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Sleep Apnea in Down Syndrome Children
Harry Yuan, DO discusses sleep apnea in children with Down syndrome. He reviews the pathophysiology and diagnostic criteria of obstructive sleep apnea in children. He highlights the risk factors, shares traditional treatments, and new approaches to obstructive sleep apnea in children with Down syndrome.
Featuring:
Harry Yuan, DO
Dr. Harry Yuan is a board-certified pediatric pulmonologist and sleep physician. He received his doctor of osteopathic medicine degree from Western University of Health Sciences. He completed his pediatric residency at Children’s Hospital of Michigan and his pulmonary/sleep fellowship at Children’s Hospital Los Angeles.
Transcription:
Melanie Cole, MS (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we’re discussing sleep apnea in children with Downs syndrome. Joining me is Dr. Harry Yuan. He’s a pediatric pulmonologist and a sleep medicine physician at the Carle Foundation Hospital. Dr. Yuan, it’s a pleasure to have you with us. What an interesting topic. Why do individuals with Down syndrome have a higher incidence of obstructive sleep apnea. Tell us a little bit about the prevalence of this.
Harry Yuan, DO (Guest): Thank you for inviting me Melanie. Obstructive sleep apnea is a sleep condition in which a person has difficulty breathing during sleep. Most of the time it is due to either a narrowing or an obstruction of the upper airway. The reason this condition is more common in children with Down syndrome is because of several reasons. One that they have a depressed nasal bridge, and two, they tend to have decrease muscle tone which makes the airway integrity less and the airway leading to airway floppiness.
Host: Well then tell us some of the complications of untreated sleep apnea. Does it lead to significant morbidity in patients with Down syndrome? What have you seen as far as if it’s left untreated?
Dr. Yuan: So in general obstructive sleep apnea should be treated because there are studies that show that it can lead to several different types of comorbidities. So, for example, there are numerous studies that show that untreated obstructive sleep apnea can lead to atherosclerosis, can lead to right-sided heart failure, can lead to diabetes, can lead to weight gain. There's some recent studies that show that it can even lead to earlier onset of Alzheimer’s disease.
Host: Are there certain risk factors, Dr. Yuan, that would let us know what children might be at more risk than others?
Dr. Yuan: So risk factors for obstructive sleep apnea in children are very similar to those that we see commonly with adults. So, for example, being overweight, especially for patients that have an increased neck circumference increases the risk of having obstructive sleep apnea. I mentioned earlier about patients with decreased muscle tone as a risk factor. In children oftentimes when the airway is obstructed due to either large adenoids or tonsils, that by itself can increase the risk of obstructive sleep apnea. Lastly for kids that have a mandibular retraction, that retracted lower jaw can also decrease the size of the airway making it more likely for them to develop obstructive sleep apnea as well.
Host: Well then Dr. Yuan, let’s talk about symptoms. As you're telling us symptoms of sleep anomalies that sleep abnormalities that parents might notice. Because the signs and symptoms don’t often correlate with disease, do you believe, in your own opinion, that children and adults with Down syndrome should receive routine screening for obstructive sleep apnea? If so, what does that look like?
Dr. Yuan: Well even though Down syndrome is the most common congenital condition in children, the severity of Down syndrome can vary quite a bit. So in my experience, I have seen Down syndrome children who are not as physically debilitated as other kids with Down syndrome. In general, the symptoms that parents can watch for that may suggest the child having obstructive sleep apnea would be the presence of snoring, the presence of gasping or apneic episodes during sleep, the preference for sleeping prone rather than supine. And daytime symptoms such as sleepiness during the day for older kids or in younger kids would be more behavioral issues such as hyperactivity or moodiness during the day.
Host: So then let’s talk about the diagnostic criteria? Can it be diagnosed? Can obstructive sleep apnea be diagnosed in children with Down syndrome based on signs and symptoms alone or is a sleep study recommended?
Dr. Yuan: In all children, not just those with Down syndrome, the diagnosis of sleep apnea does require a sleep study. Unfortunately at this time there is no home sleep study that has shown to be reliable or valid to make such a diagnosis in children, which means that all sleep studies at this time require a patient’s presence to be in the sleep lab at night. A diagnosis of obstructive sleep apnea does require a sleep study, and it is passed on a calculation called the apnea hypopnea index that determines not just the presence or absence of this condition but can also tell us the severity of this condition as well.
