Identification of Sleep Disorders in Infants of the Houston Area with Medical, Pediatric Neurology, Pulmonary Problems

Who would argue that normal oxygenation and sleep is important for development?

I came across these articles recently and wanted to share. 

Dr Susarla and I want to do as much as possible to improve the lives of our patients. Sometimes we see patients who have had unrecognized sleep problems for years. Sometimes we see patients who failed adenotonsillectomy and never followed up. 

Sleep apnea is highly prevalent in infants with complex health care needs. It is treatable...if recognized

Take some time to ask about your patient/client's sleep.  Do they look tired? Are they "over-tired" at times? Are they in a high risk group? 

Please let us know how we can help. 

Josh Rotenberg MD

Here is a link to our EEG and sleep study order form 

J Clin Sleep Med. 2014 Nov 15;10(11):1213-6. doi: 10.5664/jcsm.4204.

Comorbidities in infants with obstructive sleep apnea.

Qubty WF1, Mrelashvili A1, Kotagal S2, Lloyd RM3.

Author information

Abstract

STUDY OBJECTIVE:

The clinical characteristics of obstructive sleep apnea (OSA) in infants have been insufficiently characterized. Our aim was to describe identifiable comorbidities in infants with obstructive sleep apnea, which may assist in recognizing these patients earlier in their disease course and help improve management.

METHODS:

This was a single-center, retrospective study involving infants 0-17 months of age with a diagnosis of OSA on the basis of clinical features and nocturnal polysomnography (PSG) at the Mayo Clinic Center for Sleep Medicine between 2000 and 2011. Patients were excluded if they had central apnea accounting for greater than 50% of respiratory events. OSA severity was determined by the apnea-hypopnea index (AHI).

RESULTS:

One hundred thirty-nine patients were included. Based upon the AHI, they were subdivided into mild (AHI <5 30="" 5-9="" moderate="" or="" severe="">10; 40%) categories. Comorbidities included:

• gastroesophageal reflux in 95/139 (68%), 
• periodic limb movements in sleep in 59/139 (42%), 
• craniofacial abnormalities in 52/139 (37%), 
• neuromuscular abnormalities in 47/139 (34%), 
• prematurity in 41/139 (29%), 
• geneticsyndromes in 41/139 (29%), 
• laryngomalacia / tracheomalacia in 38/139 (27%), and 
• epilepsy in 23/139 (17%) of subjects.

 Severity of OSA correlated with prematurity, having a genetic syndrome, or neuromuscular abnormality. 

Multispecialty evaluation was needed for 119/139 (86%).

CONCLUSION:

Comorbidities in infants with OSA differ from those of older children. Based upon the comorbidities identified in our study population, it appears that appropriate management of infants with OSA requires a multidisciplinary approach involving genetics, gastroenterology, pulmonology, otolaryngology, neurology, and general pediatrics.

© 2014 American Academy of Sleep Medicine.

KEYWORDS:

Infant; obstructive sleep apnea; polysomnography; sleep disordered breathing; sleep disorders

J Plast Reconstr Aesthet Surg. 2014 Nov;67(11):1475-80. doi: 10.1016/j.bjps.2014.07.026. Epub 2014 Jul 31.

Screening for obstructive sleep apnea in children with syndromic cleft lip and/or palate.

Silvestre J1, Tahiri Y1, Paliga JT1, Taylor JA2.

Author information

Abstract

BACKGROUND:

Craniofacial malformations including cleft lip and/or palate (CL/P) increase risk for obstructive sleep apnea (OSA). While 30% of CL/P occurs in the context of underlying genetic syndromes, few studies have investigated the prevalence of OSA in this high-risk group. This study aims to determine the incidence and risk factors of positive screening for OSA in this complex patient population.

METHODS:

The Pediatric Sleep Questionnaire (PSQ) was prospectively administered to all patients cared for by the cleft lip and palate clinic at the Children's Hospital of Philadelphia between January 2011 and August 2013. The PSQ is a 22-item, validated screening tool for OSA with a sensitivity and specificity of 0.83 and 0.87 in detecting an apnea-hypopnea index (AHI) >5/hour in healthy children. The Fisher exact and Chi-square tests were used for purposes of comparison.

