What Is Infant Sleep Apnea?

Sleep apnea or sleep apnea refers to apnea and breathing disorders that occur during sleep, including obstructive sleep apnea syndrome, hypoventilation syndrome, upper airway resistance syndrome, chronic lung and neuromuscular disorders Related to sleep disordered breathing. Obstructive sleep apnea syndrome is the most common.

Basic Information

Visiting department

Pediatrics, Otorhinolaryngology Head and Neck Surgery

Multiple groups

child

Common causes

Caused by chronic otolaryngology

Common symptoms

Apnea, breathing problems, etc. during sleep

Causes of obstructive sleep apnea in children

Common causes of OSAHS in children include changes in compliance caused by increased upper airway resistance and factors that affect neural regulation.

Local factor

Adenoid and tonsil hypertrophy are the most common causes of OSAS in children. In infants with OSAS, 52% of the obstruction is in the palate and 48% is behind the tongue. Other causes such as obstructive nasal cavity diseases: rhinitis, sinusitis, nasal polyps, nasopharyngeal masses, etc .; tongue diseases: hypertrophy of the tongue, fat accumulation caused by obesity, etc .; craniofacial deformities: dysplasia in the middle of the face (Down's syndrome) , Grouzon syndrome, cartilage hypoplasia, etc.); mandibular hypoplasia, such as pierre-robinsyndrome, mandibular facial hypoplasia, shy-Drager syndrome, etc. Others, such as mucopolysaccharidosis type and IH (Hunter syndrome and Hurler syndrome), etc .; laryngeal diseases: congenital laryngeal cartilage softening, laryngeal webs, laryngeal cysts, neonatal trachea and tracheal stenosis.

2. Systemic factors

Factors affecting neuroregulation include obesity, goiter, hypothyroidism, acromegaly, Down syndrome, coma, and drunkenness. Sedative drugs are used.

Clinical manifestations of obstructive sleep apnea in children

Children's sleep apnea is mainly manifested by increased activity, accompanied by language defects, decreased appetite and difficulty swallowing, memory loss, learning difficulties, abnormal behavior, growth retardation, hypertension, pulmonary hypertension, right heart failure and other cardiovascular diseases . Non-specific behavioral difficulties often occur, such as abnormal shyness, delayed development, rebellious and aggressive behavior. Memory loss, learning difficulties, behavioral abnormalities, stunted growth, hypertension, pulmonary hypertension, right heart failure, and other cardiovascular diseases.

An important feature of pediatric OSAS is the manifestation of a series of clinical syndromes.

Day symptoms

Symptoms of children with OSAHS when they wake up in the morning include mouth breathing, morning headaches, dry mouth, disorientation, confusion, and irritability. School-age children are manifested as lack of concentration in class, daydreaming, fatigue, and decline in academic performance. 8% to 62% of children have symptoms of excessive daytime sleepiness. Daytime behavior problems are more common, mainly manifested as poor performance in school, hyperactivity, mental retardation, emotional problems, shy or withdrawn behavior, aggressive behavior and learning problems. Many children with OSAHS have stunting. It is now clear that adult OSAHS It can impair attention, memory, alertness, and motor skills, but there is not much research on the effect of children's cognitive ability during the day. Most children have hypertrophic tonsils and proliferative bodies, and most of them are breathing by mouth. Some are also accompanied by eating, swallowing difficulties, and bad breath, and show a degree of speech impairment.

2. Nocturnal symptoms

The most significant symptom at night is snoring. Almost all children with OSAHS have snoring, and most snoring sounds loud, but severe OSAHS can be without snoring or only high-pitched grunts during sleep, and snoring intensified during upper respiratory infections. In children with OSAHS, OSAS or sleep-related pulmonary insufficiency is the main type. Children show two main forms of snoring: continuous snoring and intermittent snoring. There is a quiet period in intermittent snoring. This quiet period It is usually stopped by a loud gasp or snoring. Onset of apnea in children with OSAHS is periodic and can be stopped on their own. The snoring sounds stop suddenly during the attack and the inspiratory force is exerted, but no air flow from the nose and nose enters the respiratory tract. For long-term patients, cyanosis and slowed heart rate may occur. The onset stopped, breathing resumed, loud jets appeared, awakening, and posture changes.

