Pediatric Sleep Disorders S. SHAHZEIDI, MD, FAAP, FCCP, FAASM GRAND HEALTH INSTITUTE Objectives Discuss the importance of screening for snoring Explain the signs and symptoms of parasomnias and sleep apnea Analyze the diagnostic criteria of obstructive sleep apnea based on new AAP practice guidelines Examine the management options for sleep apnea Case CC: Recurrent wheezing and snoring. HPI:Patient is an 8 year old female with asthma diagnosed at 3-4 years of age. Pt not on controller medications, no hospitalizations or ER visits. She has severe snoring and her father describes apnea looking episodes. There is night sweating. Academics/ activities: poor performance. Sleeping: Interrupted with enuresis every night O/E: Atopic dermatitis ; breasts at Tanner II -III, pubic hair Tanner I; weight is >95%, height at 75%, BMI is >95. 1
Blood Pressure Growth Charts Pediatric OSAS Sign and Symptoms Night time Symptoms Unrefreshed sleep Snoring Difficulty breathing during sleep Nighttime sweating Restlessness Unusual sleeping positions Upper airway obstruction Enuresis Daytime Symptoms Mouth breathing Moodiness Dysphagia Nasal obstruction Hyponasal speech Aggression, inattention Poor school performance Daytime sleepiness and Morning headaches often seen in adults, not consistent in children Cummings otolaryngology Head and neck Surgery 5 th Edition. Chapter 183, Obstructive Sleep Apnea Syndrome. Laura Sternki, David Tunkel. Accessed online 9.4.12 at http://www.mdconsult.com/books/page.do?eid=4-u1.0-b978-0-323-05283-2..00184-1&isbn=978-0-323-05283-2&uniqid=357956565-3#4-u1.0-b978-0-323-2
3
Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome Original guidelines published in 2002 Revised in Sept 2012 focuses on uncomplicated childhood OSAS Excludes infants younger than 1 year of age patients with central apnea or hypoventilation syndromes patients with OSAS associated with other medical disorders Shiffman et al. Pediatrics 2012;130:576 584 Key Action Statement 1: Screening for OSAS Clinicians should screen for snoring at ALL well child visits If screening positive or signs or symptoms of OSAS, clinicians should perform a more detailed history and exam Occasional snoring(1-2 times per week) is less of a concern 4
Symptoms and Signs of OSAS History Frequent snoring ( 3x/wk) Labored breathing during sleep Gasps/snorting noises/observed episodes of apnea Sleep enuresis (especially secondary enuresis) Sleeping in a seated position or with the neck hyperextended Cyanosis Headaches on awakening Daytime sleepiness ADHD Learning problems Physical examination Underweight or overweight Tonsillarhypertrophy Adenoidal facies Micrognathia/retrognathia High-arched palate Failure to thrive Hypertension Key Action Statement 2: Polysomnography/Referral/Testing If there is signs and symptoms of sleep apnea obtain a polysomnogram Gold Standard refer the patient to a sleep specialist or otolaryngologist for a more extensive evaluation IF PSG not available, alternative diagnostic test may be ordered Have weaker PPV and NPVs but better than clinical evaluation alone. Shortage of pediatric sleep labs Key Action Statement 3: Adenotonsillectomy Adenotonsillectomy recommended as first line of treatment if adenotonsillar hypertrophy is present and no contraindications Contraindications for Adenotonsillectomy Absolute contraindications No adenotonsillartissue (tissue has been surgically removed) Relative contraindications Very small tonsils/adenoid Morbid obesity and small tonsils/adenoid Bleeding disorder refractory to treatment Submucous cleft palate Other medical conditions making patient medically unstable for surgery 5
Risks of Adenotonsillectomy Minor Pain Dehydration attributable to postoperative nausea/vomiting and poor oral intake Major Anesthetic complications Acute upper airway obstruction during induction or emergence from anesthesia Postoperative respiratory compromise Hemorrhage Velopharyngeal incompetence Nasopharyngeal stenosis Death Key Action Statement 4: High Risk Patients High-risk patients should be monitored as inpatients postoperatively. Younger than 3 y of age Severe OSAS on polysomnography (AHI >10) Cardiac complications of OSAS Failure to thrive Obesity Craniofacial anomalies Neuromuscular disorders Current respiratory infection Key Action Statement 5: Reevaluation Patients should be reevaluated 2-3 months after surgery to determine whether further treatment is required. Patients who remain symptomatic and all high-risk patients should undergo objective or be referred to a sleep specialist for further evaluation 6
Additional recommendations (T&A) CPAP recommended if adenotonsillectomyis not performed or if OSAS persists postoperatively Weight loss is recommended in addition to other therapy in patients who are overweight or obese Intranasal corticosteroids for children with mild OSAS if T & A is contraindicated or for mild postoperative OSAS American Academy of Otolaryngology Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Evidence based guide for otolaryngologists Applies to children aged 2-18 yrswith sleep disordered breathing, potential candidates for tonsillectomy +/- adenoidectomy Clinician should refer children with sleep-disordered breathing for PSG if they exhibit complex medical conditions Obesity, Down syndrome, Craniofacial abnormalities, Neuromuscular disorders, Sickle cell disease, Mucopolysaccharidoses The need for surgery is uncertain Discordance between PE and reported severity of symptoms OtolaryngolHead Neck Surgery. 2011 Jul;145(1 Suppl):S1-15. Epub2011 Jun 15. 7
Parasomnia Parasomnia Abnormal behavior during physiological sleep A/ Arousal disorders: Confusionalarousals with hypnagogic dream Sleep walking Sleep terrors(night terrors) B/ Sleep-Wake transitional disorders: Rhythmic movement disorders Sleep talking Nocturnal leg cramps C/ REM sleep associated disorders: Nightmares Sleep paralysis Bruxism, nocturnal Enuresis Sleep walking 8
Sleep talking Talking in your sleep Romantic billboard, 1984 I hear the secrets that you keep, when you re talking in your sleep Dopamine receptor gene (DRD4) region Normal in younger children Could be alarming in teenagers Physical or emotional stress Parasomnia Teenagers &Sleep deprivation 9
Questions? 10