Vitamin D and Obstructive Sleep Apnea in Children 6/17/15 Vitamin D and Obstructive Sleep Apnea in Children Alexandra Dati UF Dietetic Intern June 17, 2015

Outline Objectives Review of sleep apnea Sleep apnea in children Vitamin D and sleep apnea Implications for practice

Objectives Obtain basic knowledge of obstructive sleep apnea Understand obstructive sleep apnea in children Recognize relationship of vitamin D and obstructive sleep apnea Learn clinical approaches to vitamin D and obstructive sleep apnea

Obstructive Sleep Apnea

6/17/15 What is it? A sleep disorder that is marked by pauses in breathing of ten seconds or more during sleep, and causes unrestful sleep Results in oxygen desaturation and increased carbon dioxide Need for increased respiratory effort Cortical or subcortical arousals Sleeper will typically drift back to sleep and may not be aware of arousals

6/17/15 Pathophysiology The tongue falls back against the soft palate, the soft palate and uvula fall back against the throat, effectively closing the airway Result: when the sleeper expands the chest to inhale, no air enters the lungs Small upper airway Small lower face Small mouth Large tongue Tonsil/adenoid enlargement Increased pharyngeal fat pads Increased in Back sleepers Middle-age Overweight Male two times more common in males - As the graphic shows, the sleeper’s tongue has fallen back against the soft plate, the soft palate has collapsed against the back of the throat, and both the nasal and the oral airways are obstructed, creating apnea The Nemours Foundation/KidsHealth Habib M’henni/Wikimedia Commons

Obstructive sleep apnea 6/17/15 Obstructive sleep apnea Symptoms Diagnosis Snoring Fatigue Daytime sleepiness Restless sleep Morning headaches, dry mouth, or sore throat Medical and family histories Physical exam Sleep study results Sleep study- polysomnogram- records brain activity, eye movements, heart rate, and blood pressure; records amount of oxygen in the blood, air movement through your nose while you breathe, snoring, and chest movements. Sensors on scalp, face, chest, limbs, and finger

Prevalence Affects approximately 12 million Americans Mild, moderate, or severe How many times a person pauses their breathing or has lower airflow per hour How low a person’s oxygen level in their blood drops during those times The amount of sleepiness a person feels during the day

Obstructive Sleep Apnea In Children

Prevalence Estimated 1%-5% of children have OSA 6/17/15 Prevalence Estimated 1%-5% of children have OSA Peak prevalence 2-8 years Reduced airway caliber vs. increased upper airway collapsibility Multiplicity of causative factors coexist in children with OSA Children at higher risk include: Craniofacial syndromes Dwarfism Cerebral palsy Neuromuscular disorders Spina Bifida Sickle cell disease Trisomy 21 Seasonal allergies Asthma Small lower jaw Large tongue Large tonsils and adenoids Afro Caribbean race Obesity Airway caliber: small jaw, large tonge, increased pharyngeal fat pads, and large adenoids/tonsils Increased collabsibility: presence of upper airway inflammation and altered neurological reflexes involving respiratory control of upper airway muscles emerge as most prominent

Pathophysiological Factors involved in pediatric OSA

6/17/15 Obesity and OSA Each 1 kg/m2 increment in BMI above the 50th percentile is associated with an increased risk for OSA by 12% 45% if obese children with OSA also have evidence of adenotonsillar hypertrophy Reciprocal interaction  OSA may be contributing to pathogenesis of obesity Hunger cues Physical activity One of the most significant risk factors for OSA in children Restricting the overall pharyngeal space

Symptoms MUCH MORE SCARCE THAN IN ADULTS Nighttime Daytime Snoring 6/17/15 Symptoms MUCH MORE SCARCE THAN IN ADULTS Nighttime Daytime Snoring Excessive sweating Bed wetting Restless sleep Mouth breathing Gasping Labored breathing Hyperextension of neck Difficulty concentrating Behavioral and mood problems Morning headaches Excessive daytime sleepiness Failure to thrive Require high level of suspicion or alternatively, require systematic implementation of explorative screening questions to enable their detection Studies have suggested that as many as 25 percent of children diagnosed with attention-deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea and that much of their learning difficulty and behavior problems can be the consequence of chronic fragmented sleep. Bed-wetting, sleep-walking, retarded growth, other hormonal and metabolic problems, even failure to thrive can be related to sleep apnea. Some researchers have charted a specific impact of sleep disordered breathing on "executive functions" of the brain: cognitive flexibility, self-monitoring, planning, organization, and self-regulation of affect and arousal.

