Clinical Evaluation of the Pediatric Patient

  • Hari P. R. BandlaEmail author
Part of the Respiratory Medicine book series (RM)


Obstructive Sleep Apnea (OSA) is characterized by partial or complete upper airway obstruction during sleep leading to intermittent hypoxemia, intermittent hypercapnia, and sleep fragmentation. OSA is common, affecting 2–3% of children with evidence for a peak incidence in preschool age. Although adenotonsillar hypertrophy is the most common cause for OSA in children, obesity is emerging as an equally important etiological factor, particularly in school-aged and teen-aged children. Untreated, OSA is associated with multisystem dysfunction involving the domains of neurocognition, metabolic regulation, somatic, cardiovascular, and endothelial functions. Thus early and appropriate diagnosis of OSA in children is critical in preventing these serious consequences. This chapter reviews the various diagnostic approaches for evaluation of children with symptoms of OSA.


Obstructive Sleep Apnea Excessive Daytime Sleepiness Severe Obstructive Sleep Apnea Multiple Sleep Latency Test Adenoidal Hypertrophy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Tang JP, Rosen CL, Larkin EK, et al. Identification of sleep disordered breathing in children: variation with event definition. Sleep. 2002;25:72–9.PubMedGoogle Scholar
  2. 2.
    Ali NJ, Piston D, Stradling JR. Sleep disordered breathing: effects of adenotonsillectomy on behavior and psychological functioning. Eur J Pediatr. 1996;155:56–62.PubMedGoogle Scholar
  3. 3.
    Amin RS, Caroll JL, Jeffries JL, et al. Twenty-four hour ambulatory blood pressure in children with sleep disordered breathing. Am J Resp Crit Care Med. 2004;169:950–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Waters RA, Sitha S, O’Brien LM, et al. Follow up on metabolic markers in children treated for obstructive sleep apnea. Am J Resp Crit Care Med. 2006;174:455–60.PubMedCrossRefGoogle Scholar
  5. 5.
    Bower CM, Gungor A. Pediatric obstructive sleep apnea syndrome. Otolaryngol Clin North Am. 2009;33:49–75.CrossRefGoogle Scholar
  6. 6.
    Ali NJ, Piston DJ, Stradling JR. Snoring and sleep disturbances and behavior in 4–5 yr olds. Arch Dis Child. 1993;68:360–6.PubMedCrossRefGoogle Scholar
  7. 7.
    American Academy of Pediatrics. Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704–12.CrossRefGoogle Scholar
  8. 8.
    Tang JP, Rosen CL, Larkin EK, et al. Identification of sleep-disordered breathing in children: variation with event definition. Sleep. 2002;25:72–9.PubMedGoogle Scholar
  9. 9.
    Own GO, Canter RJ, Robinson A. Overnight pulse oximetry in snoring and non snoring children. Clin Otolaryngol. 1995;20:402–6.CrossRefGoogle Scholar
  10. 10.
    O’ryan FS, Gallagher DM, LaBanc JP, et al. The relation between nasorespiratory function and dentofacial morphology: a Review. Am J Orthod. 1982;82:403–10.PubMedCrossRefGoogle Scholar
  11. 11.
    Caroll JL, McColley SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest. 1995;108:610–8.CrossRefGoogle Scholar
  12. 12.
    Brouilette RT, Hanson D, David R, et al. A diagnostic approach to suspected obstructive sleep apnea in children. J Pediatr. 1984;105:10–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Stradling JR, Thomas G, Warley R, et al. Effect of adenotonsillectomy on nocturnal hypoxemia, sleep disturbances and symptoms in snoring children. Lancet. 1990;335:239–43.CrossRefGoogle Scholar
  14. 14.
    Brooks LJ. Enuresis and sleep apnea. Pediatrics. 2005;116:799–800.PubMedCrossRefGoogle Scholar
  15. 15.
    Brooks LJ, Topol HI. Enuresis in children with sleep apnea. J Pediatr. 2003;142:515–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Basha S, Bialowas C, Ende K, et al. Effectiveness of adenotonsillectomy in the resolution of nocturnal enuresis secondary to obstructive sleep apnea. Laryngoscope. 2005;115:1101–3.PubMedCrossRefGoogle Scholar
  17. 17.
    Su MS, Li AM, So HK. Nocturnal enuresis in children: prevalence, correlates and relationship with ­obstructive sleep apnea. J Pediatr. 2011;159(2):238–42. E Pub ahead of print.PubMedCrossRefGoogle Scholar
  18. 18.
    Rittig S, Knudsen UB, Nørgaard JP, Gregersen H, Pedersen EB, Djurhuus JC. Diurnal variation of plasma atrial natriuretic peptide in normals and patients with enuresis nocturna. Scand J Clin Lab Invest. 1991;51:209–17.PubMedCrossRefGoogle Scholar
  19. 19.
