This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting.
Of 3166 articles from 1999–2010, 350 provided relevant data. Most articles were level II–IV. The resulting evidence report was used to formulate recommendations.
The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.
Introduction
Obstructive sleep apnea syndrome (OSAS) is a common condition in childhood and can result in severe complications if left untreated. In 2002, the American Academy of Pediatrics (AAP) published a practice guideline for the diagnosis and management of childhood OSAS.1 Since that time, there has been a considerable increase in publications and research on the topic; thus, the guidelines have been revised.
The purposes of this revised clinical practice guideline are to (1) increase the recognition of OSAS by primary care clinicians to minimize delay in diagnosis and avoid serious sequelae of OSAS; (2) evaluate diagnostic techniques; (3) describe treatment options; (4) provide guidelines for follow-up; and (5) discuss areas requiring further research. The recommendations in this statement do not indicate an exclusive course of treatment. Variations, taking into account individual circumstances, may be appropriate.
This practice guideline focuses on uncomplicated childhood OSAS—that is, the OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. This guideline specifically excludes infants younger than 1 year of age, patients with central apnea or hypoventilation syndromes, and patients with OSAS associated with other medical disorders, including but not limited to Down syndrome, craniofacial anomalies, neuromuscular disease (including cerebral palsy), chronic lung disease, sickle cell disease, metabolic disease, or laryngomalacia. These important patient populations are too complex to discuss within the scope of this article and require consultation with a pediatric subspecialist.
Additional information providing justification for the key action statements and a detailed review of the literature are provided in the accompanying technical report available online.2
Methods of Guideline Development
Details of the methods of guideline development are included in the accompanying technical report.2 The AAP selected a subcommittee composed of pediatricians and other experts in the fields of sleep medicine, pulmonology, and otolaryngology, as well as experts from epidemiology and pediatric practice to develop an evidence base of literature on this topic. The committee included liaison members from the AAP Section on Otolaryngology-Head and Neck Surgery, American Thoracic Society, American Academy of Sleep Medicine, American College of Chest Physicians, and the National Sleep Foundation. Committee members signed forms disclosing conflicts of interest.
An automated search of the literature on childhood OSAS from 1999 to 2008 was performed by using 5 scientific literature search engines.2 The medical subject heading terms that were used in all fields were snoring, apnea, sleep-disordered breathing, sleep-related breathing disorders, upper airway resistance, polysomnography, sleep study, adenoidectomy, tonsillectomy, continuous positive airway pressure, obesity, adiposity, hypopnea, hypoventilation, cognition, behavior, and neuropsychology. Reviews, case reports, letters to the editor, and abstracts were not included. Non–English-language articles, animal studies, and studies relating to infants younger than 1 year and to special populations (eg, children with craniofacial anomalies or sickle cell disease) were excluded. In several steps, a total of 3166 hits was reduced to 350 articles, which underwent detailed review.2 Committee members selectively updated this literature search for articles published from 2008 to 2011 specific to guideline categories. Details of the literature grading system are available in the accompanying technical report.
Since publication of the previous guidelines, there has been an improvement in the quality of OSAS studies in the literature; however, there remain few randomized, blinded, controlled studies. Most studies were questionnaire or polysomnography based. Many studies used standard definitions for pediatric polysomnography scoring, but the interpretation of polysomnography (eg, the apnea hypopnea index [AHI] criterion used for diagnosis or to determine treatment) varied widely. The guideline notes the quality of evidence for each key action statement. Additional details are available in the technical report.
The evidence-based approach to guideline development requires that the evidence in support of each key action statement be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. Evidence-based recommendations reflect the quality of evidence and the balance of benefit and harm that is anticipated when the recommendation is followed. The AAP policy statement, “Classifying Recommendations for Clinical Practice Guidelines,”3 was followed in designating levels of recommendation (see Fig 1 and Table 1).
Evidence quality. Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits and harms if a policy is carried out leads to designation of a policy as a strong recommendation, recommendation, option, or no recommendation. RCT, randomized controlled trial; Rec, recommendation.
Evidence quality. Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits and harms if a policy is carried out leads to designation of a policy as a strong recommendation, recommendation, option, or no recommendation. RCT, randomized controlled trial; Rec, recommendation.
