Oral devices to treat sleep apnea in children

This article discusses how oral devices can help treat sleep apnea in children.

Snoring and sleep apnea can affect anyone of any age.  For children, who frequently sleep alone, grinding of the teeth or reflux disease may be the first signs of the condition, and may first be noticed by a well-trained dentist.

Snoring and other signs of disturbed sleep, such as long pauses in breathing, tossing and turning in bed, chronic mouth breathing during sleep, and night sweats are possible signs of sleep apnea, according to www.sleepapnea.org.  The website states that studies suggest that as many as 25% of children diagnosed with attention-deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea, and that much of their learning difficulty and behavioral issues can be the result of chronic fragmented sleep.

Snoring occurs when the flow of air through the mouth and nose is physically obstructed.  Blocked nasal passages, poor muscle tone in the throat and tongue, bulky throat tissue (common in overweight patients), and a long soft palate or uvula can contribute to airflow obstruction.

Oral appliances for treatment of pediatric obstructive sleep apnea (OSA) can be helpful, especially in adolescents whose facial bone growth is largely incomplete.  One device, according to www.sleepapnea.com, which rapidly expands the transversal diameter of the hard palate over a six-month to one-year period, has been successfully used in patients as young as age six.

In the United States, oral devices to treat OSA can’t be sold over the counter. They must be prescribed by a physician and fitted by a dentist.  An oral breathing device used to treat pediatric OSA must be refitted periodically as the child grows.

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Sleep apnea in children and behavioral problems

This article explains the link between sleep apnea in children and behavioral problems such as ADD and ADHD.

Attention deficit hyperactivity disorder (ADHD) is the most-commonly diagnosed behavioral disorder in children. The current standard of care for youngsters with attention deficit disorder (ADD) and ADHD is prescription medication such as Adderall, Ritalin and Dexadrine. These medications may have concerning side effects such as reduced height and weight, cardiovascular effects, tics, evidence of carcinogenic and reproductive effects, and substance abuse.

Sadly, many of these children are being misdiagnosed. A child who exhibits behavior problems or difficulty paying attention at home or school may actually be suffering from another disorder, an underlying undiagnosed sleep-related breathing disorder known as obstructive sleep apnea (OSA).

Dr. Stephen Sheldon, professor of pediatrics at Northwestern University School of Medicine and director of the Sleep Medicine Center says, “There are a number of sleep disorders that if looked at, an attention deficit problem can be identified. If you take a large number of children that have attention deficit and you evaluate them for sleep-disordered breathing, about a fifth to a quarter of those youngsters will have pediatric obstructive sleep apnea.”

He continues, “The most important aspect of evaluating a child for ADHD or other attention problems is to do a sleep evaluation in every single child. One hundred percent of these children need a sleep evaluation.”

...

Nighttime symptoms of youngsters with sleep-related breathing disorders are: snoring, bruxism, mouth breathing, bed wetting, frequent awakenings, nightmares, insomnia and physically restless sleep. Resulting daytime symptoms and findings are neurocognitive impairment, headaches, hyperactivity, behavioral issues, tiredness and poor school performance.

Lack of sleep and/or poor-quality sleep affects a child’s physical and emotional health, cognitive function, behavior and academic success. Parents, teachers, counselors or anyone concerned with the growth and development, academic performance, or health and well-being of a child must have greater awareness of sleep issues. Sleep screening and interventions to improve sleep must become part of every child’s routine clinical exam.

Early diagnosis and treatment of pediatric OSA is vital if we are going to have an impact on the epidemic of OSA in our country. Today, research indicates that one in four adults in this country suffers from obstructive sleep apnea. Of these, 80 percent remain undiagnosed and untreated. Although there is a growing awareness and therefore an increase in the number of adults treated for OSA, the key is prevention and early intervention.

A YouTube video, “Finding Conner Deegan,” tells a mother’s story of her struggling son who was labeled a “troubled child” early in his life. Having exhausted every resource, potential diagnosis and treatment known to his medical community, there appeared no other options. But through his mother’s perseverance, love, relentless search and striving to understand her son, her prayers were answered. Conner, in fact, suffered from undiagnosed pediatric OSA. He simply couldn’t breathe!

Parents, teachers, counselors and doctors need to be made aware of the need to screen children for sleep-related breathing disorders and understand the significant role timely diagnosis and thorough treatment play in the healthy growth and development of our children.

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Easy Peezy

This article discusses a new product called Easy Peezy, a urine tests to diagnose obstructive sleep apnea in children.

What does good sleep have to do with peeing in a cup? For millions of kids, it could mean better, healthier sleep and possibly avoiding a mistaken diagnosis of ADHD. Meet the Easy Peezy Pee Test, an innovative new diagnostic test in development at NuSomnea that has been found to be 96.5% accurate in determining if a child has pediatric Obstructive Sleep Apnea, or OSA. This condition is associated with symptoms often mistaken for Attention Deficit/Hyperactivity Disorder, or ADHD.

