PEDIATRIC SLEEP DISORDERS (RESPIRATORY) Lee J. Brooks, MD ...Document Transcript
PEDIATRIC SLEEP DISORDERS
Lee J. Brooks, MD, FCCP
Associate Professor of Pediatrics
University of Pennsylvania
Division of Pulmonary Medicine
The Children’s Hospital of Philadelphia
34th Street and Civic Center Boulevard
Philadelphia, PA 19104
Pediatric Sleep Disorders (Respiratory)
Pediatric sleep disorders is a downloadable PDF file that presents an overview of various sleep disorders
relating to breathing in children. Topics that are covered include obstructive sleep apnea (OSA), sudden
infant death syndrome (SIDS), and apparent life-threatening events (ALTE), each with diagnosis and
various solutions and treatments. References are available for more in-depth papers. This information
has been modified from work prepared by Lee J. Brooks, MD, FCCP, of the Children’s Hospital of
Philadelphia for the American College of Chest Physicians and is published here with permission.
1. Identify children who might be at risk for obstructive sleep apnea (OSA).
2. Evaluate children with OSA.
3. Determine treatment for children with OSA.
4. Identify risk factors for sudden infant death syndrome.
5. Evaluate an infant who has had an apparent life-threatening event.
Key words: sleep, children, infants, polysomnography, apnea, SIDS, ALTE
OBSTRUCTIVE SLEEP APNEA
Snoring is the most common presenting complaint of children with obstructive sleep apnea (OSA).1
Twelve percent of children snore “on most nights,” and a significant amount of sleep and breathing
irregularities occur in almost 1% of 4-5 year olds. 2 OSA can have important effects on daytime
cognitive function 3, 4 and behavior, 5 as well as cardiopulmonary (heart and lung) function.
Just as sucking on a wet paper drinking straw results in collapse of the straw, the tendency of the
human airway is to collapse when we breathe inwards. This tendency for our airway to collapse is
balanced by muscles in our airway, including the tongue, whose activity when we inhale helps maintain
an open airway. Thus, any factors that decrease the size of the airway or increase the floppiness allow
the individual airway to collapse and obstruct. Pediatric conditions that increase the floppiness and
collapsibility of the airway include normal sleep, as well as neurological conditions including cerebral
palsy. Pediatric conditions that decrease the size of the airway include enlarged adenoids and tonsils
and craniofacial conditions such as Pierre Robin syndrome, achondroplasia, and midfacial hypoplasia.
Some conditions such as obesity, Down’s syndrome, and Prader-Willi syndrome may result in both a
small and floppy airway. 6
Airway collapse may produce complete obstruction of the airway resulting in a pause in breathing,
called apnea, or less than complete obstruction, termed a partial obstruction or obstructive hypopnea.
Either an apnea or a hypopnea may result in decreases in the body’s oxygen level and increases in the
carbon dioxide level, which can produce brief awakenings; many of the long-term effects of OSA are a
result of repetitive drops in the oxygen level or disrupted sleep (Table 1). The laboratory evaluation of
patients with snoring and suspected OSA is dedicated to detecting and quantifying apneas and
hypopneas and their effects on the body’s oxygen level and sleep disruption. 7
Clinical Signs and Symptoms
Clinical findings may occur during both sleep and wakefulness (Table 2). It is important to obtain the
clinical history from a parent or even a sibling who shares a room and might have observed the patient
while sleeping; few of us are aware of (and admit to) snoring and other nighttime symptoms. Snoring is
usually the presenting complaint of patients with OSA.
Respiratory pauses, often ending with a snort or gasp, are also often described. The snoring may be
cyclical, worsening with the decrease in motor tone associated with rapid eye movement (REM), dream
sleep. During REM sleep, the body loses the tone of some muscles that assist in breathing, allowing
worsening of OSA. These symptoms are often worse when sleeping on our back when gravity pulls the
tongue to block the airway. Restless sleep may be a sign of frequent brief awakenings secondary to
pauses in breathing. The patient does not usually know these brief awakenings are happening. It is
often helpful to inquire about the condition of the bedclothes in the morning; the only clue to the extent
of restless sleep may be finding the sheets and blankets all askew.
