Please note that the following is a general guideline only.
Definitions
Snoring
Partial upper airway obstruction
E estimated that about 10-30% of children snore, and of those, 1-3% meet criteria for sleep apnea
However, a significant portion of children who do not meet OSA criteria can still have growth-related issues due to snoring
Apnoea event
cessation of ventilation despite effort for 10 seconds in adults or two breath cycles in older children, or 6 seconds or 1.5-2 breaths in younger infants
OSA Syndrome
No universally accepted paediatric criteria have been agreed on as of yet, most would agree that 1 apnea event should qualify a child as having OSA
Aetiology
Mostly Tonsil and Adenoid enlargement in children. However, other carnifacial-esp syndromic/palate/obesity should be considered.
Nasal obstruction with open mouth leads to more retroglossal collapse.
Symptoms and Signs
Night Symptoms
presence of loud snoring
witnessed apnoea or chocking (best to see a clip 3-4 hrs into the child's sleep)
frequent night-time arousals
chronic mouth breathing
bed wetting and extreme restless sleep
Day Symptoms
daytime somnolence is an infrequent feature of childhood OSA
school-aged patients to exhibit poor sleep hygiene and behavioural issues
neonates and infants show failure to thrive as a common feature of OSA
Examination
enlarged tonsils and adenoids
presence of small tonsils and adenoids alerts the treating- physician to an atypical patient
CF anomaly/ nasal obstruction/ ear-OME consequence
Clinical effect of OSA in Children
Essential to identify the far-reaching effects of OSA in children.,these problems include
Medical Problems
metabolic changes
growth inhibition
pulmonary hypertension
Behavioural and cognitive effects
Depression: children can exhibit these neurocognitive sequelae of OSA
Diagnosis/ Investigation
HX: and examination- good 1st line diagnostic tool-but can overdiagnose compared to PSG.
Good to see a video clip 3-4 hrs into the child's sleep.
PSG: looking for apnoeas. But can have UARS hence can miss if sole reliance on PSG data
Good for high-risk surgical patients
Best for patients with unclear history and physical examination findings
The history and physical examination continue to be important in identifying most paediatric patients with OSA secondary to adenotonsillar hypertrophy. If unclear history video evidence of sleep issues 3-4 hrs into the child's sleep is of great value.
If significant sleep-disordered breathing, most of these patients could benefit from surgery without documentation by PSG (which remains the standard but impractical to obtain in every child with a clinically clear sleep disordered breathing)
Most children with sleep-disordered breathing could benefit from Tonsil and Adenoid Surgery.
PSG-negative patient should still be considered, as the reported data show improvement in clinical factors in these patients when history and physical findings indicate significant OSA
Adult criteria for OSA are not applicable to children and that patients with ‘primary snoring’ often benefit from intervention.
Treatment
Adenoidectomy alone in Young
Adenoid hypertrophy alone can be the most significant cause of OSA in the infant. Tonsillectomy or partial tonsillectomy also is an option and best done in the hospital with a paediatric ICU backup.
T&A
T+As remains the most commonly recommended treatment for paediatric patients with OSA
although the benefits of T+As have been described for decades, the improvements in behaviour and cognition have recently been formally documented with improvements in disease-specific QOL scores
CONCLUSION
Diagnosis and treatment of OSA in children remain challenging.
There are no universally accepted criteria for OSA in children.
Recent data suggest that PSG, as currently used, may not identify all patients who will benefit from treatment.
Significant cognitive, behavioural, and functional deficits can occur in paediatric patients with Sleep Disordered Breathing.
Clear history and examination and selected patients undergoing T+A are appropriate in most paediatric patients with obvious slope apnoea.
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