OBJECTIVES: This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. METHODS: Of 3166 articles from 1999–2010, 350 provided relevant data. Most articles were level II–IV. The resulting evidence report was used to formulate recommendations. RESULTS AND CONCLUSIONS: The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.

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Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

Pediatric obstructive sleep apnea (OSA) has become widely recognized only in the last few decades as a likely cause of significant morbidity among children. Many of the clinical characteristics of pediatric OSA, and the determinants of its epidemiology, differ from those of adult OSA. We systematically reviewed studies on the epidemiology of conditions considered part of a pediatric sleep-disordered breathing (SDB) continuum, ranging from primary snoring to OSA. We highlight a number of methodologic challenges, including widely variable methodologies for collection of questionnaire data about symptomatology, definitions of habitual snoring, criteria for advancing to further diagnostic testing, and objective diagnostic criteria for SDB or OSA. In the face of these limitations, estimated population prevalences are as follows: parent-reported “always” snoring, 1.5 to 6%; parent-reported apneic events during sleep, 0.2 to 4%; SDB by varying constellations of parent-reported symptoms on questionnaire, 4 to 11%; OSA diagnosed by varying criteria on diagnostic studies, 1 to 4%. Overall prevalence of parent-reported snoring by any definition in meta-analysis was 7.45% (95% confidence interval, 5.75–9.61). A reasonable preponderance of evidence now suggests that SDB is more common among boys than girls, and among children who are heavier than others, with emerging data to suggest a higher prevalence among African Americans. Less convincing data exist to prove differences in prevalence based on age. We conclude by outlining specific future research needs in the epidemiology of pediatric SDB.

/pdf/epidemiology-of-pediatric-obstructive-sleep-apnea-aypunpylsd.pdf

Epidemiology of pediatric obstructive sleep apnea

Attention-deficit/hyperactivity disorder (ADHD) is currently defined as a cognitive/behavioral developmental disorder where all clinical criteria are behavioral. Inattentiveness, overactivity, and impulsiveness are presently regarded as the main clinical symptoms. The dynamic developmental behavioral theory is based on the hypothesis that altered dopaminergic function plays a pivotal role by failing to modulate nondopaminergic (primarily glutamate and GABA) signal transmission appropriately. A hypofunctioning mesolimbic dopamine branch produces altered reinforcement of behavior and deficient extinction of previously reinforced behavior. This gives rise to delay aversion, development of hyperactivity in novel situations, impulsiveness, deficient sustained attention, increased behavioral variability, and failure to "inhibit" responses ("disinhibition"). A hypofunctioning mesocortical dopamine branch will cause attention response deficiencies (deficient orienting responses, impaired saccadic eye movements, and poorer attention responses toward a target) and poor behavioral planning (poor executive functions). A hypofunctioning nigrostriatal dopamine branch will cause impaired modulation of motor functions and deficient nondeclarative habit learning and memory. These impairments will give rise to apparent developmental delay, clumsiness, neurological "soft signs," and a "failure to inhibit" responses when quick reactions are required. Hypofunctioning dopamine branches represent the main individual predispositions in the present theory. The theory predicts that behavior and symptoms in ADHD result from the interplay between individual predispositions and the surroundings. The exact ADHD symptoms at a particular time in life will vary and be influenced by factors having positive or negative effects on symptom development. Altered or deficient learning and motor functions will produce special needs for optimal parenting and societal styles. Medication will to some degree normalize the underlying dopamine dysfunction and reduce the special needs of these children. The theory describes how individual predispositions interact with these conditions to produce behavioral, emotional, and cognitive effects that can turn into relatively stable behavioral patterns.

/pdf/a-dynamic-developmental-theory-of-attention-deficit-4cmd8e2wks.pdf

A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD) predominantly hyperactive/impulsive and combined subtypes.

Rationale: The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined.Objectives: To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS.Methods: A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI).Measurements and Main Results: Data from 578 children (mean age, 6.9 ± 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT...

https://www.atsjournals.org/doi/pdf/10.1164/rccm.200912-1930OC

Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study.

