1. Diagnosis

   1. Aetna considers nocturnal polysomnography (NPSG) for children and adolescents younger than 18 years of age with habitual snoring during sleep medically necessary when performed in a healthcare facility to differentiate primary snoring versus obstructive sleep apnea syndrome (OSAS). 

   2. Aetna considers NPSG for children medically necessary when performed in a healthcare facility after an adenotonsillectomy or other pharyngeal surgery for OSAS when any of the following is met (study should be delayed 6 to 8 weeks postoperatively):

      1. Age younger than 3 years; or
      2. Severe OSAS was present on preoperative polysomnography (a respiratory disturbance index of 19 or greater); or
      3. Cardiac complications of OSAS (e.g., right ventricular hypertrophy); or
      4. Failure to thrive; or
      5. Obesity; or
      6. Prematurity; or
      7. Recent respiratory infection; or
      8. Craniofacial anomalies; or
      9. Neuromuscular disorders; or

      10. Symptoms of OSAS persist after treatment.

   3. Aetna considers the use of abbreviated or screening techniques, such as videotaping, nocturnal pulse oximetry, daytime nap polysomnography, or unattended home polysomnography, experimental and investigational for diagnosis of OSAS in children because their effectiveness for this indication has not been established.

2. Treatment

   Aetna considers the following treatments for OSAS in children with habitual snoring medically necessary when the apnea index is greater than 1 on a NPSG.

   1. Aetna considers adenotonsillectomy medically necessary for treatment of OSAS in children. Childhood OSAS is usually associated with adenotonsillar hypertrophy, and the available medical literature suggests that the majority of cases will benefit from adenotonsillectomy.

   2. Aetna considers continuous positive airway pressure (CPAP) medically necessary for treatment of OSAS in children when any of the following is met:

      1. Adenotonsillectomy is delayed; or
      2. Adenotonsillectomy is contraindicated; or

      3. Adenotonsillectomy is unsuccessful in relieving symptoms of OSAS.

   3. Aetna considers oral appliances or functional orthopedic appliances medically necessary in the treatment of children with craniofacial anomalies with signs and symptoms of OSAS. 

   4. Aetna considers oral appliances or functional orthopedic appliances experimental and investigational for treatment of OSAS in otherwise healthy children.  There is insufficient evidence that oral appliances or functional orthopedic appliances are effective in the treatment of OSAS in healthy children.

   5. Aetna considers the following interventions experimental and investigational for obstructive sleep apnea in children (see CPB 4 - Obstructive Sleep Apnea in Adults):

      1. Uvulectomy;
      2. Laser-assisted uvuloplasty (LAUP);
      3. Somnoplasty or Coblation;
      4. Repose System;
      5. Injection snoreplasty;
      6. Cautery-Assisted Palatal Stiffening Procedure (CAPSO);
      7. Pillar Palatal Implant System;
      8. Flexible Positive Airway Pressure;
      9. Transpalatal advancement pharyngoplasty;
      10. Nasal surgery; and

      11. Mandibular distraction osteogenesis.

See also CPB 004 - Obstructive Sleep Apnea in Adults, CPB 330 - Multiple Sleep Latency Test (MSLT), CPB 452 - Noninvasive Positive Pressure Ventilation, and CPB 549 - Distraction Osteogenesis for Craniofacial Defects.

Obstructive sleep apnea syndrome (OSAS) is a disorder of breathing in which prolonged partial upper airway obstruction and/or intermittent complete obstruction occurs during sleep disrupting normal ventilation and normal sleep patterns. The signs and symptoms of OSAS in children include habitual snoring (often with intermittent pauses, snorts, or gasps) with labored breathing, observed apneas, restless sleep, and daytime neurobehavioral problems.  Nocturnal enuresis, diaphoresis, cyanosis, mouth breathing, nasal obstruction during wakefulness, adenoidal facies, and hyponasal speech may also be present.  Daytime sleepiness is sometimes reported but hyperactivity can frequently occur. Case studies report that OSAS in children can lead to behaviors easily mistaken for attention-deficit/hyperactivity disorder as well as behavioral problems and poor learning; however, most case studies have relied on histories obtained from parents of snoring children without objective measurements, control groups, or sleep studies.  Severe complications of untreated OSAS in children include systemic hypertension, pulmonary hypertension, failure to thrive, cor pulmonale, and heart failure. 

History and physical examination have been shown to be sensitive but not specific for diagnosing OSAS in children.  Primary snoring is often the presenting symptom reported by parents, and should warrant careful screening for OSAS.  Primary snoring is defined as snoring without obstructive apnea, frequent arousals from sleep or abnormalities in gaseous exchange.  It is estimated that 3 % to 12 % of children are habitual snorers but only 2 % will be diagnosed with OSAS.  Although surgical treatment has been shown to improve quality of life, it is not without risks (e.g., bleeding, velopharyngeal insufficiency, post-obstructive pulmonary edema). Thus, clinicians must be able to distinguish between primary snoring and OSAS.  Primary snoring among children without obstructive sleep apnea is usually considered a benign condition although this has not been well evaluated.

