Obstructive sleep apnea in children: Different approaches for screening, management, and patient engagement

• Author / Creator

  Fernandes Fagundes, Nathalia Carolina

• BACKGROUND: The disruption of normal respiratory and ventilation patterns during sleep, also called sleep-disordered-breathing (SDB), is a condition that may vary from simple snoring to obstructive sleep apnea (OSA). The heterogeneity of this disorder may result in difficulties in diagnosis and management, which may contribute to increased costs to the healthcare system and negative consequences for children and their families. The most common line of treatment for pediatric OSA is adenotonsillectomy (T&A), and the persistence of OSA after T&A is called residual OSA. Some orthodontic management options, such as rapid maxillary expansion and mandible repositioning, have displayed short-term improvement in pediatric OSA signs and symptoms; however, the association between craniofacial morphology and pediatric OSA is still mostly unclear. Beyond the craniofacial perspective, patients’ experiences with OSA management alternatives may provide insights into their impact on sleep quality and their interaction with health services. The goals of this thesis are to (i) evaluate the role of craniofacial screening in identifying children at high-risk for OSA, (ii) understand parents’ experiences with services for managing residual pediatric OSA and (iii) set up a prospective cohort study to assess the impact of orthodontic management alternatives in a group of children with residual OSA.
  METHODS: To evaluate the role of craniofacial screening in identifying children at high-risk for OSA, a systematic review, three cross-sectional studies were completed. The systematic review explored the association between skeletal and soft craniofacial features in children with pediatric OSA. The first prospective study evaluated facial 3D stereophotogrammetry's effectiveness as a screening tool for pediatric OSA when used by dental specialists from a sample of children fully diagnosed with pediatric OSA through nocturnal polysomnography (PSG) or at high- or low-risk of pediatric OSA. In the second prospective study, we investigated the role of craniofacial features as a means of identifying phenotypes of children with OSA symptoms, using a clustering analysis method to identify and characterize craniofacial phenotypes. The retrospective study evaluated differences in mandibular cortical width (MCW) among children diagnosed with OSA or at high- or low-risk for OSA. Parents' experiences with services for managing pediatric OSA were explored through a qualitative descriptive study. Finally, a protocol to develop a cohort study investigating the impact of orthodontic treatment among children with residual OSA was proposed.
  RESULTS: Our systematic review suggested that neither an association nor a lack thereof between craniofacial features and pediatric OSA could be supported at this time. In both the prospective and the retrospective studies, even though a soft facial features analysis did not show reasonable results to be used alone as a pediatric OSA screening tool by dental specialists, some specific craniofacial features were associated to pediatric OSA. A reduced mandibular cortical width was observed among children diagnosed with or at high risk of OSA compared to healthy children. Children from 7-9 years with suspected OSA, without obesity, and moderate severity of obstructive sleep events, presented mildly arched palate, higher upper facial height, and higher mandible dimensions; however, children from the same age range and sleep features with obesity presented different craniofacial features suggestive of orthodontic treatment need, including excessive lower facial height and midface deficiency. Overall, parents reported that their actions and the services received from several care providers at primary, secondary, and tertiary levels of care were largely ineffective or suboptimal in addressing the sleep issue that negatively affected their children’s sleep quality and life. Based on these findings and considering the need to better understand the role of orthodontic treatment among children with residual OSA, a cohort study evaluating the effectiveness of orthodontic interventions compared to a control group is proposed.
  CONCLUSION: Soft craniofacial features, mandibular cortical width, and specific craniofacial features may help explain the heterogeneity and complexity of pediatric OSA and describe children with and without obesity presenting a high risk for the condition. However, soft-craniofacial-based tools alone cannot be used as a screening tool. Specific phenotyping may be the best way to identify a subgroup of pediatric OSA children that could be screened based on their craniofacial features or that would directly benefit from specific orthodontic interventions. There is also a suggested need for improving the effectiveness of services to deal with sleep issues.

• Subjects / Keywords

  • Obstructive sleep apnea
  • Child
  • Face

• Graduation date

  Spring 2023

• Type of Item

  Thesis

• Degree

  Doctor of Philosophy

• DOI

  https://doi.org/10.7939/r3-0rg2-6j61

• License

  This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.