Pediatric Sleep Disorders

Although the field of pediatric sleep medicine is relatively young, it is becoming increasingly apparent that inadequate or disrupted sleep negatively affects children’s health and development in clinically significant ways. The American Academy of Pediatrics supports delayed school start times to reduce chronic sleep insufficiency in adolescents, as this has been associated with adverse health and safety issues in this population. The pediatric obesity epidemic in the United States has resulted in an increasing prevalence of obstructive sleep apnea (OSA) and obesity-related hypoventilation in the pediatric population and is a major driver of the use of nocturnal positive airway pressure (CPAP or BiPAP) in children. Untreated OSA can be an important factor in the etiology of attention deficit disorder and other behavioral problems in children. Emerging evidence suggests that sleep-disordered breathing has wide-ranging effects on human health, including hypertension, obesity, and psychiatric and cognitive disorders.

Evaluation

Evaluation for sleep disorders in the pediatric population begins with a thorough history and physical exam. The BEARS mnemonic is one of the screening tools for pediatric sleeping disorders.

BEARS Screening Tool for Pediatric Sleep Disorders

	Toddler/Preschool (2 to 5 Years)	School-Age (6 to 12 Years)	Adolescent (13 to 18 Years)
Bedtime problems	Does your child have any problems going to bed? Falling asleep?	Does your child have any problems at bedtime? (P) Do you have any problems going to bed? (C)	Do you have any problems falling asleep at bedtime? (C)
Excessive daytime sleepiness	Does your child seem overtired or sleepy a lot during the day? Does he/she still take naps?	Does your child have difficulty waking in the morning, seem sleepy during the day, or take naps? (P) Do you feel tired a lot? (C)	Do you feel sleepy a lot during the day? In school? While driving? (C)
Awakenings during the night	Does your child wake up a lot at night?	Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? (P) Do you wake up a lot at night? Have trouble getting back to sleep? (C)	Do you wake up a lot at night? Have trouble getting back to sleep? (C)
Regularity and duration of sleep	Does your child have a regular bedtime and wake time? What are they?	What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep? (P)	What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get? (C)
Snoring	Does your child snore a lot or have difficulty breathing at night?	Does your child have loud or nightly snoring or any breathing difficulties at night? (P)	Does your teenager snore loudly or nightly? (P)

When sleep-disordered breathing is suspected, an in-lab sleep study (polysomnography) is generally warranted. Polysomnograms consist of EEG leads, electromyography leads (detecting muscle tone and movement), airflow sensors, pulse oximetry and heart-rate sensors, a microphone to detect snoring, and a chest band to detect respiratory effort.

[Image] — **Typical Leads in a Basic Polysomnogram**

An obstructive respiratory event is diagnosed on polysomnogram by ≥90% reduction in oronasal airflow during at least two breath cycles despite evidence of inspiratory effort. Conversely, central sleep apnea is defined as an absence of oronasal airflow for ≥20 seconds without respiratory effort. A patient may also demonstrate mixed apnea or hypopneas. The number of apneas and hypopneas per hour is termed the apnea-hypopnea index (AHI). The AHI is used to quantify the degree of obstruction. An AHI of 1-4 events per hour is considered mild disease, 5-10 is moderate, and >10 is severe.

Management

Patients with OSA may respond to conservative measures such as weight loss. However, many will benefit from adenotonsillectomy or nocturnal positive pressure (PAP) therapy such as CPAP or BiPAP.

Patients with central apnea may require a PAP modality with a guaranteed respiratory rate. Chiari malformation should be ruled out in this population.

Caffeine can be effective in treating apnea of prematurity until a postconception age of 44 weeks. Patients on caffeine need to be monitored for gastroesophageal reflux disease.

Research

Landmark clinical trials and other important studies

Research

Montelukast for Children with Obstructive Sleep Apnea: A Double-Blind, Placebo-Controlled Study

Goldbart AD et al. Pediatrics 2012.

Daily treatment with oral montelukast for 12 weeks reduced the severity of obstructive sleep apnea and the magnitude of adenoidal hypertrophy in children with nonsevere obstructive sleep apnea.

Outcomes of Drug-Induced Sleep Endoscopy Directed Surgery for Pediatric Obstructive Sleep Apnea

He S et al. Otolaryngol Head Neck Surg 2018.

This study assessed the effectiveness of pediatric drug-induced sleep endoscopy (DISE)-directed surgery in children with infant obstructive sleep apnea (OSA) or OSA after adenotonsillectomy. DISE-directed surgery used to identify sites of obstruction and guide surgical intervention was associated with improved mean obstructive apnea-hypopnea index and mean oxygen saturation nadir post-operatively.

Hypoglossal Nerve Stimulation in Adolescents with Down Syndrome and Obstructive Sleep Apnea

Diercks GR et al. JAMA Otolaryngol Head Neck Surg 2018.

In this pilot study, hypoglossal nerve stimulator placement in patients aged 12-18 years with Down syndrome for the treatment of severe obstructive sleep apnea despite prior adenotonsillectomy was well tolerated and effective in reducing the apnea hypopnea index by 56%-85% at 6- to 12- month follow-up.

Sustained Benefits of Delaying School Start Time on Adolescent Sleep and Well-Being

Lo JC et al. Sleep 2018.

In this study of the impact of a 45-minute delay in school start time on sleep and the well-being of adolescents, delaying school start resulted in sustained benefits on sleep duration, daytime alertness, and mental well-being.

A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea

Marcus CL et al. N Engl J Med 2013.

This randomized trial of 464 patients with obstructive sleep apnea compared early adenotonsillectomy to watchful waiting and demonstrated reduced symptoms and improved secondary outcomes in the treatment group.

Read the NEJM Journal Watch Summary