Q&A: OSA represents 'prevalent and impactful sleep disorder' in children
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A session from SLEEP on pediatric sleep medicine that was intended for technologists focused on helping these professionals “deliver top quality care to even the youngest of patients,” according to the session’s chair.
“While anyone interested in pediatric sleep medicine can learn from the talk, the session was part of a series of talks intended for the education of sleep technologists. These are the professionals who help support patients and sleep labs by performing overnight studies, daytime studies and home sleep studies designed to diagnose sleep disorders,” Caroline Okorie, MD, MPH, clinical assistant professor of pediatric pulmonary and sleep medicine and associate program director of the pediatric residency program at Stanford Children’s Hospital, told Healio Neurology. “They work closely with patients in these settings, so this session was designed to offer increased background and knowledge not only about obstructive sleep apnea in pediatric patients, but also about potential new therapies and diagnostic studies related to OSA in this population.”
An increased understanding of clinical principles has been shown to help these professionals “continue to deliver top quality care to even the youngest of patients,” according to Okorie.
“These sessions at the annual SLEEP meeting are specially curated for our polysomnographic technologist colleagues, but I have found that they are often great sessions for physicians and other sleep clinicians as well,” Kevin Gipson, MD, MS, pediatric pulmonologist and sleep medicine physician at Massachusetts General Hospital and instructor at Harvard Medical School, told Healio Neurology.
Gipson and Shannon Sullivan, MD, clinical professor of pediatrics — pulmonary medicine at Stanford University, presented during the session that Okorie chaired. Healio Neurology spoke with them to learn more about the findings they discussed.
Healio Neurology: Can you provide an overview of your talk?
Gipson: Pediatric obstructive sleep apnea is a prevalent and impactful sleep disorder of childhood. Though clinicians and researchers within the field of pediatric sleep have known for decades that OSA can negatively impact the health, behavior and cognitive development of our pediatric patients, I am frequently surprised by how little understanding and awareness there is in the broader medical community. So much has changed in how we approach pediatric OSA over the past few years: We now better understand the often-nuanced ways in which undetected and untreated (or undertreated) OSA can negatively impact health, behavior and learning in children. Our diagnostic tools and metrics have advanced rapidly and become better attuned to the dynamic nature of pediatric sleep breathing disorders. Our treatments have developed beyond solely “adenotonsillectomies for everyone” to become more personalized to each patient’s needs. We have also begun to better incorporate preventive medical strategies in pediatric sleep, acknowledging that OSA can develop over time in infants and children with certain, often-subtle risk factors.
Sullivan: My talk was “Alternatives to Lab Testing in Pediatrics: Home Sleep Apnea Tests." The talk covered three objectives: first, the American Academy of Sleep Medicine position on use of home sleep apnea tests (HSATs) for children; second, a review of recent investigations and research assessing possible uses of HSATs in children; and third, discussion of limitations and potential applications of HSATs in pediatrics. This is a salient area because the COVID-19 pandemic has, in many ways, forced pediatric sleep providers to find creative ways to address the needs of their patients.
Healio Neurology: What were the take-home messages?
Gipson: As our audience was a group of highly trained sleep technologists and general sleep professionals, my first goal was to convey how prevalent and important OSA is to childhood health and development. Pediatrics is a wonderful field, because we can accomplish so much for an individual’s longitudinal health simply by being aware of the risk factors and earliest manifestations of disease in childhood. Better awareness of this sleep disorder is key to early interventions, which can meaningfully change health trajectories. I really believe that we can prevent important health consequences by treating OSA and its causes early.
Beyond this core message of awareness and early intervention, we discussed important nuances in pediatric polysomnography and in important newer diagnostic adjuncts, including computer-aided event detection, home sleep apnea testing and sleep endoscopy. We also reviewed gold standard OSA management, including adenotonsillectomy and positive airway pressure therapy, and discussed emerging medical, orthodontic and surgical adjunctive treatments. The management of pediatric OSA in particular has become a multidisciplinary endeavor, involving pediatric sleep clinicians and technologists, otorhinolaryngologists, oral-maxillofacial surgeons, orthodontists and others, and I tried to emphasize this need for collaboration in our talk.
