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Running on Empty

For Children, an OSA Diagnosis Is Anything But Typical

By Lunzeta Brackens
Jun 01, 2008

It’s no surprise that a child who fails to get a full night’s sleep would feel less refreshed in the morning. If a child appears to sleep throughout the night and yet awakes irritable and drowsy, however, it could signify a problem — especially if snoring is present. Occasionally, a cold, stuffy nose or allergies cause snoring, but when these culprits are missing and a child snores, it should not be taken lightly.

“Children that constantly snore are abnormal as far as their breathing mechanism,” explains Dr. William C. Kohler, D.A.B.S.M., director of pediatric sleep services at University Community Hospital in Tampa and medical director of the Florida Sleep Institute. “Longitudinal studies have shown that children that snore are more likely to have behavioral problems, cognitive problems and be at the bottom of the class.”

Snoring could be an indicator of a more serious sleep disorder, such as obstructive sleep apnea (OSA). Other apneas, such as central and mixed, are not as common in children.

Signs and Symptoms of Pediatric Sleep Apnea

According to the American Sleep Apnea Association, OSA is estimated to occur in 1 to 3 percent of otherwise healthy preschool children. Peak prevalence is between the ages of 2 and 6, though OSA can occur at any time between infancy and adolescence. Sleep apnea is thought to be equally prevalent among boys and girls.

“When we go to sleep, our body relaxes and our throat relaxes. If our throat is already narrow because our tonsils are big, our tongue base is big or if we have a small jaw or a jaw that’s pushed back like an overbite, it makes for less space in the back of the throat, leaving an apneic episode more likely to occur,” Kohler says.

In addition to problems with the throat, nasal issues, such as large adenoids or significant nasal constriction, contribute to potential apnea as well. Two of the main causes of obstructive sleep apnea in children are large tonsils and adenoids. More than 90 percent of the time removing the tonsils and adenoids remedies the problem, says Kohler, who suggests taking out both the adenoids and tonsils. Some surgeons are reluctant to take out both, but Kohler has noticed that clinically, both tonsils and adenoids contribute significantly. After a tonsillectomy and adenoidectomy, children tend to rebound rather quickly, he adds.

Typically, children who do not opt for surgery have some type of neuromuscular condition that prohibits them from breathing at night, according to Gary Hamilton, B.S., RRT, at ResMed, Poway, Calif. In this case, surgery may not be beneficial.

In fact, obstructive sleep apnea is commonly found in children with muscular dystrophies, certain neuropathies, cerebral palsy, craniofacial anomalies and obese children. Interestingly enough, Kohler says, “most children that are morbidly obese have sleep apnea, but most children that have sleep apnea are not morbidly obese.”

Identifying sleep apnea in children can be rather difficult. Unlike adults who exhibit daytime sleepiness, children are often hyperactive. Children with obstructive sleep apnea may have similar behaviors as children with ADHD, says Natalie DiFeo, RRT, CRNP, at the Children’s Hospital of Philadelphia in Pennsylvania. “Unlike adults who’ll nap when tired, children react paradoxically by increasing their activity to stay awake, mimicking hyperactivity as seen in ADHD,” DiFeo says. “A tired child will have difficulty concentrating and have school performance problems, both of which are symptoms of ADHD.”

Hyperactivity, lack of concentration, problems in school, irritability and depression are all potential signs of sleep apnea in children. Infants typically exhibit irritability.

When sleep apnea hits a child between the ages of 2 and 5, sometimes it’s really hard to get them diagnosed, Hamilton says. Some children may outgrow OSA as their airways get bigger, but in the meantime, OSA can impact growth and mental capabilities.

“We’re always concerned that there is a critical period of damage and that the damage is already too great at some point to repair that underlying problem,” Kohler says. “So, the sooner it’s corrected, the better.” Obstructive sleep apnea can carry on into adulthood if untreated.

In severe cases of OSA, children experience loss of slow wave sleep. “When we go to sleep, we go into stages I and II, then slow wave sleep, deeper stages of sleep and a progression,” Kohler says. “If we have an apneic episode in stage II, we go back to stage I. We never get down to the deeper stages of sleep III and IV. In stages III and IV, our body secretes growth hormones. In severe cases of sleep apnea, children do not grow properly because they’re not getting the proper stage III and IV sleep.”

If the condition is treated early enough, however, children have a better chance of growing at a normal rate.
“(Physicians) will diagnose (children) with a sleep disorder, treat it and then all of a sudden they’ll hit this growth spurt and actually be attentive in school,” Hamilton says. Children may be harder to convince of the treatment than adults, but if parents buy into the program, treatment is much easier.

