New quality measures for treating childhood sleep apnea

New quality measures for treating childhood sleep apnea have been developed to ensure that assessing and treating the condition are followed.

A work group of physicians from leading academic medical centers across the country, including NYU Langone Medical Center, has developed new quality measures for the detection and treatment of childhood obstructive sleep apnea (OSA), a potentially morbid, life-altering condition that affects hundreds of thousands of children and adolescents nationwide. The measures, commissioned and endorsed by the American Association of Sleep Medicine (AASM), are published on March 15 in a special section of The Journal of Clinical Sleep Medicine.

Several different practice guidelines already exist for diagnosing and treating childhood OSA. The newly proposed measures, however, differ from existing guidelines in that they measure and track the quality of services provided by clinicians. According to Pediatric OSA Workgroup lead author Sanjeev V. Kothare, MD, Director of the Pediatric Sleep Program at NYU Langone Medical Center, the new metrics will help to ensure that guidelines for assessing and treating childhood OSA are actually followed.

"Guidelines recommend a course of action, but quality metrics document what is actually done," says Dr. Kothare

The new quality measures have important implications for both providers and patients, according to Dr. Kothare. "Providers, especially those who don't regularly diagnose OSA as part of their clinical practices, will have greater guidance in utilizing optimal detection and treatment processes," he says. "Likewise, parents of OSA patients, as they become aware of the new metrics, will be more likely to confirm that the recommended steps are being taken by their child's physician. And payers will benefit, too. They will be able to better monitor providers' documented clinical processes. By observing the AASM-recommended quality metrics, providers also will avoid being penalized by insurers."

Currently, there is no standardization of methods for detection, management and assessing outcomes for pediatric OSA across clinical disciplines. Children with OSA may be seen by a number of different physicians: general practitioners, pediatricians, otolaryngologists, and sleep specialists, all of whom may have different approaches to assessing symptoms, performing physical exams, and creating different action plans. A primary care physician, for instance, might refer the patient to a specialist, a sleep specialist might order a polysomnogram (PSG), and an otolaryngologist might perform surgery. Each of these actions is endorsed by the American Academy of Pediatrics' clinical practice guidelines.

Recognizing this variability, the Pediatric OSA Workgroup focused on offering choices and flexibility to clinicians while ensuring that certain minimal practice standards are maintained. To develop the new metrics, the workgroup examined a total of 960 peer-reviewed journal articles that addressed quality care or metrics in OSA, concentrating on the articles that provided either an empirical basis for selection of outcome measures, or which linked processes to outcomes. The papers were graded on the strength of association between processes and desired outcome.

Through this analysis, the workgroup was able to define five desirable processes for pediatric patients with suspected OSA: 1) assessment of symptoms and risk factors, 2) initiation of an action plan, 3) evaluation of high-risk children, 4) reassessment of OSA within 12 months, and 5) documentation of positive airway pressure (PAP) adherence.

Following these processes, the researchers conclude, should lead to two desirable outcomes: 1) improved detection, and 2) reduced signs and symptoms of childhood OSA. Justifications for exceptions to each process were noted and classified as having medical, patient, or system reasons.

Pediatric OSA is thought to affect up to 5 percent of children in the U.S., although experts think the actual prevalence may be greater because OSA symptoms often go unrecognized. In the disorder, the upper airway continually collapses during sleep, leading to oxygen deprivation and multiple partial awakenings. Because OSA interferes with the deep, restorative slow wave sleep that is vital for normal childhood growth and development, it can have lingering complications that can persist through adulthood. Children with OSA may become moody and irritable and have learning and behavioral problems, including difficulty paying attention and hyperactivity, mimicking ADHD. They can develop the symptoms of metabolic syndrome, including hypertension, abnormal blood lipid levels, and type 2 diabetes. Adults whose OSA went untreated as children are at increased risk of having earlier onset for heart attacks.

OSA also creates imbalances in the body's appetite-controlling hormones, ghrelin and leptin. In a vicious cycle, the hormonal imbalance increases appetite, leading to weight gain, which can exacerbate OSA.

The most common symptom of childhood OSA is frequent snoring, sometimes accompanied by gasping or choking. Other nighttime symptoms include tossing and turning in bed, labored breathing, night sweats, and need to urinate many times throughout the night. The main causes of pediatric OSA are large tonsils or adenoids, obesity, cranio-facial abnormalities, and genetic disorders, such as Down syndrome.

