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BackTable / ENT / Article
Diagnosing Pediatric Obstructive Sleep Apnea: Key Considerations & Strategies
Megan Saltsgaver • Updated Aug 7, 2024 • 39 hits
Diagnosing pediatric obstructive sleep apnea (OSA) requires a multifaceted approach that balances observational management, timely sleep studies, and a comprehensive assessment of persistent symptoms. By following structured protocols and maintaining open communication with parents, healthcare providers can effectively manage this condition and improve the quality of life for affected children.
Dr. Ron Mitchell's insights highlight the importance of tailored, patient-specific strategies in navigating the complexities of pediatric OSA. Read on to learn how to successfully diagnose pediatric OSA. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• The journey to a pediatric OSA diagnosis can look different for many families. It often involves a holistic approach not just based on diagnostic testing, but also on the quality of life of the child.
• Observational management with a provider should include close follow up and educational material for parents that details what to look out for if a child's OSA seems to be progressing.
• Conservative measures, such as nasal sprays, should be considered if the patient and family are wanting to delay surgical management
• Sleep studies are not needed in children with profound OSA. However, a sleep study can be beneficial when a child has multiple OSA risk factors or when there are discrepancies between symptoms and clinical picture.
• Some children might have negative sleep studies, yet still be good candidates for tonsillectomy. This is where a holistic approach comes in to determine if a child's behavior and daily life would benefit from a tonsillectomy with or without adenoidectomy.
Table of Contents
(1) Observational Management of Pediatric OSA & When To Become More Involved
(2) When To Pursue a Sleep Study in Pediatric OSA
(3) Negative Sleep Study Despite Persistent OSA Symptoms
Observational Management of Pediatric OSA & When To Become More Involved
Pediatric obstructive sleep apnea is a condition that requires careful monitoring and management, particularly when initial treatment involves observation. Observational management can be an effective approach for children with mild symptoms, but it demands regular follow-up to ensure the child's condition does not deteriorate.
Pediatric otolaryngologist Dr. Ron Mitchell emphasizes the importance of structured follow-up protocols. Parents should be educated on the symptoms to watch for and encouraged to keep detailed records of their child's sleep patterns and daytime behaviors. Some symptoms to watch out for include excessive daytime sleepiness, an increase in disruptive behaviors or learning problems, and increased snoring, specifically with pauses, gasps, or snorts. Regular check-ins with healthcare providers are important, ideally every six to eight weeks, to assess the child's progress and make any necessary adjustments to the treatment plan.
In some cases, adjunctive treatments such as nasal steroids or montelukast may be introduced to help alleviate symptoms. These medications can provide significant relief and improve the child's quality of life. The decision to use these treatments should be based on a thorough assessment of the child's symptoms and overall health.
[Dr. Gopi Shah]
Dr. Mitchell, in your clinic, for the kids that you observe, when do you follow back up in clinic? Then for that observation group, who do you offer the Nasonex and the montelukast to versus just nothing at all?
[Dr. Ron Mitchell]
Yes. Many of the, again, over a period of many years, and with higher realization of sleep problems in kids being very common, I am increasingly seeing kids who are already on some type of medication. The challenge, I think, for all of us is that they've been started on a medicine, but they haven't used it a whole lot. Often what I'm seeing in clinic is when you ask the parents, "Have you used a nasal steroid spray?" "Yes." "How often have you used it?" "Twice and then stopped."
I encourage the parents to use it for six to eight weeks. I myself actually very rarely start them on montelukast, and I normally defer to the pulmonologist. Again, I see a fair number who already have been started on it. The audience, the people listening to this may be aware that there has been concern about montelukast being used, especially in older kids and affecting mood. There's been some concern that they can lead to suicidal thoughts, so on. I tend to shy away from it, but maybe we should all be more aggressive with this medication.
When do I observe them without intervention? It's when the parent tells me that they just do not think the child will tolerate any medication. Sprays in the nose tend to be effective after the age of four or five and tend to be very ineffective below that age. Occasionally, you'll see a kid where the kid just loves it and uses it and the parent is there, but more often than not, it doesn't happen to the younger kids.
If it seems or if the kid has some behavioral problems, I'm thinking particularly about autistic kids or some kids with Down syndrome, you may not be able to use any medication. In those kids, you may want to see them in six to eight weeks and ask the parent to observe the kids. We live in an era where many, if not all, parents have phones. What I always tell them is, "Go into the child's room at night, an hour or two after the child has gone to bed, and take a video clip and bring it to me, and let's look at it together." That's always a good way of assessing how the kid is doing. I think it's fair to see them again after two months.
