1. Vitamin D and Obstructive Sleep Apnea in Children
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Vitamin D and Obstructive Sleep Apnea in Children
Alexandra Dati
UF Dietetic Intern
June 17, 2015

2. Outline Objectives Review of sleep apnea Sleep apnea in children
Vitamin D and sleep apnea
Implications for practice

3. Objectives Obtain basic knowledge of obstructive sleep apnea
Understand obstructive sleep apnea in children
Recognize relationship of vitamin D and obstructive sleep apnea
Learn clinical approaches to vitamin D and obstructive sleep apnea

4. Obstructive Sleep Apnea

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What is it?
A sleep disorder that is marked by pauses in breathing of ten seconds or more during sleep, and causes unrestful sleep
Results in oxygen desaturation and increased carbon dioxide
Need for increased respiratory effort
Cortical or subcortical arousals
Sleeper will typically drift back to sleep and may not be aware of arousals

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Pathophysiology
The tongue falls back against the soft palate, the soft palate and uvula fall back against the throat, effectively closing the airway
Result: when the sleeper expands the chest to inhale, no air enters the lungs
Small upper airway
Small lower face
Small mouth
Large tongue
Tonsil/adenoid enlargement
Increased pharyngeal fat pads
Increased in
Back sleepers
Middle-age
Overweight
Male
two times more common in males
- As the graphic shows, the sleeper’s tongue has fallen back against the soft plate, the soft palate has collapsed against the back of the throat, and both the nasal and the oral airways are obstructed, creating apnea
The Nemours Foundation/KidsHealth
Habib M’henni/Wikimedia Commons

7. Obstructive sleep apnea
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Obstructive sleep apnea
Symptoms
Diagnosis
Snoring
Fatigue
Daytime sleepiness
Restless sleep
Morning headaches, dry mouth, or sore throat
Medical and family histories
Physical exam
Sleep study results
Sleep study- polysomnogram- records brain activity, eye movements, heart rate, and blood pressure; records amount of oxygen in the blood, air movement through your nose while you breathe, snoring, and chest movements.
Sensors on scalp, face, chest, limbs, and finger

8. Prevalence Affects approximately 12 million Americans
Mild, moderate, or severe
How many times a person pauses their breathing or has lower airflow per hour
How low a person’s oxygen level in their blood drops during those times
The amount of sleepiness a person feels during the day

9. Obstructive Sleep Apnea In Children

10. Prevalence Estimated 1%-5% of children have OSA
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Prevalence
Estimated 1%-5% of children have OSA
Peak prevalence 2-8 years
Reduced airway caliber vs. increased upper airway collapsibility
Multiplicity of causative factors coexist in children with OSA
Children at higher risk include:
Craniofacial syndromes
Dwarfism
Cerebral palsy
Neuromuscular disorders
Spina Bifida
Sickle cell disease
Trisomy 21
Seasonal allergies
Asthma
Small lower jaw
Large tongue
Large tonsils and adenoids
Afro Caribbean race
Obesity
Airway caliber: small jaw, large tonge, increased pharyngeal fat pads, and large adenoids/tonsils
Increased collabsibility: presence of upper airway inflammation and altered neurological reflexes involving respiratory control of upper airway muscles emerge as most prominent

11. Pathophysiological Factors involved in pediatric OSA

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Obesity and OSA
Each 1 kg/m2 increment in BMI above the 50th percentile is associated with an increased risk for OSA by 12%
45% if obese children with OSA also have evidence of adenotonsillar hypertrophy
Reciprocal interaction  OSA may be contributing to pathogenesis of obesity
Hunger cues
Physical activity
One of the most significant risk factors for OSA in children
Restricting the overall pharyngeal space

13. Symptoms MUCH MORE SCARCE THAN IN ADULTS Nighttime Daytime Snoring
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Symptoms
MUCH MORE SCARCE THAN IN ADULTS
Nighttime
Daytime
Snoring
Excessive sweating
Bed wetting
Restless sleep
Mouth breathing
Gasping
Labored breathing
Hyperextension of neck
Difficulty concentrating
Behavioral and mood problems
Morning headaches
Excessive daytime sleepiness
Failure to thrive
Require high level of suspicion or alternatively, require systematic implementation of explorative screening questions to enable their detection
Studies have suggested that as many as 25 percent of children diagnosed with attention-deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea and that much of their learning difficulty and behavior problems can be the consequence of chronic fragmented sleep. Bed-wetting, sleep-walking, retarded growth, other hormonal and metabolic problems, even failure to thrive can be related to sleep apnea. Some researchers have charted a specific impact of sleep disordered breathing on "executive functions" of the brain: cognitive flexibility, self-monitoring, planning, organization, and self-regulation of affect and arousal.

