Rob Steele, MD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode, and you can do so by visiting cmkc.link/CMEpodcast.

And then click the claim CME button. Today, we are joined by Dr. Zarmina Ehsan to discuss pediatric sleep apnea. Dr. Ehsan is a Pediatric Pulmonologist and Sleep Medicine Physician at Children's Mercy Kansas City and an Associate Professor of Pediatrics at UMKC. She holds several roles within the American Thoracic Society and American Academy of Sleep Medicine.

And Dr. Ehsan has published guidelines focusing on obstructive sleep apnea in children and has been an invited speaker on this topic at national and international meetings over the past years. Dr. Ehsan, thank you so much for joining us today.

Zarmina Ehsan, MD: Thank you so much for having me, Dr. Steele.

Host: And rumor has it, you've taken up sourdough bread making. Is that true?

Zarmina Ehsan, MD: Yes, yes, it is. We decided we didn't want to pay the six dollars you know, a bowl for the bread, but to be honest, it's taking me so much time making it that now we're making the bread.

Host: So I'm a pasta guy. I make pasta uh, you know, usually on Sundays and that actually, I've gotten it down to a relative size. I eat, the bread is it's fairly time consuming and you could kind of get into the, you know, which yeast you use. I mean, you can really kind of get real wonky about it. So I, sometimes maybe it's easier to pay the 6 dollars.

Zarmina Ehsan, MD: Oh my gosh. I think it is because with sourdough, you grow the yeast, you know, so it's growing on my counter. And I'm always worried it's gonna, you know, you have to keep it alive, so it doesn't die off. And so, yeah, it's quite, it's quite the effort at this point, but it's worth it. It's worth it.

Host: Great. Well, let's jump into it and get into uh, sleep apnea in the pediatric population. Can you discuss some of the causes and presentations that you see in sleep apnea, specifically in pediatrics?

Zarmina Ehsan, MD: Yeah. So, the overall prevalence of sleep apnea is between one and 5%. But this is higher in kids with medical complexities. And as we evolve in terms of medical care and just survival of kids, we are seeing more and more kids who are medically complex.

And so that percentage is much, much higher, the prevalence is higher in kids with complexities. And so these are kids with genetic syndromes or craniofacial syndromes, or, brain abnormalities, anything that can make it harder for the air to go into your lungs. And so, what sleep apnea is, is basically a disorder during sleep.

It's a breathing disorder that happens when you sleep. And the way I like to simplify it the causes are anything that can make it harder for the air from the outside world to go into the lungs. And that's how I explain it to families. So, if you have a nose deformity, a congenital deformity of your face where there's obstruction to your upper airway, then the air can't get in.

If you have swelling at the back of your airway, so tonsils can do that. So masses, tonsils, most commonly adenoids, both of those things can obstruct the airway. A large tongue with kids who have genetic syndromes, they can have larger tongues. Again, those kind of cramp up that space and so the air can't get in and you have apneas during sleep.

Then if there's something different about the bone, the bony confines of your face. So again, craniofacial deformities with a small jaw, a small maxilla, which is the nasal aspect those can also cause sleep apnea. And so what happens is when you're awake, you have your brain, your cognitive brain engaged, and you can take those deeper breaths.

But when you go to sleep, all your muscles relax and you already have some sort of medical condition that may predispose you. And so everything relaxes and that's what predisposes you to having those pauses in your breathing, the oxygen levels going down, and just disrupted sleep from that. And so that's really how I like to talk about sleep apnea.

Host: Yeah. So, you know, I think you bring up a really great point because for many, particularly in the lay public are going to think, well, sleep apnea is a function of obesity, which of course, I imagine that is true in the pediatric population too, but your point with regard to those with congenital defects or for other more genomic reasons there may be a higher predisposition to sleep apnea. Is that a fair statement?

Zarmina Ehsan, MD: Yes, exactly. And then, so we do see obese adolescents, for example, who are at risk of sleep apnea, and we call that the adult phenotype because in adults, you're absolutely right. You know, obese adults are what the typical risk factor is for sleep apnea when you look at older adults.

Host: Yeah. Great. Well, so, for the primary care pediatrician who are largely our audience here, what is your advice with respect to how do they go about evaluating whether one, this might be an issue and then two what to do about it?

