Summary of the New Zealand Guidelines for the Assessment of Sleep Disordered Breathing in Childhood
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Investigation and Management of suspected Obstructive Sleep Apnoea (OSA) in children
This document is a summary of the New Zealand Guidelines for the Assessment of Sleep Disordered Breathing in Childhood. This guideline is intended for GPs and paediatricians involved in the care of children and young people 2 years and older.
What is Obstructive Sleep Apnoea (OSA)?
Obstructive sleep apnoea (OSA) is a condition where narrowing of the airways at the back of the nose and throat during sleep is enough to cause a child to have difficulty breathing, or results in pauses in their breathing. The child will then wake up briefly because they cannot breathe properly, often with a loud gasp or snort. Oxygen saturations may or may not be reduced, but sleep can be disrupted.
These episodes can happen many times through the night and the disturbed sleep can result in changes in behaviour during the day such as sleepiness, hyperactivity, impulsivity, poor attention and difficulty learning at school.
- Habitual snoring (snoring ≥ 3 nights per week) is the cardinal feature of OSA
- 1 in 10 children snore most nights and up to 1 in 20 have OSA
- OSA peaks in children aged 3-6 years of age
- Unlike adults children with OSA are much more likely to be hyperactive or inattentive than sleepy
- OSA can result in adverse cardiovascular and neurocognitive/behavioural consequences.
What are the risk factors for OSA?
In most children OSA is caused by large tonsils and/or adenoids. Children who are at a higher risk of OSA and complications include those who are overweight/obese, and children with Down syndrome, neuromuscular disease and spina bifida, craniofacial anomalies, achondroplasia, allergies/asthma and other chronic lung disease e.g. Cystic Fibrosis.
How is OSA in children assessed?
- As part of routine health consultations ALL children should be assessed for sleep problems. The BEARS mnemonic can be used as a guide for history taking. Parents should be asked about snoring or noisy breathing in particular.
- If symptoms of snoring or noisy breathing are noted, a paediatric OSA screening questionnaire should be completed (LINK). For the linked questionnaire add up the "Yes" scores for the 22 items. A score greater than 7 with no missing items, or a percentage value of 0.33, has a 78% sensitivity and a 72% specificity for detecting polysomnograph (PSG) diagnosed OSA (AHI >5).
- It is recommended that paediatricians consider combining the ENT examination findings and OSA questionnaire score, with an overnight oximetry as this will increase the specificity and positive predictive value for OSA.
- Note that a normal overnight oximetry does not rule out OSA.
How is OSA in children managed?
- If an otherwise healthy child with no additional risk factors, is determined to have OSA based on history +/- questionnaire and has adenotonsillar hypertrophy, refer to ENT for consideration of adenotonsillectomy as first line treatment.
- If the child has significant additional risk factors refer to a paediatrician for further evaluation.
- A weight management plan is essential for children who have OSA and are overweight or obese. Adenotonsillectomy may still be first line management.
- Nasal steroids may be considered as treatment for mild OSA, particularly in children with allergic rhinitis, or when adenotonsillectomy is contraindicated, with appropriate follow-up to determine the effect of treatment.
- Children who have symptoms of OSA but do not have enlarged tonsils or adenoids, or for whom adenotonsillectomy is contraindicated, should be referred for more extensive evaluation or discussed with a centre with expertise in paediatric sleep medicine. It is suggested that GPs and paediatricians familiarise themselves with their nearest centre's resources, and contact those centres directly to discuss cases as needed.
What follow up is needed?
- All children undergoing adenotonsillectomy for OSA should undergo clinical review 6-8 weeks post-adenotonsillectomy. If symptoms remain unresolved further evaluation is indicated by a centre with expertise in paediatric sleep medicine.
- If symptoms persist or recur post-surgery, refer to a paediatrician or discuss with a centre with expertise in paediatric sleep medicine.
When is a sleep study necessary?
- OSA can often be diagnosed without the need for elaborate tests and treated effectively with adenotonsillectomy. However when the diagnosis is in doubt, when there are underlying comorbidities or anaesthetic risk, or when ENT intervention fails to resolve symptoms, most experts recommend formal evaluation using sleep studies (polysomnography, PSG) with consideration to other treatments (e.g. CPAP respiratory support).
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