An example of how the new metrics could improve care is that existing guidelines recommend that children at high risk of OSA, such as those with Down syndrome, be evaluated by having a sleep study every year. That recommendation, however, is not always followed. With adoption of the new metrics that guideline is more likely to be heeded because clinicians will risk being penalized by payers if it is not.

"Quality measures are now in place in neurology and several other specialties," says Dr. Kothare. "Other medical disciplines will soon follow. Metrics are the mantra of the future, and will help ensure that patients are getting the best care possible."

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Sleep deprivation and obesity in children

This article explains that sleep deprived children are more likely to be obese than children who get enough sleep.

Tired and hungry. There is a reason why these two conditions seem to go together so easily.

A “well established” link in medical research suggests young children and infants who do not get enough sleep are likely to develop obesity —and a host of devastating related health conditions — before they enter their teen years.

And by then, reversing the obesity is almost impossible, health experts say.

A study published in May in the journal “Pediatrics” hypothesizes that children sleeping less in early childhood developed obesity by age 7.

But the findings — from researchers at Massachusetts General Hospital for Children — are hardly shocking, say local physicians.

While studies such as this are likely to be confirmed by additional research in the years ahead, the other non-controversial conclusion is that obese children who suffer from obstructive sleep apnea also experience a variety of health issues, according to Dr. Ignacio Tapia, a pediatric pulmonologist and sleep medicine specialist at the Sleep Center in The Children’s Hospital of Philadelphia.

Tapia notes that youngsters of normal weight who experience deep sleep and REM or rapid eye movement sleep find sleep restorative, resulting in benefit for everything from brain activity to hormone secretions.

But the obese often cannot attain deep sleep because of the apnea, a condition characterized by brief, numerous involuntary breathing pauses that prevent people from reaching restorative levels of slumber.

When children do not get the sleep they need, they are at risk for health, performance and difficulties in school; researchers find that sleep deficiencies in children can be misdiagnosed as attention-deficit or behavior disorders.

Young patients with sleep apnea can be treated effectively with surgery to remove their tonsils and adnoids but for obese children, such a procedure may not resolve the issue. Further treatment can involve wearing cumbersome masks that help regulate breathing.

“Remember when your grandparents told you you need to go to sleep to grow?” Tapia asked. “Well, that turned out to be true. Growth is associated with longer sleep. The people who sleep less (for example) may have less insulin secretion which can be related to diabetes and pre-diabetes.”

Since the 1800s, each generation has lived longer than the one that preceded it, said Tapia, also assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Such longevity can be linked to the development of antibiotics and advances in cardiac care.

Now, this generation may be the one that loses ground, because of the epidemic of obesity, which is a complex issue relating to social and cultural issues as well and having income components, physicians say. Those who earn less may not have ready access to healthy foods while eating at fast-food chains has been made increasingly affordable, Tapia said. Portion size also is an issue in this country.

“We are seeing patients who are not a little big but really really big,” he said. “It is not rare to see patients who have doubled their ideal weight. They do not weigh 20 or 30 percent more but 100 percent more’’ than growth charts indicate.

The “Pediatrics” study measured the effect of sleep deficiencies over time, using data from Project Viva, a longitudinal research study of women and children that examines the effects of mothers’ diets and other factors during pregnancy and after birth.

Obesity “definitely spans all ages,” said Dr. Tina Rakitt, a pediatric gastroenterologist at the Unterberg Children’s Hospital at Monmouth Medical Center. But the study published in May “is unique enough to say the obesity and sleep link even exists in young children,” she added. “There are many reasons for that link. People who don’t sleep well tend to eat more and they tend to eat more of the wrong things.”

The battle is lost once children are old enough to select their own snacks or meals, unless they are taught correctly. Physicians say healthy eating must be established when children are infants and must be carried on by the family. Obesity does not exist in a vacuum, the experts said.

“The obesity epidemic is not only an adult problem; it is a adult-pediatric problem,” Rakitt said. “We are seeing more sleep apnea…That is a terrible one. Children are developing fatty liver disease. We are starting to see some kids with serious complications either in their childhood or young adult years.”

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The link between childhood obesity and sleep apnea

This article discusses the link between childhood obesity and sleep apnea.

