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Pediatric Obesity and Sleep Apnea
From: ENT Today, July 2012
by Jennifer L.W. Fink
Is bariatric surgery for a teenager ever an appropriate treatment for obstructive sleep apnea?
It can be, said Brian Kaplan, MD, chairman of the department of otolaryngology at the Greater Baltimore Medical Center. “I had a 16- or 17-year-old patient who was morbidly obese,” he said. “The child had sleep apnea and was already on CPAP, but it was clear that CPAP was not going to be a long-term solution. We had the child evaluated, and he ended up getting gastric bypass surgery. Over the next six months, he lost about 50 pounds, and we were able to decrease the CPAP settings almost in half.”
Obesity is inextricably linked to obstructive sleep apnea (OSA). And as pediatric obesity numbers have climbed, so have the number of children with OSA. “There’s a whole multifactorial element when it comes to sleep apnea in the obese pediatric population,” Dr. Kaplan said. “You don’t just have big tonsils and adenoids taking up space, but you have collapse of the soft tissues of the throat. There are also different fat pads within the throat and in the neck that further narrow the airway. Pressure on the stomach and chest from fat collection also makes it harder to take a deep breath. And there’s probably some central element to obesity that we don’t totally understand yet, which also contributes to the development of apnea.”
An interdisciplinary approach is often required and, increasingly, pediatric sleep specialists and otolaryngologists are working closely with pediatric obesity experts to design treatment plans that tackle both OSA and obesity.
Start with Compassion
Obese children and their families are often the targets of criticism, and anti-fat attitudes can even exist within medical practices. Research has shown that it’s not uncommon for health professionals to perceive obese patients as “lazy,” “stupid” or “worthless” (Obes Res. 2003;11(9):1033-1039). Replacing such attitudes with compassionate concern is the first step toward effectively caring for overweight and obese children, said Stephen Pont, MD, MPH, medical director of the Texas Center for the Prevention and Treatment of Childhood Obesity in Austin. “Every touch point that the child and parent have with medical care is the opportunity to plant small seeds of change and encouragement for them,” said Dr. Pont. “If we step back and say, ‘What’s the most effective way to help someone get healthier?’ it’s not to guilt and blame them into it. Instead, you want to empower the parents and patient.”
All otolaryngologists and sleep specialists should obtain a BMI, or body mass index, on their pediatric patients. “It takes very little time but is very important,” said Dr. Pont. A child who falls in the 85th to 95th percentile for their age and gender is considered overweight, while a child who is beyond the 95th percentile is clinically obese. Those terms are not the best to use when talking with children or families, however. “Instead, we might say, ‘Your child has excess weight that could be impacting his health,’” Dr. Pont said. “Those kinds of tweaks in language help establish rapport and really open the door to a productive conversation, rather than putting people on the defensive.”
Referring an obese child and his family to a weight management program, if they are open to such a referral, may improve the child’s long-term health and the odds of successfully treating OSA. “The single most effective intervention you can take for sleep apnea is weight loss,” Dr. Kaplan said. “Of course, referring to a weight management program isn’t going to preclude the need for surgical intervention if the patient has tonsils and adenoids that are contributing to sleep apnea. But what they can do is start the patient on the road to the behavioral changes that are necessary for long-term weight management.”
Another important aspect of the assessment and treatment of obese children is the early involvement of other members of the health care team, including sleep medicine physicians, nutritionists, behavioral psychologists and even genetic specialists, said Dr. Kaplan. If he suspects sleep apnea in an obese pediatric patient, he’ll order a pediatric sleep study and initiate a referral to a nearby pediatric obesity program. Such multidisciplinary approaches to weight management are becoming increasingly common. Many academic medical centers and children’s hospitals now include pediatric obesity or weight management programs.
Pediatric weight management experts are very aware of the link between obesity and sleep apnea and often refer their patients to sleep specialists or otolaryngologists as well. “Because of the known relationship between sleep apnea and obesity, at least one nearby obesity center sends all of their obese patients for sleep studies as part of their routine workup,” said Lewis Kass, MD, director of pediatric sleep medicine at Norwalk Hospital in Norwalk, Conn.
Dr. Kass initiates CPAP in approximately 95 percent of the children referred to him by the obesity clinic. “It may seem aggressive to try CPAP on a kid who only has mild sleep apnea, but I do it anyway,” he said. “With kids, it’s not about the severity of apnea; it’s about the presence or absence. If it’s there, it’s probably affecting the child’s metabolism and daytime functioning.”
Beginning CPAP may help address the obesity issue as well. “The most exciting science I’ve seen in the last five years has been findings that suggest that treatment for obstructive sleep apnea, all by itself, improves metabolism,” Dr. Kass said. “Fat calls secrete a peptide called leptin, and when they over-secrete leptin, we get leptin resistance, and leptin resistance leads to insulin resistance. When you treat obstructive sleep apnea, the leptin goes away.” One 2003 study found that insulin sensitivity in patients with OSA improved after just two days of CPAP and remained improved at three months (Am J Resp Crit Care Med. 2004;169:156-162).
