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Obstructive Sleep Apnea in Children: Are We Really That Careful?

Pediatric obstructive sleep apnea (OSA) is a highly prevalent condition in children, affecting nearly 1 to 5 percent of all children. Similar to what has already been demonstrated in adults suffering from OSA, OSA in children is associated with significant morbidity during childhood, a period that is critical for both growth and development.
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Pediatric obstructive sleep apnea (OSA) is a highly prevalent condition in children, affecting nearly 1 to 5 percent of all children. Similar to what has already been demonstrated in adults suffering from OSA, OSA in children is associated with significant morbidity during childhood, a period that is critical for both growth and development. The potential dangers of untreated OSA in children are vast, with multiple health consequences including elevated inflammation within the body, metabolic disease, cardiovascular disease, and recent evidence suggesting poor asthma control in asthmatic children. Not surprisingly, Pediatric OSA is associated with increased health care utilization, thereby accounting for greater overall societal costs.

Thus, the American Academy of Pediatrics has published guidelines prompting clinicians towards earlier treatment of children with OSA; and the mainstay of treatment is adenotonsillectomy (AT), or the surgical removal of the adenoids and the tonsils. The premise to remove the adenoids and tonsils is related to our observations that these tissues are enlarged in certain children and are indeed central to obstructing the airway during their sleep, which is characteristic of Pediatric OSA. Related to both an increase in prevalence and awareness of OSA in children, AT remains as one of the most common surgical procedures in children in the United States.

Despite the high frequency of AT and the aforementioned guidelines supporting AT in the treatment of Pediatric OSA, recent evidence has revealed that AT is not an entirely benign procedure. In a carefully designed meta-analysis published this year, De Luca Canto and colleagues surveyed 1,254 studies, of which 23 were adequate for their meta-analysis. They revealed that complications of AT are relatively common with secondary bleeding occurring in 2.6 percent of all children, and respiratory complications occurring in 9.4 percent of all children following AT. Even more striking was the observation that children with OSA had nearly 5 times more respiratory complications following AT than in children without OSA undergoing AT for other indications including recurrent tonsillitis.

Given the context of the potential risks associated of AT, particularly in the setting of Pediatric OSA, one could confer that clinicians would simply be more cautionary in caring for children who have OSA. Unfortunately, such is not the case.

In a study blindly observing the practices of anesthesiologists, clinicians who administer anesthesia and ensure safety of children during operative procedures, OSA is in fact only routinely screened for in 37 percent of all children undergoing any surgical procedures including AT, this a rather disheartening statistic. Thus, current trends would suggest that OSA is not a routine screening procedure, this "despite the ASA (American Society of Anesthesiologists) recommendations to do so," as stated by Stacey Ishman, lead author of the study published just this year in the Journal of Clinical Sleep Medicine. Ishman further emphasizes that there was "no correlation between the likelihood of screening for OSA and risk factors for OSA."

Given the importance that we as pediatricians strive to ensure that children are as safe as possible, including in the hospital setting, the evidence suggests that we still lag far behind when in comes to children with OSA. Ishman emphasizes "the most important thing is that anesthesiologists should screen all children for OSA in order to provide the safest and most effective anesthesia care. It is also important that we specifically target screening of children who are otherwise undiagnosed/not undergoing AT."

Notwithstanding, the lack of routine screening by anesthesiologists does suggest a possible lack of awareness of the potential ramifications of OSA in routine administration of anesthesia. As we strive to ensure that all children be kept safe, we as sleep researchers and educators must be proactive in increasing this awareness and underscoring the importance of identifying OSA in children to parents and health care practitioners, which includes anesthesiologists.

References:
  1. Lumeng JC, Chervin RD, authors. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242-52.
  2. Montgomery-Downs HE, O'Brien LM, Holbrook CR, Gozal D, authors. Snoring and sleep-disordered breathing in young children: subjective and objective correlates. Sleep. 2004;27:87-94.
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