PEDIATRICS Vol. 110 No. 6 December 2002, pp. 1255-1257
Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome
To the Editor.—I have major reservations in respect to the recent clinical practice guideline on obstructive sleep apnea syndrome (OSAS).1 Although it is important to alert pediatricians to the existence of this condition, the ramifications of following the guideline do not appear to have been given adequate consideration.
The authors signed letters stating they did not have a conflict of interest. I assume this means they do not run polysomnography (PSG) labs, as an obvious consequence of the report will be a markedly increased demand for their use.
One problem concerns children with primary snoring (PS). This can be seen, according to the report, in up to 12% of preschool-aged children. Furthermore, there is apparently no way to rule out OSAS in these children, without doing PSG. The unmistakable conclusion, therefore, is that up to 12% of preschool-aged children should be undergoing PSG. Do other pediatricians find this concept as ludicrous as I do?
A second issue concerns those children with mild OSAS, mild meaning that they are not demonstrating obvious problems such as daytime somnolence or pulmonary hypertension. These children are diagnosed when their sleep studies are found to be abnormal (ie, at the tail end of the distribution curve). The guideline indicates, in one sentence in the section on research recommendations, that the natural history of these children is not known. That did not stop the committee from recommending that these children undergo adenotonsillectomy, however, even though it is not known whether mild OSAS is an actual disease or merely a statistical finding.
In summary, I believe the guideline to be poorly thought out, and it goes beyond the available evidence in its recommendations. I strongly recommended the report be retracted until the scientific knowledge is available to warrant revisiting the subject.
Jon Matthew Farber, MD
Alexandria, VA, 22310
REFERENCE
1. American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome.
Pediatrics.2002; 109
:704
–712
In Reply.—
Dr Farber’s letter provides us with the opportunity to furnish some additional perspective on the clinical practice guideline on obstructive sleep apnea syndrome (OSAS). I believe that his chagrin suggests that our committee was successful at communicating that OSAS is a common but underappreciated problem in childhood whose diagnosis is difficult. Perhaps we were less successful at conveying and explaining the rationale for our evidence-based diagnostic and therapeutic approaches.
Although my 20-page technical report1 may have appeared somewhat foreboding, it can be summarized simply as showing (page numbers refer to the technical report):
- Habitual snoring is very common in children, and OSAS is common (page 3 and Table 1).
- Severe OSAS can cause pulmonary hypertension and cor pulmonale; the incidence of these complications is unknown but probably rare. OSAS can also cause systemic hypertension and decreased weight gain, and is clearly associated with a higher risk of behavior problems, learning disability, and attention-deficit/hyperactivity disorder (ADHD). It may also be associated with enuresis (pages 3–8, Tables 2–4).
- OSAS cannot be distinguished from primary snoring by clinical examination, even including the use of a structured questionnaire. Current alternatives to overnight polysomnography (PSG) are insensitive (overnight oximetry, nap PSG), nonspecific (video and audiotape), and/or require more study (home PSG, video/audiotape, nap PSG). They all may be useful in selected contexts (page 8–11, Tables 5 and 6).
- Tonsillectomy is usually curative, though postoperative complications may occur after surgery for OSAS, especially in children with very abnormal PSG. Patients with persistent snoring posttonsillectomy should be reevaluated (page 11–13, Tables 7 and 8).
In my opinion, these points are clearly supported by published literature.
Contrary to Dr Farber’s assertion, the guideline2 does not suggest that every child who snores needs overnight PSG. On pages 705 and 706, it states:
"If a history of nightly snoring is elicited, a more detailed history regarding labored breathing during sleep, observed apnea, restless sleep, diaphoresis, enuresis, cyanosis, excessive daytime sleepiness, and behavior or learning problems (including attention-deficit/hyperactivity disorder) should be obtained ... [H]istory and physical examination are useful to screen patients and determine which patients need additional investigation for OSAS."
This point is further reiterated in the flow diagram (Fig 1) provided with the guideline. As a former pediatrician in private practice, I realized when we submitted them that these guidelines would be disturbing, as they run counter to "common wisdom" and against the flow of typical current pediatric primary care. Periodically throughout my own career, pediatricians have received new recommendations (regarding immunization practices, asthma, otitis media, occult bacteremia, etc) that have initially seemed "ludicrous" but then eventually become accepted as routine. OSAS is a common problem that is responsible for significant and often unrecognized childhood morbidity. I believe that the conclusions of our committee are a logical response to the data as currently known. As for the concern that insurance companies will not pay for overnight PSG in children, I would counter that practice guidelines such as ours will make it easier to obtain these studies, and place the onus on the insurer to justify denial of service. This should not feel threatening to the concerned practitioner.
