II. Epidemiology

  1. Prevalence in Children
    1. Snoring: 3-12%
    2. Obstructive Sleep Apnea: 1-5%
  2. Onset: Ages 2-8 years old
  3. Gender predominance: Males and females equally affected

III. Types

  1. Obstructive Sleep Apnea (OSA)
  2. Upper Airway Resistance Syndrome (UARS)
    1. Disordered breathing despite normal Polysomnogram

IV. Risk Factors

  1. Black ethnicity
  2. Obesity
  3. Neuromuscular disease
  4. Pectus Excavatum
  5. Craniofacial abnormalities
    1. Craniosynostosis (e.g. Apert's Syndrome)
    2. Micrognathia (e.g. Pierre Robin Syndrome)
    3. Retrognathia
    4. Midfacial hypoplasia
    5. Trisomy 21 (Down Syndrome)
    6. Macroglossia
    7. Choanal Atresia

V. Causes

  1. Large tonsils, adenoids (Adenotonsillar Hypertrophy)
  2. Nasoseptal obstruction
  3. Allergic Rhinitis

VI. Symptoms

  1. Altered observed sleep-related breathing patterns
    1. Snoring
    2. Mouth breathing
    3. Nocturnal awakenings
    4. Witnessed apneas or paradoxical breathing
  2. Behavior changes
    1. Daytime Sleepiness (less common, but seen in obese children)
    2. Nocturnal Enuresis
    3. Decreased attention
    4. Unusual behavior
    5. Poor academic performance
  3. Atypical sleep position
    1. Hyperextended neck
    2. Seated with mouth open
  4. Associated symptoms
    1. Morning Headache
    2. Night Sweats

VII. Signs

  1. Adenotonsillar Hypertrophy
    1. See Tonsillar Hypertrophy Grading Scale
    2. See Mallampati Score
  2. Craniofacial abnormalities (e.g. Micrognathia)
  3. Nasal obstruction
    1. Choanal Atresia or septal deviation in infants
    2. Turbinate swelling or Nasal Polyps in children
  4. Chest abnormalities (e.g. Pectus Excavatum)
  5. Neurologic Exam
  6. Assess growth
    1. Obtain height and weight and plot for Growth Velocity
    2. Assess for Failure to Thrive
    3. Calculate Body Mass Index for pediatric Obesity

VIII. Imaging

  1. Lateral neck XRay (consider)

IX. Associated Conditions

X. Complications

  1. Failure to Thrive
  2. Pulmonary Hypertension
  3. Attention Deficit Disorder-like behavior (or other worsening school performance)

XI. Diagnosis

  1. Adenotonsillar Hypertrophy with OSA symptoms
    1. See Tonsillar Hypertrophy Grading Scale
    2. No further studies needed to indicate Tonsillectomy
  2. Polysomonogram
    1. Indications (required in most cases of suspected pediatric OSA)
      1. Craniofacial abnormalities
      2. Comorbid conditions
      3. Unclear diagnosis
    2. Precautions
      1. Polysomnogram may be normal despite UARS (above)
    3. Criteria for Obstructive Sleep Apnea Diagnosis
      1. Pediatric criteria differs from that for adults
      2. Apnea-Hypopnea Index >1.5 events per hour of sleep
      3. Minimum Oxygen Saturation <92%

XII. Management

  1. Adenotonsillar Hypertrophy
    1. Adenotonsillectomy is treatment of choice
      1. Tarasiuk (2004) Pediatrics 113:351-6 [PubMed]
  2. Management if Tonsillectomy not effective or indicated
    1. Continuous positive airway pressure (CPAP)
      1. See CPAP for Obstructive Sleep Apnea
      2. Recheck mask fitting every 6 months
    2. Treat concurrent Allergic Rhinitis
      1. Nasal Corticosteroids
    3. Treat recurrent Tonsillitis
      1. Consider course of antibiotics
    4. Rapid Maxillary expansion
      1. Orthodontic device to widen the upper jaw
    5. Uvulopalatopharyngoplasty (UPPP) Indications
      1. No longer recommended due to low efficacy in adults
      2. Oropharyngeal soft tissue obstruction
        1. See Mallampati Score
      3. Severe OSA without Adenotonsillar Hypertrophy
      4. Trisomy 21
  3. Indications for sleep medicine referral: higher risk conditions
    1. Cardiorespiratory failure
    2. Craniofacial abnormalities or congenital defects
    3. Attention Deficit Disorder
  4. Management of severe OSA refractory to above measures
    1. Tracheotomy

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