RESULTS:

178 patients with syndromic CL/P completed the PSQ. Mean cohort age was 8.1 ± 4.4 years. Patients were predominately female (53.9%), Caucasian (78.1%), and had Veau Class II cleft (50.6%). Craniofacial syndromes included isolated Pierre Robin Sequence (PRS) (29.8%), 22q11.2 deletion syndrome (14.6%), Van der Woude syndrome (6.7%), and other rare genetic abnormalities (28.8%). The overall incidence of positive OSA screening was 32.0%. Males were at increased risk for positive OSA screening (P = 0.030), as were non-Caucasians (P = 0.044). Symptoms with the highest positive predictive value for OSA were "others comment on child appearing sleepy" (76.2%) and "stops breathing during the night" (75.0%). Notably, patients with 22q11.2 deletion syndrome were at highest risk for positive screens (50.0%, P = 0.042).

CONCLUSIONS:

Nearly a third of our patients with syndromic CL/P screened positively for OSA (32.0%), highlighting the importance of screening in this at-risk population. Future work will correlate screening results with polysomnograms to help validate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, III.

Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

KEYWORDS:

Cleft lip and palate; Obstructive sleep apnea; Pediatric; Questionnaire; Screening

HOUSTON AREA ATAXIA SUPPORT GROUP MEETING - GREATER HOUSTON AREA

HOUSTON AREA ATAXIA SUPPORT GROUP MEETING - GREATER HOUSTON AREA 

for Patients, Family Members, Care Team

Sunday, January 25, 2015
2:00 PM to 4:00 PM

Multipurpose Recreation Center
5200 Burke Rd
Pasadena, TX 77504

Meeting Agenda:
Meet &  Greet

Refreshments

Family, friends, and caregivers are welcome! An RSVP is appreciated.

To RSVP, more information, or to be added to the mailing list for this group please contact

Facebook Group HERE

Bonnie Sills at (713) 944-5183 texasnanow@aol.com or David Brunnert at (713) 578-0607 david.brunnert@sbcglobal.net

We hope to see you there!

Home testing and monitoring for epilepsy - Available in the Houston Area ..and now in London.

A hospital in London is pioneering a home diagnosis test and monitoring for epilepsy. This is described as a first of its kind. 

But, as an epilepsy specialist, I noted the value and convenience of such a service. My pediatric neurology practice has been offering home EEG service for the Houston area a number of years. 

-JR

A London hospital is the first in Britain to pioneer home testing for epilepsy patients.

The brain-scanning service rolled out by King’s College Hospital NHS Foundation Trust will benefit hundreds of people who suffer devastating seizures, and improve treatment.

Home monitoring allows patients to carry on with daily life without the disruption of days in hospital — it is also thought to be a more accurate method.

The service is called Home Video Telemetry and the patient wears a special head device fitted with electrodes which records brain activity over several days.

A video camera also captures the physical seizures. A technician visits the patient’s home and collects the data on a daily basis which is analysed by a consultant.  Epilepsy affects about 600,000 people in the UK including more than 60,000 children. The condition affects the brain and causes multiple seizure attacks in severe cases. Brain scanning is crucial for doctors to diagnose patients with suspected epilepsy correctly and provide them with tailored treatment.

Hospital checks have been the gold standard until now for those who suffer multiple attacks. However, other NHS trusts are now expected to adopt home testing following the success of pilots by King’s. It comes as new research reveals that testing epilepsy patients in hospital may produce biased results. Dr Franz Brunnhuber at King’s has carried out work revealing that people are about half as likely to experience seizures in hospital than at home.

The consultant clinical neurophysiologist said this can make it difficult for doctors to determine the exact nature of a patient’s condition.

He added: “Misdiagnosis is a major problem with epilepsy because there are lots of conditions which mimic the disorder so it’s crucial to capture seizure attacks accurately. The home service is more convenient for patients. Hospital is a huge stress factor for them. Home testing means patients can lead a normal life.”

Read more here

Dr Rotenberg named to the 2014 List of GOOD Neurologists...Epileptologists...and Pediatric Doctors.

