Optimal infant sleep habits may help prevent childhood obesity

"When parents keep babies up longer, they just sleep less". 

"the babies in the bedtime techniques group gaining weight more slowly than the control group, and less likely to be overweight by age one"- JR

Healthy infant sleep habits may help prevent childhood obesity

Perfect Baby (free image labeled for reuse. Not a patient)

-Review of research published in JAMA Pediatrics discussing the importance of regulating an infant's sleep schedule. -JR

US research out this week suggests that teaching parents techniques to help encourage healthy sleep habits in their children could help to prevent obesity. The new study, conducted by Penn State College of Medicine researchers, could lead to a new intervention technique to help tackle the growing levels of obesity worldwide.

The team studied the use of the intervention using data from the INSIGHT study (Intervention Nurses Start Infants Growing on Healthy Trajectories), a longitudinal trial study which looks at how responsive parenting intervention can prevent obesity.

A total of 291 mother and baby pairs were recruited, with the mothers randomly assigned to one of two groups.

One group was given obesity prevention education that covered sleep-related behaviours, bedtime routines, improving sleep duration and avoiding feeding and rocking to sleep. The other group, a control, were given safety education about preventing sudden infant death syndrome.

The study showed that the infants of parents who had learned the bedtime techniques went to bed earlier, had a more consistent bedtime routine, and slept for longer than the infants whose parents had been given safety education.

The infants were also more likely to self-soothe to sleep without being fed, and were less likely to be fed back to sleep when they awoke during the night.

And at nine months, infants who both self-soothed and went to bed by 8 p.m. slept for on average 80 minutes longer or more than those whose bedtimes were after 8 p.m. and did not self-soothe.

In addition, the team saw that the intervention also had a positive effect on obesity as well as sleep, with the babies in the bedtime techniques group gaining weight more slowly than the control group, and less likely to be overweight by age one.

Misconceptions about infant sleep

Commenting on the findings lead author Ian M. Paul had this advice for parents, “A lot of parents try to keep their babies up longer, thinking that then they’ll sleep longer at night and they won’t wake up. We found that’s not true. When parents keep babies up longer, they just sleep less.”

“If you want your baby to sleep longer and better, put them to sleep earlier. Regardless of what time you put babies to sleep, they wake overnight. If we don’t set the expectation that they’re going to be picked up and fed, they learn to soothe themselves back to sleep.”

In addition to helping prevent obesity, better sleep habits also have added health benefits for both parents and children, with lack of sleep previously shown to have a negative effect on a child’s development and parents’ psychological well-being.

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What causes poor sleep, and how do I get better sleep?

This article discusses health conditions that cause a person to get poor sleep, and discusses things everyone can do to get better sleep.

With any illness, injury or sniffle, you'll hear one common suggestion: Get plenty of rest. Whether we're nursing a broken bone or trying to recover from the flu, we are led to believe that adequate sleep will put us right on the path to recovery. But just how important is sleep, and what about those of us who can't seem to get quality sleep?

Lack of sleep is linked to several health concerns:

Colds, flu, viruses and infections. One of the first systems to be adversely affected by lack of quality sleep is immune function. When you're tired, you feel worn down -– and that's not just a feeling. Your body is using all energy reserves to fight off the viruses and exposure to germs that might not affect a person with a thriving immune system. Also, if you receive vaccines, the sleep-deprived are slow to respond to the immunity the vaccines are designed to build.

Heart disease. According to Donna Arand, clinical director of the Kettering Sleep Disorder Centers in Dayton, Ohio, lack of sleep causes an inflammatory response to the cardiovascular system. Rises in C-reactive protein due to impaired sleep are warning signs that the body is responding to a perceived injury, infection or disease. In this case, lack of sleep is that perceived threat that results in inflammation. Poor sleep also causes the body to produce more stress hormones, which may contribute to cardiovascular disease. Chronic stress coupled with lack of quality sleep causes double trouble for the heart, arteries and ventricles.

Diabetes. In the past decade, there has been growing evidence that too little sleep can affect hormones and metabolism in ways that promote diabetes. According to a study published in the Lancet in 1999, healthy men with a week of impaired sleep –- only four hours a night –- showed dramatic changes in glucose tolerance. They also had higher-than-normal glucose levels after just one week. This study involved healthy people with no previous record of insulin resistance or history of diabetes.