Sleep apnea is a disorder where a person’s breathing is interrupted and may stop during the sleep schedule. Recent reports claim that this disorder may afflict not only adults, but also children. Previous research has focused on behavioral issues for children suffering from sleep apnea as well as other health concerns such as diabetes.

CHEO Research Institute’s principal investigator Dr. Sherri Katz claims that there is a direct link between obesity and sleep apnea. “In the past we used to see predominantly preschool-age children who had large tonsils and large adenoids, that was the basis for their obstructive sleep apnea. As time goes on we are seeing a second wave of children with obstructive sleep apnea, predominantly over the age of eight, where obesity is the major factor contributing to their sleep disorder.” Dr. Katz said before adding, “Rates of sleep apnea are about three to 10 times higher in children with obesity. There aren’t sufficient pediatric sleep laboratory resources across the country to manage the growing demand.”

Dr. Indra Narang, who is the director of sleep medicine at The Hospital for Sick Children in Toronto, echoed the concerns voiced by Dr. Katz, explaining that a main determinant in children visiting the sleep medicine department that she oversees is due to obesity.

“We are inundated with referrals for obesity-related sleep apnea. We also believe that probably 60 to 70 per cent of obesity-related sleep apnea isn’t even diagnosed because of a lack of an awareness of sleep apnea associated with obesity. I think the disaster is happening as we speak. Not only do they not sleep well at night, but these children are affected during the day. They are sleeping, they are tired, they don’t learn as well, they don’t do as well at school. They can’t participate in physical activity. Our concern is 75 per cent of obese children will become obese adults and will have untreated obstructive sleep apnea and what we will see is an epidemic of premature cardiovascular death because of obesity and because of related obstructive sleep apnea,” Dr. Narang said.

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When you should get checked for sleep apnea

This article outlines what sleep apnea is and the process by which diagnosis and treatment occur.

Eighteen million Americans are estimated to suffer from sleep apnea, according to the National Sleep Foundation.

Sleep apnea is a common disorder, with a person having one or more pauses in breathing or experiencing shallow breaths while sleeping. The pauses can last a few seconds to several minutes. Thirty or more such pauses are possible in a single hour.

The result is a poor quality of sleep and daytime fatigue. The condition is usually noted by a family member, not the person with the disorder.

Dr. Anne Magauran at the Center for Sleep Disorders at Exeter Hospital said sleep apnea is treatable and she enjoys helping patients get a better night's sleep. She said anyone who is constantly tired during the day should discuss the problem with their primary care physician because a sleep disorder can be the cause and sometimes people are not aware they have sleep apnea issues.

"Sleep apnea is possible at any age," Magauran said. "When a person is referred to us, we have a list of questions called the Stop Bang questionnaire. If they answer yes to three or more of the questions, we suspect a sleep disorder and may do a sleep study."

Among the questions are whether the person snores, feels tired during the day, has high blood pressure or is overweight. Also, patients are asked whether anyone has ever observed them stop breathing while they are asleep.

"Sleep apnea is more common in people over the age of 50 and it is more common in men than in women," Magauran said. "We get referrals from primary care doctors or from specialists like pulmonary or cardiology because this increases the risk of heart attacks or strokes."

Once a referral is made, Magauran will conduct a detailed interview with the patient for a complete medical history, which includes lifestyle, medications, intake of caffeine and alcohol, exercise, weight and neck size — all factors in sleep disorders. Her questions also include the length of time a person has had sleep problems. She said people who say they are suffering from insomnia are often surprised to learn sleep apnea can be a cause.

Once diagnosed, sleep apnea requires long-term management and possibly surgery to correct airway issues. The best way to diagnose sleep apnea is for medical experts to conduct a sleep study. During the overnight study, doctors observe a patient and measure brain waves, eye and chin movements, heart rate and rhythms, respiration, levels of oxygen and carbon dioxide in the blood, and leg movements.

A sleep study can be done in a medical setting or at home. Magauran said a home study has less monitoring but does use an apparatus that the patient wears to bed. The device records the way the person sleeps and it is returned to the sleep center to be analyzed. Then a treatment plan is developed if necessary.

"Sleep apnea has defined criteria," Magauran said. "We look at how many times per hour the airway narrows or closes for 10 seconds or more, associated with a drop in oxygen and patient arousal."