2014 Comprehensive List of GOOD Neurologists…Epileptologists…Neurosurgeons…and Pediatric Doctors | January 5, 2014

2 Votes

Below is a compilation by website forum members who have had positive experiences with docs over the years.

This list is based on personal recommendations and, of course, is purely subjective.

But I thought it might be helpful for anyone looking for a good Neurologist…Epileptologist…Neurosurgeon…or Pediatric Doctor.

NOTE: The National Association of Epilepsy Centers (NAEC) provides a directory of specialized epilepsy centers in the U.S. along with other useful information about epilepsy.http://www.naeclocator.org/find.htm

Link to list here

Thank you for the recognition and confidence.

Serving Houston, Sugar Land, Missouri City, Rosenberg, Katy, Cinco Ranch, Cypress, the Woodlands

CDC claims 1 in 10 children has ADHD

A new poll by the CDC shows that 1 in every 10 children has ADHD. This is higher than the last poll done in 2007 showing ADHD cases are rising.

One in every 10 U.S. children has been diagnosed with attention-deficit/hyperactivity disorder (ADHD), but the steady rise in cases has started to slow, a new government survey shows.

The 2011 poll of more than 95,000 parents showed that about 11 percent -- or about 6.4 million -- of children aged 4 to 17 had been diagnosed with ADHD. That's up from a 2007 survey that found that 9.5 percent of youngsters in that age group had an ADHD diagnoses.

Nearly one in every five high-school age boys, and about one in every 11 high school age girls, was reported by their parents as being diagnosed with having ADHD, the U.S. Centers for Disease Control and Prevention report found.

Numbers also varied widely between states, as well, with 15 percent of children in Arkansas and Kentucky reporting a history of ADHD treatment, compared to just 4 percent of those in Nevada.

The number of children placed on ADHD medications -- which include stimulants such as Ritalin or Concerta -- also rose by about 1 million between 2003-04 and 2011-12, the CDC said. That means that more than 3.5 million youngsters between the ages of 4 and 17 are now taking an ADHD drug.

The survey was published Nov. 22 in the Journal of the American Academy of Child and Adolescent Psychiatry.

According to the survey, half of children with ADHD are diagnosed with the disorder by the age of 6.

"This finding suggests that there are a large number of young children who could benefit from the early initiation of behavioral therapy, which is recommended as the first-line treatment for preschool children with ADHD," study author and CDC researcher Susanna Visser said in a journal news release.

Not every child with ADHD is getting proper treatment, the study found. According to the survey, 18 percent of kids with ADHD had not received either psychiatric counseling or drug therapy during 2011-2012.

"This finding raises concerns about whether these children and their families are receiving needed services," Dr. Michael Lu, senior administrator at the U.S. Health Resources and Service Administration (HRSA), said in the journal news release.

There was some good news from the survey, however. The CDC noted that ADHD diagnoses among American children were rising at a rate of about 6 percent a year in the mid-2000s, but that rate slowed to 4 percent a year from 2007 to 2011.

Visser told the Associated Press that this slower rate of diagnoses might reflect that doctors are closer to identifying most of the youngsters with the disorder.

ADHD makes it difficult for kids to pay attention and control impulsive behaviors. Treatments can include drugs, behavioral therapy or both.

Read more here

Clinical Report: Returning to Learning Following a Concussion - School Considerations

From the American Academy of Pediatrics:Clinical Report: Returning to Learning Following a Concussion

• Mark E. Halstead, 
• Karen McAvoy, 
• Cynthia D. Devore, 
• Rebecca Carl,
• Michael Lee, 
• Kelsey Logan, 
• Council on Sports Medicine and Fitness,
• and Council on School Health

Pediatrics 2013; 132:5 948-957; published ahead of print October 27, 2013, doi:10.1542/peds.2013-2867

• Abstract
 
• Full Text
 
• Full Text (PDF)

1. Caution recommended when treating concussion with cognitive or physical rest

   • Marc P DiFazio, M.D., Pediatric Neurologist
    
   • Joshua Rotenberg, M.D. Pediatric Neurologist

   Childrens National Medical Center, Washinton, DC
   
   

