Elsevier

Sleep Medicine Reviews

Volume 12, Issue 5, October 2008, Pages 339-346
Sleep Medicine Reviews

Clinical review
The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents

https://doi.org/10.1016/j.smrv.2007.11.002Get rights and content

Summary

The prevalence of childhood obesity is increasing worldwide. One of the obesity-related complications that has received increasing attention in recent years is sleep-disordered breathing. Obese children are at a higher risk of developing sleep-disordered breathing, including habitual snoring, obstructive sleep apnea syndrome and desaturations preceded by central apneas. Both adiposity and upper airway factors, such as adenotonsillar hypertrophy, modulate the severity of sleep-disordered breathing in these children. Adenotonsillectomy seems to be effective against obstructive sleep apnea syndrome in obese children. On the other hand, there are limited data on the effects of weight loss and of treatment with continuous positive airway pressure on the severity of sleep apnea in obese children and adolescents.

Introduction

The prevalence of childhood obesity has reached epidemic proportions worldwide and is still increasing. Obesity in children and adolescents is now recognized as a major medical and public health problem that affects nearly every major organ system.1 Furthermore, the development of cardiovascular morbidity can begin in childhood and in adolescence, which stresses the importance of early prevention, diagnosis and treatment for obesity and its related complications.2, 3, 4 One of the obesity-related complications that has received increasing attention in recent years is sleep-disordered breathing (SDB). SDB in overweight children and adolescents has been independently associated with the metabolic syndrome and its components*5, 6; thus, SDB becomes a potential additional risk factor for the development of cardiovascular morbidity. Secondly, SDB in children also results in behavioral and neurocognitive complications.7 Therefore, remaining alert for the presence of SDB in this high-risk population and subsequently seeking appropriate management is important. In this review, we will examine the current understanding regarding the prevalence of SDB; the role of adenoids, tonsils and adiposity in the development of SDB; and the various treatment options for SDB in overweight children and adolescents.

Section snippets

Prevalence of sleep-disordered breathing: primary snoring and obstructive sleep apnea syndrome

The main component of obstructive types of SDB, obstructive sleep apnea syndrome (OSAS), is characterized by recurrent events of partial and/or complete upper airway obstruction resulting in a disruption of normal ventilation and sleep.8 Obstructive SDB is also considered an entire continuum, which also encompasses upper airway resistance syndrome (UARS), in which the increased resistance at the upper airway is sufficiently large, which causes sleep fragmentation in the absence of blunt apneas

Prevalence of sleep-disordered breathing: central sleep apnea

In contrast to the evidence of a higher prevalence of OSAS among obese children, limited data have been reported on the occurrence of other respiratory abnormalities during sleep, i.e. central apneas. Several studies have provided reference data on the occurrence of apneas during sleep in normal children and adolescents. These studies all agree that short-duration central apneas (<20 s) are a normal phenomenon in children. Furthermore, these central events are almost never accompanied by serious

Anatomical correlates

The classical-risk factor for obstructive SDB in normal-weight children is an enlargement of the adenoids and/or tonsils. In obese children, one can expect that both lymphoid hypertrophy and obesity could compromise the upper airway. Several studies which demonstrated a significant relation between the degree of adiposity and AHI*24, 46 have already been reported and discussed. Silvestri et al.22 found that subjects without any adenotonsillar hypertrophy had a milder spectrum of respiratory

Treatment

Several treatment options can be considered for the obese child with SDB, including adenotonsillectomy, weight loss and continuous positive airway pressure (CPAP). Several of the previously discussed studies anecdotally reported a decrease in SDB symptoms and/or a normalization of the respiratory abnormalities after one of these treatment options was pursued.*22, *23, *24 Secondly, various reports have systematically investigated the effect of adenotonsillectomy in obese children with

Conclusion

In this review, we have shown that childhood obesity is associated with an increased prevalence of all types of SDB, specifically PS, OSAS and central sleep apnea that was marked by serious oxygen desaturations following the central apnea episodes. In view of the many SDB-related complications, we suggest that obese children and adolescents should be screened for SDB. However, it has to be noted that valid screening instruments for SDB are still lacking.60 We have also documented that upper

References (63)

  • H. Schafer et al.

