The Examination Of The Pediatric Patient

Sleep complaints or disorders occur in 1% to 28% of the pediatric population (121-123) (More information on the examination of the pediatric patient can be found in Chapter 15.). The incidence of OSA in children can range from 1% to 10%, while snoring can occur in 3% to 12% (123-126). These studies often emphasize the idea that the presentation of sleep disorders in children is different from those in adults. While this literature is interesting, for the purposes of this chapter, the basic elements of the history and physical have limitations in regard to common measures and approaches from which to make firm evidence-based conclusions.

One issue is relatively clear however. Children, with the possible exception of those who are obese, less commonly present with EDS (127). Rather, they present with a failure to thrive, attention and behavior problems, and show impaired academic performance. Thus, the approach and the thresholds for clinical suspicion of sleep disorders differ somewhat in the pediatric population.

History Taking

It is crucial that an appropriate historian (parent, guardian or other adult caregiver) is involved in the diagnostic process. A substantial proportion of pediatric sleep disorders involve psychosocial issues that can only be assessed by talking with the primary caregiver, and the value of teacher input is emphasized in this literature as well. The parent-child interaction should be observed closely for clues to extrinsic problems, such as sleep-onset association, limit setting disorder, or child maltreatment syndrome (126).

An age-appropriate history should be obtained. Certain elements stressed or elaborated on during a pediatric sleep-related history are similar to adults, while others are not (Table 1). As with the adult patient, features of the age of onset, degree of severity/stability, and frequency of the patient's sleep complaint, as well as responses to any attempts at treating the problem can give clues. Any new daytime or nocturnal symptoms or signs can also provide information; for instance, new-onset enuresis in a child can indicate a sleep disorder like sleep apnea. Occasionally, a child is recognized with a sleep disorder during a family vacation when there is greater opportunity for parents to observe children while sharing hotel rooms. Home-video footage both of waking and sleep behaviors can also provide invaluable information, if available.

Physical Examination

Routine key vital statistics include blood pressure, respiratory rate, heart rate, height, weight, age-appropriate BMI (for children with OSA can be either too thin or too heavy), and their position (relative population-based percentile standing) on age-appropriate growth charts.

A thorough examination would include mention of the child's general appearance and craniofacial characteristics such as midface hypoplasia, micrognathia, and occlusal relationships. In infants, septal deviation, choanal atresia, nasolacrimal cysts, and nasal aperture stenosis must be excluded, while in older children, nasal polyps and turbinate hypertrophy must be considered as a cause for upper airway obstruction (128).

Adenotonsillar hypertrophy is a common finding not only in the general pediatric population but in pediatric OSA patients as well. Oral assessment includes screening for signs of mouth breathing, tissue redundancy, and cleft lip/palate, as well as evaluation of tongue size, dentition, and tonsillar grading, including Mallampati staging (Fig. 2). Consideration for adenoid assessment with lateral neck radiography or nasopharyngoscopic examination can also be helpful.

Neuromuscular disorders, such as myotonic dystrophy, can be associated with chronic obstructive hypoventilation from a combination of oropharyngeal muscle weakness that leads to airway collapse and hypoventilation from diminished respiratory muscle excursion (126). Hoarseness of the voice, decreased gag reflex, and abnormal tendon reflexes could be clues to brainstem abnormalities, such as Chiari malformation (129).

Congenital craniofacial syndromes are associated with OSA. Children who have syndromes with craniosynostosis, such as Apert's syndrome, Crouzon's disease, Pfeiffer's syndrome, and Saethre-Chotzen syndrome; abnormalities of the skull base; and accompanying maxillary hypoplasia may have nasopharyngeal obstruction (126). Children with syndromes that involve micrognathia, such as Treacher Collins syndrome, Pierre Robin syndrome, and Goldenhar's syndrome, become obstructed at the hypopharyngeal level; and children with trisomy 21 often have a narrow upper airway combined with macroglossia and hypotonic musculature predisposing them to OSA (126).

The Insomnia Battle

The Insomnia Battle

Who Else Wants To Sleep From Lights Out 'Til Sunrise Without Staring At The Ceiling For Hours Leaving You Feeling Fresh And Ready To Face A New Day You know you should be asleep. You've dedicated the last three hours in the dark to trying to get some sleep. But you're wide awake.

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