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When To Pursue a Sleep Study in Pediatric OSA
Determining when to perform a sleep study is the next aspect of diagnosing and managing pediatric OSA. Not every child who snores or has sleep disruptions requires a sleep study. Dr. Mitchell recommends getting a sleep study in patients such as children with comorbidities (e.g. Down syndrome, significant obesity, craniofacial abnormalities, neuromuscular diseases) that are at higher risk for severe OSA and may benefit from an early sleep study. Sleep studies can also be helpful in patients who have symptom discrepancies where the symptoms observed by the parents do not align with physical findings. Parental concern is another major push for pursuing a sleep study. Many parents come in with major concerns despite the child's mild symptoms. A sleep study can provide peace of mind and guide further management.
[Dr. Gopi Shah]
Do you repeat the sleep study in like a year, or how do you make that decision?
[Dr. Ron Mitchell]
First of all, I think the first question is probably, when do we get a sleep study? For the purposes of our study, as an entry criteria, they all get a sleep study. In many kids with mild symptoms or a short history, I don't go ahead and get a sleep study at the beginning. I will actually not get a sleep study, send them out with treatment, see them again.
Now, again, at that point, when do we get a sleep study? When the child is a high-risk for surgery, and by that I mean the kids who have a lot of comorbidities, Down syndrome or significant obesity, craniofacial problems, neuromuscular disease. We also get sleep studies when a child has very small tonsils or adenoids and the symptoms don't seem to go with what we see on examination, or sometimes the parent just wants a confirmation of the diagnosis. I think that's a perfectly good reason to get a sleep study.
We also need to appreciate that we would not be able to get a sleep study in every child who snores, we need to be selective in it. We need to select those kids who will benefit most from a sleep study, which will help us in terms of the decision-making and the management of that kid if they do go ahead with surgery. I will rarely get two sleep studies after a period of observation because they tend to be very similar, and we should go by symptoms and quality of life.
[Dr. Ashley Agan]
That makes sense. If a mom or dad comes in and it looks like they have a video where the patient is continuing to have sleep-disordered breathing or obstruction and there's concern for that and you already know that there's mild obstructive sleep apnea, then you might start thinking more about surgery. Is that right?
[Dr. Ron Mitchell]
I would like to see a minimum of three months of symptoms. I would like to see an attempt at treating it medically, if possible. I would like to confirm that the child has both night-time and day-time symptoms. It's not simply that the child snores, but there are some consequences to it. Does the child wake up tired? Does the child have attention or hyperactivity problems? Is the child basically grumpy? All parents know what that means.
Negative Sleep Study Despite Persistent OSA Symptoms
One of the most challenging scenarios in managing pediatric OSA is dealing with a negative sleep study despite persistent sleep apnea symptoms. Dr. Mitchell explains that a negative sleep study does not necessarily rule out OSA. Instead, it requires a comprehensive approach to assess the child's overall health and quality of life.
If a sleep study shows very mild OSA, the decision to proceed with surgery should involve a thorough discussion with the parents. Shared-decision making is important here since parents must understand the risks and benefits of the surgery. He explains that if a sleep study reveals only mild OSA but the child's daily life is significantly impacted, the decision to pursue tonsillectomy and adenoidectomy (TNA) should be considered based on the overall clinical picture and not just the study results.
[Dr. Gopi Shah]
Ashley and I were talking about this. How often do you have a negative sleep study, but there's some snoring and concern for attention and two plus tonsils? How do is a TNA appropriate in those kids or not?
[Dr. Ron Mitchell]
This is what we are actually studying, PATS study, it's exactly this chat. One of the issues that I always discuss with the parents is, "If we do get a sleep study and it shows that the condition is very mild, are you willing and happy to observe the child?" If they tell you that, "Whatever the sleep study shows, I want a tonsillectomy because the child's day-to-day life is affected significantly on this," there's really no reason to get the sleep study. In this situation-- The first thing to say, avoid the situation where the parent wants to proceed with surgery regardless of a sleep study.
We do occasionally have children who were sent for a sleep study either by the pulmonologist or the PCP and they're seeing us with the sleep study and the sleep study is very mild. I think this is a situation that, first of all, after the PATS study, we will know a lot more about what we should do because we will have data comparing the child who has surgery to the child who has been observed for a year.
In the absence of that data, I think this is an area that really lends itself to shared decision-making. What I mean by that is, you have to sit down with the parent, you have to talk about the risks and benefits of the surgery versus the risks and benefits of observation. If the child is having a lot of problems, we know that a sleep study that shows very mild OSA or no OSA does not mean that the child doesn't have behavioral problems or quality of life issues. It makes it less likely that you need to do surgery immediately, but that child may benefit from the surgery as much as the child who has severe OSA, in terms of behavior and quality of life.
Podcast Contributors
Dr. Ron Mitchell
Dr. Ron Mitchell is a Professor and Vice Chairman of the Department of Otolaryngology at UT Southwestern Medical Center and serves as Chief of Pediatric Otolaryngology. He specializes in pediatric otolaryngology and airway conditions.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2020, September 20). Ep. 6 – Managing Pediatric OSA Like A Boss [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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