Zarmina Ehsan, MD: So things to look for in the history would be if the parent is saying that the child is snoring or having pauses in breathing when they sleep. So those are the nighttime symptoms. Or just disrupted sleep. And this can change as kids get older. So the younger kids, they typically have a baby camera monitor or parents are keeping them close. So they know whether they're snoring or not. As they get older, the teenage years, or they're sleeping separately, that history is really hard to know because the child themselves you don't hear yourself snoring. And so somebody else hears you to know that. And so for the older kids, I say, if they have daytime disturbances. And again, adults with sleep apnea will be sleepy during the day. Kids with sleep apnea, who have had disrupted sleep at night, may be the opposite.

So they're hyperactive. They're not staying on task. They may be sleepy in circumstances where you wouldn't expect them to be. Short car rides. I always ask families, if you're going to the grocery store, and your child is falling asleep in the car, or if they're missing out on events.

Okay. So if they're, there's a birthday party and they'd rather sleep, or there's something else fun going on and they'd rather be asleep; that's a problem. Parents will often say, well, they're just bored. For kids, the last thing they're going to do is sleep. Okay. So if they're bored, you know, they do anything but sleep.

And so you know, it's different with them. And so those are your signs. Again, for an on exam, if they have big tonsils, big adenoids, adenoids are difficult to see when, for any general pediatrician's office, but they have big tonsils, or they have other genetic conditions or craniofacial conditions, again, if you think about it, that predispose them to that air, that upper airway obstruction, or that hindrance to the air going into their lungs; those would be your kids who would need a referral to get a sleep study, which is the test that we do to evaluate for sleep apnea.

Host: Yeah, great. So, you bring up some really great pearls of wisdom there. You're exactly right. I mean as kids go, if there's fun to be had they're generally having fun, right? And if they're choosing something else, then you have to ask the question as to why. So, I think that's a really good pearl there.

So, as, that patient then gets evaluated and in fact does have some form of sleep apnea. Maybe you could talk about sort of the continuum of severity of that and then what are the treatment options? What are those possibilities that we pursue?

Zarmina Ehsan, MD: Yeah. So, for sleep apnea, there's two broad categories. There's central sleep apnea, where there's a delay in the signal from the brain telling you to breathe. And more commonly, we know as sleep apnea as we know it is obstructive sleep apnea. Again, and causing apneas, there's an obstruction in the airway causing the apneas.

On the sleep study, there's different criteria to classify this into mild, moderate, and severe. For mild sleep apnea, if you don't have daytime symptoms of sleepiness or inattention and so forth, you know, for most kids we treat with, we call it medical management. So intranasal steroids for six months and see if things improve.

Now, the caveat here is if you have mild sleep apnea and you're falling asleep in class, can't get through the day, or an older teenager who can't get through the day, then sometimes we'll need those other treatment options, like continuous positive airway pressure or CPAP, which we more traditionally use for worse sleep apnea.

We may still need it for mild sleep apnea if there's a lot of daytime problems. So for moderate or severe sleep apnea, treatment options are if they have big tonsils or adenoids; they go to get those taken out. Okay. So you see an ENT surgeon. If the family is reluctant, does not desire surgery or for some reason they just, they want to just hold off on that, then the next best step would be CPAP, which is wearing a mask attached to a machine.

They wear it every night. And, for severe sleep apnea, it's the same. So what I tell families is, sleep apnea, if you have large tonsils and adenoids, this is potentially curable where you get surgery and you would be cured. So, I like to recommend that as a first step.

And then if you still have sleep apnea, despite getting surgery, then we can look at the plan B, which is CPAP. Now I will say here, some kids, will need CPAP, even if they're going to get surgery for their tonsils and adenoids. So if you're morbidly obese, okay, outcomes from surgery are not as good.

So if your sleep apnea is very, very severe, a lot of times the ear, nose and throat surgeons will ask you to start CPAP while you wait to get surgery. If for some reason the wait to get your tonsils out is six months, then, then we start your CPAP right away while you wait to get surgery. So there's some nuances with next steps in terms of treatment, but broad categories are medicine, which is a nasal steroid to decrease the size of your adenoids or getting surgery for your adenoids or tonsils or using CPAP.

