Download Obstructive Sleep Apnea Syndrome in Children

JIAOMR
10.5005/jp-journals-10011-1232
REVIEW ARTICLE
Obstructive Sleep Apnea Syndrome in Children
Obstructive Sleep Apnea Syndrome in Children
1
Soheyl Sheikh, 2Shambulingappa Pallagatti, 3Aman Kalucha, 4Amit Aggarwal, 5Harkamal Kaur
1
Professor and Head, Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research
Ambala, Haryana, India
2
Professor, Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research, Ambala, Haryana, India
3
Senior Lecturer, Department of Oral Medicine and Radiology, Desh Bhagat Dental College and Hospital, Muktsar, Punjab, India
4
Senior Lecturer, Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research
Ambala, Haryana, India
5
Senior Lecturer, Department of Oral and Maxillofacial Surgery, Genesis Institute of Dental Sciences and Research
Ferozepur, Punjab, India
Correspondence: Aman Kalucha, Senior Lecturer, Department of Oral Medicine and Radiology, Desh Bhagat Dental College
and Hospital, Muktsar, Punjab, India, e-mail: [email protected]
ABSTRACT
Sleep, probably a quarter of every human’s life, forms an important factor in children’s development. Sleep disorders can impair children’s
sleep and lead to negative consequences. The consequences of these disorders can be substantial, leading to hypersomnolence,
neurocognitive deficits, and significant cardiovascular morbidity and mortality. Risk factors for obstructive sleep apnea (OSA) syndrome
include adenotonsillar hypertrophy, Down’s syndrome, obesity, family history of snoring or any condition leading to narrowing of upper
airway. As the dentists are becoming increasingly aware of the issue of OSA, they are frequently involved in treatment of this condition using
oral appliances. Moreover, they play an active role in identifying those with enlarged tonsils and referring them for sleep assessment. This
paper provides an overview of OSA, including an outline of the diagnostic protocol and a summary of the wide variety of treatment modalities
in children.
Keywords: Sleep apnea, Risk factors, Dentists, Child.
INTRODUCTION
An increasing number of people are realizing that changes in
their sleeping habits and daytime behavior may be attributable
to obstructive sleep apnea syndrome (OSAS). This new
awareness has led many patients to seek both information and
definitive treatment. 1 Pediatric obstructive sleep apnea
syndrome is characterized by episodes of partial or complete
upper airway obstruction that occur during sleep, usually
associated with a reduction in oxyhemoglobin saturation or
hypercarbia.2 OSAS is the most common condition among a
group of disorders, known as sleep-disordered breathing, which
can affect anyone irrespective of age and sex.3
OSAS is currently a public health problem of great
importance. First, its main clinical manifestation, daytime
hypersomnia, has an important impact on the family, work and
society, including a deterioration in personal relationships, job
absenteeism, traffic accidents, etc. Second, its prevalence is
estimated to be quite high.4 Approximately 3 to 12% children
around the world snore and out of them 1 to 10% may have
OSAS.5 As sleep disorders may have devastating effects not
only on the child, but also on their family, dentists may be the
first to recognize such disorders and help in their treatment.
breathing. There is an immediate increase in upper airway
resistance with sleep onset, with an initial ‘overshoot’ in this
resistance that decreases very quickly. Still, this resistance
during established sleep is mildly higher than during
wakefulness.6 The size of the pediatric airway is dependent on
craniofacial and soft tissue structures.7 The available airway
space may be reduced by abnormalities of oral cavity,
larynx, nose, nasopharynx and oropharynx.6 OSA in children
is the result of a complex interaction between an airway
predisposed toward collapse and neuromuscular compensation.
During wakefulness, there is robust activation of pharyngeal
dilator muscles and a stable ventilatory pattern. At sleep onset,
there is a marked reduction in the activation of airway muscles,
an increased ventilatory variability, and the appearance of an
apneic threshold close to eupneic levels. Arousal from sleep
contributes to ventilatory instability and therefore exacerbates
obstructive cycling.7
Risk factors for development of OSA in children include
adenotonsillar hypertrophy, Down’s syndrome (DS), obesity,
family history of snoring or any condition leading to narrowing
of upper airway. Other studies have shown that sleep-disordered
breathing occurs in at least 50 to 80% of children with DS.8
Pathophysiology
Clinical Features of Pediatric Obstructive
Sleep Apnea
Understanding obstructive sleep apnea syndrome in
children requires knowledge of the physiology of sleep and
There is ample literature regarding sleep apnea in children and
how it affects them in day-to-day life. Yet the dentists as well
Journal of Indian Academy of Oral Medicine and Radiology, October-December 2011;23(4):609-612
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Soheyl Sheikh et al
as physicians usually fail to diagnose it. The prevalence of OSAS
is estimated around 2%2,3 in children and about 2.5 to 6% among
adolescents.3 OSAS has a bimodal age of occurrence with the
first peak coinciding with the developmental peak of
adenotonsillar hyperplasia (2-5 years). The second peak appears
in middle to late adolescence. Gender distribution is equal in
prepubertal groups which shifts to male dominance in
postpubertal group.2
Signs of OSA in children include continuous snoring, pauses
in breathing while asleep, indifferent sleeping position, enlarged
tonsils, stunted growth and disruptive behavior in school.
