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 ID: 677678
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Slide1
Vitamin D and Obstructive Sleep Apnea in Children
Alexandra Dati
UF Dietetic Intern
June 17, 2015Slide2
Outline
Objectives
Review of sleep apnea
Sleep apnea in children
Vitamin D and sleep apnea
Implications for practiceSlide3
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 apneaSlide4
Obstructive Sleep ApneaSlide5
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
su
b
cortical
arousals
Sleeper will typically drift back
to sleep and may not be aware of
arousalsSlide6
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
L
arge tongue
Tonsil/adenoid enlargement
Increased pharyngeal fat pads
Increased inBack sleepersMiddle-ageOverweightMale
Habib M’henni/Wikimedia Commons
The Nemours Foundation/
KidsHealthSlide7
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 resultsSlide8
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 daySlide9
Obstructive Sleep Apnea In ChildrenSlide10
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
BifidaSickle cell diseaseTrisomy 21
Seasonal allergiesAsthmaSmall lower jawLarge tongueLarge tonsils and adenoidsAfro Caribbean race
Obesity Slide11
Pathophysiological Factors involved in pediatric OSASlide12
Obesity and OSA
Each 1 kg/m
2
increment in BMI above the 50
th
percentile is associated with an increased risk for OSA by 12%
45% if obese children with OSA also have evidence of
adenotonsillar
hypertrophy
R
eciprocal interaction
OSA may be contributing to pathogenesis of obesityHunger cuesPhysical activitySlide13
Symptoms
Nighttime
Daytime
Snoring
Excessive sweating
Bed wetting
Restless sleep
Mouth breathing
Gasping
Labored breathing
Hyperextension of neck
Difficulty concentrating
Behavioral and mood problemsMorning headachesExcessive daytime sleepinessFailure to thrive
MUCH MORE SCARCE THAN IN ADULTSSlide14
Morbidity of Pediatric OSASlide15
Treatment
A
denotonsillectomy
For children with
adenotonsillar
hypertrophy
Residual OSA may still exist
CPAP/BIPAP
Adherence can be challengingSlide16
Vitamin DSlide17
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/mLSlide18
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
R
ecent
preliminary study suggested that children at risk for
adenotonsillectomy may exhibit lower serum 25-hydroxyvitamin D concentrationsSlide19
http://
ods.od.nih.gov
/factsheets/
VitaminD-HealthProfessional
/Slide20
Vitamin D levels and obstructive sleep apnea in children
Kheirandish-Gozel
,
Peris
,
Gozal
, 2015Slide21
Methods
176 children underwent sleep study
Monitored for apnea events
Plasma Assays
CRP, serum lipid levels, insulin levels, glucose
levles
25-hydroxyvitamin DSlide22
Results
Subdivision of children
Presence or absence of obesity and OSA
African
A
merican 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
S
everity
of OSA were not significantly different in obese and non-obese children with OSA. Slide23
Results
Obese children without OSA had lower
vitamin D levels
than non-obese children without OSA
N
on
-obese children with OSA also exhibited lower
vitamin D
levels compared to non-obese controls
O
bese
children with OSA demonstrated the lowest 25-hydroxyvitamin D levels Low vitamin D levels are associated with insulin resistance but not dyslipidemiaSlide24
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 Slide25
Implications for practiceSlide26
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
V
itamin D rich foods
S
un exposure
Vitamin D supplementationSlide27
Healthy lifestyle
Promote healthy diet
Physical activity
Limit screen time
Portion controlSlide28
Vitamin D supplementation
Over the counter
Relatively inexpensiveSlide29
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.