Treatment of obstructive sleep apnea in children: do we really know how?

doi:10.1053/smrv.2001.0256

Sleep Medicine Reviews

Volume 7, Issue 1, February 2003, Pages 61-80

https://doi.org/10.1053/smrv.2001.0256 Get rights and content

Abstract

Obstructive sleep apnea syndrome (OSAS) is a frequent, albeit underdiagnosed problem in children. If left untreated, OSAS may lead to substantial morbidities affecting multiple target organs and systems. The immediate consequences of OSAS in children include behavioral disturbance and learning deficits, pulmonary hypertension, as well as compromised somatic growth. However, if not treated promptly and early in the course of the disease, OSAS may also impose long-term adverse effects on neurocognitive and cardiovascular function, thereby providing a strong rationale for effective treatment of this condition. This review provides a detailed description of the current treatment modalities for pediatric OSAS, and uncovers the potential limitations of the available data on these issues. Furthermore, we postulate that OSAS will persist relatively often after tonsillectomy and adenoidectomy, and that critical studies need to be conducted to identify such patients and refine the clinical management algorithm for pediatric OSAS.

References (100)

JL Carroll et al.
Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children
Chest
(1995)
LP Singer et al.
Complications of pediatric obstructive sleep apnea
Otolaryngol Clin North Am
(1990)
EC Fletcher
Effect of episodic hypoxia on sympathetic activity and blood pressure
Respir Physiol
(2000)
N Peled et al.
Contributions of hypoxia and respiratory disturbance index to sympathetic activation and blood pressure in obstructive sleep apnea syndrome
Am J Hypertens
(1998)
BG Phillips et al.
Neural and humoral mechanisms mediating cardiovascular responses to obstructive sleep apnea
Respir Physiol
(2000)
S Sofer et al.
Cor pulmonale due to adenoidal or tonsillar hypertrophy or both in children. Noninvasive diagnosis and follow-up
Chest
(1988)
CL Marcus et al.
Determinants of growth in children with the obstructive sleep apnea syndrome
J Pediatr
(1994)
A Bar et al.
The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome
J Pediatr
(1999)
RC Wang et al.
Accuracy of clinical evaluation in pediatric obstructive sleep apnea
Otolaryngol Head Neck Surg
(1998)
LJ Brooks et al.
Adenoid size is related to severity but not the number of episodes of obstructive apnea in children
J Pediatr
(1998)

T Shintani et al.

The effect of adenotonsillectomy in children with OSA

Int J Pediatr Otorhinolaryngol

(1998)

M Zucconi et al.

Habitual snoring and obstructive sleep apnea syndrome in children: effects of early tonsil surgery

Int J Pediatr Otorhinolaryngol

(1993)

GJ Wiet et al.

Surgical correction of obstructive sleep apnea in the complicated pediatric patient documented by polysomnography

Int J Pediatr Otorhinolaryngol

(1997)

JR Stradling et al.

Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children

Lancet

(1990)

RT Brouillette et al.

Obstructive sleep apnea in infants and children

J Pediatr

(1982)

E Hultcrantz et al.

Tonsillectomy or tonsillotomy? – A randomized study comparing postoperative pain and long-term effects

Int J Pediatr Otorhinolaryngol

(1999)

O Friedman et al.

Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children – a preliminary report

Int J Pediatr Otorhinolaryngol

(1999)

RT Brouillette et al.

Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea

J Pediatr

(2001)

KK Li et al.

An unreported risk in the use of home nasal continuous positive airway pressure and home nasal ventilation in children: mid-face hypoplasia

Chest

(2000)

R Downey et al.

Nasal continuous positive airway pressure use in children with obstructive sleep apnea younger than 2 years of age

Chest

(2000)

CL Marcus et al.

Use of nasal continuous positive airway pressure as treatment of childhood obstructive sleep apnea

J Pediatr

(1995)

C Guilleminault et al.

Home nasal continuous positive airway pressure in infants with sleep disordered breathing

J Pediatr

(1995)

F McNamara et al.

Obstructive sleep apnea in infants and its management with nasal continuous positive airway pressure

Chest

(1999)

SR Cohen et al.

