In a recent scientific statement, the American Heart Association (AHA) outlined evidence highlighting the effect of obstructive sleep apnea (OSA) on the cardiovascular health of children and adolescents. The full statement was published in Journal of the American Heart Association.
The AHA noted that this statement may be used to develop future guidelines in managing OSA with regard to cardiovascular disease (CVD) risk in the pediatric population.
Epidemiology and Risk Factors
Patients with OSA experience disruption during sleep caused by upper airway obstruction. In children and adolescents, the clinical presentation of the condition can vary by age, but it is generally characterized by habitual snoring, labored breathing, gasps/snorting noises, and daytime sleepiness. According to the AHA, 1% to 6% of children and adolescents have OSA. Current evidence suggests that the OSA prevalence in a pediatric population peaks between 2 and 8 years of age and corresponds to a peak in adenotonsillar hypertrophy prevalence.
Primary risk factors for OSA in the pediatric population include obesity, allergic rhinitis, upper and lower airway disease, enlarged tonsils and adenoids, low muscle tone, neuromuscular disorders, and craniofacial malformations. In addition, sickle cell disease (SCD) may be an independent risk factor for OSA. Premature birth, or birth that occurs prior to 37 weeks’ gestation, may also be associated with an increased risk for sleep-disordered breathing among children, partially because of delayed development of respiratory control.
The AHA statement emphasized the use of gold-standard polysomnography for the diagnosis of sleep-disordered breathing in children, as recommended by the American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS). The sleep study is also recommended prior to a tonsillectomy in children who have OSA, among other concomitant conditions associated with increased risks for surgical complications (eg, Down syndrome, obesity, neuromuscular disorders, craniofacial abnormalities, and SCD).
The AHA suggested the use of anesthesia medicine be carefully considered in children with severe OSA and recommended attempts “to reduce opioid-associated respiratory depression” in these patients. Clinicians are also advised to closely monitor breathing after surgery. In addition, the AHA scientific statement recommended hospitalization for 23 hours or more after surgery for children with severe OSA and those with significant comorbidities, given the risk for subsequent severe airway obstruction.
Cardiovascular and Metabolic-Related Complications
Similar to adults, children and adolescents with OSA may be at an increased risk for hypertension. In the statement, the AHA described how children and adolescents with vs without sleep-disordered breathing tend to have a smaller decrease in blood pressure (BP) during sleep. Normally, BP tends to be 10% greater during sleep than during waking, so a smaller percentage reduction in BP may be indicative of abnormal daytime BP regulation. The AHA therefore recommended that children and adolescents with OSA undergo a 24-hour BP measurement to collect both waking and sleeping BP data.
Children with OSA, including those with mild cases, may also be at a higher risk for metabolic syndrome. Metabolic syndrome is characterized by the presence of several abnormalities associated with an increased risk for CVD, including hypercholesterolemia, hyperinsulinemia, obesity, low levels of high-density lipoprotein (HDL), hypertension, and hypertriglyceridemia. The AHA stated that continuous positive airway pressure (CPAP) may significantly reduce triglyceride levels and improve levels of HDL, in addition to treating OSA. Adenotonsillectomy may also result in short-term improvements of several metabolic syndrome markers in children and adolescents, including fasting glucose and insulin resistance, serum triglycerides, and HDL cholesterol.
In the statement, the AHA also provided an overview of research that suggests that children and adolescents with long-term severe OSA have a heightened risk for pulmonary hypertension. However, additional studies are needed to establish OSA as a significant risk factor for CVD.
The AHA noted that the full discussion of OSA treatment in youth “is beyond the scope of this scientific statement,” but adds that there is currently “no universally accepted criteria for initiation of treatment.” The statement suggested that behavioral, medical, and surgical interventions could be effective options for the management of inadequate sleep duration and sleep efficiency as well as OSA. In addition, the AHA pointed to evidence supporting later school times in improving sleep duration among adolescents.
In addition to discussing CPAP, the scientific statement also called out OSA treatment recommendations from clinical guidelines previously published by the American Academy of Pediatrics, the American Academy of Sleep Medicine, and the AAO-HNS. All evidence-based guidelines agreed on the use of adenotonsillectomy as a first-line option of upper airway obstruction. In children with mild cases of the disease, the guidelines also suggest watchful waiting as a potential option before employing more aggressive measures.
Baker-Smith CM, Isaiah A, Melendres MC, et al. Sleep-disordered breathing and cardiovascular disease in children and adolescents: a scientific statement from the American Heart Association. J Am Heart Assoc. Published online August 18, 2021. doi:10.1161/JAHA.121.022427