In a prior post I described obstructive sleep apnea (OSA), a common condition associated with snoring where the upper airway (breathing tube) closes intermittently at night leading to sleep disruption. The traditional image of the child with sleep apnea was a skinny, hyperactive child with large tonsils, usually between ages 3-8. This child would present with snoring and gasping at night. Removal of the tonsils and adenoids (adenotonsillectomy) would result in resolution of the snoring and sleep disruption, weight gain, and daytime behavioral issues– in short, a cure.
Things are different now. That classic picture of the child with OSA still exists. However, with the obesity epidemic in the USA and worldwide, the evaluation and management of children with snoring has become more complex. Obesity is defined by the Centers for Disease Control as a body mass index (measure including height and weight) greater than the 95 percentile for age. In other words, an obese child is heavier than 95% of “normal” sized children. In the most recent data, 16.9% of children ages 2-19 years of age were obese; 9.5% of infants and toddlers were obese. How do you know if your child is obese? You can see it on your child’s growth chart at the pediatrician. Or you can can just put your child’s height and weight into this calculator.
Why does this matter if a child is obese and snoring?
- Because the risk of obstructive sleep apnea is much higher. One third of obese children will suffer from OSA, compared with 2-4% of non-obese children. Fifty percent of obese snoring children will have OSA. It is not clear why this is. It may be because the upper airway is smaller and thus easier to collapse. Or, as we have shown in our research, fat in the belly is more likely to be associated with OSA, perhaps by pushing up on the lungs and making them smaller.
- Because OSA in obese children usually looks more like adult OSA in that it is associated with daytime sleepiness and depression.
- Because OSA pushes obese children towards obesity related medical conditions such as hypertension, cholesterol problems, and prediabetes.
- Because the sleep apnea is more severe. Drops in oxygen levels are more common and more severe in children with obesity.
- Because OSA is more difficult to treat. Removal of the tonsils and adenoids is still helpful but significantly less likely to result in a cure. Surgery is more likely to have complications in obese children. Obese children frequently gain more weight after surgery and have a higher rate of recurrence of sleep apnea.
Evaluation and treatment of an obese child with OSA
- Sleep studies are criticalfor both determining whether OSA is present or not, and if surgery is undertaken, determining if there has been a cure.
- Overnight observation in the hospital after adenotonsillectomy is recommended for children with severe OSA as the risk of surgical complications is higher.
- Alternative treatments are frequently necessary. Most commonly, this consists of continuous positive airway pressure (CPAP) which is pressure applied via a mask during the night. These keeps the airway open. Although it takes a bit of getting used to, I have school age kids and older who have done well with this therapy. Orthodontic work and further airway surgery may be helpful as well.
- Weight loss is critical. I routinely refer all of my patients with obesity to a nutritionist. If this is ineffective, I send them to the MGH Weight Center.