Sleep apnea surgery in children helps improve asthma control

Removing a child's tonsils and adenoids for sleep apnea can help his or her asthma control.

Researchers from the University of Chicago found that surgical removal of the tonsils and adenoids in children suffering from sleep apnea is associated with decreased asthma severity. The study was published in PLOS Medicine (November 4, 2014).

In the first year after the operation, the children who had their tonsils and adenoids removed had a 30% reduction in acute asthma exacerbations and a 38% decrease in acute status asthmaticus, episodes of severe asthma that do not respond to repeated courses of therapy.

"Several small studies have described a strong association between obstructive sleep apnea and asthma, two common inflammatory conditions that impair breathing in children. But we wanted to test the strength of the connection when studied in a much larger population," said lead study author Rakesh Bhattacharjee, MD, an assistant professor of pediatrics at the University of Chicago and an authority on pediatric sleep medicine, in a statement.

Obstructive sleep apnea is affects an estimated 2% to 3% of all children. The removal of the adenoids and tonsils, known as surgical adenotonsillectomy, is considered standard therapy.

Asthma is the third-most prevalent chronic pediatric disease in the U.S., affecting an estimated 7.1 million according to the Centers for Disease Control and Prevention and is the third-most common cause of hospitalization of U.S. children younger than age 15.

In the study, researchers also noted that pediatric patients who received the surgery had a 36% reduction in asthma-related hospitalizations and a 26% decline in asthma-related emergency room visits. Children who did not have the surgery did not have significant reductions in these categories.

"Our study adds weight to the growing sense that obstructive sleep apnea aggravates asthma and further tips the balance toward early identification of obstructive sleep apnea," Dr. Bhattacharjee said. "This will help physicians advocate for surgical intervention, not just to eradicate sleep-disordered breathing, but also to reduce asthma severity and decrease reliance on medications in asthmatic children."

Data on more than 40,000 children between the ages of 3 and 17, obtained from Truven Health's MarketScan databases were included in the study. More than 13,500 U.S. children with asthma who underwent removal of their adenoids and tonsils as treatment for obstructive sleep apnea were included. Asthma symptoms from the year before surgery to the year afterward were compared. Researchers also matched those results to the results of more than 27,000 children with asthma who still had their tonsils and adenoids.

Overall, adenotonsillectomy brought significant improvement: The frequency of acute status asthmaticus dropped almost 40%, from 562 in the year before surgery to 349 in the year after. In children who did not have surgery, such severe asthma attacks also decreased but by only 7%, from 837 to 778.

Acute asthma exacerbations fell from more than 2,200 before surgery to 1,566 after, a 30% reduction. Exacerbations for children who did not have surgery also fell from 3,403, to 3,336, a 2% drop.

Also decreasing significantly for those children who had the surgery was the incidence of secondary asthma outcomes, such as acute bronchospasm and wheezing, while rates were unchanged for those who did not. Prescription refills followed the same pattern.

The authors' concerns about the MarketScan database included that it only includes those patients with private insurance and a lack of available data why patients underwent adenotonsillectomy.

Despite the limitations, they emphasize the many plausible connections that link obstructive sleep apnea to asthma:

• Both are inflammatory diseases.
• Both share risk factors, such as allergies, obesity, and exposure to tobacco smoke.
• Severe obstructive sleep apnea is often associated with poorly controlled asthma.

A prospective, randomized, controlled clinical trial is still needed to show a direct causal relationship, Dr. Bhattacharjee noted.

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Sleep apnea symptoms persist after adenoid and tonsil removal in children

A study claims that children with severe obstructive sleep apnea saw residual sleep apnea symptoms following an adenotonsillectomy procedure.

Children with severe obstructive sleep apnea before adenotonsillectomy were more likely to experience residual symptoms after surgery, according to findings in a retrospective study.

Researchers evaluated data from 283 children younger than 3 years (mean age, 22 months). Each child underwent a preoperative polysomnogram between 2002 and 2010.

Of the study population, 61.8% were boys and 84.8% were black. According to their BMI, 46.7% of the children were obese, whereas 33.1% were classified as having a healthy weight. At baseline, 65.7% of the children had a severe apnea hypopnea index (>10).

Seventy of the children also underwent a post-adenotonsillectomypolysomnogram after a mean time of 7.7 months. Compared with the children who only underwent a preoperative polysomnogram, those who had preoperative and postoperative polysomnograms were younger (23 vs. 20 months; P=.002), shorter (81 cm vs. 79 cm; P=.04) and weighed less (13 kg vs. 11 kg; P=.01). They were also more likely to have had a severe index before surgery (22 vs. 35; P=.002) and lower mean minimal oxygen saturations (83% vs. 77%; P<.001).

