Paediatric OSA

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https://www.sleepclinc.com.au

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Definition

Snorring

Partial upper airway obstruction documented as < 5 AHI due to partial upper airways obstruction during sleep.

E estimated that about 10-30% of children snore, and of those, 1-3% meet criteria for sleep apnea

However significant portion of children who does not meet OSA criteria still have growth related issues due to snoring 

Apnoea event 

cessation of ventilation despite effort for 10 seconds or two breath cycles in older children, or 6 seconds or 1.5-2 breaths in younger infants

OSA Syndrome

No universally accepted paediatric criteria have been agreed on as of yet, most would agree that 1 apnea event should qualify a child as having OSA

Aetiology

Mostly T&A (other carnifacial-esp syndromic/ palate / obesity)

Postion-open mouth / nasal obstruction leads to more retroglossal collapse

Symptoms and Signs

Night Sy

       presence of loud snoring

       witnessed apnoea

       frequent night-time arousals

        chronic mouth breathing

Day Sy

      daytime somnolence is an infrequent feature of childhood OSA

       school-aged patients to exhibit poor sleep hygiene and behavioural and  attention abnormalities

       neonates and infants show failure to thrive as a common feature of OSA

Examination

       enlarged tonsils and adenoids 

       presence of small tonsils and adenoids alerts the treating- physician to an atypical patient

       CF anomali/ nasal obstruction/ ear-OME consequence

Clinical effect of OSA in Chilren

important to identify the far-reaching effects of OSA in children.,these problems include 

Medical Problems

metabolic changes

growth inhibition

pulmonary hypertension

Behavioural and cognitive effects

Psychological effects

Depression: children can exhibit these neurocognitive sequelae of OSA

Diagnosis/ Investigation

HX: and examination- good 1st line diagnostic tool-but overdiagnose compared to PSG

PSG: looking for > 5 AHI. But can have UARS hence can miss if sole reliance on PSG data

   For high-risk surgical patients

   For patients with unclear history and physical examination findings

   For those in whom CPAP or nonsurgical intervention is likely to be indicated

Summary

the history and physical examination continue to be important in identifying most paediatric patients with OSA secondary to adenotonsillar hypertrophy

most these patients will benefit from surgery without documentation by PSG, which remains the community standard

benefit of T+As in the PSG-negative patient should be considered, as the reported data show improvement in clinical factors in these patients when history and physical findings indicate significant OSA

adult criteria for OSA are not applicable to children and that patients with ‘primary snoring’ often benefit from intervention

Treatment

Adenoidectomy alone in Young

adenoid hypertrophy alone can be the most significant cause of OSA in infant

T&A

T+As remains the most commonly recommended treatment for paediatric patients with OSA

although the benefits of T+As have been described for decades, the improvements in behaviour and cognition have recently been formally documented with improvements in disease-specific QOL scores

Other

in severe case may need Tracheostomy

CONCLUSION

diagnosis and treatment of OSA in children remain challenging for physicians due to evolving standards

complicating this problem is the fact that no universally accepted criteria for OSA in children exist

recent data suggest that PSG, as currently used, may not identify all patients who will benefit from treatment

important features of the PSG that are sometimes overlooked include REM-specific sleep data and the arousal index

it is increasingly clear from recent data that significant cognitive, behavioural, and functional deficits can occur in paediatric patients with OSA

a directed history and physical examination followed by a T+A are appropriate in most paediatric patients with obvious OSA, reserving PSG for patients with an unclear history, incongruent examination findings, or high risk for surgery

for appropriately selected paediatric patients, T+A for OSA is extremely beneficial, with resolution of signs and symptoms of OSA, a return to normal of PSG sleep parameters, and improvement in daytime performance