Over-Weight Obesity and Sleep Apnea

Obstructive sleep apnea (OSA) is more common among obese children than children with normal weight. Children with Over-Weight Obesity have 25-45% chances of having Obstructive sleep apnea (OSA) as compared with 1-3% in normal weight children.

Why children with Over-Weight Obesity are more predisposed to have Obstructive sleep apnea (OSA)?

In obese children, the cause of obstruction is multifactorial. The important cause are:

• Enlarged tonsil and adenoid tissue
• Deposition of fat tissue around the neck airway called as pharynx makes it narrow
• External compression from the subcutaneous tissues of the neck

When do we suspect Obstructive sleep apnea (OSA) in children with Obesity?

Obstructive sleep apnea (OSA) is usually suspected when children are having persistent snoring, difficulty in sleeping associated with frequent awakenings, sleeping in abnormal postures, excessive sleepiness during day, morning headaches and poor scholastic performance.

How do we diagnose Obstructive sleep apnea (OSA) in children with Obesity?

Children with Over-Weight Obesity who are suspected to have Obstructive sleep apnea (OSA) need to undergo a sleep study or polysomnography.

What are the consequences of Obstructive sleep apnea (OSA) in children with Obesity?

Children with Over-Weight Obesity and Obstructive sleep apnea (OSA) can have serious consequences for neurocognitive function like hyperactivity and inattention, behaviour problems and poor school performance.

What are the long term consequences of children with Over-Weight Obesity?

Children with overweight and obesity are more likely to become obese adults and are at increased risk for other health conditions including diabetes, cardiovascular disease, hypertension in addition to obstructive sleep apnea (OSA).

How do we treat Obstructive sleep apnea (OSA) in children with Obesity?

Tonsillectomy and adenoidectomy is the treatment of choice for Obstructive sleep apnea (OSA). Removing the obstructive adenoids and tonsils increases the patency of the oral airway, improving OSA in most children. Since, the cause of OSA is multifactorial most obese children do not have complete resolution of OSA after tonsillectomy and adenoidectomy. Repeat sleep study is required after surgery and residual OSA is treated with CPAP or Continuous Positive Airway Pressure.

But why does this happen?

• Children with neuromuscular problems have weakness in the body muscles. This also involves the muscles of breathing.
• During sleeping the muscles of the body relax further called as hypotonia especially during dream sleep. During these stages the breathing can get difficult.

What are the problems that can happen during sleep?

• Breathing problems in sleep can occur such as pauses in breathing (sleep apneas & hypopneas) and shallow breathing (hypoventilation) leading to accumulation of carbon dioxide (waste gas). Parents can sometimes witness the pauses in breathing. These might be missed since these can occur in some specific phases of sleep.
• These factors lead to frequent awakenings during sleep (arousals) which deteriorate the quality of sleep or a disturbed sleep (sleep fragmentation).
• Child can have morning headaches, might feel dull and tired during the day.
• This shallow breathing would also lead to frequent chest infections

How do I suspect that my child is having sleep problems?

• Children with neuromuscular who are now having difficulty in walking can start having breathing problems in sleep.
• Lung function is also a good guide. If the values in the spirometry are low then also it indicates that sleep problems could be developing.
• If the child is having recurrent chest infections requiring antibiotics, this can be another indication.
• Also look for any nighttime problems such as pause in breathing, gasping and noisy breathing. Also look at daytimes symptoms such as headaches and tiredness.

How can we detect sleep problems during sleep?

• If we suspect sleep problems then we should go ahead with a sleep study.
• This will help understand child’s breathing pattern during sleep, any apneas (cessation in breathing), hypoventilation (shallow breathing), and retention of carbon dioxide (waste gas).
• For more information on sleep study visit our page on Pediatric Sleep Studies

Obstructive sleep apnea is significantly more common in children with some genetic syndromes and high risk groups. In children with genetic syndromes the cause of OSA multifactorial with multilevel airway obstruction; most important being falling back of the tongue and midface hypoplasia.

A high index of suspicion should be kept for children with underlying genetic syndromes and other medical conditions which predispose to OSA. Symptoms in these children can be subtle and non specific.

What are the genetic syndromes associated with sleep apnea?

(A) Genetic Syndromes like Craniofacial syndromes (Apert, Crouzon, Pfeiffer), Down’s syndrome, Obesity syndromes (Prader Willi or Bardeit Biedel), Pierre Robin sequence etc.
(B) High Risk groups like chronic lung diseases, Sickle cell disease, mucopolysachharidosis, Tracheo-bronchomalacia etc
(C) Neuromusular Disorders with Suspected Nocturnal Hypoventilation

• Congenital Myopathies
• Muscular Dystrophies
• Spinal muscular atrophy

Children with the above genetic syndromes or high risk groups should be appropriately screened and require a sleep study for diagnosis of sleep apnea.

Sleep related movement disorders

There are certain movement disorders where movements appear only during sleep. The common sleep related movement disorders in children are Restless Legs Syndrome, Periodic Limb Movement Disorder, Sleep-Related Bruxism and Rhythmic Movement Disorder.

Restless Legs Syndrome

Restless leg syndrome is an urge to move the legs that is usually, but not always, accompanied or caused by uncomfortable and unpleasant leg sensations. The symptoms begin or worsen during rest or inactivity and symptoms are partially or totally relieved by movements such as walking or stretching for at least as long as the activity continues. The symptoms only occur or are worse in the evening or night than during the day.

Periodic Limb Movement Disorder

This is characterized by rhythmic jerking of the legs during sleep with the sleeper generally unaware of the motor activity. At least four leg movements separated by 5 to 90 seconds between onsets of successive movements must occur in succession to be scored as Periodic Limb Movement Disorder. Periodic Limb Movement Disorder is diagnosed by a Polysomnography.

Sleep-Related Bruxism

In sleep-related bruxism (ie, tooth grinding or clenching), tonic contraction of the mastication muscles occur frequently.

Rhythmic Movement Disorder

The movements of rhythmic movement disorder (RMD) consist of stereotyped contractions of large muscle groups during drowsiness or sleep. Subtypes of RMD are described such as head banging and body rocking.