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Kids' Snoring May Loudly Signal Trouble

Doctors urged to screen for and treat obstructive sleep apnea

MONDAY, April 1, 2002 (HealthDayNews) -- Stop ignoring kids' snoring.

The nation's largest group of pediatricians is urging doctors to be on the lookout for -- and to treat more aggressively -- obstructive sleep apnea syndrome (OSAS), a nighttime breathing disorder that affects at least 2 percent of children. Snoring, though often benign in children, is a sign of the disorder.

The American Academy of Pediatrics (AAP) has issued the first clinical practice guidelines for the diagnosis and management of OSAS, which can lead to learning and behavioral problems. In severe cases, it can cause life-threatening cardiorespiratory problems. The guidelines appear in the April issue of Pediatrics.

"I don't think [OSAS] is on the rise, but it was ignored a lot in the past. If you look at the 1960s and 1970s, these children weren't diagnosed until they came in with a coma or heart failure," says Dr. Carole Marcus, head of the pediatric sleep center at Johns Hopkins University in Baltimore, and chairwoman of the AAP subcommittee that issued the guidelines.

"It has become apparent that [physicians] are doing very different things and not keeping up with the literature and not doing the best management," she says.

"The condition is underrecognized," agrees Dr. Raouf Amin, associate professor of pediatrics and director of the Sleep Disorders Clinic at Cincinnati Children's Hospital Medical Center. The American Thoracic Society had previously issued similar guidelines, but those were geared toward specialists.

The AAP guidelines are targeted to all pediatricians.

"Quite frequently, general pediatricians don't ask detailed questions about sleep apnea and general sleep disorders, so these guidelines would make pediatricians more aware of the syndrome and what are the things that they need to use in order to screen for this type of abnormality," Amin says.

Children with OSAS experience obstruction of their upper airway (often by enlarged tonsils and/or adenoids), which disrupts their breathing while they're asleep. Symptoms include snoring, disturbed sleep, and neurobehavioral problems. If left untreated, the condition can lead to severe complications, including learning and behavior problems.

Although OSAS can affect all children from babies to adolescents, it is thought to be most prevalent among preschool-aged children. This is the age when the tonsils and adenoids, which cause the obstruction, are largest in relation to the airway size.

Risk factors include obesity, craniofacial anomalies, and neuromuscular disorders.

Among other things, the AAP is recommending that pediatricians screen all children for snoring; that a diagnosis be made with the assistance of polysomnography, a machine that records several bodily functions during sleep; and that the first line of treatment be an adenotonsillectomy -- or removal of both the tonsils and adenoids.

"One of the big things about these guidelines is that we're recommending objective testing and not to make a decision to treat based on history," Marcus says.

The AAP now recommends that a detailed sleep history for snoring become part of all health-care visits. Such a case history, even along with a physical exam, are still not enough to diagnose OSAS, the Academy stresses.

The group calls the polysomnography test the "gold standard" for diagnosing OSAS. Other diagnostic techniques, such as videotaping, may be useful but only as an adjunct.

Once a diagnosis is made, adenotonsillectomy should be the first treatment considered. "In otherwise healthy children, this will cure about 95 percent of them," Marcus says.

Continuous positive airway pressure, or CPAP, is an alternative for those who are not candidates for surgery or who do not respond to surgery. CPAP involves delivering constant air pressure via a nasal mask worn durign sleep. Unlike an adenotonsillectomy, which fixes the problem immediately, CPAP has to be used indefinitely and requires the child's continued compliance.

The AAP stresses that its guidelines are only for uncomplicated childhood OSAS -- in other words, for children who are otherwise healthy.

"Children who have other underlying conditions might need further therapy," Marcus says.

What To Do

If your child snores, he or she doesn't necessarily have apnea. The noise could be harmless. Still, it may be worth getting the child checked out anyhow.

To view the new clinical practice guidelines, visit the American Academy of Pediatrics.

Check out this site from Stanford University for more information on OSAS.

SOURCES: Carole Marcus, M.B.B.Ch., head, pediatric sleep center, Johns Hopkins University, Baltimore; Raouf Amin, M.D., associate professor of pediatrics and director, Sleep Disorders Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati; April 2002 Pediatrics
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