many children who have obstructive sleep apnea will have enlarged adenoids, but not all children with enlarged adenoids have sleep apnea (Katz 2008). Incidence of peds OSA  between genders are similar until adolescence when males have higher rates of peds OSA. 

Dr. Tapia explains to parents:

Imagine you are sleeping and someone comes and places a pillow with pressure on your face (like apnea events). You would try to remove the pillow to breathe! You would feel stressed and your heart rate and your blood pressure would increase. If someone places the pillow on your face, but doesn’t apply pressure that represents hypopnea events. You may rebreathe the same air and hold onto carbon dioxide. Now imagine this happening several times during the night.  You would not have very restful sleep.

Sleep History / Workup for Pediatric OSA 

Taking a good sleep history is key (see Table 1). There are several sleep screening tools including the Pediatric Sleep Questionnaire (sensitivity of 0.85 and a specificity of 0.87) and the OSA 18 evaluates quality of life. Dr. Tapia does not recommend ordering lab studies or EKG unless you have any clinical concerns. 

Sleep Studies 

An in lab attended sleep study is the GOLD standard for diagnosing Pediatric OSA. Home sleep study testing has not been approved for children by the American Academy of Sleep Medicine, so note that not all insurance plans may cover this test (Kirk 2017). 

The sleep study provides a treasure chest of data (Beck 2009), but the apnea / hypopnea index (AHI) is a helpful measure to know for general pediatricians. The AHI is the average of the apnea / hypopnea events that happen during sleep. Dr. Tapia reports that up to 2 can be normal and greater than 10 is severe. 

Mild: 1 – 4.9 events per hour 

Moderate: 5 – 9.9 events per hour 

Severe: 9 + events per hour 

Dr. Tapia reminds us that not all AHIs are created the same. The AHIs does not tell you how long the events are and the lowest saturation reached during the study. Look for additional information like the saturation nadir to help you further understand  your patient’s study. 

Health Disparities 

There are multiple factors that impact sleep quality and access to sleep studies for kids. One study of children with OSA in Washington DC  found that Black children had a longer time to diagnosis versus white children (Kilaikode 2018). There is growing evidence that supports that Black and Hispanic children are at higher risk for developing OSA and there’s an association between OSA and poverty (Ievers – Landis 2017, Park 2022). Racism, not race, contributes to these disparities through economic and housing policy, harmful pollutants in certain neighborhoods etc.  Cost and the time required to complete sleep studies are an additional barrier to families. 

Treatment 

There are surgical and non surgical interventions available to pediatric patients with OSA and treatments can differ based on severity. 

For mild OSA, children may benefit from watchful waiting (Feherm 2020). Watchful waiting is not a dismissal of symptoms! Parents are asked to track the symptoms to see if there is improvement over time. If not, the conversation becomes about next steps in treatment!

Intranasal corticosteroids may improve rhinitis symptoms, but not meaningful endpoints for pediatric OSA like polysomnography, neurobehavioral, or symptom changes (Tapia 2022).  Oral devices (rapid maxillary expansion) have a specific role in select pediatric populations –  children with maxillary constriction and dental malocclusion (Marcus 2012). The Inspire device (upper airway stimulation device) is approved for adolescents  and older  with Down’s Syndrome (Yu 2022, FDA 2023). 

Adenotonsillectomy is the recommended treatment for children with OSA and enlarged adenoids (Marcus 2012). Additional surgical treatments can be tailored for the specific patient as needed (ex facial hypoplasia). 

Continuous airway pressure and bilevel airway pressure can also be options for pediatric patients, but requires familial commitment to using the mask at night. 

Goal

Listeners will explain the  risk factors, screening, diagnosis, and treatment of pediatric OSA

Learning objectives

After listening to this episode listeners will…  

1. Recall risk factors for Pediatric OSA 
2. Counsel families on the diagnosis of Pediatric OSA 
3. Describe the elements of a comprehensive sleep history 
4. Understand AHI and its use in Pediatric OSA diagnosis 
5. Name the options for treatment in Pediatric OSA

Disclosures

Dr Tapia reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Nwora C, Tapia, I, Masur S, Chiu C, Berk J. “#104: Snoring is Never Boring: Pediatric Obstructive Sleep Apnea”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ February 28, 2024.