Vitamin D and Obstructive Sleep Apnea in Children

Vitamin D and Obstructive Sleep Apnea in ChildrenAlexandra DatiUF Dietetic InternJune 17, 201516/17/15OutlineObjectivesReview of sleep apneaSleep apnea in childrenVitamin D and sleep apneaImplications for practiceObjectivesObtain basic knowledge of obstructive sleep apneaUnderstand obstructive sleep apnea in childrenRecognize relationship of vitamin D and obstructive sleep apneaLearn clinical approaches to vitamin D and obstructive sleep apnea

Obstructive Sleep ApneaWhat is it?A sleep disorder that is marked by pauses in breathing of ten seconds or more during sleep, and causes unrestful sleepResults in oxygen desaturation and increased carbon dioxideNeed for increased respiratory effortCortical or subcortical arousalsSleeper will typically drift back to sleep and may not be aware of arousals56/17/15PathophysiologyThe tongue falls back against the soft palate, the soft palate and uvula fall back against the throat, effectively closing the airwayResult: when the sleeper expands the chest to inhale, no air enters the lungsSmall upper airwaySmall lower faceSmall mouthLarge tongueTonsil/adenoid enlargementIncreased pharyngeal fat pads Increased inBack sleepersMiddle-ageOverweightMaleHabib Mhenni/Wikimedia CommonsThe Nemours Foundation/KidsHealthtwo times more common in males

- As the graphic shows, the sleepers 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

66/17/15Obstructive sleep apneaSymptomsDiagnosisSnoringFatigueDaytime sleepinessRestless sleepMorning headaches, dry mouth, or sore throat

Medical and family historiesPhysical examSleep study resultsSleep 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 76/17/15PrevalenceAffects approximately 12 million Americans Mild, moderate, or severeHow many times a person pauses their breathing or has lower airflow per hourHow low a persons oxygen level in their blood drops during those timesThe amount of sleepiness a person feels during the dayObstructive Sleep Apnea In ChildrenPrevalenceEstimated 1%-5% of children have OSAPeak prevalence 2-8 yearsReduced airway caliber vs. increased upper airway collapsibilityMultiplicity of causative factors coexist in children with OSA

Children at higher risk include:Craniofacial syndromesDwarfismCerebral palsyNeuromuscular disordersSpina BifidaSickle cell diseaseTrisomy 21Seasonal allergiesAsthmaSmall lower jawLarge tongueLarge tonsils and adenoidsAfro Caribbean raceObesity

Airway caliber: small jaw, large tonge, increased pharyngeal fat pads, and large adenoids/tonsilsIncreased collabsibility: presence of upper airway inflammation and altered neurological reflexes involving respiratory control of upper airway muscles emerge as most prominent106/17/15Pathophysiological Factors involved in pediatric OSA

Obesity and OSAEach 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 obesityHunger cuesPhysical activityOne of the most significant risk factors for OSA in childrenRestricting the overall pharyngeal space126/17/15SymptomsNighttimeDaytimeSnoringExcessive sweatingBed wettingRestless sleepMouth breathingGaspingLabored breathingHyperextension of neckDifficulty concentratingBehavioral and mood problemsMorning headachesExcessive daytime sleepinessFailure to thriveMUCH MORE SCARCE THAN IN ADULTSRequire 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.

136/17/15Morbidity 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

146/17/15TreatmentAdenotonsillectomy For children with adenotonsillar hypertrophyResidual OSA may still exist CPAP/BIPAPAdherence 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/bilevelAdherence: particularly those with behavioral problems or developmental delays

156/17/15Vitamin DVitamin DFat-soluble vitaminSynthesized by body and found in food and supplementsBiologically inactive goes to liver and kidneys for processingMultiple functions in the bodyRequirementsInfants: 400 IUsChildren & teens: 600 IUs25-Hydroxyvitamin D> 20 ng/mL> 30 ng/mL

Functions: helps body absorb calcium, role in nerve, muscle, and immune systemsVitamin 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 fortified176/17/15Low vitamin DDeficiencyInadequate intake or sun exposureFat malabsorptive disorderImpaired liver or kidney hydroxylation Increases in frequency and severity of metabolic dysfunction, cardiovascular disease risk factors, and incidence of upper respiratory tract infectionsRecent 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

186/17/15http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Vitamin D levels and obstructive sleep apnea in childrenKheirandish-Gozel, Peris, Gozal, 2015Methods176 children underwent sleep studyMonitored for apnea events Plasma AssaysCRP, serum lipid levels, insulin levels, glucose levles25-hydroxyvitamin D

Overnight Polysomnographic 216/17/15ResultsSubdivision of childrenPresence or absence of obesity and OSAAfrican American children had lower vitamin D levels than Caucasian childrenNo differences according to age or genderChildren with OSA had higher total and and LDL cholesterol and lower HDL cholesterolSeverity 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)

226/17/15ResultsObese 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 dyslipidemiaThis 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 236/17/15ConclusionsLow vitamin D levels are associated with adverse outcomes in systemic inflammatory diseasesVitamin D levels are reduced in pediatric OSA, particularly in obese childrenVitamin D levels account for a proportion of the variance in insulin resistance pediatric OSAThe short-term and long-term significance of reduced 25-hydroxyvitamin D in pediatric OSA remains undefined

Implications for practiceWhat we can doObese children with OSA are may consume an unbalanced diet which may lead to reduced intake of vitaminsCheck vitamin levelsTreat as necessaryEncourage vitamin DVitamin D rich foodsSun exposureVitamin D supplementation

Such as vitamin D266/17/15Healthy lifestylePromote healthy dietPhysical activityLimit screen timePortion control

Vitamin D supplementationOver the counterRelatively inexpensive$5 for 100286/17/15ReferencesNational 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. Childrens 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.

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