AAPA: Clinicians Who Treat Pediatric Sleep Apnea Must Work in the Dark

PHILADELPHIA, May 31 -- Teens suffering from sleep apnea will doze off in class and teachers will label them lazy, but younger children with the condition usually don't act sleepy. They become hyperactive and tantrum-prone.

And teachers tend to label them as troublemakers, said Carl D. Boethel, M.D., a sleep specialist at the Texas A&M University Health Science Center in Temple, Texas.

Sleep apnea affects about 2% of younger children, but current national guidelines are lacking when it comes to diagnosing and treating the condition in this patient population, Dr. Boethel said at an American Academy of Physician Assistants (AAPA) conference session here.

Other important ways in which sleep apnea differs in younger children include the following:

• Airway obstruction is usually not complete in younger children, whereas many adults experience complete obstruction during nighttime apneic episodes.
• The sleep architecture of younger children, as measured by polysomnography, tends to appear normal, whereas adults experience significantly decreased amounts of stage three and REM sleep.
• Younger children rarely wake fully during the night because of apneic episodes, whereas adults are usually roused completely.

Despite these differences, the quality of rest still suffers in children who experience significant numbers of apneic episodes during the night, Dr. Boethel said. They may be hard to wake up and sluggish in the morning (sleep inertia).

Lack of quality sleep sometimes leads to growth retardation in younger children, but the slowed growth improves with treatment, he said.

Although rare, genetic syndromes affecting the structure of the face, mouth, and airways are also sometimes a cause of sleep apnea in pediatric patients, Dr. Boethel said. Such syndromes include Downs syndrome, Pierre Robin syndrome, Treacher Collins syndrome, and Prader-Willi syndrome, he said.

Other indications of sleep apnea in younger children include nocturnal sweating, hyperextension of the neck during the night (in an attempt to open the airway), bed-wetting, and morning headaches, Dr. Boethel said.

Like teens and adults, however, younger children with sleep apnea may have trouble paying attention during the day, Dr. Boethel said.

Obesity is also a risk factor in younger children, as it is in adults, Dr. Boethel added. Snoring may also signal the condition in children, but, as with adults, snoring by itself is not indicative of sleep apnea. Evidence suggests that up to 12% of younger children snore while sleeping, he said.

Finally, enlarged tonsils and adenoids are also a chief cause of the condition in younger children. Therefore, any child with enlarged tonsils or adenoids and a combination of the above-mentioned symptoms-especially nighttime snoring and daytime hyperactivity-should be considered for referral to a sleep lab for sleep testing, Dr. Boethel suggested.

Because enlarged tonsils and adenoids are often a leading cause of sleep apnea in younger children, adenotonsillectomy tends to be the first-line treatment, Dr. Boethel said. Clinical trial evidence shows this option is effective for opening the airway and resolving symptoms in this patient population.

Before referring a child to a sleep lab, however, make certain that the lab has experience working with children and that it is accredited by the American Academy of Sleep Medicine (AASM), Dr. Boethel said.

A sleep test will likely find at least a few episodes of apnea per night, which is normal even in young children, Dr. Boethel said. However, he advised, if polysomnography reveals that a child's rest is disturbed more than once per hour because of apneic episodes, treatment for sleep apnea should be considered.

For those wishing to avoid or delay the surgical route, nasal steroids or leukotriene inhibitors may effectively open the airway, but it may take up to a month of follow-up to establish whether or not these medications are working effectively, Dr. Boethel cautioned. In addition, orthodontic appliances worn during the night that open the airway are also supported by clinical evidence and may be useful in young children, he said.

Continuous positive airway pressure (CPAP) therapy is usually the treatment of last resort for young children because of compliance difficulties, Dr. Boethel noted. The mask worn during therapy can be uncomfortable or frightening for many children, he said.

If CPAP therapy is necessary, the mask must be worn for only four hours a night to be effective, Dr. Boethel said, and recent evidence suggests that if parents are educated about how to make the mask more acceptable to children, a 76% compliance rate can be achieved. That's comparable to adult compliance rates, Dr. he said.

Strategies for achieving compliance include providing rewards for wearing the mask and having parents sleep with the child and wear a mask also to reduce the child's fear or apprehension, he said.

Further research is needed to better clarify how to identify and treat sleep apnea in preschool and elementary school age children, Dr. Boethel concluded.

This presentation was not supported by outside sources, and Dr. Boethel reported no financial conflicts of interest.