AAP Issues New Guidelines for Kids
Pediatric sleep experts focused on children with a condition known as uncomplicated obstructive sleep apnea, which occurs when breathing is
interrupted during sleep and is related to enlarged tonsils or obesity. It is a condition the AAP says affects 1.2 to 5.7 percent of American children. They reviewed evidence from 350 study articles between 1999 and 2010 to create the following recommendations:
Screening: All children and adolescents should be screened for snoring at their routine health visits.
Sleep testing: Any children who have symptoms of obstructive sleep apnea, such as habitual snoring, disturbed sleep from intermittent pauses, snorts or gasps, or daytime behavioral problems, should be referred for a sleep study.
Adenotonsillectomy: Any child with obstructive sleep apnea and enlarged tonsils should be referred to a surgeon to consider tonsil removal surgery.
High risk: A child undergoing tonsil surgery is considered “high-risk” if he or she is under age 3, has severe sleep apnea on sleep testing, is obese, or currently has an infection. These children should be closely monitored in the hospital after surgery for any complications.
Re-evaluation: After surgery, snoring children should be reassessed to see if their sleep apnea has improved or if they will need any further
CPAP: If symptoms do not improve after surgery or if a child is unable to get surgery for some reason, they should be considered for CPAP
(Continuous Positive Airway Pressure), which is a breathing apparatus, often worn at night, that keeps airways open.
Weight loss: Weight loss is recommended for any overweight or obese patient in addition to any other treatments.
Intranasal steroids: Nasal sprays are recommended for patients with mild sleep apnea symptoms, whether in lieu of or after tonsil surgery.
The last set of guidelines for pediatric sleep apnea was released in 2002. The changes reflected in these new guidelines were made in light of research over the past 11 years that has suggested that delayed diagnosis of childhood sleep apnea “can result in severe complications if left untreated,” according to the American Academy of Pediatrics report. Examples include cognitive deficits, behavior problems, hypertension and heart problems, failure to thrive, and inflammation throughout the body. With these new guidelines, the AAP hopes that more cases of childhood sleep apnea will be diagnosed sooner and children will receive the proper treatments earlier to prevent these dangerous long-term effects. The following AAP recommendations accompany the figure. The recommendations refer to evidence evaluated in another AAP technical report on childhood obstructive sleep apnea syndrome (www.pediatrics.org).
Screening for snoring should be part of routine health maintenance visits in all children; if snoring is present, a more detailed evaluation should follow (good evidence; strong recommendation). NOTE: Obstructive sleep apnea syndrome is unlikely in children who do not have habitual snoring.
Complex, high-risk patients should be referred to a subspecialist (good evidence for increased surgical risk in these patients and consequent need for more complex management; strong recommendation).
Patients who have cardiorespiratory failure cannot wait for elective evaluation. These patients are not covered in the AAP guideline because it is expected that they will be in an intensive care setting and managed by a subspecialist.
The diagnostic evaluation should be thorough. The history and physical examination have been shown to be poor in differentiating between
primary snoring and obstructive sleep apnea syndrome (strong evidence). Polysomnography is the diagnostic method of choice; it is the only test that quantifies sleep and ventilatory abnormalities. Other screening techniques, such as videotaping, audiotaping, nocturnal pulse oximetry, and daytime nap polysomnography, may be helpful if the results are positive. However, these tests have high false-negative rates, and they do not assess the severity of the syndrome (disease severity is useful in determining treatment and follow-up). When the results of other diagnostic tests are negative, polysomnography should be performed; additional audiotaping is necessary (strong evidence; strong recommendation).
In most children, adenotonsillectomy is a first-line treatment for obstructive sleep apnea syndrome; continuous positive airway pressure (CPAP) is an option in patients who are not surgical candidates or do not respond to surgical treatment (strong evidence; strong recommendation). NOTE: Potential complications of adenotonsillectomy include anesthetic-related medical problems, pain and poor oral intake in the immediate postoperative period, and hemorrhage. Patients with obstructive sleep apnea syndrome may have respiratory complications (e.g., worsening of the syndrome, pulmonary edema); death attributable to severe respiratory complications has been reported in patients with severe obstructive sleep apnea syndrome. Risk factors for complications after adenotonsillectomy in children with obstructive sleep apnea syndrome include age younger than three years, cardiac complications of the syndrome (e.g., right ventricular hypertrophy), severe obstructive sleep apnea syndrome determined by
polysomnography, failure to thrive, obesity, prematurity, recent respiratory infection, craniofacial anomalies, and neuromuscular disorders (the last two risk factors are not discussed in the AAP guideline).
High-risk patients should be hospitalized overnight after surgery and monitored continuously with pulse oximetry (strong evidence for increased risk of postoperative complications; strong recommendation).
After surgery, patients should be reevaluated to determine whether they need additional treatment; clinical reevaluation should be performed in all patients, and objective testing should be performed in high-risk patients (good evidence; strong recommendation).
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 snoring, are possible signs of sleep apnea, which is more common among teens and children than is generally recognized.
Sleep disorders, such as problems falling asleep and sleep apnea, affect your child’s ability to get the sleep needed for good growth development and overall health. Sometimes, problems with sleeping contribute to learning, mood and behavior troubles during the daytime.
LEARNING & BEHAVIOR
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 functions of the brain.
CONSEQUENCES IF NOT TREATED
Sleep apnea in children is a serious disorder that can result in health issues and behavior and academic problems if left undiagnosed and problems will get worse.
SLEEP ISSUES IN TEENS
With diagnoses of teenage mood disorders on the rise, many parents are faced with a tough decision as to what treatment to seek for their child. Recent studies indicate that successful treatment may include treatment for an underlying cause of mood disorders: sleep apnea.
Sleep apnea may cause teens to experience social problems, leading to behavioral and learning problems as well. If sleep apnea remains untreated, it may negatively affect a teenager’s ability to manage and control their emotions, behaviors, and social interactions. Such behaviors make it difficult for the teenager to be successful in school, to care for themselves, or to handle themselves in a socially appropriate manner.
Several recent studies have linked depression with sleep apnea. A study by the Centers for Disease Control and Prevention (CDC), found that the likelihood of depression in study participants increased along with the rate of gasping and stopping breathing while sleeping. A Cleveland Clinic study, presented at the annual SLEEP 2012 shows that use of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) is also linked with improving depression symptoms.
Help Your Child Breathe, Sleep, Learn and Discover Life Awake!
The good news is that with the introduction of proper treatment, learning and behavioral issues quickly improve and are in some cases completely eliminated without the need for medication.