this annotated bibliography demonstrates the complications a child suffering from obstructive sleep apnea may develop

1. OSA in Kids 1
Running head: OBSTRUCTIVE SLEEP APNEA IN KIDS
Obstructive Sleep Apnea (OSA) in Kids-Is this the Real Culprit for Behavior Issues in the
Classroom?
Victoria College
Jessica Sterr

2. OSA in Kids 2
Abstract
Obstructive sleep apnea in children is an under-diagnosed sleep disorder with short term and
long term effects that decrease the quality of life for the child. Obstructive sleep apnea occurs
during the child’s sleep; sleep pattern is interrupted by intermittent hypoxia and sleep
fragmentation because of abnormally high resistance in the upper airway. Obstructive sleep
apnea is under-diagnosed because the signs are common in children. The short term effects are
behavioral differences, especially noticed in the classroom. Inattention, hyperactivity, poor
academic performance, and failure to thrive are a few of the short term affects of obstructive
sleep apnea.

3. OSA in Kids 3
Chan, J., Edman, & J. C., Koltai, P. J. (2004). Obstructive sleep apnea in children. American
Family Physician. Retrieved September 25, 2008 from
http://www.aafp.org/afp/20040301/1147.html
Obstructive sleep apnea is a very common disorder among children, but at the same time is under
diagnosed. It is under diagnosed because signs of Obstructive sleep apnea can range from
snoring to simple mouth breathing, among the many signs. Many parents of children with
possible obstructive sleep apnea see these signs as normal behavior in children, and assume that
it will resolve itself in time. The problem of it all is that, if obstructive sleep apnea is left
untreated, it could cause severe problems in the affected child’s life. Obstructive sleep apnea is a
breathing disorder that occurs during sleep in which breathing ceases for periods of time because
of an obstruction in the upper airway. There are many reasons for upper airway obstructions.
“OSA often results from adenotonsillar hypertrophy, neuromuscular disease, and craniofacial
abnormalities” (p. 1). There is a plethora of problems that a child suffering from Obstructive
Sleep Apnea may encounter in their everyday life. “Consequences of untreated Obstructive Sleep
Apnea include failure to thrive, enuresis, attention-deficit disorder, behavioral problems, poor
academic performance, and cardiopulmonary disease” (p. 1). These behavioral problems, as
opposed to cardiopulmonary disease which could result later on in the child’s life, are having
parents of the affected children think twice about their child’s sleeping behaviors. There are
symptoms that all parents should look for if there is suspicion of obstructive sleep apnea in their
child: “periods of apnea, cor pulmonale, cyanosis, enuresis, gasping for air, irritability, nighttime
awakening, poor academic performance, pulmonary hypertension, snoring, and unusual daytime
behavior” (p. 2). Apnea is a cessation in breathing; if a person is having many episodes of apnea
during sleep, the tissues in their body are getting inadequate oxygen, which leads to intermittent
nocturnal hypoxia. “The neurobehavioral consequence of this sequence is altered behavior in
children’ (p. 3).
I chose this article because I think it is very important that parents do not overlook signs
that point to obstructive sleep apnea, as inconsequential as the signs may appear. This problem is
highly under diagnosed, but yet can set back a child so far in life and can give them a host of
diseases in their adult life. Children do not hold the capacity to diagnose themselves, nor treat
themselves. This condition needs to be caught in the early stages and hopefully, with more
education about Obstructive Sleep Apnea to the parents, there will be a wider awareness for this
condition.

