Your Guide to Paediatric Obstructive Sleep Apnoea

Dear Parents, Sleep is a vital part of every child’s growth and development. It is the time when their bodies recharge, grow, consolidate the day’s experiences and prepare for the next day’s activities. Unfortunately, many children may not always get the quality sleep they need. Paediatric Obstructive Sleep Apnoea (OSA) is an important condition in children that hinders breathing during sleep. This can have negative consequences in their ability to focus and learn during the day, preventing them from getting the best in life. Paediatric OSA is no simple issue. It has been research on for decades, and more is yet to be done. But today, we are equipped with enough of the right information to fight it. In this booklet, you will learn that information. We hope it would help you to better understand Paediatric OSA and protect your child’s sleep and future. Go forth, Guardian of the Night!

- GotN Team

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Contents What is Paediatric Obstructive Sleep Apnoea (OSA)?

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What are its effects?

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Words by A/Prof Daniel Goh

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How do I Identify Paediatric OSA?

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What else can I look for?

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How is it diagnosed?

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What treatments are there?

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What are the risk factors?

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Who can I contact?

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Do I have OSA?

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Partners and Sponsors

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© Guardians of the Night. Content vetted by Dr Daniel Goh. First Printing: December 2017. Information is correct as of time of printing.

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Paediatric Obstructive Sleep Apnoea (OSA) Paediatric OSA is a disorder where partial or complete obstruction of a child’s upper airway occurs during sleep. This results in frequent obstructed breathing, also known as a hypopnea or apnoea episode. These episodes can last for 2 obstructed breaths or longer. Mild cases start from 1 episode per hour of sleep a night and this can increase to more than 10 episodes per hour a night in more severe cases. Sleep quality is impaired as a result, affecting various parts of the body.

Guilleminault, C., Tilkian, A., & Dement, W. (1976). The Sleep Apnea Syndromes. Annual Review of Medicine, 27(1), 465–484. Epstein, L. J., Kristo, D., Strollo, P. J. Jr., Friedman, N., Malhotra, A., Patil, S. P., ... & Weinstein, M. D. (2009). Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine, 5(3), 263–276.

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What are its effects? If left untreated, Paediatric OSA would result in poor quality sleep, which is important for a child’s growth and development. It can also result in poor oxygen delivery which can affect a child’s fragile body both mentally and physically. Freezer, N., Bucens, I., & Robertson, C. (1995). Obstructive sleep apnoea presenting as failure to thrive in infancy. Journal Of Paediatrics And Child Health, 31(3), 172–175. Beebe, D., & Gozal, D. (2002). Obstructive sleep apnea and the prefrontal cortex: towards a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioral deficits. Journal Of Sleep Research, 11(1), 1–16. Stradling, J., Davies, R., Mullins, R., & Jenkinson, C. (1999). Obstructive sleep apnoea. The Lancet, 354(9185), 1213. Sowers, J. R., Epstein, M., & Frohlich, E. D. (2001). Diabetes, hypertension, and cardiovascular disease. Hypertension, 37(4), 1053–1059. Parati, G., Lombardi, C., Hedner, J., Bonsignore, M., Grote, L., Tkacova, R., … & McNicholas, W. (2012). Position paper on the management of patients with obstructive sleep apnea and hypertension. Journal of Hypertension, 30(4), 633–646.

Reports have shown that when Paediatric OSA is treated, children tend to concentrate and focus better in learning. Children who receive treatment show a catch-up for the delays in physical and cognitive development.

Gozal, D. (1998). Sleep-disordered breathing and school performance in children. Pediatrics, 102(3), 616-620.

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Words by A/Prof Daniel Goh Why is Paediatric OSA an important and urgent issue?

Sleep is an essential part of everyday life and even more significant in the growing and developing child. In today’s complex world, sleep is often placed at a low priority in exchange for pursuits of academic achievement and other material successes. While sleep quantity is measurable in terms of hours of sleep from bedtime to wake time each 24 hours, sleep quality is much harder to ascertain and measure. Both sleep quantity and quality are essential for good health and development.

Who is at risk of Paediatric OSA?

