Obstructive sleep apnea in pediatric patients generally responds to adenotonsillectomy. However, not all children with obstructive sleep apnea (OSA) are surgical candidates.
Adenotonsillectomy, along with weight normalization, is considered the first line of therapy in children and adolescents with obstructive sleep apnea. Surgically removing the tonsils and adenoids increases cross-sectional airway caliber in patients, although it does not directly affect the fatty infiltration of the soft tissues of the velopharynx and hypopharynx that occurs in children who are obese. Children with obstructive sleep apnea who are obese generally require follow-up polysomnography 8-12 weeks following adenotonsillectomy to assess for residual sleep apnea and determine whether other interventions (eg, continuous positive airway pressure [CPAP]) are needed.
Some children have profound craniofacial deformities that are not easily remedied. Occasionally, surgical procedures undertaken to remedy obstructive sleep apnea only help the problem but do not completely eliminate it. In these situations, therapy is usually best accomplished with devices that deliver CPAP.
- CPAP is the mainstay of therapy for most adults with obstructive sleep apnea, as well as a large number of children and adolescents. Continuous distending airway pressure is applied during sleep using a nasal mask and small compressor. CPAP acts as a pneumatic splint to maintain airway patency. By simultaneously increasing the functional residual capacity, this pressure also helps prevent oxygen desaturation even if airway obstruction breaks through.
- Various patient interfaces are available, including nasal masks, facemasks, gel masks, and nasal pillows to help facilitate a comfortable fit and adherence to therapy. The amount of CPAP pressure must be individualized for each patient and is determined during a CPAP titration study in the sleep laboratory. The goal is to find an optimal pressure that eliminates apnea and minimizes snoring but is still comfortable and does not lead to excessive air swallowing, gastric distention, and air leak around the mask or through the mouth. Long-term effects of nasal CPAP therapy on maxillofacial structure development in children are unknown.
- Numerous commercially available oral (PO) appliances assist in bringing the lower jaw and tongue forward during sleep, thus improving obstructive sleep apnea. These devices are expensive, require special dental expertise, and are associated with frequent adverse effects such as jaw pain and temporal mandibular joint dysfunction. Small growing children are likely to outgrow appliances, necessitating refitting and replacement. In general, PO appliances have extremely limited usefulness, if any, in pediatric patients.
- Over-the-counter, disposable, adhesive covered nasal strips purported to decrease nasal airflow resistance have been promoted as a treatment for snoring and obstructive apnea. These have not been proven to be effective in pediatric sleep apnea, and their use should be discouraged.
- Obstructive apnea is generally worse in supine sleeping than in prone sleeping. Measures to encourage patients to sleep prone, such as sewing a pocket to the back of the pajama shirt and putting a tennis ball into it, have some minimal success among adults who snore or have very mild obstructive apnea. This strategy is generally not helpful in managing significant childhood sleep apnea.
- Nasal fluticasone administered daily for 6 weeks is shown to ameliorate the frequency of obstructive events in children with mild-to-moderate obstructive sleep apnea due to tonsil or adenoid hypertrophy by about one half.
- Nasal steroids offer an opportunity to reduce obstructive events pending surgery or can be an alternative remedy for children with mild disease whose parents are reluctant to pursue surgical treatment.3
- Steroids are not shown to decrease obstructive symptoms, eliminate the need for surgery, prevent oxygen desaturation, or shrink tonsil or adenoid tissue.
- No long-term studies are available to assess the duration of steroid effect, and whether beneficial aspects persist even if therapy is continued is unknown.
- A trial of topical steroid therapy should not delay surgical treatment of obstructive apnea in children with severe tonsillar hypertrophy or moderate-to-severe obstructive sleep apnea.
- No studies have assessed the efficacy of topical steroid therapy in children with craniofacial abnormalities and obstructive sleep apnea.
- Short courses of systemic steroids (prednisone, 1 mg/kg/d PO for 5 d) have been shown to be ineffective in the treatment of childhood obstructive sleep apnea due to tonsil or adenoid hypertrophy.
