Treating sleep apnea helps children behave

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

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

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

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

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

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

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

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

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

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Signs and treatments for obstructive sleep apnea in children

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

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

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

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

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

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

Blocked Airways Impede Breathing

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

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

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

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

Hyperactivity in Sleepy Children

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

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

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

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

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

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

Expert Diagnosis and Treatment

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

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

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

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

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

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

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Home test can diagnose sleep apnea in children

Of course this is interesting, but consider the importance of sleep studies in kids is not just to find evidence of sleep apnea. We need to identify those who have severe apnea to know who is at medical risk of complications from surgery.  

This is why the AAP recommends a sleep study BEFORE tonsillectomy.

Note that the agreement was higher in the lab for the same device. So..can you trust the results at home?

I dont like "probably" as an answer.

So, if its positive, a child needs a psg ...and..if its negative, the child needs a psg. 

Bottom line: kids are different than adults....JR


A respiratory polygraphy test that can be administered at home accurately diagnoses children with sleep apnea.

The use of home respiratory polygraphy to diagnose children with sleep apnea was reliable and comparable to the results of polysomnography and an in-laboratory respiratory polygraphy, according to study results.

‘This study shows that [home respiratory polygraphy (HRP)] provides a reasonably valid alternative to [in-laboratory polysomnography (PSG)] for the diagnosis of [obstructive sleep apnea-hypopnea syndrome (OSAS)] in children clinically referred with a high index of clinical suspicion for the presence of OSAS,” María Luz Alonso-Álvarez, MD, of the Hospital Universitario de Burgos in Spain, and colleagues wrote. “This frequent and highly prevalent pediatric condition is associated with adverse consequences and excessive and costly use of health care services.”

The researchers conducted a prospective, blinded study on 50 randomly selected children (mean age, 5.3 years) being evaluated for clinical suspicion of OSAS. Participants were given an HRP and within 2 weeks a simultaneousPSG and in-laboratory respiratory polygraphy (LRP).

Sixty-six percent of the children were diagnosed with OSAS based on a PSG-defined obstructive respiratory disturbance index (ORDI) of at least three events per hour during sleep.

Using the interclass correlation coefficient, ORDI agreement between PSG and LRP (ORDI = 96.5; 95% CI, 92.3-98.2) as well as HRP (ORDI = 86.7; 95% CI, 76.5-92.5) was greater than 80% in all cases but higher for LRP than HRP.

The researchers emphasized the importance and validity of using HRP in the diagnoses of children suspected of having OSAS, namely reduced cost and the comfort of home testing.

“We should stress, however, that when inconclusive HRP findings occur, a conventional PSG should be performed, and we further recommend incremental research efforts, particularly for the mild diagnosis of OSA using HRP in children,” the researchers wrote.

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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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New quality measures for treating childhood sleep apnea

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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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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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

Obesity and body fat in children are affected by chronic insufficient sleep

A study shows that chronic insufficient sleep can affect obesity and body fat in children.

One of the most comprehensive studies of the potential link between reduced sleep and childhood obesity finds compelling evidence that children who consistently received less than the recommended hours of sleep during infancy and early childhood had increases in both obesity and in adiposity or overall body fat at age 7. The study from MassGeneral Hospital for Children (MGHfC) investigators, published in the June issue of Pediatrics, also finds no evidence of a specific period during which insufficient sleep has greater influence on later obesity.

"Our study found convincing evidence that getting less than recommended amounts of sleep across early childhood is an independent and strong risk factor for obesity and adiposity," says Elsie Taveras, MD, MPH, chief of General Pediatrics at MGHfC and lead author of the Pediatrics paper. "Contrary to some published studies, we did not find a particular 'critical period' for the influence of sleep duration on weight gain. Instead, insufficient sleep at any time in early childhood had adverse effects."

While several studies have found evidence of an association between sleep and obesity in young children, few have examined the effects of constant sleep deprivation across time or used measures other than body mass index (BMI), which determines obesity based solely on height and weight. The current study analyzed data from Project Viva, a long-term investigation of the health impacts of several factors during pregnancy and after birth. Information used in this study was gathered from mothers at in-person interviews when their children were around 6 months, 3 years and 7 years old, and from questionnaires completed when the children were ages 1, 2, 4, 5 and 6.