Definitions and Recommendation Implications
| Statement | Definition | Implication |
|---|---|---|
| Strong recommendation | A strong recommendation in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms (as a strong recommendation against an action is made when the anticipated harms clearly exceed the benefits) and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendations may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. | Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
| Recommendation | A recommendation in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high-quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. | It would be prudent for clinicians to follow a recommendation, but they should remain alert to new information and sensitive to patient preferences. |
| Option | Options define courses that may be taken when either the quality of evidence is suspect or carefully performed studies have shown little clear advantage to one approach over another. | Clinicians should consider the option in their decision-making, and patient preference may have a substantial role. |
| No recommendation | No recommendation indicates that there is a lack of pertinent published evidence and that the anticipated balance of benefits and harms is presently unclear. | Clinicians should be alert to new published evidence that clarifies the balance of benefit versus harm. |
| Statement | Definition | Implication |
|---|---|---|
| Strong recommendation | A strong recommendation in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms (as a strong recommendation against an action is made when the anticipated harms clearly exceed the benefits) and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendations may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. | Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
| Recommendation | A recommendation in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high-quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. | It would be prudent for clinicians to follow a recommendation, but they should remain alert to new information and sensitive to patient preferences. |
| Option | Options define courses that may be taken when either the quality of evidence is suspect or carefully performed studies have shown little clear advantage to one approach over another. | Clinicians should consider the option in their decision-making, and patient preference may have a substantial role. |
| No recommendation | No recommendation indicates that there is a lack of pertinent published evidence and that the anticipated balance of benefits and harms is presently unclear. | Clinicians should be alert to new published evidence that clarifies the balance of benefit versus harm. |
Definition
This guideline defines OSAS in children as a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns,”4 accompanied by symptoms or signs, as listed in Table 2. Prevalence rates based on level I and II studies range from 1.2% to 5.7%.5,–7 Symptoms include habitual snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems. Daytime sleepiness may occur, but is uncommon in young children. OSAS is associated with neurocognitive impairment, behavioral problems, failure to thrive, hypertension, cardiac dysfunction, and systemic inflammation. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders. Only the first 2 risk factors are discussed in this guideline. In this guideline, obesity is defined as a BMI >95th percentile for age and gender.8
Symptoms and Signs of OSAS
| History |
| Frequent snoring (≥3 nights/wk) |
| Labored breathing during sleep |
| Gasps/snorting noises/observed episodes of apnea |
| Sleep enuresis (especially secondary enuresis)a |
| Sleeping in a seated position or with the neck hyperextended |
| Cyanosis |
| Headaches on awakening |
| Daytime sleepiness |
| Attention-deficit/hyperactivity disorder |
| Learning problems |
| Physical examination |
| Underweight or overweight |
| Tonsillar hypertrophy |
| Adenoidal facies |
| Micrognathia/retrognathia |
| High-arched palate |
| Failure to thrive |
| Hypertension |
| History |
| Frequent snoring (≥3 nights/wk) |
| Labored breathing during sleep |
| Gasps/snorting noises/observed episodes of apnea |
| Sleep enuresis (especially secondary enuresis)a |
| Sleeping in a seated position or with the neck hyperextended |
| Cyanosis |
| Headaches on awakening |
| Daytime sleepiness |
| Attention-deficit/hyperactivity disorder |
| Learning problems |
| Physical examination |
| Underweight or overweight |
| Tonsillar hypertrophy |
| Adenoidal facies |
| Micrognathia/retrognathia |
| High-arched palate |
| Failure to thrive |
| Hypertension |
Enuresis after at least 6 mo of continence.
Key Action Statements
Key Action Statement 1: Screening for OSAS
As part of routine health maintenance visits, clinicians should inquire whether the child or adolescent snores. If the answer is affirmative or if a child or adolescent presents with signs or symptoms of OSAS (Table 2 ), clinicians should perform a more focused evaluation. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)
Evidence Profile KAS 1
Aggregate evidence quality: B
Benefit: Early identification of OSAS is desirable, because it is a high-prevalence condition, and identification and treatment can result in alleviation of current symptoms, improved quality of life, prevention of sequelae, education of parents, and decreased health care utilization.
Harm: Provider time, patient and parent time.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: Panelists believe that identification of a serious medical condition outweighs the time expenditure necessary for screening.
Role of patient preferences: None.
Exclusions: None.
Intentional vagueness: None.
Strength: Recommendation.
Almost all children with OSAS snore,9,–11 although caregivers frequently do not volunteer this information at medical visits.12 Thus, asking about snoring at each health maintenance visit (as well as at other appropriate times, such as when evaluating for tonsillitis) is a sensitive, albeit nonspecific, screening measure that is quick and easy to perform. Snoring is common in children and adolescents; however, OSAS is less common. Therefore, an affirmative answer should be followed by a detailed history and examination to determine whether further evaluation for OSAS is needed (Table 2); this clinical evaluation alone does not establish the diagnosis (see technical report). Occasional snoring, for example, with an upper respiratory tract infection, is less of a concern than snoring that occurs at least 3 times a week and is associated with any of the symptoms or signs listed in Table 2.