For those already diagnosed with diabetes, sleep deprivation leads to extremely poor blood sugar control. These studies do not include control factors of the snowball effect that often starts with losing a night's sleep. Sleepy people don't usually reach for healthy foods as snacks and meals. They don't usually choose to walk during their lunch break -– or head to the weight room after work. Tight glucose control involves nutrition and exercise parameters, and both of those are adversely affected by just one night of impaired sleep.

How Can We Improve Our Sleeping Patterns? 
1. Keep the bedroom for sleep and sex. Don't let the bedroom become the home office. Keep the clutter and distraction of that quickly approaching timeline out of the bedroom. Keep a cool temperature, and design the room for its purpose. Walking into your bedroom should be a clear change from the rest of the house.

2. Put down the screens. An hour or more before bedtime, put down the computer, smartphone and TV. Dim the lights throughout the house, and start getting your mind ready to wind down. Some people use blackout shades in the bedroom during the summer months. Before electricity, people stayed awake two or three hours past dusk with candlelight, and their natural circadian rhythms prompted them to sleep. There's a lot of research that links artificial light –- including blue-light from screens -– with interrupted sleep patterns. If we're staying up six or more hours past dusk with fluorescent light glowing, our bodies don't know when it’s time to sleep.

3. Pay attention to what you eat and drink before bedtime. Try not to go to bed ravenous or stuffed. Be aware that a glass of wine might help calm the nerves, but metabolizing alcohol keeps the body in an alert mode while the mind is trying to snooze. Have that glass of wine earlier in the evening. And yes, eating bad pizza right before bed can cause nightmares. So can stuffing yourself with any food minutes before trying to sleep. Your body is trying to do two things: metabolize food and sleep. The food is going to win, and that's a cause for dreams and other disruptions to quality sleep.

4. Move your body. There is substantial evidence that exercise helps you sleep. Even moderate exercise like a daily walk promotes better sleep -– in terms of quality and quantity. Be careful with your exercise timing, so you're not too energized with endorphins to sleep. There's also a direct link between exercise and stress, and stress is a big factor in sleep-deprived people. Move your body. Manage your stress. Get quality sleep.

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Too little sleep impairs children's health

This article explains how getting too little sleep impairs a child's health.

In a new study, children who regularly got too little sleep had worse physical, emotional and social health than those who slept the average amount.

"Sleep is important for a lot of reasons, and can influence health and well-being and cognitive functioning," said lead author Christopher A. Magee. "The typical sleep pattern appeared to have the best outcomes as measured in this paper," he told Reuters Health in an email.

But since this is a relatively new area of research, the researchers can't say for sure that this pattern of sleep causes better health and wellbeing, said Magee, of the University of Wollongong in Australia.

Genetics do influence the regulation of sleep, but the results suggest that environmental and social factors, like household financial hardship, may play a role as well, he said.

The researchers used Medicare Australia data from a group of almost 3,000 children to track the kids' health and quality of life at four points between birth and seven years of age.

Parents completed sleep journals and answered interview questions about their children's sleep patterns, and included how often their children had experienced problems like difficulty waking, feeling sad, problems socializing or missing school due to illness, which were meant to rate the child's overall quality of life.

Researchers divided the kids into four groups based on their sleep patterns: "typical sleepers" slept the most as infants, about 14 hours, and gradually decreased their sleep duration until age seven, when they got an average of almost 11 hours per night.

"Persistent short sleepers" showed a similar decline in sleep hours over time, but they always got about an hour less sleep than the typical sleepers. Only 11 percent of kids fell into this group.

"Initially short sleepers" started out like the short sleepers, but by age five or six were getting as much sleep as typical sleepers. This group included 45 percent of the kids, followed by typical sleepers, who made up 40 percent.

Less than three percent of kids had the most unusual sleep pattern, which started short, with sleeps of less than 10 hours in infancy, gradually increasing with time. Researchers called this group the "poor sleepers."

