OSA represents ‘prevalent and impactful sleep disorder’ in children

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Healio interviews

disclosures:
Gipson, Okorie and Sullivan report no relevant financial disclosures.

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A SLEEP session on pediatric sleep medicine, intended for technologists, aimed to help these professionals “deliver top quality care to even the youngest patients,” the session chair said.

“While anyone interested in pediatric sleep medicine can learn from the lecture, the session was part of a series of lectures aimed at training sleep technologists. These are the professionals who help support patients and sleep labs by conducting nighttime, daytime, and home sleep studies designed to diagnose sleep disorders,” Caroline Okorie, MD, MPH, clinical assistant professor of pediatric pulmonary and sleep medicine and associate program director of the pediatric residency program at Stanford Children’s Hospital, Healio told Neurology. “They work closely with patients in these settings, so this session was designed to provide more background and knowledge not only about obstructive sleep apnea in pediatric patients, but also about potential new therapies and diagnostic studies related to OSA in this population. “

A better understanding of clinical principles has been shown to help these professionals “continue to deliver top quality care to even the youngest patients,” Okorie said.

“These sessions at the annual SLEEP meeting are specially curated for our polysomnographic technologist colleagues, but I’ve found that they are often great sessions for doctors and other sleep therapists as well,” Kevin Gipson, MD, MS, pediatric pulmonologist and sleep physician at Massachusetts General Hospital and instructor at Harvard Medical School, Healio told Neurology.

Caroline Okorie

Gipson and Shannon Sullivan, MD, clinical professor of pediatrics – pulmonary medicine at Stanford University, presented during the session that Okorie chaired. Healio Neurology spoke to them to learn more about the findings they discussed.

Healio Neurology: Can you give an overview of your lecture?

Gypsy: Obstructive sleep apnea in children is a common and profound sleep disorder in childhood. While clinicians and researchers in pediatric sleep have known for decades that OSA can negatively impact the health, behavior, and cognitive development of our pediatric patients, it often amazes me how little understanding and awareness there is in the wider medical community. So much has changed in recent years in the way we approach pediatric OSA: we now better understand the often nuanced ways in which undetected and untreated (or undertreated) OSA can negatively impact health, behavior and learning in children. Our diagnostic tools and statistics have advanced rapidly and are more attuned to the dynamic nature of sleep-breathing disorders in children. Our treatments have evolved beyond just “adenotonsillectomies for all” to be more tailored to the needs of each patient. We have also begun to better integrate preventive medical strategies into children’s sleep, recognizing that OSA can develop over time in infants and children with certain, often subtle, risk factors.

Sullivan: My lecture was “Alternatives to Laboratory Tests in Pediatrics: Sleep Apnea Tests at Home.” The lecture had three objectives: first, the position of the American Academy of Sleep Medicine on the use of home sleep apnea tests (HSATs) for children; second, a review of recent studies and research on the potential use of HSATs in children; and third, discussion of limitations and potential uses of HSATs in pediatrics. This is a striking area as the COVID-19 pandemic is in many ways pediatric sleep providers has forced creative ways to meet the needs of their patients.

Kevin Gipson

Healio Neurology: what were the groceries for the home?

Gypsy: Since our audience was a group of highly trained sleep technologists and general sleep professionals, my first goal was to convey how common and important OSA is to children’s health and development. Pediatrics is a wonderful field because we can achieve so much for an individual’s longitudinal health simply by being aware of the risk factors and the earliest manifestations of illness in childhood. Better awareness of this sleep disorder is key to early interventions, which can meaningfully change health trajectories. I truly believe that we can prevent important health consequences by treating OSA and its causes early.