Key Action Statement 2A: Polysomnography
If a child or adolescent snores on a regular basis and has any of the complaints or findings shown in Table 2 , clinicians should either (1) obtain a polysomnogram (Evidence Quality A, Key Action strength: Recommendation) OR (2) refer the patient to a sleep specialist or otolaryngologist for a more extensive evaluation (Evidence quality D, Key Action strength: Option). (Evidence Quality: Grade A for polysomnography; Grade D for specialist referral, Recommendation Strength: Recommendation.)
Evidence Profile KAS 2A: Polysomnography
Aggregate evidence quality: A
Benefits: Establish diagnosis and determine severity of OSAS.
Harm: Expense, time, anxiety/discomfort.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: Panelists weighed the value of establishing a diagnosis as more important than the minor potential harms listed.
Role of patient preferences: Small because of preponderance of evidence that polysomnography is the most accurate way to make a diagnosis.
Exclusions: See Key Action Statement 2B regarding lack of availability.
Intentional vagueness: None.
Strength: Recommendation.
Evidence Profile KAS 2A: Referral
Aggregate evidence quality: D
Benefits: Subspecialist may be better able to establish diagnosis and determine severity of OSAS.
Harm: Expense, time, anxiety/discomfort.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: Panelists weighed the value of establishing a diagnosis as more important than the minor potential harms listed.
Role of patient preferences: Large.
Exclusions: None.
Intentional vagueness: None.
Strength: Option.
Although history and physical examination are useful to screen patients and determine which patients need further investigation for OSAS, the sensitivity and specificity of the history and physical examination are poor (see accompanying technical report). Physical examination when the child is awake may be normal, and the size of the tonsils cannot be used to predict the presence of OSAS in an individual child. Thus, objective testing is required. The gold standard test is overnight, attended, in-laboratory polysomnography (sleep study). This is a noninvasive test involving the measurement of a number of physiologic functions overnight, typically including EEG; pulse oximetry; oronasal airflow, abdominal and chest wall movements, partial pressure of carbon dioxide (Pco2); and video recording.13 Specific pediatric measuring and scoring criteria should be used.13 Polysomnography will demonstrate the presence or absence of OSAS. Polysomnography also demonstrates the severity of OSAS, which is helpful in planning treatment and in postoperative short- and long-term management.
Key Action Statement 2B: Alternative Testing
If polysomnography is not available, then clinicians may order alternative diagnostic tests, such as nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, or ambulatory polysomnography. (Evidence Quality: Grade C, Recommendation Strength: Option.)
Evidence Profile KAS 2B
Aggregate evidence quality: C
Benefit: Varying positive and negative predictive values for establishing diagnosis.
Harm: False-negative and false-positive results may underestimate or overestimate severity, expense, time, anxiety/discomfort.
Benefits-harms assessment: Equilibrium of benefits and harms.
Value judgments: Opinion of the panel that some objective testing is better than none. Pragmatic decision based on current shortage of pediatric polysomnography facilities (this may change over time).
Role of patient preferences: Small, if choices are limited by availability; families may choose to travel to centers where more extensive facilities are available.
Exclusions: None.
Intentional vagueness: None.
Strength: Option.
Although polysomnography is the gold standard for diagnosis of OSAS, there is a shortage of sleep laboratories with pediatric expertise. Hence, polysomnography may not be readily available in certain regions of the country. Alternative diagnostic tests have been shown to have weaker positive and negative predictive values than polysomnography, but nevertheless, objective testing is preferable to clinical evaluation alone. If an alternative test fails to demonstrate OSAS in a patient with a high pretest probability, full polysomnography should be sought.