14. Morbidity of Pediatric OSA
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Morbidity of Pediatric OSA
OSA is strongly associated with the presence of insulin resistance and altered lipid homeostasis, as well as with systemic inflammation and endothelial dysfunction, and an increased prevalence of respiratory illnesses that lead to higher healthcare utilization costs

15. Treatment Adenotonsillectomy CPAP/BIPAP
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Treatment
Adenotonsillectomy
For children with adenotonsillar hypertrophy
Residual OSA may still exist
CPAP/BIPAP
Adherence can be challenging
Residual primarily in obese children, children who had severe OSA before surgery (AHI . 20/hour TST), older children (those aged .7 years), and children with asthma
PAP- positive airway pressure; continuous/bilevel
Adherence: particularly those with behavioral problems or developmental delays

16. Vitamin D

17. Vitamin D Fat-soluble vitamin
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Vitamin D
Fat-soluble vitamin
Synthesized by body and found in food and supplements
Biologically inactive  goes to liver and kidneys for processing
Multiple functions in the body
Requirements
Infants: 400 IUs
Children & teens: 600 IUs
25-Hydroxyvitamin D
> 20 ng/mL
> 30 ng/mL
Functions: helps body absorb calcium, role in nerve, muscle, and immune systems
Vitamin D has other roles in the body, including modulation of cell growth, neuromuscular and immune function, and reduction of inflammation 
Milk, infant formula, cereals, and some other foods are fortified

18. Low vitamin D Deficiency
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Low vitamin D
Deficiency
Inadequate intake or sun exposure
Fat malabsorptive disorder
Impaired liver or kidney hydroxylation
Increases in frequency and severity of metabolic dysfunction, cardiovascular disease risk factors, and incidence of upper respiratory tract infections
Recent preliminary study suggested that children at risk for adenotonsillectomy may exhibit lower serum 25- hydroxyvitamin D concentrations
Interventions aimed at increased 25(OH)D concentrations have resulted in improvements in these outcomes

20. Vitamin D levels and obstructive sleep apnea in children
Kheirandish-Gozel, Peris, Gozal, 2015
Vitamin D levels and obstructive sleep apnea in children

21. Methods 176 children underwent sleep study Plasma Assays
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Methods
176 children underwent sleep study
Monitored for apnea events
Plasma Assays
CRP, serum lipid levels, insulin levels, glucose levles
25-hydroxyvitamin D
Overnight Polysomnographic

22. Results Subdivision of children
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Results
Subdivision of children
Presence or absence of obesity and OSA
African American children had lower vitamin D levels than Caucasian children
No differences according to age or gender
Children with OSA had higher total and and LDL cholesterol and lower HDL cholesterol
Severity of OSA were not significantly different in obese and non-obese children with OSA.
4 groups, based on the presence or absence of obesity (OB) and OSA (i.e., OSA-NOB, NOSA-NOB, OSA-OB, NOSA-OB)

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Results
Obese children without OSA had lower vitamin D levels than non-obese children without OSA
Non-obese children with OSA also exhibited lower vitamin D levels compared to non-obese controls
Obese children with OSA demonstrated the lowest 25- hydroxyvitamin D levels
Low vitamin D levels are associated with insulin resistance but not dyslipidemia
This study shows that both obese children and children with OSA exhibit significantly lower 25(OH)D plasma levels when compared to healthy controls, even when adjusted for ethnicity

24. Conclusions
Low vitamin D levels are associated with adverse outcomes in systemic inflammatory diseases
Vitamin D levels are reduced in pediatric OSA, particularly in obese children
Vitamin D levels account for a proportion of the variance in insulin resistance pediatric OSA
The short-term and long-term significance of reduced 25- hydroxyvitamin D in pediatric OSA remains undefined

25. Implications for practice

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What we can do
Obese children with OSA are may consume an unbalanced diet which may lead to reduced intake of vitamins
Check vitamin levels
Treat as necessary
Encourage vitamin D
Vitamin D rich foods
Sun exposure
Vitamin D supplementation
Such as vitamin D

27. Healthy lifestyle Promote healthy diet Physical activity
Limit screen time
Portion control

28. Vitamin D supplementation
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Vitamin D supplementation
Over the counter
Relatively inexpensive
$5 for 100

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References
National Institutes of Health. Obstructive Sleep Apnea. Pub Med Health Web site. Available at N.D.
American Sleep Apnea Association. Obstructive Sleep Apnea. ASAA Web site. Available at N.D.
Tan HL, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: a critical update. Nature and Science of Sleep. 2013;5:
Schmidt-Nowara W. Patient Information:Sleep Apnea in Adults (Basic and Beyond). UpToDate Web site. Available at Updated July 2, 2014.
National Institutes of Health. How is Sleep Apnea Diagnosed? National Heart Lung and Blood Web site. Available at Published July 10, 2012.
Eisenber JM. Treating Sleep Apnea. Pub Med Health Web site. Available at Published August 8, 2011.
American Sleep Apnea Association. Children’s Sleep Apnea. ASAA Web site. Available athttp:// N.D.
US National Library of Medicine. Vitamin D. MedlinePlus Web site. Available at Updated May 19, 2015.
Pazirandeh S, Burns DL. Overview of Vitamin D. UpToDate Web site. Available at Updated May 8, 2014.
Kheirandish-Gozel L, Peris E, Gozal D. Vitamin D Levels and Obstructive Sleep Apnea in Children. Sleep Medicine ;15(4):