Excessive daytime sleepiness and snoring with pauses is usually
seen in adults.
Diagnostic Criteria and Evaluation
The dental office can play an important role in screening patients
who may have OSAS by including few questions on the medical
questionnaire: Do you snore loudly? Do you have difficulty
staying awake when you are inactive (e.g. while reading,
watching television or driving)? A positive response to these
questions should lead the dentist to suspect OSAS.1
A complete physical examination and history should be
obtained in children with suspected OSAS. History of snoring
every night is most significant in predicting OSA. Carroll et al9
in 1995 reported the inability of clinical history alone to
differentiate primary snoring from OSAS in children. Nocturnal
attended polysomnography, which requires an overnight stay
in a sleep facility, is the standard diagnostic modality in
determining if a patient has OSA.10
The polysomnogram records parameters including
electroencephalography (brain waves), electrooculography (eye
movement), electrocardiography, electromyography (chin and
leg movement), sleep positioning, respiratory activity and
oxygen saturations. 11 Apnea is defined as the cessation
of airflow—a complete obstruction for at least 10 seconds with
a concomitant 2 to 4% drop in arterial oxygen saturation. The
definition of hypopnea is more variable, but it commonly is
thought of as a reduction in airflow of at least 30 to 50% with a
drop in oxygen saturation. The apnea-hypopnea index (AHI) is
the average number of apneas and hypopneas per hour of sleep.
The American Academy of Pediatrics (AAP) has established
clinical guidelines for better recognition and management of
young patients with OSA. Dentists should also be aware of these
guidelines. The guidelines recommended that for the diagnosis
of OSA.12
1. Compulsory screening is must in all children with snoring.
2. Referral to a specialist for high complex high-risk patients.
3. Elective evaluation for patients with cardiorespiratory
failure.
4. Diagnostic evaluation is useful in discriminating primary
snoring and OSA, with the gold standard being
polysomnography.
5. The first line of treatment remains adenotonsillectomy for
most children, and continuous positive airway pressure is
an option for those who are not candidates for surgery or
who do not respond to surgery.
610
6. High-risk patients should be monitored as inpatients
postoperatively.
7. All patients should undergo clinical reevaluation
postoperatively to determine whether additional treatment
is required.
Management of Pediatric OSA
OSAS can be managed nonsurgically or surgically. The
treatment should target the potential contributing factors
identified by the history, the physical examination and upper
airway imaging. The severity of the patient’s condition must
also be considered in developing a treatment plan. Speciality
referral is guided by the chief complaint of the parents and initial
physical examination. The decision on type of intervention
depends on severity of OSA. OSA severity is classified on the
basis of the patient’s AHI score, into three categories: Mild
(AHI score between 5 and 15), moderate (AHI score between
15 and 30) and severe (AHI score greater than 30). Among
children, an AHI score more than one and oxygen desaturation
more than four percent are indicators of mild OSA.
The various treatment options are listed below:
Diet and medications: Weight loss and a healthy diet may
work as the only and ultimate treatment in some children.
Guiding the parents to help in proper sleep posture may help.
A short course of broad spectrum antibiotics and treatment of
nasal pathology (if any) should be given.
Continuous positive airway pressure (CPAP): The most
successful nonsurgical treatment is CPAP. The use of CPAP in
the treatment of OSAS was first described in 1981.13 Since then
it has become the gold standard in the treatment of this condition.
CPAP therapy is indicated in children with specific surgical
contraindications, minimal adenotonsillar tissue, or persistent
OSAS after adenotonsillectomy or for those who prefer
nonsurgical alternatives. It has to be used indefinitely, unlike
surgical treatment which is a onetime procedure.
CPAP is noninvasive and continuously pumps room air
under pressure through a sealed face or nose mask into the upper
airway and the lungs. It increases the upper airway caliber by
acting as a pneumatic splint. CPAP has better tolerance in older
children and requires frequent clinician assessment of adherence
and efficacy. Attention to compliance with this therapy is must.
Surgery: The main surgical treatments offered for OSA
target the anatomical areas of the posterior airway where
collapse is suspected to occur. Surgical procedures include
adenotonsillectomy, septoplasty, uvulopharyngoplasty (UPP),
tracheotomy, maxillary/mandibular surgery, etc.
