Sleep-disordered Breathing Tied to Multiple Causes in Young Children

By Marilynn Larkin

September 23, 2019

NEW YORK (Reuters Health) - Both early- and late-onset sleep-disordered breathing (SDB) are associated with various conditions that cause pharyngeal dysfunction in young children, a retrospective study reveals

"The essence is that interrupted or abnormal breathing during sleep has several reasons other than enlarged tonsils and adenoids," Dr. Hamdy El-Hakim of the University of Alberta Hospital in Canada told Reuters Health. "That is why we are seeing more and more that indiscriminate removal of these structures is not beneficial in a good proportion of children."

"Further, 'children' are a large group that contains different subgroups," he said by email. "Although there are some overlapping reasons and associations of SDB in these groups, there are also many differences."

"This work was an attempt to see if there are associations that are unique to two disparate age groups," he explained. "The idea is based on the premise that the pharynx is the conduit of air that gets affected by these associations and loses its ability to maintain that automatic patency throughout sleep."

Dr. El-Hakim and colleagues analyzed data on children ages three years or younger who underwent management for SDB, and compared diagnoses for this early-onset group with two late-onset (four years or older) groups. Diagnoses included gastroesophageal reflux disease (GERD), swallowing dysfunction, prematurity, asthma, and obesity.

As reported online September 3 in the International Journal of Pediatric Otorhinolaryngology, 73 children (mean age, 2.25; 51 boys) were in the early-onset groups. The late-onset groups included 75 children with a mean age of 7.58 (39 boys) and 72 with a mean age of 8.04 (45 boys). The median McGill sleep scores for all groups was one.

The early-onset SDB group had a higher prevalence of pharyngeal dysfunction, with 35 of the 73 children being diagnosed compared to 41 of 147 children with late-onset SDB.

Further, early-onset SDB children were more likely to have GERD or swallowing dysfunction, while those with late-onset SDB more commonly presented with associated asthma or obesity.

No statistically significant difference in airway lesions was seen between groups.

"Early-onset SDB is associated with conditions causing (pharyngeal dysfunction) more often than later-onset SDB," the authors conclude. "Identifying these conditions and optimizing their management may impact outcomes in treating pediatric SDB."

Dr. El-Hakim said, "If one attends to obesity and control of asthma, breathing during sleep would improve. Similarly, looking for gastroesophageal reflux or swallowing dysfunction and attending to it - rather than focusing on tonsils and adenoids - could help."

"The implications on the threshold for recommending tonsil and adenoid surgery could be significant," he said. "I certainly do not do tonsil and adenoid surgery as much as I was taught and trained to do earlier in my career. I promptly use my colleagues in pulmonary, sleep medicine, gastroenterology and sleep and language pathology to manage these children in multi-disciplinary specialized clinics."

"I estimate that I have reduced my case load of these operations by at least a third," he added. "When one bears in mind that these are amongst the most common surgeries done in the world, the impact on health care resources can only be imagined."

Dr. Zarmina Ehsan, a specialist in pulmonology and sleep medicine at Children's Mercy Kansas City, told Reuters Health by email, "This study involves a large sample size and was thoughtfully conducted. However, I have a few concerns regarding their findings."

"Firstly, it is not certain whether these children had obstructive sleep apnea in the first place. The gold standard for this is a polysomnogram," she said.

Although the Pediatric Sleep Questionnaire was used as a screening tool for SDB in the study, "it has not been validated in those under two years of age," she noted. "Moreover, they (use) the McGill oximetry score in lieu of polysomnography, and yet report a median score of 1 in all groups. This score is...'inconclusive for OSA.'"

"Their airway endoscopy findings are not novel - anatomic obstruction is seen in older kids who are more prone to adenotonsillar enlargement, and airway collapse is seen in younger kids," she continued.

"Lastly, we know from clinical practice that asthma is more prevalent and in fact, often only formally diagnosed, in the older age group, whereas (GERD) is near universal in the younger children, especially infants," she noted.

"Therefore, I suggest exercising caution when interpreting these results in the face of these confounders," she said. "Nevertheless, I agree with the authors that more work is needed to phenotype children with OSA, as changes are seen throughout childhood as the upper airway evolves and natural maturation occurs."


Int J Pediatr Otorhino 2019.