Obstructive sleep apnea: Should all children with Down syndrome be tested?

OBJECTIVES To determine the incidence of obstructive sleep apnea syndrome in children aged 2 to 4 years with Down syndrome and to determine parents' ability to predict sleep abnormalities in this patient population. DESIGN Prospective cohort study. SETTING Tertiary care pediatric referral center. PATIENTS Sixty-five children participating in a 5-year longitudinal study in which the otolaryngologic problems seen in Down syndrome were evaluated. Fifty-six completed overnight polysomnography (PSG) between 4 and 63 months of age (mean age, 42 months). INTERVENTIONS Overnight PSG was performed. Parents also completed a questionnaire regarding their impressions of their child's sleep patterns before PSG. MAIN OUTCOME MEASURES Polysomnograms were classified as abnormal if the obstructive index was greater than 1, if the carbon dioxide level was greater than 45 mm Hg for more than two thirds of the study or greater than 50 mm Hg for more than 10% of the study, and/or if there was unexpected hypoxemia less than 92% during sleep or repeated intermittent desaturations less than 90%. We also identified a group of children whose PSGs findings were normal except for an arousal index greater than 10 and were associated with increased work of breathing. RESULTS The PSGs revealed that 57% of the children had abnormal results and evidence of obstructive sleep apnea syndrome. If we also include an elevated arousal index, 80% of the PSGs had abnormal results. Sixty-nine percent of parents reported no sleep problems in their children, but in this group, 54% of PSGs had abnormal results. Of the parents who reported sleep problems in their children, only 36% had abnormal sleep study results. CONCLUSION Because of the high incidence of obstructive sleep apnea syndrome in young children with Down syndrome, and the poor correlation between parental impressions of sleep problems and PSG results, baseline PSG is recommended in all children with Down syndrome at age 3 to 4 years.

[1]  R Mathur,et al.  Frequency of EEG arousals from nocturnal sleep in normal subjects. , 1995, Sleep.

[2]  A. Rechtschaffen,et al.  A manual of standardized terminology, technique and scoring system for sleep stages of human subjects , 1968 .

[3]  C. Marcus,et al.  Daytime Sleepiness and Hyperactivity in Children With Suspected Sleep-Disordered Breathing , 2004, Pediatrics.

[4]  C L Marcus,et al.  Obstructive sleep apnea in children with Down syndrome. , 1991, Pediatrics.

[5]  M. Carskadon,et al.  Sleep, breathing, and cephalometrics in older children and young adults. Part II -- Response to nasal occlusion. , 1996, Chest.

[6]  Gabriel G. Haddad,et al.  Standards and indications for cardiopulmonary sleep studies in children. American Thoracic Society. , 1996, American journal of respiratory and critical care medicine.

[7]  C. Marcus,et al.  Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. , 1998, Journal of applied physiology.

[8]  C L Marcus,et al.  Normal polysomnographic values for children and adolescents. , 1992, The American review of respiratory disease.

[9]  T. Hashimoto,et al.  Sleep in the down syndrome , 1989, Brain and Development.

[10]  M. Katz‐Salamon,et al.  Abnormal heart rate response to hypercapnia in boys with an apparent life‐threatening event , 2002, Acta paediatrica.

[11]  V. Somers,et al.  Sympathetic nerve activity in obstructive sleep apnoea. , 2003, Acta physiologica Scandinavica.

[12]  M. Bonnet.  The effect of sleep fragmentation on sleep and performance in younger and older subjects , 1989, Neurobiology of Aging.

[13]  J. W. Bland,et al.  Pulmonary vascular complications of chronic airway obstruction in children. , 1997, Archives of otolaryngology--head & neck surgery.

[14]  M. Dyken,et al.  Prospective polysomnographic analysis of obstructive sleep apnea in down syndrome. , 2003, Archives of pediatrics & adolescent medicine.

[15]  C. Guilleminault,et al.  EEG arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association. , 1992, Sleep.

[16]  C. Marcus,et al.  Polysomnographic values in children 2–9 years old: Additional data and review of the literature , 2005, Pediatric pulmonology.

[17]  American Academy of Pediatrics: Health supervision for children with Down syndrome. , 2001, Pediatrics.

[18]  T. Gislason,et al.  Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old. An epidemiologic study of lower limit of prevalence. , 1995, Chest.

[19]  D. Southall,et al.  Sleep related upper airway obstruction in a cohort with Down's syndrome. , 1991, Archives of disease in childhood.

[20]  B Dan,et al.  Normal sleep architecture in infants and children. , 1996, Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society.

[21]  A. Rechtschaffen.  A manual of Standardized Terminology , 1968 .

[22]  Asaf Levanon,et al.  Sleep characteristics in children with Down syndrome. , 1999, The Journal of pediatrics.

[23]  Y. Pamula,et al.  Reduced neurocognition in children who snore , 2004, Pediatric pulmonology.

[24]  M. Mograss,et al.  Movement/arousals. Description, classification, and relationship to sleep apnea in children. , 1994, American journal of respiratory and critical care medicine.

[25]  Shelagh A Mulvaney,et al.  Learning in children and sleep disordered breathing: Findings of the Tucson Children's Assessment of Sleep Apnea (TuCASA) Prospective Cohort Study , 2003, Journal of the International Neuropsychological Society.

[26]  J. Stradling,et al.  Snoring, sleep disturbance, and behaviour in 4-5 year olds. , 1993, Archives of disease in childhood.

[27]  E. Wolpert.  A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. , 1969 .

[28]  C. Hunt,et al.  A diagnostic approach to suspected obstructive sleep apnea in children. , 1984, The Journal of pediatrics.

[29]  J. Owens,et al.  The Children's Sleep Habits Questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. , 2000, Sleep.

[30]  David Gozal,et al.  The Effect of Chronic or Intermittent Hypoxia on Cognition in Childhood: A Review of the Evidence , 2004, Pediatrics.

[31]  A. Sandler,et al.  Inattention, hyperactivity, and symptoms of sleep-disordered breathing , 2002 .

[32]  S. Redline,et al.  Cardiorespiratory sleep studies in children: Establishment of normative data and polysomnographic predictors of morbidity , 1999 .