Obstructive sleep apnea (OSA), a highly prevalent condition in children, affecting nearly 1% to 5% of all children1,2 is associated with significant morbidity during childhood. Further, childhood OSA is associated with increased health care burden and utilization accounting for heightened societal costs.3 Prompt treatment of children with OSA including adenotonsillectomy (AT)4,5 is imperative to ensure the well-being of the child.
The potential dangers of untreated OSA in children includes a multitude of physiological derangements including systemic inflammation,6 metabolic disease,7,8 cardiovascular disease,9 and recent evidence suggesting poor asthma control in asthmatic children.10 In addition, and of particular relevance to the new study by Ishman and colleagues11 in this issue of the Journal of Clinical Sleep Medicine, surgical treatment of OSA, namely adenotonsillectomy (AT), confers a greater anesthesia risk than non-OSA indications of AT, including recurrent tonsillitis, or recurrent adenoiditis.12 Given the cumulative risks associated with childhood OSA, it is plausible that the presence of OSA in children amounts to a greater risk to all surgical procedures in children.
Ishman and colleagues address specifically whether pediatric anesthesiologists, prior to ANY operative procedure, routinely conduct screening for OSA. In their study, they observed anesthesiologists during their preoperative assessment of 101 consecutive children. At the time, anesthesiologists were not aware that they were being observed. The findings of the study reveal that despite the significant aforementioned health and potential operative risks of OSA, anesthesiologists only screened for OSA in 37% of children, a rather disheartening statistic. In addition, application of the OSA-18 questionnaire to parents revealed a relatively high OSA-18 score, particularly in patients undergoing AT, and that despite relatively high OSA-18 scores, anesthesiologists frequently failed to screen for OSA. The authors report that in only AT procedures or children with a known history of OSA were anesthesiologists more likely to screen for OSA. Neither the OSA-18 score nor an otolaryngology surgical procedure was significantly associated with the likelihood of screening. Taken together, the findings suggest that in the vast majority of operative procedures in children, screening for OSA is not routinely conducted.
Prior to drawing a conclusion, it is important to recognize that methods to screen for OSA are rather ineffective. History and physical examination often fail to reliably diagnose OSA in children.13,14 The utility of screening questionnaires has also recently come into question. In fact, the authors themselves had recently published that the OSA-18 questionnaire they used in this study is fraught with poor sensitivity and specificity in sufficiently diagnosing OSA in children.15 This then begs the question: should anesthesiologists even screen for OSA during the preoperative assessment if screening is ineffective compared to polysomnography, the gold standard of diagnosis of OSA in children?
Notwithstanding, given the potential risks of intraoperative and postoperative complications in children with OSA, the lack of routine screening by anesthesiologists does suggest a lack of awareness of the potential ramifications of OSA in routine administration of anesthesia. We as sleep researchers must be proactive in increasing awareness and underscoring the importance of identifying OSA in children to other health care practitioners, such as anesthesiologists.
Dr. Bhattacharjee has indicated no financial conflicts of interest.
Bhattacharjee R. When it comes to children, are we really that cautious? J Clin Sleep Med 2015;11(7):697–698.
Lumeng JC, Chervin RD, authors. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242–52. [PubMed Central][PubMed]
Montgomery-Downs HE, O'Brien LM, Holbrook CR, Gozal D, authors. Snoring and sleep-disordered breathing in young children: subjective and objective correlates. Sleep. 2004;27:87–94. [PubMed]
Tarasiuk A, Greenberg-Dotan S, Simon-Tuval T, et al., authors. Elevated morbidity and health care use in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2007;175:55–61. [PubMed]
Tarasiuk A, Simon T, Tal A, Reuveni H, authors. Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization. Pediatrics. 2004;113:351–6. [PubMed]
Marcus CL, Brooks LJ, Draper KA, et al., authors. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:e714–55. [PubMed]
Gozal D, Serpero LD, Sans Capdevila O, Kheirandish-Gozal L, authors. Systemic inflammation in non-obese children with obstructive sleep apnea. Sleep Med. 2008;9:254–9. [PubMed Central][PubMed]
Gozal D, Capdevila OS, Kheirandish-Gozal L, authors. Metabolic alterations and systemic inflammation in obstructive sleep apnea among nonobese and obese prepubertal children. Am J Respir Crit Care Med. 2008;177:1142–9. [PubMed Central][PubMed]
Redline S, Storfer-Isser A, Rosen CL, et al., authors. Association between metabolic syndrome and sleep-disordered breathing in adolescents. Am J Respir Crit Care Med. 2007;176:401–8. [PubMed Central][PubMed]
Bhattacharjee R, Kheirandish-Gozal L, Pillar G, Gozal D, authors. Cardiovascular complications of obstructive sleep apnea syndrome: evidence from children. Prog Cardiovasc Dis. 2009;51:416–33. [PubMed]
Bhattacharjee R, Choi BH, Gozal D, Mokhlesi B, authors. Association of adenotonsillectomy with asthma outcomes in children: a longitudinal database analysis. PLoS Med. 2014;11:e1001753. [PubMed Central][PubMed]
Ishman SL, Tawfi k KO, Smith DF, Cheung K, Pringle LM, Stephen MJ, Everett TL, Stierer TL, authors. Screening for pediatric obstructive sleep apnea before ambulatory surgery. J Clin Sleep Med. 2015;11:751–5.
Sanders JC, King MA, Mitchell RB, Kelly JP, authors. Perioperative complications of adenotonsillectomy in children with obstructive sleep apnea syndrome. Anesth Analg. 2006;103:1115–21. [PubMed]
Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM, authors. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest. 1995;108:610–8. [PubMed]
Brietzke SE, Katz ES, Roberson DW, authors. Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/hypopnea syndrome? A systematic review of the literature. Otolaryngol Head Neck Surg. 2004;131:827–32. [PubMed]
Ishman SL, Yang CJ, Cohen AP, et al., authors. Is the OSA-18 predictive of obstructive sleep apnea: comparison to polysomnography. Laryngoscope. 2015;125:1491–5. [PubMed]