INTRODUCTION
Obstructive sleep apnoea (OSA) is part of a spectrum of sleep-disordered breathing diseases. This ranges from benign simple snoring, affecting up to 12% of children, to severe upper airways resistance and OSA, which affects 1–2% of children.1 Paediatric OSA can be associated with serious consequences including cor pulmonale, right ventricular hypertrophy, and systemic hypertension, if left untreated.1,2
The majority of paediatric OSA is caused by adenotonsillar hypertrophy in children with no pre-existing medical conditions; this is known as ‘uncomplicated OSA’.1 ‘Complicated OSA’ refers to a subgroup of children with medical conditions predisposing to OSA (Table 1); obesity is an important predisposing condition.3 Traditionally, paediatric OSA occurs among pre-school children, although there is an emerging peak in middle childhood and adolescence attributed to the rising obesity epidemic.3 OSA affects boys and girls in equal numbers.1
Presentation of the paediatric form of the disease differs from adult OSA, as children are more likely to present with behavioural problems, poor attention, and reduced academic performance than daytime sleepiness.2,4 It is therefore important to be vigilant for OSA, take an otolaryngology history, and specifically ask about snoring and other common symptoms, especially in children who are disruptive or struggling at school. With treatment, prognosis is excellent. GP referrals for paediatric OSA are increasing as awareness of the disease improves, although diagnosis is still delayed, with up to 31% of patients waiting 4 years for treatment.2
HISTORY
Night-time symptoms — differentiating OSA from simple snoring
Some key questions to ask parents are:
Do you ever notice that your child stops breathing or snoring for periods during sleep?
Do you ever watch over your child due to concern they are not breathing?
Do you ever find that your child’s breathing gets quieter or that they gasp while sleeping?
Are episodes worsened by cold/flu symptoms?
— This is due to inflammation and excessive mucus in the airway worsening symptoms.
Does your child sleep with their neck arched backwards?
— The child is compensating for airway abnormality.
Have you ever noticed your child turning blue during sleep?
— Cyanotic episodes can occur.
Episodes of bed wetting after being dry at night?
— This is due to decreased appropriate arousals during sleep and may signify the child has OSA.5
Daytime symptoms — how is the child progressing?
It is important to ask the following questions in order to complete the sleep history, as parents may not associate daytime symptoms with sleep-disordered breathing:
Does the child have any behavioural problems, such as reduced concentration, hyperactivity, or irritability?
— These symptoms affect up to 25% of children with OSA and can mimic attention-deficit/hyperactivity disorder.1
Poor school performance?
— Evidence suggests that children with OSA are significantly more likely to be in the bottom 25th centile for school performance.2
Ensure that the patient’s (parent and child’s) ideas, concerns, and expectations are explored. In particular, parental concern about the child’s breathing is a key indicator of OSA.1
EXAMINATION
Does the child appear to be mouth breathing or have nasal speech? This indicates nasopharyngeal obstruction, which could be due to adenotonsillar enlargement.
— If uncertain, simply placing a metal spoon under the child’s nose can confirm mouth breathing with the absence of nasal misting.
Can you hear a snoring sound when the child is awake (stertor)?
Inspect nasal cavity with an otoscope.
— Rhinitis (clear, thin, watery discharge)? This is associated with nasal obstruction and adenotonsillar hypertrophy.
— Nasal polyps? These cause nasal obstruction.
Inspect the ears.
— Glue ear? This may exist alongside adenoid hypertrophy.
Check the child’s BMI and plot height and weight on a centile chart, because paediatric OSA is more common in obese children.3
REFERRAL
Refer any child with a history of regular night-time snoring when well in conjunction with adenotonsillar hypertrophy plus any of the symptoms of OSA to an ENT surgeon for further investigation.6 Children with suspected complicated OSA should be referred to paediatrics first. Currently there is no role for ‘watchful waiting’ by the GP in symptomatic children as adenotonsillectomy has been shown to improve symptoms.2 Preliminary investigation involves home pulse oximetry, where a soft cuff is fitted to the child’s toe or finger prior to bedtime. A positive result is a strong predictor that the child has OSA, although a negative test does not exclude it.2 Specialist centres may perform a more detailed sleep study (polysomnography), used to assess severity and decide postoperative care.2
TREATMENT AND PROGNOSIS
In the overwhelming majority of uncomplicated OSA, adenotonsillectomy resolves symptoms, leading to improvement in sleep and quality of life, as well as resolution of behavioural symptoms.2 For the few children that adenotonsillectomy fails, or if it is contraindicated, they should be referred for continuous positive airway pressure (CPAP).2 Nasal steroid sprays may be trialled in atopic children; however, if there is a strong suspicion of OSA the child should also be referred. Rhinitis may be secondary to adenoidal hypertrophy.5 It is important to emphasise that nasal steroids must be continued following surgery in children with evidence of allergic rhinitis to prevent re-accumulation of adenotonsillar tissue.2
For children with a high BMI and evidence of OSA there is an even more urgent necessity for improvement of their airway at night and adenotonsillectomy has been shown to achieve this.2 Weight loss lifestyle advice should be offered for long-term management, specifically informing parents what a healthy diet consists of and advice to exercise for 1 hour per day.3 Consider referral to a healthy-lifestyle programme for further support.
CONCLUSION
GPs should be vigilant for paediatric OSA as it is common and may affect up to 1 in 30 children. OSA in children may present with behavioural problems and poor attention, which parents may not necessarily link to a sleep disorder. It is therefore important that the GP elicits a sleep history. Obesity is a risk factor and is thought to be responsible for rising levels of paediatric OSA. Any child with a history of snoring and any of the daytime or night-time symptoms of OSA should be referred; with treatment the prognosis is excellent.
Information for patients is available from the British Lung Foundation.7
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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- Received October 15, 2016.
- Revision requested October 26, 2016.
- Accepted December 7, 2016.
- © British Journal of General Practice 2017