Poor and initially short sleepers tended to have a lower physical functioning score on the quality of life scale than typical sleepers. Persistent short sleepers also had the physical disadvantage, as well as lower emotional and social functioning scores, according to the results published in Pediatrics.

Following one group of kids for seven years helps to focus on the problem of too little sleep as a chronic issue, not just one bad night, said Dr. Elsie M. Taveras, director of Pediatric Population Health Management at Massachusetts General Hospital in Boston.

Taveras worked on a similar study published in the same issue of the journal, following 1,000 kids from age six months to seven years, and found that kids who chronically slept too little tended to have more body fat at age seven than longer sleepers.

Kids who had shortened sleep most often were more than twice as likely to be obese than kids who rarely or never had short sleep duration. That's a significant increase in risk, she said.

"Two times the odds of obesity for any risk factor for obesity is very rare," she said.

In Taveras' study, short sleepers not only had more fat, but more abdominal fat than longer sleepers.

"Abdominal fat is particularly hazardous for later cardiometabolic diseases," like diabetes and heart disease, she told Reuters Health by phone.

Taking the results of her study with the results of the Australian quality of life study, the amount of sleep kids get seems to be linked to a huge number of areas of health, she said.

According to recommendations from the National Sleep Foundation and the National Heart, Lung and Blood Institute, toddlers need more than 12 hours of sleep per day, children up to four years old need between 10 and 11 hours and up to age seven kids should get at least 10 hours, Taveras said.

"For many children, good sleep could be promoted by having regular bedtimes, limiting household noise, and limiting TV viewing and electronic media near bedtime," Magee said, but some sleep problems like sleep apnea or primary insomnia may need specialized treatment.

"If a child has persistent problems sleeping and this is impacting on their normal daily activities, then it may be a good idea to seek some advice," he said. "A general practitioner could be a good starting point."

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Not getting enough sleep adds to health problems in teens

A study shows that teenagers increase their risk of developing health issues due to  getting too little sleep (6 hours or less). Electronics in the bedroom are blamed for getting too little sleep.

Many teens from lower- and middle-income homes get too little sleep, potentially adding to the problems of kids already at risk for health issues, new research finds.

The study of 250 high school students found they slept an average of six hours a night, far less than the recommended amount -- about nine hours.

Kids who skimp on sleep are more likely to report feeling hopeless, as well as smoke, drink alcohol and use marijuana, according to background information in the report, published online April 21 in Pediatrics.

"Many teenagers, especially blacks, do not get enough sleep, which may contribute to their risk for poor health," said lead researcher Karen Matthews, a professor of psychiatry at the University of Pittsburgh School of Medicine.

"Inadequate sleep can result in academic underachievement, health-damaging behaviors and negative mood," she said.

Matthews said sleep deprivation isn't confined to the poor. "Many kids who come from upper class families also do not get enough sleep, but our study focused on poorer children because of a lack of data available in those [upper class] students," she said.

The researchers wondered if the challenges of living in disadvantaged circumstances would affect sleep patterns. In their sample, 60 percent of the kids lived in single-family homes. Overall, the kids were heavier than national average, the researchers said.

Matthews isn't sure why these teens aren't sleeping enough. "However, factors that determine bedtime play a key role for sleep duration because of mandatory school start times," she said.

"Bedtimes can be quite late if students are using electronic devices late into the evening, and bright light exposure [from these devices] can keep them up," she said.

Late-night studying was not a factor in this sample, Matthews said.

Dr. Metee Comkornruecha, an adolescent medicine specialist at Miami Children's Hospital, said the study shows "what a lot of us are thinking -- that adolescents aren't getting enough sleep."

Kids are prone to a lot of distractions, he said. "Cell phones are used not only for texting but to look on the Internet and for various types of social media. That frequent stimulation can keep these kids up."

Comkornruecha recommended removing electronic distractions from the bedroom. "Take the phones, computer and TVs away from the bedroom. If they're there, kids are going to use them. But if the bedroom is a safe haven for sleeping, then that's what it is going to be used for," he said.

Among the students whose sleep patterns were monitored, 57 percent were black and 54 percent were girls. All came from low- to middle-class families.

