According to recent studies, at least one in 50 children suffer from obstructive sleep apnea (OSA), or "recurring episodes of recurrent complete or partial airway obstruction giving rise to hypoxemia and sleep disruption," according to Eliot Katz, MD, of the Respiratory Diseases Division and the Center for
Pediatric Sleep Disorders at Children's Hospital Boston.
Dr. Katz, who researches the determinants of sleep-disordered
breathing in children, says there doesn't need to be complete apnea for a child to have symptoms of OSA. For example, hypopnea
produces the same adverse outcomes as complete apnea.
OSA may occur any time from birth to adolescence, but the
peak age is between 2 and 8. Its principal cause is adenoid-tonsillar
hypertrophy—the enlargement of the tonsils and/or adenoids.
Other causes include the effect of neuromuscular weakness on airway muscles, cranio facial abnormalities (including narrowing of the upper or lower jaws) and the deposition of fat in the upper airway due to obesity.
The minimum threshold of sleep-disordered breathing that
produces symptoms has not yet been established in children. "One complicating factor is that, in addition to having sleep
apnea, individuals have a variable response to sleep disruption," Dr. Katz says. Furthermore, one of the main symptoms of OSA is snoring, which is usually viewed as nothing more than an
annoying habit, but can actually be a sign of a major health problem. Until recently, the consequences of OSA weren't widely known, especially the consequences and possible causes of
habitual snoring. "Everybody recognizes that excessive coughing, vomiting or limping are abnormalities that require investigation or intervention," Dr. Katz says."Snoring is often seen as a
symptom that's not related to a serious medical problem, but it can be associated with cardiovascular abnormalities, including systemic high blood pressure, as well as pulmonary hypertension, poor growth and secondary enuresis."
Even if there's no major problem, sleep-disordered breathing can still be problematic. "In some kids, it's so disruptive that it's been
associated with daytime consequences, such as neuro-cognitive
impairment and poor school performance," Dr. Katz says. "Sleep
disorder breathing disrupts the normal cycling in a very subtle way, such that...the overall sleep quality is not good or the sleep is not restorative. Therefore, memory and daytime alertness can be impaired."
Despite the prevalence of sleep disorders in children, they often remain undiagnosed. Dennis Rosen, MD, also of the Respiratory Diseases Division and the Center for Pediatric Sleep Disorders, says, "Approximately 25 percent of children have some form of sleep disorder at some time in their lives, with an estimated 2
percent suffering from OSA, yet the majority of these children are not referred to specialists."
Maria Gabriel, MBA, CMET, REEGT, technical director of the Division of Epilepsy/Clinical Neurophysiology, believes that
underdiagnosis may result from parents' lack of understanding about the severity of sleep disorders. "Kids who sometimes don't sleep well at night could have a big problem. In order to find out, you need a sleep study," Gabriel says.
That's where Children's comes in. The Center for Pediatric Sleep Disorders was established by Richard Ferber, MD, in 1978 as the world's first comprehensive center dedicated to the management of sleep disorders in children. Diagnostic and treatment services for a wide range of sleep disorders, including insomnia, excessive
sleepiness, sleep terrors and OSA are available. While the center already has satellite clinics in Lexington, Peabody and Waltham, the latter clinic will soon expand to include a lab for sleep studies.
The expansion, which will be headed up by the same doctors who run the Boston center, including Dr. Ferber, director of the center, will not only serve as a valuable means for continuing
research, but will also add to the availability of services. "The
increase in the number of beds should considerably reduce the waiting time," Dr. Rosen says. This expansion will enhance
Children's ability to diagnose. "The laboratory gives us more
opportunity to actually monitor their sleep at night,"
Dr. Ferber says.
After the patient is diagnosed, a plan of treatment is devised. In the case of adenoid-tonsillar hypertrophy, surgery is often the
preferred treatment. According to Katz, the success rate for these procedures is approximately 80 percent. Alternatively, a child may use a continuous positive airway pressure (CPAP) mask every night to open the airway for easier breathing. Children with OSA resulting from jaw problems might benefit from orthodontic
therapy. In extreme cases, in which CPAP therapy is neither
effective nor tolerated and there is no beneficial surgical approach, tracheotomies may be performed, particularly on children with cranio facial abnormalities. For children with OSA resulting from obesity, weight loss is usually the recommended treatment.
