Dear Dr. Gwenn,

Our son (aged 29 months) was referred to ENT for sleep apnea. The overnight monitor showed his O2 levels to be low, but not enough to warrant a tonsillectomy.

However, his resting pulse rates through the night set off the monitor alarm for dropping below 56, should we be worried and push for a further consultation?

Signed,
R.H.

Dear RH:

Thank you for your question. Let me give you some background on some of the details to help you make an informed decision about what is best for your son.

There are a number of issues to consider. First, the diagnosis of sleep apnea in children is more clinical than test-dependent. Interpreting sleep studies in kids is not easy and there is no clear consensus on criteria for those studies. So, if your child is snoring and has behavioral changes the next day, likely your child has sleep apnea that requires intervention with a tonsillectomy. However, if your child has no daytime symptoms, the surgery is likely unnecessary. The ENT you consulted seems to be focusing on the test results, not the big picture. Talk to your pediatrician and if you are still not comfortable a second ENT consult with a pediatric ENT would be a good idea.

Interpreting oxygen saturation and heart rate is difficult in kids because the probes don't always pick up. Any movement can produce a false alarm that a low number is present when in fact it is just that the probe can not read the data accurately. The big picture is more important than any one isolated number. So, if your child is snoring but find during the day, likely the sleep issues are not impacting him. However, if he is exhausted during the day and having behavioral issues, then his sleep is disturbed.

The ENT literature does support the diagnosis of sleep apnea clinically and also highlights the need to not over read the sleep studies due to how inaccurate they can be in kids. Here's some links for more information on the diagnosis of sleep apnea and current thinking:

http://www.entnet.org/ent-press/pressreleases/ASPO3.cfm

http://www.entlink.net/ent-press/pressreleases/COSM2003_10.cfm

http://www.entlink.net/KidsENT/apnea.cfm

As for the heart rate, that is difficult to evaluate without knowing what was occurring at that point in the sleep study. Your pediatrician or the medical staff performing the test can tell you best. Like with oxygen saturations, there can be aberrant readings on a heart rate monitor that do not reflect the child's true rate.

Finally, as I mentioned earlier, the reason for a second opinion is two fold:

1. You are not comfortable with the initial advice 2. Your son has daytime symptoms that imply his sleep is disturbed at night.

I find parents have a very fine tuned sixth sense when it comes to their kids. Trust that sense and pursue this a little more.

Best,
Dr. Gwenn

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About the Author
Pediatrician, Dr. Gwenn Schurgin O'Keeffe, MD, is a board-certified pediatrician and Fellow of the American Academy of Pediatrics. Dr. Gwenn is an experienced columnist, educator, and practicing pediatrician. Dr. Gwenn strives to write as if she were talking to a parent. As a parent herself, she knows how important it is to obtain information but also understand how precious little time parents have to find that information on the internet. Pediatrics Now was developed to fill that gap and provide a bridge between the parenting and pediatrics worlds.

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