Another pediatric otolaryngologist, Norman Friedman, MD, Director of the Pediatric Pulmonary Sleep Laboratory at the University of Colorado, told ENToday that he too has seen discrepancies in his practice.
Explore This IssueFebruary 2007
In one case, he saw a two-year-old boy whose parents reported some snoring but no real struggle to breathe. The child had 4+ enlarged tonsils. His sleep study had severe OSA with episodic hypoxemia, and he required supplemental oxygen prior to his surgery, he said.
The reality is, most of us perform surgery on children with a parental history consistent with OSA and an abnormal physical exam. It is difficult to predict the accuracy of a clinician’s exam, he said.
In a chapter he wrote for the book Clinician’s Guide to Pediatric Sleep Disorders, he described how history alone often does not predict the presence of sleep-disordered breathing.
The parents could report loud snoring, mouth breathing, pauses, but their history was not consistently confirmed by PSG. This implicates that the presence of snoring is not diagnostic of OSA, he wrote.
Indeed, the symptom of snoring is more common than the incidence of OSA, so most children who snore do not have OSA. A meta-analysis of 10 studies on the topic of pediatric OSA found that 55% of children suspected as having OSA actually had OSA as confirmed by PSG.
Although objective testing is important when it comes to pinpointing a diagnosis, sometimes testing alone doesn’t tell the whole story. According to Dr. Norman Friedman, recent studies suggest that snoring, even without apnea, can be detrimental to a child’s health-and shouldn’t be ignored.
He also described a case he saw of a seven-year-old girl with Down syndrome who had markedly enlarged tonsils of 4+. The mother reported snoring, but no pauses. While children with Down syndrome are at increased risk for OSA, especially with enlarged tonsils, in this case the mother was correct. A sleep study did not reveal any obstruction-just snoring.
When listening to the parents, doctors need to listen for clues. Dr. Ellen Friedman described a case of an eight-year-old girl who was brought in for swallowing complaints.
The mother said she might have been playing with some coins before this happened but wasn’t sure. But the child’s grandmother had died recently from scleroderma-which had a principal complaint of trouble swallowing. The physician listening to this thought the girl’s swallowing problem was a psychological grief reaction to her grandmother’s death, she said.