    Body fat distribution, serum leptin, and cardiovascular risk factors in men with obstructive sleep apnea

    Chest

    (2002)
  • P.D. Levinson et al.

    Adiposity and cardiovascular risk factors in men with obstructive sleep apnea

    Chest

    (1993)
  • M. Carotenuto et al.

    Waist circumference predicts the occurrence of sleep-disordered breathing in obese children and adolescents: a questionnaire-based study

    Sleep Med

    (2006)
  • G.J. Wiet et al.

    Surgical correction of obstructive sleep apnea in the complicated pediatric patient documented by polysomnography

    Int J Pediatr Otorhinolaryngol

    (1997)
  • R.B. Mitchell et al.

    Adenotonsillectomy for obstructive sleep apnea in obese children

    Otolaryngol Head Neck Surg

    (2004)
  • L.M. O’Brien et al.

    Obesity increases the risk for persisting obstructive sleep apnea after treatment in children

    Int J Pediatr Otorhinolaryngol

    (2006)
  • R. Tauman et al.

    Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy

    J Pediatr

    (2006)
  • R.B. Mitchell et al.

    Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children

    Otolaryngol Head Neck Surg

    (2007)
  • A. Spector et al.

    Adenotonsillectomy in the morbidly obese child

    Int J Pediatr Otorhinolaryngol

    (2003)
  • A.S. Gami et al.

    Obesity and obstructive sleep apnea

    Endocrinol Metab Clin North Am

    (2003)
  • P.W. Speiser et al.

    Childhood obesity

    J Clin Endocrinol Metab

    (2005)
  • G.S. Berenson et al.

    Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa heart study

    N Engl J Med

    (1998)
  • A.R. Sinaiko et al.

    Influence of insulin resistance and body mass index at age 13 on systolic blood pressure, triglycerides, and high-density lipoprotein cholesterol at age 19

    Hypertension

    (2006)
  • S.L. Verhulst et al.

    Sleep-disordered breathing and the metabolic syndrome in overweight and obese children and adolescents

    J Pediatr

    (2007)
  • S. Redline et al.

    Association between metabolic syndrome and sleep disordered breathing in adolescents

    Am J Respir Crit Care Med

    (2007)
  • D.W. Beebe

    Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review

    Sleep

    (2006)
  • American Thoracic Society

    Standards and indications for cardiopulmonary sleep studies in children

    Am J Respir Crit Care Med

    (1996)
  • M.G. Greene et al.

    Consequences of sleep-disordered breathing in childhood

    Curr Opin Pulm Med

    (1997)
  • W. Anuntaseree et al.

    Snoring and obstructive sleep apnea in Thai school-age children: prevalence and predisposing factors

    Pediatr Pulmonol

    (2001)
  • N.J. Ali et al.

    Snoring, sleep disturbance, and behaviour in 4–5 year olds

    Arch Dis Child

    (1993)
  • G.M. Corbo et al.

    Snoring in children: association with respiratory symptoms and passive smoking

    Br Med J

    (1989)
  • Cited by (186)

    • Supraglottoplasty in children with obstructive sleep apnea

      2023, Operative Techniques in Otolaryngology - Head and Neck Surgery
    • Surgical management of obstructive sleep apnea following adenotonsillectomy

      2023, Snoring and Obstructive Sleep Apnea in Children
    • Cardiovascular complications of pediatric obstructive sleep apnea

      2023, Snoring and Obstructive Sleep Apnea in Children
    • Positional therapy for pediatric obstructive sleep apnea

      2023, Snoring and Obstructive Sleep Apnea in Children
    View all citing articles on Scopus

    The most important references are denoted by an asterisk.

    View full text