Cardiovascular Complications of Obstructive Sleep Apnea Syndrome: Evidence from Children

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Obstructive Sleep Apnea Syndrome (OSAS) is a common condition in children, and is characterized by intermittent partial or complete occlusion of the upper airway during sleep, leading to profound disturbances in homeostatic gas exchange, frequent arousals and disturbed sleep architecture. Pediatric OSAS is associated with a multitude of end-organ morbidities, most of which have been uncovered in the last decade. Of particular interest are the cardiovascular complications that may develop in children with OSAS, since they are posited to have not only an immediately significant impact on cardiovascular health during childhood, but may also affect cardiovascular outcomes later during adult life. In this review, we will present the specific cardiovascular complications that have thus far been described in children with OSAS, with reference to pertinent mechanisms, and potential implications.

Section snippets

Pathophysiology of OSAS in Childhood

Transition to the sleep state will normally result in elevations of upper airway resistance,17, 18 primarily linked to reductions in airway diameter resulting from reduced tone of the pharyngeal dilator and constrictor muscles.19, 20, 21 In children, the cardinal abnormality associated with increased probability of OSAS is the presence of adenotonsillar hypertrophy. This is not surprising because anatomical impingement of the upper airway by the enlarged upper airway lymphoid tissue will

Genetic Influences of OSAS in Childhood

Genetic and ethnic factors have been identified in the pathogenesis of OSAS.39, 40, 41, 42, 43, 44, 45, 46 For example, African Americans are at higher risk than whites when controlling for age, sex, and body mass index.47 Although no specific genes have been thus far identified for OSAS, it has become apparent that OSAS is likely a polygenic disease and that specific genes impacting on factors such as oral mucosa thickness and facial structure will play a deterministic role in OSAS. The

Treatment of OSAS in Childhood

As could be deduced from the pathophysiology of OSAS in childhood, surgical removal of enlarged adenotonsillar tissues constitutes the initial treatment approach to most children diagnosed with the disease. Although studies have yet to demonstrate the efficacy and overall outcomes of this approach in pediatric OSAS, the published evidence suggests that this intervention will lead to significant improvements in most cases, as recently reported from a meta-analysis.48 More recent studies however,

Noncardiovascular Morbidity of OSAS in Childhood

As mentioned above, the peak prevalence of OSAS in childhood occurs in the preschool and early school years.13, 66 During the early years after the initial description of OSAS in childhood,2 failure to thrive was extremely frequent and attributed to increased metabolic expenditure caused by the elevated work of breathing during sleep, reduced nutrient intake due to tonsillar hypertrophy, and most likely to disrupted growth hormone–insulin growth factor pathways in the presence of recurrent

Cardiovascular Morbidity of Pediatric OSAS

To facilitate the discussion of several aspects of cardiovascular involvement in children with OSAS, we have arbitrarily divided our review into specific sections. We would like to emphasize that this partition is artificial because a great degree of overlap exists between the various aspects of cardiac and vascular morbidity in the context of OSAS.

Conclusions

In summary, we have recently witnessed the emergence of a rather extensive, yet somewhat preliminary body of evidence, to support a causative link between OSAS and cardiovascular disease in children. Although the putative mechanisms underlying cardiovascular disease and OSAS are far from being completely elucidated, the heretofore-published studies support the notion that these processes do occur even in “supposedly protected” individuals, such as children. Although the deleterious effects of

References (241)

  • GaultierC. et al.

    Genetics, control of breathing, and sleep-disordered breathing: A review

    Sleep Med

    (2001)
  • GuilleminaultC. et al.

    Familial aggregates in obstructive sleep apnea syndrome

    Chest

    (1995)
  • BrietzkeS.E. et al.

    The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: A meta-analysis

    Otolaryngol Head Neck Surg

    (2006)
  • DowneyR. et al.

    Nasal continuous positive airway pressure use in children with obstructive sleep apnea younger than 2 years of age

    Chest

    (2000)
  • MarcusC.L. et al.

    Use of nasal continuous positive airway pressure as treatment of childhood obstructive sleep apnea

    J Pediatr

    (1995)
  • McNamaraF. et al.

    Obstructive sleep apnea in infants and its management with nasal continuous positive airway pressure

    Chest

    (1999)
  • BrouilletteR.T. et al.

    Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea

    J Pediatr

    (2001)
  • BrunettiL. et al.

    Prevalence of obstructive sleep apnea syndrome in a cohort of 1,207 children of southern Italy

    Chest

    (2001)
  • BarA. et al.

    The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome

    J Pediatr

    (1999)
  • FrancoR.A. et al.