Matthews said besides looking at kids from poorer families, they wanted to look at any differences by race because two studies of middle-aged adults suggested that blacks had worse sleep than whites. "Thus, we conducted our study at an integrated high school that had black and white students of similar economic backgrounds," Matthews added.

The researchers had the students complete questionnaires and keep a diary of the length and quality of their sleep. At night, the teens were hooked up to an electronic device that monitored their sleep.

On school nights, the teens slept about six hours, and on the weekend, about seven hours. Matthews' team found that blacks and males slept less than other kids, and their sleep was more fragmented. Girls reported poorer quality of sleep and said they were often tired during the day.

The researchers previously reported that insufficient sleep is linked to higher blood pressure and insulin resistance, a risk factor for diabetes.

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Children who get more sleep weigh less

A study claims that children who sleep more weigh less than their sleepier counterparts. This shows how important getting enough sleep is to children and their health.

Getting a good night's rest is an essential part of our every-day health. It's as simple as that.

The American Psychological Association shows that as many as 40 million Americans suffer from over 70 different sleep disorders, and 60 percent of adults report having sleep problems a few nights a week or more. Not enough sleep can greatly interfere with daily activities, create moodiness and instability in an individual's life and can also be a contributor to weight gain, among other health problems.

A recent study shows that more than ever, sleep is particularly important for children-and this can play a major contribution to losing weight.

"Achieving a good night's sleep during childhood should be explored as an important strategy to enhance prevention and intervention approaches for obesity," said associate professor of public health at Temple University's Center for Obesity Research and Education in Philadelphia, Chantelle Hart. She is also the lead study author of the research.

While looking at a three-week study involving 37 children ages 8 to 11, findings suggest that increasing sleep could help decrease food intake over time and improve weight regulation in this age group.

The children who added sleep tended to eat less, with an average of 134 calories a day. They also shed about half a pound on average and had lower morning levels of the hormone leptin-a 16-kDa adipokin that plays a key role in weight regulation.

Researchers are hoping to determine if sleep over a longer period may help prevent weight loss, as well.

"The evidence is incredibly strong and consistent that a short list of lifestyle factors has a phenomenal influence on weight, health and even gene expression," Dr. David Katz, director of the Yale University Prevention Research Center in New Haven, Conn. said, via Health.

Combined with a good night's rest, physical activity, eating a healthy diet, not smoking and stress reduction, these all play an important role in helping lose or maintain a healthy weight.

While adults can scrap by with eight hours a night, the National Sleep Foundation suggests that children and teens may need more.

For instance, school-aged children should get 10 to 11 hours a night while teens need around 9.25 hours of sleep, according to the organization.

At the end of their research, study authors note that while there is not a solid link between more sleep and weight loss, it potentially opens the door for greater research regarding the topic.

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Why is sleep so important to maintaining a healthy lifestyle?

This article discusses three studies, all which show how important sleep is in order to maintain a healthy lifestyle.

Three new studies show just how critical it is for adults to seek treatment for a sleep illness and aim for seven to nine hours of sleep each night in order to maintain a healthy lifestyle.

One study of 2,240 adults is the first to examine the link between obstructive sleep apnea (OSA) and mortality in Asians. Results show that all-cause mortality risk was 2.5 times higher and cardiovascular mortality risk was more than 4 times higher among people with severe OSA. The results are consistent with previous studies in the U.S. and other countries.

Another study of 2,673 patients in Australia found that untreated OSA is associated with an increased risk of motor vehicle crashes in very sleepy men as well as near-misses in men and women. Participants with untreated OSA reported crashes at a rate three times higher than the general community.

That last study examined the relationship between sleep duration and self-rated health in Korean adults. Results show that short sleep duration of 5 hours or less per day and long sleep duration of 9 hours or more per day was associated with poor self-rated health. The results add weight to recent data emphasizing the importance of adequate sleep in physical and mental health.

All three of the studies are in the Oct. 15 issue of the Journal of Clinical Sleep Medicine, which is published by the American Academy of Sleep Medicine.

The AASM reports that at least 12 to 18 million adults in the U.S. have untreated obstructive sleep apnea, which involves the repetitive collapse of the upper airway during sleep. OSA is a serious sleep illness that is associated with an increased risk of high blood pressure, heart disease, diabetes, depression and stroke. The most effective treatment option for OSA is CPAP therapy, which helps keep the airway open by providing a stream of air through a mask that is worn during sleep.

