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Snoring in Children
New Guidelines Report That Snoring In Children May Mean Sleep Apnea
Snoring in children may be a sign of sleep apnea, a common but under-diagnosed condition that has been linked to learning problems, slow growth and even bed wetting and high blood pressure, according to a new Clinical Practice Guideline published recently by the American Academy of Pediatrics. The guidelines recommend that routine checkups should include questions about snoring to better diagnose the syndrome, which often can be cured by surgery to remove tonsils and adenoids.
While snoring can be harmless in some children, it also is one of the most common symptoms for the disorder. Studies suggest that about half a million children ages 2-8, the most vulnerable ages, are most affected. Sleep experts say that this is likely an underestimate, because most parents and pediatricians may dismiss snoring as just an annoying habit. The guidelines, the Academy’s first on obstructive sleep apnea, are published in the April 2002 issue of the Academy’s medical journal, Pediatrics.
If a history of nightly snoring is elicited, a more detailed history regarding labored breathing during sleep, observed apneas, restless sleep, sweating, bed wetting, daytime sleepiness and behavior or learning problems (including attention-deficit/hyperactivity disorder) should be obtained. Findings on physical examination during wakefulness are often normal.
A number of studies have shown there is no relation between the size of the tonsils and adenoids and the presence of sleep apnea. Likewise, the presence of large tonsils and adenoids does not necessarily mean that the patient has sleep apnea. An accurate diagnosis is required not only to insure that appropriate treatment is provided and to avoid any unnecessary treatment, but to also determine which children are at risk of complications resulting from the treatment.
Multiple studies have shown the limited utility of history and physical examination, audio or videotaping or sleep-related questionnaires. The guidelines recommend that nocturnal polysomnography (sleep study) is the only diagnostic technique shown to quantify the sleep-related breathing disordered breathing, and is currently the gold standard. By definition, polysomnography can distinguish primary snoring from sleep apnea, can determine the severity of the disorder, and can help determine the risk of postoperative complications following tonsillectomy and adenoidectomy. These factors include variables such as age < 3 years, obesity, right ventricular hypertrophy and others described in the guidelines.
For patients with specific surgical contraindications or persistent sleep apnea after surgery, continuous positive airway pressure (CPAP) is an option. This is a long-term therapy and requires frequent clinician assessment of adherence and efficacy. This is generally tolerated well in older children, but younger children or those with learning or behavioral problems may require desensitization techniques to accept this form of treatment.
Research suggests that learning and behavioral problems improved after the operation, and children also often have a growth spurt. Symptoms of poor quality sleep and daytime sleepiness can disappear after surgery, according to Dr. Carole Marcus, Director of Johns Hopkins University’s Sleep Center and head of the Academy committee that wrote the guidelines. You can visit their web site at www.pediatrics.org.
Patient education brochures on this and other pediatric sleep disorders are available by contacting the sleep center at 949/764-8070 or via e-mail at sleepcenter@hoagHospital.org.
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