Treating sleep apnea helps children behave

According to this article, treating sleep apnea helps children behave.

Obstructive sleep apnea makes it nearly impossible to get a good night's sleep. Imagine air stopping in your throat, prompting you to choke anobesity, AHDH, and heart disease. If that weren't reason enough to seek treatment, maybe this will: A recent study conducted by the University of Michigan Health System found remedying a child’s sleep apnea improves their behavior, no matter if they have a low or high IQ.

"When a clinician sees a pediatric patient who has a problem in school, they ask about sleep," said Dr. Ronald Chervin, neurologist and director of the University of Michigan Sleep Disorders Center, in a statement. "We wondered, in high-performing children, do we still need to worry about snoring or sleep issues?"

Chervin and his colleagues recruited 147 children between the ages of 3 and 12 who were scheduled to undergo an adenotonsillectomy — a procedure that removes the patient’s tonsils and adenoids. Adenotonsillectomy is usually performed when children are suspected of having obstructive sleep apnea, which is characterized by enlarged tonsils and adenoids that stop children from breathing up to ten seconds throughout the night.

Researchers conducted sleep tests that monitored brain wave patterns, eye movements, heart rhythm, muscle activity, airflow out the nose and mouth, chest movements, and snoring. They then asked parents to grade their child's behavior with regard to inattention, hyperactivity, social problems, and perfectionism. The results showed children from both low and high IQ groups experienced similar behavioral improvements when they were reevaluated six months after the adenotonsillectomy.

"Regardless of intellectual level, we can expect to see some behavioral improvement along with better sleep," said Dr. Bruno Giordani, a professor of neurology, psychiatry, psychology, and nursing. "Once behavior improves, attention in school improves, and emotional ability and behavioral and impulsivity control improve."

Although children with high IQs were included in the study, identifying children with high IQs and obstructive sleep apnea is difficult in practice because they don't typically show problems with school performance. Spotting a child who is struggling from a lack of good sleep is a lot tougher than an adult who almost certainly will appear to be tired the next day, if not outright complain about it. Children, on the other hand, often react to a lack of sleep by being hyperactive the next day.

"Children with obstructive sleep apnea are fidgeting and not able to stay on task, because they're doing anything they can to stay awake," said Dr. Seockhoon Chung. "Even when those behavioral problems are minimal, improvement is still possible."

Studies have shown improved behavioral problems related to sleep apnea is imperative to ensuring these behaviors don't carry over into teenage years. A study presented at SLEEP 2012 found children with untreated obstructive sleep apnea suffered more from long-term behavioral problems, including aggression, hyperactivity, difficulty in controlling their behavior, and many other social and behavioral problems.

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Signs and treatments for obstructive sleep apnea in children

Obstructive sleep apnea in children may be missed due to misdiagnosis of symptoms such as hyperactivity, tossing and turning, and irregular breathing at night.

Is your hyperactive child having trouble learning at school? Does your son constantly toss and turn at night? Can you hear your daughter's irregular breathing during sleep?

All of these symptoms could be the result of obstructive sleep apnea, a serious but treatable disorder that can lead to health problems, behavioral issues and learning difficulties in children and adolescents.

"One to 4 percent of all children have obstructive sleep apnea, but many go undiagnosed and untreated because people do not recognize the symptoms," says Dr. Rochelle Goldberg, director of sleep medicine services at Main Line Health and an associate professor at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Further complicating matters is that some children with sleep apnea are misdiagnosed with attention deficit hyperactivity disorder because, unlike adults, disrupted sleep makes kids hyperactive, experts say.

"As many as 25 percent of children diagnosed with ADHD may in fact have obstructive sleep apnea," says Tracy Nasca, executive director of the American Sleep Apnea Association, a nonprofit organization based in the District of Columbia.

Blocked Airways Impede Breathing

Sleep apnea is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. People with untreated sleep apnea stop breathing repeatedly during sleep, often waking or almost waking multiple times during the night.

"The result is fragmented sleep that can impact every aspect of your life," Goldberg says.