On September 16, 2014, NuSomnea launches an Indiegogo fundraising campaign to help complete the development of the urinalysis test and to conduct another validation study in children, to confirm the results found in initial studies.

The Indiegogo campaign will offer contributors a variety of perks including fun t-shirts and backpacks featuring "The Peezies," the adorable characters from the Easy Peezy video, as well as the Easy Peezy Pee Test when it becomes available.

The aptly named Easy Peezy Pee Test identifies the urinary concentrations of four proteins that are predictive of pediatric OSA, representing a remarkable improvement over traditional, and costly, diagnostic methods. "Diagnosing OSA usually requires an expensive stay at a sleep lab. It's inconvenient for parents and uncomfortable for kids," said Michael Thomas, co-founder of NuSomnea. "We're changing that with a simple urine test that's more accessible, more accurate and costs about seventy-five percent less."

Obstructive Sleep Apnea is a common sleep disorder resulting from the collapse of the pharyngeal airway during sleep, often hundreds of times per night, depleting blood oxygen saturation and contributing to a host of serious health problems. Pediatric OSA is linked to a greater incidence of childhood obesity, asthma, nervous conditions and bed-wetting. Left untreated, pediatric OSA can lead to hypertension, cardiovascular disease and diabetes as children grow older. While OSA is usually associated with adults, research shows that 2-5% of children have pediatric OSA, and it is a growing problem in the US.

Snoring is one of the indicators that a child may have OSA. Studies have reported that 27% of children snore and it can be difficult for doctors to determine from a medical exam alone which patients should be tested for OSA.

In children, other common indicators of OSA are behavioral problems, learning disabilities, hyperactivity and attention problems, which may frequently be diagnosed as ADHD or ADD. Nearly 7 million children between 4 and 17 years old are currently diagnosed with ADHD, but research has reported that up to 50% might actually have pediatric OSA. Further, a large percentage of kids with ADHD respond to the standard treatment for OSA -- tonsil and adenoid surgery -- reinforcing the conclusion that many have OSA in addition to or instead of ADHD. If a child has OSA, treating only for ADHD with stimulant drugs may not resolve the issue.

Because the Easy Peezy Pee Test is so convenient to administer, it has the potential to be used as both a diagnostic tool and a disease management tool to more closely monitor therapy effectiveness and improve patient outcomes.

The Easy Peezy Pee Test by NuSomnea is still in clinical development and should be available to doctors in 2016.

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Weight gain triggered by tonsillectomy

A study shows that weight gain in children can be triggered by tonsillectomies used to treat sleep apnea.

Tonsillectomies are commonly done to relieve sleep apnea in children, but a new study confirms that the treatment can speed kids' weight gain -- especially if they're already overweight.

The researchers said that's a concern, because obesity is a risk factor for a range of health problems -- including, ironically, sleep apnea. But they're not advising against tonsillectomy for kids who need it.

Instead, they said, doctors and parents should be aware that a healthy diet and exercise become even more important after children have the surgery.

"You can't just treat the sleep apnea. You have to have nutrition and lifestyle counseling, too," said lead researcher Dr. Eliot Katz, a respiratory disease specialist at Boston Children's Hospital.

A pediatric sleep specialist who was not involved in the study agreed.

"Nutrition and exercise are just as important as treating the sleep apnea with a single procedure," said Dr. Sangeeta Chakravorty, who co-directs the pediatric sleep evaluation center at Children's Hospital of Pittsburgh.

Obstructive sleep apnea arises when constriction in the airways causes repeated pauses in breathing during the night. In children, the most common cause is swelling in the tonsils and adenoids -- infection-fighting tissues in the back of the throat and the nasal cavity, respectively. And surgery to remove those tissues (known technically as adenotonsillectomy) is often recommended.

Doctors have long known that after the surgery, kids can gain weight at an accelerated clip, Chakravorty said.

But the new study, reported online July 28 and in the August print issue of the journal Pediatrics, offers "certainty" that it's actually an effect of the treatment, Katz said.

That's because children in the study were randomly assigned to have surgery or to "watchful waiting" -- putting off surgery and staying with other options, such as medications to better control any nasal allergies or asthma symptoms.

Altogether, 204 children aged 5 to 9 were assigned to have surgery right away, while 192 stuck with watchful waiting. Katz's team found that over seven months, children who underwent surgery showed a quicker average weight gain, versus kids in the comparison group.

It was a small difference overall, Chakravorty said. And for children who were normal weight, there was no major effect.

"It's not making normal-weight children obese," Chakravorty noted.

