Sleep Medicine in Special Populations and Comorbid Disease
What you must know
Pediatrics: OSA in children often presents with snoring, mouth breathing, and adenotonsillar hypertrophy; adenotonsillectomy is first-line for most. Pediatric PSG uses different scoring rules (e.g., hypopnea criteria, obstructive apnea ≥1 event). Behavioral insomnia of childhood responds to extinction and bedtime routines.
Pregnancy: OSA risk rises with gestational weight gain and edema; snoring and hypertension warrant evaluation. Supine sleep position in late pregnancy is associated with stillbirth; encourage side sleeping.
Older adults: insomnia and sleep-disordered breathing are common; benzodiazepines increase fall and cognitive risk. Advanced sleep phase is more common.
Comorbid disease: OSA worsens atrial fibrillation, hypertension, and stroke; treat appropriately. COPD-OSA overlap requires careful titration. Chronic kidney disease and heart failure interact with sleep apnea and restless legs.
Traps
- Applying adult AHI thresholds to children.
- Missing OSA in a child with attention problems and snoring.
- Forgetting pregnancy supine-position risk.
- Overlooking drug interactions and fall risk in older adults.
Rule of thumb
"In children, think adenotonsillar hypertrophy and behavior; in pregnancy, think position and blood pressure."
Worked example
A 6-year-old with snoring, mouth breathing, and daytime inattention has tonsillar hypertrophy. Refer for adenotonsillectomy evaluation; PSG if severe or comorbid.