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

Race and socioeconomic status (SES) moderated the link between children's sleep and cognitive functioning. One hundred and sixty-six 8- to 9-year-old African and European American children varying in SES participated. Sleep measures were actigraphy, sleep diaries, and self-report; cognitive measures were from the Woodcock-Johnson III and reaction time tasks. Children had similar performance when sleep was more optimal, but after controlling for SES, African American children had lower performance with sleep disruptions. Children from lower and higher SES had similar performance with better sleep quality and less variability in sleep schedules, but when sleep was more disrupted, higher SES children had better performance. Examination of environmental variables associated with race and SES that may underlie these effects may lead to directions for interventions to improve cognitive performance.

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Children's Sleep and Cognitive Functioning: Race and Socioeconomic Status as Moderators of Effects.

Marital conflict was examined as a predictor of the quality and quantity of sleep in a sample of healthy 8- to 9-year-olds. Parents and children reported on marital conflict, the quantity and quality of children's sleep were examined through an actigraph worn for 7 consecutive nights, and child sleepiness was derived from child and mother reports. Increased marital conflict was associated with disruptions in the quantity and quality of children's sleep as well as subjective sleepiness, even after controlling for child age, ethnic group membership, socioeconomic status, sex, and body mass index. The results support the sensitization hypothesis in that exposure to marital conflict may influence an important facet of children's biological regulation, namely sleep.

Marital conflict and disruption of children's sleep

Background: Sleep problems are prevalent in American children. A critical need is to identify sources and processes related to sleep disruptions and their sequelae. We examined a model linking parental marital conflict and children's emotional insecurity, sleep disruptions, and their adjustment and academic problems.

Method:  One hundred and sixty-six elementary school children reported on marital conflict and their emotional insecurity, the quantity and quality of children's sleep were examined through actigraphy, and parents and teachers reported on child functioning.

Results:  In the context of exposure to normative levels of marital conflict, children's emotional insecurity regarding their parents’ marital relationship is an intervening variable in the marital conflict–sleep disruptions link. In turn, disruptions in the quality and duration of children's sleep have a negative effect on children's behavioral, emotional, and academic performance.

Conclusions:  Findings highlight the importance of marital conflict and children's emotional insecurity as variables that can affect a fundamental aspect of biological regulation, sleep, which consequently influences children's adjustment and academic performance.

Erika Szymanski

Papers

School performance, race, and other correlates of sleep-disordered breathing in children