Alternatives to Surgery

When surgery fails to correct the problem or is not an option, children typically need other types of intervention, such as maxillary expanders to expand a child’s palate or CPAP.

Finding FDA-approved equipment for pediatrics can pose a problem, as there isn’t a lot available, Hamilton says. It’s especially challenging to find a mask that’s small enough for children.

“Those who do pediatrics are special therapists and special techs because it’s not everything handed to them,” he says. “They’re really interested in patient care and they really have to fight.”

Hamilton believes the reason most manufacturers don’t make devices and masks for children is because sleep therapy in children doesn’t reflect a large portion of the population.

Only a few devices are available for children. As a result, many children that require PAP therapy do not have access to pediatric equipment, DiFeo says. Currently, ResMed offers an FDA-approved bilevel device, the VPAP III STA, for a person weighing 66 pounds or more and at least 7 years of age. Respironics also has cleared devices for children at least 7 years of age and weighing 40 pounds, BiPAP S/T and BiPAP AVAPS. The AVAPS, C-Flex and Bi-Flex functions on theBiPAP AVAPS device are not approved for pediatric use.

ResMed’s Kidsta is an FDA-approved pediatric mask. Respironics also offers a youth mask, the Profile Lite Youth Mask. In many cases, petite and small adult masks are used for children.

Educating for Compliance

In educating both children and parents, clinicians must use simple language to describe OSA. DiFeo says she explains OSA to children by telling them that they need air to get into their lungs in order to play and have fun, but when they go to sleep at night, their throat blocks off the air and it can’t get to their lungs. For reinforcement, she implements diagrams and pictures.

DiFeo believes in letting children and parents practice with the equipment during office visits and hospitalization. For instance, the CPAP/BiPAP device is demonstrated by letting parents and children feel the air on their hands first before progressing to the face. Some children may need to wear the mask for a week or more before introducing the flow/pressure, DiFeo says.

“We try to allow the child to have some control by choosing a mask,” DiFeo says. The child tries on two to three masks and is then allowed to pick the one that they like the best. Physicians have preferences on how equipment is administered to children, but most often there is a period of habituation particularly for very young or developmentally delayed children.

Some children have sensory integration disorder and need several weeks to habituate to the feel of the tubing, mask and sound of the machine when turned on. “In such a case, the child may hold the mask with the machine turned on but not anywhere near them,” DiFeo says. The machine may be in a corner of a room and is gradually moved closer to the child over time.

This process could take several weeks or even months. In cognitively intact older children, the process is much faster. These children are fitted with a mask, given a demo, and once they receive the equipment from the DME, begin to use it.
“It is most important for them to put the mask on while still awake so that they have a memory of the mask being on their face when they have an awakening in the middle of the night,” DiFeo says. Otherwise, the child may pull off the mask.

Because sleep therapy isn’t particularly comfortable, education is typically the best way to foster compliance. For children to comply, the parents must be involved from the beginning, DiFeo adds. Hamilton says some parents will say, “Oh you’ll outgrow it” or “I had that too when I was your age, you’ll make do.” “People just don’t know that much about sleep,” he says.

Lack of knowledge shouldn’t keep a child from being healthy and getting a good night’s rest, however. If parents realize the benefits early on, they can help the child by dispelling fears and negative perceptions about masks. Some children may perceive the mask as strange, so it’s a good idea to play creative games with them, such as spaceman, to acclimate them to wearing it, Kohler says.

Older children sometimes feel that they’ll never be able to go to a sleepover again because of the equipment. They also fear that if they leave the device at home, they’ll snore and wake everyone up.

Besides the look and feel of the mask, DiFeo pointed out a few other issues to compliance:

Insurance coverage — Not all insurances cover the devices prescribed.
Patient comfort — Poor mask fit and lack of heated humidity are major factors affecting comfort and compliance.
Developmental level — Toddlers and children who are cognitively impaired are more of a challenge. Often-times, adolescents are resistant to using CPAP even though they understand OSA and the reason for CPAP.
Parents’ attitude — Parents can be a barrier if they don’t buy into the use of CPAP. Parents need to understand OSA and how CPAP works to maintain the airway. If a parent feels that CPAP will emotionally or physically cause harm, they won’t support its use.
Maternal education — Studies show that children whose mothers are more educated use their CPAP for more hours per night.

Successfully treating OSA in children is all about early intervention. “It’s such an exciting thing about treating children with sleep apnea,” Kohler says. “You can have such a positive influence on their positive growth and development, so it’s very important to recognize it early and get it treated early.”