Pediatric Sleep Apnea

Newswise — Snoring and obstructive sleep apnea are sleep disorders normally associated with middle-aged, overweight, males. Yet some 12 percent of pre-school children have primary, habitual snoring and more alarmingly, some one to three percent of children have the potentially life threatening medical condition of obstructive sleep apnea (OSA). OSA occurs after periodic obstruction of the upper airway that interferes with normal breathing consequently disturbing normal sleep. Children with OSA often present to the family and physician specialist with a picture of snoring and witnessed apneas. If not properly treated, OSA can result in cardiorespiratory disorders and growth retardation.

Most physicians agree that the gold standard for diagnosis of pediatric OSA is full night polysomnography (PSG) or sleep study. However, the PSG is expensive, time-consuming, and frequently unavailable at institutions that treat children with OSA. Consequently, the surgeon's clinical diagnosis of OSA is often a subjective. While PSG provides objective data regarding the presence and severity of sleep apnea, this diagnostic test fails to assess the quality of life changes that accompany pediatric OSA.

Adenotonsillectomy, or the removal of tonsils and adenoids, is one of the most common procedures performed in children. Approximately 274,000 adenotonsillectomies were performed in the United States in 1996. In the last decade, this surgical procedure has been utilized with increasing frequency to treat OSA instead of infected tonsils. However, much controversy remains concerning the diagnostic indications for this procedure, as there are few randomized controlled trials that exist to identify diagnostic strategies and treatment indications for this sleep disorder.

How pediatric OSA influences behavior, neurocognition, and emotion has yet to be fully defined. Recent literature on the health status of children with OSA highlights the significant impact of this disease process on quality of life (QOL). Uncertainty regarding treatment for OSA in children underscores the importance of considering health-related QOL in the assessment of surgical outcomes. Outcome studies better evaluate changes in morbidity following adenotonsillectomy through the utilization of validated QOL surveys.

Several such disease-specific QOL surveys, including the Obstructive Sleep Disorders-6 (OSD-6), the Tonsil and Adenoid Health Instrument, and the OSA-18 have been developed for children with OSA. The OSA-18 is the most widely utilized QOL instrument in the pediatric OSA literature. This assessment tool features 18 items organized into the five domains of sleep disturbance, physical suffering, emotional distress, daytime problems, and caregiver concerns. The OSA-18 correlates with respiratory disturbance index (RDI) on nap polysomnography and has been validated as both an evaluative and discriminative instrument in pediatric OSA.

Past clinical trials focusing on quality of life (QOL) for children with OSA have addressed sleep apnea and tonsillitis and have failed to systematically use a full-night PSG during the trial. Other research efforts lacked a control group or proper randomization of the subjects.

A new research effort addresses the lack of consensus on surgical indications for pediatric OSA by assessing QOL outcomes following adenotonsillectomy. This first meta-analysis effort examines the existing data on pediatric OSA and QOL to compare healthy pediatric patients and those with OSA. The study also sought to determine QOL in children with OSA after adenotonsillectomy in both short and long-term follow-up.

The author of "The Impact of Pediatric Sleep Apnea on Quality of Life," is Cristina Baldassari MD, from the Virginia Commonwealth University, Richmond, VA. Her findings are being presented at the 110th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 17-20, 2006, at the Metro Toronto Convention Centre, Toronto, Canada.

MethodologyThe researcher reviewed studies that focused on QOL in children with obstructive sleep apnea published between the years 1970 and 2005 and listed in the National Library of Medicine's PubMed database. Studies were included if they met the following criteria: (1) clinical diagnosis of sleep disordered breathing, obstructive sleep apnea, and/or chronic tonsillitis; (2) patient age range of 1 to 18 years; (3) use of the Child Health Questionnaire (CHQ) to assess health related QOL in children with OSA; (4) use of the OSA-18 QOL survey to evaluate outcomes in children undergoing adenotonsillectomy; (5) reporting of QOL data at least 4 weeks after adenotonsillectomy in the short term or 6 months follow-up in the long term (6) surgical adenotonsillectomy. Utilization of PSG for diagnosis of OSA was not an inclusion criterion.

The articles were organized into three separate groups. The first set (Group 1) included studies that utilized the Child Health Questionnaire Survey (CHQ) to analyze QOL in healthy children, children with OSA, and children with chronic conditions such as juvenile rheumatoid arthritis. Papers, which reported QOL in children following the intervention of adenotonsillectomy, were divided into two categories (Group 2 & Group 3). Group 2 was comprised of studies with short-term follow-up of at least four weeks, while Group 3 featured studies that reported QOL data at least 6 to 12 months following adenotonsillectomy. Results Nineteen studies on quality of life in pediatric OSA were identified. After exclusions, ten publications that met the criteria and were included in this meta-analysis. A total of 535 children with adenotonsillar hypertrophy comprised the study population. The meta-analysis revealed that 193 patients with OSA were compared to 815 healthy children using the Child Health Questionnaire (CHQ). Mean CHQ subscale scores for children with OSA were significantly lower than controls. Children with OSA had scores that were similar to those of children with chronic medical conditions like juvenile arthritis. In a series of seven publications, 342 children with OSA undergoing adenotonsillectomy were studied utilizing the OSA-18 QOL instrument. The mean total OSA-18 score and each of the individual domain scores significantly decreased (indicating an improvement in QOL) following surgical intervention. 66 children completed at least one year of follow-up after undergoing adenotonsillectomy for OSA. The improvements in QOL were maintained in the long-term.

The meta-analysis confirms that children with adenotonsillar hypertrophy have a poorer health status than healthy children. Pediatric patients with OSA scored significantly lower in eight of the 12 CHQ subscales. Furthermore, health status in children with OSA was similar to that of children with juvenile rheumatoid arthritis. Quality of life in pediatric patients with OSA markedly improves following adenotonsillectomy. Both the OSA-18 total score and individual domain scores were significantly lower (indicating better QOL) following surgery. This improvement in QOL was maintained in long-term follow-up at six to 12 months.

ConclusionsOne of the main strengths of this publication is the large study population. Much of the current literature on QOL in children with OSA features small patient groups. By combining the data from various papers, the researchers were able to generate outcome data for a large number of children with diverse ethnicities, other illnesses, and socioeconomic statuses. Thus, our findings are applicable for the average child presenting with obstructive sleep symptoms. Recent publications on pediatric OSA highlight the controversies surrounding the need for adenotonsillectomy. This research effort shows a clear improvement in quality of life following surgical intervention. OSA has a significant detrimental impact on pediatric patients' quality of life. The high prevalence of OSA in children should make the diagnosis and treatment of pediatric OSA a public health priority.