Skeletal expansion combined with soft-tissue reduction in the treatment of obstructive sleep apnea in children: physiologic results

Otolaryngol Head Neck Surg

(1998)

HLJ Hoeve et al.

Management of obstructive sleep apnea syndrome in children with craniofacial malformation

Int J Pediatr Otorhinolaryngol

(1999)

CM Bower et al.

Tonsillectomy and adenoidectomy in patients with Down syndrome

Int J Pediatr Otorhinolaryngol

(1995)

JR Kosko et al.

Uvulopalatopharyngoplasty: treatment of obstructive sleep apnea in neurologically impaired pediatric patients

Int J Pediatr Otorhinolaryngol

(1995)

NJ Ali et al.

Snoring, sleep disturbance, and behaviour in 4–5 year olds

Arch Dis Child

(1993)

GM Corbo et al.

Snoring in children: association with respiratory symptoms and passive smoking (published erratum appears in

BMJ

(1990)

GO Owen et al.

Snoring, apnoea and ENT symptoms in the paediatric community

Clin Otolaryngol

(1996)

E Hulcrantz et al.

The epidemiology of sleep related breathing disorders in children

Int J Pediatr Otorhinolaryngol

(1995)

AM Ferreira et al.

Snoring in Portuguese primary school children

Pediatrics

(2000)

Am J Resp Crit Care Med

(1996)

Marcus et al.

Normal polysomnographic values for children and adolescents

Am Rev Resp Dis

(1992)

DY Goh et al.

Sleep architecture and respiratory disturbances in children with obstructive sleep apnea

Am J Respir Crit Care Med

(2000)

HPR Bandla et al.

Dynamic changes in EEG spectra during obstructive apnea in children

Pediatr Pulmonol

(2000)

D Gozal et al.

Objective sleepiness measures in pediatric obstructive sleep apnea

Pediatrics

(2001)

W Hill

On some causes of backwardness and stupidity in children: and the relief of the symptoms in some instances by nasopharyngeal scarifications

BMJ

(1889)

M Weissbluth et al.

Signs of airway obstruction during sleep and behavioral, developmental and academic problems

Dev Behav Pediatr

(1983)

J Leach et al.

Polysomnographic and clinical findings in children with obstructive sleep apnea

Arch Otolaryngol Head Neck Surg

(1992)

Guilleminault et al.

Winkle, R. A review of 50 children with obstructive sleep apnea syndrome

Lung

(1981)

NJ Ali et al.

Snoring, sleep disturbance, and behavior in 4–5 year olds

Arch Dis Child

(1993)

NJ Ali et al.

Natural history of snoring and related behaviour problems between the ages of 4 and 7 years

Arch Dis Child

(1994)

R Chervin et al.

Symptoms of sleep disorders, inattention, and hyperactivity in children

Sleep

(1997)

J Owens et al.

Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders

Pediatrics

(1998)

NJ Ali et al.

Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological functioning

Eur J Pediatr

(1996)

D Gozal

Sleep-disordered breathing and school performance in children

Pediatrics

(1998)

EC Fletcher et al.

Renin activity and blood pressure in response to chronic episodic hypoxia

Hypertension

(1999)

CL Marcus et al.

Blood pressure in children with obstructive sleep apnea

Am J Respir Crit Care Med

(1998)

RS Amin et al.

Echocardiographic changes in children with obstructive sleep apnea

Sleep

(2000)

Cited by (152)