Host: Then let’s talk about treatment options that are available. Tell us a little bit about some of the traditional treatments and new approaches to obstructive sleep apnea in children with Down syndrome. Tell us a little bit about that.
Dr. Yuan: So the more traditional treatments for obstructive sleep apnea in children are first and foremost whether the child has enlarged tonsils or adenoids that can be removed to widen the airway. That is one of the differences between treatment for obstructive sleep apnea in children versus treatment for obstructive sleep apnea in adults. Aside from tonsillectomy and adenoidectomy, the other alternative treatments can be a CPAP or BiPAP machine, which unfortunately many children may not tolerate very well. If a child has mild obstructive sleep apnea, another possible alternative is the use of supplemental oxygen rather than a PAP machine for sleep. Lastly, there were a few studies that came out several years ago—one specifically from Boston Children’s—looking at obstructive sleep apnea in Down syndrome children. They have found that if the obstructive sleep apnea is mild that many of these children may actually outgrow the condition within 12 months. So one of the possible treatments specifically for obstructive sleep apnea in Down syndrome children is to do nothing and just monitor and repeat another study in 12 months to determine whether the condition is still present.
Host: That’s so interesting. If you are attempting to use CPAP, what about adherence? That’s got to be tough in this situation.
Dr. Yuan: It is. There's studies that show even with adults using CPAP for sleep apnea that the adherence is not great. In children, the studies show that the adherence rate is even lower. I do tend to try CPAP for certain patients if I feel like there are no other options that are appropriate. Usually in children, CPAP is one of the last treatments we use for obstructive sleep apnea as opposed to being the first treatment with adults.
Host: Yes, that’s what I found interesting as well. Dr. Yuan, as we wrap up please let the listeners know what the take home message is in sleep apnea in children with Down syndrome and what you’d like them to know about the newest, latest treatments and why it’s so important to refer.
Dr. Yuan: Well, for closing remarks I just want to mention that when providers see a patient with Down syndrome to please screen for sleep conditions. So it would only involve asking a few questions about their sleep, whether they snore at night, whether they feel like they had a restful night sleep, whether they have any daytime issues. If the patient does present with any of these concerns that they should be referred to a sleep specialist to be screened for obstructive sleep apnea. To also stress to the families that it is not necessarily a lifelong condition for these patients, but it may be very important to find out whether they have it and whether it needs to be treated or not.
Host: Well it’s so important. Thank you so much, Dr. Yuan, for joining us today and sharing your expertise. What an interesting topic. Thank you, again, and that concludes this episode of Expert Insights with the Carle Foundation hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.
Melanie Cole, MS (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we’re discussing sleep apnea in children with Downs syndrome. Joining me is Dr. Harry Yuan. He’s a pediatric pulmonologist and a sleep medicine physician at the Carle Foundation Hospital. Dr. Yuan, it’s a pleasure to have you with us. What an interesting topic. Why do individuals with Down syndrome have a higher incidence of obstructive sleep apnea. Tell us a little bit about the prevalence of this.
Harry Yuan, DO (Guest): Thank you for inviting me Melanie. Obstructive sleep apnea is a sleep condition in which a person has difficulty breathing during sleep. Most of the time it is due to either a narrowing or an obstruction of the upper airway. The reason this condition is more common in children with Down syndrome is because of several reasons. One that they have a depressed nasal bridge, and two, they tend to have decrease muscle tone which makes the airway integrity less and the airway leading to airway floppiness.
Host: Well then tell us some of the complications of untreated sleep apnea. Does it lead to significant morbidity in patients with Down syndrome? What have you seen as far as if it’s left untreated?
Dr. Yuan: So in general obstructive sleep apnea should be treated because there are studies that show that it can lead to several different types of comorbidities. So, for example, there are numerous studies that show that untreated obstructive sleep apnea can lead to atherosclerosis, can lead to right-sided heart failure, can lead to diabetes, can lead to weight gain. There's some recent studies that show that it can even lead to earlier onset of Alzheimer’s disease.
Host: Are there certain risk factors, Dr. Yuan, that would let us know what children might be at more risk than others?
Dr. Yuan: So risk factors for obstructive sleep apnea in children are very similar to those that we see commonly with adults. So, for example, being overweight, especially for patients that have an increased neck circumference increases the risk of having obstructive sleep apnea. I mentioned earlier about patients with decreased muscle tone as a risk factor. In children oftentimes when the airway is obstructed due to either large adenoids or tonsils, that by itself can increase the risk of obstructive sleep apnea. Lastly for kids that have a mandibular retraction, that retracted lower jaw can also decrease the size of the airway making it more likely for them to develop obstructive sleep apnea as well.