As in adults, obesity may predispose the individual to OSA. 8,9 In contrast to adults, however, children
with OSA may fail to thrive, perhaps because of increased difficulty breathing during sleep, burning
additional energy.10 These children usually display catch-up growth after effective treatment for their
The frequent awakenings and poor quality sleep may result in daytime sleepiness. Sometimes this is
obvious, as in the child who falls asleep in school or at the dinner table. Frequently, it is more subtle, as
a short temper, behavior problems, or academic difficulty in school. These children may be
misdiagnosed with attention deficit hyperactivity disorder. The teacher may report the child
“daydreams” excessively or is inattentive; these episodes may represent brief “microsleeps” as the child
attempts to repay his “sleep debt.” Sleepiness in the absence of snoring may suggest narcolepsy or
simply inadequate sleep due to insomnia or schedule problems. Nocturnal asthma and gastroesophageal
reflux (heartburn) may also disturb nocturnal sleep and result in excessive somnolence.
Not all children who snore have OSA. No combination of historical or physical factors has been useful
in distinguishing OSA from primary snoring. 11-14 Laboratory confirmation is essential to confirm the
diagnosis and establish the severity of the disorder so that the appropriate therapy may be instituted.
The child with suspected OSA should be evaluated with overnight polysomnography (PSG) in a sleep
laboratory experienced in the care of children. This includes an atmosphere that is friendly and not
threatening, resembling a home bedroom as much as possible. A parent should be encouraged to stay
overnight with a young child. A nap study is inadequate since REM intensifies through the night and
the severity of the problem may not be appreciated if sufficient REM sleep is not achieved. 15 Full PSG
includes measures of respiratory effort, airflow, carbon dioxide, oxygen levels, electrocardiogram (heart
beat), and electroencephalography (brainwaves) and electromyography (muscle movements) to analyze
sleep (Table 3). In this manner, the nature and extent of any heart and breathing events, as well as their
effects on sleep quality, can be assessed. 7 It is important to record the quality of sleep since a reduction
of REM sleep or sleep in general may result in underestimating the severity of the disorder. Although
there is some night-to-night variability in heart and breathing functions, and particularly sleep quality,
this is not enough to invalidate a technically adequate study.
Normal PSG values in children are not well defined. One study suggests that more than one obstructive
apnea per hour of sleep is abnormal in children,16 but there are no data defining any clinical
consequences of so few respiratory events. In young adults, a respiratory disturbance index (RDI,
apneas plus hypopneas per hour of sleep) of up to 5 is considered normal, and there may be a marked
increase in mortality in patients with apnea more then 20 per hour of sleep. 17 Since young patients may
not exhibit the classical obstructive pattern seen in adults with OSA, 18 the laboratory must be
experienced with children in order to detect these often-subtle events. Abnormal heart rhythms are
uncommon in children, but when present, indicate the need for prompt intervention.
OSA cannot be differentiated from primary snoring by history and physical findings alone; only about
half of the patients who present with signs and symptoms suggestive of OSA have the syndrome, as
confirmed on PSG.11-14 Although enlarged adenoids and tonsils are commonly associated with OSA, the
size of the tonsils and adenoids do not predict the number of nighttime respiratory events.8 The PSG is
also helpful in predicting response to treatment and the need for follow-up,13 as well as predicting
postoperative risk and the extent of monitoring that is required after treatment. 19,20 More limited
diagnostic methods have not been helpful in confirming the diagnosis of OSA, 21 although some show
promise with careful patient selection and careful attention to technique.22
Treatment in Otherwise Normal Children
Seasonal variations of the symptoms suggest the possibility of an allergic component that can be defined
by a type of skin testing. A clinical trial of nasal decongestants and/or anti-inflammatory medications
(nasal steroids or cromolyn) may be warranted. If this does not result in marked improvement, a sleep
study is required to establish the diagnosis and severity of OSA. An x-ray picture of the side of the neck
can help identify enlarged adenoids and the extent that the adenoids decrease the size of the airway.
