Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

Abstract

To the Editor.—I have major reservations in respect to the recent clinical practice guideline on obstructive sleep apnea syndrome (OSAS).1 Although it is important to alert pediatricians to the existence of this condition, the ramifications of following the guideline do not appear to have been given adequate consideration.The authors signed letters stating they did not have a conflict of interest. I assume this means they do not run polysomnography (PSG) labs, as an obvious consequence of the report will be a markedly increased demand for their use.One problem concerns children with primary snoring (PS). This can be seen, according to the report, in up to 12% of preschool-aged children. Furthermore, there is apparently no way to rule out OSAS in these children, without doing PSG. The unmistakable conclusion, therefore, is that up to 12% of preschool-aged children should be undergoing PSG. Do other pediatricians find this concept as ludicrous as I do?A second issue concerns those children with mild OSAS, mild meaning that they are not demonstrating obvious problems such as daytime somnolence or pulmonary hypertension. These children are diagnosed when their sleep studies are found to be abnormal (ie, at the tail end of the distribution curve). The guideline indicates, in one sentence in the section on research recommendations, that the natural history of these children is not known. That did not stop the committee from recommending that these children undergo adenotonsillectomy, however, even though it is not known whether mild OSAS is an actual disease or merely a statistical finding.In summary, I believe the guideline to be poorly thought out, and it goes beyond the available evidence in its recommendations. I strongly recommended the report be retracted until the scientific knowledge is available to warrant revisiting the subject.In Reply.—Dr Farber’s letter provides us with the opportunity to furnish some additional perspective on the clinical practice guideline on obstructive sleep apnea syndrome (OSAS). I believe that his chagrin suggests that our committee was successful at communicating that OSAS is a common but underappreciated problem in childhood whose diagnosis is difficult. Perhaps we were less successful at conveying and explaining the rationale for our evidence-based diagnostic and therapeutic approaches.Although my 20-page technical report1 may have appeared somewhat foreboding, it can be summarized simply as showing (page numbers refer to the technical report): In my opinion, these points are clearly supported by published literature.Contrary to Dr Farber’s assertion, the guideline2 does not suggest that every child who snores needs overnight PSG. On pages 705 and 706, it states: This point is further reiterated in the flow diagram (Fig 1) provided with the guideline. As a former pediatrician in private practice, I realized when we submitted them that these guidelines would be disturbing, as they run counter to “common wisdom” and against the flow of typical current pediatric primary care. Periodically throughout my own career, pediatricians have received new recommendations (regarding immunization practices, asthma, otitis media, occult bacteremia, etc) that have initially seemed “ludicrous” but then eventually become accepted as routine. OSAS is a common problem that is responsible for significant and often unrecognized childhood morbidity. I believe that the conclusions of our committee are a logical response to the data as currently known. As for the concern that insurance companies will not pay for overnight PSG in children, I would counter that practice guidelines such as ours will make it easier to obtain these studies, and place the onus on the insurer to justify denial of service. This should not feel threatening to the concerned practitioner.In Reply.—We appreciate the interest displayed in the recent clinical practice guideline on the obstructive sleep apnea syndrome (OSAS).1Dr Farber is concerned that the authors of the guideline may have been influenced by economic reasons. This is a valid concern and raises an area of controversy. One would hope that the Committee members writing the guidelines would be experts with experience in the topic covered, but any expert in the area is likely to be affiliated with a sleep laboratory. Of the 4 members of the Committee with specific training and expertise in sleep medicine (all of whom are full-time, salaried medical school faculty), 1 receives some income derived from reviewing sleep studies, and 3 are members of academic pulmonary divisions that have sleep labs and, therefore, indirectly receive some income from the labs. To balance any possible bias, the Committee also included a general pediatrician, an otolaryngologist and an epidemiologist, none of whom receives income related to PSG. It should be noted that the Pulmonology section worked very closely with the Section on Otolaryngology and Bronchoesophagology (represented on the Co