Introduction: There is very little data of Indian children with sleep disordered breathing (SDB), regarding the common clinical presentation, etiological factors, radiological and polysomnographic features. We therefore carried out a study to evaluate these factors in Indian children presenting to a tertiary care hospital.
Material And Method: Forty consecutive children were referred from the ENT outpatient for overnight polysomnography because of symptoms suggestive of sleep disordered breathing (SDB). A complete general, physical and systemic examination, including height, weight, BMI, was conducted. ENT examination was performed to include craniofacial characteristics such as mid face hypoplasia, micrognathia and occlusal relationships. Radiological examination of the airway was performed. Digital skiagram of soft tissue neck in lateral view was obtained and A-N ratio (adenoid:nasopharynx ratio), H-MP (H-MP = distance from mandible to hyoid) and PAS (PAS= Posterior airway space) were assessed.
Results: The age of the children varied from 1 to 15 years. A male preponderance was noticed (72.5%). Maximum number of the children was underweight (82.5%). All the children complained of snoring and mouth breathing. The other symptoms noted were disturbed sleep (65%); frequent cold and difficult swallowing (62.5%). Poor school performance was seen in 30%; Enuresis in 22.5% and aggressive behaviour in 7.5%. Analysis of the behavioural symptoms showed that 30% of the children had poor school performance, 22.5% had bedwetting, 7.5% had aggressive behaviour, 2.5% each had sleep terror and sleep walking respectively. The upper airway examination (clinical and endoscopic) showed that adenotonsillar enlargement was the most common cause of upper airway obstruction among these children. The other findings were adenoid enlargement (7.5%), tonsil enlargement (22.5%), deviated nasal septum (2.5%), deviated nasal septum with adenoid (2.5%), polyp (7.5%) and rhinitis (2.5%). Cephalometric analysis showed that The S-PAS value in controls was 15-20 mm whereas that of the cases was only 2-5mm. The distance from mandible to hyoid (H-MP) value was also found to be increased, thus indicating a low position of the mandible in 67.5% of cases. A:N ratio (A N ratio=adenoid:nasopharynx) was abnormal in 65% of the children. Polysomnography showed that 60% children had severe SDB (RDI>10 per hour) and 30% of them had moderately severe SDB (RDI 5-10/hr). About 50% children showed significant oxygen desaturation.
Conclusions: In conclusion it can be said that every child who snores is a suspected case of SDB. So there should be proper evaluation and management at the earliest to prevent potentially serious complications.
Ali NJ, Pitson DJ, Stradling JR. Snoring, sleep disturbance and behaviour in 4-5 year olds. Arch Dis Child 1993; 68: 360-366.
Suri JC, Sen M.K. Epidemiology of sleep disorders in schoolchildren of Delhi: a questionnaire-based study. Indian J sleep Med 2008;3(2). (in Press)
Schechter MS. Section on pediatric pulmonology, subcommittee on obstructive sleep apnea syndrome. Technical report : diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002; 109 : e69.
Owen GO, Canter RJ, Robinson A. Snoring, apnea and ENT symptoms in the paediatric community. Clin otolaryngol 1996; 21 : 130-4.
Katz ES, Marcus CL. Diagnosis of obstructive sleep apnea syndrome in infants & children. In : Sheldon SH, Ferber R, Kryger MH, editors. Principles & practice of Pediatric sleep medicine. USA. Elseirer Saunders; 206 197-210.
Section on Pediatric Pulmonology, subcommittee on OSAS American academy of pediatrics Clinical practice guidelines: diagnosis and management of childhood OSAS, Pediatrics 109; 2002, 704-712
Sher AE : OSAS : a complex disorder of the upper airway. Otolaryngol Clin North Am 23 : 593-608, 1990.
Chaudhary BA, Speir WA. Sleep apnea syndrome. South Med J 1982;75:39-45.
Acebo C, Millman RP, Rosenberg C et al. Sleep, breathing and cephalometrics in older children & young adults. Part I Normotensive values. Chest 1996; 109 : 664-672.
Shintani T, Asakura K, Katawra A. OSA in Children. Advance Otorhinolaryngol (1992), 47; 267-270.
Miles PG, Uig PS, Weijant RJ et al. Cranio facial structure and OSAS : a qualitative analysis of the literature. Am J Orthod Dentofacial Orthop 1996; 109: 163-172.
Pracharktam M, Hans MG, Stohl K P et al. Upright & supine cephalometric evaluation of OSAS & snoring subjects. Angle Orthod 1994; 64 : 63-74.
Chan J, Edman JC, Kolsai PJ : OSA in children. Am Fam Physician 2004; 69 : 1147-1154.