When there are enlarged tonsils and adenoids in the presence of OSA, surgically removing the tonsils
and adenoids is usually sufficient to treat children with mild to moderate OSA. Surgery may not be
curative in children with severe OSA (RDI>20), so follow-up PSG is usually required to insure an
adequate response to surgery, even in the absence of continued snoring. 13 In patients without enlarged
tonsils or adenoids, patients with an inadequate response to removal of tonsils and adenoids, or patients
who would prefer to avoid surgery, nasal continuous positive airway pressure (CPAP) is a useful
option. 23 CPAP is the use of air pressure to maintain an open airway using a flow generator, tubing and
seal over the nose. Determining the amount of CPAP required for the individual and the type of mask
that provides the most comfortable delivery of pressure is best done in a sleep laboratory experienced in
CPAP titration in children. We do not recommend attempting to titrate CPAP in the home or in the
latter half of a diagnostic PSG. A considerable amount of education of both the parent and child, as well
as some positive reinforcement, is required to establish patient cooperation and compliance and to
determine the proper mask fit and pressure. Children may require changes in mask size or pressure as
they grow, so regular follow-up with an individual experienced with OSA in children is essential.
Unlike adults, children may be able to discontinue CPAP with growth of the facial structures and/or
maturation of neuromuscular function of the airway.
A comprehensive weight loss program should be initiated in children who are obese, and this may be
sufficient to normalize mild to moderate OSA. Patients with more severe OSA or symptoms of daytime
sleepiness may be treated with CPAP while they lose weight.
Children With Craniofacial or Neurological Disorders
As many as half the children in some series have obvious abnormal facial structure or underlying
neurologic disorders.24 Physicians caring for children with craniofacial or neurologic disorders should
have a high index of suspicion for OSA since these children are at risk because of a small and/or floppy
airway. Some medications such as benzodiazepines may also decrease airway muscle tone. Treatment
is best undertaken with a team approach with the sleep physician working with the surgeons,
pediatricians, and family.25 Families should be questioned about snoring or other symptoms of OSA
and, if present, the children should be evaluated with a sleep study. The presence of OSA may
accelerate the decision to perform craniofacial surgery. Conversely, nasal CPAP can be used while
children achieve the optimal age and/or weight for surgery. Occasionally patients require a
tracheostomy (small hole in the lower neck) to bypass the upper airway completely. Fortunately, this is
required much less frequently with the advent of CPAP. Some procedures performed in adults that
change the position of the upper and lower jaws are usually not performed in children to avoid affecting
growth of the facial structures.
Almost 10% of children who snore have significant sleep and breathing disorders. Obstructive sleep
apnea results in drops in the body’s oxygen level and disrupted sleep that can lead to poor school
performance, behavior problems, high blood pressure, heart failure, and poor weight gain. Treatment
should be considered only when the severity of the syndrome has been established by objective testing.
An overnight sleep study in a laboratory experienced in the evaluation of children remains the gold
standard for differentiating primary snoring from OSA. A sleep study can also guide the choice of
treatment, intensity of monitoring, and need for follow-up. In otherwise normal children with OSA and
enlarged tonsil and adenoid tissue, surgically removing the tissue is usually curative of mild to moderate
OSA. In children with more severe OSA, nasal CPAP may be required. CPAP is also helpful in
children with neurologic problems, or craniofacial problems in whom surgery is not yet appropriate.
CPAP is best initiated by an individual with skill and experience with CPAP in children.
SUDDEN INFANT DEATH SYNDROME
Sudden infant death syndrome (SIDS) is defined as the sudden death of any infant or young child that is
unexplained by history and in which a thorough post-mortem examination fails to demonstrate an
adequate cause of death.26 It is the most common cause of postneonatal infant death, occurring in about
1 per 1,000 live births and causing about 3,000 deaths per year.27 Infants at high risk include those
born prematurely, infants who have had apparent life threatening events (ALTEs), and perhaps, infants
who have lost a sibling to SIDS. However, the vast majority of infants succumbing to SIDS have no
known predisposing causes.
SIDS is more common in male than female infants. It is more common in the winter than the summer.
It is more common in lower socioeconomic groups. Maternal risk factors include young age, inadequate
prenatal care, lack of breast-feeding, and maternal substance abuse. SIDS is more common in infants
whose mothers smoke either during or after the pregnancy.
