Pediatric Obesity and Obstructive Sleep Apnea
By Wayne Peacock, RPSGT
MD, associate professor of pediatrics at the
Obesity has become a serious problem
University of Texas Southwestern Medical
for today’s youth. In a world of fast food
School, 10 to 20 percent of normal children
and video games, many young people are no
have primary snoring on a regular or
longer healthy, active children. Is childhood
intermittent basis.3 In addition to snoring, a
obesity leading to obstructive sleep apnea
(OSA) and the medical and behavioral
child with OSA may exhibit these symptoms:
complications that result from OSA?
 Slow rate of growth
Pediatric OSA often is undiagnosed,
 Mouth breathing
in part because children generally do
 Enlarged tonsils and/or adenoids
not present with the same symptoms
 Restless sleep
as adults. Adults with OSA frequently
 Excessive daytime sleepiness or
complain of daytime sleepiness, but
hyperactivity
Wayne Peacock,
pediatric patients with OSA may be
 Daytime cognitive or behavioral
RPSGT
hyperactive. The most common cause
problems
of OSA in children is adenotonsillar
hypertrophy (i.e., enlarged tonsils and adenoids). The
Yuen-yu Lam, et al., found that obese children have a
increase in body mass index (BMI) in children also has
significantly higher apnea-hypopnea index, or AHI, (median,
been correlated with higher risks for developing OSA.
1.5 ; interquartile range (IQR) 0.2 to 7.0) than the AHI of
It is likely that the rise in childhood obesity will be
non-obese children (median, 0.7; IQR, 0.0 to 2.5).4 One
1
accompanied by higher rates of pediatric OSA.
scoreable respiratory event or more per hour (i.e., apnea or
hypopnea of at least two respiratory cycles in duration) is
part of the diagnostic criteria for pediatric OSA.5
Prevalence
With the rise in pediatric obesity, pediatricians are
According to the American Heart Association
faced with an increasing number of patients who have
(AHA), overweight children are more likely to become
pulmonary complications of obesity, especially OSA.
overweight adults. Statistics show that a high
In addition to having OSA, these children are at an
percentage of American children are overweight:
increased risk of developing asthma, restrictive lung
disease and central hypoventilation.6
Between ages 6 and11 the following are overweight:
The potentially dangerous effects of childhood OSA
 Whites, 16.9 percent of boys and 15.6 percent
include hypoxemia (i.e., lack of oxygen in the blood),
of girls
hypercapnia (i.e., high level of carbon dioxide in the
 Blacks, 17.2 percent of boys and 24.8 percent
blood) and fragmented sleep associated with sympatheticof girls
nervous-system surges.6 Complications of OSA can
 Hispanics, 25.6 percent of boys and 16.6
include cardiovascular damage and neurobehavioral
percent of girls
symptoms. Children with OSA often will present with
impaired cognition, poor school performance and attention
Between the ages of 12 and 19 the following are
problems. In contrast to adults with OSA, children often
overweight:
have fewer complaints of excessive daytime sleepiness
 Whites, 17.9 percent of boys and 14.6 percent
(EDS); however, they may be sleepier than the average,
of girls
healthy child. If left untreated or undiagnosed, problems
 Blacks, 17.7 percent of boys and 23.8 percent
related to EDS are likely to become worse in adolescence.6
of girls
 Hispanics, 20.0 percent of boys and 17.1
percent of girls2
Diagnosis
The gold standard for diagnosing OSA in children is
full, nocturnal polysomnography (PSG), as this is the
Data from the 1999-2004 National Health and
most accurate diagnostic tool for differentiating simple
Nutrition Examination Survey show that the prevalence
or primary snoring from OSA.7
of obesity in children between the ages of six and 11
has increased from four percent to 17.5 percent when
According to the American Academy of Pediatrics, the
compared with data from 1971-74.2
following are recommendations for diagnosing OSA in
the pediatric patient:
Obesity is not the most common cause of OSA in the
1.All children should be screened for snoring.
pediatric population; however, an increased BMI may
2.Complex, high-risk patients should be referred
exacerbate the problem. Clinical presentation of the
to a specialist.
pediatric-OSA patient varies and often does not mimic that
3.Patients with cardio-respiratory failure cannot
of the adult population. According to Vincent Iannelli,
20
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• volume 16 • number 3
await elective evaluation.
4.Diagnostic evaluation is useful in
discriminating between primary snoring and
OSA, with the gold standard being PSG.
5.Adenotonsillectomy is the first line of
treatment for most children, and continuous
positive airway pressure (CPAP) is an option for
those who either are not candidates for surgery
or do not respond to surgery.
6.High-risk patients should be monitored as
inpatients post-operatively.
7.Patients should be re-evaluated postoperatively
to determine whether additional treatment is
required.7
It is also recommended that diagnosis include a
history and physical exam, including a sleep history
with screening for snoring. It is rare that a child
without habitual snoring will show positive for OSA.7
Overnight PSG is the only diagnostic technique shown
to quantitate the ventilatory and sleep abnormalities
associated with sleep disordered breathing, and it can
be performed on patients of any age if appropriate
equipment is used and trained staff are available.7
Pediatric studies should be scored and interpreted
using age-appropriate criteria as outlined in the AASM
Manual for the Scoring of Sleep and Associated Events.8
Other methods that have been used in addition to
PSG include audio/video taping, abbreviated PSG and
unattended home studies.
