An estimated 2-4% of children have obstructive sleep apnea (OSA), a sleep disorder that occurs when the airflow into the lungs is obstructed at the upper airway level, causing airflow to start and stop during sleep. Over time, untreated OSA can lead to serious health complications.
According to David Gozal, MD, a leading expert in the treatment of pediatric sleep disorders, professor of pediatrics at the University of Chicago, and president of the American Thoracic Society, OSA in children is associated with a wide variety of health risks. These include developing academic and behavioral issues, and as the severity of sleep apnea increases, an increased risk of developing cognitive deficits, particularly in areas related to executive function, memory and verbal learning.
Other subtle yet serious risks include elevated blood pressure, the beginning or acceleration of atherosclerosis, insulin resistance (particularly in obese children) and changes in lipids that resemble conditions of hyperlipidemia. OSA is also associated with changes in mood and depression, morning headaches, bedwetting and stunted growth.
In reference to these health risks, Gozal said, “The list is long, and therefore all the more illustrates why sleep apnea not only is a very prevalent disease, but one that we should pay substantial attention to and try to detect early in order to avoid many of these complications.”
Polysomnography vs. Home Sleep Tests
Currently, the gold standard for diagnosing OSA in children and adolescents is in-laboratory polysomnography (PSG). However, home sleep testing has been considered an alternative due to its potential to be more cost-effective, convenient to the family and accessible. Various studies have sought to determine the feasibility and diagnostic accuracy of home sleep tests.
In terms of convenience for the patient and family, there are clear advantages to using a home sleep test. As Gozal pointed out, “Using a sleep study at home prevents the need for spending the night in a laboratory. No matter how comfortable the lab bed might be, there’s nothing like sleeping at home even when compared to sleeping at a hotel, right?”
However, it’s important to recognize that home sleep testing in children has inherent limitations. According to Gozal, it’s still less common to perform a home sleep test in children over a lab test for two main reasons. First is the challenge of getting home without the child interfering with any of their hookups. “Adults come, get hooked and then go home and won’t do anything to their hookup,” Gozal said. Children, on the other hand, have a much higher probability of destroying their hookups on their way home.
Second, the failure rate at home is much higher in children than in adults. Technical difficulties may arise during the night – which would normally be resolved by a technician in the laboratory – that could lead to an unsuccessful completion of the test. Even if a technician goes to the home, there is still a possibility that technical problems will result in an unsuccessful study. For these reasons, a complete PSG in-home sleep study in children is a very expensive proposition because of the failure rate that they’re associated with, Gozal said.
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Despite these limitations, pediatric home sleep tests are not impossible to complete. One option is to slightly reduce the complexity of the sleep study, in which case it becomes a multi-channel home respiratory polygraphy rather than polysomnography. According to Gozal, studies have shown that this intervention is readily achievable, though it still involves a slightly higher technical failure rate than with adults. “Kids are more likely to pull off their leads than adults are, and parents, justifiably not being experts in how to reposition those leads, create the possibility that there will be technical failures,” Gozal said.
This also raises the question: Is home respiratory polygraphy as valuable as polysomnography? Home respiratory polygraphy is helpful in that it decreases the wait times for busy sleep laboratories, but there are some issues involved, Gozal said.
First, it’s impossible to determine when the child is sleeping and when the child is awake. “Instead of having to calculate any type of apnea-hypopnea index or any of the other measure indices that are calculated as a function of total sleep time, you’re now calculating them as a function of total recording time,” Gozal said. Because total recording time is always longer than the total sleep time, the index will be artificially reduced.
It’s also impossible to quantify arousals with whole respiratory polygraphy. “If you have snore-associated arousals, for example, or any other type of perturbation of sleep that leads to an arousal, that arousal cannot be computed because you don’t have an EEG,” Gozal said.
Therefore, respiratory polygraphy is useful when the diagnosis is clear. If the diagnosis is positive, it’s comparable to polysomnography in the laboratory. But if it’s negative in a symptomatic child, it could potentially represent a false negative study. Therefore, any negative polygraphic study requires conducting polysomnography in the laboratory.
“It’s still done, and people are still doing it, but a variety of other considerations come into play,” Gozal concluded. The reimbursement rate, increased labor and failure rate all cast doubt on whether pediatric home sleep tests are worthwhile. “We have advocated for it if we have areas that have remote access or where the wait list is very high, but this is not done across the board nationwide,” Gozal said.
Ultimately, if a child demonstrates symptoms of OSA, such as habitually snoring, feeling tired, having headaches, falling asleep or not performing well in school, a formal evaluation should be performed. It’s still preferable to conduct polysomnography in a sleep laboratory, but if the waiting list is too long or the patient cannot access a sleep lab, then a home test can provide an alternative for making a diagnosis of OSA.
Kirsten Malenke is a staff writer at ADVANCE. Contact:email@example.com.