4. OSA in Kids 4
Capdevila, O. S., Kheirandish-Gozal, L., Dayyat, E., & Gozal, D. (2007). Pediatric obstructive
sleep apnea: Complications, Management, and Long-term Outcomes. Proceedings of
the American Thoracic Society, 5, 274-282. Retrieved September, 25, 2008
Obstructive sleep apnea in children creates a host of problems, both short term and long term.
The short term problems a child with obstructive sleep apnea would experience are behavioral,
where as the long term problems deal with the Central Nervous System, the Cardiovascular
System, and the metabolic system; both types of problems leading to a reduced quality of life.
“Behavioral and neurocognitive dysfunction as well as reduced scholastic achievements are now
well characterized morbidities of OSA in children, and associations between OSA and
hyperactivity and inattentive behaviors as well as cognitive deficits have been identified” (p. 2).
It has been shown that children with obstructive sleep apnea produce more C-reactive protein
levels than those children without this condition which leads to decreased cognitive performance
(p. 2). Obstructive sleep apnea can be characterized as sleep fragmentation and episodic hypoxia.
When a child is constantly awoken at night by episodes of apnea and are suffering from hypoxia
at the same time, there are going to be great complications in the child’s daily life. “When
sleepiness is measured objectively, using the Multiple Sleep Latency Test, approximately
13-20% of children fulfilling the criteria for OSA displayed EDS (Excessive Daytime
Sleepiness)” (p. 3). Cardiovascular morbidities have now been linked to pediatric obstructive
sleep apnea. This is due to the increase in sympathetic activity which has correlation to the
change in geometry of the left ventricle and hypertension. The increased levels of C-reactive
protein that has been shown to decrease cognitive performance is also linked to cardiovascular
disease. Also, the episodic hypoxia experienced in apnea, may lead to right ventricular
dysfunction and elevated pulmonary artery pressure. Obstructive seep apnea decreases the
quality of life for any child. “It is also likely that the sleep disturbance associated with OSA will
increase fatigue and lead to increased irritability, depressed mood, impaired concentration, and
decreased interest in daily activities, and that these impairments in daily functioning may in turn
interfere with other aspects of a child’s life, including relationships with family, school, and
peers” (p. 4).
I chose this article because it was more specific on the effects of obstructive sleep apnea.
This article taught me how hypoxia could lead to cardiovascular disease and it made it easy to
comprehend. Also, I learned how the hypoxia experienced in the episodes of apnea and the
increase in C-reactive protein levels that affected a child would later on affect them as an adult,
but in a much more serious manner. It is so important to catch obstructive sleep apnea in the
early stages. It can affect a child physically, mentally, and psychologically all at the same time.
This is a serious problem that parents need to be more aware about.

5. OSA in Kids 5
Guilleminault, C., Lee, J. H., & Chan, A. (2005). Pediatric obstructive sleep apnea syndrome.
Archives of Pediatrics & Adolescent Medicine, 159, 775-785. Retrieved September 25,
2008 from http://archpedi.ama-assn.org/cgi/content/full/15918/775
It is important to fully understand what happens to the child’s breathing and sleep with
obstructive sleep apnea. It is easier to determine the best solution and just have a general
understanding of what is going on with the child during the episodes of obstructive sleep apnea.
As a person sleeps, there is already more resistance in breathing and a slight decrease in tidal
breathing as opposed to a person who is breathing while he or she is awake. For a child with
obstructive sleep apnea, there is even more resistance and tachypnea. “ . . . There will be an
increase in breathing frequency (tachypnea) and in respiratory efforts . . . The repetitive
challenges resulting from a reduction of upper airway size have negative consequences on a
child’s well being” (p. 5). There are people with craniofacial abnormalities that may have more
trouble breathing during sleep or that may have obstructive sleep apnea. “Abnormal narrowing in
the nose, nasopharynx, oropharynx, or hypopharynx causes abnormal air exchange during sleep,
which in turn leads to clinical symptoms” (p. 2). If there is suspicion of obstructive sleep apnea,
one must take in their child for a thorough examination of the pharynx, to see if there are any
abnormalities. There are also genetic and environmental factors that may increase obstructive
sleep apnea. “The familial dolichocephaly (or narrow face) has also been implicated as a risk
factor, independent on ethnicity . . . Clearly there is an increased risk of sleep disordered
breathing in a family in which a member is affected” (p. 7-8). There are several options for
treatment of obstructive sleep apnea, which all involve broadening the airway space.
Adenotonsillectomy is where the surgeon will remove the adenoids and tonsils; no matter what
the size of the adenoids or the tonsils, once removed, it will create more airway space (p. 8).
Also, the use of the CPAP has been extremely useful in managing obstructive sleep apnea.
“Continuous positive airway pressure is very useful when sleep disordered breathing is related to
major craniofacial deformities or other illnesses” (p. 10).
I chose this article because it showed a more in depth view of the physiology of
obstructive sleep apnea. It also went in depth of the many ways to treat obstructive sleep apnea,
which was a little bit more enlightening than the other articles. There are many ways to treat this
condition, both invasive and noninvasive. The key is to catch it on time and treat it right then and
there before it becomes a potentially bigger problem. The CPAP saved my little sister’s life.

