ALLERGY/PULMONARY/RESPIRATORY: Updated guidelines for childhood sleep apnea

New practice guidelines for managing childhood obstructive sleep apnea syndrome (OSAS) were highlighted by Michael Schechter, MD, on behalf of Carole Marcus, MBBCh. The presentation ”Clinical Practice Guideline Update: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome (OSAS)” reviewed the 2012 update to the previous 2002 AAP Clinical Practice Guideline intended for use by primary care clinicians for the diagnosis and management of childhood OSAS. The guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. Since that time, there has been a wealth of publications and research on the topic, leading to the current update and revision.

Childhood OSAS is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns. Symptoms include habitual snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems with or without excessive sleepiness. In addition, OSAS is associated with neurocognitive impairment, behavioral problems, failure to thrive, hypertension, cardiac dysfunction, and systemic inflammation. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders.

The revised guidelines make the following recommendations:

• All children and adolescents should be screened for snoring.
• Polysomnography should be performed in children and adolescents with snoring and symptoms of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered.
• Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy.
• High-risk patients should be monitored as inpatients postoperatively.
• Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or who have persistent symptoms or signs of OSAS after therapy.
• Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively.
• Weight loss is recommended in addition to other therapy in patients who are overweight or obese.
• Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.

Carole L. Marcus, MBBCh, is professor of pediatrics at the Children’s Hospital of Philadelphia, Pennsylvania.

Michael S. Schechter, MD, MPH, is professor of pediatrics and chief, Division of Pulmonary Medicine, Department of Pediatrics, at Virginia Commonwealth University School of Medicine, Richmond, and Children’s Hospital of Richmond at VCU.

If OSAS is left untreated, important sequelae include cardiovascular, growth, cognitive, and behavioral deficits; reduced quality of life; and increased health care costs. The condition is common in childhood (1%-5%), but in the absence of routine screening for OSAS, the diagnosis is often delayed for several years.

As the electronic health record becomes part of clinical practice, common signs and symptoms of OSAS can be embedded into general health screens. Because obesity and family history of OSAS are both risk factors for developing OSAS in childhood, and hypertension can be an associated sequela, clinicians who regularly screen for obesity and hypertension are likely to uncover even more children in whom OSAS should be suspected. Adenotonsillectomy, the usual first-line treatment, most often cures or ameliorates the disorder. The revised guideline helps the clinician identify children at increased risk for perioperative and postoperative complications and well as children who may need further treatment such as continuous positive airway pressure for unresolved OSAS.

Carol Rosen, MD, is professor, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, and a member of the Pediatric Pulmonary, Allergy, Immunology, and Sleep Division, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland.

READING LIST

Standards and indications for cardiopulmonary sleep studies in children. American Thoracic Society. Am J Respir Crit Care Med. 1996;153(2):866-878.

Schechter MS, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):e69.

Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome, American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):704-712.

Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714-e755.

Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576-584.