Pediatric Sleep Apnea: Treatment and Prevention

By Admin

Doctor Colin Sullivan, the inventor of continuous positive airway pressure (CPAP), once told an interviewer from the National Sleep Foundation that addressing the problem of sleep apnea should be as much about prevention as treatment. “Sleep disordered breathing in childhood,” Sullivan explains, is not only neglected in comparison to adult sleep medicine, but can be “instrumental” in cognitive development and behavioral issues. As with adult sleep apnea, pediatric sleep apnea has emerged as a prevalent condition that recent advances in screening and diagnostic technologies have helped us better treat and manage. But as a disorder with a large number of comorbidities, many of which can last into adulthood, there is still a sufficient need for more public awareness about such things as warning signs, treatment options, and preventive measures that can improve the health of children and possibly save their lives.

Facts About Pediatric Sleep Apnea

Pediatric sleep apnea is similar to adult sleep apnea, and in recent years has become even more similar in its clinical profile. According to research published by the American Thoracic Society, the classic “clinical prototype” of pediatric sleep apnea has been replaced in recent years by a different set of symptoms more closely resembling adult syndromes. In the past, a majority of child-age sleep apnea syndromes have been the result of enlarged tonsils/adenoids, and has been linked to problems of attention and hyperactivity (ADD and ADHD). A second type, as identified by medical researchers, has been related more to obesity and includes insulin resistance, altered blood pressures, and in some cases, hypertrophy of the heart. Connections have also been made between more recent cases of pediatric sleep apnea and depression or shyness and social withdrawal. This has motivated some researchers to describe pediatric sleep apnea as two distinct types: type I and type II pediatric OSA. So how do you know if your child has sleep apnea? The first sign to look for is habitual snoring during sleep, often known as the “hallmark indicator” of upper airway resistance. As with middle-aged adults, snoring is very common among children, with a reported frequency of about 10% among K-12 age groups. Of those, approximately 2–3% will have a sleep apnea problem, with the peak age being 2 to 5 years. The only way to tell the difference between a common snorer and an apnea-prone child is to listen for severity, slowed or stopped breathing, or choking episodes. Restlessness at bedtime is also common for those prone to apnea syndromes. If there is any uncertainty, it is best to err on the side of professional help. There are home sleep tests that record oxygen levels (nocturnal pulse oximetry) and other data, and using video or infant monitors can help keep track of any abnormalities at night or during nap times. Given the seriousness of sleep apnea symptoms and dangers, some medical professionals recommend sleep tests for any any child who snores or shows signs of sleep problems. If left untreated, sleep apnea can result in serious growth and development complications for children of any age. Failure to thrive, a condition involving stagnations in growth and development, is associated with classic pediatric OSA, but is still prevalent in youths left untreated for prolonged periods. Reports have also suggested that children with OSA syndromes are at risk for neurocognitive deficits such as poor learning and memory problems. The continued growth and development of children is highly dependent upon the oxygen and nutrients that obstructed airways cut off. As a result, degrees of high blood pressure and pulmonary hypertension may be common, and at early ages, apnea events are associated with Sudden Infant Death Syndrome (SIDS), leading many parents to worry about sleep positions due to cautions about sleeping on both the back and the stomach. What most sleep specialists and pediatricians will tell you is that OSA syndromes develop later in the toddler years (2 to 5), while newborns and infants tend to have central or mixed apneas resulting from developmental problems that may or may not correct themselves with age. In regard to positioning, the back is still considered safest for the first year of life. While Cheynes Stokes Respiration (CSR), a common type of Central Sleep Apnea (CSA), can be provoked by the supine position in the same way that OSA is, Cheynes-Stokes syndrome is very rare in children.

OSA and Breastfeeding

Sleep apnea and sleep disordered-breathing have been linked to deficient growth of the mouth and teeth, which are developed in specific ways by nursing behaviors. The longer a mother breastfeeds, the more likely her child will develop healthy breathing habits that exclude snoring or apnea events. For this reason and many others, doctors recommend breastfeeding at least six months after birth. In addition, avoidance of spouted cups or bottles at early ages can give the palate time for proper width to develop in the airway. The preemptive relationship between healthy breastfeeding and lowered rates of obesity has been well documented, and it is no surprise that the same protections apply to sleep apnea syndromes and other breathing disorders.

OSA and Obesity

Studies in the past have firmly established a link between problems of sleep and issues of weight, and this connection can begin as early as the womb for some. Whether or not excess weight or low-quality sleep is the culprit, the correlation is clear. Roughly 18 percent of American children are overweight, and one in three end up overweight as adults. This triple threat of obesity, low-quality sleep, and breathing difficulties is associated with a wide range of comorbidities, and many are very serious for the long-term health prognosis in early life.

Common Treatments

Adenoid hypertrophy (enlarged adenoids) is still the primary cause of OSA in young children, which is most often treated with the surgical removal of the enlarged adenoids (pharyngeal tonsil). While there have been increasing numbers of pediatric sleep apnea cases resulting from other factors, Adenotonsillectomy remains the first line of treatment for most children. This is a fairly simple procedure, but complications can arise if the patient is not monitored postoperatively. If additional treatment is needed, this will become clear during reevaluation. Other treatments include the use of corticosteroids or antiinflammatory measures for asthma or allergy related apnea syndromes, orthodontics such as the rapid maxillary expansion (RME) procedure, and continuous positive airway pressure (CPAP) therapy using child-size masks.

CPAP for Children

The development of child-size CPAP and BiPAP masks has greatly benefitted young patients with sleep apnea syndromes, especially those who are diagnosed during the first two years of their lives. But it should be noted that for CPAP therapy to be effective with children, professional help is advised to assess the proper machine settings and mask fittings for the child’s size and age group. Some child-size models on the market include the Philips Respironics Noninvasive Pediatric Nasal Mask for ages beyond one year, the Circadiance SleepWeaver Advanced Pediatric Mask for ages 2 to 7, and the Philips Respironics Profile Lite Youth Size Mask and Youth Size Gel Nasal Mask for children and small adults. ResMed has designed three child-size CPAP masks; the Pixi Pediatric Mask for toddlers, and the Mirage Micro Mask and Mirage Kidsta Nasal Mask for ages 7 and older. For younger children only a few months old, the Philips Wisp Pediatric Nasal Mask is small enough for infant faces, and even includes animal-themed padding fabrics to help children warm up to the experience of therapy.

Prevention and Adjunct Treatments

Along with primary treatments, adjunctive treatments are often good recommendations for any child, whether or not they are prone to apnea events or related disorders. Healthy diets, exercise, and quality sleep habits can do more than prevent sleep apnea, but can promote healthy aging and a higher quality of life for years to come. As a parent, one should be aware of a child’s environments as well. All children can benefit from avoidance of environmental allergens or irritants such as tobacco smoke, car exhaust, or toxins associated with factory food production. In addition, positional therapies focus primarily on sleep posture, mostly as avoidance measures when snoring is observed. Recommended positions may change as a child ages, or as apnea hypopnea index (AHI) readings vary from one position to the next, but a best course of action for parents is to observe their children during sleep and inform their family physician of any possible symptoms. As a general rule, doctors recommend that children 1 to 2 years of age should sleep between 10 and 14 hours a day (including naps) for optimal health conditions, and children 3 to 5 years of age should sleep 9 to 11 hours. Teens, while needing slightly less than younger children, still require between 8 and 10 hours daily. That may seem like a lot of sleep, but there’s a good reason for all that rest. Unlike adults, children use up a lot of their daily energies simply trying to grow.