Does your child snore? Does your child show other signs of disturbed sleep: long pauses in breathing, much tossing and turning in the bed, chronic mouth breathing during sleep, night sweats (owing to increased effort to breathe)? All these, and especially the snoring, are possible signs of sleep apnea, which is commoner among children than is generally recognized. It's estimated than 1 to 4 percent of children suffer from sleep apnea, many of them being between 2 and 8 years old.
Furthermore, while there is a possibility that affected children will "grow out of" their sleep disorders, the evidence is steadily growing that untreated pediatric sleep disorders including sleep apnea can wreak a heavy toll while they persist. Studies have suggested that as many as 25 percent of children diagnosed with attention-deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea and that much of their learning difficulty and behavior problems can be the consequence of chronic fragmented sleep. Bed-wetting, sleep-walking, retarded growth, other hormonal and metabolic problems, even failure to thrive can be related to sleep apnea. Some researchers have charted a specific impact of sleep disordered breathing on "executive functions" of the brain: cognitive flexibility, self-monitoring, planning, organization, and self-regulation of affect and arousal.
Several recent studies show a strong association between pediatric sleep disorders and childhood obesity. Judith Owens, M.D., director of sleep medicine at the National Children&'s Medical Center in Washington, DC, who is a member of the ASAA board of directors, believes that adequate healthy sleep is as important as proper diet and sufficient exercise in preventing childhood obesity.
Finding a Specialist
If you suspect your child may have OSA, you may wish to seek out a pediatrician who specializes in sleep disorders. The association has assembled a partial list of sleep medicine professional who indicate they specialize in treating pediatric sleep disorders.
Making the Diagnosis
As in adults, polysomnography is the only tool for definitive diagnosis and assessment of the severity of pediatric obstructive sleep apnea. It needs to be conducted during an overnight stay in a sleep lab, with the test conducted by technologists experienced in working with children and the data interpreted by a sleep medicine physician with pediatric experience. At present there is too little data as to the feasibility and validity of pediatric home studies to list them as a reliable alternative. In addition, since children&'s sleep apnea is frequently most pronounced during REM sleep late in the sleep cycle, so-called "nap studies" at sleep labs are less useful and may be misleading.
When to treat
Currently there are no universally accepted guidelines as to when children's OSA is sufficiently severe as to warrant treatment. Unlike adults, normal children rarely experience obstructive apnea events. Consequently, most pediatric sleep specialists regard an apnea index (AI) of more than 1 or an apnea hypopnea index (AHI) of 1.5 as abnormal and most recommend treatment of any child with an AI greater than 5. (An apnea index includes only respiratory events with an absence of airflow and does not include hypopneas, or respiratory events with reduced air flow). In the case of an AHI of 5 to10 (mild to moderate OSA) or more than 10 in a child who is 12 or younger, which indicates moderate to severe pediatric OSA, the decision to treat is usually straightforward.
How to proceed is less clear in children with AHIs between 1 and 5. Several recent studies have found behavioral problems in children who snore that parallel problems found in children with OSA. An assessment of risk factors and possible developments yet to come by an experienced health care practitioner in each individual case will help determine the relative cost-benefit of treatment.
Surgical removal of the adenoids and tonsils is the most common treatment for pediatric OSA. In uncomplicated cases, the operation results in complete elimination of OSA symptoms in 70 to 90 percent of the time. Although generally an outpatient procedure, some children with chronic medical conditions like obesity or severe OSA or complications of OSA should be carefully monitored overnight following the surgery.because breathing abnormalities may not appear until REM sleep begins several hours in the next extended sleep cycle after the operation.. Owing to post-operative swelling, full resolution of the OSA symptoms may not occur for six to eight weeks.
If adenotonsillectomy is not indicated or if the surgery does not fully resolve the symptoms, positive airway pressure therapy like that commonly prescribed for adults probably will be helpful.. (PAP therapy may also be prescribed before surgery in severe pediatric OSA cases.) PAP should be regarded as palliative rather than curative, however. Optimal pressure settings (sufficient to reduce or eliminate obstructive events without increasing arousals or central apneas) should be determined in an overnight sleep study, and efficacy studies and re-titrations should be regularly conducted: generally yearly or when there are significant weight changes in older children and adolescents.
As in adults, compliance with PAP therapy is a key factor in determining success. Adolescents pose a particular challenge. For many children, however, the dramatic improvement in the way they feel after PAP therapy is begun becomes an important motivating factor.
Other Treatment Steps
Oral appliances for treatment of pediatric OSA are helpful in some cases, especially in adolescents whose facial bone growth is largely complete. One device that rapidly expands the transversal diameter of the hard palate over a six-month to one-year period has been used successfully in children as young as 6.
Weight management, including nutritional, exercise, and behavioral elements, should be strongly encouraged for all children with OSA who are overweight or obese. An adequate nightly duration of sleep is an important component of weight management.
Other treatments are directed towards additional risk factors in individual cases; i.e., allergy medications for children with seasonal/environmental allergies, asthma medications/inhalers and treatment for gastroesophageal reflux.
Sources of Support
For parents and others responsible for the care of children with sleep apnea, one excellent place to go for voices of experience is your local A.W.A.K.E. group. There you will find helpful discussions of many facets of sleep apnea, including children's sleep apnea.