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Pediatric Obstructive Sleep Apnea |
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Sleep disordered breathing (SDB) is a common problem for
adults leading to hypertension, heart attack, stroke, and
early death. Other consequences are bedroom disharmony,
excessive daytime sleepiness, weight gain, poor performance
at work, failing personal relationships, and increased risk
for accidents, including motor vehicle accidents.
Sleep disordered breathing in children, from infancy through
puberty, is in some ways a similar condition but has
different causes, consequences, and treatments. A child with
SDB does not necessarily have this condition as an adult.
Pediatric obstructive
sleep apnea
The premiere symptom of
sleep disordered breathing is snoring that is loud, present
every night regardless of sleep position, and is ultimately
interrupted by complete obstruction of breathing with
gasping and snorting noises. Approximately 10 percent of
children are reported to snore. Ten percent of these
children (one percent of the total pediatric population)
have obstructive sleep apnea.
When an individual,
young or old, obstructs breathing during sleep, the body
perceives this as a choking phenomenon. The heart rate
slows, the sympathetic nervous system is stimulated, blood
pressure rises, the brain is aroused, and sleep is
disrupted. In most cases a child’s vascular system can
tolerate the changes in blood pressure and heart rate.
However, a child’s brain does not tolerate the repeated
interruptions to sleep, leading to a child that is sleep
deprived, cranky, and ill behaved.
Consequences
of untreated pediatric sleep disordered breathing
- Snoring: A problem if a child
shares a room with a sibling and during sleepovers.
- Sleep deprivation: The child may
become moody, inattentive, and disruptive both at home
and at school. Classroom and athletic performance may
decrease along with overall happiness. The child will
lack energy, often preferring to sit in front of the
television rather than participate in school and other
activities. This may contribute to obesity.
- Abnormal urine production: SDB also
causes increased nighttime urine production, and in
children, this may lead to bedwetting.
- Growth: Growth hormone is secreted
at night. Those with SDB may suffer interruptions in
hormone secretion, resulting in slow growth or
development.
- Attention deficit disorder (ADD) / attention
deficit hyperactivity disorder (ADHD): There
are research findings that identify sleep disordered
breathing as a contributing factor to attention deficit
disorders.
Diagnosis of sleep
disordered breathing
The first
diagnosis of sleep disordered breathing in children is
made by the parent’s observation of snoring. Other
observations may include obstructions to breathing,
gasping, snorting, and thrashing in bed as well as
unexplained bedwetting. Social symptoms are difficult to
diagnose but include alteration in mood, misbehavior,
and poor school performance. (Note: Every child who has
sub par academic and social skills may not have SDB, but
if a child is a serious snorer and is experiencing mood,
behavior, and performance problems, sleep disordered
breathing should be considered.)
A child with
suspected SDB should be evaluated by an otolaryngologist
– head and neck surgeon. If the symptoms are significant
and the tonsils are enlarged, the child is strongly
recommended for T&A, or tonsillectomy and adenoidectomy
(removal of the tonsils and adenoids). Conversely, if
the symptoms are mild, academic performance remains
excellent, the tonsils are small, and puberty is eminent
(tonsils and adenoids shrink at puberty), it may be
recommended that SDB be treated only if matters worsen.
The majority of cases fall somewhere in between, and
physicians must evaluate each child on a case-by-case
basis.
There are other pediatric sleep disorder
diagnoses. Sudden infant death syndrome (SIDS) and
apparent life threatening episode (ALTE) are considered
forms of sleep disordered breathing. Children with these
conditions warrant thorough evaluation by a pediatric
sleep specialist. Children with craniofacial
abnormalities, primarily abnormalities of the jaw bones,
tongue, and associated structures, often have sleep
disordered breathing. This must be managed and the
deformities treated as the child grows.
The sleep
test is the standard diagnostic test for sleep
disordered breathing. This test can be performed in a
sleep laboratory or at home. Sleep tests can produce
inaccurate results, especially in children. Borderline
or normal sleep test results may still result in a
diagnosis of SDB based on parental observation and
clinical evaluation.
Treatment
for sleep disordered breathing
Enlarged tonsils are the most common cause for SDB, thus
tonsillectomy/adenoidectomy is the most effective
treatment for pediatric sleep disordered breathing. T&A
achieves a 90 percent success rate for childhood SDB. Of
the nearly 400,000 T&As performed in the U.S. each year,
75 percent are performed to treat sleep disordered
breathing.
Not every child with snoring should
undergo T&A. The procedure does have risks and possible
complications. Aside from the mental anguish experienced
by the parent and child, potential problems include:
anesthesia risks, bleeding, and infection.
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