But there was a clearer impact on kids who were overweight before surgery. Of those children, 52 percent had become officially obese seven months after surgery, compared with 21 percent of overweight children in the watchful-waiting group, the study found.

There are a few possible explanations for the post-surgery weight gain, according to Katz's team. Calorie-burning may dip when children are no longer laboring to breathe during sleep. And some kids may burn fewer calories during the day because they become less active after their sleep apnea improves. (Paradoxically, poor sleep often causes children to be "hyperactive," rather than drowsy, Katz explained.)

Sleep apnea itself also causes metabolic changes, Katz said. Growth hormone is released at night, and the sleep disorder can interfere with that. So the body may adapt metabolism in an effort to maintain a child's growth.

"When the sleep apnea is relieved, they're set up for rapid weight gain," Katz said.

It was once common for children with sleep apnea to be underweight and have "failure to thrive," Chakravorty noted. For those kids, rapid weight gain after tonsillectomy can be a good thing.

But these days, with childhood obesity on the rise, many kids with sleep apnea are already overweight or obese. If they rapidly put on pounds, Katz said, their sleep apnea might return in six months to a year.

"After surgery, parents are often very satisfied," Katz noted. "Their kids are sleeping better, and they may be better behaved and doing better in school. But there's this insidious issue of weight gain."

Chakravorty agreed that diet and exercise are key for children with sleep apnea -- but she said that's true regardless of the treatment approach. And, for heavy kids, weight loss alone might clear up the sleep apnea.

But if children ultimately do need surgery, parents shouldn't skip it due to worries about weight gain, according to Katz. He noted that if improved sleep apnea symptoms explain the post-surgery pounds, then other treatments -- including medication or continuous positive airway pressure devices -- could also spur excess weight gain.

"I think there are implications beyond surgical treatment," Katz said.

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Those with sickle cell anemia are more likely to have sleep apnea

A study shows that children who have sickle cell anemia are more likely to have sleep apnea.

Children with sickle cell anemia are more likely to suffer from sleep apnea than children who are otherwise healthy, according to the findings of a study published online in the journal Pediatrics.

The study, which was published last week, was funded by the National Institutes of Health. 

The findings underscore the importance for physicians to screen sickle cell patients on a routine basis for sleep apnea, said one of the study's co-investigators, Dr. Carol Rosen, a pediatric sleep medicine specialist and medical director of the Pediatric Sleep Center at University Hospitals Rainbow Babies & Children's Hospital and professor of pediatrics at Case Western Reserve University.

Obstructive sleep apnea is a sleep-related breathing problem that can reduce blood oxygen levels during the night. Patients with the disorder stop breathing for periods lasting from a few seconds to a few minutes, dozens of times during the night.

An estimated 1 to 5 percent of all children in the United States suffer from it, according to the American Sleep Apnea Association. Risk factors include chronic swollen tonsils and adenoids, smaller upper airways and obesity.

Sickle cell disease is one of the most common genetic diseases in the country and is typically diagnosed in newborns.  In the United States, it's estimated that sickle cell anemia affects 70,000–100,000 people, mainly African Americans. The disease occurs in about 1 out of every 500 African American births.

It can cause frequent bouts of joint or organ pain, vulnerability to infection, stroke, slow growth or internal organ damage. When red blood cells sickle, or become malformed (shaped like a sickle or a crescent), it makes blood flow and oxygen flow to nearby tissue more difficult, causing pain and organ injury.

Children with sickle cell anemia – the most common form of sickle cell disease – have lower oxygen levels than healthy children, and may be even more vulnerable to the effects of low oxygen that come with asthma or sleep apnea.

Dr. Michael DeBaun (now at Vanderbilt University School of Medicine) and Dr. Robert Strunk (Washington University School of Medicine) conceived of the study while both were colleagues at St. Louis Children's Hospital.  They noticed a relationship between breathing problems like asthma and increased hospitalizations for pain and chest problems in children with sickle cell anemia.

Collaborating with researchers at UH Rainbow and University College of London Institute of Child Health and Great Ormond Street Hospital in England, they launched a study.  They wanted to see if their hypothesis - that children with sickle cell anemia would have a higher-than-expected prevalence of sleep apnea – was correct.

Of the 243 sickle cell anemia patients enrolled in the study, 59 were patients at UH Rainbow. Nearly all of the patients were of African heritage.

Data was collected through the use of questionnaires for medical history (including asthma, allergies and sleep); physical exams that included breath tests and measuring oxygen levels; and sleep studies.

What they found was a higher prevalence of sleep apnea in children with sickle cell anemia. Those with sleep apnea had more aggravated symptoms of their sickle cell anemia than patients who did not have sleep apnea.

