Saturday, June 30, 2012

A window of opportunity for intervention? Early identification of sleep problems in preschool children with behavioral problems.

This is a very interesting article. It is well known that children develop cognitive problems when they have sleep apnea. IQ drops. Neuronal in the hippocampus  is lost.  However,  there may be a window to intervene early  before the evolution of cognitive problems.  

This article suggests that children with behavioral problems should be screened for sleep apnea early before cognitive problems are noted. JR

Sleep-disordered breathing in preschool children is associated with behavioral, but not  cognitive, impairments.


 2012 Jun;13(6):621-31. Epub 2012 Apr 13.Psychological Sciences, The University of Melbourne, Melbourne, Australia.



Sleep-disordered breathing (SDB) has been associated with impaired cognitive and behavioral function in school children; however, there have been limited studies in preschool children when the incidence of the disorder peaks. Thus, the aim of this study was to compare cognitive and behavioral functions of preschool children with SDB to those of non-snoring control children.


A clinical sample of 3-5year-old children (primary snoring [PS], n=60; mild obstructive sleep apnea syndrome [OSAS], n=32; moderate/severe [MS] OSAS, n=24) and a community sample of non-snoring control children (n=37) were studied with overnight polysomnography. Cognitive performance and behavioral information were collected.


Children with PS and mild OSAS had poorer behavior than controls on numerous measures (p<.05-p<.001), and on some measures they had poorer behavior than the MS OSAS group (p<.05). In contrast, all groups performed similarly on cognitive assessment. Outcomes related more to sleep than respiratory measures.


SDB of any severity was associated with poorer behavior but not cognitive performance. The lack of significant cognitive impairment in this age group may have identified a "window of opportunity" where early treatment may prevent deficits arising later in childhood.

Reflux and Sleep Apnea in Children - Its a two way street!

This is a very interesting article. For years we have known that sleep apnea exacerbates reflux. Also, we know the treatment of reflux reduces fragmentation of sleep. This is exciting article showing an improved response  in sleep apnea due to reflux treatment. JR

Original Article

Respiratory response to proton pump inhibitor treatment in children with obstructive sleep apnea syndrome and gastroesophageal reflux disease

  • Jolanta WasilewskaaCorresponding author contact informationE-mail the corresponding author
  • Janusz Semeniuka
  • Beata Cudowskaa
  • Mark Klukowskib
  • Katarzyna DÄ™bkowskac
  • Maciej Kaczmarskia
  • a Department of Pediatrics, Gastroenterology and Allergology, Medical University of Bialystok, Waszyngtona Street 17, 15-274 Bialystok, Poland
  • b Department of Pharmacology, Medical University of Bialystok, Waszyngtona Street 17, 15-274 Bialystok, Poland
  • c Department of Business Informatics and Logistics, Technical University of Bialystok, Tarasiuka Street 2, 16-001 Kleosin, Poland

 Link to abstract

Full-size image (26K)Full-size image (3K)



Evaluation of the respiratory response to proton pump inhibitors (PPI) in children with obstructive sleep apnea syndrome (OSAS) and gastroesophageal reflux disease (GERD).


Of 131 children diagnosed with OSAS (Apnea Hypopnea Index, AHI >1/h), 37 children (6.9 years; 28.24%) with GERD symptoms (>3 times/week) were included. Overnight polysomnography with 24 h pH-metry was performed before and after 4–8 weeks of PPI treatment (omeprazole once a day, 1 mg/kg).


Of 37 children, 21 were diagnosed with acid GERD where pre- and post-treatment reflux indexes were 14.09 ± 1.47 vs. 7.73 ± 1.36; (p < 0.001). The number of obstructive apneas and hypopneas decreased after PPI treatment, resulting in an AHI reduction from 13.08 ± 3.11/h to 8.22 ± 2.52/h; (p < 0.01). Respiratory response to PPI ranged from complete resolution of OSA (three children with mild OSA; AHI < 5/h; 10.31 years; 14.29%) to lack of significant AHI change (six children with severe OSA; AHI > 10/h; 3.62 years; 28.57%). Post-treatment AHI was predicted by pre-treatment reflux index (adjusted R2 = 0.487;p < 0.001).


Reduction of obstructive respiratory events following short-term PPI treatment in children with both GERD and OSAS may suggest a causal relationship between apnea and reflux in some children. Questionnaire screening for GERD in children with OSAS may be of benefit.