The traditional surgical procedure for treating OSAS in
children is tonsillectomy with adenoidectomy. The goal of this
procedure is to remove the obstruction by resection of all the
lymphoid tissue of the tonsils. E Eviatar et al in 2008 undertook
a study to found the long-term effectiveness of previously treated
children (having OSAS) by tonsillectomy and tonsillotomy.
They concluded that tonsillotomy is as effective as tonsillectomy
for the long-term treatment of children suffering from OSAS
due to hypertrophic tonsils.14
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Obstructive Sleep Apnea Syndrome in Children
Uvulopalatopharyngoplasty: Fujita et al first described the
use of the UPPP for the treatment of OSAS in 1981.15 It is
usually considered in case of long thick palate and uvula.
However, parents should be made aware of potential velopharyngeal insufficency postoperatively.
In case of nonresponsiveness to all above measures,
tracheotomy remains the most reliable treatment. It is indicated
in recalcitrant cases, infant with Robin sequence, severe
glossoptosis and small tonsils.
Oral appliances: The availability of more than 55 dental
devices on the market for sleep apnea itself explains the role of
a general dental practitioner in its management.16 Oral appliances
are portable and require no cumbersome headgear, nasal mask
or electric power. They generally fall into two broad categories.
1. Tongue-retaining devices
2. Mandibular advancement devices.
By repositioning the lower jaw and thus the tongue, the oral
appliance keeps the pharyngeal airway open. Tongue retainers
are used less commonly and are more cumbersome, but they
tend to be an effective appliance. It has a suction cup that
attaches to the front of the tongue, hence preventing the tongue
from collapsing. It is difficult to tolerate in cases of Down
syndrome.
Mandibular advancement appliances reduce the number of
apneas and hypopneas, improve oxygen desaturation and
improve overnight sleep quality. They work best for patients
with primary snoring and in mild-to-moderate OSA cases.
Consequences of Untreated OSA
OSA in children can lead to various unwanted medical problems.
Its effect can negatively influence mood, behavior, cognitive
capacity and family function.
It causes increased strain on cardiovascular system due to
acute rise in blood pressure and associated arrhythmias.
Regardless of whether obstructive sleep apnea is sufficient to
cause heart failure, there is enough evidence to believe that it
could adversely affect left ventricular function in those with an
already failing heart.17
Depression has been reported to be the most common mood
disorder associated with OSAS. It still remains unclear if
depression and anxiety in OSAS is a primary consequence or if
it occurs secondary to OSAS-related symptoms (sleepiness,
sleep problems, irritability, social withdrawal) or to other factors
related to OSAS.18
In advanced childhood OSAS, carbon dioxide accumulation
coupled with acidosis leads to impaired response to growth
hormone. Increased respiratory effort during sleep depletes the
calorie bank, leading to impaired somatic growth and failure to
thrive in severe cases. Apart from these, the child could face
neurobehavioral problems and may suffer from attention deficit
hyperactivity disorder in future.
Role of Dentist
The dentist may be the first to recognize a patient’s sleep
disorder. Patients with sleep apnea have a wide range of physical
and dental attributes. The most common orofacial characteristics
encountered include a retrognathic mandible, narrow palate,
large neck circumference, long soft palate, tonsillar hypertrophy,
nasal septal deviation and relative macroglossia.
A dentist can act as a ‘gatekeeper’ in identifying children
with adenotonsillar hypertrophy.3 Screening for such patients
is not cumbersome. Surgical extractions in patients undergoing
CPAP should be avoided as it may predispose the patient to
subcutaneous emphysema.19 Such patients should not be
prescribed intravenous sedation because of compromised
airway. 20 Clinicians can quantify patients’ daytime
hypersomnolence by administering the Epworth Sleepiness
Scale21 to their parents or guardians (a total score greater than
10 suggests excessive daytime sleepiness).
Dentists suspecting OSA can go for lateral cephalogram of
the patient to determine hooking of soft palate. Hooking of the
soft palate while awake may facilitate pharyngeal collapse
during sleep.22 Dentists caring for these patients can perform
restorative procedures that enhance the dentition and enable
the patient to properly masticate a high-fiber, high-protein, lowcalorie diet that is nutritious and conducive to weight loss.
CONCLUSION
OSAS is a common condition associated with significant
morbidity and mortality. It is therefore important that dental
professionals be aware of the signs and symptoms of OSAS, so
that the diagnosis can be confirmed and treatment initiated as
soon as possible. As knowledge about the pathophysiology of
OSAS improves, treatments may be designed to address the
specific causes of the condition. Oral appliances play a major
role in the nonsurgical management of OSA and have become
the first line of treatment. Also, it is necessary to be in touch
with other healthcare professionals, to offer good multidisciplinary treatment.
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