Past studies on population screening of OSA in childhood in Singapore reported the prevalence to be in the range of 1 to 2% of children. With our local birth cohort of about 40,000 each year, this translates to 400 to 800 cases yearly in Singapore. Imagine this number of students impeded in their learning and development each year, and one would appreciate the significance and magnitude of this condition. Chng SY, Goh DY, Wang XS, Tan TN, Ong NB. Snoring and atopic disease: a strong association. Pediatr Pulmonol 2004;38:210-6.

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How should parents treat this issue?

The first step to better awareness is to educate the parents and the public. This would include informing them of the subtle signs and symptoms of OSA, and what to look out for in their child, With this, the parent is in a better position to highlight concerns to the doctor who can escalate the evaluation of the child in an appropriate manner.

A/Prof Daniel Goh

MBBS(S’pore), MMed(Paeds), FRCPCH(UK), FCCP(USA), FAMS

Senior Consultant, Division of Paediatric Pulmonary & Sleep National University Hospital (NUH)

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How do I Identify it? You may only have time to check your child at night, so here are 3 simple checks to perform while your child is asleep.

Observe for Restless Sleep

As the child naturally tries to keep the upper airway open, he or she may frequently shift positions during sleep in search of an optimal posture to breath better.

This may appear as tossing and turning in bed. Bedding and blankets may be thrown and kicked around during sleep and the child may turn and move all over the mattress. As the child struggles to breathe, there is an alternate rising and falling of the chest and stomach during the process. This is described as the see-saw movement of the chest and abdomen during breathing. Dehlink, E., & Tan, H. L. (2016). Update on paediatric obstructive sleep apnoea. Journal of thoracic disease, 8(2), 224

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Watch out for Unusual Sleep Postures

When trying to keep the upper airway open, children attempt sleeping positions that stretch the neck backwards. Examples include hanging of the head off the bed or leaning forward in a sitting posture during sleep. An open mouth posture is also dangerous, as it indicates mouth-breathing: a clear sign of obstruction in the nasal passages.

Listen for Regular or Frequent Snoring

Habitual snoring is defined by snoring for at least 3 nights a week. The noise that is generated is due to vibrations caused by an obstruction in the airway. A child’s snoring may not be as obvious and loud as an adult’s, but it is still just as urgent. Snoring is not caused by tiredness.

If you suspect Paediatric OSA, seek a medical diagnosis (page 12).

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What else can I look for? Although we advise looking for only 3 symptoms at night as a simple activity, Paediatric OSA symptoms can occur in many forms during the day and night. If you are able to, you may observe your child in the day. Paediatric OSA may manifest in one or more of these symptoms.

Day-time Symptoms Mouth-breathing Difficulties in learning or deteriorating school performance Excessive daytime sleepiness (less common than in adults) Hyperactivity and is easily agitated Dry mouth and/or throat upon awakening Forward-Head Posture

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Night-time Symptoms Habitual Snoring (Snoring regularly, for at least 3 nights a week)

Beebe, D. W., Groesz, L., Wells, C., Nichols, A., & McGee, K. (2003). The neuropsychological effects of obstructive sleep apnea: a meta-analysis of norm-referenced and case-controlled data. Sleep, 26(3), 298-307. Gozal, D. (2008). Obstructive Sleep Apnea in Children: Implications for the Developing Central Nervous System. Seminars in Pediatric Neurology, 15(2), 100–106. Oksenberg, A., & Arons, E. (2002). Sleep bruxism related to obstructive sleep apnea: the effect of continuous positive airway pressure. Sleep Medicine, 3(6), 513-515.

Night-time bed-wetting Restless sleep Unusual sleeping postures (mouth open, sleeping facedown, etc. Heavy, laboured breathing during sleep. Episodes of cessation of breathing, choking and awakening Grinding and clenching of teeth

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How is it diagnosed? Polysomnography (PSG) / Sleep Study

This is the definitive test to diagnose Paediatric OSA and to determine its severity. Performed over a single night, parents can choose to stay throughout the treatment. Before the test, there will be a review of medical history followed by a short physical examination. Several sensors are attached to the child’s body throughout the test to use in evaluation and assessment. The sensors are harmless and will not hurt, although there may be slight discomfort wearing them and when the adhesive tapes are removed. Photo by Robert Lawton 2006 - CC BY-SA2.5

