Multidisciplinary Strategies for Pediatric Sleep Apnea

Similar to its prevalence in the adult population, obstructive sleep apnea (OSA) in children is one of the most common manifestations of sleep-related breathing disorders. The prevalence of OSA in children has significantly increased in the last 20 years, particularly among the younger population, possibly linked to the rise in obesity. Estimates of sleep apnea and snoring in school-aged children vary widely in the literature, ranging from 1.2% to 5.8%. Pediatric OSA peaks occur between 2 and 8 years old due to adenotonsillar hypertrophy and, during adolescence, is generally linked to weight gain. Some studies report habitual snoring estimates ranging from 3% to 21%.

Recent evidence suggests a correlation between nasal and upper airway obstruction and a reduced transversal and sagittal development of the maxillary and mandibular structures. Early intervention and collaboration by a multidisciplinary team to evaluate the relationship between anatomical, neuromuscular, and skeletal factors could lead to a timelier reduction or resolution of the condition.^1-3

Pathophysiology

The multifactorial pathogenesis of pediatric OSA is determined by a comprehensive interaction of anatomical, neuromuscular, hormonal, and genetic elements. Anatomical upper airway abnormalities play a crucial role, with adenotonsillar hypertrophy emerging as a classic clinical phenotype. This manifestation underscores the significance of enlarged tonsils and adenoids in obstructing the airway, contributing substantially to the development of OSA in pediatric patients.

Moreover, the reduced neuromuscular control leading to upper airway collapse adds another layer to the intricate pathophysiology of pediatric OSA. Neural signals and muscular responses become disrupted, creating a scenario where the upper airway collapses during sleep. In addition to these primary factors, hormonal and genetic elements contribute to the development of pediatric OSA, too. Three distinct phenotypes can be described in pediatric subjects:

• Classic: prominently characterized by adenotonsillar hypertrophy.
• Adult: closely associated with obesity-related factors.
• Congenital: intricately linked to congenital syndromes.

This phenotypic diversity highlights the heterogeneity within the pediatric OSA population, necessitating a personalized approach to diagnosis and treatment.

Understanding the multifactorial nature of pediatric OSA is essential for healthcare professionals to tailor interventions that address the specific contributing elements in each case. Full comprehension of the multifaceted pathogenesis helps the multidisciplinary team navigate the intricate landscape of pediatric OSA and enhance the quality of care provided to affected children.

Pediatric Clinical Features

Pediatric OSA exhibits distinctive symptoms that can be categorized into nocturnal and daytime manifestations. Children with OSA often exhibit daytime hyperactivity rather than the excessive daytime sleepiness commonly observed in adult cases. This deviation in symptoms emphasizes the importance of recognizing age-specific indicators for accurate diagnosis and intervention.

Nocturnally, children with OSA frequently experience disruptions in their sleep patterns, episodes of loud snoring, intermittent pauses in breathing, and restlessness. These nocturnal manifestations can lead to fragmented sleep, causing daytime-relevant consequences that affect neurocognitive development. Thus, the impact of pediatric OSA extends beyond sleep-related issues, affecting cognitive function, behavior, and overall quality of life.

This hyperactivity can be misunderstood, potentially delaying the diagnosis and appropriate management of OSA. Timely intervention prevents potential long-term consequences for the child’s health and development. Children with untreated OSA may exhibit difficulties in concentration, learning, and memory, emphasizing the comprehensive nature of this sleep disorder. Addressing these daytime manifestations requires a multidisciplinary approach involving pediatricians, dentists, orthodontists, otolaryngologists, neurologists, and sleep medicine professionals to customize the interventions considering the nocturnal and daytime aspects of pediatric OSA.^4-5

Untreated pediatric OSA can lead to various complications, including cardiovascular effects such as pulmonary hypertension, hypertension, and cardiac pathologies. Neurocognitive and behavioral consequences include memory and attention deficits, behavioral issues, and a higher prevalence of attention-deficit/hyperactivity disorder (ADHD). OSA can also impact growth and development due to fragmented sleep, which affects the endocrine system and growth hormones.⁶

Pediatric Sleep Disorder Diagnosis

Diagnosing sleep-disordered breathing involves a specific medical history, clinical assessment, and instrumental evaluation. Various validated questionnaires, such as the Pediatric Sleep Questionnaire (PSQ) and the Sleep Disturbance Scale for Children (SDSC), aid in the comprehensive assessment of pediatric OSA.