- In the pediatric population, most obstructive sleep apnea is related to tonsillar hypertrophy or adenoid hypertrophy. Adenotonsillectomy is curative in most instances. Children with obstructive sleep apnea who undergo adenotonsillectomy demonstrate improvement in measures of neurocognitive function.
- Certain children who are known to have a high risk of postoperative complications should only undergo surgery at institutions that possess pediatric intensive care facilities (PICUs). This high-risk group includes children younger than 3 years and those with craniofacial abnormalities, failure to thrive, hypotonia, morbid obesity, a history of previous airway trauma, and severe abnormalities on polysomnography (respiratory disturbance index [RDI] >40 or oxygen desaturations <70%).
- Uvulopalatopharyngoplasty (UPPP [ie, UP3]) is not commonly performed in children. During the procedure, the uvula, posterior margins of the soft palate, and lateral pharyngeal wall mucosa are removed via scalpel or laser ablation. UPPP surgery is likely to be successful in relieving obstructive sleep apnea only if the major site of obstruction is localized to the soft palate. This surgery carries a risk of velopharyngeal insufficiency, which may be increased among pediatric patients. Although UPPP may effectively eliminate most snoring, the procedure does not always cure obstructive sleep apnea. Follow-up polysomnography 2-3 months after surgery is warranted to reassess for residual apnea.
- Tongue reduction procedures (midline partial glossectomy) may have some use in a small number of carefully selected pediatric patients (eg, Beckwith-Wiedeman syndrome).
- Tracheotomy remains an effective surgical option for life-threatening obstructive apnea that is not amenable to other therapies.
Teams of pediatric specialists often collaborate in the care of infants and children with sleep apnea. Members of the following specialty groups have specific expertise that may help the primary care physician coordinate the care of their patient with sleep apnea:
- Pediatric sleep medicine
- Pediatric otolaryngology
- Pediatric plastic surgery
- Orthognathic surgery
- Pediatric neurosurgery
- Pediatric anesthesia
- Pediatric endocrinology
- Pediatric pulmonology
- Pediatric cardiology
- Obstructive sleep apnea may aggravate gastroesophageal reflux. Children and adolescents with significant sleep apnea should avoid eating large amounts just before bedtime. This is especially the case if children are being treated with CPAP, which can lead to air swallowing and gastric distention.
- Caloric intake limitation and dietary counseling are necessary if obesity complicates obstructive apnea.
- Many individuals with obstructive sleep apnea have daytime sleepiness with reduced attention span and difficulty focusing their concentration. Warn teenagers who drive about the potential danger of falling asleep at the wheel; advise them to avoid driving long distances without a break or driving when they are unusually tired. Numerous epidemiologic studies link obstructive sleep apnea to motor vehicle accidents.4
No effective pharmacologic therapy for childhood obstructive sleep apnea (OSA) is recognized. Individuals with obstructive sleep apnea and hypersomnolence should have the underlying cause of their obstructive apnea addressed, rather than use stimulant medication during the day in an attempt to help stay alert.
Nocturnal supplemental oxygen is generally not advised as a primary treatment for obstructive sleep apnea. Although oxygen may blunt the degree of hemoglobin desaturation during sleep, it does not prevent sleep fragmentation, sleep deprivation, or associated autonomic stimulation during the obstructive episodes. Preoperative supplemental oxygen treatment has been reported to worsen obstructive hypoventilation in some children. Therefore, if oxygen is used as a bridge to more definitive therapy, the effect of supplemental oxygen should be documented during nocturnal polysomnography.
Intranasal fluticasone propionate (Flonase) administered daily for 6 weeks has been shown to ameliorate the frequency of obstructive events in children with documented mild-to-moderate obstructive sleep apnea caused by tonsil and/or adenoid hypertrophy by about one half. Intranasal corticosteroids have not been shown to decrease obstructive symptoms, eliminate the need for surgery, prevent oxygen desaturation, or shrink tonsil or adenoid tissue; therefore, if intranasal corticosteroids are used, the treatment is only temporary pending a more permanent solution. Systemic corticosteroids have not been shown effective and have no role in treatment.
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