Key Action Statement 3: Adenotonsillectomy
If a child is determined to have OSAS, has a clinical examination consistent with adenotonsillar hypertrophy, and does not have a contraindication to surgery (see Table 3 ), the clinician should recommend adenotonsillectomy as the first line of treatment. If the child has OSAS but does not have adenotonsillar hypertrophy, other treatment should be considered (see Key Action Statement 6). Clinical judgment is required to determine the benefits of adenotonsillectomy compared with other treatments in obese children with varying degrees of adenotonsillar hypertrophy. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)
Contraindications for Adenotonsillectomy
| Absolute contraindications |
| No adenotonsillar tissue (tissue has been surgically removed) |
| Relative contraindications |
| Very small tonsils/adenoid |
| Morbid obesity and small tonsils/adenoid |
| Bleeding disorder refractory to treatment |
| Submucus cleft palate |
| Other medical conditions making patient medically unstable for surgery |
| Absolute contraindications |
| No adenotonsillar tissue (tissue has been surgically removed) |
| Relative contraindications |
| Very small tonsils/adenoid |
| Morbid obesity and small tonsils/adenoid |
| Bleeding disorder refractory to treatment |
| Submucus cleft palate |
| Other medical conditions making patient medically unstable for surgery |
Evidence Profile KAS 3
Aggregate evidence quality: B
Benefit: Improve OSAS and accompanying symptoms and sequelae.
Harm: Pain, anxiety, dehydration, anesthetic complications, hemorrhage, infection, postoperative respiratory difficulties, velopharyngeal incompetence, nasopharyngeal stenosis, death.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: The panel sees the benefits of treating OSAS as more beneficial than the low risk of serious consequences.
Role of patient preferences: Low; continuous positive airway pressure (CPAP) is an option but involves prolonged, long-term treatment as compared with a single, relatively low-risk surgical procedure.
Exclusions: See Table 3.
Intentional vagueness: None.
Strength: Recommendation.
Adenotonsillectomy is very effective in treating OSAS. Adenoidectomy or tonsillectomy alone may not be sufficient, because residual lymphoid tissue may contribute to persistent obstruction. In otherwise healthy children with adenotonsillar hypertrophy, adenotonsillectomy is associated with improvements in symptoms and sequelae of OSAS. Postoperative polysomnography typically shows a major decrease in the number of obstructive events, although some obstructions may still be present. Although obese children may have less satisfactory results, many will be adequately treated with adenotonsillectomy; however, further research is needed to determine which obese children are most likely to benefit from surgery. In this population, the benefits of a 1-time surgical procedure, with a small but real risk of complications, need to be weighed against long-term treatment with CPAP, which is associated with discomfort, disruption of family lifestyle, and risks of poor adherence. Potential complications of adenotonsillectomy are shown in Table 4. Although serious complications (including death) may occur, the rate of these complications is low, and the risks of complications need to be weighed against the consequences of untreated OSAS. In general, a 1-time only procedure with a relatively low morbidity is preferable to lifelong treatment with CPAP; furthermore, the efficacy of CPAP is limited by generally suboptimal adherence. Other treatment options, such as anti-inflammatory medications, weight loss, or tracheostomy, are less effective, are difficult to achieve, or have higher morbidity, respectively.
Risks of Adenotonsillectomy
| Minor |
| Pain |
| Dehydration attributable to postoperative nausea/vomiting and poor oral intake |
| Major |
| Anesthetic complications |
| Acute upper airway obstruction during induction or emergence from anesthesia |
| Postoperative respiratory compromise |
| Hemorrhage |
| Velopharyngeal incompetence |
| Nasopharyngeal stenosis |
| Death |
| Minor |
| Pain |
| Dehydration attributable to postoperative nausea/vomiting and poor oral intake |
| Major |
| Anesthetic complications |
| Acute upper airway obstruction during induction or emergence from anesthesia |
| Postoperative respiratory compromise |
| Hemorrhage |
| Velopharyngeal incompetence |
| Nasopharyngeal stenosis |
| Death |
Key Action Statement 4: High-Risk Patients Undergoing Adenotonsillectomy
Clinicians should monitor high-risk patients (Table 5 ) undergoing adenotonsillectomy as inpatients postoperatively. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)
Risk Factors for Postoperative Respiratory Complications in Children With OSAS Undergoing Adenotonsillectomy
| Younger than 3 y of age |
| Severe OSAS on polysomnographya |
| Cardiac complications of OSAS |
| Failure to thrive |
| Obesity |
| Craniofacial anomaliesb |
| Neuromuscular disordersb |
| Current respiratory infection |
| Younger than 3 y of age |
| Severe OSAS on polysomnographya |
| Cardiac complications of OSAS |
| Failure to thrive |
| Obesity |
| Craniofacial anomaliesb |
| Neuromuscular disordersb |
| Current respiratory infection |
It is difficult to provide exact polysomnographic criteria for severity, because these criteria will vary depending on the age of the child; additional comorbidities, such as obesity, asthma, or cardiac complications of OSAS; and other polysomnographic criteria that have not been evaluated in the literature, such as the level of hypercapnia and the frequency of desaturation (as compared with lowest oxygen saturation). Nevertheless, on the basis of published studies (primarily Level III, see Technical Report), it is recommended that all patients with a lowest oxygen saturation <80% (either on preoperative polysomnography or during observation in the recovery room postoperatively) or an AHI ≥24/h be observed as inpatients postoperatively as they are at increased risk for postoperative respiratory compromise. Additionally, on the basis of expert consensus, it is recommended that patients with significant hypercapnia on polysomnography (peak Pco2 ≥60 mm Hg) be admitted postoperatively. The committee noted that that most published studies were retrospective and not comprehensive, and therefore these recommendations may change if higher-level studies are published. Clinicians may decide to admit patients with less severe polysomnographic abnormalities based on a constellation of risk factors (age, comorbidities, and additional polysomnographic factors) for a particular individual.
