The Patient
When 8-year-old “Mark” was brought to the Sleep and Breathing
Disorders Center at Arkansas Children’s Hospital, his legal guardian
reported that his sleep was very restless and punctuated by snoring and
gasping. He was “tossing, turning and flinging his arms,” she said, and
the symptoms had worsened in the four or five months before the clinic
visit. She reported that he was difficult to awaken in the morning and
was often “short and snappy.” His school performance had deteriorated in
recent months, and his teachers reported that he had become inattentive
in class, was often caught staring into space and frequently picked
fights with his classmates.
On clinical examination, “Mark” was found to be slightly overweight
but otherwise a physically healthy, normal child. His tonsils were not
overly large, at 2+ on a scale of 0 to 4. Because his symptoms were
typical of a sleep disorder, he was scheduled for a polysomnogram, or
sleep study, in the clinic’s sleep lab.
While this child’s clinical presentation was relatively unremarkable,
the results of his polysomnogram were severely abnormal. His apnea-hypopnea
index (AHI), a count of obstructive episodes per hour, was 42.7, more
than eight times the level considered acceptable. During REM sleep, the
AHI rose to 51.4. His lowest O2 saturation level was quite alarming at
57%; he spent 10.6% of his sleep time with his O2 saturation below 90%,
and 2.6% of his sleep time with his O2 saturation at less than 85%. His
end tidal CO2 was 59 mmHg. He aroused from deep sleep to REM or from REM
to awakening 60 times per hour; the maximum acceptable limit of such
arousals is 10 per hour. He awakened 7 times during the night.
The diagnosis was severe obstructive sleep apnea, severe hypoxia,
severe CO2 retention and severely disturbed sleep. An electrocardiogram
indicated no related heart damage, and bloodwork revealed no
abnormalities. The recommended course of treatment was adenotonsillectomy
and uvulapalatoplasty (UP3). A follow-up polysomnogram revealed that his
OSA was resolved. His lowest O2 saturation was 91% and end tidal CO2 was
48 mmHg. His arousal index was 5.1 per hour. His guardian reports
“unbelievable” improvement in his daytime behavior.
The value of polysomnography for children
While most laypeople consider snoring to be associated mainly with
older adults, studies have shown that about 10% of children 10 years of
age and younger snore. Of all children who snore, about 20% will be found
to have obstructive sleep apnea syndrome (OSAS) if sleep studies are
performed. However, some studies have indicated that a large percentage
of snoring children have partial obstruction of airways, or upper airway
resistance syndrome (UARS), which can interfere with daytime functioning.
In years past, physicians who were faced with a snoring child and a
worried parent most often recommended adenotonsillectomy. But in recent
years, several studies, including one I conducted, have confirmed that
OSAS cannot be effectively diagnosed based solely on clinical exam and
medical history. Pediatric patients today are much more likely than in
years past to be referred to a sleep lab for a polysomnogram.
An appreciation for the value of polysomnography in pediatrics has
been slow to come. Few physicians would attempt to prescribe surgery or
CPAP (continuous positive airway pressure) to an adult without a
definitive diagnosis, and if they did, most insurance companies would
refuse to pay. Yet children have been routinely subjected to
adenotonsillectomy-a surgical procedure that is not without morbidity and
mortality- simply because they snore or exhibit other nonspecific
symptoms or behaviors.
A polysomnogram is the best way to detect a sleep disorder, confirm a
diagnosis and determine the condition’s severity so that appropriate
postoperative care can be provided after a tonsillectomy or other
procedure. Because severe obstructive sleep apnea can put patients at an
increased risk for anesthesia-related complications, some cases may
require postoperative intensive care.
If performed appropriately in a child-friendly setting with a parent
or guardian nearby, polysomnography is not traumatic for the child. It
requires an overnight stay in the sleep lab, so that the child can be
observed by technicians and/or physicians. The data generated by the
sleep study is hand-scored by technicians the next day, and this data is
interpreted, along with the clinical examination and medical history, to
make the diagnosis, in keeping with the recommendations of the American
Academy of Sleep Medicine and the American Thoracic Society.
While adenotonsillectomy is usually the first step in treating
obstructive sleep apnea in children, other measures may need to be taken.
Rarely, a young patient will require additional surgery, such as
uvulapalatoplasty. Some patients can benefit from CPAP or BiPAP (bilevel
positive airway pressure, which has different levels of airway pressure
for exhaling and inhaling).
It is critical to emphasize to the parent that treatment is necessary
and that OSAS can cause much more than snoring and restless sleep. Left
untreated, OSAS puts an increased strain on the heart and lungs, which
over the years may lead to heart failure and other serious health
problems.
Also, adults need to be made aware that sleep-deprived children do not
act like sleep-deprived adults. Children are more likely to fight their
fatigue, which often manifests as oppositional behavior, a shortened
attention span and inability to focus on schoolwork and other tasks.
Childhood OSAS can cause significant impairment of daytime cognitive
function which, over time, can seriously degrade a child’s school
performance and overall quality of life.
In fact, children with OSA may be misdiagnosed as having attention
deficit hyperactivity disorder and treated with stimulants such as
Ritalin. Often, children with true ADHD also have troubled sleep and so
may benefit from a sleep study and treatment for any sleep disorders that
might be revealed, including OSA.
Bottom line:
Children who snore do not necessarily have obstructive sleep apnea
syndrome, and OSAS cannot be diagnosed through clinical examination and
medical history. Polysomnography in a full-service pediatric sleep lab is
important in confirming suspected cases of childhood OSAS before
tonsillectomy and adenoidectomy, and in determining the severity of the
condition so that appropriate postoperative steps can be taken. A sleep
study is also useful in diagnosing other sleep disorders, which often
accompany-or may be misdiagnosed as-ADHD or other disorders.
Adenotonsillectomy is the first-line therapy for OSA in children but
additional surgery, CPAP or BiPAP may be necessary in some cases.
John L. Carroll, M.D., is section chief of Pediatric
Respiratory Medicine and director of the Pediatric Sleep Medicine Center
at Arkansas Children’s Hospital. He is a professor of pediatrics on the
faculty of the University of Arkansas for Medical Sciences.
Degree:
University of Texas Southwestern School of Medicine
Internship and Residency:
State University of New York Department of Pediatrics, Upstate Medical
Center, Syracuse, New York
Fellowships:
Pediatric pulmonary clinical year, University of Arizona Health Science
Center, Tucson; Pediatric pulmonary research, respiratory medicine, The
Montreal Children’s Hospital, McGill University; Research, newborn
respiratory physiology, Department of Physiology, McGill University,
Montreal
Certification:
Pediatrics, Pediatric Pulmonary
For more information or to make a referral to Dr. Carroll, call
501/320-1006 or 501/320-1893.