Then we get into other options beyond CPAP. There's hypoglossal nerve stimulators, which we are now using in, older teens with trisomy 21, for example. So it's a pacemaker for your tongue. It kind of moves the tongue forward during sleep and so it prevents that obstruction. This is being used widely in adults, but we're now more commonly using it in older teens. So 16 or above for trisomy 21. It hasn't quite we're not quite using it for otherwise healthy older teens yet, but, that is the population. Other options such as other types of surgery. So if you have a very small jaw then is that something that can be done as an older teen to treat your sleep apnea?

So there's some other treatment options out there. Those are discussions that are typically had once you're, in the sleep clinic and talking about next steps.

Host: So, you know, obviously um, quite a few options from which to choose all depending on exactly the patient severity and all those. Can you give our listeners a sense of, what happens if it's untreated, if it's unrecognized and what are the short and long term. You've talked a little bit about short term problems with untreated sleep apnea. What about long term?

Zarmina Ehsan, MD: That's a great question, and families will often ask that. We know from data in adults, we know data from children, but there's more robust data in adults. There's just more large scale trials done that it can affect any organ system of your body. So from a cardiovascular standpoint, high blood pressure is most common, you know, other cardiovascular events.

Again, if you're nine years old and you have severe sleep apnea, you have a long ways to go till your 40, 50, 60. And so all these years of untreated sleep apnea and the stress it will place on your heart, the brain, okay. Stroke, other sort of impact on the brain, then metabolic. So diabetes. Remember what's happening in your sleep is your oxygen levels are going down and your heart starts beating faster. Your brain wakes up, okay. Your brain wakes up to tell you that, to breathe. That's what it's supposed to do. So now you're getting disrupted sleep. Every time your brain is waking up, you have changes in EEG, you have changes in heart rate. Where in general, you know, in layman's terms, your body is supposed to rest when it's sleeping. Everything kind of shuts down. And so in, with severe sleep apnea, it's working over time. So over the course of decades here, we're, we're seeing, you know, could this impact, high blood pressure when they're young adults, stroke risk and all those sorts of things, neurocognitive development.

So those are the, like, the types of discussions that I have with my patients.

Host: Yeah, great. And then now we've made interventions and patient seems to be doing well. How do you monitor this over the long term? Is it something that you're expecting that interventions are going to be required for a very long time. And at what point do you start looking at discontinuing those interventions, if at all?

Zarmina Ehsan, MD: So if they have mild sleep apnea, we like to follow them in the clinic and see if daytime symptoms are better or nighttime, the snoring is resolved. And if it isn't at that point, at the six month mark, we talk about getting another sleep study to see objectively where things are.

If they have moderate or severe sleep apnea and they get their tonsils or adenoids taken out, then we do recommend getting a repeat sleep study to get that objective measure of where things are within about three to six months. And if they still have sleep apnea at that point, point, it's called persistent sleep apnea.

So you've gotten your adenoids and tonsils out, you still have sleep apnea. Then we talk about options such as CPAP. Again some of this will depend on the reason they have the sleep apnea. So kids with genetic abnormalities and differences, you know, if they have sleep apnea, they may need treatment long term.

So this is years and years. If this is an obese adolescent who loses weight, then their CPAP need may just be transient because their sleep apnea, if it's related to the weight, once they lose all that weight, the sleep apnea may go away. So some of this will depend on the other comorbidities of the child.

Host: Very good. Well, Dr. Ehsan, thank you so much for imparting your wisdom on this important topic. It's been very enlightening and you've given a lot of information in a short amount of time, which is awesome. So, thank you again. The only question I'll have is if I need to borrow some yeast to get started on my own sourdough, can I give you a call?

Cause uh, you know starting it all from scratch is always a challenge and I, my understanding is you can share the yeast a little bit to get it started.

Zarmina Ehsan, MD: Yes, for sure. Absolutely. And you can make good pasta with sourdough starter as well. So in case you want to go that route.

Host: Okay. All right. Good to know. Very good. Well, thank you again for joining us today. As a reminder, claim your CME credit for listening to our show today.

Visit cmkc.link/CMEpodcast, and then click the claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. I'm Dr. Rob Steele. See you next time.