Most adults need about seven to eight hours of nightly sleep to feel alert and well rested. However, 30 percent of adults in the U.S. regularly get insufficient sleep.

Help for people who have OSA or another sleep problem is available from board certified sleep medicine physicians at more than 2,500 AASM accredited sleep disorders centers.

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Childhood Epilepsy, Memory, and Health Quality - No Connection to Seizure Frequency

Children with epilepsy and poor memory, in this study,  appear to have lower health-related quality of life.

Interestingly, this finding is not connected to seizure frequency.

As an illness, there is an experience that is broader than just the "seizures". 

Ask your neurologist about cognitive, attention, and emotional problems. Assess your child's sleep. Assess the effects of medications. Bone health, nutrition, weight gain and loss are all common problems. - JR

Poor memory in children with epilepsy linked to lower health related quality of life

(dailyRx News) Memory is often an area of concern for people with epilepsy. For children who are just learningabout the world around them, memory can be of particular importance to their physical, mental, emotional and social development.

A recent study investigated the link between memory and health-related quality of life - or how overall well-being is affected over time by disease, disability or other health issues - in children with epilepsy.

The study found that verbal, emotional difficulty and behavioral problems were associated with a lower health-related quality of life more than other factors, including frequent and intense seizures.

Marianne Hrabok, PhD, of the Alberta Children’s Hospital Research Insititute in Calgary, Alberta, Canada, and colleagues studied 90 children with epilepsy at a children’s hospital.

The number and frequency of seizures in the children varied. Thirty-seven percent of children had fewer than one seizure a month while 15 percent had more than one seizure a day.

Verbal skills and health-related quality of life assessments were examined. The researchers also looked at intellectual function, executive function, behavior and ability to adapt.

Details on socio-demographic factors and neurological status were included in the study.

Gender, age and socioeconomic status are examples of socio-demographic factors. Number of antiepileptic drugs and seizure severity are examples of neurological status.

The researchers found that health-related quality of life was not associated with socio-demographic and neurologic factors.

However, neuropsychological factors - including verbal memory, IQ, executive function, emotional and behavioral function and adaptability - were associated with health-related quality of life. Memory, emotional function and behavioral function had a particular relationship to health-related quality of life.

Those with low verbal memory had a two times greater risk of low health-related quality of life than those who did not have low verbal memory. Those with emotional and behavioral difficulty had a 10 times greater risk of low health-related quality life than those without the difficulty.

Having both low verbal memory and emotional and behavioral difficulty resulted in a risk 17 times greater than not having those difficulties.

The study authors believe these results showed the importance in neuropsychological assessment. Identifying those with poor memory and emotional function could help doctors identify those more likely to have a low health-related quality of life.

The authors suggested that psychosocial interventions for children with epilepsy include a team of health professionals with varying disciplines, an emphasis on involvement of the parents, psychological education, cognitive and behavioral strategies and the development of coping skills. Past studies have shown that a six-week program that includes these factors can improve health-related quality of life.

The study was published in Pediatrics. The research received no external funding. The authors did not report any conflicts of interest.

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What Immediate Health Problems are Linked to Childhood Obesity

Researchers at UCLA shows that childhood obesity has negative immediate health effects in addition to the well-studied long-term health issues.

While a great deal of research on childhood obesity has spotlighted the long-term health problems that emerge in adulthood, a new UCLA study focuses on the condition's immediate consequences and shows that obese youngsters are at far greater risk than had been supposed.

Compared to kids who are not overweight, obese children are at nearly twice the risk of having three or more reported medical, mental or developmental conditions, the UCLA researchers found. Overweight children had a 1.3 times higher risk.

"This study paints a comprehensive picture of childhood obesity, and we were surprised to see just how many conditions were associated with childhood obesity," said lead author Dr. Neal Halfon, a professor of pediatrics, public health and public policy at UCLA, where he directs the Center for Healthier Children, Families and Communities. "The findings should serve as a wake-up call to physicians, parents and teachers, who should be better informed of the risk for other health conditions associated with childhood obesity so that they can target interventions that can result in better health outcomes."

