Pediatric obstructive sleep apnea syndrome.
Guilleminault C, Lee JH, Chan A.
Stanford University Sleep Disorders Program, Stanford, CA 94305, USA. cguil@stanford.edu
Arch Pediatr Adolesc Med. 2005 Aug;159(8):775-85.
OBJECTIVE: To review evidence-based knowledge of pediatric obstructive sleep apnea syndrome (OSAS). DATA SOURCES AND EXTRACTION: We reviewed published articles regarding pediatric OSAS; extracted the clinical symptoms, syndromes, polysomnographic findings and variables, and treatment options, and reviewed the authors' recommendations. DATA SYNTHESIS: Orthodontic and craniofacial abnormalities related to pediatric OSAS are commonly ignored, despite their impact on public health. One area of controversy involves the use of a respiratory disturbance index to define various abnormalities, but apneas and hypopneas are not the only abnormalities obtained on polysomnograms, which can be diagnostic for sleep-disordered breathing. Adenotonsillectomy is often considered the treatment of choice for pediatric OSAS. However, many clinicians may not discern which patient population is most appropriate for this type of intervention; the isolated finding of small tonsils is not sufficient to rule out the need for surgery. Nasal continuous positive airway pressure can be an effective treatment option, but it entails cooperation and training of the child and the family. A valid but often overlooked alternative, orthodontic treatment, may complement adenotonsillectomy. CONCLUSIONS: Many complaints and syndromes are associated with pediatric OSAS. This diagnosis should be considered in patients who report the presence of such symptoms and syndromes.1 in every 4 Australian males snore. We are all aware that the male of the species can be a bit noisy at night, especially if they are tired, or have had a couple of wines, and there are not many wives who haven’t resorted to the old nudge in the back to stop a particularly loud session, or to wake our significant other up enough to have a gulp of air.
This is no laughing matter, and can be very dangerous for both occupants of the bed, as it means that neither of them is getting their required amount of sleep. In later posts I will deal with the consequences of this. For now I would like to discuss the causes and consequences of sleep apnea for our children, stating with the causes.
Sleep apnea occurs in children just as it does in adults. The consequences in young, developing children can be devastating. Some of the consequences we know by other names, such as ADHD, bed wetting, or learning difficulties. The cause and treatment of the problem is different from the adult condition.
Some of the risk factors or sleep apnea, such as a small upper jaw, and a long, high palate are universal for children and adults, but there are other differences. Children are small, and so are their airways. The tongue reaches adult size at 8 years of age, but the mouth does not start to approach adult size until the permanent teeth start to erupt at around 12 years. Tonsils, adenoids, and nasal tissue all conspire to block things off. This tissue usually starts to shrink after 12 years of age, but can be problematic until then.
Any blockage of the airway causes a change in breathing from nasal to oral breathing. Any change to oral breathing causes more snoring,( more information later). A change in breathing pattern and head posture at an early age can lead to a change in the facial growth pattern, dental crowding, a high palate, and a narrow smile. In turn, this will establish the physical traits that predispose to adult sleep apnea.
Children are particularly susceptible to allergens such as pollens, dust, and dietary factors like dairy and gluten, which can cause enlargement of the soft tissue turbinates in the nose as well as the tonsils and adenoids. There are forms of asthma which are caused by oral rather than nasal breathing, which allows the allergens to bypass the filters in the nose and travel directly to the lungs.
This means that treatment of pediatric sleep apnea needs a team that includes the ear nose and throat surgeon, the dentist, and possibly a speech therapist, and dietician. Although adenotonsillectomy is a treatment that improves pediatric sleep apnea in a high proportion of cases, it is not always successful, and adenotonsillectomy alone may not be sufficient to change the pattern of breathing. Follow up assessment of the change in sleep is necessary. Listening to snoring alone is not sufficient. Grinding of teeth, bed wetting, and night terrors are all indicators of sleep apnea in children.
The next blog will start to deal with the consequences of sleep disordered breathing in children
Karen