   The paper by Halstead et al brings welcomed attention to the medical- academic needs of children with concussion. However, with respect to brain and body "rest", several recommendations for management are presented without a balanced appraisal of conflicting data or solid evidentiary support. We fear that these recommendations, presented as a standard, may contribute both to sub-optimal individual outcomes as well as to counter-productive policies. The authors recommend cognitive and physical rest after concussion. However, there is no evidence that the brain can be "put to rest" volitionally. Rest recommendations are based on conjecture from animal data demonstrating a "metabolic mismatch" in a vulnerable period occurring after brain trauma. Even if human pathophysiology matches lab-models in rodents and even if we had clinical markers of a vulnerable period, it is hard to imagine how "avoiding concentration" could supersede reparative mechanisms of brain recovery. Continuing this line of reasoning of a metabolic vulnerability, should we deprive concussed humans of sleep? REM sleep maintains nearly the same overall metabolic rate as wakefulness (even greater in certain regions such as the cingulate cortex).

   Cognitive rest remains ill-defined from a practical standpoint - a rest "dosage" for activities does not exist. Suddenly, students and families are now being told to avoid exercise, television, texting, and even spicy foods. When there is no evidence that using technology "stresses" the brain more than any other activity, should professionals really be advising parents that their role on a "team" is to enforce this advice? Enforced rest does not appear to improve recovery from many medical and neurologic conditions.1 And, regarding concussion, growing evidence suggests that cognitive rest does not result in hastened recovery.2 Of greater concern, there is evidence that enforced rest may result in deconditioning, and potentially exacerbate or even produce symptoms typically attributed to the post-concussive syndrome itself.3,4 We suggest that the authors are over-cautious when they assert that students should be at their "academic baseline" before a return to activity. Although judgment should be exercised before returning students to high risk physical activities, this recommendation is excessively broad. As noted, there is potential harm in enforcing rest. In practice, we have observed a self-perpetuating cycle: physicians interpret the re- occurrence of post-concussive symptoms to be an indicator of persistent and worsening brain injury and encourage more rest. We applaud the authors' cooperative approach between schools and providers who advocate for rationale accommodations during recovery. Education about concussion and early reassurance appears to reduce the chance of persistent symptoms after mild traumatic brain injury.5 Solid expert advice about the "known" and rational admission of "knowable unknowns" may ease patient and parental anxiety. Consequently, we agree that pediatric specialists should be engaged in prolonged or atypical cases. Appreciating the merits of this statement and its contribution to practice, we join the authors to stress an individualized patient-centered approach to the prescription of cognitive or physical rest.

   References

   1 McLean SA, Clauw DJ. Predicting chronic symptoms after an acute "stressor" - lessons learned from 3 medical conditions. Med Hypotheses. 2004;63:653-658.

   2 Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27:839-42.

   3 Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28:250-9.

   4 Kirkwood MW, Randolph C, Yeates KO. Sport-related concussion: a call for evidence and perspective amidst the alarms. Clin J Sport Med. 2012;22:383-4.

   5 Ponsford J, Willmott C, Rothwell A, Cameron P, Ayton G, Nelms R, Curran C, Ng K. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108:1297-303.

   Conflict of Interest:

   None declared

Children's blood pressure may raise with a bad night's sleep

Children who had a bad night's sleep, or who lost hours of sleep, see a moderate raise in their blood pressure. This can lead to health complications later in life such as heart disease.

Kids who don't get enough sleep at night may experience a slight spike in their blood pressure the next day even if they are not overweight or obese, a new study suggests.

The research included 143 kids aged 10 to 18 who spent one night in a sleep lab for observation. They also wore a 24-hour blood pressure monitor and kept a seven-day sleep diary.

The participants were all normal weight. None had significant sleep apnea -- a condition characterized by disrupted breathing during sleep. The sleep disorder has been linked to high blood pressure.

According to the findings, just one less hour of sleep per night led to an increase of 2 millimeters of mercury (mm/Hg) in systolic blood pressure. That's the top number in a blood pressure reading. It gauges the pressure of blood moving through arteries.

One less hour of nightly sleep also led to a 1 mm/Hg rise in diastolic blood pressure. That's bottom number, which measures the resting pressure in the arteries between heart beats.

