PORTLAND, ORE. – Polysomnography may be the gold standard in the diagnosis of obstructive sleep apnea, but in children it should be reserved for high-risk patients, Mark A. Richardson, M.D., said at a conference sponsored by the North Pacific Pediatric Society.
In children aged older than 3 years with no underlying condition, a history and a physical exam with findings of adenoid or tonsillar hypertrophy often provide the basis for recommending surgery, said Dr. Richardson of Oregon Health and Science University in Portland. This is especially true if the parents can provide supporting objective information about the child's snoring, such as a videotape or an audiotape.
“I think if you have an otherwise healthy patient with a consistent and chronic history of obstruction at night, that's probably all you really need to have,” Dr. Richardson said.
Polysomnography has several disadvantages. It's expensive, it's unavailable in some areas, and the experience of being in a sleep lab overnight may affect the child's normal sleep. Polysomnography is also subject to false positives and false negatives, especially when an abbreviated “nap” study is used.
Furthermore, polysomnographic results do not correlate well with the behavioral disturbances that about 40% of children with sleep disorders exhibit. Simple snoring and a positive pediatric sleep questionnaire, on the other hand, do correlate with those behavioral disturbances, which include attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and primary disorder of vigilance.
“To me, that suggests that somehow we are missing something on the polysomnography,” Dr. Richardson said. “I don't know what that is, and we're trying to add a variety of measures to polysomnograms right now to see if we can identify that. Obviously, it must be fairly subtle in terms of arousals or partial arousals.”
While clinical judgment is enough for a diagnosis of obstructive sleep apnea in many children, others will require more consideration of polysomnography, Dr. Richardson said. These include children aged under 3 years, those with neuromuscular or craniofacial disorders, and those with complicating medical conditions.
When there is clear evidence of enlarged tonsils or adenoids, adenotonsillectomy is the treatment of choice in children. About 80% will be helped by this surgery, Dr. Richardson said. This is in contrast to adults with obstructive sleep apnea, few of whom respond to adenotonsillectomy.