    American Sleep Disorders Association. International classification of sleep disorders, revised: diagnostic and coding manual. Rochester, MN: American Sleep Disorders Association; 1997.Google Scholar
  20. 20.
    Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540–5.PubMedGoogle Scholar
  21. 21.
    Anders TF, Carskadon MA, Dement WC, Harvey K. Sleep habits of children and the identification of pathologically sleepy children. Child Psychiatr Hum Dev. 1978;9:56–63.CrossRefGoogle Scholar
  22. 22.
    Chervin RD, Weatherly RA, Ruzicka DL, et al. Subjective sleepiness and polysomnographic correlates in children scheduled for adenotonsillectomy vs other surgical care. Sleep. 2006;29:495–503. Sleep. 1991;14:540–5.PubMedGoogle Scholar
  23. 23.
    Gozal D, Wang M, Pope Jr DW. Objective sleepiness measures in pediatric obstructive sleep apnea. Pediatrics. 2001;108:693–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Bandla HP, Gozal D. Dynamic changes in EEG spectra during obstructive apnea in children. Pediatr Pulmonol. 2000;29:359–65.PubMedCrossRefGoogle Scholar
  25. 25.
    Chervin RD, Burns JW, Ruzicka DL. Electro­encophalographic changes during respiratory cycles predict sleepiness in sleep apnea. Am J Resp Crit Care Med. 2005;171:652–8.PubMedCrossRefGoogle Scholar
  26. 26.
    O Brien LM, Tauman R, Gozal D. Sleep pressure correlates of cognitive behavioral morbidity in snoring children. Sleep. 2004;27:279–82.Google Scholar
  27. 27.
    Marcus CL, Curtis S, Koerner CB, Joffe A, Serwint JR, Loughlin GM. Evaluation of pulmonary function and polysomnography in obese children and adolescents. Pediatr Pulmonol. 1996;21:176–83.PubMedCrossRefGoogle Scholar
  28. 28.
    Schechter MS. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:e69.PubMedCrossRefGoogle Scholar
  29. 29.
    O’Brien LM, Mervis CB, Holbrook CR, et al. Neurobehavorial correlates of sleep disordered breathing in children. J Sleep Res. 2004;13:165–72.PubMedCrossRefGoogle Scholar
  30. 30.
    Everett AD, Koch WC, Saulsbury FT. Failure to thrive due to obstructive sleep apnea. Clin Pediatr (Phila). 1987;26:90–2.CrossRefGoogle Scholar
  31. 31.
    Li AM, Yin J, Chan D, et al. Sleeping energy expenditure in pediatric patients with obstructive sleep apnea syndrome. Hong Kong Med J. 2003;9(5):353–6.PubMedGoogle Scholar
  32. 32.
    Marcus CL, Caroll JL, Koerner CB, et al. Determinants of growth in children with obstructive sleep apnea syndrome. J Pediatr. 1994;125:556–62.PubMedCrossRefGoogle Scholar
  33. 33.
    Bland RM, Bulgarelli S, Vdentham JC, et al. Total energy expenditure in children with obstructive sleep apnea syndrome. Eur Respir J. 2001;18:164–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Williams III EF, Woo P, Miller R, et al. The effects of adenotonsillectomy on growth in young children. Otolaryngol Head Neck Surg. 1991;104:509–16.PubMedGoogle Scholar
  35. 35.
    Soultan Z, Wadowski S, Rao M, et al. Effect of treating obstructive sleep apnea by tonsillectomy and /or adenoidectomy on obesity in children. Arch Pediatr Adolesc Med. 1999;153:33–7.PubMedGoogle Scholar
  36. 36.
    Gozal D, Kheirandish-Gozal L. The obesity epidemic and disordered sleep during childhood and adolescence. Adolesc Med State Art Rev. 2010;21:480–90. viii–ix.PubMedGoogle Scholar
  37. 37.
    Marcus CL, Greene MG, Caroll JL. Blood pressure in children with obstructive sleep apnea. Am J Resp Crit Care Med. 1998;157:1098–103.PubMedGoogle Scholar
  38. 38.
    Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clin North Am. 1989;36:1551–69.PubMedGoogle Scholar
  39. 39.
    Ahlquist-Rastad J, Hultcrant Z, Svanholm H. Children with tonsillar obstruction: indications for and efficacy of tonsillectomy. Acta Paediatr Scand. 1988;77:831–5.CrossRefGoogle Scholar
  40. 40.
    Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation. A prospective study. Can Anaesth Soc J. 1985;32:429–34.PubMedCrossRefGoogle Scholar
  41. 41.