Host: Well then Dr. Yuan, let’s talk about symptoms. As you're telling us symptoms of sleep anomalies that sleep abnormalities that parents might notice. Because the signs and symptoms don’t often correlate with disease, do you believe, in your own opinion, that children and adults with Down syndrome should receive routine screening for obstructive sleep apnea? If so, what does that look like?
Dr. Yuan: Well even though Down syndrome is the most common congenital condition in children, the severity of Down syndrome can vary quite a bit. So in my experience, I have seen Down syndrome children who are not as physically debilitated as other kids with Down syndrome. In general, the symptoms that parents can watch for that may suggest the child having obstructive sleep apnea would be the presence of snoring, the presence of gasping or apneic episodes during sleep, the preference for sleeping prone rather than supine. And daytime symptoms such as sleepiness during the day for older kids or in younger kids would be more behavioral issues such as hyperactivity or moodiness during the day.
Host: So then let’s talk about the diagnostic criteria? Can it be diagnosed? Can obstructive sleep apnea be diagnosed in children with Down syndrome based on signs and symptoms alone or is a sleep study recommended?
Dr. Yuan: In all children, not just those with Down syndrome, the diagnosis of sleep apnea does require a sleep study. Unfortunately at this time there is no home sleep study that has shown to be reliable or valid to make such a diagnosis in children, which means that all sleep studies at this time require a patient’s presence to be in the sleep lab at night. A diagnosis of obstructive sleep apnea does require a sleep study, and it is passed on a calculation called the apnea hypopnea index that determines not just the presence or absence of this condition but can also tell us the severity of this condition as well.
Host: Then let’s talk about treatment options that are available. Tell us a little bit about some of the traditional treatments and new approaches to obstructive sleep apnea in children with Down syndrome. Tell us a little bit about that.
Dr. Yuan: So the more traditional treatments for obstructive sleep apnea in children are first and foremost whether the child has enlarged tonsils or adenoids that can be removed to widen the airway. That is one of the differences between treatment for obstructive sleep apnea in children versus treatment for obstructive sleep apnea in adults. Aside from tonsillectomy and adenoidectomy, the other alternative treatments can be a CPAP or BiPAP machine, which unfortunately many children may not tolerate very well. If a child has mild obstructive sleep apnea, another possible alternative is the use of supplemental oxygen rather than a PAP machine for sleep. Lastly, there were a few studies that came out several years ago—one specifically from Boston Children’s—looking at obstructive sleep apnea in Down syndrome children. They have found that if the obstructive sleep apnea is mild that many of these children may actually outgrow the condition within 12 months. So one of the possible treatments specifically for obstructive sleep apnea in Down syndrome children is to do nothing and just monitor and repeat another study in 12 months to determine whether the condition is still present.
Host: That’s so interesting. If you are attempting to use CPAP, what about adherence? That’s got to be tough in this situation.
Dr. Yuan: It is. There's studies that show even with adults using CPAP for sleep apnea that the adherence is not great. In children, the studies show that the adherence rate is even lower. I do tend to try CPAP for certain patients if I feel like there are no other options that are appropriate. Usually in children, CPAP is one of the last treatments we use for obstructive sleep apnea as opposed to being the first treatment with adults.
Host: Yes, that’s what I found interesting as well. Dr. Yuan, as we wrap up please let the listeners know what the take home message is in sleep apnea in children with Down syndrome and what you’d like them to know about the newest, latest treatments and why it’s so important to refer.
Dr. Yuan: Well, for closing remarks I just want to mention that when providers see a patient with Down syndrome to please screen for sleep conditions. So it would only involve asking a few questions about their sleep, whether they snore at night, whether they feel like they had a restful night sleep, whether they have any daytime issues. If the patient does present with any of these concerns that they should be referred to a sleep specialist to be screened for obstructive sleep apnea. To also stress to the families that it is not necessarily a lifelong condition for these patients, but it may be very important to find out whether they have it and whether it needs to be treated or not.
Host: Well it’s so important. Thank you so much, Dr. Yuan, for joining us today and sharing your expertise. What an interesting topic. Thank you, again, and that concludes this episode of Expert Insights with the Carle Foundation hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.