Changes in behavioral and cognitive abilities after rapid maxillary expansion in children affected by persistent snoring after long-term adenotonsillectomy: A noncontrolled study
2024, American Journal of Orthodontics and Dentofacial Orthopedics
The objective of this study was to verify changes in behavioral abilities and cognitive functions after rapid maxillary expansion (RME) in children with refractory sleep-disordered breathing (SDB) in the long term after adenotonsillectomy.
A prospective clinical trial study using RME therapy was conducted. Participant inclusion criteria were children who had adenotonsillectomy with maxillary transverse deficiency and persistent SDB (obstructive apnea-hypopnea index ≥1). The study included 24 children aged 5-12 years, and of these 24 children, 13 had primary snoring and 11 had obstructive sleep apnea. The patients underwent laryngeal nasofibroscopy and a complete polysomnography. In addition, patients completed the Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire. Behavioral and neurocognitive tests were also completed before and after RME.
The Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life scores showed a statistically significant decrease in both groups (P <0.001) after RME. The results showed that neurocognitive and behavioral parameters (Child Behavior Checklist scale) were similar in primary snoring and obstructive sleep apnea (OSA) groups before RME. In the OSA group, the mean scores of the “Somatic” and “Aggressiveness” domains decreased significantly (P <0.05). The cognitive functions did not register significant differences pre- and post-RME in any of the cognitive functions, except for visuospatial function in the OSA group.
The noncontrolled design was a major limitation of our study. The need for treatment for SDB should consider the association of symptoms and behavioral disturbances with the child’s obstructive apnea-hypopnea index. RME might prove to be an alternative treatment for children with SDB refractory to adenotonsillectomy, improving quality of life and behavioral aspects. However, a larger sample size with a control group is needed to substantiate these claims.
Disorders of Breathing During Sleep
2019, Kendig's Disorders of the Respiratory Tract in Children
Trends in management of obstructive sleep apnea in pediatric patients with Down syndrome
2018, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
DISE and cine magnetic resonance imaging (MRI) during a sleep state are tools used by the Otolaryngologist to identify sites of obstruction in the upper airway of children with OSA. There is a consensus amongst Otolaryngologists at multiple academic medical centers for performing DISE in a child with severe OSA following T&A regardless of other co-morbidities [5]. Based on the level of obstruction, additional surgical procedures can then be performed concurrently, or at a later time based on discussions with family members.
Residual obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) is a common problem in children with Down Syndrome (DS). Our objective was to describe trends in surgical and medical management of OSA in pediatric patients with DS, and to present an algorithmic approach to managing these children.
Retrospective case series of children with DS seen at a tertiary care medical center between 1/2008-6/2016 who underwent polysomnography (PSG) after having a T&A performed for sleep disordered breathing (SDB).
Sixty-five patients met inclusion criteria. The mean age at T&A was 4.8 years and 52.0% were male. The mean apnea-hypopnea index (AHI) was 23.2 events/hour for patients who had pre-T&A PSGs. The mean AHI was 10.7 events/hour after T&A. Twenty-three patients (35.4%) underwent at least one additional surgical procedure after T&A; 5 (7.7%) patients had ≥ two additional procedures. The most common additional surgical procedures were revision adenoidectomies (n = 8) and lingual tonsillectomies (n = 13). Fifteen (23.1%) patients underwent at least one drug-induced sleep endoscopy (DISE) to help direct selection of surgical site/s.
Residual OSA is common after T&A in children with Down syndrome and can be managed by additional surgical interventions in many instances with successful reduction of the AHI. DISE has become part of a standard algorithm for managing persistent OSA in children with Down syndrome after T&A.
Risk of failure of adenotonsillectomy for obstructive sleep apnea in obese pediatric patients
2017, International Journal of Pediatric Otorhinolaryngology
Pediatric obesity is a leading risk factor for obstructive sleep apnea (OSA), a condition commonly treated with adenotonsillectomy (T&A). It has been hypothesized that obesity increases a child's risk of failing T&A for OSA, however this relationship has not yet been quantified. The primary objective of this study was to investigate the relationship between obesity as measured by perioperative Body Mass Index (BMI) and persistent OSA following T&A as measured by polysomnography (PSG).
Retrospective chart review.
Pediatric patients who underwent T&A between Jan. 2004 and Jan. 2016 were included. We recruited both obese and non-obese patients to compare caregiver/self reported improvement. Obese patients were recruited from a weight management clinic and included if they had a BMI z-score >1.65 and had pre- and post-operative polysomnograms (PSGs). Control patients included those undergoing T&A for OSA at our institution with BMI <1.65. These patients were age matched to the obese patient population. Age, gender, perioperative BMI z-score, caregiver/self reported improvement, total Apnea-Hypopnea Index (AHI), and O₂ saturation nadir were collected where available. Univariate linear regressions were calculated between perioperative BMI z-score and PSG data.
