The Snoring Child

Evaluation and Management

Dr Teoh Oon Hoe
Head & Senior Consultant
Respiratory Medicine Service
KK Women’s & Children’s Hospital

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 Approach to Sleep History in Children

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 Approach to Sleep History in Children

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 Approach to Sleep History in Children

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 Approach to Sleep History in Children

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 Approach to Sleep History in Children

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 Snoring

• Respiratory sound typically

– Occurring during inspiration (or expiration)
– Generated from vibration of the upper airway walls during sleep
– Due to partial upper airway obstruction

• Reported prevalence ranges from 5% to 20% in children

• A symptom of a continuum of upper airway obstruction during sleep

Increasing degree of airway obstruction

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 Paediatric Obstructive Sleep Apnoea
(OSA)
• Disorder of breathing during sleep, characterised by
– Prolonged partial upper airway obstruction – obstructive hypoventilation
and/or
– Intermittent complete or partial obstruction – obstructive apnoea or
hypopnoea

• Disrupts
– Normal ventilation – hypoxia, hypercarbia
– Normal sleep patterns – sleep fragmentation

American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children
Am J Respir Crit Care Med 1996

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 Global Prevalence of OSA

• Overall incidence of OSA in children about 0.7% to 3%

Ali NJ, Pitson D, Stradling JR. Arch Dis Child 1993
Gislason T, Benediktsdottir B. Chest 1995
Chay OM, Goh A, Abisheganaden J et al. Pediatr Pulmonol 2000

• Incidence in obese children much higher, ranging from

13% to 66%
Chay OM, Goh A, Abisheganaden J et al. Pediatr Pulmonol 2000
Mallory BG Jr, Fisher DH, Jackson R. J Pediatr 1989
Silvestri JM, Weese-Mayer DE, Bass MT et al. Pediatr Pulmonol 1993
Marcus CL, Curtis S, Koerner CB et al. Pediatr Pulmonol 1996
Wing YK, Hui SH, Pak WM et al. Arch Dis Child 2003

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 Definitions

• Primary snoring
Snoring during sleep without
– Apnoea
– Hypoventilation
– Hypoxaemia
– Hypercarbia
– Sleep disturbance
– Daytime symptoms

• Upper airway resistance syndrome

Partial upper airway obstruction sufficient to cause
– Sleep disruption
– Daytime symptoms
– NO gas exchange abnormalities

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 Causes, Risk Factors & Associated
Conditions
▪ Most commonly
 Tonsillar and/or adenoidal enlargement
 Associated with atopic diseases eg. allergic rhinitis
 Obesity

▪ Others
 Conditions causing anomaly of upper airway
 Isolated
 Syndromes
 Neuromuscular diseases
 Family history of OSA
 Prematurity
 Race
 African-Americans more susceptible than Caucasians

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 Causes, Risk Factors and Associated
Conditions
❑ Chronic nasal obstruction ❑ Prader Willi syndrome
✓ Choanal stenosis, severe septal deviation ❑ Beckwith-Wiedemann syndrome
✓ Allergic rhinitis
❑ Achondroplasia
✓ Nasal polyps and rare nasal and/or pharyngeal
tumours ❑ Klippel-Feil syndrome
❑ Laryngomalacia, glottic/subglottic ❑ Marfan syndrome
anomalies
❑ Mucopolysaccharidoses
❑ Cleft palate, isolated or as part of a
❑ Neuromuscular diseases
syndrome
✓ Duchenne muscular dystrophy
❑ Orthodontic conditions e.g. malocclusion, ✓ Spinal muscular atrophy
maxillary contraction, mandibular ✓ Guillain Barré syndrome
retrognathism
✓ Myotonic dystrophy
❑ Craniofacial conditions ✓ Myotubular myopathy
✓ Pierre Robin sequence ✓ Myasthenia gravis
✓ Craniosynostosis (Crouzon syndrome, Apert
syndrome, Pfeiffer syndrome)
❑ Spina bifida/Chiari malformation
✓ Treacher Collins syndrome ❑ Cerebral palsy
✓ Goldenhar syndrome ❑ Hypothyroidism
❑ Down syndrome ❑ Sickle cell anaemia

