1. Sleep Disordered Breathing (SDB) in Children Bergen County School Nurses Association November 18, 2013 Lee D. Eisenberg M.D., M.P.H., F.A.C.S. ENT and Allergy Associates, LLP Englewood, NJ

2. SDB in Children Definition: Breathing difficulties during sleep 10% of Children snore regularly 2-4% have obstructive sleep apnea

3. SDB-Definition Sleep disordered breathing (SDB) is characterized by an abnormal respiratory pattern during sleep, and includes snoring, mouth breathing, and pauses in breathing. SDB encompasses a spectrum of disorders that increase in severity from snoring to obstructive sleep apnea. Obstructive sleep apnea is diagnosed when SDB is accompanied by an abnormal PSG with obstructive events

4. SBD: Risk Factors Obesity Enlarged Tonsils and Adenoids Down’s Syndrome Other Craniofacial Disorders (Treacher-Collins) Neuromuscular Disorders (i.e. Cerebral Palsy) Sickle Cell Disease

5. How do you determine if a child is Obese Appearance Weight Body Mass Index Body Mass Index percentile for Age Different Criteria than adults

6. Obesity BMI: indirect measure of body fat ▪ BMI for age: sex and age specific values BMI % for age: indicates the relative position of the child's BMI number among children of same sex and age: Obese > 95% Indirect measure of excess fat and may need to confirm by measuring skin fold thickness

7. BMI Percentage Similar idea as for height and weight for age. Age 4 years 10 months, 40 inches, 50 pounds: BMI 22.0 (>=97%) Age 5 years 10 months, 44 inches, 50 pounds: BMI 18.2 (90-94%)

8. Symptoms of Sleep Disordered Breathing Snoring Daytime fatigue Hyperactivity Audible Breathing (The Darth Vader sound) Restless Sleep

9. Symptoms of Sleep Disordered Breathing Chronic Mouth Breathing Gasping (arousals) Enuresis Sleep in an odd position Extended neck Head over the bed

10. Symptoms of Sleep Disordered Breathing Co-Morbid Conditions-Common Growth Retardation Poor School Performance Behavioral Problems Irritability Decreased Quality of Life Occasionally ADHD

11. Symptoms of Sleep Disordered Breathing Co-Morbid Conditions-Uncommon Systemic Hypertension Pulmonary Hypertension Right Heart Failure: now rare

12. Diagnosis of SDB/OSA History and Physical Alone Adenoidal Facies Tonsil hypertrophy Audio or Visual Recording Evidence of struggling while breathing Sleep Study Overnight oxygen recording

13. Adenoidal Facies

14. Tonsil Hypertrophy

15. Adenoidal Hypertrophy endoscopic view

16. Polysomnography When Not all children need PSG before surgery After surgery in children with persistent symptoms After surgery in all children in whom PSG is strongly recommended

17. Polysomnography Who? Obesity Down’s Children Other Craniofacial Anomalies Children with Sickle Cell Disease Neuromuscular disorder (i.e. Cerebral Palsy) When the symptoms do not match the physical exam

18. Polysomnography Interpretation Not everyone agrees but if the following, OSA: Apnea Hypopnea Index (AHI) >1 Pulse oximetry levels <92% There may be significant hypoxemia despite a low AHI Low Oxygen saturation levels can negatively effect school performance

19. SDB Treatment Standard is Adenotonsillectomy Weight loss and exercise if indicated CPAP High Flow Nasal oxygen if CPAP not tolerated in special circumstances

20. Risk Factors for Postoperative Respiratory Complications in Children With OSAS Undergoing Adenotonsillectomy AAP Practice Guideline: OSA in Children Pediatrics 2002;109;704 Risk Factors for Postoperative Respiratory Complications in Children With OSAS Undergoing Adenotonsillectomy Age younger than 3 years Severe OSAS on polysomnography (AHI>10 or Oxygen Saturation below 85%) Cardiac complications of OSAS (e.g., right ventricular hypertrophy) Failure to thrive Obesity Prematurity Recent respiratory infection Craniofacial anomalies Neuromuscular disorders

21. T&A Who should stay overnight? Down’s children Other Craniofacial disorders Neuromuscular disorders AHI>10 or Oxygen Saturation =<85% Obese child Under the age of 2 (possibly age 3)

22. T&A: The “easy” but dangerous procedure Perioperative anesthetic issues Post operative hemorrhage (2-5%) Dehydration Respiratory Suppression (acetaminophen with codeine- FDA black box warning) Post operative death-most commonly related to respiratory suppression

23. Predictors of Failure After T&A Age > 7 years Obesity - BMI % > 95% Presence of Asthma Preop PSG with AHI > 10 events an hour Bhattacharjee R Am JResp C 2010

24. Does Every Child with SDB Need Surgery? Study by Marcus et al: A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea Downloaded from nejm.org on June 12, 2013. “Children with obstructive sleep apnea who had a common surgery to remove their adenoids and tonsils showed notable improvements in behavior, quality of life and other symptoms compared to those treated with "watchful waiting" and supportive care. However, there was no difference between both groups in attention and executive functioning, as measured by formal neuropsychological tests.”

25. Study by Marcus et al: A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea Downloaded from nejm.org on June 12, 2013. There were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group.

26. Does Every Child with SDB Need Surgery? If SDB are mild or intermittent, academic performance and behavior is not an issue, the tonsils are small or the child is near puberty (tonsils and adenoid often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated only if symptoms worsen. Fact Sheet: Pediatric Sleep Disordered Breathing/Obstructive Sleep Apnea. American Academy of Otolaryngology/Head and Neck Surgery, Inc. Updated 11/15/11

27. Does Every Child with SDB Need Surgery? The bottom line: There is no urgency for surgery in those children with mild symptoms, but their quality of life, and therefore their parents or caregivers, may be adversely affected

28. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome American Academy of Pediatrics Pediatrics 2002;109;704 This guideline specifically excludes infants younger than 1 year, patients with central apnea or hypoventilation syndromes, and patients with OSAS associated with other medical disorders, including but not limited to Down syndrome, craniofacial anomalies, neuromuscular disease (including cerebral palsy), chronic lung disease, sickle cell disease, metabolic disease, or laryngomalacia.

29. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome American Academy of Pediatrics 1) all children should be screened for snoring; 2) complex high-risk patients should be referred to a specialist; 3) patients with cardiorespiratory failure cannot await elective evaluation; 4) diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography;

30. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome American Academy of Pediatrics 5) adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery; 6) high-risk patients should be monitored as inpatients Postoperatively; 7) patients should be reevaluated postoperatively to determine whether additional treatment is required.

31. References Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome: American Academy of Pediatrics, Pediatrics 2002;109;70 Polysomnography for Sleep Disordered Breathing in Children Prior to Tonsillectomy: American Academy of Otolaryngology-Head and Neck Surgery-Clinical Practice Guideline http://www.entnet.org/guide_lines/Polysomnography.cfm http://www.entnet.org/guide_lines/Polysomnography.cfm Tonsillectomy in Children: American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guideline http://www.entnet.org/guide_lines/Tonsillectomy.cfmhttp://www.entnet.org/guide_lines/Tonsillectomy.cfm A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea: Marcus, C et.al. NEJM, Published May 21, 2013. Accessed June 12, 2013 Surgery on Adenoid and Tonsils Improves Outcomes in Children with Obstructive Sleep Apnea: National Sleep Foundation (Summary of Marcus Article) Accessed November 9, 2013

32. Questions