Pediatric Snoring

OVERVIEW: Sleep disordered breathing (SDB) represents a spectrum of disorders including snoring, upper airway resistance syndrome, obstructive hypoventilation, and, at the extreme end of the spectrum, obstructive sleep apnea syndrome. Certain behavioral and developmental problems in children have been shown to be related to SDB, including ADHD, poor school performance, neurocognitive impairment, enuresis, and daytime somnolence.1,2 Adenotonsillectomy (T&A) is potentially curative for the whole spectrum of sleep disordered breathing.3

ISSUE: How do we determine which children will benefit from adenotonsillectomy for sleep disordered breathing?

Although polysomnograhy (PSG) is considered the gold standard for the diagnosis of obstructive sleep apnea syndrome, there are several reasons why PSG may not be appropriate for routine use in screening for SDB in children. In fact, in one survey of practice patterns among otolaryngologists, less than 5% of school-aged children received PSG before undergoing adenotonsillectomy. Some of the reasons for such low usage include cost and availability of sleep centers that can accommodate children. More importantly, there is not enough good normative data on PSG in children to allow for consistent and accurate interpretation of results based on the apnea-hypopnea index. Also, several studies demonstrate that there is not necessarily a direct relationship between the severity of obstructive sleep apnea syndrome (OSAS), as measured by AHI, and the degree of associated behavioral and developmental impairment. Some children may have a normal sleep study but still have significant SDB in the form of snoring or upper airway resistance syndrome that is contributing to impairment.3

Several questionnaires have been developed that may help identify children that will benefit from T& A. The two that the physicians at Raleigh ENT have found to be most helpful are the OSA-18 and the pediatric sleep questionnaire (PSQ). The OSA-18 is a validated, disease-specific quality of life (QOL) survey consisting of 18 questions in five domains: sleep disturbance, physical symptoms, emotional symptoms, daytime function, and caregiver concerns.4 Parents are asked to rate each issue on a scale of 1 to 7, and then a total score is calculated from 18 to 126. A score less than 60 suggests a small impact on health-related quality of life (HRQL), scores between 60 and 80 suggest moderate impact, and scores above 80 suggest a large impact. The PSQ also can be used to identify children with sleep-related breathing disorders (SRBD). 5 Parents are asked to indicate which questions describe their child’s sleep or behavior. Eight or more positive responses suggest a high risk for SRBD with reasonable sensitivity and specificity. A copy of both of these questionnaires is attached.

BOTTOM LINE: Adenotonsillectomy has been shown to normalize sleep parameters in up to 83% of pediatric patients with SRBD.1
Although PSG remains the gold standard for diagnosis of obstructive sleep apnea, it may not identify all children with SRBD, and the severity of sleep apnea as measured by AHI does not necessarily correlate with quality-of-life measures. Children suspected of having severe OSAS, those with comorbidities (e.g., congenital heart disease or craniofacial abnormalities), or those with known complications of OSAS such as cor pulmonale should probably undergo PSG prior to any surgical procedure. For other children, the combination of a positive OSA-18 or PSQ and physical exam demonstrating tonsil and/or adenoid hypertrophy may be adequate to identify those that will benefit from T&A. Steve Boyce, MD, FACS

1. Garetz, S. Behavior, cognition and quality of life after adenotonsillectomy for pediatric sleep disordered breathing. Otolaryngology-HNSurgery 2008; 138, S19-26
2. Beebe, D. Neurobehavioral morbidity associated with disordered breathing during sleep. Sleep 2006; 29 (9): 1115-11134
3. Wei, J., et.al. Improved behavior and sleep after adenotonsillectomy in children with sleep disordered breathing. Arch Oto/HNS 2007; 133 (10) : 974-979
4. Franco, Jr., R., et. al. Quality of life for children with obstructive sleep apnea. Oto-HNS 2000; 123:9-16
5. Chervin, R., et. al. Pediatric sleep questionnaire (PSQ): validity and reliability scales for sleep-disordered breathing, snoring, sleepiness and behavioral problems. Sleep Medicine 2000; 1:21-32

 

PEDIATRIC SLEEP QUESTIONNAIRE

Please have the parent(s) circle the numbers of those questions which apply to their child. More than 8 positive responses may indicate a problem with sleep-related breathing disorder.

While sleeping, does your child...
1. snore more than half the time?
2. always snore?
3. snore loudly?
4. have trouble breathing, or struggle to breathe?
5. have “heavy” or loud breathing?

Have you ever...
6. seen your child stop breathing during the night?

Does your child...
7. tend to breathe through the mouth during the day?
8. have a dry mouth on waking up in the morning?
9. occasionally wet the bed?

Does your child...
10. wake up feeling un-refreshed in the morning?
11. have a problem with sleepiness during the day?
12. have a teacher or other supervisor commented that your child appears sleepy during the day?
13. wake up with headaches in the morning?
14. Is it hard to wake your child up in the morning?
15. Did your child stop growing at a normal rate at any time since birth?

This child often...
17. does not seem to listen when spoken to directly.
18. has difficulty organizing task and activities.
19. is easily distracted by extraneous stimuli.
20. fidgets with hands or feet or squirms in seat.
21. is "on the go" or often acts as if "driven by a motor."
22. interrupts or intrudes on others (e.g., butts into conversations or games).



QUALITY OF LIFE SURVEY (OSA-18)

	None of the time	Hardly any of the time	A little of the time	Some of the time	A good bit of the time	Most of the time	All of the time
Sleep disturbance
During the past 4 weeks, how often has your child had...
...loud snoring?	1	2	3	4	5	6	7
...breath-holding spells or pauses in breathing at night?	1	2	3	4	5	6	7
...choking or making gasping sounds while asleep?	1	2	3	4	5	6	7
..restless sleep or frequent awakening?	1	2	3	4	5	6	7
Physical symptoms
During the past 4 weeks, how often has your child had...
..mouth breathing because of nasal obstruction?	1	2	3	4	5	6	7
..frequent colds or upper respiratory infections?	1	2	3	4	5	6	7
..nasal discharge or runny nose?	1	2	3	4	5	6	7
..difficulty swallowing?	1	2	3	4	5	6	7
Emotional symptoms
During the past 4 weeks, how often has your child had...
..mood swings or temper tantrums?	1	2	3	4	5	6	7
..aggressive or hyperactive behavior?	1	2	3	4	5	6	7
..discipline problems?	1	2	3	4	5	6	7
Daytime function
During the past 4 weeks, how often has your child had...
..excessive daytime sleepiness?	1	2	3	4	5	6	7
..poor attention span or concentration?	1	2	3	4	5	6	7
..difficulty getting up in the morning?	1	2	3	4	5	6	7
Caregiver concerns
During the past 4 weeks, how often have the problems above...
..caused you to worry about your child's general health?	1	2	3	4	5	6	7
..created concern that your child is not getting enough air?	1	2	3	4	5	6	7
..interfered with your ability to perform daily activities?	1	2	3	4	5	6	7
..made you frustrated?	1	2	3	4	5	6	7

SCORE______________ 0-60 small impact on health-related quality of life 60-80 moderate impact 80+ severe impact