1. Pediatric OSA in Obesity:
Challenges in Treatment
Baha Al-Shawwa, MD, FCCP Associate Professor of Pediatrics Director of Sleep Medicine
Pediatric Sleep Fellowship Program Director
Children’s Mercy Hospital
© The Children's Mercy Hospital, 2017

2. Disclosure
None

3. Aim Obesity pandemic in children Relationship of Obesity and SDB
Pathogenesis
Treatment options

4. Childre
KANSAS CIT

5. Prevalence* of Self-Reported Obesity Among U.S. Adults
BRFSS, 2012
*Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to those before 2011.
15%–<20%
20%–<25% 25%–<30%
30%–<35%
≥35%

6. by State and Territory, BRFSS, 2016
Prevalence¶ of Self-Reported Obesity Among U.S. Adults
by State and Territory, BRFSS, 2016
¶ Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before 2011.
No state had a prevalence of obesity less than 20%
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

7. 17% of children are Obese
:The prevalence of obesity has remained fairly stable at about 17% and affects about 12.7 million children and adolescents.

8. Prevalence of obesity* among children and adolescents, ages 5– 19, 1975–2016 (crude estimate): Both sexes, 2016-WHO 8

9. Association between
OSA & Obesity

10. Prevalence of OSA in children
Graff et al, Sleep 2009;32(6):

11. Prevalence of OSA in children
(Preschoolers)
N= 60 participants included
Mean age was 4.4 years (± 1.7),
Mean BMI z-score was 3.0 (SD ± 1.2).
22/60 (36.6%) had OSA (AHI > 2/hr) 11

12. More OSA in Morbidly Obese Children
OSA increases as BMI increase
Karla et al, OBESITY RESEARCH Vol. 13 No. 7 July 2005

13. More obesity in OSA patients
Redline et al, AM J RESPIR CRIT CARE MED 1999;159:1527–1532.

14. More obesity in OSA patients
Redline et al, AM J RESPIR CRIT CARE MED ;159:1527–1532.

15. Pathophysiology of OSA in Obese Children
Mechanical Factors
Adeno-tonsillar hypertrophy
Adipose tissue
Restrictive Pulmonary impairment and Decrease FRC leading to more hypoxia, hypoventilation
Functional Factors
Altered neuromuscular tone leading to increase collapsibility
Increased tissue inflammation leading to more collapsibility

16. OSA
Obesity ?

17. Insulin Resistance/ MS
OSA
Obesity
Insulin Resistance/ MS
Inflammation
Sleep disruption duration EDS/ Energy Level Leptin/ Ghrelin/ Cortisol Eating pattern Cardiovascular/HTN

18. Meta-analysis Sleep Duration and Obesity in Children

19. Insulin Resistance/ MS
OSA
Obesity
Insulin Resistance/ MS
Inflammation
Sleep disruption duration EDS/ Energy Level Leptin/ Ghrelin/ Cortisol Eating pattern Cardiovascular/HTN 19

20. EDS and Obesity/OSA
50 obese and 50 non-obese children (6-9 yrs) underwent PSG and MSLT
Obese children had MSL 12.9 min vs min in non-obese
Obese children had lower MSL (more sleepy) in any level of OSA
More EDS lead to decrease level of activity and less energy expenditure and Obesity
Gozal et al, Pediatrics 2009;123:13–18

21. Insulin Resistance/ MS
OSA
Obesity
Insulin Resistance/ MS
Inflammation
Sleep disruption duration EDS/ Energy Level Leptin/ Ghrelin/ Cortisol Eating pattern Cardiovascular/HTN

22. Sleep Fragmentation and inflammation
Kim and Gozal et al, Respir Physiol Neurobiol September 30; 178(3): 465–474.

23. Insulin Resistance/ MS
OSA
Obesity
Insulin Resistance/ MS
Inflammation
Sleep disruption duration EDS/ Energy Level Leptin/ Ghrelin/ Cortisol Eating pattern Cardiovascular/HTN

24. Gozal 2012, Ann. N.Y. Acad. Sci. ISSN 0077-8923

25. Treatment Effect
© The Children's Mercy Hospital, 2017

26. A Randomized Trial of T&A
Childhood Adenotonsillectomy Trial (CHAT)
464 children (5 to 9 years) with OSA
Comparison between
Early adenotonsillectomy or a strategy of watchful waiting.
Polysomnographic, cognitive, behavioral, and health outcomes were
assessed at baseline and at 7 months
Improvement in behavioral, QOL, PSG finding (79% compared to 46%)
with early intervention
But did not significantly improve attention or executive function as measure by neuropsychological testing
Marcus et al, N Engl J Med June 20; 368(25): 2366–2376

27. A Randomized Trial of T&A Childhood Adenotonsillectomy Trial (CHAT)
Normalization of Polysomnographic Findings
Marcus et al, N Engl J Med June 20; 368(25): 2366–2376

28. Effect of T&A in obese children
578 children (mean age, 6.9 ± 3.8 yr)
50% were obese.
Adeno-Tonsilectomy resulted in a significant AHI reduction from
18.2 to 4.1 /hour (P < 0.001).
Only 157 (27.2%) had complete resolution of OSAS (AHI < 1/hr)
Gozal et al, Am J Respir Crit Care Med Vol 182. pp 676–683, 2010

29. Effect of T&A in obese children
Gozal et al, Am J Respir Crit Care Med Vol 182. pp 676–683,

30. Effect of T&A in obese children
Gozal et al, Am J Respir Crit Care Med Vol 182. pp 676–683,

31. Effect of T&A in obese children
Gozal et al, Am J Respir Crit Care Med Vol 182. pp 676–683,

32. Effect of T&A in obese children
Gozal et al, Am J Respir Crit Care Med Vol 182. pp 676–683, 2010

33. Effect of T&A in obese children
Meta-analysis of 110 obese children
underwent T&A
Results
49% had AHI < 5/hr
25% had AHI < 2/hr
12% had AHI < 1/hr
Otolaryngology -- Head and Neck Surgery April :

34. Effect of T&A in obese children
100 90 80 70
87%
81%
Meta-analysis
51 studies
3413 subjects were enrolled
61% 60 50 40 30 20 10
56%
51%
34%
AHI < 1/hr Total
AHI < 5/hr Non-Obese
Obese 34
Clin Otolaryngol.2016 Oct;41(5):

35. Long term effect of A &T
Amin et al, Am J Respir Crit Care Med Vol 177. pp 654–659, 2008

36. Effect of OSA after Bariatric Surgery
Amin et al, OBESITY RESEARCH Vol. 13 No. 7 July 2005

37. Children'sMercy
KANSAS CITY

38. Obesity Hypoventilation (Pickwikian Syndrome)
Significant Hypoventilation with or without OSA
High morbidity and mortality
Needs aggressive therapy and NIV
Think about ROHHAD

39. ROHHAD
Rapid-onset obesity, hypothalamic dysfunction, hypoventilation and autonomic dysfunction
Used to be named LO-CHS (late onset central hypoventilation syndrome)
Starts usually with very rapid weight gain but the
hypothalamic dysfunction may comes years later
Think about it and continue to follow the patient closely

40. Children'sMercy
KANSAS CITY

41. Gozal et all, Proc Am Thorac Soc Vol 5. pp 274–282, 2008

42. Conclusions Obesity is a pandemic SDB is very common in Obese patients
The interaction between OSA and obesity goes both way
T & A is less helpful in obese children with OSA compared to non- obese children
Close follow up and repeating of PSG is important in obese children since a very high chance of residual disease (may be more important than having the baseline study)

43. Thank you

44. 44