With the dramatic rise in childhood obesity over the past two decades, there has been a parallel rise in the prevalence of other childhood-onset health conditions, such as attention deficit-hyperactivity disorder, asthma and learning disabilities. But previous studies on the topic have been limited due to a narrow focus on a specific region of the county, a small sample size or a single condition.

The new UCLA research, a large population-based study of children in the United States, provides the first comprehensive national profile of associations between weight status and a broad set of associated health conditions, or co-morbidities, that kids suffer from during childhood.

Overall, the researchers found, obese children were more likely than those who were classified as not overweight to have reported poorer health; more disability; a greater tendency toward emotional and behavioral problems; higher rates of grade repetition, missed school days and other school problems; ADHD; conduct disorder; depression; learning disabilities; developmental delays; bone, joint and muscle problems; asthma; allergies; headaches; and ear infections.

For the study, the researchers used the 2007 National Survey of Children's Health, analyzing data on nearly 43,300 children between the ages 10 and 17. They assessed associations between weight status and 21 indicators of general health, psychosocial functioning and specific health disorders, adjusting for sociodemographic factors.

Of the children in the study, 15 percent were considered overweight (a body mass index between the 85th and 95th percentiles), and 16 percent were obese (a BMI in the 95th percentile or higher).

The study, which is currently available online, will be published in the January-February print issue of the journal Academic Pediatrics.

The UCLA researchers speculate that the ongoing shift in chronic childhood conditions is likely related to decades of underappreciated changes in the social and physical environments in which children live, learn and play. They propose that obesity-prevention efforts should target these social and environmental influences and that kids should be screened and managed for the co-morbid conditions.

The researchers add that while the strength of the current study lies in its large population base, future studies need to examine better longitudinal data to tease out causal relationships that cannot be inferred from a cross-sectional study.

"Obesity might be causing the co-morbidity, or perhaps the co-morbidity is causing obesity -- or both might be caused by some other unmeasured third factor," Halfon said. "For example, exposure to toxic stress might change the neuroregulatory processes that affect impulse control seen in ADHD, as well as leptin sensitivity, which can contribute to weight gain. An understanding of the association of obesity with other co-morbidities may provide important information about causal pathways to obesity and more effective ways to prevent it."

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Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

• It is very gratifying to see the AAP strongly endorse our practice's message! I am happy that my practice can make state of the art sleep assessment and treatment available to the children of Texas.  JR
• 
  
• From the American Academy of Pediatrics

Clinical Practice Guideline

Diagnosis and Management of   

Childhood Obstructive Sleep Apnea 

Syndrome

1. Carole L. Marcus, MBBCh, 
2. Lee Jay Brooks, MD, 
3. Kari A. Draper, MD,
4. David Gozal, MD, 
5. Ann Carol Halbower, MD, 
6. Jacqueline Jones, MD,
7. Michael S. Schechter, MD, MPH, 
8. Stephen Howard Sheldon, DO, 
9. Karen Spruyt, PhD, 
10. Sally Davidson Ward, MD, 
11. Christopher Lehmann, MD, and
12. Richard N. Shiffman, MD

Next Section

ABSTRACT

OBJECTIVES: This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting.

METHODS: Of 3166 articles from 1999–2010, 350 provided relevant data. Most articles were level II–IV. The resulting evidence report was used to formulate recommendations.

RESULTS AND CONCLUSIONS: The following recommendations are made. 

(1) All children/adolescents should be screened for snoring. 

(2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. 

(3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy

(4) High-risk patients should be monitored as inpatients postoperatively. 

(5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. 

(6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. 

(7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. 

(8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.

This practice guideline focuses on uncomplicated childhood OSAS—that is, the OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. This guideline specifically excludes infants younger than 1 year of age, patients with central apnea or hypoventilation syndromes, and patients with OSAS associated with other medical disorders, including but not limited to Down syndrome, craniofacial anomalies, neuromuscular disease (including cerebral palsy), chronic lung disease, sickle cell disease, metabolic disease, or laryngomalacia. These important patient populations are too complex to discuss within the scope of this article and require consultation with a pediatric subspecialist.

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