Growth failure and sleep disordered breathing: A review of the literature

Summary

Objective

While otolaryngologists consider growth failure an absolute indication for tonsillectomy and adenoidectomy (T&A), they may not be accustomed to screening for poor growth, and thus unlikely to consider it when recommending a T&A. This paper will (a) familiarize otolaryngologists with the definition, prevalence, and etiology of growth failure and (b) review the published findings that examine the inter-relationship among sleep disordered breathing, growth failure, and adentonsillar hypertrophy in children.

Methods

This paper is divided into three sections. The first section presents a brief overview of growth failure for the otolayngologist. The second section reviews the evidence base linking sleep disordered breathing, growth failure, and adenotonsillar hypertrophy in children. The anthropometric outcomes of children presenting for T&A, or having sleep symptoms assessed, are presented. The third section presents pilot data (n = 28) on the prevalence of growth failure and sleep disordered breathing among children presenting for T&A at our institution.

Results

Among children presenting for T&A or having sleep symptoms assessed, growth failure was at least twice the expected rate in six of eight published studies. Across these six studies, this rate ranged from a low of 6% of children <3rd percentile for weight and 6% <3rd percentile for height in one study, to a high of 52% who were <3rd percentile in weight in a second study, and 44% who were ⩽5th percentile for height in a third. Among children presenting for T&A at our own institution, 14% were ⩽5th percentile in height, and 11% were ⩽5th percentile in weight. Among children under 6 years of age, 21% were either ⩽5th percentile in weight and/or height.

Conclusions

Published studies, as well as our own pilot data support the hypothesis that SDB, secondary to adenotonsillar hypertrophy increases the risk of growth failure in children. Adenotonsillar hypertrophy and sleep disordered breathing may be unrecognized risk factors in the etiology of growth failure. Otolaryngologists can play an important role in identifying growth failure, and referring children to the appropriate specialists.

Introduction

Evidence starting from the 1980s supports a causal relationship between sleep disordered breathing (SDB) and growth failure (GF) in children [1], [2], [3], [4]. For most children, adenotonsillar hypertrophy is the primary factor leading to SDB; tonsillectomy and adenoidectomy (T&A) is curative in 80% of cases [5], [6]. Nearly every study finds that otherwise healthy children experiencing GF show significant catch up growth following T&A. The American Academy of Pediatrics identifies GF as a serious complication of untreated obstructive sleep apnea [7].

Yet, primary care providers’ differential diagnosis of GF in children does not routinely include an assessment of upper airway obstruction [8], [9], [10], [11], [12], [13]. Only half of pediatricians surveyed identify a relationship between poor growth and obstructive sleep apnea (OSA) [14]. Pediatric subspecialties in genetics [15], GI [16], [17], and endocrine [18] do not routinely include such an assessment in their differential diagnosis of GF either. This is not surprising, given that the underlying cause of GF is nearly always attributed to under-nutrition, despite multiple biologically plausible pathways from SDB to GF. For over 20 years, there has been an as yet unheeded call for assessment of SDB in children with growth problems [4], [19], [20], [21], [22], [23], [24].

Otolaryngologists identify GF as an absolute indication for T&A; dysphagia, caused by hypertropic tonsils and/or adenoids is generally cited as the primary causal mechanism [25]. With rare exception [26], the otolaryngology literature does not discuss the potential role of growth hormone [1] and/or energy expenditure disturbances [27] in SDB-related GF. In contrast, the association between SDB and GF is well documented in the sleep disorders literature [7], [21], [28]. Furthermore, a survey of otolaryngologists’ reasons for performing T&A among school age children, did not present growth disorders as an option, despite 59% of procedures being reported for obstructed breathing of any type and 39% for OSA [25].

This paper is divided into three sections. The first section presents a brief overview of GF for the otolayngologist. In the second section, we review the literature on SDB, GF, and adenotonsillar hypertrophy and present a model of the proposed associations. The third section presents pilot data on the prevalence of both SDB symptoms and GF among children presenting for T&A at our institution.