OBJECTIVE: This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS). METHODS: The literature from 1999 through 2011 was evaluated. RESULTS AND CONCLUSIONS: A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

OBJECTIVES. Positive airway pressure therapy (PAP) is frequently used to treat children who have obstructive sleep apnea syndrome and do not respond to adenotonsillectomy. However, no studies have evaluated objectively adherence to PAP in children, and few studies have evaluated objectively the effectiveness of PAP. The objective of this study was to determine adherence and effectiveness of PAP (both continuous [CPAP] and bilevel [BPAP] pressure) in children with obstructive apnea.METHODS. A prospective, multicenter study was performed of children who were randomly assigned in a double-blind manner to 6 months of CPAP versus BPAP. Adherence was measured objectively using the equipment's computerized output. Effectiveness was evaluated using polysomnography.RESULTS. Twenty-nine children were studied. Approximately one third of children dropped out before 6 months. Of the 21 children for whom 6-month adherence data could be downloaded, the mean nightly use was 5.3 Ϯ 2.5 (SD) hours. Parental assessment of PAP use considerably overestimated actual use. PAP was highly effective, with a reduction in the apnea hypopnea index from 27 Ϯ 32 to 3 Ϯ 5/hour, and an improvement in arterial oxygen saturation nadir from 77 Ϯ 17% to 89 Ϯ 6%. Results were similar for children who received CPAP versus BPAP. Children also had a subjective improvement in daytime sleepiness.CONCLUSIONS. Both CPAP and BPAP are highly efficacious in pediatric obstructive apnea. However, treatment with PAP is associated with a high dropout rate, and even in the adherent children, nightly use is suboptimal considering the long sleep hours in children. T HE OBSTRUCTIVE SLEEP apnea syndrome (OSAS) affects ϳ2% of children. 1 The pathogenesis of childhood OSAS is multifactorial. Contributing factors include anatomic narrowing (as a result of both soft tissue and craniofacial structure) and abnormal upper airway neuromotor control. 2 In most children with OSAS, the primary factor that leads to the upper airway obstruction is adenotonsillar hypertrophy, and OSAS can be treated effectively with tonsillectomy and adenoidectomy. 3 However, in a small number of children in whom additional anatomic factors (including obesity) or abnormal upper airway neuromotor tone is the predominant cause for OSAS, OSAS persists postoperatively. 4 In these children, continuous positive airway pressure (CPAP) is usually used as the second line of treatment. 5 Although home CPAP use has been reported in Ͼ300 children of all ages, 5-7 it is not yet approved by the Food and Drug Administration (FDA) for use in children who weigh Ͻ30 kg. Furthermore, few studies have evaluated the effectiveness of positive airway pressure (PAP) therapy in children, and no prospective studies have evaluated objective measures of adherence in the pediatric age group. We therefore conducted a multicenter, prospective study of PAP therapy in children with OSAS. The objectives of this study were to assess objectively adherence to and effectiveness of PAP in children. In addition, we sought in a r...

BackgroundChildhood obstructive sleep apnea (OSA) is associated with neuropsychological deficits of memory, learning, and executive function. There is no evidence of neuronal brain injury in children with OSA. We hypothesized that childhood OSA is associated with neuropsychological performance dysfunction, and with neuronal metabolite alterations in the brain, indicative of neuronal injury in areas corresponding to neuropsychological function.Methods and FindingsWe conducted a cross-sectional study of 31 children (19 with OSA and 12 healthy controls, aged 6–16 y) group-matched by age, ethnicity, gender, and socioeconomic status. Participants underwent polysomnography and neuropsychological assessments. Proton magnetic resonance spectroscopic imaging was performed on a subset of children with OSA and on matched controls. Neuropsychological test scores and mean neuronal metabolite ratios of target brain areas were compared.Relative to controls, children with severe OSA had significant deficits in IQ and executive functions (verbal working memory and verbal fluency). Children with OSA demonstrated decreases of the mean neuronal metabolite ratio N-acetyl aspartate/choline in the left hippocampus (controls: 1.29, standard deviation [SD] 0.21; OSA: 0.91, SD 0.05; p = 0.001) and right frontal cortex (controls: 2.2, SD 0.4; OSA: 1.6, SD 0.4; p = 0.03).ConclusionsChildhood OSA is associated with deficits of IQ and executive function and also with possible neuronal injury in the hippocampus and frontal cortex. We speculate that untreated childhood OSA could permanently alter a developing child's cognitive potential.

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