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 Causes, Risk Factors and Associated
Conditions
❑ Chronic nasal obstruction ❑ Beckwith-Wiedemann syndrome
✓ Choanal stenosis, severe septal deviation ❑ Prader Willi syndrome
✓ Allergic rhinitis
❑ Achondroplasia
✓ Nasal polyps and rare nasal and/or pharyngeal
tumours ❑ Klippel-Feil syndrome
❑
Upper airway
Laryngomalacia, glottic/subglottic ❑ Marfan syndrome
anomalies size ❑ Mucopolysaccharidoses
❑ Cleft palate, isolated or as part of a
❑ Neuromuscular diseases
syndrome
✓ Duchenne muscular dystrophy
❑ Orthodontic conditions e.g. malocclusion, ✓ Spinal muscular atrophy
maxillary contraction, mandibular ✓ Guillain Barré syndrome
retrognathism
❑ Craniofacial conditions
Neural Collapsibility
✓ Myotonic dystrophy

✓
control of
Pierre Robin sequence
of ✓✓upper
Myotubular myopathy
Myasthenia gravis
✓ Craniosynostosisupper airway
(Crouzon syndrome, Apert airway
syndrome, Pfeiffer syndrome)
❑ Spina bifida/Chiari malformation
✓ Treacher Collins syndrome ❑ Cerebral palsy
✓ Goldenhar syndrome ❑ Hypothyroidism
❑ Down syndrome ❑ Sickle cell anaemia

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 Clinical Features

▪ Snoring
 6 to 12% of children have habitual snoring
Chng SY, Goh DYT, Wang XS et al. Pediatr Pulmonology 2004
Ng DK, Kwok KL, Cheung JM et al. Chest 2005
Ali NJ, Pitson DJ, Stradling JR. Arch Dis Child 1993

▪ Symptoms/signs suggestive of OSA in snoring children

 Observed cyanosis or apnoea during sleep, snorting, gasping
 Laboured/paradoxical breathing during sleep
 Unusual sleeping position, hyperextended neck
 Restlessness and frequent awakening
 Diaphoresis
 Frequent daytime mouth breathing
 Difficulty getting up in the morning
 Unrefreshed after an overnight sleep
 Morning headaches

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 Clinical Features

• Excessive daytime sleepiness

– Not as common in children compared to adults
• 11% to 22% by self report and MSLT
– More common in
• Obese children
• Severe OSAHS

Gozal D, Wang M, Pope DW Jr. Pediatrics 2001

Tang JPL, Chay OM, Goh A et al. APSS 17th Annual Meeting; June 2003

• Nocturnal enuresis

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 Clinical Features

• Behavioural and learning problems

– Hyperactivity, aggressive behaviour, restlessness
– Poor school performance
– Poor performance in measures of attention, vigilance and executive
functioning
• Improve with treatment for OSAHS
• At least partially reversible, possible residual learning deficit
Gozal D. Pediatrics 1998
Gozal D, Pope DE Jr. Pediatrics 2001
Tang JPL, Chay OM, Goh A et al. 45th Annual Meeting JRS; April 2005
Yeo F, Tang JPL, Yap J et al. KKH ASM; July 2006

• Failure to thrive
– Accelerated growth after adenotonsillectory
Williams EF III, Woo P, Miller R, et al. Otolaryngol Head Neck Surg 1991
Nieminen P, Lopponen T, Tolonen U et al. Pediatrics 2002
Marcus CL, Carroll JL, Koerner CB et al. J Pediatr 1994

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 Physical Examination
Region/System Findings
Face and neck Adenoid facies
Midface hypoplasia, flat nasal bridge, facial asymmetry
Microngathia, retrongathia
Short thick neck, neck masses
Nose Turbinate hypertrophy, deviated nasal septum, nasal mass

Mouth Size of oropharynx, Mallampati score

Adenotonsillar hypertrophy
Large tongue
High arch palate, redundant soft palate
Dentition, malocclusion
Breathing Mouth breathing, stridor

Voice Hyponasal speech, hoarse/weak voice

Chest Pectus excavatum, scoliosis, barrel shaped chest

Growth Failure to thrive, obesity

Cardiopulmonary Hypertension, pulmonary hypertension, cardiac failure

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 Complications if Untreated

• Systemic hypertension, pulmonary hypertension, cor

pulmonale
• Gastroesophageal reflux (GERD)
• Insulin resistance and metabolic syndrome
– Conflicting results in children compared to adults
Kaditis AG, Alexopoulos EL, Damani E et al. Pediatr Pulmonol 2005
De La Eva RC, Baur LA, Donaghue KC, Waters KA. J Pediatr 2002