    Erdamar B, Souglu Y, Cuhadaroglu C, et al. Evaluation of clinical parameters in patients with obstructive sleep apnea and possible correlation with severity of disease. Eur Arch Otorhinolaryngol. 2001;258:492–5.PubMedCrossRefGoogle Scholar
  42. 42.
    Friedman M, Ibrahim H, Joseph NJ. Staging of obstructive sleep apnea/hypopnea syndrome. A guide to appropriate treatment. Laryngoscope. 1999;109:1901–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Miyaao E, Noda A, Miyao M. The role of Malocclusion in non-obese patients with obstructive sleep apnea syndrome. Int Med. 2008;47:1573–8.CrossRefGoogle Scholar
  44. 44.
    Salam OH, Briss BS, Annino DJ. Nasorespiratory function and craniofacial morphology—a review of the surgical management of the upper airway. Semin Orthod. 2004;1:54–62.CrossRefGoogle Scholar
  45. 45.
    Tourne LP. Long face syndrome and impairment nasopharyngeal airway. Angle Orthod. 1990;60: 167–76.PubMedGoogle Scholar
  46. 46.
    Zettergren-Witjk L, Frosberg CM, Linder-Aronson S, et al. Changes in dentofacial morphology after adeno-tonsillectomy in young children with obstructive sleep apnoea—a 5-year follow-up study. Eur J Orthodontics. 2006;28:319–26.CrossRefGoogle Scholar
  47. 47.
    Breitzke ES, Katz DW. Roberson, can history and physical examination reliably diagnose pediatric obstructive sleep apnea/hypopnea syndrome? a systematic review of the literature. Otolaryngol Head Neck Surg. 2004;131:827–32.CrossRefGoogle Scholar
  48. 48.
    Stewart MG, Friedman EM, Sulek M. Quality of life and health status in pediatric tonsil and adenoidal disease. Arch Otolaryngol Head Neck Surg. 2000;126:45–8.PubMedGoogle Scholar
  49. 49.
    Crabtree VM, Varni JW, Gozal D. Health-related quality of life and depressive symptoms in children with suspected sleep disordered breathing. Sleep. 2004;27:1131–8.PubMedGoogle Scholar
  50. 50.
    Gozal D, Kheirandish-Gozal L. Obesity and excessive daytime sleepiness in pre pubertal children with obstructive sleep apnea. Pediatrics. 2009;123:13–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Ryan S, Mc Nicholas WT. Inflammatory cardio vascular risk markers in obstructive sleep apnea syndrome. Cardiovasc Hematol Agents Med Chem. 2009;7:76–81.PubMedCrossRefGoogle Scholar
  52. 52.
    Tauman R, Ivanenko A, O’Brien LM, et al. Plasma C-reactive protein levels among children with sleep-disordered breathing. Pediatrics. 2004;113:e564–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Tauman R, O’Brien LM, Ivanenko A, et al. Obesity rather than severity of sleep-disordered breathing as the major determinant of insulin resistance and altered lipidemia in snoring children. Pediatrics. 2005;116(1): e66–73.PubMedCrossRefGoogle Scholar
  54. 54.
    Gozal D, Jortani S, Snow AB, et al. Two-dimensional differential in-gel electrophoresis proteomic approaches reveal urine candidate biomarkers in pediatric obstructive sleep apnea. Am J Resp Crit Care Med. 2009;180:1253–61.PubMedCrossRefGoogle Scholar
  55. 55.
    Fernbach SK, Brouilette RT, Riggs TW, et al. Radiologic evaluation of adenoids and tonsils in children with obstructive sleep apnea: plain films and fluoroscopy. Pediatric Radiol. 1983;13:259–65.CrossRefGoogle Scholar
  56. 56.
    Li AM, Wong E, Kew J, et al. Use of tonsil size in the evaluation of obstructive sleep apnea. Arch Dis child. 2002;87:156–9.PubMedCrossRefGoogle Scholar
  57. 57.
    Brooks LJ, Stephens BM, Bacevice AM. Adenoid size is related to severity but not the number of episodes of obstructive apnea in children. J Pediatr. 1998;132:682–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Shintani T, Asakura K, Kataura A. Adenotonsillar hypertrophy and skeletal morphology of children with obstructive sleep apnea. Acta Otolaryngol (Stockh). 1996;523:222–4.Google Scholar
  59. 59.
    Pirilä-Parkkinen K, Löppönen H, Nieminen P, et al. Cephalometric evaluation of children with nocturnal sleep disordered breathing. Eur J Orthol. 2010;32: 662–71.CrossRefGoogle Scholar
  60. 60.
    Donelley LF, Strife JL, Myer CM. Dynamic sleep fluoroscopy in children with obstructive sleep apnea. Appl Radiol. 2001;30:30–4.CrossRefGoogle Scholar
  61. 61.
