SDB Morbidity in Children Can Be Improved by Surgery

WASHINGTON, DC-Sleep-disordered breathing (SDB) is a major problem in children because it is associated with behavioral, cognitive, and emotional morbidity. The silver lining to this cloud is that removal of the tonsils and adenoid tissue (T&A) normalizes children’s sleep and improves their behavior problems, while achieving dramatic reduction in health care resource utilization and cost savings.

Children with SDB exhibit sleepiness, cardiovascular problems, poor growth, depressed mood, and a spectrum of behavioral problems that can include aggression, poor academic performance, irritability and hyperactivity, and inattention, explained Norman R. Friedman, MD, Associate Professor at the University of Colorado Health Sciences Center and Director of the Pediatric Pulmonary Sleep Lab in Denver.

A large survey of 1600 cases showed that children who snored between the ages of two and six were more likely to be at the bottom of their class, Dr. Friedman said. Another review of 12 studies showed that children with SDB had lower intelligence quotients (IQ) compared with controls. Dr. Friedman explained that even mild SDB is associated with lapses in attention and lower IQ, and that his threshold for intervention has dropped.

click for large version

Figure. In addition to excessive daytime sleepiness, children with SDB are prone to cardiovascular problems, poor growth, depressed mood, and a range of behavioral problems.

If a child exhibits night-time symptoms (snoring, gasping for breath, noisy breathing, frequent awakening, and parasomnias), daytime symptoms (described above), and enlarged tonsils, he advises removing the tonsils.

If snoring is present, I am less likely to get a sleep study before intervening, he said.

Sleep Testing

Dr. Friedman said that children at high risk for SDB should undergo sleep testing. Factors that place children at high risk include prematurity, age under two, and obesity, Down syndrome, genetic or neuromuscular disorders, and sickle cell disease.

Sleep studies can be complicated to interpret. Also, different labs use different indices and cutoff points. The main indices used include the Apnea/Hypopnea Index (AHI), the Central Apnea Index (CAI), the Respiratory Disturbance Index (RDI), the Arousal Index (AI), and the Respiratory Event-Related Arousal Index (RERA). These indices measure different things, he said.

Sleep labs use different cutoff points for these indices to define clinical significance.

New studies suggest that more than five events per hour represents a clinically significant AHI, he said. However, if oxygen desaturations are associated with the respiratory events, the clinical relevance threshold drops below five events per hour. Dr. Friedman also emphasized the importance of measuring end-tidal CO₂. The number can be normal but the wave form can be abnormal, signaling decreased ventilation, he commented.