– Respiratory disturbance index independent predictor of insulin

resistance after correction for IBW
Tang JPL, Chay OM, Goh A et al. 15tht ASM of the Australasian Sleep Association; 2002 Oct

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 Complications if Untreated

• Obesity hypoventilation (Pickwickian syndrome)

– Abnormal response both hypercarbic and hypoxemic stimuli to breathe
– Daytime hypoventilation and hypercarbia
• Death

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 Diagnostic Criteria for Paediatric OSA
Both clinical and polysomnographic criteria should be present for a child to be
definitively diagnosed with OSA

Clinical criteria – The presence of 1 or more of the following clinical symptoms

• Snoring
• Laboured, paradoxical, or obstructed breathing during child’s sleep
• Sleepiness, hyperactivity, behavioural problems, or learning problems

Polysomnographic criteria – The PSG demonstrates 1 or both of the following

• One or more obstructive apneas, mixed apneas, or hypopnoeas, per hour of sleep
• A pattern of obstructive hypoventilation, defined as at least 25 percent of total sleep time
with hypercapnia (PaCO2 > 50 mmHg) in association with 1 or more of the following
▪ Snoring
▪ Flattening of the nasal pressure waveform
▪ Paradoxical thoracoabdominal motion

American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed.
American Academy of Sleep Medicine 2014

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 Diagnostic Criteria for Paediatric OSA

Ng et al. The Asian Paediatric Pulmonology Society (APPS) position statement on

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childhood obstructive sleep apnea syndrome. Pediatr Respirol Crit Care Med 2017
 Diagnostic Approach

• Children of all ages should be screened for snoring and symptoms of OSA during
routine health checks
• If snoring or OSA symptoms are present, diagnostic evaluation for OSA consists of
the following
– Focused sleep history
– Physical examination, including oropharynx
– PSG and/or referral to a specialist in sleep medicine or ENT for further evaluation
and treatment
• The PSG is needed to make a definitive diagnosis of OSA and can assist with
treatment decisions
• Specialty referral and PSG depend on individual patient characteristics and severity
of symptoms
Marcus et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012
Ng et al. The APPS position statement on childhood obstructive sleep apnea syndrome. Pediatr Respirol Crit Care Med 2017

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 Diagnostic Approach – Ideal World

• Children of all ages should be screened for snoring and symptoms of OSA during
routine health checks
• If snoring or OSA symptoms are present, diagnostic evaluation for OSA consists of
the following
– Focused sleep history
– Physical examination, including oropharynx
– PSG and/or referral to a specialist in sleep medicine or ENT for further evaluation
and treatment
• The PSG is needed to make a definitive diagnosis of OSA and can assist with
treatment decisions
• Specialty referral and PSG depend on individual patient characteristics and severity
of symptoms
Marcus et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012
Ng et al. The APPS position statement on childhood obstructive sleep apnea syndrome. Pediatr Respirol Crit Care Med 2017

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 Diagnostic Approach – Real World
• Reality
– Local resources – PSG availability, waiting time for PSG, other diagnostic modalities
available
– Local expertise – Availability of paediatric pulmonologist, sleep specialist, ENT surgeon,
orthodontist
– Local practice patterns – Awareness and experience of primary care doctors, healthcare
model and funding
– Patient/parental preference – Cost, tolerance of PSG and other diagnostic modalities,
perception of need for evaluation and treatment
– Disease severity – Urgency of diagnosis and treatment, complications of disease
– Patient complexity – Presence of high risk factors, co-morbidities, risk of surgery and other
interventions, combination of interventions
• Existing literature does not indicate which type of specialty referral or diagnostic modality serves
different areas and population best
• Selection, sequence and timing of specialty referral, diagnostic modality and
treatment/intervention depends on above factors

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 Types of Sleep Study

▪ 4 classes of sleep studies based upon how channels are recorded and whether a
sleep technologist is present throughout the recording to provide oversight
("attended" or "unattended")

▪ Level 1 PSG – Performed in a sleep laboratory with a sleep technologist present, recording a
minimum of 7 channels including EEG, EOG, chin EMG, ECG/heart rate, and SpO2

▪ Level 2 PSG – A Level 1 PSG which is recorded unattended, in or out of the sleep laboratory

▪ Level 3 study – Records a minimum of 4 channels, including ventilation, oximetry, ECG, or

heart rate, and is done at home or outside of the sleep laboratory, unattended

▪ Level 4 study – Records 2 to 3 cardiorespiratory signals (most often airflow, SpO2, and heart
rate) and is typically done at home, unattended

Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of
unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med 2007

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 Sleep Study Modalities

• Comprehensive in-laboratory overnight PSG (Level 1)

• Home sleep apnoea testing (Level 2/3)

• Daytime nap PSG (Level 1)

• Overnight continuous pulse oximetry (Level 4)

• Nocturnal home audio or video recordings

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 Polysomnography

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 Overnight Pulse Oximetry

• Monitors pulse rate, pulse amplitude and SpO2

saturation
• Can identify OSA in some children by detecting clusters
of desaturation events
– Positive predictive value 97%
– Negative predictive value 53%

Brouillette et al. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnoea

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 Overnight Pulse Oximetry

Brouillette et al. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnoea

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 Overnight Pulse Oximetry

Desaturation: ≥ 4% fall in saturation

Cluster: ≥ 5 desaturations within a 30 minute period

Brouillette et al. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnoea

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 Audiotapes & Videotapes

• Audiotapes identify OSA with a

– Positive predictive value of 50% to 75%
– Negative predictive value of 73% to 83%

• Videotapes identify OSA with a

– Positive predictive value of 83%
– Negative predictive value of 88%

Lamm C, Mandell J, Kattan M. Pediatr Pulmonol 1999

Goldstein NA, Sculerati N, Walsleben JA et al. Otolaryngol Head Neck Surg 1994
Sivan Y, Kornecki A, Schonfeld T. Eur Respir J 1996

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 Treatment

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 Medical Treatment

• May be helpful in primary snoring, mild OSA at diagnosis or residual

OSA after surgical intervention
– Topical nasal corticosteroids
– Leukotriene antagonists

• Meta-analysis of studies in children show reduction in apnoea hypopnoea

index (AHI) with medical treatment
– Nasal corticosteroids by 1.1
– Leukotriene antagonists by 2.7
– Nasal corticosteroids with leukotriene antagonists by 3.3

Liu et al. Am J Rhinol Allergy 2016

Ng et al. Pediatr Respirol Crit Care Med 2017

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 Surgical Treatment

• Tonsillectomy and/or adenoidectomy (T&A)

– First line treatment in paediatric OSA with adenotonsillar hypertrophy

• Often, but does not always result in cure

– Prevalence of residual OSA after T&A ranged from 34% to 87%, depending
the population characteristics and AHI definition used for residual OSA

Lee et al. Clin Otolaryngol 2016

• Meta-analysis of studies in children

– Postoperative AHI < 5 in 80% of all children and 55% of obese children
– Postoperative AHI < 1 in 55% of all children and 30% of obese children

Ng et al. Pediatr Respirol Crit Care Med 2017

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 Surgical Treatment

• The Childhood Adenotonsillectomy Trial (CHAT)

• 464 mild to moderate OSA above 5 years old
• Randomised to early adenotonsillectomy (eAT) or watchful waiting with supportive
care (WWSC)
• AHI, oxygen desaturation index, hypercapnia and arousal index improved in both
groups but significantly more so in eAT group
• Normalization of PSG findings in 79% of eAT versus 46% of WWSC on
assessment after 7 months
• Significantly greater reported reduction in symptoms and improvement in
behaviour and quality of life in the eAT than WWSC group
• eAT compared to WWSC did not significantly improve attention or executive
function as measured by neuropsychological testing

• Normalization rate of 46% in the WWSC group, who nevertheless had

worse behavioural performance, warrants further study

Marcus et al. N Engl J Med 2013

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 Surgical Treatment

• Children at increased risk of post-operative complications

– Below 3 years old
– Severely obese
– Severe OSAHS
– OSAHS complicated by cor pulmonale or failure to thrive
– Underlying abnormalities
• Neuromuscular disorders
• Cerebral palsy
• Trisomy 21
• Craniofacial disorders
• Achondroplasia
• Upper/lower airway abnormalities
• Asthma

Also at risk of residual OSA post T&A

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 Surgical Treatment

• Children at increased risk of post-operative complications

– Below 3 years old
– Severely obese
– Severe OSAHS
– OSAHS complicated by cor pulmonale or failure to thrive
– Underlying abnormalities
• Neuromuscular disorders
• Cerebral palsy
• Trisomy 21
• Craniofacial disorders
• Achondroplasia
• Upper/lower airway abnormalities
• Asthma