3. Accompanying symptoms

Hypoxemia usually occurs in many children with OSAHS. In some children with severe OSAHS, SaO ₂ can drop below 50%. SaO ₂ in children with continuous partial obstruction decreases and remains low for a long time at the beginning of the obstruction. Hypercapnia is also characteristic of children with OSAS. Half of the hypercapnia (end-tidal CO ₂ > 6.0 kPa) is associated with OSAS or persistent partial obstruction. Low body weight is found in most children with obstructive pulmonary ventilation. In addition, children with airway obstruction during sleep are prone to gastroesophageal reflux, sudden awakening, crying, screaming, etc. Another study found that children with OSAHS experience behavioral disorders.

4. Signs

Including snoring, dyspnea, nasal fan, intercostal and supraclavicular depression, paradoxical movements of the chest and abdomen during inhalation; sweating at night, parents may notice that children are unwilling to be covered at night, stop breathing and then wheeze. The typical sleeping position is In the prone position, the head turns to one side, the neck is overstretched with an open mouth, and the knees are flexed to the chest.

Some craniofacial features often indicate the presence of sleep-disordered breathing, such as the triangular mandible, the mandible plane being too steep, the mandible backward, the long face, the hard palate, and / or the long palate.

Obstructive sleep apnea test in children

Polysomnography

It is considered the gold standard for diagnosing sleep apnea. Marcus et al. Pointed out that the diagnostic criteria for obstructive sleep apnea in children over 1 year of age is: 1 obstructive sleep apnea during sleep per hour, with SaO ₂ 53 mm Hg PET, or PETCO ₂ > 45 mm Hg during 60% or more of the sleep time is abnormal. All-night polysomnography should be continuously monitored for more than 6-7 hours at night, including EEG, EEG, and electromyography Figures, leg movements, and electrocardiograms should be monitored at the same time as blood oxygen saturation, end-tidal carbon dioxide partial pressure, chest and abdominal wall movement, mouth and nose airflow, blood pressure, snoring, esophageal pH or pressure, etc.

2. Electrostatic charge sensitive bed

In this method, an electrostatic load layer and a motion sensor are set under a standard foam mattress. The patient only needs a blood oxygen saturation level without any electrodes when sleeping on the bed. The original motion signal is pre-amplified and frequency filtered respectively. Enter the following 3 leads and divide OSAS patients into 4 types of periodic breathing according to the pattern of increased respiratory resistance. At present, this method is mainly used for primary screening obstructive and central sleep apnea, and with upper airway resistance Increased severe snoring.

3. Other inspections

There are lateral nasopharyngeal X-rays, CT and MRI examinations, fiber nasopharyngoscopy, etc., which are helpful for understanding the structure of the upper airway, showing the location and degree of stenosis and obstruction, and multiple sleep latency tests are helpful for daytime sleepiness Judgment and identification of narcolepsy, while diagnosing sleep apnea syndrome, attention should also be paid to the diagnosis of other diseases throughout the body.

Diagnosis of obstructive sleep apnea in children

Obstructive sleep apnea (obstructivesleepapnea (OSA)) refers to the cessation of mouth and nasal airflow during sleep, but chest and abdominal breathing still exist. Hypopnea is defined as a 50% reduction in peak nasal airflow signals, accompanied by a decrease in blood oxygen saturation above 0.03 and / or awakening. The duration of a respiratory event is defined as greater than or equal to 2 breathing cycles. Polysomnogruphy (PSG) monitoring: Obstructive apnea index (OAI) greater than or equal to 1 / hour or AHI (sleep apnea hypopnea index) greater than 5 during nightly sleep is abnormal. Hypoxemia was defined as the lowest arterial oxygen saturation (LSaO ₂ ) below 0.92. Satisfying the two above can diagnose OSAHS.

1. Diagnostic criteria for OSAS in children

The diagnosis of OSAS in children should be combined with clinical manifestations, physical examination and PSG results

(1) The caregiver complains that the child has breathing sounds during sleep, and / or inappropriate daytime sleepiness or behavior problems.

(2) A complete or partial airway obstruction during sleep.

(3) Accompanying symptoms include: growth disorders; sudden awakening; gastroesophageal reflux; inhalation of nasopharyngeal secretions; hypoxemia; hypercapnia; behavior disorders;

(4) Detection results of polysomnography: obstructive pulmonary ventilation; one or more obstructive apnea per hour, usually accompanied by one or more of the following (arterial oxygen saturation below 90% 92%; sleep awakening related to upper airway obstruction; multiple sleep latency tests show abnormal sleep latency at this age)

(5) It is usually accompanied by other diseases, such as proliferation and tonsil hypertrophy.

(6) There may be other manifestations of sleep disorders, such as narcolepsy.

2. Indexing

Pediatric OSAS is divided into three degrees according to its severity.