  • Obstructive sleep apnea syndrome; 
  • Gastroesophageal reflux disease; 
  • Omeprazole; 
  • Polysomnography; 
  • pH metry; 
  • Reflux Index

Devices help determine potential concussions on the field

For almost a decade, helmet-maker Riddell has gauged the frequency and severity of head impacts through helmets lined with sensors that communicate wirelessly to the sidelines. But Able "wanted to develop a technology that provided impact data for all sports, not just helmeted sports."
The result is the X2 Impact, an electronics-packed mouth guard that records direction, force and number of impacts to the head, then wirelessly sends the information to sideline staff. Able worked with engineer Christoph Mack and Seattle-based Anvil Studios to develop the "boil-and-bite" mouth guard, which has a gyroscope, accelerometer, radio and chipset inside to record and relay information.
Together with research partner Stanford University, whose football and women's soccer and field hockey teams are wearing the mouth guard, X2 is collecting data that it hopes will help coaches and medical professionals better determine when a concussion may have been suffered or at least when to pull an athlete off the field.
Neither monitoring system tells a trainer if a concussion has been suffered — unlike other injuries, a concussion isn't necessarily easy to see and instead is determined by symptoms that may (or may not) include nausea, dizziness, confusion, clumsiness and forgetfulness. Also, Able said, "so many times kids will hide their head injuries because they don't want to sit on the bench."
"We're an information and awareness tool," said Able, about X2. "We're giving information that helps a trained medical professional make a better assessment of a kid."
Some college trainers are immediately notified via pager with Riddell's system if an athlete has suffered an abnormally hard hit, so they can focus on that player.
Studies have shown that long-term exposure to concussion and blows to the head can result in Chronic Traumatic Encephalopathy, which can cause memory loss, confusion, impaired judgment, impulse-control problems, aggression, depression and eventually, progressive dementia, according to Boston University's Center for the Study of Traumatic Encephalopathy.
The mouth guard joins the nearly decade-old Head Impact Telemetry System and Sideline Response System, owned and co-developed by Riddell and product development firm Simbex. Data on 1.8 million on-field head impacts have been collected through the HITS system, leading to dozens of published studies and several rule changes, including:
Brown and Dartmouth successfully lobbied the Ivy League to eliminate in-season, full-contact practices and reduce them in preseason because of how many head impacts athletes were exposed to. "Reducing impact exposure will ultimately reduce athletes' risk of concussion," explained Thad Ide, Riddell's senior vice president of research and product development.
A study involving HITS data on 7- and 8-year-olds prompted several rule changes in Pop Warner Football this June: No full speed, head-on (face-to-face) blocking or tackling drills are allowed when players are more than 3 yards apart and, full contact will be reduced to a maximum of one-third of practice time. The study was conducted by Virginia Tech-Wake Forest University researchers.
The NFL moved the kickoff line up 5 yards to lower the number of collisions during kickoff returns, in part based on HITS data.
Virginia Tech uses the HITS system to rank football helmets by their concussion-reduction capabilities.
"Virginia Tech, UNC, Brown and Dartmouth, Indiana and Purdue — all of them use the (Riddell) system and study and pool their data," Ide said. "They're just scratching the surface of what they can learn from that data."
Coaches have used the system to change drills or plays that increase head-impact exposure. "If you have someone review the data regularly," added Ide, "you can look at the number and types of hits of a particular player and compare that to other players in that same position and skill level to determine if they're using their head improperly or too much.
"There's so much that's not known about concussion and impact exposure, so the research part is extremely important right now in order for us to make better choices in the long run."

For information on concussion and youth sports:
For how to recognize possible signs of concussion, go to
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Brain Scan Can Detect Early Signs of Autism in Infants

A new study shows significant differences in brain development in high-risk infants who develop autism starting as early as age 6 months. The findings published in the American Journal of Psychiatry reveal that this abnormal brain development may be detected before the appearance of autism symptoms in an infant's first year of life. Autism is typically diagnosed around the age of 2 or 3.

The study offers new clues for early diagnosis, which is key, as research suggests that the symptoms of autism -- problems with communication, social interaction and behavior -- can improve with early intervention. "For the first time, we have an encouraging finding that enables the possibility of developing autism risk biomarkers prior to the appearance of symptoms, and in advance of our current ability to diagnose autism," says co-investigator Dr. Alan Evans at the Montreal Neurological Institute and Hospital -- the Neuro, McGill University, which is the Data Coordinating Centre for the study.
"Infancy is a time when the brain is being organized and connections are developing rapidly," says Dr. Evans. "Our international research team was able to detect differences in the wiring by six months of age in those children who went on to develop autism. The difference between high-risk infants that developed autism and those that did not was specifically in white matter tract development -- fibre pathways that connect brain regions." The study followed 92 infants from 6 months to age 2. All were considered at high-risk for autism, as they had older siblings with the developmental disorder. Each infant had a special type of MRI scan, known as diffusion tensor imaging, at 6 months and a behavioral assessment at 24 months. The majority also had additional scans at either or both 12 and 24 months.
At 24 months, 30% of infants in the study were diagnosed with autism. White matter tract development for 12 of the 15 tracts examined differed significantly between the infants that developed autism and those who did not. Researchers evaluated fractional anisotropy (FA), a measure of white matter organization based on the movement of water through tissue. Differences in FA values were greatest at 6 and 24 months. Early in the study, infants who developed autism showed elevated FA values along these tracts, which decreased over time, so that by 24 months autistic infants had lower FA values than infants without autism.
The study characterizes the dynamic age-related brain and behavior changes underlying autism -- vital for developing tools to aid autistic children and their families. This is the latest finding from the on-going Infant Brain Imaging Study (IBIS), which is funded by the National Institutes of Health (NIH) and brings together the expertise of a network of researchers from institutes across North America. The IBIS study is headquartered at the University of North Carolina, and The Neuro is the Data Coordinating Centre where all IBIS data is centralized.
Read more here

