Letters to the Editor

Treating Children with Obstructive Sleep Apnea



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Am Fam Physician. 2005 Apr 15;71(8):1490-1493.

to the editor: I would like to comment on a few points raised by the authors of “Obstructive Sleep Apnea in Children,”1 in American Family Physician. First, they state that “in children, an apnea-hypopnea index greater than 1…is considered abnormal.”1 This is incorrect: the study2 the authors cited clearly states that the recommended normal value of apnea index (not apnea-hypopnea index) is less than or equal to 1. The normal value of apnea-hypopnea index has not been established for children even though hypopnea is as important as apnea. Apnea-hypopnea index values of 5, 10, 15, 20, and 30 were used as definitions of obstructive sleep apnea in children.3 Using an apnea-hypopnea index greater than 1 as the definition of obstructive sleep apnea is not supported by the current evidence. The authors1 commented that adenotonsillectomy has been shown to improve weight problems. This is certainly true for failure to thrive, but not for obesity. It has been well documented that obesity often worsens after adenotonsillectomy.4,5 Hence, dietary and exercise advice is an essential component in managing children who are obese and have obstructive sleep apnea. One study6 reported resolution of sleep apnea after weight loss in five children who were morbidly obese.

REFERENCES

1. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004;69:1147–54.

2. Marcus CL, Omlin KJ, Basinki DJ, Bailey SL, Rachal AB, Von Pechmann WS, et al. Normal polysomnographic values for children and adolescents. Am Rev Respir Dis. 1992;146(5 pt 1):1235–9.

3. Redline S, Sanders M. Hypopnea, a floating metric: implications for prevalence, morbidity estimates, and case findings. Sleep. 1997;20:1209–17.

4. Marcus CL, Carroll JL, Koerner CB, Hamer A, Lutz J, Loughlin GM. Determinants of growth in children with the obstructive sleep apnea syndrome. J Pediatr. 1994;125:556–62.

5. Soultan Z, Wadowski S, Rao M, Kravath RE. Effect of treating obstructive sleep apnea by tonsillectomy and/or adenoidectomy on obesity in children. Arch Pediatr Adolesc Med. 1999;153:33–7.

6. Willi SM, Oexmann MJ, Wright NM, Collop NA, Key LL Jr. The effects of a high-protein, low-fat, ketogenic diet on adolescents with morbid obesity: body composition, blood chemistries, and sleep abnormalities. Pediatrics. 1998;101(1 pt 1):61–7.

in reply: As seen in previous studies,1,2 episodes of complete airway obstruction in children are relatively uncommon. Obstructive sleep apnea may manifest mainly as hypopneas and continuous hypoventilation with partial cessation of airflow. Therefore, incorporating information about hypopneas may be as important as data on apneas. Hopefully, further research in this area will lead to clearer guidelines regarding hypopneas and apneas.

We agree that adenotonsillectomy has been shown to be effective in improving weight in children with failure to thrive and not in children with obesity.3,4 It is stated in several places in our article5 that medical management of obesity may benefit the overweight child and potentially resolve their obstructive sleep apnea.5,6

REFERENCES

1. Marcus CL, Omlin KJ, Basinki DJ, Bailey SL, Rachal AB, Von Pechmann WS, et al. Normal polysomnographic values for children and adolescents. Am Rev Respir Dis. 1992;146(5 pt 1):1235–9.

2. Uliel S, Tauman R, Greenfeld M, Sivan Y. Normal polysomnographic respiratory values in children and adolescents. Chest. 2004;125:872–8.

3. Mitchell RB, Kelly J. Adenotonsillectomy for obstructive sleep apnea in obese children. Otolaryngol Head Neck Surg. 2004;131:104–8.

4. Soultan Z, Wadowski S, Rao M, Kravath RE. Effect of treating obstructive sleep apnea by tonsillectomy and/or adenoidectomy on obesity in children. Arch Pediatr Adolesc Med. 1999;153:33–7.

5. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004;69:1147–54.

6. Willi SM, Oexmann MJ, Wright NM, Collop NA, Key LL Jr. The effects of a high-protein, low-fat, ketogenic diet on adolescents with morbid obesity: body composition, blood chemistries, and sleep abnormalities. Pediatrics. 1998;101(1 pt 1):61–7.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.



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