Obstructive Sleep Apnea Syndrome in Children Clinical Features

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Obstructive sleep apnea syndrome (OSAS) is characterized by episodes of partial or complete upper airway obstruction that occur during sleep, usually associated with a reduction in oxyhemoglobin saturation and/or hypercarbia.

OSAS in children differs significantly from that in adults. Excessive daytime sleepiness (EDS) and snoring with apnea are essential diagnostic elements for OSAS in adults. EDS appears to be uncommon in children with equally severe OSAS. Some children are obese like adults, but most are not. Some have large tonsils and adenoids, while some with enormous adenoids or tonsils have only mild OSAS or are completely asymptomatic. In adults enlarged tonsils and adenoids are uncommon. OSAS in adults occurs predominantly in males and postmenopausal females. In children there isn't a significant difference between males and females.

OSAS is more common in adults than in children, and the prevalence of OSAS in adults increases with age (Carroll and Loughlin 1995). Habitual snoring not associated with obstructive apnea, hypoxia, or hypoventilation is common in childhood, and occurs in 13% of preschool and school-aged children (Castronovo et al. 2003). OSAS is present in approximately 2% of 4- to 5-year-old children. OSAS occurs in children of all age. The peak incidence occurs between 3 and 6 years of age, mirroring the peak age of adenotonsillar hypertrophy.

Symptoms reported in children with OSAS to be present on awakening in the morning include dry mouth, grogginess, disorientation, confusion, headaches, and mouth breathing. During the day, children with OSAS may present hyperactivity, decreased intellectual performance, and learning problems. During sleep some children with OSAS snore loudly and habitually. Sometimes they have grunting, snorting, gasping, or other form of noisy breathing.

Frequently they have respiratory retractions and episodes of increased respiratory effort associated with lack of airflow. Cyanosis or pallor may occur during sleep. Children with OSAS frequently sleep in positions to promote airways patency, such as prone, seated, or with hyperextension of the neck. The complications of OSAS result from chronic nocturnal hypoxia, acidosis, and sleep fragmentation. Pulmonary hypertension is a major cause of morbility in patients with OSAS, and if untreated will progress to cor pulmonare (Brouillette, Fembach, and Hunt 1982). Failure to thrive is a frequent complication of OSAS in children. Causes for poor growth include anorexia or dysphagia secondary to adenotonsillar hypertrophy, increased work of breathing, hypoxia, or abnormal nocturnal growth hormone secretion (Marcus, Koerner, Pysik, and Loughlin 1994).

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