Although SRBD in children have many important similarities to the adult versions of these diseases, there are also marked differences in presentation, diagnosis, and management (Table 1). While awake breathing is typically silent, and the most obvious of nocturnal SRBD is snoring. Snoring indicates turbulent airflow and is not normal in children (21,35-39). The American Academy of Pediatrics (AAP) has recommended all children should be screened for snoring as part of well child care (40). If a sleeping animal is vulnerable to be attacked by a predator, why would it make breathing noises when its guard is down? Indeed animals in the wild do not seem to snore; only domestic animals snore. Not all snoring is due to OSA. It may be due to other forms of obstruction such as nasal allergies or a cold (41,42).
The prevalence of SDB in children was studied by Rosen et al. (43), who performed a cross-sectional study of school-aged children in a Cleveland cohort. The cohort consisted of 829 children, 8 to 11 years old, all of whom had unattended in-home overnight cardiorespiratory sleep recordings. SDB was defined by either parent-reported habitual snoring or objectively-measured OSA. Forty (5%) children
TABLE 1 Comparison of Sleep-Related Breathing Disorders in Adults Vs. Children
Sleepiness, fatigue, nocturia
Behavioral problems, learning difficulty, nocturnal enuresis No difference prior to puberty
More common and severe in males
Obese, large neck circumference
High-arched palate, enlarged tonsils, orthodontic problems,
Apnea duration 10 seconds Diagnostic criteria AHI > 5 Primary treatment Positive airway less likely obese, failure to thrive Two breaths AHI > 1
Abbreviation: AHI, apnea-hypopnea index.
were classified as having OSA [median apnea-hypopnea index (AHI) = 7.1 per hour], and another 122 (15%) had primary snoring without OSA. The remaining 667 (80%) had neither snoring nor OSA. Functional outcomes were assessed with two parent ratings scales of behavior problems: the Child Behavioral Checklist and the Conners Parent Rating Scale-Revised:Long. Children with SDB had significantly higher odds of elevated problem scores in the following domains: externalizing, hyperactive, emotional lability, oppositional, aggressive, internalizing, somatic complaints, and social problems. The authors concluded that children with relatively mild SDB, ranging from primary snoring to OSA, have a higher prevalence of problem behaviors, with the strongest, most consistent associations for externalizing, hyperactive-type behaviors. An interesting finding in this study was that only 55% of the parents of children diagnosed by polysomnography with OSA reported loud snoring. If pediatricians and surgeons screen for OSA by asking the parents/ caregiver if the child snores loudly, they may miss close to half of the cases (44).
The daytime behavior is an important difference between adults and children with SDB. The abnormal daytime sleepiness may be recognized more often by schoolteachers than by parents of young children. An increase in total sleep time or an extra-long nap may be considered as normal by parents. Nonspecific behavioral difficulties are mentioned to the pediatrician such as abnormal shyness, hyperactivity, developmental delays, rebellious or aggressive behavior (45). Chervin et al. found conduct problems and hyperactivity are frequent among children referred for SDB during sleep. They surveyed parents of children aged 2 to 14 years at two general clinics between 1998 and 2000. Parents of 872 children completed the surveys. Bullying and other specific aggressive behaviors were generally two to three times more frequent among children at high risk for SDB (46). Other daytime symptoms may include speech defects, poor appetite, or swallowing difficulties (4,47). Nocturnal enuresis or bedwetting accidents should raise suspicion of possible SDB (48).
Many of these children are mouth breathing. Regular mouth breathing should always lead to suspicion of SDB (49). Children with SDB may avoid going to bed at night due to hypnagogic hallucinations. Upon awakening these children may report morning headaches, dry mouth, confusion or irritability. As mentioned, daytime sleepiness may not be obvious depending on the age. It may translate only as a complaint of daytime tiredness or may also present itself as a tendency to take naps easily anywhere.