"Having low oxygen is a trigger for [the cells] sickling," Rosen said. "If you have sleep apnea with episodes of low oxygen, cells may be more likely to sickle and cause additional health problems."

Study participants have now been followed for several years.  The next step will be to look at whether having sleep apnea is a risk factor for future problems like increased hospitalizations for pain or a serious lung condition called acute chest syndrome.

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Sleep apnea treatment helps Texas child with night terrors

This article tells the story of one Texas child whose night terrors were helped by sleep apnea treatment.

Sleep apnea is a serious sleep disorder that occurs when a persons sleep is interrupted by their breathing being paused. In many cases sleep apnea goes undiagnosed and it's very common among children.

One family shares their battle with us, we were introduced to the Weedon family of Longview.
Six-year-old Emma was not sleeping through the night since she was nine-months old, waking up sometimes every 30 minutes, she was having night terrors and it was giving her anxiety.

"Her mother Misty Weedon noticed that Emma had some difficulty staying still in her Pre-K school," said Dr .RV Ghuge, Sleep Medicine Institute of Texas. "We were starting kindergarten and I was afraid that someone was going to try to look at her and say that she had ADHD."

After several visits with their pediatrician the Weedon family just figured to contact Dr. Ghuge with the Sleep Medicine Institute of Texas. "Her parents just refused to allow her to be on medications for that, they wanted to explore other alternatives and look at root cause of these problems and they were convinced that sleep was the problem," said Dr. Ghuge.

A sleep test showed what was happening when Emma closed her eyes for bedtime was irregular, from her breathing pattern, teeth grinding and moaning. Emma was diagnosed with sleep apnea a little over a year ago.

She has to wear a CPAP breathing mask while she sleeps, every night. "I put it on and breathe through it and I have better dreams," said little Emma.

"When we did her sleep test she has shown tremendous improvement in her breathing at night and her teeth grinding and the oxygen that she was losing before," said Dr. Ghuge.

"She wasn't growing, since she's been on her CPAP she's grown three inches and that's been in the past year," said Misty Weedon.

After treating her sleep disorder Emma can sleep eight to nine hours.

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Snoring in Children

This article discusses what is important to know about snoring in children.

Snoring in children is a common event, with estimates placing it at about 12 to 15 percent. Most of these children are healthy, show no symptoms and have primary snoring. Snoring happens during sleep due to a blockage of air when breathing as it passes through the back of the mouth. The loudness is affected by how much air passes through and how fast the throat tissue is vibrating. Snoring can be due to an upper respiratory infection, allergies, or it can be a sign of obstructive sleep apnea (OSA).

Infants and toddlers spend over half of their lives sleeping and, by adolescence, greater than on third of our lives are spent sleeping. Quality sleep is essential for proper development and daily functioning. Proper sleep helps with learning, consolidating memories, physical growth, recharging the body and helping our bodies fight infections.

Approximately 2 to 3 percent of children have OSA, which occurs when the posterior air collapses and blocks the throat. Frequent pauses in breathing, lasting from several seconds to a minute, often lead to the brain briefly waking up and causing us to breathe. This leads to gasping or snorting, waking us up and re-breathing. This can occur all through out the night.

Interrupted sleep can lead to behavioral issues, problems with social function, poor school performance and poor growth. These children are also more likely to be hyperactive and have trouble paying attention in school, mimicking signs of attention-deficit hyperactivity disorder (ADHD).

Studies also show that children with OSA are at risk of developing heart and lung problems which can lead to serious consequences later in life if it goes undetected. Untreated OSA, in the short term, often leads to daytime sleepiness, morning headaches, irritability, bed wetting and mouth breathing. The risk of apnea is higher in overweight children.

Other signs might include large tonsils and/or adenoids with frequent mouth breathing, restless sleep or sleep in abnormal positions, sleep in elevated position or with neck extended, excessive sweating during sleep, nasal speech, poor weight gain or being overweight, and high blood pressure. Even primary snoring (i.e. snoring without breathing pauses, frequent arousals, or drips in oxygen levels), which was once thought to be normal, still can lead to problems in school performance or behavior issues.

If you suspect your child may have symptoms of OSA don’t assume his or her snoring will go away on its own. Talk to your child’s doctor. The American Academy of Pediatrics has recognized this as a serious problem and has published recent guidelines for screening of obstructive sleep apnea, which will help doctors recognize, diagnose, and treat children with OSA.

Testing can be done if your child is suspected of having OSA, including an overnight sleep study. You may also videotape your child’s sleep to bring to the doctor for review. Night-time pulse oximetry to measure oxygen levels is also a useful tool. Your doctor may refer your child to a sleep specialist as well, as sometimes these tests are normal even when your child may still have OSA.