Treatment
Adenotonsillectomy is the most common, firstline treatment for children with OSA, although
it may not always be sufficient.7 A recent study
showed that children who are obese when diagnosed
with OSA are more likely to have OSA persist after
adenotonsillectomy.9 In some cases patients with
OSA may develop respiratory complications such as
worsening OSA or pulmonary edema (i.e., fluid in the
lungs) in the immediate post-operative period.7
In cases when surgical treatment is not an option or
there is persistent OSA after surgery, CPAP therapy is
an option. This device delivers constant, positive air
pressure via a mask and leads to a mechanical stenting
of the airway and improved functional residual capacity
in the lungs. Pressure requirements vary among patients
and will need to be titrated manually in a sleep laboratory.
Regular follow-ups are needed to assess adherence and
efficacy as therapy may be required indefinitely.6 Older
children are more likely to adhere to therapy without
complication, whereas younger children, or those with
learning and behavioral difficulties, may require a
desensitization program to accept therapy.7
Diet and Exercise
In addition to medical intervention, the obese child
should be treated via dietary changes. The AHA
recommends reaching and maintaining an ideal body
weight. In order to do this the child will need a reduced
caloric intake and increased activity levels, as well as the
involvement of parents in modeling healthy eating habits.
The process of losing weight will be aided by visiting
frequently with a nutritionist, having parents participate
in the dietary program and exercising regularly.2 Small
changes are easier to implement and more readily
accepted than radical changes to the child’s diet. Healthier
eating should become a part of everyday life instead of
being portrayed as a “diet.” Short-term changes and
quick-fix diets are less likely to be maintained. If a child
is overweight, then the first goal should be to stop gaining
weight or to gain less weight per year.
Here are a few suggestions to help prevent obesity in
children:
 Limit the number of calories consumed in
drinks.
 Limit the amount of milk young children drink.
 Avoid frequent meals of fast food.
 Don’t force children to clean their plates;
instead, allow them to stop eating when full.
 Encourage regular activity.
 Keep children from eating in front of the
television.
 Instead of restricting calories, try to offer
healthy alternatives to sweets.
Summary
Obesity in the pediatric population is more prevalent
than ever before, and studies are beginning to link
increased body mass with OSA in this age group. Obese
children should be screened for snoring and symptoms of
OSA when they present in the clinic. When these children
snore every night and have labored breathing or daytime
sleepiness, they should be referred to a specialist for an
evaluation that will likely require overnight PSG.6 The
primary treatment option is adenotonsillectomy, although
the patient’s medical history or inadequate response
to adenotonsillectomy may indicate that CPAP be used.
Although medical intervention and treatment are necessary
and usually successful, preventive steps should be taken
early in childhood to ensure that OSA is not exacerbated by
an increase in weight due to poor diet and lack of exercise.
References
1. Tauman R, Gozal D. Obesity and obstructive sleep apnea
in children. Paediatr Respir Rev. 2006;7(4):247-259.
Continued on page 22
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Pediatric Obesity and Obstructive Sleep Apnea cont
By Wayne Peacock, RPSGT
http://aappolicy.aappublications.org/cgi/content/full/
pediatrics;109/4/704. Accessed June 21, 2007.
Continued from page 21
2. American Heart Association. Overweight in children.
Available at: http://www.americanheart.org/presenter.
jhtml?identifier=4670. Accessed June 21, 2007.
3. Iannelli V. Symptoms of sleep apnea in children. About.
com Web site. Available at: http://pediatrics.about.com/
cs/sleep/a/sleep_apnea.htm. Accessed June 21, 2007.
4. Lam Y, Chan EYT, Ng DK et al. The correlation among
obesity, apnea-hypopnea index, and tonsil size in
children. Chest. 2006;130:1751-1756. Available
at: http://www.chestjournal.org/cgi/content/
abstract/130/6/1751. Accessed June 21, 2007.
5. American Academy of Sleep Medicine. International
classification of sleep disorders: diagnostic and coding
manual. 2nd ed. Westchester, Ill: American Academy of
Sleep Medicine; 2005.
22
6. Marcus CL. Obese children at risk for obstructive sleep
apnea syndrome. AAP News. 2006;27(9):18.
7. American Academy of Pediatrics. Clinical practice
guideline: diagnosis and management of childhood
obstructive sleep apnea syndrome. Pediatrics.
2002;109(4):704-12. Available at:
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8. American Academy of Sleep Medicine. The AASM manual
for the scoring of sleep and associated events: rules,
terminology and technical specifications. Westchester, Ill:
American Academy of Sleep Medicine; 2007.
9. O’Brien LM, Sitha S, Baur LA Waters KA. Obesity
increases the risk for persisting obstructive sleep
apnea after treatment in children. Int J Pediatr
Otorhinolaryngol. 2006;70(9):1555-60.
Additional Reading
Schechter MS et al. Technical report: diagnosis and
management of childhood obstructive sleep apnea syndrome.
Pediatrics. 2002;109(4):e69.
National Center for Health Statistics. National Health and
Nutrition Examination Survey. CDC Growth Charts: United States.
Available at: http://www.cdc.gov/nchs/about/major/nhanes/
growthcharts/charts.htm. Accessed June 21, 2007.
Wayne Peacock, RPSGT, has been in the sleep field for 10
years, and he currently works as a sleep scoring technologist
for Respironics UK located in Chichester, England.