26 obese study and 47 control subjects were identified for analysis. T&A resulted in statistically significant improvements in total AHI (p = 0.030) and nadir O₂ saturation (p = 0.013) in obese subjects. There was no significant difference between the rate of caregiver/self reported improvement in the two groups. There was a statistically significant correlation between perioperative BMI z-score and the change in total AHI (p = 0.049). Within our population, for every increase by 0.1 in perioperative BMI z-score, the improvement in total AHI post-operatively decreased by 1.63 events/hr. Further, patients with BMI more than 3 standard deviations away from the age-derived normative mean received essentially no benefit from T&A alone.
Our study established an inverse linear relationship between perioperative BMI z-score and improvement in total AHI with essentially no improvement in patients with BMI z-scores >3. Further studies are required to further elucidate this relationship and investigate the role of additional procedures in the initial management of OSA in obese children.
Obstructive Sleep Apnoea: Children are not little Adults
2017, Paediatric Respiratory Reviews
During a child's development, several important developmental physiological sleep processes occur, and, occasionally, pathological disorders occur, which results in differences between obstructive sleep apnoea (OSA) in adults and children. There are major differences in sleep and respiratory physiology as well as OSA symptoms and treatment options between children and adults. Many practitioners do not realize these differences, which results in delays in the diagnosis and treatment of OSA in children. The treatment options for OSA in children are markedly different compared with adults, effective in most children. The use of positive airway pressure (PAP) therapy delivered through continuous or bi-level positive airway pressure modes is successful in children and even in infants; however, there are several challenges facing parents and practitioners to achieve good compliance. The early recognition and treatment of paediatric OSA are essential to prevent deleterious consequences. This article discusses the major differences between paediatric and adult OSA and demonstrates why children are not little adults.
Mometasone furoate intranasal spray is effective in reducing symptoms and adenoid size in children and adolescents with adenoid hypertrophy
2020, Acta Otorrinolaringologica Espanola
The use of mometasone furoate (MF) intranasal spray in treating adenoid hypertrophy (AH) has a variable outcome due the different methods of adenoid size evaluation. The aim of our study was to evaluate the effect of MF intranasal spray in children and adolescents with AH using a reliable and consistent endoscopic evaluation.
A prospective interventional study was conducted. Evaluation took place during the first visit (week 0) and second visit (week 12). Symptoms of nasal obstruction, rhinorrhoea, cough and snoring were assessed, and an overall total symptoms score was obtained. A rigid nasoendoscopic examination using a four-grading system of adenoid size from 1 to 4 was performed. Patients were treated with MF intranasal spray for 12 weeks. Patients’ aged 7–11-years old used 1 spray in each nostril once daily, while patients aged 12–17 used two sprays in each nostril once daily. Reassessment was carried out during the second visit (week 12).
A total of 74 patients was recruited. There were significant improvements from week 0 to week 12 in the symptoms’ score for nose obstruction, rhinorrhoea, cough, snoring including the total nasal symptoms’ score (p < 0.001). AH significantly reduced in size from week 0 (2.89 ± .87) to week 12 (1.88 ± .83) (p < 0.001).
MF intranasal spray is effective in improving the symptoms attributed to AH as well as reducing the adenoid size. MF intranasal spray is advocated as a treatment option before adenoidectomy is considered.
El papel del aerosol nasal de mometasona furoato (MF) para tratar la hipertrofia adenoidea (HA) tiene un resultado variable, debido a los diferentes métodos de evaluación del tamaño de las adenoides. El objetivo de nuestro estudio fue evaluar el efecto del aerosol nasal de MF en niños y adolescentes con HA, utilizando una evaluación endoscópica fiable y consistente.
Se llevó a cabo un estudio prospectivo intervencionista. La evaluación se realizó durante la primera visita (semana 0) y la segunda visita (semana 12). Se valoraron los síntomas de obstrucción nasal, rinorrea, tos y ronquidos, obteniéndose una puntuación de síntomas totales globales. Se realizó un examen nasoendoscópico rígido utilizando un sistema de clasificación del tamaño adenoideo, con valores de 1 a 4. Los pacientes fueron tratados con aerosol intranasal de MF durante 12 semanas. Los pacientes con edades comprendidas entre 7 y 11 años utilizaron 1 pulverización en cada fosa nasal una vez al día, mientras que los pacientes de 12 a 17 años utilizaron 2 pulverizaciones en cada fosa nasal una vez al día. La re-evaluación se realizó durante la segunda visita (semana12).
Reunimos a un total de 74 pacientes. Se produjeron mejoras significativas de la semana 0 a la 12 en cuanto a puntuación de los síntomas de obstrucción nasal, rinorrea, tos y ronquidos, incluyendo la puntuación total de síntomas nasales (p < 0,001). Se redujo significativamente el tamaño de HA de la semana 0 (2,89 ± 0,87) a la semana 12 (1,88 ± 0,83) (p < 0,001).
El aerosol intranasal de MF es efectivo para mejorar los síntomas atribuidos a HA, así como reducir el tamaño de las adenoides. Se propone el uso de dicho aerosol intranasal como opción de tratamiento, antes de considerarse la adenoidectomía.