Not discussed in these guidelines.
Evidence Profile KAS 4
Aggregate evidence quality: B
Benefit: Effectively manage severe respiratory compromise and avoid death.
Harm: Expense, time, anxiety.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: The panel believes that early recognition of any serious adverse events is critically important.
Role of patient preferences: Minimal; this is an important safety issue.
Exclusions: None.
Intentional vagueness: None.
Strength: Recommendation.
Patients with OSAS may develop respiratory complications, such as worsening of OSAS or pulmonary edema, in the immediate postoperative period. Death attributable to respiratory complications in the immediate postoperative period has been reported in patients with severe OSAS. Identified risk factors are shown in Table 5. High-risk patients should undergo surgery in a center capable of treating complex pediatric patients. They should be hospitalized overnight for close monitoring postoperatively. Children with an acute respiratory infection on the day of surgery, as documented by fever, cough, and/or wheezing, are at increased risk of postoperative complications and, therefore, should be rescheduled or monitored closely postoperatively. Clinicians should decide on an individual basis whether these patients should be rescheduled, taking into consideration the severity of OSAS in the particular patient and keeping in mind that many children with adenotonsillar hypertrophy have chronic rhinorrhea and nasal congestion, even in the absence of viral infections.
Key Action Statement 5: Reevaluation
Clinicians should clinically reassess all patients with OSAS for persisting signs and symptoms after therapy to determine whether further treatment is required. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)
Evidence Profile KAS 5A
Aggregate evidence quality: B
Benefit: Determine effects of treatment.
Harm: Expense, time.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: Data show that a significant proportion of children continue to have abnormalities postoperatively; therefore, the panel determined that the benefits of follow-up outweigh the minor inconveniences.
Role of patient preferences: Minimal; follow-up is good clinical practice.
Exclusions: None.
Intentional vagueness: None.
Strength: Recommendation.
Clinicians should reassess OSAS-related symptoms and signs (Table 2) after 6 to 8 weeks of therapy to determine whether further evaluation and treatment are indicated. Objective data regarding the timing of the postoperative evaluation are not available. Most clinicians recommend reevaluation 6 to 8 weeks after treatment to allow for healing of the operative site and to allow time for upper airway, cardiac, and central nervous system recovery. Patients who remain symptomatic should undergo objective testing (see Key Action Statement 2) or be referred to a sleep specialist for further evaluation.
Key Action Statement 5B: Reevaluation of High-Risk Patients
Clinicians should reevaluate high-risk patients for persistent OSAS after adenotonsillectomy, including those who had a significantly abnormal baseline polysomnogram, have sequelae of OSAS, are obese, or remain symptomatic after treatment, with an objective test (see Key Action Statement 2) or refer such patients to a sleep specialist. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)
Evidence Profile KAS 5B
Aggregate evidence quality: B
Benefit: Determine effects of treatment.
Harm: Expense, time, anxiety/discomfort.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: Given the panel’s concerns about the consequences of OSAS and the frequency of postoperative persistence in high-risk groups, the panel believes that the follow-up costs are outweighed by benefits of recognition of persistent OSAS. A minority of panelists believed that all children with OSAS should have follow-up polysomnography because of the high prevalence of persistent postoperative abnormalities on polysomnography, but most panelists believed that persistent polysomnographic abnormalities in uncomplicated children with mild OSAS were usually mild in patients who were asymptomatic after surgery.
Role of patient preferences: Minimal. Further evaluation is needed to determine the need for further treatment.
Exclusions: None.
Intentional vagueness: None.
Strength: Recommendation.
Key Action Statement 6: CPAP
Clinicians should refer patients for CPAP management if symptoms/signs (Table 2 ) or objective evidence of OSAS persists after adenotonsillectomy or if adenotonsillectomy is not performed. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)
Evidence Profile KAS 6
Aggregate evidence quality: B
Benefit: Improve OSAS and accompanying symptoms and sequelae.