Nutrtionals that are reported to ease migraine symptoms

I am very careful about recommending nutritionals in children. Nutrtional does automatically not mean inert or beneficial. What are the long term effects? We dont know. I stick to vitamins with some supportive data like riboflavin and CoQ10. 
The data supports a modest effect of magnesium on menstrual migraine.

As always, consult your physician before starting any agent as treatment.

 Headaches, including migraine and tension-type headaches, are a huge medical concern in the United States, affecting more than 45 million Americans.
While some people are affected by headaches only intermittently, many have frequent debilitating symptoms that lead to work absences and loss of income.
The American Academy of Neurology and the American Headache Society recently published new guidelines for the prevention of migraine headaches, and the updated guidelines now endorse the use of several alternative therapies to help keep migraine headaches at bay.
The botanical supplement that received the most attention in the new guidelines is Petadolex, which is the herb butterbur. Studies have shown that 75 mg of Petadolex taken twice daily can reduce the frequency, duration and intensity of migraine headaches by close to 50 percent, which is comparable to many of the prescription medications used to prevent migraines.
Butterbur seems to work by reducing spasms in arteries in the brain; it also acts as an anti-inflammatory agent. Butterbur is also effective in reducing allergy symptoms, so if you have both migraine headaches and allergies, butterbur would be a good choice for you.
It is generally well tolerated, though in sensitive people it may actually cause headaches and allergic-type symptoms, especially in those who are allergic to ragweed, marigolds and similar plants. The main concern with butterbur however is that if not prepared properly, it can be contaminated with pyrrolizidine alkaloids, which are carcinogenic; they can also cause liver and kidney damage.
If you try butterbur, be sure to purchase a product that says "PA-Free," like Petadolex. Data suggest that Petadolex is safe in kids ages 6-17; it is not recommended in pregnancy or during lactation, however.
Other supplements may also help to prevent migraine headaches; magnesium is probably one of the best. Many people in the U.S. are felt to be magnesium-deficient, either from poor diet or from the daily consumption of stomach acid medications and diuretics.
Coffee, alcohol, soda and salt can also lower magnesium levels. The dose that seems to be the most effective for headache prevention is 600 mg of magnesium taken at bedtime. If you are prone to loose stools, look for magnesium glycinate or magnesium gluconate, which are less likely to cause diarrhea. If you have kidney disease, do not take high-dose magnesium supplements without talking with your doctor.
Coenzyme Q10 (ubiquinol) may also reduce headaches, usually by about 30 percent; studies have shown that 100 mg three times daily is the effective dose; kids need smaller doses. The main side effect from Coenzyme Q10 is on your wallet – it's expensive. Melatonin may also be useful for both migraines and cluster headaches; doses range from 3 to 10 mg at bedtime.
Feverfew has been one of the most popular herbs used to prevent migraines, though it may not work that well in capsule form. In England however, people traditionally chew two to three fresh feverfew leaves per day to prevent migraines, and in one study more than 70 percent of patients using feverfew in this way had reduced headaches.

Read more here

Friday, June 29, 2012

Can statins cause fatigue and exercise intolerance?

Researchers delving into the side effects of statins found evidence that the popular cholesterol-lowering drugs may sap energy levels in users.

The study indicates that statin drugs may contribute to a drop in energy and fatigue upon exertion.

The danger of the potential adverse effect was particularly enhanced in women.

Lead author of the study, Dr. Beatrice Golomb, associate professor of medicine at the University of California-San Diego stated, "We found that even at comparatively modest doses, statins were associated with a not-inconsequential drop in energy in some patients, a rise in fatigue with exertion in others and sometimes both.

She added, "This was true for both men and women. But it appears to be more of a problem for female patients."

Study Details
In a study designed to investigate whether statins can cause energy drain and exercise intolerance for users, the researchers tracked 1,016 healthy adults (700 men and more than 300 women) from the San Diego region.

The participants were all aged 21 years or older with elevated LDL or ‘bad’ cholesterol. However, none had a history of heart disease or diabetes.