There can be a variety of contributors to Paediatric OSA. Some children may even have multiple. We do not recommend or advise you to receive any sepcific treatment without diagnosis. This section is an objective overview of treatment practices. Marcus, C. L., Brooks, L. J., Ward, S. D., Draper, K. A., Gozal, D., Halbower, A. C., ... & Shiffman, R. N. (2012). Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 130(3), e714-e755. Huang, Y. S., & Guilleminault, C. (2017). Pediatric Obstructive Sleep Apnea: Where Do We Stand?. In Lin, H.-C. (Ed.), Sleep-Related Breathing Disorders (Vol. 80, pp. 136-144). Basel: Karger Publishers. O’Brien, L. M., Sitha, S., Baur, L. A., & Waters, K. A. (2006). Obesity increases the risk for persisting obstructive sleep apnea after treatment in children. International journal of pediatric otorhinolaryngology, 70(9), 1555-1560.

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What treatment are there? Allergy Control

Treatment of upper airway allergies especially in the nose (Allergic Rhinitis) may help alleviate some symptoms of OSA.

Weight Loss

If obesity is present, it can be a contributor to Paediatric OSA in a child. Weight reduction has been demonstrated in research studies to help reduce severity of OSA and improve quality of life.

Myofunctional Therapy

In dental/orthodontic practice, myofunctional therapy is a noninvasive treatment used for retraining abnormal positions and functions of the jaw and facial musclest to create a normal bite.

Continuous Positive Airway Pressure (CPAP)

CPAP Machines provide continuous air pressure to ensure that the upper airway remains unobstructed, using a mask worn during sleep.

Removal of Tonsils and Adenoid

When tonsils and adenoid are determined to be the primary cause, doctors may advise surgical removal of a child’s tonsils and adenoid. Paradise, J. L. (1996). Tonsillectomy and adenoidectomy. Pediatric Otolaryngology, 2, 1054–1065. Brouillette, R. T., Manoukian, J. J., Ducharme, F. M., Oudjhane, K., Earle, L. G., Ladan, S., & Morielli, A. (2001). Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. The Journal of Pediatrics, 138(6), 838–844. Guimarães, K. C., Drager, L. F., Genta, P. R., Marcondes, B. F., & Lorenzi-Filho, G. (2009). Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. American Journal of Respiratory and Critical Care Medicine, 179(10), 962–966. Werman, Howard A., Karren, K. & Mistovich, Joseph (2014). “Continuous Positive Airway Pressure(CPAP)”. In Werman A. Howard; Mistovich J; Karren K. Prehospital Emergency Care, 10e. Pearson Education, Inc. p.242 Gami, A. S., Caples, S. M., & Somers, V. K. (2003). Obesity and obstructive sleep apnea. Endocrinology and Metabolism Clinics, 32(4), 869-894.

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Risk Factors There are several factors that can cause or contribute to development of Paediatric OSA. In some patients, there may be one or a combination of multiple factors.

Short Tongue Frenulum

A short tongue frenulum (the string-like tissue below the tongue) may restrict the tongue from lifting up to the palate during function and rest. This impairs facial and jaw growth, reducing width of upper airway and increasing risk of its collapse and obstruction in sleep.

Obesity

A common cause for OSA in adults, obesity in children may also lead to OSA due to the deposition of fat around the upper airway, compromising the upper airway calibre especially during sleep.

Asian Genetics

Asians of orient descent tend to have flatter facial structures than Caucasians. This structure is more likely to obstruct the airways, which is why Asians are at higher risk of OSA than Caucasians, although this phenomena has not yet been tested in children. Cayler, G. G., Johnson, E. E., Lewis, B. E., Kortzeborn, J. D., Jordan, J., & Fricker, G. A. (1969). Heart failure due to enlarged tonsils and adenoids: The cardiorespiratory syndrome of increased airway resistance. American Journal of Diseases of Children, 118(5), 708–717. Gami, A. S., Caples, S. M., & Somers, V. K. (2003). Obesity and OSA. Endocrinology and Metabolism Clinics, 32(4), 869-894. Li, K. K., Kushida, C., Powell, N. B., Riley, R. W., & Guilleminault, C. (2000). Obstructive sleep apnea syndrome: a comparison between Far‐East Asian and white men. The Laryngoscope, 110(10), 1689-1693. Cayler, G. G., Johnson, E. E., Lewis, B. E., Kortzeborn, J. D., Jordan, J., & Fricker, G. A. (1969). Heart failure due to enlarged tonsils and adenoids: The cardiorespiratory syndrome of increased airway resistance. American Journal of Diseases of Children, 118(5), 708–717. Gami, A. S., Caples, S. M., & Somers, V. K. (2003). Obesity and OSA. Endocrinology and Metabolism Clinics, 32(4), 869-894. Huang, Y. S., Quo, S., Berkowski, J. A., & Guilleminault, C. (2015). Short lingual frenulum and obstructive sleep apnea in children. Int J Pediatr Res, 1(003).