Harm: Expense, time, anxiety; parental sleep disruption; nasal and skin adverse effects; possible midface remodeling; extremely rare serious pressure-related complications, such as pneumothorax; poor adherence.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: Panelists believe that CPAP is the most effective treatment of OSAS that persists postoperatively and that the benefits of treatment outweigh the adverse effects. Other treatments (eg, rapid maxillary expansion) may be effective in specially selected patients.
Role of patient preferences: Other treatments may be effective in specially selected patients.
Exclusions: Rare patients at increased risk of severe pressure complications.
Intentional vagueness: None.
Policy level: Recommendation.
CPAP therapy is delivered by using an electronic device that delivers air at positive pressure via a nasal mask, leading to mechanical stenting of the airway and improved functional residual capacity in the lungs. There is no clear advantage of using bilevel pressure over CPAP.15 CPAP should be managed by an experienced and skilled clinician with expertise in its use in children. CPAP pressure requirements vary among individuals and change over time; thus, CPAP must be titrated in the sleep laboratory before prescribing the device and periodically readjusted thereafter. Behavioral modification therapy may be required, especially for young children or those with developmental delays. Objective monitoring of adherence, by using the equipment software, is important. If adherence is suboptimal, the clinician should institute measures to improve adherence (such as behavioral modification, or treating side effects of CPAP) and institute alternative treatments if these measures are ineffective.
Key Action Statement 7: Weight Loss
Clinicians should recommend weight loss in addition to other therapy if a child/adolescent with OSAS is overweight or obese. (Evidence Quality: Grade C, Recommendation Strength: Recommendation.)
Evidence Profile KAS 7
Aggregate evidence quality: C
Benefit: Improve OSAS and accompanying symptoms and sequelae; non–OSAS-related benefits of weight loss.
Harm: Hard to achieve and maintain weight loss.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: The panel agreed that weight loss is beneficial for both OSAS and other health issues, but clinical experience suggests that weight loss is difficult to achieve and maintain, and even effective weight loss regimens take time; therefore, additional treatment is required in the interim.
Role of patient preferences: Strong role for patient and family preference regarding nutrition and exercise.
Exclusions: None.
Intentional vagueness: None.
Strength: Recommendation.
Weight loss has been shown to improve OSAS,16,17 although the degree of weight loss required has not been determined. Because weight loss is a slow and unreliable process, other treatment modalities (such as adenotonsillectomy or CPAP therapy) should be instituted until sufficient weight loss has been achieved and maintained.
Key Action Statement 8: Intranasal Corticosteroids
Clinicians may prescribe topical intranasal corticosteroids for children with mild OSAS in whom adenotonsillectomy is contraindicated or for children with mild postoperative OSAS. (Evidence Quality: Grade B, Recommendation Strength: Option.)
Evidence Profile KAS 8
Aggregate evidence quality: B
Benefit: Improves mild OSAS and accompanying symptoms and sequelae.
Harm: Some subjects may not have an adequate response. It is not known whether therapeutic effect persists long-term; therefore, long-term observation is required. Low risk of steroid-related adverse effects.
Benefits-harms assessment: Preponderance of benefit over harm.
Value judgments: The panel agreed that intranasal steroids provide a less invasive treatment than surgery or CPAP and, therefore, may be preferred in some cases despite lower efficacy and lack of data on long-term efficacy.
Role of patient preferences: Moderate role for patient and family preference if OSAS is mild.
Exclusions: None.
Intentional vagueness: None.
Strength: Option.
Mild OSAS is defined, for this indication, as an AHI <5 per hour, on the basis of studies on intranasal corticosteroids described in the accompanying technical report.2 Several studies have shown that the use of intranasal steroids decreases the degree of OSAS; however, although OSAS improves, residual OSAS may remain. Furthermore, there is individual variability in response to treatment, and long-term studies have not been performed to determine the duration of improvement. Therefore, nasal steroids are not recommended as a first-line therapy. The response to treatment should be measured objectively after a course of treatment of approximately 6 weeks. Because the long-term effect of this treatment is unknown, the clinician should continue to observe the patient for symptoms of recurrence and adverse effects of corticosteroids.
Areas for Future Research
A detailed list of research recommendations is provided in the accompanying technical report.2 There is a great need for further research into the prevalence of OSAS, sequelae of OSAS, best treatment methods, and the role of obesity. In particular, well-controlled, blinded studies, including randomized controlled trials of treatment, are needed to determine the best care for children and adolescents with OSAS.