Morbidity of Pediatric OSA 6/17/15 Morbidity of Pediatric OSA OSA is strongly associated with the presence of insulin resistance and altered lipid homeostasis, as well as with systemic inflammation and endothelial dysfunction, and an increased prevalence of respiratory illnesses that lead to higher healthcare utilization costs

Treatment Adenotonsillectomy CPAP/BIPAP 6/17/15 Treatment Adenotonsillectomy For children with adenotonsillar hypertrophy Residual OSA may still exist CPAP/BIPAP Adherence can be challenging Residual primarily in obese children, children who had severe OSA before surgery (AHI . 20/hour TST), older children (those aged .7 years), and children with asthma PAP- positive airway pressure; continuous/bilevel Adherence: particularly those with behavioral problems or developmental delays

Vitamin D

Vitamin D Fat-soluble vitamin 6/17/15 Vitamin D Fat-soluble vitamin Synthesized by body and found in food and supplements Biologically inactive  goes to liver and kidneys for processing Multiple functions in the body Requirements Infants: 400 IUs Children & teens: 600 IUs 25-Hydroxyvitamin D > 20 ng/mL > 30 ng/mL Functions: helps body absorb calcium, role in nerve, muscle, and immune systems Vitamin D has other roles in the body, including modulation of cell growth, neuromuscular and immune function, and reduction of inflammation  Milk, infant formula, cereals, and some other foods are fortified

Low vitamin D Deficiency 6/17/15 Low vitamin D Deficiency Inadequate intake or sun exposure Fat malabsorptive disorder Impaired liver or kidney hydroxylation Increases in frequency and severity of metabolic dysfunction, cardiovascular disease risk factors, and incidence of upper respiratory tract infections Recent preliminary study suggested that children at risk for adenotonsillectomy may exhibit lower serum 25- hydroxyvitamin D concentrations Interventions aimed at increased 25(OH)D concentrations have resulted in improvements in these outcomes

http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Vitamin D levels and obstructive sleep apnea in children Kheirandish-Gozel, Peris, Gozal, 2015 Vitamin D levels and obstructive sleep apnea in children

Methods 176 children underwent sleep study Plasma Assays 6/17/15 Methods 176 children underwent sleep study Monitored for apnea events Plasma Assays CRP, serum lipid levels, insulin levels, glucose levles 25-hydroxyvitamin D Overnight Polysomnographic

Results Subdivision of children 6/17/15 Results Subdivision of children Presence or absence of obesity and OSA African American children had lower vitamin D levels than Caucasian children No differences according to age or gender Children with OSA had higher total and and LDL cholesterol and lower HDL cholesterol Severity of OSA were not significantly different in obese and non-obese children with OSA. 4 groups, based on the presence or absence of obesity (OB) and OSA (i.e., OSA-NOB, NOSA-NOB, OSA-OB, NOSA-OB)

6/17/15 Results Obese children without OSA had lower vitamin D levels than non-obese children without OSA Non-obese children with OSA also exhibited lower vitamin D levels compared to non-obese controls Obese children with OSA demonstrated the lowest 25- hydroxyvitamin D levels Low vitamin D levels are associated with insulin resistance but not dyslipidemia This study shows that both obese children and children with OSA exhibit significantly lower 25(OH)D plasma levels when compared to healthy controls, even when adjusted for ethnicity

Conclusions Low vitamin D levels are associated with adverse outcomes in systemic inflammatory diseases Vitamin D levels are reduced in pediatric OSA, particularly in obese children Vitamin D levels account for a proportion of the variance in insulin resistance pediatric OSA The short-term and long-term significance of reduced 25- hydroxyvitamin D in pediatric OSA remains undefined

Implications for practice

6/17/15 What we can do Obese children with OSA are may consume an unbalanced diet which may lead to reduced intake of vitamins Check vitamin levels Treat as necessary Encourage vitamin D Vitamin D rich foods Sun exposure Vitamin D supplementation Such as vitamin D

Healthy lifestyle Promote healthy diet Physical activity Limit screen time Portion control

Vitamin D supplementation 6/17/15 Vitamin D supplementation Over the counter Relatively inexpensive $5 for 100

6/17/15 References National Institutes of Health. Obstructive Sleep Apnea. Pub Med Health Web site. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024431/. N.D. American Sleep Apnea Association. Obstructive Sleep Apnea. ASAA Web site. Available at http://www.sleepapnea.org/learn/sleep-apnea/obstructive-sleep-apnea.html. N.D. Tan HL, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: a critical update. Nature and Science of Sleep. 2013;5:109-123. Schmidt-Nowara W. Patient Information:Sleep Apnea in Adults (Basic and Beyond). UpToDate Web site. Available at http://www.uptodate.com/contents/sleep-apnea-in-adults-beyond-the-basics. Updated July 2, 2014. National Institutes of Health. How is Sleep Apnea Diagnosed? National Heart Lung and Blood Web site. Available at http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/diagnosis. Published July 10, 2012. Eisenber JM. Treating Sleep Apnea. Pub Med Health Web site. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0016158/. Published August 8, 2011. American Sleep Apnea Association. Children’s Sleep Apnea. ASAA Web site. Available athttp://www.sleepapnea.org/treat/childrens-sleep-apnea.html. N.D. US National Library of Medicine. Vitamin D. MedlinePlus Web site. Available at http://www.nlm.nih.gov/medlineplus/vitamind.html. Updated May 19, 2015. Pazirandeh S, Burns DL. Overview of Vitamin D. UpToDate Web site. Available at http://www.uptodate.com/contents/overview-of-vitamin-d. Updated May 8, 2014. Kheirandish-Gozel L, Peris E, Gozal D. Vitamin D Levels and Obstructive Sleep Apnea in Children. Sleep Medicine. 2014;15(4):459-463.