Pediatric Sleep Disorders/Sleep in Children with Chronic Illness.

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WHAT IS OBSTRUCTIVE SLEEP APNEA?

Obstructive sleep apnea (OSA) is a breathing problem that occurs only during sleep. Both chil- dren and adults can have sleep apnea. Sleep apnea involves brief (typically lasting 10–20 sec- onds) breathing pauses (or apneas) that occur frequently throughout the night. These breathing pauses are caused by some type of airway blockage (or obstruction). In children, enlarged tonsils and adenoids are the most common cause. These breathing pauses can lead to a temporary de- crease in oxygen levels. These changes in oxygen levels alert the brain that there is a problem. The brain then “jump starts” breathing again by waking up the sleeping person. Although breath- ing resumes, these brief wakings disrupt and fragment sleep. It’s just like being poked by some- one 30 or 40 times a night while you are trying to sleep. Both the frequent dips in oxygen and the multiple wakings negatively affect normal daytime functioning. This is because adequate oxygen is necessary for optimal brain function and briefly waking frequently throughout the night can lead to significant daytime sleepiness.

WHAT CAUSES OBSTRUCTIVE SLEEP APNEA?

In most children, large tonsils and/or adenoids cause sleep apnea. Large tonsils can block airflow through the mouth. Large tonsils reduce airflow through the nose. Being overweight or obese can also affect breathing. It is an increasingly common risk factor for sleep apnea in children. Allergies, asthma, frequent sinus infections, and gastroesophageal reflux (frequent heartburn, sour taste) are also risk factors for sleep apnea. Having one or more close family members with sleep apnea or loud snoring also increases your child’s likelihood of having sleep apnea. Other children who are at risk for sleep apnea are those with a narrow facial bone structure or a small jaw. Children with neuromuscular disorders such as cerebral palsy, and some genetic conditions, such as Down syndrome and Prader-Willi syndrome, are also more likely to have sleep apnea.

WHAT ARE THE SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA?

n Snoring, especially if it is loud and occurs every night n Breathing pauses during sleep or frequently choking or gasping when asleep n Nasal congestion, nasal voice, and difficulty breathing through the nose n Restless sleep n Frequent nightwakings n Sweating during sleep n Morning headaches n Difficulty waking and/or being irritable in the morning

Children with OSA also frequently have symptoms during the day, as a result of not sleeping well at night. They may appear sleepy during the day, doze off on short car rides or in front of the TV, or fall asleep in school. Other children with sleep apnea have more subtle symptoms of sleepiness. For example, they may be moody, irritable, or have behavior problems, such as hy- peractivity, aggressiveness, defiance, or poor impulse control. Some children with sleep apnea

Obstructive Sleep Apnea in Children

© Mindell JA & Owens JA (2010). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems, 2nd ed. Philadelphia: Lippincott Williams & Wilkins

2 ObStruCtive Sleep ApneA in Children

© Mindell JA & Owens JA (2010). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems, 2nd ed. Philadelphia: Lippincott Williams & Wilkins

have problems paying attention and focusing in school. And some may even be diagnosed with attention deficit hyperactivity disorder. Many children with sleep apnea have problems in school.

HOW IS OBSTRUCTIVE SLEEP APNEA DIAGNOSED?

Children with symptoms of OSA may require an overnight sleep study to confirm the diagno- sis. The overnight sleep study, which is done in a specialized sleep laboratory, uses a variety of sensors to monitor snoring, breathing, heart rate, oxygen levels, sleep stages, body movements, and sleep disruptions. A parent typically sleeps in the same room with the child during the sleep study. (For more information on preparing your child for a sleep study see Appendix D11.) Your doctor will review the results of the sleep study with you and recommend the best treatment for your child.

HOW IS OBSTRUCTIVE SLEEP APNEA TREATED?

Because most children with sleep apnea have large tonsils and/or adenoids, an operation to re- move the tonsils and adenoids is typically the recommended treatment. This surgery generally takes care of the problem. A referral to an ear, nose, and throat specialist (otolaryngologist) is required for such surgery. Most of the time, the surgery can be done on an outpatient basis. Some children may require another sleep study after the surgery to confirm that the sleep apnea has improved.

For other children, such as those whose tonsils and adenoids have already been removed or are not enlarged or in children with very mild sleep apnea, other treatments may be recommended. For example, children who are overweight should be counseled about nutrition and exercise to help them lose weight. Those with allergies or asthma may be treated with medications. Reduc- ing exposure to allergens, such as tobacco smoke and dust mites, can help. Plastic coverings on bedding and air filters can also improve breathing during the night. Sometimes allergy shots may even be recommended. In addition, sleep apnea is typically worse when a child sleeps on his back. Therefore, sewing a hard ball into a pajama or t-shirt pocket and then wearing this back- wards to bed may help keep your child from rolling over onto his back during the night. Body pillows can also help.

Finally, some children with sleep apnea will require a treatment called continuous (or bi-level) positive airway pressure. This is a portable breathing machine that is used at night to relieve blocked breathing. This treatment requires another overnight sleep study to find the best fitting mask and pressure settings.