6. OSA in Kids 6
Mulvaney, S. A., Goodwin, J. L., Morgan, W. J., Rosen, G. R., Quan, St. F., & Kaemingk, K. L.
Behavior problems associated with sleep disordered breathing in school-aged children-
The Tucson children’s assessment of sleep apnea study. Journal of Pediatric
Psychology, 31, 322-330. Retrieved September 25, 2008 from
http://Jpepsy.oxfordjournals.org/cgi/content/full/31/3/322
There have been a multitude of studies that support that sleep disturbances, which a child with
obstructive sleep apnea would possess, directly affects behavioral difficulties during the daytime.
This study has taken a range of children from different ethnicities and studied their breathing
patterns with overnight polysomnographies and then followed up with the parents’ reports on
how their child behaved for the next few days. Polysomnography directly monitors and
quantifies the amount of respiratory occurrences during sleep and the resulted hypoxemia and
arousals during sleep related to the respiratory occurrences. The results showed that there is a
direct link between lack of sleep or apneic periods and behavioral difficulties related to
obstructive sleep apnea. “An increased frequency of aggressive or oppositional behavior, as well
as cognitive/attention and social problems were apparent for those subjects with a relatively high
RDI . . . ” (p. 6). RDI refers to Respiratory Disturbance Index. This simply measures any
respiratory occurrences during the study. For example, a child with a high RDI would have many
different occurrences during their sleep study, consequently, according to this study, the
likelihood of increase in behavioral problems a child may display. “In this study, the RDI was
defined as the number of respiratory events (apneas and hypopneas) per hour of total sleep time
irrespective of any associated oxygen desaturation or arousal” (p. 4). “There was no difference
between the average RDI for Caucasian . . . and Hispanic subjects . . . ” (p. 4). Out of the four
hundred children, sixty-three children were placed in the higher RDI categorization, the rest were
placed in the lower spectrum of the RDI categorization. ADHD or Attention deficit
hyperactivity disorder can be linked to Obstructive Sleep Apnea as well, if going by the RDI.
“Although hyperactivity may be a result of disinhibition in ADHD and other disorders, it is an
intermittent sign in this range of RDI severity” (p. 7).
I chose this article because it taught more about the actual sleep study and how it works.
Polysomnography seems like an excellent tool in deciphering whether a child has obstructive
sleep apnea or not. It gives very accurate results and can only take up to one night. Even if a
child does not have the severity of obstructive sleep apnea, it will show if there is any sleep
disordered breathing occurring, which can still be harmful to a child’s life. If there are any signs
of obstructive sleep apnea in a child, it would almost be ignorant not to have them monitored
under a polysomnograph, which I learned can actually be done in the comfort of one’s own
home.