Subcommittee on Obstructive Sleep Apnea Syndrome*
Carole L. Marcus, MBBCh, Chairperson (Sleep Medicine, Pediatric Pulmonologist; Liaison, American Academy of Sleep Medicine; Research Support from Philips Respironics; Affiliated with an academic sleep center; Published research related to OSAS)
Lee J. Brooks, MD (Sleep Medicine, Pediatric Pulmonologist; Liaison, American College of Chest Physicians; No financial conflicts; Affiliated with an academic sleep center; Published research related to OSAS)
Sally Davidson Ward, MD (Sleep Medicine, Pediatric Pulmonologist; No financial conflicts; Affiliated with an academic sleep center; Published research related to OSAS)
Kari A. Draper, MD (General Pediatrician; No conflicts)
David Gozal, MD (Sleep Medicine, Pediatric Pulmonologist; Research support from AstraZeneca; Speaker for Merck Company; Affiliated with an academic sleep center; Published research related to OSAS)
Ann C. Halbower, MD (Sleep Medicine, Pediatric Pulmonologist; Liaison, American Thoracic Society; Research Funding from Resmed; Affiliated with an academic sleep center; Published research related to OSAS)
Jacqueline Jones, MD (Pediatric Otolaryngologist; AAP Section on Otolaryngology-Head and Neck Surgery; Liaison, American Academy of Otolaryngology-Head and Neck Surgery; No financial conflicts; Affiliated with an academic otolaryngologic practice)
Christopher Lehman, MD (Neonatologist, Informatician; No conflicts)
Michael S. Schechter, MD, MPH (Pediatric Pulmonologist; AAP Section on Pediatric Pulmonology; Consultant to Genentech, Inc and Gilead, Inc, not related to Obstructive Sleep Apnea; Research Support from Mpex Pharmaceuticals, Inc, Vertex Pharmaceuticals Incorporated, PTC Therapeutics, Bayer Healthcare, not related to Obstructive Sleep Apnea)
Stephen Sheldon, MD (Sleep Medicine, General Pediatrician; Liaison, National Sleep Foundation; No financial conflicts; Affiliated with an academic sleep center; Published research related to OSAS)
Richard N. Shiffman, MD, MCIS (General pediatrics, Informatician; No conflicts)
Karen Spruyt, PhD (Clinical Psychologist, Child Neuropsychologist, and Biostatistician/Epidemiologist; No financial conflicts; Affiliated with an academic sleep center)
Oversight from the Steering Committee on Quality Improvement and Management, 2009–2012
Staff
Caryn Davidson, MA
*Areas of expertise are shown in parentheses after each name.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
The recommendations in this report do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
ACKNOWLEDGMENTS
The committee thanks Jason Caboot, June Chan, Mary Currie, Fiona Healy, Maureen Josephson, Sofia Konstantinopoulou, H. Madan Kumar, Roberta Leu, Darius Loghmanee, Rajeev Bhatia, Argyri Petrocheilou, Harsha Vardhan, and Colleen Walsh for assisting with evidence extraction.
Comments
Re:OSAS Guideline may benefit from clarifications
We thank Dr. Marshall for his comments on the recent Clinical Practice Guideline on childhood obstructive sleep apnea syndrome (OSAS)1.The concern is raised that there is an overemphasis on the diagnosis of OSAS.
The guidelines state that if a child is noted to snore, "an affirmative answer should be followed by a detailed history and examination to determine whether further evaluation for OSAS is needed." This is a reasonable requirement as OSAS is common (1-3% of children)2, is frequently underdiagnosed, and can result in significant morbidity. Snoring is discussed as being of concern if it "occurs at least 3 times a week and is associated with any of the symptoms or signs listed in Table 2." Thus, the guidelines do not recommend evaluating any child with failure to thrive, ADHD or enuresis for OSAS, but only those who also have habitual snoring. We agree wholeheartedly that children with conditions such as failure to thrive, enuresis etc. need to be evaluated for causes other than OSAS; this is beyond the scope of these guidelines. However, if these conditions occur in association with habitual snoring, than OSAS needs to be part of the differential diagnosis.
The Guidelines were kept concise so as to make them practical for the busy pediatrician. However, the accompanying Technical Report provides further details and extensive references for those wishing more information. Tables 5-7 of the Technical Report provide further description of the characteristics of snoring.
Sincerely, Carole L. Marcus, M.B.B.Ch. and the AAP Subcommittee on Obstructive Sleep Apnea Syndrome
Reference List
1. Marcus CL, Brooks LJ, Draper KA et al. Diagnosis and management of childhood obstructive sleep apnea syndrome: Clinical practice guideline. Pediatrics 2012;130(3):576-584.
