Snoring and obstructive sleep apnea in young children

A 6-month follow-up study

Peter Nieminen

Department of Otorhinolaryngology, University of Oulu
Department of Clinical Neurophysiology, University of Oulu
Department of Paediatrics, University of Oulu
Institute of Dentistry, University of Oulu

Abstract

Seventy-eight prepubertal children 3 to 10 years old (mean age 5,67 years, range 2.4 - 10.5 years), with symptoms suggestive of obstructive sleep apnea syndrome (OSAS) were studied. Based on overnight polysomnography (PSG) results, 32 children were classified as having OSAS, whereas 46 children were considered as primary snorers (PSs'), when an obstructive apnea-hypopnea index (AHIO) of over one was considered abnormal. Symptoms, signs and findings in these two groups were compared in a cross-sectional study. Fifty-eight of the children were retrieved for a follow-up visit, which was scheduled six months from the first visit. The children with an initial AHIO of 2 or over (n = 21) had been subjected to adenotonsillectomy swiftly after the first visit, whereas the others (n = 37) were observed without intervention. The changes in symptoms, signs and findings were analysed within and between these groups.

Relative risk (RR) ratios were calculated in order to find clinical symptoms and signs predicting OSAS in snoring children. Observed apneas, restless sleep, constant snoring and tonsillar hypertrophy were significantly associated with an increased risk of OSAS.

Dental arch measurements indicated that AHIO was significantly associated with the amount of overjet, suggesting that altered breathing may affect the dentofacial morphology.

Nasalance measurements revealed no group differences between the OSAS children and PSs'. Adenotonsillectomy had no significant influence on the nasalence scores. Measurements of nasalance seem to contribute little to the diagnostics of OSAS in children.

At the first visit the mean circulating concentrations of insulin-like growth factor-1 (IGF-1) were of the same magnitude in the OSAS children, the PSs' and the age-matched control group, but both the OSAS children and the PSs' had lower IGF-binding protein-3 (IGFBP-3) concentrations than the control subjects. At the second visit a significant increase of the peripheral concentrations of IGF-1 and IGFBP-3, along with increases in weight for height and BMI were observed in the surgically treated children, whose respiratory parameters and symptoms had improved highly significantly, as well. These results indicate that the growth of children with obstructed nighttime breathing is potentially affected through impaired growth hormone secretion.

None of the primary snorers developed OSAS during the observation period, which finding suggests a favorable prognosis for primary snoring in children.

Table of Contents
Acknowledgements
Abbreviations
List of original communications
1. Introduction
2. Review of the literature
2.1. History of sleep apnea among children
2.2. Normal sleep in 3 to 10 year old children
2.3. Definitions
2.3.1. Primary snoring
2.3.2. Obstructive apneas
2.3.3. Obstructive hypopneas
2.3.4. Obstructive hypoventilation
2.3.5. Central apneas
2.3.6. Mixed apneas
2.3.7. Desaturation
2.3.8. Arousals and sleep architecture
2.3.9. Autonomic arousals
2.4. Classification of sleep-related airway obstruction
2.4.1. UARS
2.4.2. OSAS
2.5. Diagnostic criteria for OSAS
2.6. Diagnostic methods
2.6.1. Polysomnography
2.6.2. Clinical diagnosis
2.6.3. Pulseoximetry
2.6.4. Sleep sonography
2.6.5. Video and cardiorespiratory monitoring
2.6.6. Radiology
2.6.7. Endoscopy
2.6.8. Nasal cannula/pressure transducer
2.7. Prevalence
2.8. Pathophysiology
2.9. Etiology
2.10. Morphological and odonthological considerations
2.11. Clinical symptoms
2.11.1. Nighttime symptoms
2.11.2. Daytime symptoms
2.12. Complications
2.12.1. Failure to thrive
2.12.2. Cardiovascular complications
2.12.3. Developmental aspects
2.13. Treatment
2.13.1. Surgery
2.13.2. Other
2.14. Treatment complications
2.15. Natural history
3. Aims of the present study
4. Subjects and methods
4.1. Subjects
4.2. Methods
4.2.1. Questionnaire
4.2.2. Clinical evaluation
4.2.3. Polysomnography
4.3. Symptoms and signs (studies I & IV)
4.4. Dental arch dimensions (study II)
4.5. Nasalance studies (study III)
4.6. Growth characteristics (study V)
4.7. Protocol
4.8. Statistics
4.9. Ethical aspects
5. Results and comments
5.1. First visit
5.1.1. Polysomnography results
5.1.2. Symptoms and signs
5.1.3. Risk factors (Study I)
5.1.4. Dental arch dimensions (Study II)
5.1.5. Nasalance scores (Study III)
5.1.6. Growth characteristics (Study V)
5.2. Follow-up study
5.2.1. Polysomnography results
5.2.2. Symptoms (Study IV)
5.2.3. Impact on nasalence (study II)
5.2.4. Effects on growth
6. General discussion
7. Conclusions
References
List of Tables
1. Abnormal polysomnographic criteria for children according to Marcus et al. (1992)
2. Comparison of the symptoms and some other features of OSAS in adults and children
3. Most common nighttime symptoms of pediatric OSAS and their prevalence in various reports.
4. The number of OSAS children and primary snorers successfully measured and evaluated in the diverse studies. PS = primary snorers.
5. The polysomnography findings of the whole study material. The data are mean, (SD)(range).
6. General information about the OSAS children, primary snorers and the controls and of their symptoms and signs. Linear- by linear association test has been applied for the symptoms with more than two answering alternatives. p1 indicates the statistical difference between the OSAS children and the primary snorers, p2 the difference between the primary snorers and the controls and p3 the difference between the OSAS children and the controls.
7. Relative risk ratios for symptoms and signs predicting OSAS in snoring children are expressed at various levels with cumulative number of cases.
8. Anthropometric measurements on the first visit in the children with OSAS, the children with primary snoring and the control group presented as mean values and their 95% confidence intervals.
9. Polysomnography results of the 21 children operated on. Unless otherwise indicated, data are mean (SD) (range). p1 indicates the statistical difference between the results from the first and second measurements.
List of Figures
1. The schematic spectrum of the severity of airway obstruction in children.
2. The Starling resistor model of upper airway. The airway is represented by a tube with a collapsible segment (pharynx) between two rigid segments with fixed diameters, resistances and pressures (nasal and trachel segments). The airway collapses when the pressure surrounding the airway becomes greater than the pressure within the airway.
3. Polysomnographic and video equipment for the recording of sleep patterns during one overnight observation period
4. Plasma IGF-1 levels in children treated surgically for OSAS and in primary snorers (non-operated) at the first and second visits 6 months apart and in the control subjects. Each box-plot represents the median (thick black band) and the 25th and 75th centiles. The error bars represent the smallest and largest observed values except the outliers.
5. Serum IGFBP-3 levels in children treated surgically for OSAS and in primary snorers (non-operated) at the first and second visits 6 months apart and in the control subjects. Each box-plot represents the median (thick black band) and the 25th and 75th centiles. The error bars represent the smallest and largest observed values except the outliers.
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