Fifteen of the 70 children had residual obstructive sleep apnea (index, >5) and a significantly higher preoperative index (P=.02) compared with those without residual symptoms. However, these 15 children had a mean apnea hypopnea index that dropped from 55 to 21 (P=.03), whereas mean minimum oxygen saturations increased from 74% to 82% (P=.09) after surgery.

“Our data support the finding that, although [adenotonsillectomy] leads to a dramatic improvement in this age group, a high proportion of this population will have residual [obstructive sleep apnea],” the researchers wrote. “Although this proportion gives some insight into residual disease after [adenotonsillectomy] in this young population, the result is flawed because of the retrospective design of the study and the fact that only 25% of the children treated received postoperative [polysomnogram].”

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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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Rising number of children with sleep disorders

This article discusses how sleep issues in children are rising through stories of specific children and the stories of their sleep issues.

When it came to her son's sleeping habits Sherrie Sharlow considered herself lucky. It was common for her 1-year-old son Ethan Cain to sleep for a solid 12 hours, providing a respite for his parents.

Facts

Sleep Tips for Children and Infants 


Babies up to 1 year old should always be placed on their backs on a firm surface to reduce the risk of Sudden Infant Death Syndrome.
- Establish a routine by setting your child's bedtime at the same time each night and doing similar activities before bed.
- All children and adolescents who snore regularly should be tested for sleep apnea. Additional symptoms can include labored breathing during sleep, gasps, snorts or pauses in breath.
- Create a technology curfew by requiring children to hand over devices such as laptops, tablets, cellphones and turning off television before bedtime.

SOURCE: American Academy of Pediatrics

But despite the child's long slumbers, he was always tired. Sharlow, 44, also noticed that her son would gasp for air while sleeping and would frequently snore. A doctor confirmed Ethan Cain had obstructive sleep apnea, a condition in which breathing slows or decreases during sleep due to a narrow or blocked airway.

"He was such a good baby," the Port Orange resident recalled. "He would just fall asleep on me or we'd be out and the next thing I knew, he was sleeping. Everyone said I was so lucky, but the whole while sleep was doing damage to my child and I had no idea."

Like the majority of children diagnosed with sleep apnea, Ethan Cain had surgery to remove his tonsils and adenoids. Sharlow said her son, now 9, is able to sleep throughout the night and she's seen an improvement in his behavior and mood.

Sleep disorders affect 20 to 25 percent of children and adolescents, according to the American Academy of Pediatrics. While childhood obesity is a contributing factor to disorders like sleep apnea, sleepless nights also appear to be intensified by modern life's hectic schedules and dependence on technology, said Dr. Mary Wagner, director of the pediatric sleep lab at the University of Florida.

"Sometimes there are other disruptions that are causing kids to stay up late," Wagner said. "Maybe they are on their phones or texting. Because there is so much fun stuff do to 24/7, sometimes it's hard to get in bed, turn the lights off and go to sleep."

Edgewater resident Kimberly Adams believes that placing her 1-year-old daughter, Zoe, and 4-year-old son, Zane, on a strict bedtime schedule has made a difference in their behavior. Because her husband wakes up for work each morning at 4:30, the entire family goes to bed at 8 p.m., she said.

"We try not to do a lot of running around during the week," Adams said. "We sit down to dinner every night at 6, and then shower and get ready for bed. We have always had a consistent schedule from when my son was first born."

The AAP recommends children ages 5 to 13 receive 10 hours of sleep per night, and eight to nine hours each night for 14- to 18-year-olds. Irregular or disrupted sleep in children can cause side effects such as lack of concentration, impulsiveness and irritability. Researchers are studying the correlation between sleep disorders and attention deficit hyperactivity disorder because of the similar side effects.

"We are seeing an increase in children and teens with sleep disorders, especially with obstructive sleep apnea because of obesity and weight issues," said Amy Korn-Reavis, program director of the neurodiagnostic technology program at Concorde Career Institute in Orlando. "We don't know if there is a correlation but the symptoms of sleep disorders and ADHD are exactly the same."

A 2007 study published in the Journal of the AAPfound that 50 percent of parents of children and adolescents with ADHD reported sleep problems but the relationship is not well understood.

"It's unclear whether the sleep problem or the psychiatric disorder is the primary problem," researchers wrote in the study.

Joellen Salce Rogers, a licensed school psychologist and behavioral analyst in Daytona Beach, said the ADHD screenings she conducts with her patients evaluate habits such as eating and sleeping.

"If they don't sleep well or fitfully there is a possibility that there is a correlation and it warrants looking into," Rogers said. "There is no question that our lives are crazier now and we are running in different directions. But there is also a huge genetic component associated with ADHD."