7. OSA in Kids 7
Ievers-Landis, C. E., & Redline, S. (2006). Pediatric sleep apnea: Implications of the epidemic of
childhood overweight. American Journal of Respiratory and Critical Care Medicine,
175, 436-441. Retrieved September 25, 2008 from
http://ajrccm.atsjournals.org/cgi/content/full/175/5/436
Obstructive sleep apnea can potentially affect any child, given the circumstances, but now we are
learning that obesity can be linked to it as well. “Current evidence suggests that overweight is
modestly associated with obstructive sleep apnea syndrome (OSAS) among young children, but
strongly associated with OSAS in older children and adolescents” (p. 1). There are both short
term and long term problems a child may endure with obstructive sleep apnea. “The chronic
comorbidities associated with untreated pediatric OSAS include cognitive deficits, behavioral
problems (inattention, hyperactivity, aggression, conduct problems, attention-
deficit/hyperactivity disorder), mood impairments, excessive daytime sleepiness, impaired
school performance, and poor quality of life” (p. 2). These symptoms of course are only the
short term effects of this condition, which is devastating to a child’s youth. The long term affects
are even more harmful to a person’s life, such as affected metabolism and cardiovascular disease,
which is a direct threat to one’s well being. “Specifically, a 1% change in body mass index
(BMI) has been estimated to lead to a 3% change in AHI, and a 10% increase in BMI increases
incident OSAS by sixfold” (p. 2). AHI stands for apnea-hypopnea index. This being stated, it is
very safe to say that obesity is linked to obstructive sleep apnea. An obese child has more fat
surrounding the pharynx than that of a child of normal weight, which may lead to alteration in
size of the pharynx, thus may make it harder to breath, especially during sleep. “Family studies
have shown that OSAS aggregates within families; evidence of intergenerational transmission”
(p. 2). Just as obstructive sleep apnea may be genetic, obesity is also genetic which may worsen
the situation if a child has the two heredities. “Severity of overweight also may be exacerbated
by effects of sleep apnea, such as reduced physical activity accompanying sleep apnea-associated
mood and energy changes” (p. 5). If a child’s obesity is affecting the condition of obstructive
sleep apnea and/or vice versa, it is very important for a parent to realize that the option of a
sensible diet should take place to relieve symptoms and maybe in the future, treat the condition.
I found this article very important because obesity is so widespread in our country, which
with all the recent findings on obstructive sleep apnea, we may see more and more cases of
obstructive sleep apnea. The condition is worsened if the child is dealing with obesity as well,
because these two conditions can exacerbate each other at the same time. The most rational move
for a parent to make is to give the child a sensible diet before moving on to more invasive
options.

8. OSA in Kids 8
Peeke, K., Hershberger, M., & Marriner, J. (2006). Obstructive sleep apnea syndrome in
children. Pediatr Nurs, 32, 489-494. Retrieved September 25, 2008 from
http://www.medscape.com/viewarticle/547635
Obstructive sleep apnea can potentially affect any child, given the circumstances, but now we are
learning that obesity can be linked to it as well. “Current evidence suggests that overweight is
modestly associated with obstructive sleep apnea syndrome (OSAS) among young children, but
strongly associated with OSAS in older children and adolescents” (p. 1). There are both short
term and long term problems a child may endure with obstructive sleep apnea. “The chronic
comorbidities associated with untreated pediatric OSAS include cognitive deficits, behavioral
problems (inattention, hyperactivity, aggression, conduct problems, attention-
deficit/hyperactivity disorder), mood impairments, excessive daytime sleepiness, impaired
school performance, and poor quality of life” (p. 2). These symptoms of course are only the
short term effects of this condition, which is devastating to a child’s youth. The long term affects
are even more harmful to a person’s life, such as affected metabolism and cardiovascular disease,
which is a direct threat to one’s well being. “Specifically, a 1% change in body mass index
(BMI) has been estimated to lead to a 3% change in AHI, and a 10% increase in BMI increases
incident OSAS by sixfold” (p. 2). AHI stands for apnea-hypopnea index. This being stated, it is
very safe to say that obesity is linked to obstructive sleep apnea. An obese child has more fat
surrounding the pharynx than that of a child of normal weight, which may lead to alteration in
size of the pharynx, thus may make it harder to breath, especially during sleep. “Family studies
have shown that OSAS aggregates within families; evidence of intergenerational transmission”
(p. 2). Just as obstructive sleep apnea may be genetic, obesity is also genetic which may worsen
the situation if a child has the two heredities. “Severity of overweight also may be exacerbated
by effects of sleep apnea, such as reduced physical activity accompanying sleep apnea-associated
mood and energy changes” (p. 5). If a child’s obesity is affecting the condition of obstructive
sleep apnea and/or vice versa, it is very important for a parent to realize that the option of a
sensible diet should take place to relieve symptoms and maybe in the future, treat the condition.
I found this article very important because obesity is so widespread in our country, which
with all the recent findings on obstructive sleep apnea, we may see more and more cases of
obstructive sleep apnea. The condition is worsened if the child is dealing with obesity as well,
because these two conditions can exacerbate each other at the same time. The most rational move
for a parent to make is to give the child a sensible diet before moving on to more invasive
options.

9. OSA in Kids 9