Once your child has been found to have obstructive sleep apnea syndrome, referral to doctors who specialize in treating OSA include pediatric otolaryngologists (ENT), pulmonologists and neurologists. Treatment options usually include removing enlarged tonsils and adenoids (T&A). Often removing the tonsils and adenoids stops the snoring and helps with improved appetite and growth in young children. It also improves academic performance and behavior in school-aged children as they get more uninterrupted, quality sleep. Other options include treating allergies or helping children lose weight. A night-time treatment called continuous positive airway pressure (CPAP) therapy is another option for children who can’t have surgery or have persistent OSA even after a T&A has been performed.

Remember to be suspicious that your child may have OSA if he or she regularly snores and has apnea, daytime sleepiness or school/behavior problems. If detected early, treatment of this problem may be reversible.

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Link between sleep apnea and ADHD

This article discusses the potential link between sleep apnea and ADHD in children.

Parents with toddlers displaying symptoms like decreased attention span, hyperactivity, irritability, sleep walking, snoring or breathing through the mouth must check with doctors if the child is suffering from sleep apnea.

Experts emphasize that even if two of these symptoms are seen, the child should be taken to a specialist and tested. If any form of sleep apnea is detected during the sleep study, then appropriate treatment should be sought, they said.

Even two-year-olds can be affected by sleep apnea, and if left untreated, it may hamper the child's growth.

"I have seen children affected almost in the same numbers as adults, and if left undetected and untreated for a long period, may affect the growth of the facial structure of a child," said Seemab Shaikh, ENT surgeon and sleep specialist. He is also the founder and national president of the Indian Association of Surgeons for Sleep Apnea. He sees at least three children with sleep apnea symptoms every day.

Sleep apnea is a condition in which the breathing pauses for a few seconds to minutes during sleep. Typically, normal breathing starts again, with a loud snort or a choking sound. If left untreated, sleep apnea may result in poor performance in academics and physical activities, and behavioral problems such as attention deficit which is sometimes diagnosed as attention deficit hyperactivity disorder (ADHD).

"Various parts of the body do not get proper supply of oxygen and over a longer period of time, this affects the cardiovascular system and the nervous system," said Shaikh.

Shripal Shrishrimal, who specializes in pulmonary medicine and is an American Board certified sleep specialist, said the common symptoms of sleep apnea in children would be - snoring, frequent nightmares, lethargy, hyperactivity, mouth breathing, drooling in sleep, irritability, lack of focus, constant headache, frequent awakening, gasping, sleep walking, bed wetting, daytime sleepiness, drop in academic performance and improper growth.

Just like adults, children too may suffer from any form of sleep apnea - obstructive, central and mixed. Obstructive sleep apnea (OSA), is the most common form and is caused by partial or complete blockage of the upper airway. Central sleep apnea occurs when the brain does not send proper signals to the muscles to control the breathing.

Shrishrimal said the most common causes of sleep apnea in children are swelling or enlargement of tonsils and adenoids, also kn as adenotonsillar hypertrophy. Children who are obese or overweight may also suffer from sleep apnea, and are in this case, asked to first lose weight and then treated through medicines.

"Though surgery is prescribed to remove polyps or correct adenotonsillar hypertrophy, in case symptoms persist, then the continuous positive airway pressure (CPAP) method is used, in which masks are to be worn over the face or nose," said KT Mohan, pulmonologist and sleep disorder breathing specialist.

Doctors say minimally invasive technologies are available to remove extra tissue and enable better breathing, such as radiofrequency ablation and coblation. Although, with early diagnosis, sometimes surgical intervention can be avoided, said Shaikh.

Shrishrimal added that if untreated, sleep apnea over a long term in children may cause cardiac complications, growth failure, learning problems and behavioral problems.

"Often, OSA is the underlying cause of various serious health problems and due to lack of awareness, goes undetected. People with no history of heart or high blood pressure suffer from life-threatening strokes," said Shaikh. "Cases of depression, poor memory, mood disorders and even marital problems happen because of sleep apnea," he added.

Don't ignore the snore

As many as four percent children are affected by sleep apnea

Symptoms

Decreased attention span, drop in academic performance, snoring, frequent nightmares, lethargy, hyperactivity, mouth breathing, drooling in sleep, irritability, lack of focus, constant headache, frequent awakening, gasping, sleep walking, bed wetting, daytime sleepiness

Treatment options

Surgery in case of enlarged tonsils, adenoids or polyps

Weight loss combined with medicine for overweight children

Positional therapy

CPAP therapy, where positive air pressure is forced through the throat by a mask worn over the nose or face

Tests for sleep apnea are a must for children who are obese, have family history of sleep apnea, have cerebral palsy, Down syndrome, or craniofacial anomalies

The link between childhood obesity and sleep apnea

This article discusses the link between childhood obesity and sleep apnea.