Sleep apnea can occur at any age, but the prime ages for children to develop the condition is between 4 to 7 years, when the tonsils and adenoids are largest, Goldberg says. Those most at risk include males, children with special needs and youth who are obese.

"With increasing childhood obesity comes increasing risk for sleep apnea," Goldberg says, noting thatobesity among youth has skyrocketed in the past three decades. Obesity rates in children ages 6 to 11 increased from 7 to 18 percent from 1980 to 2012, while the rate in youth ages 12 to 19 jumped from 5 to 21 percent, according to the Centers for Disease Control and Prevention.

Hyperactivity in Sleepy Children

Diagnosing sleep disorders in children requires special expertise because youngsters respond differently than adults when it comes to a lack of sleep, says Amber McAfee, a pediatric nurse practitioner at the Sleep Center at Seattle Children's Hospital.

"Adults with sleep apnea may feel sluggish during the day," McAfee says. "But children with sleep apnea are quite active and may even be hyperactive. They may also start experiencing learning difficulties at school because they can't remember things as well."

Adds Goldberg: "Unfortunately some of these kids get mislabeled by their well-meaning teachers as having ADHD and start taking medications they don't need." She advises parents to seek the expertise of a pediatrician and pediatric sleep specialist before assuming their child has ADHD.

In recent years, more parents have been requesting sleep evaluations for children diagnosed with ADHD, McAfee says. "We have seen an improvement in hyperactivity after treatment and we have parents who report taking their children off medication for ADHD because their hyperactivity was related to sleep apnea," she says.

Nighttime symptoms between children and adults vary, too. Kids are more likely to be restless and wake up. "The symptoms are a little more subtle in kids because their brains are responsive," McAfee says. "The brain alerts them that they aren't breathing well."

Some children may sleep with their head hanging from the end of the bed as a way to extend their neck and open their air pathway, Goldberg says. At times, children with sleep apnea may experience increased bedwetting or a recurrence of bedwetting.

Expert Diagnosis and Treatment

Experts recommend that parents whose children are experiencing sleep problems or sudden difficulties at school visit a certified pediatric sleep specialist for evaluation and testing, including an overnight sleep study, to rule out or confirm a diagnosis.

"We do a lot of hand holding and comforting," says Nasca, who assures parents that pediatric specialists can provide a child-friendly diagnostic experience. "Many pediatric sleep labs allow a parent to spend the night in the testing room and also encourage the children to bring a favorite 'blankie' or stuffed animal to create a more home-like sleep setting."

At Seattle Children's Hospital, parents are welcome to stay at the Sleep Center while their children are monitored overnight. Monitors gather information about brain activity, oxygen levels, heart rate, sleep quality and stages, eye movement, air flow, limb movement and more.

"I tell kids they're going to sleep like a robot for one night," McAfee says. The Sleep Clinic conducts approximately 200 sleep studies a month.

For many youngsters, surgically removing the tonsil and adenoids can resolve sleep apnea. Children who are overweight or obese may also need to focus on weight loss, experts say.

Some children find relief by wearing a nasal mask that uses continuous positive airway pressure, also known as CPAP. "CPAP is 100 percent effective in improving your breathing," McAfee says. "But only about 40 percent of the pediatric population wear the mask effectively through the night."

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New quality measures for treating childhood sleep apnea

New quality measures for treating childhood sleep apnea have been developed to ensure that assessing and treating the condition are followed.

A work group of physicians from leading academic medical centers across the country, including NYU Langone Medical Center, has developed new quality measures for the detection and treatment of childhood obstructive sleep apnea (OSA), a potentially morbid, life-altering condition that affects hundreds of thousands of children and adolescents nationwide. The measures, commissioned and endorsed by the American Association of Sleep Medicine (AASM), are published on March 15 in a special section of The Journal of Clinical Sleep Medicine.

Several different practice guidelines already exist for diagnosing and treating childhood OSA. The newly proposed measures, however, differ from existing guidelines in that they measure and track the quality of services provided by clinicians. According to Pediatric OSA Workgroup lead author Sanjeev V. Kothare, MD, Director of the Pediatric Sleep Program at NYU Langone Medical Center, the new metrics will help to ensure that guidelines for assessing and treating childhood OSA are actually followed.

