Sleep apnea: don’t sleep over it

It is a known fact that children need at least 7 to 8 hours of sleep to stay healthy. Having a good amount of sleep benefits the heart, weight, mind and body. It helps in energising the whole system. However, unhealthy food habits and lack of physical activity are factors that can hamper sleep. One thing that most people suffer from, especially children is Obstructive Sleep Apnea (OSA).

The word apnea means no breathing. The upper airway is blocked by the muscles that form the airway walls. If the blockage lasts sufficiently long, the oxygen in the person’s blood falls. The episode ceases when the sleep gets disturbed from a deep to a light stage or by waking up completely (“arousal”).

The risk factors for sleep apnea include obesity, structural abnormalities in the upper airway, familial hormone disorders like hypothyroidism and polycystic ovary syndrome, smoking and alcohol abuse.

Sleep apnea is common in 1% to 5% of children of any age group, but is more commonly seen in children aged between 2-6 years. Moreover, children with Down’s syndrome and craniofacial abnormalities are more vulnerable to OSA. In addition, children with muscle, nerve disease namely myopathies and cerebral palsy also are at a greater risk of OSA.

Due to lifestyle changes, unhealthy food habits and lack of physical activity lately, there is an increase in the prevalence of sleep disordered breathing in children. On an average, we see around 5-6 cases (children and adults) with sleep apnea daily.

Symptoms of sleep apnea can be categorised into night time and day time. Night time symptoms include heavy snoring, apneas (breathing stops for 10 seconds or more) witnessed by the bed partner, choking, frequent urination, sweating, erectile dysfunction and unrefreshing sleep. Day time symptoms include excessive day time sleepiness, difficulty in concentration, memory loss, irritability, fatigue and depression.

In children, besides snoring and day time sleepiness, sleeping in a seated position with hyper extended neck, sleep enuresis (bedwetting), attention deficit, hyperactive disorder, learning disorders, hyperactivity, impulsivity, irritability and aggression are noted.

Examination of a child with sleep apnea will show either underweight or overweight, tonsillar hypertrophy and adenoidal facies. Children with some facial and jaw disorders suffer from this condition commonly.

The consequences of sleep apnea include increase in blood and pulmonary pressures, heart attack, irregular heartbeat, stroke. Untreated OSA in children can result in learning/behavioural problems and cardiovascular complications.

Diagnosing OSA

Patients who have symptoms of sleep apnea can screen themselves using a questionnaire which is popularly known by the acronym STOPBAN. STOPBAN refers to: S - Snoring; T - Tiredness; O - Observed apneas; P - Blood pressure; B - BMI (Body Mass Index) >35 kg /m2; Age > 50 years; Neck Circumference > 16 inches and Gender-Male

People who score 3 or more in this questionnaire should see a sleep medicine specialist and undergo a sleep study.

A sleep study is a non-invasive, overnight exam that allows doctors to monitor you while you sleep to see what’s happening in your brain and body. For this test, the patient goes to a sleep lab usually in a hospital or a sleep centre or at home.

A sleep study will also measure brain activity, oxygen levels in your blood, heart and breathing rates, snoring, and body movements. These parameters assist the clinician in deciding the severity of the disease. The key figure looked at is the apnea-hypopnea index. This represents the number of obstructions to breathing, complete or partial during sleep, and is used to decide the need for treatment.

Precautionary measures like weight reduction, regular exercise, sleep hygiene and prompt recognition and treatment of correctable causes for sleep apnea can help in preventing sleep apnea both in adults and children. Apart from the above, avoidance of smoking/alcohol consumption among adults also can reduce the chances of being affected by the condition.

The treatment strategy of sleep apnea includes Continuous Positive Airway Pressure delivered through a face mask/nasal mask besides other precautionary measures.

If there is an abnormal growth such as tonsils or adenoids obstructing the airway, surgery to relieve the obstruction may be advised. If the patient is unwilling to use these measures, a device called Mandibular advancement device can used to advance the lower jaw during sleep. Topical intranasal corticosteroids are used in children with mild OSA.

(Sapare is a Paediatric Pulmonologist, Narayana Health City, Bengaluru and Capoor is a Pulmonologist, Narayana Medical Center, Langford)