Wijk L. Z. A longitudinal study of dento-facial morphology in young children treated for obstructive sleep apnea syndrome. Karolinska Institutet, Stockholm 2008:1-6.
Wagner MH, Torrez DM.Interpretation of the polysomnogram in children. Otolaryngol Clin N Am 2007; 40:745-759.
Uliel S, Tauman R, Green Field M et al Normal polysomnographic respiratory values in children and adolescents. Chest 2004;125:872-878
Mallampati SR, Gatt SP, Gugino LD, Desai SR, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation : a prospective study Can Anaesth. Soc J 1985; 32 : 429-434.
Arens R, Marcus CL. Pathophysiology of upper airway obstruction: a developmental perspective. Sleep 2004; 27: 997-1019.
Bar A, Tarasiuk A, Seger Y et al. The effect of adenotonsillectomy in serum insulin – like growth factor – I and growth in children with OSAS. J Pediatr 1999; 135: 76-80.
Nieminen P, Lopponen T, Tolonen U et al. Growth and biochemical markers of growth in children with snoring and OSA. Pediatrics 2002;109:e55.
Chau KU, Ng DKK, Kwak CKL, Chow PY, Ho JCS. Clinical risk factors for obstructive sleep apnea in children. Singapore Med J 2003;44:570-573.
Chervin RD, ARchibold KH. Hyperactivity and polysomnographic findings in children evaluated for sleepdisordered breathing. Sleep 2001;24:313-320.
O'Brien LM, Mervis CB, Holbrook CR et al. Neurobehavioural implications of habitual snoring in children. Pediatrics 2004;114:44-49.
O'Brien LM, Gozal D. Sleep in children with attention deficit/hyperactivity disorder. Minerva Pediatr 2004; 56: 585-601.
Dayyat E, Kheirandish-Gozal L. Childhood obstructive sleep apnea: one or two distinct disease entities? Sleep Med Clin 2007; 2: 433-444.
Zhifei X, Cheuk DKL, Lee SL. Clinical evaluation in predicting childhood obstructive sleep apnea. Chest 2006;130:6: 1765-1771.
Teculescu DB, Caillier I, Perrin P, et al: Snoring in French preschool children. Pediatr Pulmonol 1992;13:239-244.
Hulcrantz E, Lofstarnd TB, Ahlquest RJ: The epidemiology of sleep related breathing disorders in children. Int J Pediatr Otorhinolaryngol 1995;6(suppl):S63-S66.
Carroll JL, McColley SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 1995; 108: 610-618.
Leach J, Olson J, Hermann J, et al. Polysomnographic and clinical findings in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992;118:741-744
Lind MG, Lundell BP, Tonsillar hyperplasia in children. A cause of obstructive sleep apneas, CO2 retention, and retarded growth. Arch Otolaryngol 1982;108:650-4.
Freezer NJ, Bucens IK, Robertson CF. Obstructive sleep apnoea presenting as failure to thrive in infancy. J Paediatr Child Health 1995;31:172-5
Nieminen P, Tolonen U, Lopponen H. Snoring and obstructive sleep apnea in children: a 6-month follow-up study. Arch Otolaryngol Head Neck Surg 2000;126:481- 486.
Wang RC, Elkins TP, Keech D, et al. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngl Head Neck Surg 1998;118:741-744
Preutthipan A, Chantorojanasiri T, Suwanjutha S, et al. Can parents predict the severity of childhood obstructive sleep apnoea? Acta Paediatr 2000;89:708-712.
Brooks LJ, Topol HI. Enuresis in children with sleep apnea. J pediatr 2003;142:515-518.
Blunden S, Lushington K, kennedy D, Martin J, Dawson D. Behavior and neurocongnitive performance in children aged 5-10 years who snore compared to controls. J Clin Exp Neuropsychol 2000;22:554-68.
Gozal D, Pope DW Jr. Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics 2001;107:1394-9.
Owens J, Opipari L, Nobile C, Spirito A. Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders. Pediatrics 1998;102:1178- 1184.
Harvold E, Tomer B, Varggesik K, et al. Primate experiments on oral respiration. Am J Orthod 1981;79:359-372.
Traeger N, Schultz B, Pollock AN, et al. Polysomnographic values in children 2-9 years old: additional data and review of the literature. Pediatr Pulmonol 2005; 40:22-30.
American Academy of Sleep Medicine. The international classification of sleep disorders diagnostic and coding manual. 2nd ed. Westchester, II: American Academy of Sleep Medicine, 2005.
American Thoracic Society: Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med 1996;153:866-878.
Guilleminault C, Pelayo R, Leger D, Clerk A, Bocian RCZ. Recognition of sleep-disordered breathing in children. Pediatrics 1996; 98:871-882.