Use guidelines to diagnose pediatric sleep apnea

Scott E. Brietzke, MD, MPH

Who is at risk?

Mary Cataletto, MD, FAAP

Sleep disordered breathing (SDB) is a common problem in children that requires accurate diagnosis and treatment to avoid its far-reaching negative impacts on the child and family. To this end, pediatricians should routinely screen their patients for significant symptoms of SDB, says Scott E. Brietzke, MD, MPH, pediatric otolaryngologist, Joe DiMaggio Children’s Hospital at Memorial, Hollywood, Florida.

This is what Brietzke and Juan C. Martinez, MD, FAAP, medical director, Division of Pediatric Pulmonology, Cystic Fibrosis, and Sleep Medicine, and director of the Pediatric Sleep Laboratory at Joe DiMaggio Children’s Hospital, Hollywood, Florida, advised attendees at the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida, in their session titled “Pediatric sleep apnea: Evaluation and management” held on November 6.

Recent publication of 3 guidelines by 3 associations-the American Academy of Pediatrics (AAP),¹ the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS),² and the American Academy of Sleep Medicine (AASM)^3,4-attests to the importance of providing guidance to clinicians on the challenges of evaluating and managing SDB in children. Along with comparing/contrasting the 3 guidelines, the co-presenters discussed controversies in management.

Evaluate each guideline for each patient

Brietzke highlights that the guidelines differ significantly in their recommendations for similar problems. “These differences are based largely on the point of view of that specialty in its interaction with pediatric SDB patients,” he says.

To help pediatricians navigate these differences in their clinical assessment and management of a child with potential SDB, Brietzke says “it is instructive and useful to compare/contrast the different guidelines to optimize the overall management of pediatric SDB patients.”

One of the controversies highlighted by Brietzke is how to identify which children should undergo sleep studies. Although overnight polysomnography (PSG) is the gold standard for assessing pediatric SDB, he emphasizes that the study has limitations and does not always capture well some negative aspects of SBD.

“Overnight PSG is a limited resource and should be used judiciously where it can make a real impact on the management of the patient,” he says.

Brietzke also stresses that pediatric SDB is more than just the Apnea-Hypopnea Index (AHI) measured on an overnight PSG. “Mild forms of SDB including snoring and mild obstructive sleep apnea based on PSG may still have a significant negative impact on the patient and should not be discounted,” he says.

Overall, the session was devoted to ensuring that pediatricians appreciate the varied viewpoints offered by the 3 different pediatric SDB guidelines so that they have a better understanding of the optimal management of SDB in their patients.

“This can particularly be useful in developing a more pragmatic, judicious use of overnight PSG as well as considering the medical versus surgical management of pediatric SDB patients,” Brietzke says.

References

1. 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. Available at: http://pediatrics.aappublications.org/content/pediatrics/130/3/576.full.pdf. Accessed November 14, 2018.

2. Roland PS, Rosenfeld RM, Brooks LJ, et al; American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 suppl):S1-S15. Available at: https://journals.sagepub.com/doi/pdf/10.1177/0194599811409837. Accessed November 14, 2018.

3. Aurora RN, Zak RS, Karippot A, et al; American Academy of Sleep Medicine. Practice parameters for the respiratory indications for polysomnography in children. Sleep. 2011;34(3):379-388. Available at: https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/pppolysomnographychildren.pdf. Accessed November 14, 2018.

4. Kothara SV, Rosen CL, Lloyd RM, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea. J Clin Sleep Med. 2015;11(3):385-404. Available at: http://jcsm.aasm.org/viewabstract.aspx?pid=29933. Accessed November 14, 2018.

Commentary

This year the AAP‘s National Conference and Exposition featured experts in Pediatric Sleep Medicine who discussed updates and multiple guidelines for the diagnosis and treatment of obstructive sleep apnea (OSA) in children. The technical and resource challenges, as well as the presence of multiple guidelines, often leave pediatricians struggling to choose the best approach for their patient. Drs. Brietzke and Martinez offered a special session that highlighted strategies to differentiate and navigate the guidelines to individualize the best options for your patient.

Good quality sleep is essential for children. It plays an important role in growth, brain development, and behavior. Obstructive sleep apnea results in poor quality sleep and is defined (ERS 2017) as a syndrome of upper airway dysfunction during sleep.¹ It is characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility.

In the general population, prevalence rates of OSA in children range between 1% to 5%. However, with additional awareness and the advent of the obesity epidemic, more children are being screened and diagnosed with OSA.

The AAP recommends an attended in-laboratory polysomnogram or sleep study as the gold standard for diagnosis. A sleep study is a multichannel recording that monitors physiologic parameters during sleep.

Sleep studies are expensive and resources limited, especially in pediatrics. These studies are both time and labor intensive. There are limited numbers of pediatric sleep labs that can offer family-friendly resources with pediatric-trained sleep physicians, technicians, equipment, and an environment where children can be safely studied. Staffing requirements may be higher and must be appropriate to the special needs and age of each individual child. Given the rising need to study infants and children at risk for OSA, resource allocation is a priority.

In infants and young children, untreated OSA is associated with growth delay. In addition, brief, resolved, unexplained events (BRUEs) and apparent life-threatening events (ALTEs) have been reported.

Young children with OSA are more likely to have daytime sleepiness, similar to adults with OSA, whereas hyperactivity is more common in school-aged children along with reports of poor school performance, memory, and focus. Poor quality of life is frequently reported. Cardiovascular complications can include systemic hypertension and, in severe cases, cor pulmonale. Long-term sequelae of these complications are well known.

Lastly, a recent study of healthcare utilization in pediatric OSA demonstrated higher healthcare utilization at least 2 years before treatment, suggesting that sleep disordered breathing may have been present before clinical concern about the diagnosis was recognized. Following treatment, healthcare utilization decreased. However, it remained higher in children with OSA when compared with controls.

Obstructive sleep apnea is about more than just snoring. It is a multisystem disease that often requires a multispecialty team approach. Early identification can result in early diagnosis and treatment and may avoid the negative consequences described in untreated OSA. Heightened awareness to the problems and consequences of OSA will help pediatricians to screen for OSA and to make appropriate referrals.

Reference

1. Kaditis AG, Alonso Alvarez ML, Boudewyns A, et al. ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children. Eur Respir J. 2017;50(6): 1700985. Available at: http://erj.ersjournals.com/content/erj/50/6/1700985.full.pdf. Accessed November 14, 2018.

Mary Cataletto, MD, FAAP, is professor of Clinical Pediatrics, School of Medicine, Stony Brook University, Stony Brook, New York, and associate director, Pediatric Sleep Medicine, NYU Winthrop Hospital, Mineola, New York.