Objective To perform a meta-analysis of subjective (i.e., based on questionnaires) and objective (i.e., using poly-somnography or actigraphy) studies comparing sleep in children with attention-deficit/hyperactivity disorder (ADHD) versus controls. Method We searched for subjective and objective sleep studies (1987–2008) in children with ADHD (diagnosed according to standardized criteria). Studies including subjects pharmacologically treated or with comorbid anxiety/depressive disorders were excluded. Results Sixteen studies, providing 9 subjective and 15 objective parameters and including a total pooled sample of 722 children with ADHD versus 638 controls, were retained. With regard to subjective items, the meta-analysis indicated that children with ADHD had significantly higher bedtime resistance ( z = 6.94, p z = 9.38, p z = 2.15, p = .031), difficulties with morning awakenings ( z = 5.19, p z = 2.05, p = .040), and daytime sleepiness ( z = 1.96, p = .050) compared with the controls. As for objective parameters, sleep onset latency (on actigraphy), the number of stage shifts/hour sleep, and the apnea-hypopnea index were significantly higher in the children with ADHD compared with the controls ( z = 3.44, p = .001; z = 2.43, p = .015; z = 3.47, p = .001, respectively). The children with ADHD also had significantly lower sleep efficiency on polysomnography ( z = 2.26, p = .024), true sleep time on actigraphy ( z = 2.85, p = .004), and average times to fall asleep for the Multiple Sleep Latency Test ( z = 6.37, p Conclusions The children with ADHD are significantly more impaired than the controls in most of the subjective and some of the objective sleep measures. These results lay the groundwork for future evidence-based guidelines on the management of sleep disturbances in children with ADHD.

Sleep in Children With Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Subjective and Objective Studies

Objectives. This study examined the hypothesis that domains of neurobehavioral function would be selectively affected by sleep-disordered breathing (SDB). Therefore, we assessed potential relationships between objectively measured sleep disturbances and neurobehavioral function in children with reported symptoms of attention-deficit/hyperactivity disorder (ADHD) and also determined the incidence of snoring and other sleep problems in 5- to 7-year-old children in the local community and potential relationships to parental snoring and passive smoking. Methods. Parents of 5- to 7-year-old children in public schools were surveyed about their child’s sleeping habits using a validated questionnaire. The questionnaire also asked whether they believed their child to be hyperactive or have ADHD. Children with reported symptoms of ADHD and control children were randomly selected and invited to the Sleep Medicine Center for an overnight polysomnographic assessment and a battery of neurocognitive tests. Results. The questionnaire response rate was 47.6% (n = 5728). Frequent and loud snoring was reported for 673 children (11.7%). Similarly, 418 (7.3%) children were reported to have hyperactivity/ADHD, 313 (76.5%) of which were boys. Eighty-three children with parentally reported symptoms of ADHD were invited for full evaluation at the Sleep Medicine Center together with 34 control children. After assessment with the Conners’ Parent Rating Scale, 44 children were designated as having “significant” symptoms of ADHD, 27 as “mild,” and 39 designated as “none” (controls). Overnight polysomnography indicated that obstructive sleep apnea was present in 5% of those with significant ADHD symptoms, 26% of those with mild symptoms, and 5% of those with no symptoms. In the cohort, no sleep variable accounted for more than a negligible proportion of the variance in domains of neurobehavioral function. Conclusions. An unusually high prevalence of snoring was identified among a group of children designated as showing mild symptoms of ADHD based on the Conners’ ADHD index identified from a community sample. However, whereas SDB is not more likely to occur among children with significant ADHD symptoms, it is significantly highly prevalent among children with mild hyperactive behaviors. Sleep studies further revealed that rapid eye movement disturbances are more likely to occur in children with significant symptoms, and they seem to impose significant but mild effects on daytime neurobehavioral functioning. We conclude that in children with significant symptoms of ADHD, the prevalence of SDB is not different from that of the general pediatric population and that rapid eye movement sleep in these children is disturbed and may contribute to the severity of their behavioral manifestations. Furthermore, SDB can lead to mild ADHD-like behaviors that can be readily misperceived and potentially delay the diagnosis and appropriate treatment.

Brittany C Hume

Papers

Sleep and Neurobehavioral Characteristics of 5- to 7-Year-Old Children With Parentally Reported Symptoms of Attention-Deficit/Hyperactivity Disorder