1. Treatment of Pediatric OSA Dr Meir Kryger

2. Introduction: Why this is important State of alertness affects a child's ability to Concentrate Focus Learn Succeed Sleepiness can ruin a child’s life Disorders causing sleepiness such as OSA can be treated

3. Objectives Recognize the faces of sleepiness Understand the causes of sleepiness What to do with a sleepy child suspected of OSA

4. Overview Sleep breathing disorders in children are common They can cause children to fail The symptoms can be easily recognized The disorders can be treated Once treated performance can be normal

5. Important principles in dealing with pediatric sleep problems Children almost never bring a sleep problem to anyone’s attention The medical encounter is started by a parent or a teacher What is the problem? Whose problem is it?

6. How do children with apnea present? Behavioral symptoms Manifestations of sleepiness Observations of their sleep What does the parent see?

7. The faces of the sleepy child Falling asleep Difficulty concentrating Memory lapses Loss of energy Lack of initiative Emotional lability Hyperactivity

8. The differential diagnosis of sleepiness Reduced quantity of sleep Deprivation, abnormal body clock Reduced quality of sleep Sleep disruption Primary Sleep Disorder Sleep apnea Narcolepsy

9. Almost all students are sleep deprived!

10. Diary of a night owl Monday Tuesday Wednesday Thursday Friday Saturday Sunday 024681012141618202224 Time

11. What the parent observes Noisy breather Snoring, snorting Gasping Stopping breathing Restless Moves a lot Sweats

12. The HPI will cover Behavioral symptoms Manifestations of sleepiness Observations of their sleep What does the parent see? Medications Other illnesses

13. What illnesses? Congenital Skeletal structures Control of breathing Acquired

14. 14 Patient Central canal Spinal cord Spinal Cord Normal Congenital: Syringomyelia

15. Congenital: Klippel Feil

16. 16 Congenital: Down syndrome

17. Congenital: Mucopolysaccharidosis

18. 18

19. 19 Infiltration of airway

20. 20 Congenital: mysteries

21. 21 Acquired: enlarged tonsils

22. 22 Acquired: enlarged tonsils

24. 24 Acquired: (from parent) Small lower jaw

25. 25 Acquired: obesity in toddler

26. Acquired: obesity in teen

27. Acquired: misdiagnosed

28. Confirming the diagnosis

29. What you end up doing depends on Beliefs of parents Beliefs of referring clinician Beliefs of insurance companies Whether long term treatment will be needed Most of the times you’ll end up doing PSG

30. Nitty gritty of PSG in children Show child bedroom before they come in Have them bring in whatever they use to fall asleep (blankets, teddy bears) Parent/guardian in room One tech per patient– need experienced tech Don’t do split in child

31. End tidal PCO2 Synchronized video Pediatric PSG

33. Pediatric PSG: may be classic

34. Pediatric PSG: may be classic with surprises

35. Pediatric PSG: with more surprises

36. Pediatric PSG: yet more surprises

37. What is observed: may be subtle

38. What is observed sped up

39. Restless sleep and apnea

40. Mask fitting in child may be difficult

41. 3 case studies Presentation What is the problem? Whose problem is it? Assessment What data is needed to find cause of problem? Analysis How is data used to find cause of problem? Solution What was done

42. Case 1: Falling asleep in class

49. Sleep apnea occurs in children History of snoring Often have big tonsils, obesity or overbite Check bite during health exam Usually cured with treatment Remember the orthodontic window Take home messages

50. Case 2: Hyperactive child

54. Sleepiness in a child may paradoxically present as hyperactivity Do sleep evaluation in ADHD children Take home messages

55. Case 3: Falling asleep in class

57. How do you put this case together? 1.Since the apnea episodes are less than 20 seconds, no diagnosis of central apnea can be made using pediatric rules 2.The patient has a neurological disease 3.The patient likely has cardiac valve disease. 4.The patient has idiopathic central apnea

58. You have 10 seconds!!!!

59. Answer 3. The patient had a streptococcus B. infection of her tonsils, followed by bizarre neurological symptoms. These symptoms are those of Sydenham's Chorea, which is very frequently associated with rheumatic fever, which in turn often causes valvular heart disease. The Chorea (also called St. Vitus's dance) can come on up to several months after the rheumatic fever.

60. What to expect with treatment

61. Summary You have learned sleep disorders common in children can cause difficulty in school patterns can be recognized How you can help the child suspect sleep problems when student falls asleep in class or is hyperactive snores or jaw is small

62. Thank you I’ll be happy to take questions