Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Rania Habib, who is here to discuss obstructive sleep apnea or OSA in children. Dr, Habib, thank you for being here.

Rania Habib: Thank you. It is quite the honor, Bill. I'm very excited to be here with you today and talk to you about a topic that I'm very passionate about.

Bill Klaproth (host): Yes. Dr. Habib, again, so great to have you here. So, let's start with this. What is obstructive sleep apnea or OSA? When we think about this, we generally think about adults, not children. How many children are affected?

Rania Habib: So, the good news, Bill, is that it's very rare. We only see one to five percent of children affected by OSA. But it does take parents by surprise, right? They're not the typical patient. You're thinking about the patient who's maybe overweight or has a really small jaw. And that's who we typically think of as that patient. So, it does surprise parents that the child can be the patient.

What occurs during obstructive sleep apnea is that during sleep, the upper airway can be obstructed by several things. It could be excess tissue, large tonsils or even a large tongue. Also, what can contribute to that problem are the airway muscles. They can relax and collapse during sleep as well as the nasal passages and the actual position of the jaw, primarily the mandible, which is the lower jaw, but it can also be affected by a narrow upper jaw as well. And what happens is the cessation of breathing is what we deem apnea, that's what that term is, is brought about by these factors. There should be an impulse that's actually initiated from the brain to wake the person up just enough to restart that breathing process. And when that doesn't occur, that's when you get that moment where they stop breathing and that's the apnea.

Bill Klaproth (host): So, how is OSA defined? And I'm sure there are different ranges of severity levels to it.

Rania Habib: Yes, there are. So, sleep apnea is generally defined as the presence of more than three apneas during a typical like seven-hour sleep period. In severe cases, however, those periods of not breathing may last for as long as 60 to 90 seconds. And they can sometimes occur up to 500 times a night.

Bill Klaproth (host): Wow. That's really interesting. Earlier, you said we think of children with small airways or children that are overweight who might be susceptible to OSA. So, what are the other factors that causes this?

Rania Habib: So, one is we went back to the small jaws. So, actually in infancy, we can also see it in patients who are born with a sequence called Pierre-Robin sequence. In this sequence, the children are born with a very tiny lower jaw, which is called the mandible, that can be recessed, meaning pushed back. The tongue itself can be pushed up into the palate. And they can also have a cleft palate. And those combined with the musculature, which can be hypotonia, meaning that they're not as effective in that breathing sequence, that can cause obstructive sleep apnea in infants. So, we can see that in syndromic kids as well. So if we see pediatric obstructive sleep apnea in children, as young as infancy, we usually also try to run a genetic test and work with our geneticists to see if there's additional underlying cause.

Bill Klaproth (host): So, now that we've defined OSA in children, what are the symptoms of a child suffering with this? How would a parent know or be cued in, like, "Hmm, maybe there's a problem here?"

Rania Habib: No, that's a really great question. So, during sleep, when that upper airway is obstructed by that excessive tissue that we talked about, that obstruction causes the diaphragm and those chest muscles to work harder. In some patients with that malposition of the jaw or a thick neck or a narrow nasal passage, those can all contribute to the problem.

When you have that cessation of the breathing, which is the apnea portion and that reduction of the airflow, you're going to hear snoring. So, the conditions that most parents will typically see is, one, loud snoring. Number two, they might often wake up abruptly gasping for air. They might be a mouth breather. They might have episodes of bedwetting, difficulty in school. Because if you think about it, if you're not sleeping well, it's going to be very difficult to concentrate the next day when you're sitting in the classroom. Failure to thrive, like poor growth because they have hypotonia or condition that might not be feeding as well. Behavioral issues can be big because when kids don't have the words to form that they're tired, you might see them acting out. So, behavioral issues are big. And then lastly, we also sometimes sadly see poor academic performance because they're falling asleep in class, they can't concentrate and therefore they can't do well. So, sometimes unfortunately the symptoms are quite subtle.

Bill Klaproth (host): Yeah. I was just thinking some of these, you might think of something else right away other than OSA. Poor academic performance, behavior issues, failure to thrive. You might think of other things, not OSA. Parents might think, "Oh, my kid is sleeping fine." Is that fair to say?

Rania Habib: It is, or they're slacking off, right? We've always heard that term. But if it's a pattern that we've seen, we want to investigate it and say what is causing these issues if you've normally seen your child sort of perform at a different level that they're no longer performing at?

Bill Klaproth (host): So in adults, we understand how you do the sleep test to find out ultimately if someone has OSA. How does it work in children?

Rania Habib: So, in children, you still have the same options. They are a lot more difficult, right? Because how can you get a child to sleep in a different center that's not their bed? There are the take-home polysomnography tests, but again, not very accurate because the parent has to run it.

So, we typically look for physical signs and symptoms, so we can look at different X-rays to look at the positioning of the airways themselves. Physical exam is big. If they're cooperative, we can do a little scope down the nose, which is called a nasal endoscopy to look at that.

We will sometimes get our speech therapist or our ENT specialists or a sleep medicine specialist to help with an evaluation as well. And we kind of use all of those tools together to help make the diagnosis.