A study from Israel found that children with SDB had lower scores on neuro-cognitive testing compared to controls but the scores improve after treatment (23). This prospective study of 39 children aged five to nine years underwent a battery of neurocognitive tests containing process-oriented intelligence scales. Children with SDB had lower scores compared with healthy children in some Kaufman Assessment Battery for Children (K-ABC) subtests and in the general scale Mental Processing Composite, indicating impaired neurocognitive function. Six to 10 months after adenotonsillectomy, the children with OSAs demonstrated significant improvement in sleep characteristics, as well as in daytime behavior. Their neurocognitive performance improved considerably, reaching the level of the control group in the subtests Gestalt Closure, Triangles, Word Order, and the Matrix analogies, as well as in the K-ABC general scales, Sequential and Simultaneous Processing scales, and the Mental Processing Composite scale. The authors concluded neurocognitive function is impaired in otherwise healthy children with SDB. Most functions improve to the level of the control group, indicating that the impaired neurocognitive functions are mostly reversible, at least 3 to 10 months following adenotonsillectomy (23). An abrupt and persistent deterioration in grades must also raise the question of abnormal sleep and SDB (20,21,50,51).
In schools the tiredness and sleepiness may be labeled as "inattentiveness in class," "daydreaming," or "not being there" (22,52). Concerns about school performance were raised in the original description of OSA syndrome in children (3). More recently, the possible association between SDB, learning problems, and attention-deficit disorder has been studied (8,18,19,21,22,52-56). A study by Gozal et al. examined the hypothesis that domains of neurobehavioral function would be selectively affected by SDB. They study 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 a public school system. Children with reported symptoms of ADHD and control children were randomly selected for an overnight polysomnographic assessment and a battery of neurocognitive tests. Frequent and loud snoring was reported for 673 children (11.7%). Similarly, 418 (7.3%) children were reported to have hyperactivity/ADHD. Children with reported symptoms of ADHD and control children were randomly selected for an overnight polysomnographic assessment and a battery of neurocog-nitive tests. Eighty-three children with parentally reported symptoms of ADHD had sleep studies together with 34 control children. After assessment with the ADHD subscale of 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 OSA was present in 5% of those with significant ADHD symptoms, 26% of those with mild symptoms, and 5% of those with no symptoms. The authors concluded 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 subscale. SDB can lead to mild ADHD-like behaviors that can be readily misperceived and potentially delay the diagnosis and appropriate treatment (22).
Additional clinical signs of SDB include increased respiratory efforts with nasal flaring, suprasternal or intercostal retractions, abnormal paradoxical inward motion of the chest occurring during inspiration, and sweating during sleep. The sweating may be limited to only the nuchal region particularly in infants; it may be severe enough to necessitate changing clothes during the night. The parents may mention the child feeling warm at night or preferring to sleep without a blanket.
Parents may also observe the child stop breathing, then gasping for breath. It is surprising to note how often parents have observed abnormal breathing patterns during sleep but were never questioned about it by pediatricians during regular visits. Information regarding the sleep position is helpful. Typically, the neck is hyper-extended and the mouth is open. Another typical sleeping position is prone with the knee tucked under the chest with head turned to the side and hyperextended. Rarely, the child with SDB prefers to sleep propped up on several pillows (4).
Parasomnias may be triggered or exacerbated by SDB. Ohayon (57) has found that individuals identified with SDB have a much higher incidence of nightmares, with reports of "drowning," "being buried alive," and "choking." SDB leads to sleep fragmentation or disruption. Any condition that disrupts slow-wave sleep may lead to sleep terrors and sleepwalking in children (58). SDB should be included in the evaluation of any child with parasomnias.
A physical finding that may be overlooked in a child with SDB is a narrow and high-arched palate (4). Interestingly, the description of attention-deficit disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) mentions that minor physical anomalies such as high-arched palates may be present (59). Since both conditions may have similar daytime behavior in the same age group, a child with SDB could be misidentified as having attention-deficit disorder. The possibility of a sleep disorder being present should be considered in any child being evaluated for attention-deficit disorder. This is particularly important since treatment of SDB may improve behavior and academic performance (60,61).
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