Sleep apnea is a disorder where a person’s breathing is interrupted and may stop during the sleep schedule. Recent reports claim that this disorder may afflict not only adults, but also children. Previous research has focused on behavioral issues for children suffering from sleep apnea as well as other health concerns such as diabetes.

CHEO Research Institute’s principal investigator Dr. Sherri Katz claims that there is a direct link between obesity and sleep apnea. “In the past we used to see predominantly preschool-age children who had large tonsils and large adenoids, that was the basis for their obstructive sleep apnea. As time goes on we are seeing a second wave of children with obstructive sleep apnea, predominantly over the age of eight, where obesity is the major factor contributing to their sleep disorder.” Dr. Katz said before adding, “Rates of sleep apnea are about three to 10 times higher in children with obesity. There aren’t sufficient pediatric sleep laboratory resources across the country to manage the growing demand.”

Dr. Indra Narang, who is the director of sleep medicine at The Hospital for Sick Children in Toronto, echoed the concerns voiced by Dr. Katz, explaining that a main determinant in children visiting the sleep medicine department that she oversees is due to obesity.

“We are inundated with referrals for obesity-related sleep apnea. We also believe that probably 60 to 70 per cent of obesity-related sleep apnea isn’t even diagnosed because of a lack of an awareness of sleep apnea associated with obesity. I think the disaster is happening as we speak. Not only do they not sleep well at night, but these children are affected during the day. They are sleeping, they are tired, they don’t learn as well, they don’t do as well at school. They can’t participate in physical activity. Our concern is 75 per cent of obese children will become obese adults and will have untreated obstructive sleep apnea and what we will see is an epidemic of premature cardiovascular death because of obesity and because of related obstructive sleep apnea,” Dr. Narang said.

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Medicine instead of tonsillectomy for children with mild obstructive sleep apnea - Ask a Pediatric Sleep Specialist

This article claims that a specific drug combination can replace the need for a tonsillectomy for children who have mild obstructive sleep apnea.

The anti-inflammatory asthma drug montelukast (Singulair) plus intranasal corticosteroids was an effective initial alternative to surgery for mild obstructive sleep apnea (OSA) in children, a retrospective study showed.

That strategy was associated with normalization of sleep findings in 62%,David Gozal, MD, of Chicago's Comer Children's Hospital, and colleagues found.

Overall, taking into account nonadherence and parents refusing the strategy, 81% were able to avoid surgery, the researchers reported online in Chest.

With "the absence of significant side effects and overall favorable safety profile associated with the use of either intranasal corticosteroids, or of oral montelukast," the combination "may ultimately replace adenotonsillectomy as the first line of treatment in mild OSA," they suggested.

Pediatric sleep apnea can resolve on its own, and that might have accounted for some of the results, Gozal's group acknowledged.

However, "the combined evidence from in vitro experiments showing marked reductions in tonsillar and adenoid tissue proliferation with application of corticosteroids or montelukast, and the experience garnered from clinical trials using either intranasal corticosteroids alone or oral montelukast alone," support a real effect.

Prospective randomized controlled trial evidence is "sorely" needed, the group concluded.

Until such a trial is done, it would be premature to offer the drug combo routinely,Christopher Carroll, MD, medical director of surgical critical care at Connecticut Childrens Medical Center in Hartford, commented in an interview with MedPage Today.

Nevertheless, "I don't think there's any problem with trying this before going to surgery," he suggested, noting that its OSA resolution rate was fairly competitive with the 75% rate found for surgery in a recent review.

"We tend to think that surgery is definitive and is curative 100% of the time, but that's just not true," he said. "And it carries a significant risk."

The retrospective review included 836 otherwise healthy children ages 2 to 14 who were clinically and polysomnographically diagnosed with mild OSA at three centers.

Among them, 752 accepted open-label treatment with a combination of oral montelukast and an intranasal corticosteroid for 12 weeks, with continued montelukast for 6 to 12 months if symptoms persisted at subsequent polysomnographs or a recommendation for surgery if they worsened.

Predictors of nonresponse were older age (odds ratio 2.3 for age older than 7, 95% CI 1.43-4.13) and obesity (OR 6.3 with BMI z score over 1.65, 95% CI 4.23-11.18).

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Removing both adenoids and tonsils for childhood sleep apnea

This study discusses the success of removing both the tonsils and the adenoids for childhood sleep apnea.

A recently published study evaluated the effect of early adenotonsillectomy on polysomnographic, cognitive, behavioral, and health outcomes assessed over a 7-month period.1 A total of 464 children aged 5 to 9 years with obstructive sleep apnea syndrome were randomized to a strategy of watchful waiting or early adenotonsillectomy, and outcomes were assessed at baseline and at 7 months. The primary outcome was the attention and executive-function score on the Developmental Neuropsychological Assessment. 