Nocturnal polysomnography (NPSG) remains the gold standard diagnostic test to differentiate primary snoring from OSAS in children.  It is the only diagnostic technique that is able to quantitate the ventilatory and sleep abnormalities associated with sleep-disordered breathing and can be performed in children of any age.  It should be noted that interpretation of NPSG values in children with OSAS is not unanimously agreed upon in the literature (Sargi and Younis, 2007) and only a limited number of studies designed to establish normal values for sleep-related respiratory variables in children have been reported.  However, based on normative data, an obstructive apnea index of 1 is frequently chosen as the threshold of normality.  Other normative values reported in the literature for children aged 1 to 15 years include: central apnea index 0.9; oxygen desaturation, 89%; baseline saturation, 92 %; and PETCO2 (end-tidal carbon dioxide pressure) greater than 45 mmHg for less than 10 % of total sleep time (Verhulst, 2007; Uliel, 2004; Schechter, 2002).

Studies have shown that abbreviated or screening techniques, such as videotaping, nocturnal pulse oximetry, and daytime nap polysomnography tend to be helpful if results are positive but have a poor predictive value if the results are negative. Unattended home polysomnography in children was evaluated by one center (Jacob, 1995) and produced similar results to laboratory studies; however, the equipment was relatively sophisticated and included respiratory inductive plethysmography, oximeter pulse wave form and videotaping.  Unattended home studies in children using commercially available 4  to  6-channel recording equipment has not been studied. Portable monitoring based only on oximetry is inadequate for identifying OSAS in otherwise healthy children (Kirk, 2003).

Treatment of OSAS in children depends on the severity of symptoms and the underlying anatomic and physiologic abnormalities. Childhood OSAS is usually associated with adenotonsillar hypertrophy, and the available medical literature suggests that the majority of cases (75 % to 100 %) will benefit from adenotonsillectomy (the role of adenoidectomy alone is unclear).  Other causes of pediatric OSAS include obesity, craniofacial anomalies, and neuromuscular disorders. Obese children may have less satisfactory results with adenotonsillectomy, but it is generally considered the first-line therapy for these patients as well.  If the patient is not a candidate for adenotonsillectomy, other treatment options include weight loss (if patient is obese) and continuous positive airway pressure (CPAP).  Nocturnal masks for CPAP or procedures for mask respiration are effective in children, but are only used in exceptional cases, such as when adenotonsillectomy is delayed, contraindicated, or when symptoms of OSAS remain after surgery.  Severely affected children may require uvulopalatopharyngoplasty (UPPP) or tracheostomy to relieve their obstruction; however, neither have been well studied in children and is rarely indicated.  The success of pharmacological treatment of OSAS in children has not been evaluated in controlled clinical trials (Erler and Paditz, 2004).

A Cochrane review (2007) on oral appliances and functional orthopedic appliances for obstructive sleep apnea in children 15 years old or younger reported that there is insufficient evidence to state that oral appliances or functional orthopedic appliances are effective in the treatment of OSAS in children.  Oral appliances or functional orthopedic appliances may be helpful in the treatment of children with craniofacial anomalies that are risk factors of apnea. 

According to the American Academy of Pediatric's Guidelines on Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome (2002), complex high-risk patients should be referred to a specialist with expertise in sleep disorders.  These patients include infants, and children with any of the following: craniofacial disorders, Down syndrome, cerebral palsy, neuromuscular disorder, chronic lung disease, sickle cell disease, central hypoventilation syndrome, and genetic/metabolic/storage diseases. 

Indications for a repeat NPSG after an adenotonsillectomy or other pharyngeal surgery for OSAS include (i) high-risk children, or (ii) if symptoms of OSAS persist after treatment.  High-risk children include those of age younger than 3 years, severe OSAS was present on pre-operative polysomnography (a respiratory disturbance index of 19 or greater), cardiac complications of OSAS (e.g., right ventricular hypertrophy), failure to thrive, obesity, prematurity, recent respiratory infection, craniofacial anomalies, and neuromuscular disorders.  Patients with mild to moderate OSAS who have complete resolution of signs and symptoms do not require repeat NPSG (AAP, 2002).

In a meta-analysis of mandibular distraction osteogenesis, Ow and Cheung (2008) concluded that mandibular distraction osteogenesis is effective in treating craniofacial deformities, but further clinical trials are needed to evaluate the long-term stability and to compare the treatment with conventional treatment methods, especially in cases of OSA or class II mandibular hypoplasia.