700 600

Michael A Lucia, MD FCCP DABSM FAASM

500

Diplomat, American Board Of Sleep Medicine ABMS Board-Certified: Pulmonary & Sleep Medicine

Total Sleep in Minutes

Pediatric Sleep Apnea: Diagnosis and Treatment

Sleep and Age Total time in bed Awake in bed Non-REM stage 1 REM Non-REM stage 2 Non-REM delta

400 300 200 100 I 10

I 20

I 30

I 40

I 50

I 60

I 70

I 80

Age in Years

Adapted from Williams, et al. Electroencephalography (EEG) of Human Sleep: Clinical Applications; 1974.

Asthma prevalence among children 0 to 17 years of age in the United States, in 1980–2007.

The Pediatric Obesity Epidemic

Akinbami L J et al. Pediatrics 2009;123:S131-S145

©2009 by American Academy of Pediatrics

Epidemiology of Pediatric OSA

Associated Risk Factors/Syndromes

10-20% of preschoolers snore chronically 1-3% of preschoolers have OSA Peak incidence at ages 2-6 yrs Second peak at puberty Boys=girls until puberty, then boys>girls Increased in African American children Family history is a strong risk factor

Consequences of OSA/Obesity in Children Pulmonary HTN Insulin resistance LVH and Hypertension Asthma/Allergies GERD Delayed growth Abnormal neurobehavioral development ADD/ADHD

Clinical Manifestations Snoring Apnea Sweating Restless or agitated Sleep Unusual Sleep Positions Parasomnias1 Nocturnal Enuresis2 1Guilleminault 2Brooks

MD, et al Pediatrics 2003;111e17-e25 JL et al J of Peds 2003;142:515ff

Enuresis- The Data2 Studied 90 boys and 70 girls Risk of Enuresis in SDB  35

Percent 

30 25 20 15

Other Clinical Clues Mouth breathing Chronic nasal congestion Hyponasal speech Swallowing difficulty High-arched palate Micrognathia Retrognathia

Frequent ear/sinus infections Poor appetite/failure to thrive Excessive sleepinesss Headaches on awakening

10 5 0

RDI1

Associated Sleep Disorders of OSA in Children Enuresis (bed-wetting) Behavioral sleep issues (bedtime resistance) Nocturnal seizures Parasomnias (night terrors) REM behavior disorder Sleep walking/talking/eating Periodic limb movement disorder Nocturnal head-banging

Airflow Obstruction Risk Factors Nasal – Deviated septum – Allergic rhinitis – Nasal polyps

Oropharynx – – – – –

Tonsillar hypertrophy Macroglossia Retro/micrognathia Obesity High arched palate

Nasopharynx – Midfacial hypoplasia – Adenoidal hypertrophy

Hypopharynx – Vocal cord paralysis – Subglottic stenosis

Sleep Disordered Breathing Categories in Children Primary Snoring Upper Airway Resistance Syndrome Obstructive Hypopnea Nocturnal Hypoventilation Obstructive Sleep Apnea Central Sleep Apnea

Other Airway Risk Factors Permanent (2ary) tooth removal Orthodontia, esp w/ retraction headgear TMJ disorders Bruxism Arched or vaulted palate Speech impediments or delays

Academic Manifestations Learning difficulties4 Inattention Hyperactive/Impulsive behavior5 Aggression Odds Ratio for Hyperactive Children of 2.2 between snorers and nonsnorers5 4Gozal

D, Pediatrics 1998;102:616-620 RD et al Pediatrics 2002;109:449-456

5Chervin,

Sequelae of Failure To Treat Abnormal Growth Hormone Production6 Pulmonary Hypertension Cor Pulmonale Adult OSA Neurobehavioral – ADHD – Cognitive 6Neiminen

P, et AL, Pediatrics 2002;

109:e55

Pediatric Screening for OSA: 2012 AAP Guidelines All children should be screened for snoring Positive patients should be referred to a sleep specialist Polysomnography in-lab is the gold standard for diagnosis Adenotonsillectomy is the primary treatment for most patients High-risk patients should be monitored as inpatients postoperatively (1-3 days)

Oximetry Not recommended by ASDA, AASM or ACCP or AAP Provides no data regarding sleep or respiratory effort Significant percentage of SDB patients will have normal results i.e. low sensitivity (41%), but high specificity(>90%) No standard criteria Never indicated in children as most will not desaturate with OSA events ( 1-5 O2 saturation < 92% Desat > 4% from baseline Increase of end-tidal pCO2 > 53 More than 50% of sleep with pCO2 > 45

Multimodal Therapy

Treatment of OSA in Children Surgery (T & A) CPAP Oral Appliance Nasal/allergy treatment Positional therapy Wt loss Palatal expansion/orthodontics Mandibular-maxillary advancement (MMA)

Surgery

Surgery

Oral Appliance

CPAP

Topical Nasal Tx

Risks of T & A Minor: – Pain – Dehydration/ nausea/vomiting

Major: – – – – – – –

Anesthesia complications Acute upper airway obstruction Post-op respiratory failure Hemorrage Velopharyngeal incompetence Nasopharyngeal stenosis Death

Tonsillar Hypertrophy

Tonsillectomy/adenoidectomy UPPP (uvulopalatopharyngoplasty) – Effective in less than 50% – High morbidity procedure, esp in children Hyoid suspension Uvulopalatal flap Genioglossus (tongue) advancement Septoplasty/turbinate reduction Mandibular/maxillary advancement Tracheostomy

MMA

High Risk Surgical Patients Co-morbid disease (obesity) Age10) Craniofacial anomalies (Down’s) Failure to thrive Neuromuscular disorders

Maxillary Distraction

CPAP ‘Gold standard’ therapy for OSA in adults Secondary treatment in children Compliance (30-80%) is greatest challenge Poorly tolerated in children and mentally challenged (Down’s pts) Can be used as a bridge to surgery Often required after surgery in patients with craniofacial anomalies

CPAP Indications in Children Failure of surgery to resolve apnea Contraindications to T & A exists As an adjunct to surgery As an adjunct to oral appliance therapy

Modern Nasal Pillows

CPAP Compliance Generally 4-5 hrs of use per night initially Improves to 7-8 hrs over 3-6 weeks Pattern of use/compliance established in first 21 days Mostly affected by close follow-up Higher compliance in more severe disease Can be improved with simple measures, education, follow-up

Risk Factors for Poor CPAP Compliance Minimal EDS prior to therapy Nasal obstruction or Sx Hx of claustrophobia Lack of family support & social isolation Poor socioeconomic status Co-morbid disease

Lifestyle

CPAP Compliance Measures Pre-PSG – Sleep physician evaluation – Instructional videos – Pt. literature – Sleep lab visit – Mask desensitization – Medication changes – Improved nasal patency – Coaching of parents!

Post-PSG – Sleep Provider visit within 4 weeks – Heated humidifier – C-flex/software – Sedatives? – Recruitment of family members – CPAP compliance monitoring

Parental influences

OSA in Children Paradigm

Societal influences Nasal Allergies/ Mouth Breathing Decreased GH Decreased Craniofacial growth