Catching up on sleep over the weekend can help improve blood pressure somewhat, but is not enough to reverse this effect entirely, report researchers led by Chun Ting Au, at the Chinese University of Hong Kong.

So, even though the overall effect of sleep loss on blood pressure was small, it could have implications for risk of heart disease in the future, they suggested.

Exactly how lost sleep leads to increases in blood pressure is not fully understood, but Au and colleagues speculate that it may give rise to increases in stress hormones, which are known to affect blood pressure. The findings are published online Dec. 16 and in the January print issue of Pediatrics.

Participants in the study slept anywhere from seven hours or less to more than 10 hours. The less sleep they got, the higher their blood pressure was the following day.

U.S. experts said the new findings emphasize the importance of good quality sleep for all kids.

"The study separates the effect of sleep apnea from sleep loss, and conclusively shows that sleep loss in the absence of sleep apnea raises both systolic and diastolic blood pressure," said Dr. Sanjeev Kothare, a pediatric sleep expert at NYU Langone Medical Center, in New York City.

"Pediatricians must screen for diabetes, and [high blood pressure] in teenagers with sleep loss besides screening for snoring and sleep apnea in obese teenagers," Kothare said.

According to the National Sleep Foundation, children aged 5 to 12 need 10 to 11 hours of sleep. Teens need about 9.25 hours of sleep each night to function best, but for some, 8.5 hours is enough.

"Being healthy is not only getting regular exercise and eating right, but also trying to get the appropriate amount of sleep," said Dr. Rubin Cooper, chief of pediatric cardiology at Cohen Children's Medical Center, in New Hyde Park, N.Y.

To encourage better sleep, "start a bedtime routine that helps your children wind down before bed and limit texting or social media at night," Cooper said. "Keep a similar schedule on weekdays and weekends." Other sleep hygiene tips include avoiding caffeine before bedtime.

These measures may be even more important among kids who are overweight and obese. "If you have kids who are staying up late and getting up early on top of obesity and sleep apnea, it is the perfect storm," Cooper said. But exactly how big of a difference better sleep would make in this scenario is unknown, he noted.

Although the study found an association between kids getting less sleep and a slight increase in blood pressure, it did not establish a cause-and-effect relationship.

The bottom line is that "sleep isn't optional for adolescents," said Dr. Metee Comkornruecha, an adolescent medicine specialist at Miami Children's Hospital.

Read more here

What do I do if someone is having a seizure?

This article details what you should do if you see someone having a seizure. The most important thing to do is to stay calm.

What should you do if someone appears to be having a seizure?

“The main thing is to stay calm yourself,” said Dr. Richard Kanoff, a child neurologist for Essentia Health who specializes in treating epilepsy.

A person having a complex partial seizure may be confused and uncertain who you are even if you are a family member or friend.

“The important thing is to approach them slowly, to talk softly, be calm,” Kanoff said. “All you’re trying to do is guide them to a safe place. See if you can get them to sit down or lie down in a place where things are relatively out of the way.”

A person having a grand mal seizure may stiffen and shake all over, Kanoff said.

“Again, the recommendation is to stay calm, to approach that person and move things out of their way the best you can so they don’t bang against things,” he said.

If you can, Kanoff said, help the patient to lie on his or her side. That way, if the patient begins vomiting the substance will come out the mouth and not back into the lung.

There are a couple of things you shouldn’t do.

“We don’t restrain anybody, because those muscles are going to twitch anyway,” Kanoff said. “If you provide a restraint, you might facilitate another injury like a broken bone.”

And don’t put anything in the patient’s mouth, not even your finger.

The old thinking that you need to prevent the patient from “swallowing his tongue” has long been discounted, said Mary Giese, regional outreach coordinator for the Epilepsy Foundation of Minnesota.

Putting something in the patient’s mouth has more potential to block the airway than to open it, Kanoff said.

“People do bite their tongues, but it’s rare that anybody needs stitches in their tongues as a result of that,” he said. “It’s much better to have them have the bruise from the bite on the tongue than have them lose their airway because you pushed something in there.”

Read more here

Sunny climates may reduce ADHD prevalence

A study shows that the prevalence of ADHD may be influenced by sunny climates and amount of sunlight.

