1. Enough Zzzs? Sleep, Snoring, and Sleep Apnea Evaluation in Underinsured Overweight and Obese Children
Cassandra Garcia, MSN, RN, FNP-BC
Mobile Clinic Provider
Texas Children’s Mobile Clinic Program
April 7, 2018

2. Objectives
Identify the importance of assessing children for enough quality hours of sleep and sleep apnea.
Recognize the importance of properly evaluating overweight and obese children for sleep apnea.

3. Recommended Hours of Sleep Per Day
Background
Amount and quality of sleep is important for health and well-being
Age Group
Recommended Hours of Sleep Per Day
Newborn
0–3 months
14–17 hours (National Sleep Foundation)1 No recommendation (American Academy of Sleep Medicine)2
Infant
4–12 months
12–16 hours per 24 hours (including naps)2
Toddler
1–2 years
11–14 hours per 24 hours (including naps)2
Preschool
3–5 years
10–13 hours per 24 hours (including naps)2
School Age
6–12 years
9–12 hours per 24 hours2
Teen
13–18 years
8–10 hours per 24 hours2
Adult
18–60 years
7 or more hours per night3
61–64 years
7–9 hours1
65 years and older
7–8 hours1
The recommended number of hours an individual needs is broken down by age group in the table.
For this study, we only enrolled school age and teenage children.
(CDC, 2017)

4. Background Adequate sleep duration for age leads to:
Improved attention
Behavior learning
Memory
Emotional regulation
Quality of life
Mental and physical health
(APP, 2018)

5. Background Insufficient sleep each night is associated with:
Increase in injuries
Hypertension
Obesity
Depression
(APP, 2018)

6. Background
Insufficient sleep and sleep disorders frequently diagnosed in overweight and obese children
Uninsured families are less likely to seek preventative medical care due to barriers
Sleep disorders, in particular sleep apnea, need to be evaluated by a specialist for evaluation, diagnosis, and treatment.
Uninsured children are less likely to visit providers for check-ups to receive sleep counseling, appropriate evaluation for sleep disorder, and referrals to specialist for sleep disorders when necessary.

7. Objective
To evaluate sleep quality, snoring, and frequency of referrals to specialists for sleep apnea in uninsured, primarily Hispanic, overweight and obese children.

8. Methods
Children were recruited for the 1 month program because they were overweight or obese at well child check
Paper survey was given to 45 parents whose children were enrolled in a lifestyle modification program on a mobile clinic
Care for primarily uninsured children in Houston, Texas.
The program was conducted to determine whether a mobile lifestyle modification program could reach overweight and obese uninsured children who otherwise have limited access to care.

9. Results
45 overweight/obese uninsured children ages (42% male) were surveyed
73% of families surveyed had an annual family income less than $40,000
4% reported that their child had been diagnosed previously with a chronic medical condition
91% Hispanic
Spanish was the primary language spoken at home (73%)

10. Results

11. Results
No statistically significant differences between BMI and hours of sleep or frequency of snoring
46% of parents reported that their child snores
Only 6% had received formal evaluation for sleep apnea

12. OSA 1-3% of children suffer from OSA
Peak age group is pre-school years
Most common cause is enlarge tonsils and adenoids
Obesity is a risk factor
As obesity rates rise, rates of OSA are also expected to rise

13. Snoring and OSA Snoring and noisy breathing can be normal
Snoring and noisy breathing can be a sign of OSA
Increased work of breathing (sleep)
Pauses in breathing (sleep)
Choking, gasping, or snorting (sleep)
Restless sleep
Sweating during sleep
Unusual sleep positions
Mouth breathing (day and sleep)
Neurobehavioral symptoms
Sleepiness

14. OSA Complications Difficulty paying attention and learning
Behavior problems
Failure to thrive
Pulmonary hypertension
Cor pulmonale

15. Recommendations for OSA
AAP recommends that all children be screened for snoring
Detailed history regarding labored breathing during sleep, observed apnea, restless sleep, diaphoresis, enuresis, cyanosis, excessive daytime sleepiness, and behavior or learning problems
Referral to Pulmonology, otolaryngology, or sleep medicine specialist
Polysomnography (overnight sleep study)

16. Conclusion
Uninsured children may not be sleeping enough quality hours at night
Understood risk factor for obesity
Overweight/obese uninsured children who snore may not receive sleep evaluations due to barriers
High cost
Poor insurance access
Lack of established care
Transportation barriers

17. Conclusion
Further studies are needed to understand how to reach uninsured children and provide recommended sleep counseling and evaluation for sleep disorders

18. References
American Academy of Pediatrics Supports Childhood Sleep Guidelines (2016). American Academy of Pediatrics. Retrieved by room/pages/American-Academy-of-Pediatrics-Supports-Childhood-Sleep-Guidelines.aspx
Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome (2002). Pediatrics. Retrieved from
How much sleep do I need? (2017). Center fro Disease Control and Prevention. Retrieved from
Marcus et al. (2012). Diagnosis and management of childhood obstructive sleep apnea syndrome. American Academy of Pediatrics. Retrieved by
Wise, M. S., Chervin, R. D., & Hoppin, A. G. (2018). Assessment of sleep disorders in children. UpToDate. Retrieved from sleep-disorders-in- children?search=snoring%20in%20children&source=search_result&selectedTitle=3~145& usage_type=default&display_rank=3