Pediatric Sleep-Disordered Breathing

Pediatric Sleep-Disordered Breathing

Stacey L. Ishman

David F. Smith

Sally R. Shott


Sleep-disordered breathing (SDB) represents a continuum of obstructive disease that encompasses a range of specific diagnoses including snoring, upper airway resistance syndrome, obstructive hypoventilation, and obstructive sleep apnea (OSA). OSA, itself, is characterized by increasing limitation of flow through the upper airway, sometimes resulting in complete obstruction of the airway. OSA presents differently in children than it does in adolescents and adults, and identification can be hampered by the fact that children are far less likely to complain about problems with sleep than adults. In many cases, parents or guardians will be the first to express concerns about a child’s sleep, and they often highlight complaints of increased fatigue or sleepiness (hypersomnia), difficulty initiating or maintaining sleep (insomnia), sleeping in strange positions and restless sleep, or other abnormal behaviors that are recognized during the sleep cycle. For this reason, a thorough history provided by the caregivers, in addition to a complete physical exam, is essential for the assessment of pediatric sleep disorders.


Many epidemiologic studies have sought to accurately identify the number of children in the United States (US) with SDB and OSA, as well as to identify the risk factors associated with both; however, these figures are highly variable. In a recent study, 3.2% to 34.5% of parents reported that their children snored often to always (1), while another notes that approximately 25% of children aged 3 to 12 years old snore (2). Most population studies indicate that 1% to 4% of children in the US have OSA (1). However, OSA seems to be more prevalent in the male gender (1), and SDB is strongly associated with low socioeconomic status. This relationship may simply reflect a higher body mass index (BMI) within this subgroup (3).

Ethnicity and genetic factors are also associated with a higher risk of SDB. Black children in the US are at an increased risk of developing OSA when compared to white children (4, 5, 6, 7). Other studies utilizing validated questionnaires, polysomnography (PSG), or cephalometric measurements have verified a higher rate of OSA in black and Asian children (8, 9, 10). Airway obstruction and OSA may be missed in children with craniofacial anomalies unless specifically addressed as parents may assume that this is “normal” for their child. One study showed more than a doubling of OSA diagnoses when using a specifically applied sleep questionnaire in a group of children with Apert, Crouzon, and Pfeiffer syndrome (11). A full list of children at higher risk for OSA is presented in Table 139.1. SDB has also been associated with specific clinical risk factors including nightly snoring, caregiver witnessed apneas, male gender, exposure to cigarette smoke, and anatomic factors including adenotonsillar hypertrophy and obesity (12, 13).

Consequences of OSA

Over the last decade, studies have sought to identify the long-term complications associated with SDB and OSA. Behavioral problems that can occur as a result of untreated OSA include hyperactivity, attention-deficit disorders, aggression, and poor socialization (2). Neurocognitive disorders linked to OSA include poor school performance and variable learning disorders, such as deficits in memory, learning, and problem-solving skills (2). Much of what has been learned over the last decade suggests that children with OSA are at a much higher risk to suffer from behavioral, neurocognitive, and emotional difficulties, as well as a decrease in quality of life (QOL). In fact, both neuropsychological behavior and QOL tend to normalize after the airway obstruction has resolved (14, 15, 16). Besides the host of behavioral and neurocognitive disorders, children with OSA for prolonged periods can suffer from cardiovascular
and pulmonary complications. Elevated systemic blood pressure has been found in children with OSA (17, 18, 19, 20, 21). More importantly, children with elevated blood pressures are more likely to suffer from hypertension and metabolic syndrome as adults (22). Although previous studies evaluating the association between primary snoring and increases in blood pressure in children have been somewhat conflicting (23, 24, 25, 26), more recent data suggest that children with primary snoring have higher nighttime blood pressures when compared to those control patients without snoring (27). Further, a dose-response relationship exists between SDB and the severity of blood pressures in children (27). Although not fully understood, clear risks exist for those children with prolonged SDB.




Apert syndrome


Beckwith-Wiedemann syndrome

Cerebral palsy

Crouzon syndrome

Choanal atresia

Down syndrome

Cleft palate

Klippel-Feil syndrome


Pierre Robin sequence


Pfeiffer syndrome


Prader Willi syndrome

Pharyngeal flap patient

Treacher Collins syndrome

Recurrent respiratory papillomatosis


Continuous Positive Airway Pressure

Positive airway pressure (PAP) has become a commonly accepted treatment option for children with OSA in specific circumstances. Nasal continuous positive airway pressure (CPAP) is effective in treating OSA in children, and it has been approved for use in children since 2006. It is primarily used as an adjunct therapy, especially in children that have persistent OSA after adenotonsillectomy, but it is also used in patients in whom surgery is contraindicated. CPAP is composed of a source for warm humidified air or oxygen, a generator that creates positive pressure, and a patient delivery system (for children with OSA, it is in the form of a nasal mask) (57). Ideally, CPAP titration is performed during PSG, with a minimum starting pressure of 4 cm H2O and a maximum of 15 cm H2O for children under the age of 12 years old (58). The goal of titration is to eliminate obstructive events with positive airflow in order to maintain airway patency (58). A large series showed that RDI was reduced and oxygen saturation increased in children aged 2 to 16 years using CPAP for OSA; however, at least 30% stopped the use of CPAP in less than 6 months (59).

As with PSG, there are certain limitations with CPAP for the treatment of OSA in children. A national survey of sleep centers found that protocols for titration varied widely between institutions, and 22% of the centers do not utilize written protocols (60). The continued use of CPAP also carries with it certain risks. Many children discontinue the use of CPAP due to the discomfort of the mask or the noise that is created by the machine. Long-term use of the mask can also lead to skin defects or potentially harmful craniofacial abnormalities, with 68% experiencing global facial flattening, 37% with maxillary retrusion, and 48% resulting in damage of the skin (61).

May 24, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Pediatric Sleep-Disordered Breathing
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