Wagner said that education among doctors, parents and psychologists is important for making sure a child is receiving the best treatment for sleep and behavioral disorders. She also recommends that children who are being tested for ADHD are also screened for sleep disorders.

"We are getting better at making diagnoses, but the people who know children best are the parents," Wagner said. "They should bring concerns to the attention of a primary care provider."

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Sleep Apnea May Be Tied to 'Silent' Strokes, Study Finds

Other research also suggests rapid memory loss may be linked to a fatal brain attack

URL of this page: http://www.nlm.nih.gov/medlineplus/news/fullstory_121447.html (*this news item will not be available after 05/01/2012)

Wednesday, February 1, 2012

WEDNESDAY, Feb. 1 (HealthDay News) -- Sleep apnea, the disorder marked by abnormal pauses in breathing during sleep, is already known to boost the risk of stroke. Now, a new study links sleep apnea to so-called silent strokes, in which there is tissue death in the brain without symptoms.

In another new study, researchers found that rapid memory loss before a stroke boosts the risk of the stroke being fatal.

Both studies are slated for presentation Wednesday at the American Stroke Association's International Stroke Conference in New Orleans.

Stroke affects 795,000 Americans annually, according to the association.

In one study, Dr. Jessica Kepplinger, a fellow at the University of Technology in Dresden, Germany, and her colleagues evaluated 56 patients who had a stroke. They knew that silent strokes had been linked to an increased risk of strokes. However, "there are barely any studies that have investigated the relationship between sleep apnea and the so-called clinically silent strokes," she said.

To look at the relationship, they first gave patients in-hospital testing for apnea. "We found an overall high frequency of sleep apnea, 91 percent, in our study population of acute stroke patients, which underlines the importance of this stroke risk factor," Kepplinger said.

The team also performed brain-imaging studies. Those with sleep apnea were more likely to have the silent strokes, as evidenced on the brain scans, the researchers found. Having more than five episodes a night was linked with having silent strokes. The higher the severity of the apnea, the more likely these silent strokes were found on brain imaging.

The more severe the apnea, the less favorable the outcome when the patient was discharged.

The patients were on average 67 years old, and just over half of them were women, the study authors noted.

While the study found an association between sleep apnea and stroke, it did not prove a cause-and-effect relationship.

In the second study, Qianyi Wang, a graduate student at the Harvard University School of Public Health, and colleagues evaluated nearly 12,000 men and women, all above age 50, enrolled in the U.S. Health and Retirement Study.

All were stroke-free at the start. The men and women were given memory tests every two years for up to 10 years.

Over time, 1,820 strokes were reported, including 364 people who died after the stroke.

The others were stroke-free for the entire follow-up period, the study authors noted.

The research looked at the memory declines over time. Those who later survived a stroke "had memory decline that is nearly twice as fast as stroke-free individuals, even before their stroke," Wang said.

"For people who do not survive stroke, this difference is even more striking," said M. Maria Glymour, an assistant professor of society, human development and health at Harvard and a study co-author. "Prior to stroke, people who later died shortly after stroke were declining three times as fast as the stroke-free."

The study was funded by the U.S. National Institute on Aging and the American Heart Association.

"Our study is the first national picture of how memory changes over the long-term before and after stroke onset, compared to individuals who do not have a stroke," Glymour said.

Both studies provide some valuable information, said Dr. Ralph Sacco, chair of neurology at the University of Miami Miller School of Medicine and past president of the American Heart Association. He reviewed the findings.

"It's been mainly in smaller studies that sleep apnea has been shown to be a risk factor for stroke," Sacco said. The new research, he noted, goes even further by linking sleep apnea with the milder "silent" strokes.

"There are many reasons to treat sleep apnea, including reducing the risk for clinical and now silent stroke," Sacco said.

The memory-loss study, he said, "is telling us that those who have the worst memory loss may have a greater death rate when they have the stroke." Those with more memory loss in the study may also have had more risk factors for stroke, Sacco added.

Even so, he said, the message seems to be that taking care of brain health may help us in several ways. "What is good for our memory may also be good for surviving a stroke," Sacco said.

Because these studies were presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

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SOURCES: Jessica Kepplinger, fellow, University of Technology Dresden, Germany; Ralph Sacco, M.D., chair of neurology, University of Miami Miller School of Medicine; M. Maria Glymour, S.D., assistant professor of society, human development and health, Harvard School of Public Health; Qianyi Wang, graduate student, Harvard School of Public Health; Feb. 1, 2012, presentations, International Stroke Conference, New Orleans

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Related MedlinePlus Pages

• Sleep Apnea
• Stroke

Page last updated on 02 February 2012