The greatest risk for SIDS occurs at the age of 2 to 3 months. Over 90% of SIDS deaths occur in
infants 6 months or younger. Some post mortem studies suggest low oxygen levels and/or struggles to
breathe. However, these findings are not universal. Studies have been unable to confirm a relationship
between apnea and SIDS 30,31 and attempts to identify individuals who will die of SIDS have not been
successful. However, infants who have experienced ALTE may have several differences from controls
in terms of breathing response to hypoxia and hypercapnia 32 and arousal. 33
The most significant finding in recent years has been the observation that there may be a greater risk for
SIDS in infants who sleep on their belly.34 In 1992 the American Academy of Pediatrics convened a
task force to review the literature and make recommendations regarding positioning and SIDS. They
recommended, “The weight of evidence implicates the prone position as a significant risk factor for
SIDS.” 35 Since these recommendations, and with the start of the “Back to Sleep” campaign, there has
been a considerable reduction in the rate of death from SIDS in the United States.36
In the prone position infants have increased sleep, increased quiet (non-REM) sleep and fewer, shorter
awakenings.37 This may increase their risk for SIDS by decreased ability to respond to stimuli that
should result in awakening. Oyen et al38 calculated the effects of various interventions on the rate of
SIDS deaths (38). They estimated that 74% of SIDS death could be avoided if all infants slept on their
backs. Eliminating maternal smoking would prevent 47% of SIDS death, while eliminating preterm
birth or low birth weight would reduce the rate of SIDS by 16%.
Apparent Life Threatening Event
An ALTE is defined as an episode that is frightening to the observer and is characterized by some
combination of apnea (central or occasionally obstructive), color change, marked change in muscle tone,
choking, or gagging. In some cases, the observer fears that the infant has died.26 The most common
identifiable cause of ALTE in one study was gastroesophageal reflux followed by central nervous
system abnormalities, respiratory disease, metabolic disease, and cardiovascular disease.39
In over one third of the cases, the cause was not found. Unexplained ALTE used to be referred to as
“near miss SIDS.” However, the terminology was changed since the link between ALTE and SIDS has
not been proven.
Evaluation of an infant presenting with an ALTE is dedicated to identifying a possible underlying cause
If the cause of the ALTE is found, it should be treated. If the cause is unknown or can not be corrected,
home cardiorespiratory monitoring may be indicated. A monitor does not prevent apnea or low
heart rates; it simply alerts caregivers to the event. Therefore, it is crucial that all caregivers know
how to respond to the monitor and assess the infant and are proficient in infant CPR.
The decision to discontinue home monitoring is based on clinical parameters. Some experts
recommend the monitor may be safely stopped when the infant “has had 2 to 3 months without
significant numbers of alarms or episodes of apnea…additionally assessing the infant’s ability to tolerate
stress (eg, immunizations, illness) during this time is advisable, requiring one or more two-channel basic
sleep study (pneumogram) with normal findings before discontinuing the monitor may prolong
needlessly the monitoring period.” 26
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Table 1.— Sequelae of OSA
Results of hypoxemia/hypercarbia (low oxygen/high carbon dioxide)
Hypertension (high blood pressure)
Cor pulmonale (right heart failure due to chronic respiratory disease)
Failure to thrive
Results of sleep fragmentation
Poor school performance
Irritability, behavior changes
Table 2.— Symptoms of OSA
Nocturnal (Nighttime) Diurnal (Daytime)
Respiratory pauses Behavior problems
Restless sleep Poor school performance
Enuresis (bedwetting) Morning headaches
Table 3.— Polysomnography
EEG, Submental EMG
Is adequate sleep and REM achieved to constitute a reliable test?
How do cardiorespiratory events effect arousals and sleep architecture?
Chest wall and abdomen
RIP or strain gauges
Are respiratory events central, obstructive, or mixed?
Do events produce arousal and/or oxyhemoglobin saturation?
Pulse oximeter, end-tidal CO2
Exhaled CO2, thermisters, and/or nasal pressure transducers
Table 4.— Evaluation of ALTE
History and physical examination
Selective tests may include:
-CBC (infection, anemia)
-Electrolytes, NH3 (metabolic disorders)
-Chest roentgenogram (infection, aspiration, heart size)
-ECG (arrhythmia, RVH)
-Physiologic monitoring during sleep