Bill Klaproth (host): So, when it comes to OSA in children, you were talking about a sleep study. I'm curious when does the OMS come in? And at what time should a parent think about seeking treatment?

Rania Habib: That's an excellent question. So, the infants that are actually in the hospital, we see them pretty early on usually in conjunction with ENT. We want to check their feeding, check their airway, check their jaw. We typically get an X-ray to check for those things and try to figure out the cause of the OSA in the infant to see if it's a surgical problem that we can help with.

In the older children, they're typically brought to the office and we can do the examination there. And we're looking for the physical signs and specific X-ray signs or CT signs that we can help determine is this a surgical issue that we can deal with. Like, for instance, if it's the tonsils, we may refer them to our colleagues in pediatric ENT, because typically when we're seeing kids get the obstructive sleep apnea in maybe that elementary school age, it's typically because the tonsil size relative to the airway size are significantly larger. So, sometimes the issue is the tonsillectomy and we'll refer them to the pediatric ENT. We try to find the source of the problem to determine if it's surgical or if it's an older child that might benefit from a CPAP or an oral device, then we may be able to get them into that if they're compliant, depending on age.

Bill Klaproth (host): So you said infant. I wasn't even thinking infant. I was thinking kids that are five, six, seven or older teenagers. Infant even?

Rania Habib: Yeah. So, in the infants, typically we see number of reasons. But a lot of times these kids are born with a smaller mandible. It can be present in syndromes. It can be part of Pierre-Robin sequence. And when we see that, that's actually a surgical problem that we can help fix. So typically, those infants are infants who can't necessarily feed or might have a supplemental oxygen or may require laying on their stomachs rather than on their backs because they can't breathe, that's relieving the obstruction of the tongue falling forward to open that posterior airway.

So in those kids, we sometimes can offer them surgery if we do determine that the main cause of that obstruction is the size of the lower jaw. And that's a very unique procedure called distraction osteogenesis, where we actually very specifically make cuts in the jawbone to elongate the jawbone. And interestingly enough, we grow bone while we do that. So, it does take anywhere from about three to four weeks. We are very active in that process. We're there every day. And we do it to the point that the child is now breathing on their own. They're no longer needing a feeding tube. We distract a little bit more because there's always a little bit of relapse and we try to account for that, but we do that in the extreme cases where we want to try to avoid the breathing tube through the trachea, so that the child is not going home with a trach.

Bill Klaproth (host): Absolutely. So, what are some of the other treatment options available then for children who are older?

Rania Habib: So, the older children, if they've reached skeletal maturity, we can sometimes consider jaw surgery, which is orthognathic surgery. Something that oral and maxillofacial surgeons are actually experts in. And sometimes moving that jaw forward is exactly what they need to open those airways and make them able to breathe better. But we're also making sure that we're harmonizing the face all at the same time. So, the teeth are fitting together, we're making sure that all of their facial structures are harmonized and that's really great. So, that's the added benefit.

And we also do that surgery through the mouth, which is great. So, there's no scars on the outside of the face. We can work with a sleep specialist to get them into a CPAP if they're old enough to tolerate that or, you know, they may need a referral to an ENT, as I mentioned earlier, to look at potentially getting tonsils or adenoids out depending on where the source of the problem is.

Bill Klaproth (host): So, even with children, when we talk about sleep hygiene with adults, does that apply as well?

Rania Habib: It can. So, we talk about creating that wonderful sleep environment, right? So, limiting screen time, we want to try to make sure that we're winding down. Removing sources of distraction within the room, so you can get rid of TVs, imagine that. Temperature's a big deal. So, if you look at certain studies within the sleep community, taking the temperature colder around 68 degrees has been deemed one of the ideal temperatures for sleep, interestingly enough. Not giving water before sleep, so that you're not getting up in the middle of the night. So, small little things to increase sleep hygiene can really help.

Bill Klaproth (host): Yeah. And the preteens and teens that have phones, right? Getting those devices out of their hands, so they're not scrolling or looking right before bedtime as well.

Rania Habib: Sleep mode needs to be put on and go to sleep.

Bill Klaproth (host): Yeah. So as we wrap up talking about this, Dr. Habib, and thank you so much for your time, any additional thoughts you want to add?

Rania Habib: I would just say, you know, if you have a child or a spouse or a loved one that you do think might be suffering from obstructive sleep apnea, whether it's a pediatric or adult patient, definitely seek out an oral and maxillofacial surgeon, an ENT or a sleep apnea specialist, because it sometimes is a life-changing experience to get rid of that OSA that can be causing a lot of other problems. So, we're really advocates for making sure that patients are getting treated for obstructive sleep apnea.

Bill Klaproth (host): And the earlier the better, as you said. Some parents might think, "Oh, my child is sleeping fine, but maybe not," and that really can be detrimental as they grow up. That's for sure. Yeah. Well, Dr. Habib, thank you so much for your time. This has been a pleasure.

Rania Habib: Thank you so much, Bill. This was wonderful. Thank you.

Bill Klaproth (host): Once again, that is Dr. Rania Habib. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast to be interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.