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SPA Newsletter.
Neurobehavioral Implications of Habitual Snoring in Children.O'Brien CM, et al. Pediatrics 2004; 116:44-50 Clinical Assessment of Pediatric Obstructive Sleep Apnea.Goldstein NA. Pediatrics 2004; 144:33-43 Plasma C-Reactive Protein Levels Among Children with Sleep Disordered Breathing.Pediatrics 113 e564-69 (www.pediatrics.org/cgi/content/full/113/6/e564) Aden tonsillectomy in Children with Obstructive Sleep Apnea Syndrome Reduces Health Care Utilization.Tarasiuk A, Pediatrics 2004; 113:351-356 This series of studies from several different institutions and departments approaches the problem of snoring +/- OSA from a number of viewpoints. Habitual snoring may occur in 10-12% of young children. OSA in 1-3%. Snoring is a major clinical sign of obstructive sleep apnea (OSA). Primary snoring (PS) occurs in children who do not fit the criteria for OSA by polysomnography. Children may outgrow PS by the time they are ~ nine years old and according to recently published guidelines do not routinely require therapy. Neurobehavioral problems are significantly more common in habitual snorers, although prior studies have not differentiated patients with PS vs. OSA. Tonsillectomy and adenoidectomy (T&A) have been shown to completely eliminate airway obstruction in 85-95% of otherwise healthy patients with OSA and result in significant improvement in clinical symptoms. Work from sleep disorder clinics have shown that there is a continuum of severity from partial obstruction of the upper airway producing snoring to increased upper airway resistance syndrome (UARS) and OSA. The first two referenced studies find that PS may be more clinically significant than previously realized or appreciated. O'Brien et al. found that PS seems to be associated with significant neurobehavioral deficits in a subset of children, possibly because of increased sleep fragmentation. These deficits included measures related to attention, social problems and anxious/depressive symptoms. They were careful to differentiate patients with PS from those with evidence of OSA on polysomnography. They conclude that larger studies are required to further clarify this issue. Goldstein et al. in a small group of patients with clinical symptoms suggestive of OSA but with a negative polysomnograph, found that T&A significantly improved their symptoms. In comparison, children who met the above criteria but were observed for 6 months had minimal clinical improvement. The clinical symptoms included snoring, pauses, daytime sleepiness, enuresis (children > 4 yrs.), irritability, hyperactivity, etc. The study was randomized prospective and investigator blinded. The last two referenced studies emphasize the potential impact of OSA. Tarasiuk found that T&A in patients with OSA reduces health care utilization and Taumann found increased plasma levels of C-reactive protein in patients with sleep disordered breathing. These changes were more prominent in patients who presented sleepy or with neurobehavioral comments at the time of the study. Comments: These are interesting preliminary studies that I thought were well done, although the sample size is small. They suggest a greater than previously appreciated physiologic disturbance in patients that suffer from "benign" snoring or sleep disordered breathing. Goldstein's small but elegantly done study confirms what many of us have suspected and that is that even patients who don't have "OSA" by strict criteria, improve after T&A. Further elucidation of the mechanism of sleep disordered breathing and UARS, as well as the clinical impact of these problems, may lead to an increase in the number of T&A's being performed. Reviewed by: Rita Agarwal MD, FAAP
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