Sleep‐disordered breathing (SDB) includes a spectrum of conditions ranging from primary snoring, upper airway resistance syndrome, obstructive hypoventilation, to obstructive sleep apnea (OSA).^1-3 OSA in adults is associated with systemic hypertension, glucose dysregulation, arrhythmia, stroke, coronary artery disease, and heart failure. OSA in childhood is also not benign and may be associated with elevated daytime blood pressure (BP), dysregulated diurnal BP, ventricular remodeling, and ventricular dysfunction.^4,5 OSA is particularly common among obese children and occurs in as many as 30-60% of obese youth.⁶ Parents and providers should maintain a high index of suspicion for the presence of OSA. While not all children who snore have sleep apnea, habitual snoring (>3 nights per week) may suggest that a child has sleep apnea. Pauses in a child's breathing during sleep should definitely raise concern that a child might have sleep apnea. However, the gold standard for diagnosing OSA is polysomnography (PSG), a sleep study.⁷ Treatment options for OSA include adenotonsillectomy, continuous positive airway pressure (CPAP), and/or weight loss among obese youth.^2,3

Here are ten important points to remember about SDB and cardiovascular disease (CVD) in children and adolescents:

1. Clinicians should maintain a high degree of suspicion for the presence of OSA among children and adolescents, especially in the obese.
2. Risk factors for OSA in children and adolescents include overweight/obese status, premature birth, craniofacial structural variants, and adenotonsillar hypertrophy (ATH).^2,3
3. Degree of ATH and clinical scores have not been shown to correlate well with severity of airway obstruction.⁷
4. More severe OSA is more likely associated with abnormal BP, best determined with combined in-clinic and ambulatory BP assessment, given the concern for nocturnal hypertension and attenuated diurnal variation.^4,5
5. Children with OSA should undergo weight and BP assessment, with counseling regarding potential long-term CVD risk.⁸
6. Children and adolescents with OSA have markers of metabolic syndrome (MetS), which have been shown to improve with therapy.^8,9
7. Children with OSA may have increased left ventricular mass and left ventricular hypertrophy (LVH).^6,8,9
8. PSG is the gold standard for diagnosis and disease severity stratification of upper airway obstruction.^2,3,7
9. Patients at greatest risk for perioperative complications of adenotonsillectomy include those with severe OSA by PSG and those under 3 years of age with cardiac involvement (e.g., right ventricular hypertrophy), obesity, Down syndrome, sickle cell disease, failure to thrive, history of prematurity, craniofacial abnormalities, neuromuscular diseases, and chronic lung disease.^2,3
10. Children with OSA are at risk for CVD, especially with the co-existence of obesity.   Systemic hypertension, impaired glucose homeostasis, and pulmonary hypertension are not uncommon in these children.^2,3,5

References

1. Sateia MJ. International classification of sleep disorders‐third edition: highlights and modifications. Chest 2014;146:1387–94.
2. Kaditis AG, Alonso Alvarez ML, Boudewyns A, et al. Obstructive sleep disordered breathing in 2‐ to 18‐year‐old children: diagnosis and management. Eur Respir J 2016; 47:69–94.
3. Marcus CL, Brooks LJ, Ward SD, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130:576-84.
4. Hinkle J, Connolly HV, Adams HR, Lande MB. Severe obstructive sleep apnea in children with elevated blood pressure. J Am Soc Hypertens 2018;12:204–10.
5. Roche J, Corgosinho FC, Dâmaso AR, et al. Sleep‐disordered breathing in adolescents with obesity: when does it start to affect cardiometabolic health? Nutr Metab Cardiovasc Dis 2020;30:683–93.
6. Hanlon CE, Binka E, Garofano JS, Sterni LM, Brady TM. The association of obstructive sleep apnea and left ventricular hypertrophy in obese and overweight children with history of elevated blood pressure. J Clin Hypertens (Greenwich) 2019;21:984–90.
7. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: polysomnography for sleep‐disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 2011;145:S1–S15.
8. Chan KC, Au CT, Hui LL, Wing YK, Li AM. Childhood osa is an independent determinant of blood pressure in adulthood: longitudinal follow‐up study. Thorax 2020;75:422–31.
9. Corral J, Mogollon MV, Sánchez‐Quiroga MÁ, et al. Echocardiographic changes with non‐invasive ventilation and CPAP in obesity hypoventilation syndrome. Thorax 2018;73:361–68.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Pulmonary Hypertension, Hypertension, Sleep Apnea

Keywords: Adolescent, Child, Polysomnography, Snoring, Overweight, Pediatric Obesity, Continuous Positive Airway Pressure, Blood Pressure, Hypertrophy, Left Ventricular, Cardiovascular Diseases, Coronary Artery Disease, Hypertension, Pulmonary, Hypertrophy, Right Ventricular, Hypoventilation, Metabolic Syndrome, Sleep Apnea, Obstructive, Risk Factors, Risk Factors, Weight Loss, Severity of Illness Index, Ventricular Dysfunction, Neuromuscular Diseases, Neuromuscular Diseases, Airway Obstruction, Arrhythmias, Cardiac, Sleep, Craniofacial Abnormalities

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