Orthodontic considerations in pediatric OSA involve radiographic assessments, including lateral cephalograms and 3-D imaging techniques like computed tomography (CT) and magnetic resonance imaging (MRI). These assessments help evaluate craniofacial structures and airway dimensions, aiding in treatment planning.^7-8

Multidisciplinary Approach

Treatment options range from medical interventions, such as nasal corticosteroids and weight control, to surgical interventions, like adenotonsillectomy. Orthodontic interventions, such as rapid maxillary expansion, play a crucial role in treating anatomical abnormalities. Recent studies highlight how increasing maxillary volume positively affects nasal respiration, which is fundamental for the immune system, the production of nitric oxide, air humidification and filtration, and craniofacial development. Other therapies such as continuous positive airway pressure (CPAP) are effective but present challenges with pediatric compliance and the potential to affect the normal development of the craniofacial structures.

The multidisciplinary approach in pediatric OSA patients emerges as a fundamental element to ensure comprehensive and integrated health. In particular, synergistic collaboration among various professionals, such as pediatricians, pediatric dentists, otolaryngologists, pulmonologists, and sleep medicine professionals, represents the goal for the optimal management of pediatric health. This approach is based on the awareness that a child’s health involves multiple aspects, and cooperation among specialists allows for a comprehensive and targeted approach to address challenges that may arise during growth and development.

The pediatrician plays a central role in this context, as they are often the first point of contact for the overall assessment of a child’s health. Through open and frequent communication with other professionals, the pediatrician can effectively coordinate the management of conditions involving different systems, promoting a holistic approach to pediatric patient care.

Pediatric dentists should not limit their role in only treating dental conditions but extend their field of care to assisting in the diagnosis and treatment of OSA. Given their frequent interactions with children and families, they can act as diagnostic sentinels, often becoming the frontline detectors of potential sleep-related issues. On the other hand, oral health is also closely linked to general health and well-being, and untreated dental or occlusal conditions can influence issues such as ear infections or respiratory difficulties. Collaboration between pediatricians and dentists allows for the timely identification of warning signs and targeted interventions to prevent future complications in a number of conditions.^9-10

Otolaryngologists come into play when addressing issues related to the auditory and respiratory systems. Recurrent ear infections, hearing problems, or respiratory disorders may require specialized evaluation. Collaboration between otolaryngologists and pediatricians is essential to diagnose and effectively manage conditions such as recurrent ear infections or OSA, which can have a significant impact on the child’s quality of life. The role of the orthodontist in maxillary expansion can delay or prevent the need for adenotonsillectomy treatment.

Pulmonologists complete the multidisciplinary framework, dealing with issues related to the respiratory system. In cases of lung disease or childhood asthma, collaboration with pediatricians becomes crucial to ensure integrated and personalized patient management.⁶

Conclusion

Early diagnosis and appropriate management of pediatric OSA are essential to mitigate potential long-term consequences on neurocognitive, cardiovascular, hormonal, and physical growth. In conclusion, the multidisciplinary approach in pediatric patients represents an advanced and patient-centered care model. The synergy among pediatricians, pediatric dentists, otolaryngologists, and pulmonologists allows for a comprehensive approach to addressing challenges in child health, promoting long-term well-being and ensuring quality health care from early childhood onward.

Source: SleepWorld Magazine

References

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7. Kaditis AG, Alonso Alvarez ML, Boudewyns A, et al. Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J. 2016 Jan;47(1):69-94.
8. Guilleminault C, Lee JH, Chan A. Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med. 2005 Aug;159(8):775-85.
9. Aloufi F, Preston CB, Zawawi KH. Changes in the upper and lower pharyngeal airway spaces associated with rapid maxillary expansion. ISRN Dent. 2012;2012:290964.
10. Li Z, Celestin J, Lockey RF. Pediatric sleep apnea syndrome: An update. J Allergy Clin Immunol Pract. 2016 Sep-Oct;4(5):852-61.

Alberto De Stefani, DDS, MS, is an Adjunct Professor at the Department of Neuroscience, University of Padua in Italy.

alberto.destefani@unipd.it

Giovanni Bruno, DDS, MS, is an Adjunct Professor at the Department of Neuroscience, University of Padua in Italy.

giovanni.bruno.1@unipd.it