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Sleep-Related Obstructive Respiratory Disturbances in Childhood

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Robert Rogers, DMD

ABSTRACT Over the past decade, sleep disordered breathing has achieved prominent focus in the medical community and public arena. Historically, attention has been heavily weighted toward diagnosing and treating adults. Recently, the body of knowledge regarding the effect of sleep-related obstructive respiratory disturbances in children has expanded and is commanding widespread attention. Childhood sleep disordered breathing differs significantly from that of adults in regard to symptoms, pathogenesis, diagnosis, treatment and outcome parameters. Effective treatment of this childhood disorder requires an understanding of the differences.

Therapy with oral appliances to manage sleep disordered breathing has been shown to be an effective and desirable treatment modality and dentists have joined physicians at the forefront in the effort to manage this widespread problem. Historically, attention has been heavily weighted toward diagnosing and treating adults but recently the body of knowledge regarding the effect of sleep-related obstructive respiratory disturbances in children has expanded and is commanding widespread attention. Childhood sleep disordered breathing differs significantly from that of adults in regard to symptoms, pathogenesis, diagnosis, treatment and outcome parameters. Effective treatment of this childhood disorder requires an astute understanding of these differences and as care providers, dentists must develop an appreciation for the unique characteristics inherent therein.

Sleep-related obstructive respiratory disturbances in children are similar to those in adults because snoring may be present, sleep architecture may be disturbed, oxygen desaturations may occur and daytime sleepiness may be observed. Of critical import, though, is that significant sleep disordered breathing is quite often present in children who do not exhibit these cardinal signs and symptoms that are customarily seen in adult patients. Clinicians and diagnosticians must understand that small children are uniquely different than adults and as such, present their own version of sleep disordered breathing. The reader is referred to two recent articles that appeared in the ADSM journal, Sleep and Breathing, for a more detailed discussion and comprehensive references.1, 2

Sleep disordered breathing is increasingly being recognized in the younger population, affecting 1 – 3% of children. Failure to diagnose and treat obstructive sleep apnea-hypopnea syndrome (OSAS) can result in serious, but generally reversible consequences for the child including impaired growth, neurocognitive and behavioral dysfunction and cardiorespiratory failure.

Pathogenesis

The pathogenesis of OSAS in children is multifactorial in its association with narrowing of the upper airway during sleep. Unlike that in adults, however, adenotonsillary hperplasia is most often responsible and only in exceptive cases can obesity be found to be a major factor. The peak incidence is between 3 to 6 years of age, when tonsils and adenoids are largest in relation to airway size. Most children with OSAS are of normal weight or may even experience poor weight gain. It is important to note, however, that not every child with adenotonsillar hypertrophy will exhibit OSAS and adenotonsillectomy will not always improve a child’s breathing during the night.

Recognition

The signs and symptoms of sleep-related obstructive respiratory disturbances in children deviate distinctly from the characteristics of sleep disordered breathing in adulthood and are less comprehensible . Most notably, a child with significant OSAS will frequently not exhibit loud irregular snoring, but rather, only a louder breathing noise.

Restless sleep, perhaps with increased sweating and parasomnias have been described in the context with obstructive respiratory disturbances. Daytime symptoms may include mouth breathing due to aggravated nasal respiration and frequent infections of the respiratory tract resulting in disease-disturbances of concentration, performance and behavior. These may manifest as enhanced motor restlessness and occasional daytime sleepiness. Characteristic of an obstructive sleep-related disturbance of breathing is a failure to thrive that is reported in more than 50% of all cases described in the literature.

Diagnosis

Polygraphic parameters such as respiratory disturbance index (RDI), apnea-associated arousals, sleep architecture and oxygen saturation that are of diagnostic value relating to adult OSAS cannot be assessed in the same way for OSAS in children.

Children with OSAS typically have continuous partial obstructive hypoventilation with lower numbers of discrete apneas, fewer arousals, less sleep disruption on the macroscopic level and less oxygen desaturation. For children, lower threshold values than used in adults have been recommended. Although not systematically validated, typical RDI thresholds for the diagnosis in children range from 1 to 5 events per hour.

The child’s upper airway frequently does not obstruct completely and so is nearly invisible on the polysomnogram, but none-the-less will incur massive increased breathing effort. This means that children’s sleep-related respiration disturbances often represent a combination of OSAS with upper airway resistance syndrome.

Conclusion

Correctly diagnosing OSAS is far more difficult in children than in adults. Since the clinical symptoms in children are often unclear and the assessments of the polysomnographic data are challenging, increased commitment is required of all practitioners involved in this growing area of concern.

BIBLIOGRAPHY

1. Scholle, S, Characteristics of sleep-related obstructive respiratory disturbances in childhood, Sleep and Breathing, Vol. 4, No. 1, 2000, pp 17-21

2. Rosen, C, Diagnostic approaches to childhood obstructive sleep apnea hypopnea syndrome, Sleep and Breathing, Vol. 4, No. 4, 2000, pp 177-181

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