Sullivan: The AASM published a position paper on the use of HSATs in children in 2017, which stated that use of a home sleep test is not recommended for the diagnosis of sleep apnea in children. However, the paper also noted that the ultimate judgement regarding any specific care must be made by the clinician in light of circumstances, available diagnostic tools and accessible tools.
Studies remain small and usually are not nonrandomized, but a framework of incremental evidence is emerging for use of HSAT in select situations in children.
Appropriateness of HSATs in children varies with age, presentation and circumstance. After all, I think of pediatrics as "a lifetime within a lifetime.” For example, the needs of and presentation of a 16-year-old are very different from that of a 2-year-old. We should not think about them in the same way when it comes to sleep apnea testing.
There are legitimate concerns with the use of HSAT in children, ranging from limited data availability, inadequate sensitivity, concerns around feasibility and safety and inadequate validation compared with in-lab studies. That said, even in-lab polysomnography is imperfect — and very costly. In-lab polysomnography may be hampered by disparities in access, first night effects and night to night variability, and early-morning study termination, which leads to missing the important final REM period of sleep. Also, research shows that up to three-quarters of children with primarily public insurance who are referred to in-lab polysomnography are lost to follow up.
Healio Neurology: How did the COVID-19 pandemic impact your talk?
Gipson: It is a truism at this point to say that the COVID-19 pandemic has touched virtually every aspect of pediatric sleep care, including our diagnostic tests and treatments. While our pediatric sleep lab managers and technologists have done a heroic job of adapting and overcoming challenges presented by this pandemic, and in fact have maintained the highest level of safety for our patients and their families undergoing in-laboratory sleep studies, the question of a potential role for home sleep apnea testing and auto-titrating positive airway pressure modalities in pediatrics has been brought into sharper focus by the pandemic.
Sullivan: Due to infection control and safety concerns, reallocation of staff and increases in disparities, the pandemic further limited an already limited resource: available beds in pediatric sleep labs. This "ultimate judgment" statement has renewed interest as a result. I covered this in an editorial published in Journal of Clinical Sleep Medicine.
Healio Neurology: How did your session help practicing sleep medicine physicians who work in pediatrics?
Gipson: Pediatric sleep remains an under-served subspecialty; so many children receive their sleep care from clinicians with a principal background and practice focus in adult sleep medicine. A well-worn aphorism in pediatrics is that “Kids are not just little adults.” It is important to help technologists and sleep clinician colleagues stay up to date in this rapidly advancing field of care. What we do or do not do in the management of pediatric OSA has the potential for important longitudinal effects on a child or adolescent’s development and health, so the stakes are high. My hope is that our session helped, in a small way, to advance the care of pediatric patients with OSA and to foster a better awareness of the impact of OSA on the health and development of pediatric patients and the special potential for proactive and preventive care.
Sullivan: Hopefully, the session helped to update sleep practitioners on recent investigations about the feasibility, validity and reproducibility of HSATs in certain pediatric populations. While HSATs are not yet extensively or conclusively validated in children, they may be reasonable to deploy in certain well-defined circumstances, understanding that if the HSAT does not meet expectations, it could be followed by in-lab testing if needed. The FDA has approved some HSAT devices for use for some age ranges. Additionally, emerging technologies may be helpful in this space; this was touched upon in the presentation as well. Ultimately, though, technology cannot replace the need for clinical judgement.
References:
Okorie C, et al. Pediatrics update. Presented at: SLEEP; June 10-13, 2021 (virtual meeting).
Sullivan S, et al. J. Clin. Sleep Med. 2021;doi:10.5664/jcsm.9068.