Nadia is struggling in school and her parents are worried about ADHD.
Children with OSA may sleep in unusual positions such as sitting up or extending their neck
10 %
of children snore
1-5 %
of children have Obstructure Sleep Apnea (OSA)
By the end of this module, you should be able to:
- Describe consequences of untreated sleep-disordered breathing.
- Predict if a child is at high risk for sleep-disordered breathing.
- Select appropriate treatments for sleep-disordered breathing based on patient factors.
What is Sleep Disordered Breathing?
Sleep-disordered breathing is a range of abnormalities in breathing while asleep. This range includes snoring at the mild end, to sleep apnea, in which there are pauses in breathing, at the more severe end. Sleep-disordered breathing often results in daytime sleepiness and difficulties with attention and behavior. For patients found to have sleep apnea, interventions can result in improved daytime alertness and attention.
Sleep-disordered breathing can be either obstructive or central in nature. Obstructive sleep-disordered breathing is far more common, and is typically characterized by snoring, gasping and choking while asleep. Obstructive sleep apnea is the result of the airway collapsing during sleep. Central sleep-disordered breathing is much less common, and is typically characterized by silent pauses in breathing and an absence of snoring. Central sleep apnea occurs when there is no signal from the brain to the diaphragm to trigger a breath or if a child’s respiratory muscles are too weak to take a breath.
Sleep-disordered breathing is diagnosed by polysomnography (“sleep study”). Polysomnography allows a physician to review a child’s breathing while asleep to determine if sleep-disordered breathing is present, how severe it is, and if it is central or obstructive in nature.
Major types of Sleep Disordered Breathing
1 Obstructive Sleep Apnea
This is the most common form of sleep apnea, occuring in 1-5% of children. Common causes of obstructive sleep apnea include enlarged adenoids or tonsils, obesity, airway abnormalities that result in a narrow airway, or low airway muscle tone at night.
2 Central Sleep Apnea
Central sleep apnea is much less common and can be due to multiple causes:
- Primary central sleep apnea is seen without any other underlying cause, and it is thought to be related to children’s sensitivity to the arterial concentration of CO2, the main trigger for breathing while asleep.
- Primary central sleep apnea of prematurity and infancy is believed to be related to immature control of breathing in the developing brain. This will typically resolve with time.
- Certain medical conditions, which typically result in brainstem lesions, can cause central sleep apnea. The most common example of this is an Arnold-Chiari malformation.
- Medications such as sedatives or narcotics can cause central sleep apnea.
- Treatment emergent central sleep apnea can be seen in some children treated with positive airway pressure therapy, such as CPAP.
3 Late-Onset Central Hypoventilation with Hypothalamic Dysfunction
This is an extremely rare condition. Children with this condition typically have normal development until around age 2-3 years of age. At this age, children develop hyperphagia (excessive hunger and eating) and severe obesity. They then develop central hypoventilation which can present as acute respiratory failure. Associated symptoms include hypothalamic dysfunction, which manifests as a broad array of endocrine disorders, including diabetes insipidus, precocious puberty, hypothyroidism, decreased growth hormone or other disorders. Children with this condition may also have severe behavioral disturbances and are at risk for developing tumors of neural origin. The cause of this disorder is unknown.
4 Congenital Central Alveolar Hypoventilation Syndrome
This is an extremely rare condition that typically presents at birth. Infants may struggle with feeding, appear lethargic, or if intubated, be unable to wean from the ventilator. Infants will be noted to be hypercapnic and/or hypoxemic. Infants can be noted to have central apneas or may only hypoventilate. This occurs due to malfunction of central nervous system control of breathing. This is a genetic condition associated with mutations in the PHOX2B gene. Children with this condition should be monitored for tumors of neural origin. Patients with disease have an increased risk of hirschsprung's disease.
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Medicine  |
Medical providers (MD, PA, APNP) will perform a history and exam to determine next course of action including testing needed and possible treatment. This includes a comprehensive sleep history, interpreting polysomnography, and initiating therapy (e.g., CPAP, montelukast, or ENT referral). |
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Nursing  |
Care coordination with regards to treatment and follow up. School nurses or other school personnel should include sleep issues when asked to consult around issues of disruptive behavior, falling asleep in class, obesity or poor academic performance. |
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Nutrition  |
Nutritionists assess general dietary practices and provide counseling for overweight children (weight loss can be an effective treatment strategy for obstructive sleep apnea in obese children). |
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Pharmacy  |
Determine patient’s current medications (e.g., medication reconciliation) and evaluate for those that may worsen sleep apnea (e.g., benzodiazepines, opiates, muscle relaxants) as well as those that may be treatment options for this sleep disorder (e.g., montelukast). Review medication regimen for drug interactions. |
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Respiratory Therapy  |
Respiratory therapists play a role in educating patients and families on proper techniques for respiratory equipment including CPAP device teaching/set up, mask fitting, and CPAP troubleshooting. |
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Social Work and Mental Health  |
Social workers can assess for overall new stressors in the home which could be exacerbating sleep disturbances as well as the ability of the family to follow through on treatment recommendations. They can also help patients and families with CPAP adherence and assist with school issues (e.g., 504 plan, etc). |
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Family Perspective and Leadership  |
Family is key in helping children use CPAP. Prior research has shown that children of parents that use CPAP are more likely to use CPAP compared to children of parents not on PAP therapy. |
Nadia
Miguel
Miguel is a boy with Down Syndrome and hypothyroidism. He was seen at his wellness check-in with his Dad.
Sarah
Sarah is an 8 month old girl. Her mother is concerned that she stops breathing at night.
Isaiah
Isaiah is a 14 year old boy with Duchenne muscular dystrophy. Recently, he has begun having headaches in the morning.
Books and Supplemental Websites:
American Academy of Pediatrics obstructive sleep apnea clinical practice guideline
Genetics home reference: Congenital central hypoventilation syndrome
Late-onset central hypoventilation with hypothalamic dysfunction (formerly known as ROHHAD)
Nehme J, LaBerge R, Pothos M, Barrowman N, Hoey L, Monsour A, Kukko M, Katz SL. Predicting the presence of sleep-disordered breathing in children with Down syndrome. Sleep Med. 2017 Aug;36:104-108.
McGrath B, Lerman J. Pediatric sleep-disordered breathing: an update on diagnostic testing. Curr Opin Anaesthesiol. 2017 Jun;30(3):357-361.
Biggs SN, Vlahandonis A, Anderson V, Bourke R, Nixon GM, Davey MJ, Horne RS. Long-term changes in neurocognition and behavior following treatment of sleep disordered breathing in school-aged children. Sleep. 2014 Jan 1;37(1):77-84.
Walter LM, Biggs SN, Nisbet LC, Weichard AJ, Hollis SL, Davey MJ, Anderson V, Nixon GM, Horne RS. Long-Term Improvements in Sleep and Respiratory Parameters in Preschool Children Following Treatment of Sleep Disordered Breathing. J Clin Sleep Med. 2015 Oct 15;11(10):1143-51.