Michael S. Schechter, MD, MPH
Department of Pediatrics
Wake Forest University School of Medicine
Winston-Salem, NC, 27157-1081
REFERENCES
1. Schechter MS and the Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics.2002; 109(4) . Available at: http://www.pediatrics.org/cgi/content/full/109/4/e69
2. American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics.2002; 109 :704 –712
In Reply.—
We appreciate the interest displayed in the recent clinical practice guideline on the obstructive sleep apnea syndrome (OSAS).1
Dr Farber is concerned that the authors of the guideline may have been influenced by economic reasons. This is a valid concern and raises an area of controversy. One would hope that the Committee members writing the guidelines would be experts with experience in the topic covered, but any expert in the area is likely to be affiliated with a sleep laboratory. Of the 4 members of the Committee with specific training and expertise in sleep medicine (all of whom are full-time, salaried medical school faculty), 1 receives some income derived from reviewing sleep studies, and 3 are members of academic pulmonary divisions that have sleep labs and, therefore, indirectly receive some income from the labs. To balance any possible bias, the Committee also included a general pediatrician, an otolaryngologist and an epidemiologist, none of whom receives income related to PSG. It should be noted that the Pulmonology section worked very closely with the Section on Otolaryngology and Bronchoesophagology (represented on the Committee by Dr Jones) in developing these guidelines. Not only do very few otolaryngologists have ties to sleep labs, but they are probably likely to lose business as a result of these guidelines, as approximately half of sleep studies performed for suspected OSAS are normal.2 Thus, we do not think that the 4 members of the Committee with some affiliation with sleep labs influenced the guidelines to obtain personal profit.
We agree with Dr Farber that a large number of children have primary snoring (PS). Unfortunately, Dr Farber has misinterpreted the guidelines and we appreciate the opportunity to restate them. The guidelines clearly state that only those children with snoring accompanied by symptoms of OSAS require testing. We have not recommended that all children who snore have testing, but rather that all children who snore have a more detailed history to identify those who will require testing. As noted in the guidelines, if a history of nightly snoring is elicited, a more detailed history regarding labored breathing during sleep, observed apnea, daytime symptoms, etc should be obtained. Numerous studies have shown that history is not sensitive or specific enough to determine which patients require surgery.3–9 However, it does help distinguish which patients require additional evaluation. The guideline recommendations were made following a very extensive review of >2000 articles in the medical literature (see the technical report for details). The fact is that a large number of studies have shown that a history of OSAS cannot be determined by history and physical examination alone. Thus, relying on history would result in children being submitted to unnecessary surgery. Surely, a sleep study is a preferable alternative. Note that the guidelines do discuss other diagnostic tests that may be applicable under certain circumstances, such as nocturnal oximetry, videotaping, and nap studies.
The guidelines do not make any recommendation regarding the level of OSAS for which treatment is indicated. They merely state that, for those children who are thought to require treatment, adenotonsillectomy is the primary treatment. We agree that additional research is needed to determine what level of OSAS requires treatment.
Carole L. Marcus, MBBCh
Chairperson, AAP Subcommittee on Obstructive Sleep Apnea Syndrome
Johns Hopkins Pediatric Sleep Center
Baltimore, MD, 21287-2533
REFERENCES
1. American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics.2002; 109 :704 –712
2. Schechter MS and the Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics.2002; 109(4) . Available at: http://www.pediatrics.org/cgi/content/full/109/4/e69
3. Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children.
Chest.1995; 108
:610
–618
4. Brouillette RT, Morielli A, Leimanis A, Waters KA, Luciano R, Ducharme FM. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea.
Pediatrics.2000; 105
:405
–412
5. Goldstein NA, Sculerati N, Walsleben JA, Bhatia N, Friedman DM, Rapoport DM. Clinical diagnosis of pediatric obstructive sleep apnea validated by polysomnography. Otolaryngol Head Neck Surg.1994; 111 :611 –617[CrossRef][Web of Science][Medline]
6. Nieminen P, Tolonen U, Lopponen H, Lopponen T, Luotonen J, Jokinen K. Snoring children: factors predicting sleep apnea. Acta Otolaryngol Suppl (Stockh).1997; 529 :190 –194[Medline]
7. Leach J, Olson J, Hermann J, Manning S. Polysomnographic and clinical findings in children with obstructive sleep apnea.
Arch Otolaryngol Head Neck Surg.1992; 118
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8. Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg.1998; 118 :69 –73[CrossRef][Web of Science][Medline]
9. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children.
Arch Otolaryngol Head Neck Surg.1995; 121
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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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