Among other questions, the mothers were asked how much time their children slept, both at night and during daytime naps, during an average day. Measurements taken at the seven-year visit included not only height and weight but also total body fat, abdominal fat, lean body mass, and waist and hip circumferences -- measurements that may more accurately reflect cardio-metabolic health risks than BMI alone. Curtailed sleep was defined as less than 12 hours per day from ages 6 months to 2 years, less than 10 hours per day for ages 3 and 4, and less than 9 hours per day from age 5 to 7. Based on the mothers' reports at each age, individual children were assigned a sleep score covering the entire study period -- from 0, which represented the highest level of sleep curtailment, to 13, indicating no reports of insufficient sleep.

Overall, children with the lowest sleep scores had the highest levels of all body measurements reflecting obesity and adiposity, including abdominal fat which is considered to be particularly hazardous. The association was consistent at all ages, indicting there was no critical period for the interaction between sleep and weight. Lower sleep scores were more common in homes with lower incomes, less maternal education and among racial and ethnic minorities; but the association between sleep and obesity/adiposity was not changed by adjusting for those and other factors.

Facts and tips for healthy sleeping habits

While more research is needed to understand how sleep duration affects body composition, Taveras notes, potential mechanisms could include the influence of sleep on hormones that control hunger and satiety; the disruptions of circadian rhythms or possible common genetic pathways involved in both sleep and metabolism; poor ability to make good decisions on food choices and eating behaviors caused by sleep deprivation, or household routines that lead to both reduced sleep and increased food consumption. Insufficient sleep may also lead to increased opportunities to eat, especially if time is spent in sedentary activities, such as TV viewing, when snacking and exposure to ads for unhealthy foods are common.

"While we need more trials to determine if improving sleep leads to reduced obesity," she says, "right now we can recommend that clinicians teach young patients and their parents ways to get a better night's sleep -- including setting a consistent bedtime, limiting caffeinated beverages late in the day and cutting out high-tech distractions in the bedroom. All of these help promote good sleep habits, which also may boost alertness for school or work, improve mood and enhance the overall quality of life." Taveras is an associate professor of Pediatrics and Population Medicine at Harvard Medical School (HMS).

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New screening tool for sleep apnea in children

A new screening tool that looks at neck circumference in children can help screen for obstructive sleep apnea and sleep problems in children. 

Remember, the intent of "screening tools" is to find people at risk. They are not intended to be diagnostic. - JR

Clinical investigators at the Children's Hospital of Eastern Ontario (CHEO) have developed a new screening tool to help diagnose obstructive sleep apnea in children. Their findings are published in Pediatric Pulmonology.

Evidence suggests that adults with a large neck circumference are more likely to develop obstructive sleep apnea (OSA), especially males. As neck circumference varies by age and sex, there have been no reference ranges to diagnose pediatric OSA up until now. The new evidence-based diagnostic tool includes reference ranges—a new pediatric growth curve—to measure and track neck circumference for boys and girls between the ages of 6 and 17.

"The gold standard test (for OSA) is still a sleep study and we would not replace that, but because the wait is so long, we needed something quick and reliable to help bump kids up the priority list or to better understand who is at the highest risk for OSA," said Dr. Sherri Katz, principal investigator at the CHEO Research Institute and assistant professor in the Faculty of Medicine at the University of Ottawa. "If left untreated, OSA sets kids up for cardiovascular disease, diabetes and other comorbid conditions down the line."

The research team discovered for children, a neck circumference measuring greater than the 95th percentile for age and sex is associated with increased risk of OSA. When examined by sex, the association was significant in males aged 12 or older, but not in females. The research team also looked at Body Mass Index (BMI), but did not find that it stands alone as a significant predictor of OSA in this group.

"In older males, as in adults, neck size is a predictor of OSA. This suggests that in adults, it is not just overall obesity, but body fat distribution centrally—in the trunk and neck—that predicts the risk of OSA," said Katz.

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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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