Pediatric obstructive sleep apnea: Preoperative and neurocognitive considerations for perioperative management.
- No comprehensive paediatric OSA small animal model is described in the literature and therefore information is extrapolated from the adult population. There this leaves a gap in the literature as to the efficacy of AT for the long term behavioural and cognitive problems associated with OSA.
- The literature is divided with multiple small studies showing improvement of cognitive deficits with others showing no improvement. Deficits in these studies include not looking at data in the vulnerable population of younger or underweight children.
- The CHAT trial (Childhood Adenotonsillectomy Trial) looked at 464 children aged 5-9 with mild OSA assigned to either watchful waiting or early AT. A 7-month assessment showed no significant improvement in attention and executive function but did identify improvements in behaviour and quality of life in the early AT group compared with the watchful waiting group. (79% vs 46%).
- Typical behavioural improvements in children post AT for OSA include reduction in hyperactivity, impulsiveness and aggression. Exact mechanisms that produce these improvements are unknown. Nocturnal enuresis seen more commonly in children with OSA also seems to improve after AT.
- MRI exams have found regional grey matter differences in those with severe OSA and changes to both grey and white matter have been documented but further research is needed to determine the utility for early detection or assessment of disease.
- As with previous reports, children with severe OSA on PSG, age <3 years and comorbidities are at higher risk of perioperative respiratory adverse events and thus are recommended overnight hospital monitoring. The problem is PSG is not always done. The American Academy of Otolaryngology/Head and Neck Surgery recommend preoperative PSG if age <2 years or in the presence of obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease or mucopolysaccharidoses. Importantly this differs from the American Academy of Paediatrics recommendation that all children with OSA symptoms receive PSG preoperatively. In practice <10% of children get a preoperative PSG.
- All children with severe OSA should undergo AT but a non-surgical approach may be reasonable for those with mild or moderate disease.
- In terms of respiratory complications, these have been found to be more common in underprivileged minority children.
Reviewed by Dr. Katherine Lanigan