Also at risk of residual OSA post T&A

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 Surgical Treatment

• Epiglottoplasty
– Significant laryngomalacia
• Mandibular distraction osteogenesis
– Syndromes with mandibular hypoplasia
• Craniofacial surgery
– Craniosynotosis syndromes
• Tracheostomy
– Life-threatening obstructive apnoea not amenable to other therapies
• Uvulopharyngopalatoplasty
– Higher risk of velopharyngeal insufficiency in children
– May eliminate snoring but does not always cure OSAHS
• Tongue wedge resection
– Only in carefully selected conditions eg Beckwith-Wiedermann syndrome

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 Positive Airway Pressure (PAP)

• Overcomes dynamic upper airway obstruction by

stenting the airway open by pneumatic pressure
• In paediatric OSA
– Effective in improving PSG parameters
– Improvement in subjective parental assessment of sleepiness,
snoring and difficulty in breathing during sleep
– Significant improvement in neurobehavioral function in children
after 3 months of PAP therapy demonstrated, even in
developmentally delayed children

Marcus et al. J Clin Sleep Med 2012

Marcus et al. Am J Respir Crit Care Med 2012

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 Positive Airway Pressure

• CPAP/Bilevel PAP
– Pre-operative stabilisation of severe OSAHS prior to T&A
– Transient OSAHS in the perioperative period after T&A
– Long term management of OSAHS in children without
adenotonsillar hypertrophy or other surgically treatable
conditions
– Residual OSAHS after T&A or other surgical intervention
– OSAHS associated with morbid obesity
• Adherence in children is difficult
• Comfortable and well fitting interface critical
• Pressure requirements change with growth/weight
changes, need to titrate on regular basis
• Long term effects on maxillofacial structure
development in children

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 Supplemental Oxygen

• Not advised as primary treatment for OSAHS

• Improved arterial oxygen saturation but

– Does not address other pathophysiological problems of OSAHS

• Sleep fragmentation
• Sleep deprivation
• Associated autonomic stimulation during the obstructive episodes
• Associated GERD

– May blunt hypoxic drive

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 Weight Management (Loss)

• Recommended and clearly

desirable for all obese patients

– Exercise appropriate for fitness

level
– Dietary changes and good eating
habits
– Behavioural modifications
– Motivation from family, peers and
healthcare professionals

• Difficult to achieve in many cases

– Intergrated weight management

programs may be helpful

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 Appliances

• Increasing evidence in selected paediatric OSAHS

– Orthodontic treatment
• Rapid maxillary expansion
• Mandibular advancement devices

– Nasal expiratory positive airway pressure device

Huynh NT, Desplats E, Almeida FR. Orthodontics treatments for managing obstructive sleep apnea
syndrome in children: A systematic review and meta-analysis. Sleep Med Rev 2015

Kureshi et al. Pilot study of nasal expiratory positive airway pressure devices for the
treatment of childhood obstructive sleep apnea syndrome. J Clin Sleep Med 2014

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 APPS Management Algorithm

Ng et al. The Asian Paediatric Pulmonology Society (APPS)

position statement on childhood obstructive sleep apnea
syndrome. Pediatr Respirol Crit Care Med 2017

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 THANK YOU

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 Pathophysiology in Presence of Obesity

• Reduced pharyngeal lumen and increased pharyngeal collapsibility due

to
– Fat deposition in the pharyngeal muscles
– Extra-pharyngeal compression from superficial subcutaneous fat

• Reduced ventilatory effort, lung volume and oxygen reserve due to

– Reduced chest wall compliance
– Cephalad displacement of the diaphragm by abdominal fat when supine

• Reduced lung volume causes reflexive decrease in the size of the

pharyngeal airway exacerbating respiratory compromise
Horner RL, Mohiaddin RH, Lowell DG et al. Eur Respir J 1989;2:613-22
Shelton KE, Woodson H, Gay S, Surratt PM. Am Rev Respir Dis 1993;148:462-6
Hoffstein V, Zamel N, Phillipson EA. Am Rev Respir Dis 1984;130:175-8

• Potential role of leptin, a respiratory stimulant and central

chemoreceptor modulator as a link between obesity, OSAHS and
metabolic dysfunction
Saaresranta T, Polo O. Ann Med 2004:36:172-83

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 Kids are not little adults…
Adult Children

Habitual snoring 9 – 25% 3 – 12%

Bimodal Distribution
Snoring because of Peak 40 – 65 years 4 – 7 years
sleep disordered Male 3 – 8% Adolescence
breathing Female 2 % 1–3%

Male > Female Male = Female

Gender
2 – 4:1 1:1

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