Since sleep disordered breathing (SDB) emerged as a public health problem, more people are becoming aware of sleep apnea and its negative effects. The sleep therapy market is growing, with sleep centers reporting a 21% increase in bed capacity over the past 12 months.

While sleep apnea affects 20 million US adults, we tend to overlook the fact that children are also vulnerable to SDB. Several studies suggest that 2% to 3% of children between 2 and 8 years old are affected. The health consequences of pediatric SDB can be serious, ranging from daytime fatigue and hyperactivity to neurodevelopmental disorders. In 2002, the American Academy of Pediatrics encouraged pediatricians to screen all children for snoring, because it may be a sign of obstructive sleep apnea (OSA).

Five years later, with physician and public awareness greater than ever, we must address the growing need for pediatric sleep therapy solutions. More pediatric sleep laboratories are opening, and more adult laboratories find the need to expand their practices to pediatric populations. What effect will this have on DME providers who are accustomed to treating adult SDB patients, but have limited experience with pediatric patients? How will physicians, sleep labs, and DMEs meet this growing need?

PREPARING FOR THE FUTURE

To address this relatively new market, sleep medicine must evolve to provide comprehensive evaluation and diagnostic and management services for children. Dominic Gault, MD, medical director of the Pediatric Sleep Medicine Division at Greenville Hospital, decided to relocate to Greenville, SC, to develop a pediatric sleep medicine program. He gives valuable insights on how to prepare for the challenge of treating pediatric patients.

"The DME providers who will be able to care for this growing patient population must be willing to develop a true partnership with the sleep lab. This partnership may strain the DME due to the increased time and effort required for the pediatric patient," Gault says. "A more labor-intensive approach is a result of the need for proper mask fitting, desensitizing, close follow-up, and adjustments of equipment. These patients will respond differently to different device settings, such as those of the VPAP III ST-A, required to treat them."

Richard Serafino, director of the Gaylord Sleep Medicine program in Connecticut, predicts that pediatric sleep medicine will be an area of increasing clinical focus. "The pediatric population historically has been underserved by sleep specialists, and there are few dedicated pediatric sleep programs," he says. "However, the number of children with conditions related to sleep disorders, such as ADHD, obesity, and diabetes, is growing rapidly. As a leader in sleep medicine, Gaylord Hospital decided to invest in a pediatric sleep medicine program to meet this growing need."

He also points out the wide range of treatment options that are now available. "Importantly, sleep specialists now have access to a broader range of treatment options, such as ResMed's pediatric system for treating OSA. In addition, ENT surgeons are willing to consider alternatives to surgical intervention based on individual patient needs."

Kimberly Ake

ResMed's VPAP III ST-A bilevel flow generator and Mirage Kidsta™ nasal mask are the first positive airway pressure (PAP) system cleared for the treatment of respiratory insufficiency and OSA in pediatric patients who are at least 7 years old, or weigh at least 40 pounds. Rochelle Turetsky, MD, Gaylord Hospital, says, "This system is excellent news for patients and physicians and will meet a growing need in pediatric practices."

ADDRESSING THE CHALLENGES

Pediatric patients are not just small adults. The symptoms of childhood SDB can differ greatly from the symptoms of SDB in adults, with signs of apnea being more subtle in children. For example, adults experience fatigue and somnolence throughout the day, while children may not exhibit daytime fatigue and may even be hyperactive. In addition, sleep apnea in children can negatively affect their physical and mental development. For these reasons alone, it is important to understand that children and adults are different classes of patients, and we must treat them accordingly.

Because children require more attention, we have to care for them differently than adults in every aspect of their medical care, including sleep apnea therapy. Pediatric sleep studies are harder to analyze, so it is important to have specially trained technicians to perform them.

However, these specially trained technicians and pediatric sleep specialists are hard to find. According to Gault, the greatest challenge pediatric sleep labs encounter is the limited availability of qualified providers. "There are 116 board-certified pediatric sleep specialists in the country, which is a sparse number available to make in-depth clinical decisions," Gault says. "Videography and EtCO₂ monitoring are important aspects that must be reviewed in conjunction with the study. Most adult sleep labs do not want to be involved with pediatric sleep studies because they require increased labor and time."

Serafino agrees that the pediatric population requires special knowledge and experience from health care providers. "At Gaylord, we work exclusively with DME providers who realize the importance of patient education and follow-up, and who have developed effective protocols for patient aftercare," he says. "The involvement of the DME provider is essential in keeping all sleep therapy patients adherent with their therapy. It is even more critical when treating a pediatric patient."

CLINICAL BACKGROUND

SDB is prevalent in 2% of pediatric patients and most common in children aged 2 to 5. Despite this small percentage, the effects of OSA in children should not be taken lightly. In fact, the American Sleep Apnea Association states that "childhood apnea is also associated with hyperactivity, inattentiveness, aggressive behavior, and mood swings—making apnea a major new area of study for doctors who deal with attention-deficit disorders."

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Other conditions that put children at risk for OSA include Down syndrome, Prader-Willi syndrome, craniofacial syndromes (micrognathia, dwarfism), cerebral palsy, mucopolysaccharidoses, neuromuscular disorders (including scoliosis), and Marfan syndrome. Studies show that 50% to 80% of those with Down syndrome have OSA. It is recommended that Down syndrome patients under 3 years old undergo polysomnography to test for SDB.

REAPING THE REWARDS

While treating pediatric SDB patients may be a daunting task for some clinicians, sleep lab technicians, and DME providers, the rewards are undoubtedly greater than the challenge. With pediatric patients, the benefits of sleep therapy take effect more quickly and are more noticeable than in adults, partly because patients are more compliant. As a result, parents are highly appreciative of those making a difference in their children's lives, developing a long-term relationship between the provider and the patient.

Kimberly Ake has 20 years of clinical experience in various areas of respiratory care, including acute care, subacute care in the hospital, cardiac and pulmonary rehabilitation, and home care. She specialized in neonatal and pediatric care as a respiratory therapist. Ake is currently regional clinical specialist for ResMed, providing SDB-focused clinical education to physicians, respiratory therapists, nurses, polysomnography technicians, and the general public. Hear Ake in person at Medtrade 2007 (Las Vegas) on April 24, 1:30 to 2:30 pm, in a presentation titled Pediatric Sleep-Disordered Breathing: Taking Baby Steps into the Market. Ake can be reached via e-mail: .