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Enlarged Tonsils and Adenoids

In children, the size of the tonsils and adenoids usually peak between 3 to 8 years of life, corresponding to the peak age of Paediatric OSA. Children with multiple allergies tend to have larger adenoids and tonsils which then predisposes them to a higher risk of OSA as well.

Cranio-Facial Structural Abnormalities

Mouth-breathing may cause a downward jaw growth which can obstruct breathing. Obstruction is also caused by abnormalities in facial structures due to Down Syndrome, Pierre-Robin Sequence (PRS), Mucopolysaccharidosis and other metabolic conditions.

Muscle Weakness

Children with muscle weakness from any cause can result in reduced tone of the upper airway. These can include children with cerebral palsy or any muscle abnormality such as congenital myopathies.

Li, K. K., Kushida, C., Powell, N. B., Riley, R. W., & Guilleminault, C. (2000). Obstructive sleep apnea syndrome: a comparison between Far‐East Asian and white men. The Laryngoscope, 110(10), 1689-1693. Anderson, I. C. W., Sedaghat, A. R., McGinley, B. M., Redett, R. J., Boss, E. F., & Ishman, S. L. (2011). Prevalence and severity of obstructive sleep apnea and snoring in infants with Pierre Robin sequence. The Cleft Palate-Craniofacial Journal, 48(5), 614-618. Ng, D. K., Hui, H. N., Chan, C. H., Kwok, K. L., Chow, P. Y., Cheung, J. M., & Leung, S. Y. (2006). Obstructive sleep apnoea in children with Down syndrome. Singapore medical journal, 47(9), 774-779. Harari, D., Redlich, M., Miri, S., Hamud, T., & Gross, M. (2010). The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope, 2089-2093. Hsiao, K. H., & Nixon, G. M. (2008). The effect of treatment of obstructive sleep apnea on quality of life in children with cerebral palsy. Research in developmental disabilities, 29(2), 133-140.

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Who can I contact? If you suspect your child to have Paediatric OSA, consult your doctor. If needed, your doctor will refer your child for a sleep study. There are two public hospitals in Singapore that offer a sleep test: 1. KK Women’s and Children’s Hospital 2. National University Hospital There are also a few private clinics in Singapore that offer these services, such as Gleneagles Hospital. For more information on Paediatric OSA and your treatment options, visit Singhealth’s page at: bit.ly/2CMcS4H

Guardians of the Night Team

To receive updates on our campaign, follow us on our digital platforms. Get more information on Paediatric OSA, and other outreach we may have. Facebook: /GotNsg Instagram: @GotNsg Website: www.guardthenight.com You can also drop us an e-mail at: [email protected]

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Do I have OSA too? OSA is very common in adult Singaporeans. Snoring is the most common symptom of Obstructive Sleep Apnoea (OSA) in adults. So if you, your partner, or your friends and family have noticed that you snore, you might want to consider a diagnosis.

1 in 3

Singaporeans

Have moderate to severe OSA

1 in 10

Singaporeans

Have severe sleep apnea

Tan, A., Cheung, Y. Y., Yin, J., Lim, W. -Y., Tan, L. W. L., and Lee, C. -H. (2016), Prevalence of sleep-disordered breathing in a multiethnic Asian population in Singapore: A community-based study. Respirology, 21: 943–950. doi: 10.1111/resp.12747.

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www.guardthenight.com The information provided in this publication is meant purely for educational purposes and may not be used as a substitute for medical diagnosis or treatment. You should seek the advice of your doctor or a qualified healthcare provider before starting any treatment or if you have any questions related to your health, physical fitness or medical conditions.