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Anotated bibliography on Obstructive sleep apnea in children

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

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

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  • 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