    Gibson SM, Myer 3rd CM, Strife JL, et al. Sleep fluoroscopy for localization of upper airway obstruction in children. Ann Otol Rhinol Laryngol. 1996;105:678–83.PubMedGoogle Scholar
  62. 62.
    Strauss A, Burgoyne CC. Diagnostic imaging and sleep medicine. Dental Clin N A Am. 2008;52:891–915.CrossRefGoogle Scholar
  63. 63.
    Schwab RJ, Gefter WB, Hoffman EA, et al. Dynamic upper airway imaging during respiration in normal subjects and patients with sleep disordered breathing. Am Rev Res Dis. 1993;148:1385–400.Google Scholar
  64. 64.
    Ryan CF, Lowe AA, Li D, et al. Three dimensional upper airway computed tomography in obstructive sleep apnea. Am Rev Res Dis. 1991;144:428–32.CrossRefGoogle Scholar
  65. 65.
    Schwab RJ, Gupta KB, Gefter WB, et al. Upper ­airway soft tissue anatomy in normals and patients with sleep disordered breathing. Significant of the ­lateral pharyngeal walls. Am J Resp Crit Care Med. 1995;152:1673–89.PubMedGoogle Scholar
  66. 66.
    Croft CB, Pringle M. Sleep nasoendoscopy. A technique of assessment in snoring and obstructive sleep apnea. Clin Oto Laryngol Allied Sci. 1991;16:504–9.CrossRefGoogle Scholar
  67. 67.
    Kezirian EJ, Hohenhorst W, Vries ND. Drug-induced sleep endoscopy. The VOTE classification. Eur Arch Otorhinilaryngol. 2011;268(8):1233–6. E Pub ahead of print.CrossRefGoogle Scholar
  68. 68.
    Myatt HM, Beckenham EJ. The use of diagnostic sleep endoscopy in the management of children with complex airway obstruction. Clin Otolaryngol. 2000;25:200–8.PubMedCrossRefGoogle Scholar
  69. 69.
    Luginbuehl M, Kohler WC. Screening and evaluation of sleep disorders in children and adolescents. Child Adolesc Psychiatric Clin N Am. 2009;18:825–38.CrossRefGoogle Scholar
  70. 70.
    Owens JA, Daizell V. Use of the “BEARS” sleep screening tool in a pediatric resident’s continuity clinic: a pilot study. Sleep Med. 2005;6:63–9.PubMedCrossRefGoogle Scholar
  71. 71.
    Brouilette R, Hanson D, David R, et al. A diagnostic approach to suspected obstructive sleep apnea in children. J Pediatr. 1984;105:10–4.PubMedCrossRefGoogle Scholar
  72. 72.
    Marcus CL, Keens TG, Ward SL. Comparison of nap and overnight polysomnography in children. Pediatric Pulmonol. 1992;13:16–24.CrossRefGoogle Scholar
  73. 73.
    Rosen CL. Clinical features of obstructive sleep apnea hypoventilation syndromes in otherwise healthy children. Pediatr Pulmonol. 1999;27(6):403–9.PubMedCrossRefGoogle Scholar
  74. 74.
    Brouilette RT, Morelli A, Leimanis A, et al. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics. 2000;105:405–12.CrossRefGoogle Scholar
  75. 75.
    Chervin R, Hedger K, Dillon JE, et al. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep disordered breathing, snoring, sleepiness and behavioral problems. Sleep. 1997;20: 1185–92.PubMedGoogle Scholar
  76. 76.
    Li AM, Cheung A, Chan D, et al. Validation of a questionnaire Instrument for prediction of obstructive sleep apnea in Hong Kong Chinese Children. Pediatr Pulmonol. 2006;41:1153–60.PubMedCrossRefGoogle Scholar
  77. 77.
    Saeed MM, Keens TG, Stable MW, et al. Should ­children with suspected obstructive sleep apnea syndrome and normal nap sleep studies have overnight sleep studies? Chest. 2000;118:360–5.PubMedCrossRefGoogle Scholar
  78. 78.
    American Academy of Pediatrics. Section on Pediatric Pulmonology, Sub Committee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline. Diagnosis and management of Childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704–12.CrossRefGoogle Scholar
  79. 79.
    American Thoracic Society. Cardiorespiratory sleep studies in children. Establishment of normative data and polysomnographic predictors of morbidity. Am J Resp Crit Care Med. 1999;160:1381–7.Google Scholar
  80. 80.
    Iber C, Ancoli-Israel S, Chesson AL, et al. The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specifications. 1st ed. Westchester, IL: American Academy of Sleep Medicine; 2007.Google Scholar
  81. 81.
    Luginbuehl M. The initial development and validation study of the sleep disorders inventory for students. Dissertation abstracts international section. Humanities Soc Sci. 2004;64(12-A):4376.Google Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Department of PediatricsThe University of ChicagoChicagoUSA

Personalised recommendations