2. Marcus CL, Brooks LJ, Ward SD et al. Diagnosis and management of childhood obstructive sleep apnea syndrome: technical report. Pediatrics 2012;130(3):e714-e755.
Conflict of Interest:
None declared
OSAS Guideline may benefit from clarifications
September 17, 2012
To the editor:
The guideline "Diagnosis and Management of childhood Obstructive Sleep Apnea Syndrome" (1) alerts primary care pediatricians to obstructive sleep apnea syndrome (OSAS) in children but suggests an overly narrow course of screening and management when, during a routine well exam, a child is reported by parents to snore.
Snoring is a common and, as stated in the guideline, nonspecific occurrence in children. The authors fail to fully differentiate benign from abnormal snoring, offering guidance as to clearly abnormal snoring associated with cyanosis, labored breathing, gasping, etc., snoring associated with acute respiratory infections, and snoring that occurs 3 or more nights weekly. Is snoring briefly each night of concern? Does loudness or position matter? How many weeks or months of snoring defines chronicity? Like any history given by parents, there may be substantial predictive limitations. (2) Parents with insomnia or ADHD may be more likely to report snoring; anxious or suggestible parents may respond positively to a variety of questions. The bar should be set for a higher specificity.
In Table 2, several of the symptoms and signs need to be further characterized to merit inclusion and offer realistic guidance to the primary care pediatricians, nurse practitioners, and family physicians who perform most well child care visits. Since adenotonsillectomy is not indicated "for a well child troubled only by snoring" (3), the clinician must be prudent to avoid overdiagnosis. ADHD, itself an imprecise diagnosis (4), may be successfully treated with behavior therapy and/ or medication (5); sociodemographic and initial behavioral advantages, not treatment modality, are the keys to long-term outcomes (6). "Learning problems" should first be evaluated in a comprehensive manner including developmental and psychosocial evaluation; initiating an evaluation for OSAS only because the child snores would be premature. "Underweight or overweight" is much too vague; BMI and other health factors must be considered. Failure to thrive has many causes, most involve primarily psychosocial factors, and OSAS is only one of many organic causes. When a 5 year old seen for well child care is found to have recent onset of nighttime wetting, initial evaluation should include urinalysis and psychosocial history regardless of whether the child snores at night; polsomnography may or may not be appropriate for future evaluation.
In summary, the guideline would benefit from significant modification to be more useful in practice. As written, it may contribute to an excessive focus on OSAS at the expense of other diagnostic and therapeutic efforts and lead to overconcern and overdiagnosis. (7) Universal screening may risk more than just "provider time, parent and patient time;" overdiagnosis may initiate a cascade of unnecessary testing and treatments, all with the potential of iatrogenic harm. Further understanding of the long-term natural history of screening -established snoring and of the utility of early identification is needed (8).
Sincerely,
William N. Marshall, Jr. M.D. Department of Pediatrics University of Arizona College of Medicine 1501 N. Campbell Ave. P.O. Box 245073 Tucson, AZ 85724-5073 (520) 626-6303 Fax: (520) 626-2808
1. Marcus CL, Brooks LJ, Draper KA, et. al. Diagnosis and management of childhood sleep apnea syndrome. Pediatrics 2012; 130:576-584.
2. Paradise JL, Bluestone CD, Bachman RZ, et. al. History of recurrent sore throat as an indication for tonsillectomy: Predictive limitations of histories that are undocumented. N Engl J Med 1978; 298:409 -413.
3. Isaacson G. Tonsillectomy care for the pediatrician. Pediatrics 2012; 130:324-334.
4. Morrow, RM, Garland J, Wright, JM, et.al. Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children. Canadian Medical Association Journal 2012. DOI: 10.1503/cmaj.111619.
5. Subcommittee on Attention-Deficit/Hyperactivity Disorder, & Steering Committee on Quality Improvement and Management. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011; 128: 1007-1022.
6. Molina BSG, Hinshaw SF, Swanson JM, et.al. The MTA at 8 years: Prospective follow-up of children treated for combined -type ADHD in a multisite study. J. Am. Acad. Child Adolesc. Psychiatry 2009; 48: 484 - 500.
7. Moynihan R., Doust J., Henry D. Preventing overdiagnosis: how to stop harming the healthy. British Medical Journal 2012; 344:e3502
8. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years Pediatrics 2012; 129:e857-65; published ahead of print March 5, 2012, doi: 10.1542/peds.2011-1402d
Conflict of Interest:
None declared