Untreated sleep apnea can increase the risk of high blood pressure, heart attacks and stroke. It can worsen arrhythmias and diabetes. People suffering from poor sleep are more likely to be involved in car crashes and to have job performance issues.

There are three types of sleep apnea. Obstructive apnea comes from a blockage of the airway, usually the result of soft tissue that collapses and closes the rear of the throat during sleep. In central apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Mixed apnea is a combination of the first two conditions.

In mild cases, treatment may involve the use of decongestants and positional therapy. Some people snore when lying on their back and teaching them to sleep in a different position can help.

"There are devices, like an anti-snore belt that helps patients stay off of their back, if they can tolerate them," Magauran said. "It's not for everyone."

Oral devices such as a continuous positive airway pressure (CPAP) device can be used successfully in some patients.

Surgical methods can be used in adults to open a compromised airway. In children, tonsils and adenoids may be the culprit and surgery can resolve apnea completely.

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SleepSleep 2009; 32(4)

Prevalence of EEG paroxysmal activity in a population of children with obstructive sleep apnea syndrome.

Silvia Miano, Maria Chiara Paolino, Rosa Adrados, Marilisa Montesano, Salvatore Barberi, Maria Pia Villa

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STUDY OBJECTIVES:

Sleep breathing disorders may trigger paroxysmal events during sleep such as parasomnias and may exacerbate preexisting seizures. We verified the hypothesis that the amount of EEG paroxysmal activity (PA) may be high in children with obstructive sleep apnea syndrome (OSAS).

DESIGN:

Prospective study.

SETTINGS:

Sleep unit of an academic center.

PARTICIPANTS:

Polysomnographic studies were performed in a population of children recruited prospectively, for suspected OSAS, from January to December 2007, with no previous history of epileptic seizures or any other medical conditions. All sleep studies included > or = 8 EEG channels, including centrotemporal leads. We collected data about clinical and respiratory parameters of children with OSAS and with primary snoring, then we performed sleep microstructure analysis in 2 OSAS subgroups, matched for age and sex, with and without paroxysmal activity.

MEASUREMENTS AND RESULTS:

We found 40 children who met the criteria for primary snoring, none of them showed PA, while 127 children met the criteria for OSAS and 18 of them (14.2%) showed PA. Children with PA were older, had a predominance of boys, a longer duration of OSAS, and a lower percentage of adenotonsillar hypertrophy than children without PA. Moreover, PA occurred over the centrotemporal regions in 9 cases, over temporal-occipital regions in 5, and over frontocentral regions in 4. Children with PA showed a lower percentage of REM sleep, a lower CAP rate and lower A1 index during slow wave sleep, and lower total A2 and arousal index than children without EEG abnormalities.

CONCLUSIONS:

We found a higher percentage of paroxysmal activity in children with OSAS, compared to children with primary snoring, who did not exhibit EEG abnormalities. The children with paroxysmal activity have peculiar clinical and sleep microstructure characteristics that may have implications in the neurocognitive outcome of OSAS.

What increases risk for sleep apnea?

This article discusses 8 things and behaviors that can increase a person's risk for sleep apnea.

It used to be that if someone told you you snored, you shrugged it off as more of an annoyance to them than anything telling about your own health and wellbeing.

Today, we have a greater understanding of at least one potential risk of being a frequent snorer: You could have sleep apnea, a potentially harmful sleep disorder during which people stop breathing, sometimes hundreds of times a night.

Obstructive sleep apnea (OSA) is the most common type of sleep apnea, and occurs when the muscles in the back of the throat collapse, causing the opening through which air passes to disappear. (Watch this video for an in-depth explanation of what happens during OSA.)

But certain people are more likely to experience this interruption of breathing than others. We asked Dr. Matthew Mingrone, lead physician for EOS Sleep Centers in California specializing in sleep apnea and snoring issues, to help explain why.

Obesity
Likely the most indicative risk factor is carrying too much extra weight. Obese adults are seven times more likely to develop OSA than their normal-weight peers, according to WebMD. OSA is essentially a blockage of the upper airway, says Mingrone. Part of the tissue running from the nose to the voicebox collapses, cutting off the passage of oxygen. Excess weight adds to the pressure on tube, he says, making the diameter of the opening even smaller than it already is.