View all citing articles on Scopus

^f1: Correspondence should be addressed to: David Gozal, M.D., Professor and Director, Kosair Children's Hospital Research Institute, Departments of Pediatrics, Pharmacology and Toxicology, University of Louisville School of Medicine, 570 S. Preston Street, Ste. 321, Louisville, KY 40202, USA. Tel: (502) 852 2323; Fax: (502) 852 2215; E-mail:[email protected]

View full text

Clinical ReviewTreatment of obstructive sleep apnea in children: do we really know how?

Abstract

Chest

Otolaryngol Clin North Am

Respir Physiol

Am J Hypertens

Respir Physiol

Chest

J Pediatr

J Pediatr

Otolaryngol Head Neck Surg

J Pediatr

Int J Pediatr Otorhinolaryngol

Int J Pediatr Otorhinolaryngol

Int J Pediatr Otorhinolaryngol

Lancet

J Pediatr

Int J Pediatr Otorhinolaryngol

Int J Pediatr Otorhinolaryngol

J Pediatr

Chest

Chest

J Pediatr

J Pediatr

Chest

Otolaryngol Head Neck Surg

Int J Pediatr Otorhinolaryngol

Int J Pediatr Otorhinolaryngol

Int J Pediatr Otorhinolaryngol

Snoring, sleep disturbance, and behaviour in 4–5 year olds

Arch Dis Child

Snoring in children: association with respiratory symptoms and passive smoking (published erratum appears in

BMJ

Snoring, apnoea and ENT symptoms in the paediatric community

Clin Otolaryngol

The epidemiology of sleep related breathing disorders in children

Int J Pediatr Otorhinolaryngol

Snoring in Portuguese primary school children

Pediatrics

Am J Resp Crit Care Med

Normal polysomnographic values for children and adolescents

Am Rev Resp Dis

Sleep architecture and respiratory disturbances in children with obstructive sleep apnea

Am J Respir Crit Care Med

Dynamic changes in EEG spectra during obstructive apnea in children

Pediatr Pulmonol

Objective sleepiness measures in pediatric obstructive sleep apnea

Pediatrics

On some causes of backwardness and stupidity in children: and the relief of the symptoms in some instances by nasopharyngeal scarifications

BMJ

Signs of airway obstruction during sleep and behavioral, developmental and academic problems

Dev Behav Pediatr

Polysomnographic and clinical findings in children with obstructive sleep apnea

Arch Otolaryngol Head Neck Surg

Winkle, R. A review of 50 children with obstructive sleep apnea syndrome

Lung

Snoring, sleep disturbance, and behavior in 4–5 year olds

Arch Dis Child

Natural history of snoring and related behaviour problems between the ages of 4 and 7 years

Arch Dis Child

Symptoms of sleep disorders, inattention, and hyperactivity in children

Sleep

Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders

Pediatrics

Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological functioning

Eur J Pediatr

Sleep-disordered breathing and school performance in children

Pediatrics

Renin activity and blood pressure in response to chronic episodic hypoxia

Hypertension

Blood pressure in children with obstructive sleep apnea

Am J Respir Crit Care Med

Echocardiographic changes in children with obstructive sleep apnea

Sleep

Clinical Review
Treatment of obstructive sleep apnea in children: do we really know how?