In addition to this core message of awareness and early intervention, we discussed important nuances in pediatric polysomnography and in important newer diagnostic tools, including computer-aided event detection, home sleep apnea testing, and sleep endoscopy. We also reviewed gold standard OSA management, including adenotonsillectomy and positive airway pressure therapy, and discussed emerging medical, orthodontic, and surgical adjunctive treatments. In particular, the treatment of pediatric OSA has become a multidisciplinary endeavor, involving pediatric sleep physicians and technologists, ENTs, oral and maxillofacial surgeons, orthodontists, and others, and I tried to emphasize this need for collaboration in our talk.

Sullivan: The AASM published a position paper on the use of HSATs in children in 2017, stating that the use of a home sleep test is not recommended for diagnosing sleep apnea in children. However, the paper also noted that the final judgment on any specific concern should be made by the physician in light of the circumstances, available diagnostic tools, and accessible resources.

Shannon Sullivan

Studies remain small and are not usually non-randomized, but a framework of incremental evidence is emerging for the use of HSAT in certain situations in children.

The suitability of HSATs in children varies with age, presentation, and circumstance. After all, I think of pediatrics as ‘a life in a lifetime’. For example, the needs and presentation of a 16 year old are very different from a 2 year old, we should not think about that in the same way when it comes to sleep apnea testing.

There are legitimate concerns about the use of HSAT in children, ranging from limited data availability, insufficient sensitivity, feasibility and safety concerns, and insufficient validation compared to in-lab studies. That said, even in-lab polysomnography is imperfect — and very expensive. In-lab polysomnography can be hampered by inequalities in access, first night effects and night to night variability, and early morning study termination, leading to missing the important last REM sleep period. Research also shows that up to three-quarters of children with mostly public insurance who are referred to in-lab polysomnography are lost to follow-up.

Healio Neurology: How did the COVID-19 pandemic affecting your reading?

Gypsy: It’s a commonplace right now to say that the COVID-19 pandemic has affected virtually every aspect of pediatric sleep care, including our diagnostic tests and treatments. While our pediatric sleep labs and technologists have done a heroic job in adapting and overcoming the challenges of this pandemic, and in fact have maintained the highest level of safety for our patients and their families undergoing sleep studies in labs, the question of a potential The role of home sleep apnea testing and automatic titration of positive airway pressure modalities in pediatrics has been brought into sharper focus by the pandemic.

Sullivan: Due to infection control and safety concerns, redistribution of staff and increasing disparities, the pandemic has further limited an already limited resource: available beds in pediatric sleep labs. This statement of the “ultimate judgment” has therefore aroused renewed interest. I covered this in an editorial published in the Journal of Clinical Sleep Medicine.

Healio Neurology: How has your session helped sleep medicine practitioners working in pediatrics?

Gypsy: Pediatric sleep remains an underexposed subspecialty; so many children receive their sleep care from clinicians with significant background and practice orientation in adult sleep medicine. A common aphorism in pediatrics is that “Children are not just little adults.” Helping technologists and sleep physician colleagues stay current in this rapidly evolving field of care is important. What we do or don’t do in treating pediatric OSAS has the potential for important longitudinal effects on the development and health of a child or adolescent, so much is at stake. I hope our session has helped in some small way to improve care for pediatric patients with OSA and to raise awareness of the impact of OSA on the health and development of pediatric patients and its special potential for proactive and preventive care.

Sullivan: Hopefully, the session helped keep sleep practitioners informed about recent research on the feasibility, validity, and reproducibility of HSATs in certain pediatric populations. While HSATs have not yet been extensively or definitively validated in children, they may be reasonable to use in certain well-defined circumstances, provided that if the HSAT does not meet expectations, it can be followed by in-lab testing if necessary. The FDA has approved a number of HSAT devices for use in certain age groups. In addition, emerging technologies in this space can be useful; this was also discussed in the presentation. Ultimately, however, technology cannot replace the need for clinical judgment.

References:

Okorie C, et al. Pediatrics Update. Presented on: SLEEP; June 10-13, 2021 (virtual meeting).

Sullivan S, et al. J. Clin. Sleep Med. 2021;doi:10.5664/jcsm.9068.

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