Results showed no significant change from baseline to follow-up for the primary outcome of attention and executive-function score (mean [±SD] improvement, 7.1 ± 13.9 in the early-adenotonsillectomy group, and 5.1 ± 13.4 in the watchful-waiting group; P = .16). 

Significant improvements were demonstrated in the secondary end points of behavior, quality of life, polysomnographic findings, and reduction in symptoms in the early-adenotonsillectomy group compared with the watchful-waiting group. The authors concluded that the study demonstrates beneficial effects of early adenotonsillectomy with regard to behavior, quality of life, and polysomnographic findings; however, early adenotonsillectomy did not significantly improve attention or executive function as measured by neuropsychological testing.

References

1. Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376.
2. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309(21):2223-2231.
3. Buchs NC, Konrad-Mugnier B, Jannot AS, et al. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg. 2013;100(7):976-979.

- See more at: http://www.pharmacytimes.com/publications/issue/2013/August2013/Adenotonsillectomy-for-Childhood-Sleep-Apnea#sthash.kWnf9ATm.dpuf

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Adenoid and tonsil removal may help pediatric sleep apnea symptoms

This article discusses how adenoid removal or a tonsillectomy can help pediatric sleep apnea symptoms. Important - the AAP and AAFP recommend PRE-OPERATIVE sleep studies at PEDIATRIC sleep Centers- JR

Adenotonsillectomy, or the removal of the adenoids and tonsils, is performed 500,000 times a year in the United States, often as a treatment for children with obstructive sleep apnea. However, the procedure's ability to improve a child's attention and executive functioning, behavior, sleep apnea symptoms, and quality of life has not been rigorously evaluated until now. 

A study led by Susan Redline, MD, MPH, director of the Program in Sleep and Cardiovascular Medicine and Associate Clinic Director of the Division of Sleep Medicine at Brigham and Women's Hospital finds that early adenotonsillectomy in children with mild to moderately severe sleep apnea does not improve attention and executive functioning when compared to watchful waiting with supportive care. However, the study also found that early adenotonsillectomy can be beneficial in improving behavior, sleep apnea symptoms and quality of life. The research will be presented at the American Thoracic Society's International Conference and published online in the New England Journal of Medicine on May 21.

"This new evidence should be carefully considered by physicians and parents who are deciding on the best approach for a child's sleep apnea problem," said Dr. Redline. 

"Our study provided evidence that surgical treatment can lead to early improvements in many health-related areas of importance to children and their families, including children's behavior. Beneficial effects of surgery were shown even among overweight children, in whom the effectiveness of surgery has been questioned....

.... However, the study also showed that many times sleep apnea resolved without surgery and that cognitive functioning did not improve more with surgery than with medical management. Thus, watchful waiting is also a reasonable option for some children with sleep apnea without many symptoms."

The study, which was conducted in partnership with eight other institutions, examined 397 children between the ages of five and nine who had obstructive sleep apnea syndrome without prolonged levels of low oxygen. The children were randomly placed in two groups. One hundred and ninety-four children had their adenoids and tonsils removed within four weeks of being randomized to the study. The remaining 203 children underwent watchful waiting with supportive care to see if their sleep apnea symptoms resolved without surgery.

Seven months later, both groups of children underwent the Developmental Neuropsychological Assessment, which showed no significant difference between the groups in the improvement of attention and executive functioning. However, other tests, including assessments by parents and teachers, showed significant improvements in the quality of life, sleep apnea symptoms and behavior in the children who had the early adenotonsillectomy.

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People with asthma at higher risk for developing sleep apnea

Researchers find a link between asthma and the eventual development of sleep apnea.

Asthma may be a contributing factor to obstructive sleep apnea, according to researchers at the University of Wisconsin.


Using data from the Wisconsin Sleep Cohort Study, which was funded by the National Institutes of Health, researchers studied 773 participants who joined the study in 1988 when they were between the ages of 30 and 60. None of them had obstructive sleep apnea (OSA) when they joined the study. They found that during the eight year follow-up period, those who had asthma were 1.70 times more likely to develop OSA. The risk was even higher in patients who had asthma as children — they were 2.34 times more likely, according to a press release. 

They also found that for every five years a person had asthma, the likelihood of developing OSA increased by 10 percent.

"This is the first longitudinal study to suggest a causal relationship between asthma and sleep apnea diagnosed in laboratory-based sleep studies," Dr. Mihaela Teodorescu, assistant professor of medicine and lead author said. "Cross-sectional studies have shown that OSA is more common among those with asthma, but those studies weren't designed to address the direction of the relationship."