    First place—resident clinical science award 1999. Quality of life for children with obstructive sleep apnea

    Otolaryngol Head Neck Surg

    (2000)
  • DayyatE. et al.

    Childhood obstructive sleep apnea: One or two distinct disease entities?

    Clin Sleep Med

    (2007)
  • MitchellR.B. et al.

    Quality of life after adenotonsillectomy for SDB in children

    Otolaryngol Head Neck Surg

    (2005)
  • de la EvaR.C. et al.

    Metabolic correlates with obstructive sleep apnea in obese subjects

    J Pediatr

    (2002)
  • Kheirandish-GozalL. et al.

    Elevated serum aminotransferase levels in children at risk for obstructive sleep apnea

    Chest

    (2008)
  • McKenzieM.

    A manual of diseases of the throat and nose, including the pharynx, larynx, trachea, oesophagus, nasal cavities and neck

    (1880)
  • GuilleminaultC. et al.

    Sleep apnea in eight children

    Pediatrics

    (1976)
  • FerreiraA.M. et al.

    Snoring in Portuguese primary school children

    Pediatrics

    (2000)
  • KaditisA.G. et al.

    Sleep-disordered breathing in 3,680 Greek children

    Pediatr Pulmonol

    (2004)
  • Montgomery-DownsH.E. et al.

    Snoring and sleep-disordered breathing in young children: Subjective and objective correlates

    Sleep

    (2004)
  • O'BrienL.M. et al.

    Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention-deficit/hyperactivity disorder

    Pediatrics

    (2003)
  • AliN.J. et al.

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

    Arch Dis Child

    (1993)
  • O'BrienL.M. et al.

    Neurobehavioral implications of habitual snoring in children

    Pediatrics

    (2004)
  • RosenC.L.

    Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children

    Pediatr Pulmonol

    (1999)
  • HudgelD.W. et al.

    Mechanics of the respiratory system and breathing pattern during sleep in normal humans

    J Appl Physiol

    (1984)
  • WiegandL. et al.

    Changes in upper airway muscle activation and ventilation during phasic REM sleep in normal men

    J Appl Physiol

    (1991)
  • TangelD.J. et al.

    Influence of sleep on tensor palatini EMG and upper airway resistance in normal men

    J Appl Physiol

    (1991)
  • WiegandD.A. et al.

    Geniohyoid muscle activity in normal men during wakefulness and sleep

    J Appl Physiol

    (1990)
  • WiegandD.A. et al.

    Upper airway resistance and geniohyoid muscle activity in normal men during wakefulness and sleep

    J Appl Physiol

    (1990)
  • MarcusC.L. et al.

    Upper airway collapsibility in children with obstructive sleep apnea syndrome

    J Appl Physiol

    (1994)
  • ArensR. et al.

    Pathophysiology of upper airway obstruction: A developmental perspective

    Sleep

    (2004)
  • JeansW.D. et al.

    A longitudinal study of the growth of the nasopharynx and its contents in normal children

    Br J Radiol

    (1981)
  • ArensR. et al.

    Linear dimensions of the upper airway structure during development: Assessment by magnetic resonance imaging

    Am J Respir Crit Care Med

    (2002)
  • ArensR. et al.

    Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome

    Am J Respir Crit Care Med

    (2001)
  • MarcusC.L. et al.

    Obstructive sleep apnea in children with Down syndrome

    Pediatrics

    (1991)
  • TaskerR.C. et al.

    Distinct patterns of respiratory difficulty in young children with achondroplasia: A clinical, sleep, and lung function study

    Arch Dis Child

    (1998)
  • RonenO. et al.

    Influence of gender and age on upper-airway length during development

    Pediatrics

    (2007)
  • KaditisA.G. et al.

    Adiposity in relation to age as predictor of severity of sleep apnea in children with snoring

    Sleep Breath

    (2008)
  • VerhulstS.L. et al.

    Sleep-disordered breathing in overweight and obese children and adolescents: Prevalence, characteristics and the role of fat distribution

    Arch Dis Child

    (2007)
  • XuZ. et al.

    A case-control study of obstructive sleep apnea/hypopnea syndrome in obese and non-obese Chinese children

    Chest

    (2008)
  • WingY.K. et al.

    A controlled study of sleep related disordered breathing in obese children

    Arch Dis Child

    (2003)
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    RB is supported by a post-doctoral fellowship in Sleep Medicine from Jazz Pharmaceuticals. LKG is supported by an investigator-initiated grant from Merck Company and by a grant from the National Space Agency (NNJ05HF 06G). DG is supported by grants from the National Institutes of Health (HL65270 and HL83075), The Children's Foundation Endowment for Sleep Research, and The Commonwealth of Kentucky Research Challenge Trust Fund.

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