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Questionnaire can be used as a screening tool for OSA in otherwise healthy children aged 2-18 . 12 It has a sensitivity of 85 % and specificity of 87 % for sleep disordered breathing defined as AHI ≥5 events / hour , a level where surgical intervention is often indicated . 13 Sensitivity and specificity are both high when more than eight questions are positive . Key questions relate to snoring , witnessed apnoeas , mouth breathing , nocturnal enuresis and daytime symptoms including difficulty waking , daytime somnolence , school concerns , morning headaches , growth parameters and difficult to manage behaviours . Depending on the age of the child , physicians should also enquire about academic performance and concentration , which are increasingly associated with OSA in older children . Sleep patterns including bedtime , wake time , awakenings and sleep duration should be discussed . Sleep diaries can also be useful to evaluate frequency of snoring , and / or sleep patterns when considering referral to a sleep specialist .
Examination of a child with clinical suspicion of OSA should include assessment of facial morphology , nasal patency , thoracic deformities , consideration given to generalised ( or specific ) hypotonia and airway ( and tonsillar ) size . Large tonsil size predicts which child will benefit from adenotonsillectomy for OSA . Mallampati scores correlate with severity of OSA in children , with measures of obesity ( BMI ) also contributing . 14 Important features include the presence of mouth breathing , hyponasal voice , and degree of nasal airflow . Note facial features such as adenoid facies , micrognathia , asymmetries or hypoplasia of the midface or lower jaw . Routinely assess growth parameters including height , weight and head circumference .
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Sleep patterns including bedtime , wake time , awakenings and sleep duration should be discussed .
Table 1 . Obstructive sleep apnoea severity 6
Number of events per hour
≤1
≥1 and ≤5
≥5 and ≤10
Severity
Within normal limits
Mild
Moderate
> 10 Severe
Perform a cardiovascular examination to screen for OSA-related morbidities including pulmonary hypertension and cor pulmonale . Record blood pressure , especially in patients with obesity , to screen for hypertension . With ease of access to smart devices and video recording , parents often have sleep recordings which can contribute to the overall assessment of the child .
During a primary healthcare visit a history of snoring should be routine for any paediatric assessment .
Surgical management
Where there is a strong suspicion of OSA due
to adenotonsillar hypertrophy in otherwise healthy children aged three and older , consider referral to an ENT surgeon for assessment for adenotonsillectomy . Children aged less than three and / or with associated medical comorbidities have a higher risk of postoperative respiratory complications . This group or those with additional comorbidities or risk factors for OSA ( clinical , questionnaire or physical screening ) should be referred to a
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15 , 16 sleep physician for a formal PSG .
Additional screening procedures may include a lateral airway X-ray to assess for adenoid hypertrophy . Overnight home oximetry , arranged by a sleep physician , can be used to screen for the presence of OSA and to triage patients according to their risk for postoperative respiratory complications where there is no access to a formal PSG . Home studies are not currently covered for children under the MBS .
Adenotonsillectomy is most effective in curing OSA ( post-adenotonsillectomy AHI < 1 ) in male , non-obese patients with mild pre-adenotonsillectomy AHI ( AHI < 5 ). 17 Factors that are associated with a persistently high AHI post-adenotonsillectomy include age greater than seven , increased BMI z-score , asthma , and a high pre-adenotonsillectomy AHI . 17 The risk of persisting OSA is up to 59 % for children with obesity ( post-adenotonsillectomy AHI of > 5 events / hour ). 17 Therefore high-risk patients including older children , male , obese and non-obese children with either severe pre-adenotonsillectomy OSA or asthma should undergo a PSG following adenotonsillectomy . Adenotonsillectomy has been associated with improved behaviour and sleep outcomes especially in preschool aged children and improved quality of life scores . 18 , 19 Repeat PSG following surgery is also indicated for children in which symptoms persist post-adenotonsillectomy .
Medical management
Medical treatments include nasal steroids
and oral leukotriene receptor antagonists ( montelukast ), in children aged two and older . Nasal steroids include mometasone furoate , 50μg / spray , and fluticasone furoate , 27.5μg / spray . Beneficial effects of both nasal steroids and montelukast are
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likely secondary to reduction in adenoid size , however the evidence is not robust . 20 One study demonstrated an improvement in 62 % of cases of mild OSA when treated with a 12-week combination of intranasal corticosteroid and oral montelukast , however this was similar to the spontaneous improvement seen in children enrolled in the Childhood Adenotonsillectomy Trial . 21
Treatment-resistant disease
In severe or refractory cases treatment
options beyond initial adenotonsillectomy should be supervised and monitored within a specialist paediatric sleep medicine service . Options include other ENT surgery , orthodontic procedures , craniofacial and / or airway surgeries , and use of airway support therapies including CPAP or bilevel positive airway pressure .
Summary
OSA is common among children . It is important to diagnose and appropriately manage OSA to prevent adverse neurocognitive , cardiovascular and metabolic effects . Early referral to either ENT or sleep specialists is vital in improving outcomes for these children .
References on request from kate . kelso @ adg . com . au
Online resources
• Australasian Sleep Association : Paediatric resources bit . ly / 41o7H5J
• The Royal Children ’ s Hospital Melbourne — Kids health information : Obstructive sleep apnoea bit . ly / 3NWNMI1
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