Obstructive sleep apnea occurs when a person's airway becomes blocked during sleep, forcing them to wake up in order to start breathing properly again. Lacking restful sleep, a person with OSA is typically drowsy throughout the day, which results in a higher risk for car crashes, work-related accidents, and a variety of health problems, according to the National Institutes of Health.

During the course of the study, researchers also made adjustments for variables that contribute to sleep apnea such as age, sex, changes in body mass index, smoking, number of alcoholic drinks per week, and nasal congestion.

They also accounted for the 45 participants who developed asthma during the eight years. They found that these people had a 48 percent higher chance of sleep apnea, however, they pointed out that the size of this group was too small to be statistically significant.

"Forty-eight percent represents a large difference," Paul Peppard, assistant professor of population health sciences and a principal investigator for the cohort study, said. "This is one result that calls for a follow-up study. If confirmed by a larger study with more asthma cases, the finding would have important clinical relevance."

Although he considers it to be a "strong observational study," Peppard stressed that the study falls short of establishing causality between asthma and sleep apnea. He suggested that clinicians consider asthma history in addition to "more traditional factors associated with OSA such as obesity, when deciding whether to evaluate patients for OSA with a sleep study."

A week ago, Peppard released a study based on the same data suggesting the obesity epidemic played a part in the rise of sleep apnea cases. He found that cases of sleep apnea had risen from 14 to 55 percent from 1988 to 1994, and estimated that 80 to 90 percent of the increase was due to the growth of obesity in the country.

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Sleep Apnea in Children leads to Learning Complications

Obstructive sleep apnea in children leads to learning complications such as ADHD, behavioral problems, or learning problems.

New research confirms the relationship between obstructive sleep apnea in children and ADHD, as well as other behavioral and cognitive problems. Children with sleep apnea, a common type of disordered breathing during sleep, are more likely to have difficulties with learning and attention.

Obstructive sleep apnea, a type of sleep-disordered breathing (SDB), affects about 2 percent of children in the United States, according to the American Academy of Sleep Medicine. The link between obstructive sleep apnea in children and ADHD (attention-deficit hyperactivity disorder) has been previously established, but this is the first sleep study to use self-reports in assessing children's adaptive behavior, or ability to adapt to new situations.

The study, published in the April edition of the journal SLEEP, analyzed sleep and cognitive data from 263 Arizona children enrolled in the Tucson Children's Assessment of Sleep Apnea Study (TuCASA) over five years. The children, all between 6 and 11 years old, completed overnight sleep studies and standard series of neurobehavioral tests at the beginning and end of the 5-year period. Their parents also answered questionnaires about the children's behavior.

The sleep studies divided the children into four groups: those who never had sleep-disordered breathing, those who had it the first time but not the second, those who had it only the second time (new onset), and those who had it both times (persistent).

The results showed that children with new onset sleep apnea were at least four times as likely to have behavioral problems- the likelihood rose to six times higher if they had persistent sleep apnea.

The children with obstructive sleep apnea were more likely to have parents reporting problems with their hyperactivity, attention, communication abilities, self-care, and ability to adapt to new situations. They were also likely to be suffering academically, with grades of C or lower in school.

"This study provides some helpful information for medical professionals consulting with parents about treatment options for children with SDB that, although it may remit, there are considerable behavioral risks associated with continued SDB," said Dr. Michelle Perfect, the study's lead author and assistant professor in psychology at the University of Arizona in Tucson.

Obstructive sleep apnea is a major cause of snoring, occurring when soft tissue in the back of the throat relaxes too much during sleep and collapses into the airway. This cuts off oxygen intake, and the temporary suffocation sends a signal to the brain to wake up immediately. When sleep apnea is especially severe, it can interrupt sleep hundreds of times throughout the night- depriving the brain of oxygen and causing exhaustion the next day.

Children with sleep-disordered breathing generally have larger tonsils and adenoids than other children their age, and most children with sleep apnea have a history of loud snoring. Effective treatment options for children include the surgical removal of the tonsils and adenoids or the use of continuous positive airway pressure (CPAP) therapy.

The Arizona researchers say in their study that most children with sleep apnea have larger tonsils and adenoids than those without it, and are much more likely to snore loudly. Tonsillectomies can provide effective sleep apnea treatment, and so can continuous positive airway pressure (CPAP therapy).

Perfect said in a statement that obstructive sleep apnea in children typically declines into adolescence, but that "taking a wait and see approach is risky" for parents who are worried about their children's cognitive and behavioral development.

"School personnel should also consider the possibility that SDB contributes to difficulties with hyperactivity, learning and behavioral and emotional dysregulation in the classroom."

The New York Times suggests that ADHD-related learning problems may often result from obstructive sleep apnea in children, and that the symptoms could be better treated with sleep improvements than with stimulant medications like Adderall and Ritalin, which can actually increase sleep deprivation.

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