Despite the fact that CPAP is not FDA approved for children who weigh less than 40 pounds or are younger than seven years of age, it can and should be considered for the treatment of OSA in the obese pediatric population, said Carole Marcus, MBBCh, director of the Sleep Center at Children’s Hospital of Philadelphia. “We certainly use it in very young children, and so do others,” she added. Compliance can be an issue, however. “It’s much harder to get a child to wear a CPAP mask,” she said. “You can’t just have a DME [durable medical equipment] company drop off a CPAP machine at the house and expect the child to wear it. You need to use a family-centered approach and behavioral modification program, adapted to the age of the child.”
Tonsillectomy and Adenoidectomy
While adenotonsillectomy (T&A) is generally the first-line treatment for children with OSA, it’s usually not as effective in the obese pediatric population as it is for non-obese children. For most pediatric patients with sleep apnea, “removing their tonsils and adenoids results in an 80 to 90 percent cure rate,” Dr. Kaplan said. “The cure rate after T&A for the obese pediatric population is only about 50 percent.”
Many obese children will have continued OSA after T&A, so Dr. Kass recommends reassessing patients post-surgery and performing a sleep study six months after surgery, to determine whether there is a need for additional intervention. Re-evaluation is also necessary as the child grows and matures. “There’s certainly data to suggest that sleep apnea can reoccur,” Dr. Marcus said. “Children are likely to gain weight as they get older, and when males go through puberty, testosterone changes the shape and size of the airway. Plus, as children become adults, they may adopt habits, such as having a bit of alcohol, that would increase their propensity for sleep apnea.”
Bariatric surgery may seem like an extreme treatment for OSA, but there’s evidence to suggest that it may be helpful. Research studies that measured the presence and severity of OSA in obese teenagers both before and after weight-loss surgery suggest that weight-loss surgery typically resolves or greatly reduces the severity of OSA (Obesity. 2009;17(5):901-910, Obes Surg. 2003;13(1):58-61).
Evan Nadler, MD, director of the bariatric surgery program and co-director of the Obesity Institute at Children’s National Medical Center in Washington, D.C., said bariatric surgery should be considered as a possible treatment for OSA (and obesity) for morbidly obese teens. “Any adolescent who meets the adult standards for weight-loss surgery should at least be evaluated by an adolescent weight-loss surgeon, even if it’s just an information-gathering exercise,” he said. Teens who have a BMI of 35 with a significant comorbidity like sleep apnea qualify, as do teens with a BMI of 40 without a comorbidity.
“I actually had one patient who avoided an adenotonsillectomy by having weight-loss surgery,” said Dr. Nadler. “The patient had generous tonsils, but neither I nor the [otolaryngologist] felt that the tonsils were the main contributor toward the sleep apnea. So after discussing the case, he and I decided to proceed with weight-loss surgery first.” The morbidly obese teenager underwent bariatric surgery and so far has not needed any additional treatment for OSA.
Bariatric surgery requires significant commitment from the patient, so almost all obesity centers require prospective candidates to be actively involved in a weight management program before undergoing surgery. “A patient cannot be successful without a huge amount of behavior change. If they’re not in the right place mentally and showing success beforehand, then it’s likely that the surgery will not be successful in the long term,” said Dr. Pont.
Insurance companies are increasingly willing to pay for bariatric surgery. “If I have a 15- or 16-year-old with severe OSA and morbid obesity, it’s fairly easy for me to convince an insurance company why it’s in the child’s best interest to have surgery,” Dr. Nadler said.
Inhaled steroids are another option for obese children with OSA. “Using an inhaled steroid can sometimes decrease the size of the adenoids and tonsils, and that can help some kids improve their sleep quality,” Dr. Pont said. A 2008 Pediatrics study of non-obese children found that a six-week course of intranasal budesonide reduced the severity of mild OSA in 54.1 percent of children treated with the steroids. The effect persisted for at least eight weeks post-treatment (Pediatrics. 2008;122(1):e149-e155).
Inhaled steroids are expected to be included as a possible treatment modality for OSA in the next American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome, which should be released later this year.
The Importance of Collaboration
Effectively treating OSA in the obese pediatric population requires close collaboration among a host of medical experts, and such collaboration may be strange to otolaryngologists and sleep specialists who are used to treating OSA with minimal assistance. But reaching out to obesity experts benefits both patients and physicians. “If you just approach the OSA from an ENT standpoint alone, you’re destined for failure in a large percentage of these kids,” said Dr. Kaplan. “The otolaryngologist may be the point person initially, but obstructive sleep apnea in an obese child has to be managed closely with the child’s primary care doctor or pediatrician and all of the other various members of the team if you really want to see long-term success.”