As a part of the study, they were randomly assigned to receive either a placebo or 40 milligrams of Pravachol (pravastatin), the most water-soluble statin, 20 mg of Zocor (simvastatin), the most fat-soluble statin every evening before retiring for six months.

During the study, the volunteers were asked to rate their energy and fatigue levels on a five-point scale, from "much worse" to "much better." In addition they were questioned how they felt after exercising.

Outcome of the study
The study found those placed on statins were more likely to report lower energy levels and more fatigue with exertion compared to people assigned to the placebo.

The effect was more pronounced in women, with 40 percent experiencing weariness with exertion and a drop in energy while taking the daily dose.

Dr. Golomb says, “Energy is central to quality of life. Exertional fatigue not only predicts actual participation in exercise, but lower energy and greater exertional fatigue may signal triggering of mechanisms by which statins may adversely affect cell health.”

Based on the study findings, the researchers suggest that medical professionals should weigh the pros and cons before prescribing statins to people.

The findings were reported online June 11 in Archives of Internal Medicine.

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Children, like adults, are affected by sleep disorders

A good night's sleep is eluding an increasing number of people, and children are not immune.

The Centers for Disease Control has labeled "insufficient sleep" a public health epidemic. From bedwetting to loud snoring, a host of symptoms can indicate an underlying sleep problem in children. Many children suffer with disorders but are undiagnosed or misdiagnosed, says Dr. Larry Salberg, clinical associate professor of medicine at the Indiana University School of Medicine Northwest. "Approximately 2 percent of children have sleep apnea, and most of the kids are going undiagnosed," he says.

In some cases, children diagnosed with attention problems, such as ADD/ADHD, actually have a sleep disorder. Some of the symptoms are the same, such as changes in behavior and attention. "There are studies that show that up to 38 percent of our children who are on stimulant medication for ADD/ADHD do not have ADD/ADHD," Salberg says. "They have sleep deprivation or poor sleep, most of which is due to sleep apnea."

Any child that visits a doctor for possible ADD/ADHD should be screened for apnea or another disorder, says Salberg, founder of Neurological Institute and Specialty Centers in Merrillville.

People with sleep apnea have breathing that repeatedly stops and starts as they sleep, according to the Mayo Clinic. Common signs are loud snoring or feeling tired after a full night's sleep. Obese adults have an increased risk of sleep apnea, and the same rings true with children. "It's a common pathological problem," Salberg says. "It's easy to diagnose and it's easy to treat."

Left untreated, it can lead to serious health problems, such as high blood pressure. In adults, it can result in heart attacks, stroke, congestive heart failure and other maladies.

Good sleep helps reduce weight, but obesity causes poor sleep. "It's a vicious cycle," says Salberg, who has been practicing sleep medicine since 1978.

Dr. Muhammad Najjar, medical director for the Sleep Disorders Center of Franciscan Physicians Hospital in Munster, says sleep disorders in children are not new, but medical technology has improved. "Now we have the tools to treat them," he says.

The Munster center treats children, but the majority of its patients are adults. The facility just started accepting pediatric patients in February. "To the best of my knowledge, no one offers this in Northwest Indiana," Najjar says.

Aside from sleep apnea, children are susceptible to other sleep-related disorders, such as sleepwalking, insomnia, loud snoring and bedwetting. When a doctor recognizes symptoms of a sleep disorder in a child, the child may be recommended for a sleep study.

At Sleep Disorders Center, two rooms are designated for pediatrics. Designed to have a feel that's comfortable for children, it has toys, pictures on the wall and smaller beds. During a sleep study, a child spends the night in a sleep center, hooked to machines that monitor brain waves, eye movement, flow of air in the nose and mouth, heart and oxygen levels and more, Najjar says. The data are recorded and analyzed. It takes a few days to process the results and another appointment to discuss the best course of treatment.

In adults, prescribing a continuous positive airway pressure (CPAP) machine, which is a breathing mask worn at night, is a common treatment for sleep apnea.

For children with sleep apnea, a possible first step is to remove their tonsils and adenoids. If that does not correct the problem, then a doctor can explore nasal or orthodontic treatments or address a child's weight, if he is overweight, Najjar says. If fixing those issues does not work, then a CPAP machine is an option.

Salberg says children have to be re-studied in a sleep center after various treatments are tried, to ensure what appears to be working truly is working. "You have to prove that you've treated it. The only way you can document and make a diagnosis is by going through a sleep test."

If someone quits snoring, that does not mean the sleep apnea is gone. "One does not beget the other, necessarily," Salberg says.

Parents who think their child may have a sleep disorder should talk to the child's doctor. If the doctor ignores the concern or does not seem to know, parents should not be afraid to ask for a consultation with a board certified sleep specialist, Salberg says.

"We spend a third of our life sleeping," he says. "What we do during sleep has a lot to do with the day."

Read more here