In a recent scientific opinion, the American Heart Association (AHA) presented evidence highlighting the effect of obstructive sleep apnea (OSA) on cardiovascular health in children and adolescents. The full statement was published in the Journal of the American Heart Association.
The AHA noted that this statement can be used to develop future guidelines for managing OSA with regard to the risk of cardiovascular disease (CVD) in children and adolescents.
Epidemiology and Risk Factors
Patients with OSA suffer from insomnia caused by an obstruction of the upper airways. In children and adolescents, the clinical presentation of the disease may vary by age, but is generally characterized by habitual snoring, difficulty breathing, wheezing / snorting, and daytime sleepiness. According to the AHA, 1% to 6% of children and adolescents have OSA. Current evidence suggests that OSA prevalence in a pediatric population peaks between the ages of 2 and 8 years and corresponds to a peak in adenotonsillar hypertrophy prevalence.
Primary risk factors for OSA in children and adolescents are obesity, allergic rhinitis, upper and lower respiratory diseases, enlarged tonsils and polyps, poor muscle tone, neuromuscular disease, and craniofacial malformations. In addition, sickle cell disease (SCD) can be an independent risk factor for OSA. Premature birth or giving birth before 37 weeks of gestation may also be associated with an increased risk of sleep-related breathing disorders in children, in part due to delayed development of breathing control.
The AHA statement emphasized the use of gold standard polysomnography to diagnose sleep-related breathing disorders 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 tonsillectomy in children with OSA, along with other comorbidities associated with an increased risk of surgical complications (e.g., Down syndrome, obesity, neuromuscular disorders, craniofacial abnormalities, and SCD).
The AHA suggested that careful consideration be given to the use of anesthetic agents in children with severe OSA and recommended that these patients “reduce opioid-associated respiratory depression”. Doctors are also advised to closely monitor breathing after surgery. In addition, the AHA’s scientific opinion recommended hospitalization of at least 23 hours after surgery for children with severe OSA and those with significant comorbidities, as there is a risk of subsequent severe airway obstruction.
Cardiovascular and Metabolic Complications
Similar to adults, children and adolescents with OSA may be at increased risk of high blood pressure. In the statement, the AHA described that children and adolescents with vs. without sleep-related breathing disorders tend to have a lower drop in blood pressure (BP) during sleep. Typically, blood pressure is 10% higher during sleep than when awake, so a lower percentage decrease in blood pressure may indicate abnormal blood pressure regulation during the day. The AHA therefore recommended a 24-hour BP measurement for children and adolescents with OSA to collect both wake and sleep BP data.
Children with OSA, including those with mild cases, may also be at greater risk for metabolic syndrome. Metabolic syndrome is characterized by the presence of several abnormalities associated with an increased risk of cardiovascular disease, including hypercholesterolemia, hyperinsulinemia, obesity, low levels of high-density lipoprotein (HDL), hypertension, and hypertriglyceridemia. The AHA stated that in addition to treating OSA, continuous positive airway pressure (CPAP) can significantly lower triglyceride levels and improve HDL levels. Adenotonsillectomy can also provide short-term improvements in various markers of metabolic syndrome in children and adolescents, including fasting glucose and insulin resistance, serum triglycerides, and HDL cholesterol.
In the statement, the AHA also reviewed research suggesting that children and adolescents with long-term severe OSA are at increased risk of 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 adolescents “is beyond the scope of this scientific opinion,” but adds that there are currently “no generally accepted criteria for starting treatment.” The opinion suggested that behavioral, medical, and surgical interventions could be effective options for treating inadequate sleep duration and efficiency, as well as OSA. Additionally, the AHA pointed to evidence to aid later schooling in improving sleep duration in teens.
In addition to discussing CPAP, the scientific opinion also made recommendations for OSA treatment 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 the first-line option for upper airway obstruction. For children with mild illnesses, the guidelines also suggest waiting vigilantly as a possible option before taking more aggressive action.
Baker-Smith CM, Isaiah A, Melendres MC et al. Respiratory sleep disorders and cardiovascular disease in children and adolescents: a scientific opinion from the American Heart Association. J Am Heart Assoc. Published online on August 18, 2021. doi: 10.1161 / JAHA.121.022427
This article originally appeared on The Cardiology Advisor