Attention-deficit/hyperactivity disorder, or ADHD, is the most common childhood psychiatric disorder. Scientists do not know what causes it, but genetics play a clear role. Other risk factors have also been identified, including premature birth, low birth weight, a mother’s use of alcohol or tobacco during pregnancy, and environmental exposures to toxins like lead.

ADHD is characterized by an inability to focus, poor attention, hyperactivity, and impulsive behavior, and the normal process of brain maturation is delayed in children with ADHD. Many individuals with ADHD also report sleep-related difficulties and disorders. In fact, sleep disorder treatments and chronobiological interventions intended to restore normal circadian rhythms, including light exposure therapy, have been shown to improve ADHD symptoms.

Estimates suggest that the average worldwide prevalence of ADHD ranges from about 5 to 7%, but it also varies greatly by region. A simple visual comparison of data maps released by the U.S. Centers for Disease Control and Prevention and the U.S. Department of Energy that display ADHD prevalence rates by state and solar intensities (sunlight) across the country, respectively, reveals an interesting pattern indicative of an association. So does this mean that there could be an identifiable relationship between ADHD prevalence rates and the sunlight intensity levels of particular regions?

The accumulation of these points led Dr. Martijn Arns and his colleagues to systematically and scientifically investigate this question. They collected and analyzed multiple data-sets from the United States and 9 other countries. Reporting their findings in the current issue of Biological Psychiatry, they did find a relationship between solar intensity and ADHD prevalence.

Even after controlling for factors that are known to be associated with ADHD, both U.S. and non-U.S. regions with high sunlight intensity have a lower prevalence of ADHD, suggesting that high sunlight intensity may exert a ‘protective’ effect for ADHD.

To further validate their work, they also looked at this same relationship with autism and major depressive disorder diagnoses. They found that the findings were specific to ADHD, with no associations observed between the other two disorders.

“The reported association is intriguing, but it raises many questions that have no answers,” commented Dr. John Krystal, Editor of Biological Psychiatry. “Do sunny climates reduce the severity or prevalence of ADHD and if so, how? Do people prone to develop ADHD tend to move away from sunny climates and if so, why?”

As with all scientific research, further work is necessary, including a prospective replication of these findings. It is also important to realize that this data reflects only an association – not a causation – between ADHD and solar intensity levels so worried parents should not start planning cross-country moves.

However, these findings do have significant implications, explains Dr. Arns. “From the public health perspective, manufacturers of tablets, smartphones and PCs could investigate the possibility of time-modulated color-adjustment of screens, to prevent unwanted exposure to blue light in the evening.”

“These results could also point the way to prevention of a sub-group of ADHD, by increasing the exposure to natural light during the day in countries and states with low solar intensity. For example, skylight systems in classrooms and scheduling playtime in line with the biological clock could be explored further.”

Read more here

Non-concussion Head Impacts In Contact Sports Could Result In Lower Test Scores

Non-concussion Head Impacts In Contact Sports Could Result In Lower Test Scores

Blows to the head that do not result inc concussion can affect cognitive performance. Watch you child for school or emotional problems. 
 Perhaps athletes in high risk sports should be tested before and after the season?
JR

Non-concussion head impacts in sports that involve physical contact as normal play can lead to brain changes and result in lower test scores, a new study suggests.

Based on a recent study, repeated blows to the head during a season of contact sports such as football, hockey or boxing, may cause changes in the brain's white matter - tissue that contain nerve fibers -  and affect cognitive abilities even if none of the impacts resulted in a concussion.

 Researchers at the Indiana University School of Medicine and the Geisel School of Medicine at Dartmouth College found significant differences in the brain white matter of varsity football and hockey players compared with a group of non-contact sport athletes following one season of competition.

"The contact sports and non-contact sports groups differed, and the number of times the contact sports participants were hit, and the magnitude of the hits they sustained, were correlated with changes in the white matter measures," Thomas W. McAllister, M.D., chair of Indiana University's Department of Psychiatry, said in a statement.

Researchers also found that head impact in contact sports may also affect an athlete's performance.

"In addition, there was a group of contact sports athletes who didn't do as well as predicted on tests of learning and memory at the end of the season, and we found that the amount of change in the white matter measures was greater in this group," McAllister said