Neck Circumference

Obese people aren't the only demographic with larger-than-average necks. Consider the muscular build of professional athletes, for example, who aren't obese but thanks to muscle development are larger than us mere mortals.

Men with a neck circumference greater than 17 inches and women over 15 inches have a higher risk of OSA, WebMD reported.

Age
People of any age can develop sleep apnea, but the condition is more common the older you get, according to the National Heart Lung and Blood Institute. "As we get older, we lose tone and elasticity as part of the normal aging process," says Mingrone. With that natural softening of the tissue in the throat, there's higher likelihood of collapse, he says.

Family History
It's not that you have a genetic predisposition to developing sleep apnea, says Mingrone, like a specific type of cancer that may run in families. Instead, it's likely that you've inherited certain aspects of your physical makeup that increase sleep apnea risk, he says. If Mom's being treated for sleep apnea and you've inherited her narrow jaw, you may have a similar doctor's visit in your future.

Alcohol Use

Because it's a muscle relaxant, alcohol too close to bedtime can lead to episodes of apnea, says Mingrone, even in someone who doesn't have OSA. And in those with the disorder, alcohol can lengthen the duration of apnea episodes, according to the National Institute on Alcohol Abuse and Alcoholism.

Race
Studies show that both sleep apnea risk and sleep apnea severity vary by race. It may be due to anatomical differences in the airways of different ethnic groups, according to Mingrone.

Smoking

Current smokers are 2.5 times more likely to have OSA than smokers and nonsmokers combined, according to a 2001 study. "Smoking most airway tissue swell because it's an irritant," says Mingrone. Swelling in the nose and the throat further reduces the space for air to flow through.

Gender
Middle-aged men are twice as likely to have OSA than women of the same age, according to the American Lung Association. Mingrone says in his practice, about 15 to 20 percent of patients are female. The variance may be due again to anatomical differences, especially since men are simply bigger than women more often than not.

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Adenoid and tonsil removal may help pediatric sleep apnea symptoms

This article discusses how adenoid removal or a tonsillectomy can help pediatric sleep apnea symptoms. Important - the AAP and AAFP recommend PRE-OPERATIVE sleep studies at PEDIATRIC sleep Centers- JR

Adenotonsillectomy, or the removal of the adenoids and tonsils, is performed 500,000 times a year in the United States, often as a treatment for children with obstructive sleep apnea. However, the procedure's ability to improve a child's attention and executive functioning, behavior, sleep apnea symptoms, and quality of life has not been rigorously evaluated until now. 

A study led by Susan Redline, MD, MPH, director of the Program in Sleep and Cardiovascular Medicine and Associate Clinic Director of the Division of Sleep Medicine at Brigham and Women's Hospital finds that early adenotonsillectomy in children with mild to moderately severe sleep apnea does not improve attention and executive functioning when compared to watchful waiting with supportive care. However, the study also found that early adenotonsillectomy can be beneficial in improving behavior, sleep apnea symptoms and quality of life. The research will be presented at the American Thoracic Society's International Conference and published online in the New England Journal of Medicine on May 21.

"This new evidence should be carefully considered by physicians and parents who are deciding on the best approach for a child's sleep apnea problem," said Dr. Redline. 

"Our study provided evidence that surgical treatment can lead to early improvements in many health-related areas of importance to children and their families, including children's behavior. Beneficial effects of surgery were shown even among overweight children, in whom the effectiveness of surgery has been questioned....

.... However, the study also showed that many times sleep apnea resolved without surgery and that cognitive functioning did not improve more with surgery than with medical management. Thus, watchful waiting is also a reasonable option for some children with sleep apnea without many symptoms."

The study, which was conducted in partnership with eight other institutions, examined 397 children between the ages of five and nine who had obstructive sleep apnea syndrome without prolonged levels of low oxygen. The children were randomly placed in two groups. One hundred and ninety-four children had their adenoids and tonsils removed within four weeks of being randomized to the study. The remaining 203 children underwent watchful waiting with supportive care to see if their sleep apnea symptoms resolved without surgery.

Seven months later, both groups of children underwent the Developmental Neuropsychological Assessment, which showed no significant difference between the groups in the improvement of attention and executive functioning. However, other tests, including assessments by parents and teachers, showed significant improvements in the quality of life, sleep apnea symptoms and behavior in the children who had the early adenotonsillectomy.

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