Judgment of OSAHS in children

AHI or OAI (times / hour) LSaO ₂

Mild 5 to 10 or 1 to 50.85 to 0.94

Moderate 11 to 20 or 6 to 100.75 to 0.84

Severe greater than 20 or greater than 10 and less than 0.75

Differential diagnosis of obstructive sleep apnea in children

Obstructive sleep apnea should be distinguished from central sleep apnea. Central sleep apnea can be seen in a variety of conditions:

Neurological disease

Such as anterior spinal amputation, vascular embolism or degenerative lesions caused by bilateral posterior spinal cord, abnormalities of the cerebral spinal cord, such as occipital foramen malformations, poliomyelitis, lateral bulbar syndrome, abnormal autonomic nerve function: such as family Autonomic nervous disorders, insulin-related diabetes, Shy-Drager syndrome, encephalitis, brain stem tumors.

2. Muscle disease

Such as diaphragmatic disease, myotonic dystrophy myopathy and so on.

3. Other

Some obese people, congestive heart failure, etc.

Obstructive sleep apnea complications in children

OSAS children's long-term hypoxia can affect their growth and development. 30% to 40% of them have stunting, which can be complicated by hypertension, pulmonary edema, pulmonary heart disease, arrhythmia, congestive heart failure, respiratory failure, and even sudden infant death syndrome.

Obstructive sleep apnea treatment in children

Mild to moderate patients with oral appliance or tongue support during sleep have the advantages of simplicity, mildness and low cost. After the strap, the mandible can be moved forward and / or the tongue can be moved forward, which can enlarge the upper airway and increase the gap in the narrow place. Large, to prevent tongue subsidence, to alleviate OSAS to varying degrees, to prevent the occurrence of concurrent licenses. But some patients apparently feel uncomfortable.

Side or semi-recumbent position is recommended. Take a side supine sleep. Sleeping on your side can prevent the airway from being blocked by pharyngeal tissue and falling tongue. It also reduces airway pressure caused by the extra weight of the abdomen, chest, and neck.

It is recommended to lose weight, develop a weight loss plan, and ask a dietitian to formulate a weight loss diet, appropriately increase physical activity and reduce intake. Losing some weight will help you breathe. Reducing to ideal weight may cure snoring and sleep apnea syndrome.
Exercise regularly. Exercise can help you lose weight, strengthen muscles and increase lung function.

Treatment principles: early diagnosis and early treatment, removal of upper airway obstruction factors, prevention and treatment of complications.

(A) surgical treatment

1. Adenoidectomy and tonsillectomy

Adenoid and tonsillectomy can be performed in children with OSAHS caused by tonsil and adenoid hypertrophy. When both tonsils and adenoids are hypertrophic, adenoid or tonsillectomy alone has limited efficacy. Most obese children can be effectively treated by adenoid and tonsillectomy. Infants with tonsil and adenoid hypertrophy and severe OSAHS, conservative treatment is not effective, and surgery should be taken. Patients at high risk of postoperative complications are children younger than 3 years old, severe OSAHS, pulmonary heart disease, malnutrition, pathological obesity, neuromuscular tumors, and craniofacial dysplasia. In this regard, a detailed assessment must be performed before surgery, and close monitoring should be performed after surgery.

2. Other surgical treatments include

Craniofacial orthognathic surgery (for some patients with craniofacial developmental deformities), uvulopalatopharyngoplasty, inferior turbinate volume reduction, tracheotomy and other treatments may affect children's growth and development and quality of life. careful.

(B) Non-surgical treatment

1. Continuous positive airway pressure (CPAP)

For patients with contraindications to surgery, large adenoid tonsils, OSAHS after adenoid tonsillectomy, and children who choose non-surgical treatment, CPAP can be selected. CPAP pressure titration must be done in a sleep laboratory and needs to be adjusted regularly.

2. Oral appliance

It is suitable for children with mild to moderate OSAHS who cannot be treated or cannot tolerate CPAP.

3. Other

Treatment of nasal diseases: rhinitis, allergic rhinitis and sinusitis should be treated systematically and standardized. Obese children should lose weight.

Prognosis of obstructive sleep apnea in children

OSAS is a group of potentially dangerous sleep disordered breathing diseases that are prone to arrhythmia, hypertension, and even respiratory failure or sudden death. It is estimated that 3,000 people worldwide die of this disease every day. According to reports, the 5-year fatality rate of untreated patients is 11% to 13%. It takes a long process from the early symptoms of OSAS patients to the development of severe heart, lung, and brain complications, and even death. Therefore, effective treatment can improve the quality of life of patients and prolong life.