It May Be
Time to Stop Ignoring Your Child's Snoring
The nation's largest group of pediatricians
is urging physicians to be on the lookout for—and to treat more aggressively—obstructive
sleep apnea syndrome (OSAS), a nighttime breathing disorder that affects
at least 2 percent of children. .jpg) Snoring, though often benign in children, is a
sign of the disorder.
The American Academy of Pediatrics
(AAP) has issued the first clinical practice guidelines for
the diagnosis and management of OSAS, which can lead to learning and
behavioral problems. In severe cases, it can cause life-threatening
cardiorespiratory problems. The guidelines appear in the April issue
of Pediatrics, journal of the AAP.
"I don't think [OSAS] is on the rise, but
it was ignored a lot in the past. If you look at the 1960s and 1970s,
these children weren't diagnosed until they came in with a coma or heart
failure," says Dr. Carole Marcus, head of the pediatric sleep center
at Johns Hopkins University in Baltimore, and chairwoman of the AAP
subcommittee that issued the guidelines.
"It has become apparent that [physicians]
are doing very different things and not keeping up with the literature
and not doing the best management," she says.
"The condition is underrecognized," agrees
Dr. Raouf Amin, associate professor of pediatrics and director of the
Sleep Disorders Clinic at Cincinnati Children's Hospital Medical Center.
The American Thoracic Society had previously issued
similar guidelines, but those were geared toward specialists.
The AAP guidelines are
targeted to all pediatricians.
"Quite frequently, general pediatricians
don't ask detailed questions about sleep apnea and general sleep disorders,
so these guidelines would make pediatricians more aware of the syndrome
and what are the things that they need to use in order to screen for
this type of abnormality," Amin says.
Children with OSAS experience obstruction
of their upper airway (often by enlarged tonsils and/or adenoids), which
disrupts their breathing while they are asleep.
Symptoms
of OSAS
The following are the most common symptoms
of OSAS. However, each individual may experience symptoms differently.
Symptoms may include:
- loud snoring or noisy breathing during
sleep
- periods of not breathing - although
the chest wall is moving, no air or oxygen is moving through the nose
and mouth into the lungs. The duration of these periods is variable
and measured in seconds.
- mouth breathing - the passage to the
nose may be completely blocked by enlarged tonsils and adenoids.
- restlessness during sleep (with or without
periods of being awake)
- excessive daytime sleepiness or irritability
(because the quality of sleep is poor, the child may be sleepy or
irritable in the daytime)
- hyperactivity during the day
The symptoms of OSAS may resemble other
medical conditions or problems. Always consult your child's physician
for a diagnosis.
If left untreated, the condition can lead
to severe complications, including learning and behavior problems.
Although OSAS can affect all children from
babies to adolescents, it is thought to be most prevalent among preschool-aged
children. This is the age when the tonsils and adenoids, which cause
the obstruction, are largest in relation to the airway size.
Risk factors include obesity, craniofacial
anomalies, and neuromuscular disorders.
Among other things, the AAP
is recommending that pediatricians screen all children for snoring;
that a diagnosis be made with the assistance of polysomnography, a machine
that records several bodily functions during sleep; and that the first
line of treatment be an adenotonsillectomy—or removal of both the tonsils
and adenoids.
"One of the big things about these guidelines
is that we're recommending objective testing and not to make a decision
to treat based on history," Marcus says.
The AAP now recommends
that a detailed sleep history for snoring become part of all healthcare
visits. Such a case history, even along with a physical examination,
are still not enough to diagnose OSAS, the AAP stresses.
The group calls the polysomnography test
the "gold standard" for diagnosing OSAS. Other diagnostic techniques,
such as videotaping, may be useful but only as an adjunct.
Once a diagnosis is made, adenotonsillectomy
should be the first treatment considered. "In otherwise healthy children,
this will cure about 95 percent of them," Marcus says.
Continuous positive airway pressure, or
CPAP, is an alternative for those who are not candidates for surgery
or who do not respond to surgery. CPAP involves delivering constant
air pressure via a nasal mask worn during sleep. Unlike an adenotonsillectomy,
which fixes the problem immediately, CPAP has to be used indefinitely
and requires the child's continued compliance.
The AAP stresses that
its guidelines are only for uncomplicated childhood OSAS—in other words,
for children who are otherwise healthy.
"Children who have other underlying conditions
might need further therapy," Marcus says.
Always consult your child's physician for
more information.
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