"Guidelines recommend a course of action, but quality metrics document what is actually done," says Dr. Kothare

The new quality measures have important implications for both providers and patients, according to Dr. Kothare. "Providers, especially those who don't regularly diagnose OSA as part of their clinical practices, will have greater guidance in utilizing optimal detection and treatment processes," he says. "Likewise, parents of OSA patients, as they become aware of the new metrics, will be more likely to confirm that the recommended steps are being taken by their child's physician. And payers will benefit, too. They will be able to better monitor providers' documented clinical processes. By observing the AASM-recommended quality metrics, providers also will avoid being penalized by insurers."

Currently, there is no standardization of methods for detection, management and assessing outcomes for pediatric OSA across clinical disciplines. Children with OSA may be seen by a number of different physicians: general practitioners, pediatricians, otolaryngologists, and sleep specialists, all of whom may have different approaches to assessing symptoms, performing physical exams, and creating different action plans. A primary care physician, for instance, might refer the patient to a specialist, a sleep specialist might order a polysomnogram (PSG), and an otolaryngologist might perform surgery. Each of these actions is endorsed by the American Academy of Pediatrics' clinical practice guidelines.

Recognizing this variability, the Pediatric OSA Workgroup focused on offering choices and flexibility to clinicians while ensuring that certain minimal practice standards are maintained. To develop the new metrics, the workgroup examined a total of 960 peer-reviewed journal articles that addressed quality care or metrics in OSA, concentrating on the articles that provided either an empirical basis for selection of outcome measures, or which linked processes to outcomes. The papers were graded on the strength of association between processes and desired outcome.

Through this analysis, the workgroup was able to define five desirable processes for pediatric patients with suspected OSA: 1) assessment of symptoms and risk factors, 2) initiation of an action plan, 3) evaluation of high-risk children, 4) reassessment of OSA within 12 months, and 5) documentation of positive airway pressure (PAP) adherence.

Following these processes, the researchers conclude, should lead to two desirable outcomes: 1) improved detection, and 2) reduced signs and symptoms of childhood OSA. Justifications for exceptions to each process were noted and classified as having medical, patient, or system reasons.

Pediatric OSA is thought to affect up to 5 percent of children in the U.S., although experts think the actual prevalence may be greater because OSA symptoms often go unrecognized. In the disorder, the upper airway continually collapses during sleep, leading to oxygen deprivation and multiple partial awakenings. Because OSA interferes with the deep, restorative slow wave sleep that is vital for normal childhood growth and development, it can have lingering complications that can persist through adulthood. Children with OSA may become moody and irritable and have learning and behavioral problems, including difficulty paying attention and hyperactivity, mimicking ADHD. They can develop the symptoms of metabolic syndrome, including hypertension, abnormal blood lipid levels, and type 2 diabetes. Adults whose OSA went untreated as children are at increased risk of having earlier onset for heart attacks.

OSA also creates imbalances in the body's appetite-controlling hormones, ghrelin and leptin. In a vicious cycle, the hormonal imbalance increases appetite, leading to weight gain, which can exacerbate OSA.

The most common symptom of childhood OSA is frequent snoring, sometimes accompanied by gasping or choking. Other nighttime symptoms include tossing and turning in bed, labored breathing, night sweats, and need to urinate many times throughout the night. The main causes of pediatric OSA are large tonsils or adenoids, obesity, cranio-facial abnormalities, and genetic disorders, such as Down syndrome.

An example of how the new metrics could improve care is that existing guidelines recommend that children at high risk of OSA, such as those with Down syndrome, be evaluated by having a sleep study every year. That recommendation, however, is not always followed. With adoption of the new metrics that guideline is more likely to be heeded because clinicians will risk being penalized by payers if it is not.

"Quality measures are now in place in neurology and several other specialties," says Dr. Kothare. "Other medical disciplines will soon follow. Metrics are the mantra of the future, and will help ensure that patients are getting the best care possible."

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