New Guidelines for Childhood Sleep Apnea

Pauline Anderson

August 28, 2012

August 28, 2012 — As part of a routine health maintenance visit, clinicians should determine whether a pediatric patient snores, new guidelines advise. If he or she does snore, or presents with symptoms of obstructive sleep apnea syndrome (OSAS), a more focused evaluation is in order.

These are among the recommendations included in updated evidence-based guidelines for the diagnosis and management of childhood OSAS.

"Asking about snoring at each health maintenance visit [as well as at other appropriate times, such as when evaluating for tonsillitis] is a sensitive, albeit nonspecific, screening measure that is quick and easy to perform," the guideline authors, led by sleep expert Carole L. Marcus, MBBCh, professor of pediatrics at Children's Hospital of Philadelphia, Pennsylvania, conclude.

The guidelines and the accompanying technical report were developed by the American Academy of Pediatrics and were published online August 27 in Pediatrics.

Overnight Polysomnogram

Another recommendation included in the new report is that if a pediatric patient snores on a regular basis, or shows symptoms or signs of OSAS, clinicians should obtain an overnight, in-laboratory polysomnogram — the gold standard test that measures a number of physiologic functions — or should refer the patient to a sleep specialist or an otolaryngologist for more extensive evaluation.

"Polysomnography will demonstrate the presence or absence of OSAS," the authors write. "Polysomnography also demonstrates the severity of OSAS, which is helpful in planning treatment."

Given the shortage of sleep laboratories with pediatric expertise, polysomnography is not always readily available. If it is not available, clinicians may order alternative testing such as nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, or ambulatory polysomnography, the authors note.

The new guidelines, developed by a subcommittee composed of pediatricians and other experts, focus on uncomplicated childhood OSAS that is associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child. They exclude infants younger than 1 year of age, those with central apnea or hypoventilation syndromes, and those with OSAS associated with other medical conditions.

The guidelines committee recommends adenotonsillectomy (AT) as first-line treatment for patients with adenotonsillar hypertrophy.

Committee members also suggest that clinicians should refer patients for continuous positive airway pressure (CPAP) management if symptoms or signs of OSAS persist after AT, or if AT is not performed.

Because adherence is an issue with CPAP, it is not recommended as first-line therapy when AT is an option. The guidelines recommend weight loss in addition to other therapy if a child or an adolescent with OSAS is overweight or obese.

Common Condition

OSAS is a disorder of breathing during sleep that is characterized by prolonged partial upper airway obstruction or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns. OSAS is a common condition in childhood, affecting from 1.2% to 5.7% of children, and is associated with neurocognitive impairment, behavioral problems, failure to thrive, hypertension, cardiac dysfunction, and systemic inflammation.

The last related set of guidelines was issued in 2002. Since that time, the quality of OSAS studies has improved, but few randomized, blinded, controlled studies have been conducted, the authors note. In preparing the new guidelines, the subcommittee used data from 350 articles, most of which were categorized as levels II through IV.

Dr. Marcus has disclosed that she receives research support from Philips Respironics. Full disclosure details are provided in the technical report.

Pediatrics. Published online August 27, 2012. Guideline Technical report


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