Sleep Breathing Machine Shows Clear Benefits in Children with Sleep Apnea
Children and adolescents with obstructive sleep apnea had substantial improvements in attention, anxiety and quality of life after treatment with positive airway pressure (PAP)—a nighttime therapy in which a machine delivers a stream of air through a mask into the nose.
“The benefits occurred even when children didn’t fully adhere to the treatment,” said study leader Carole L. Marcus, M.D., a sleep specialist and director of the Sleep Center at The Children’s Hospital of Philadelphia. The Sleep Center follows thousands of children and adolescents with sleep problems.
The study appears online ahead of print in the American Journal of Respiratory and Clinical Care Medicine.
Obstructive sleep apnea syndrome (OSAS) is a condition of interrupted breathing caused by a narrowing in the throat or upper airway, related to large tonsils and adenoids, obesity or other medical problems. Using continuous positive airway pressure commonly relieves OSAS in adults, in whom it has been studied extensively. However, there have been few studies of PAP in children with OSAS.
“The vast majority of children with OSAS undergo surgery on their tonsils and adenoids instead of receiving PAP therapy,” said Dr. Marcus. “It is difficult to get children to wear the mask used in PAP treatments.” However, surgery is not always effective in treating OSAS in children, especially in obese children,” said Dr. Marcus. She added that many children who require PAP therapy have underlying chronic illnesses such as Down syndrome, or developmental delays. Furthermore, the rising incidence of obesity among children and adolescents has also increased the rate of OSAS in young people.
What happens in people with obstructive sleep apnoea syndrome?
When we sleep, the throat muscles relax and become floppy (like other muscles). In most people, this does not affect breathing. If you have OSAS, the throat muscles become so relaxed and floppy during sleep that they cause a narrowing or even a complete blockage of the airway.
When your airway is narrowed and the airflow is restricted, at first this causes snoring. If there is a complete blockage then your breathing actually stops (apnoea) for around 10 seconds. Your blood oxygen level then goes down and this is detected by your brain. Your brain then tells you to wake up and you make an extra effort to breathe. Then, you start to breathe again with a few deep breaths. You will normally go back off to sleep again quickly and will not even be aware that you have woken up.
Sometimes, the airway can just partially collapse and can lead to hypopnoea. Breathing becomes abnormally slow and shallow. If this happens, the amount of oxygen that is taken into your body can be halved. Hypopnoea episodes also usually last for around 10 seconds.
If someone watches you, he or she will notice that you stop breathing for a short time, and then make a loud snore and a snort, perhaps even sound as if you are briefly choking, briefly wake up, and then get straight back off to sleep.
The current study followed 52 children and adolescents with OSAS at Children’s Hospital. The patients had a mean age of 12 years old, and 10 of them had significant developmental delays. The study team assessed sleepiness, behavioral problems, attention, and quality of life at baseline and after three months of PAP treatment.
The researchers found significant improvements in attention deficits, daytime sleepiness, behaviors such as anxiety and shyness, and quality of life. Both the parents and children reported on quality of life using standardized questionnaires that asked about feelings, daily activities, getting along with other children, and keeping up with schoolwork.
What are the symptoms of obstructive sleep apnoea?
People with OSAS may not be aware that they have this problem as they do not usually remember the waking times at night. It is often a sleeping partner or a parent of a child with OSAS that is concerned about the loud snoring and the recurring episodes of apnoea that they notice.
One or more of the following also commonly occur:
Daytime sleepiness. This is often different to just being tired. People with severe OSAS may fall asleep during the day with serious consequences. For example, when driving, especially on long monotonous journeys such as on a motorway. A particular concern is the increased frequency of car crashes involving drivers with OSAS. Drivers with OSAS have a 7-12 increased risk of having a car crash compared to average. You should not drive or operate machinery if you feel sleepy.
Poor concentration and mental functioning during the day. This can lead to problems at work.
Not feeling refreshed on waking.
Morning headaches.
Depression.
Being irritable during the day.
Some people with OSAS find that they get up to pass urine frequently during the night. Less common symptoms also include night sweats, reduced sex drive, and gastro-oesophageal reflux disease.
“We found that improvements occurred even when children were only using PAP as little as three hours a night,” said Dr. Marcus, who noted that higher compliance would be expected to yield greater benefits. She added that getting children to fully adhere to treatments requires a commitment by parents and family members to a behavioral plan that supports the treatments.
Dr. Marcus said that further pediatric sleep research is warranted, such as blinded studies to compare treatment to a placebo group and further investigations of neurobehavioral outcomes. “This study was the first comprehensive study of PAP use in children, so more research should be performed, but our results have encouraging implications for using this treatment in children with sleep apnea,” she concluded.
Symptoms of Obstructive Sleep Apnea (OSA) are: snoring, restless/disturbed sleep, frequent partial or total wakenings and daytime mouth breathing. Some children with OSA have odd sleep positions, often with their neck bent backwards, or even in a sitting position. Some children with OSA sweat profusely during sleep. In adults, there is an association of obesity, but that’s not a common association in children. Some children will have daytime grumpiness or sleepiness, but it’s not common. Some children may have noisy swallowing as well.
Children with Down syndrome (DS) are certainly at risk for OSA. In 1991, one study showed 45% had OSA. This can be caused by several different factors present in DS: the flattened midface, narrowed nasopharyngeal area, low tone of the muscles of the upper airway and enlarged adenoids and/or tonsils.
Why is this important? Well, first, there’s the obvious problem of the child not getting enough quality sleep and the behavioral effects that brings. Second, I’ve mentioned above that during sleep apnea, the oxygenation of the blood decreases. It has been shown that in children with DS and heart disease this low oxygenation causes an increase in the blood pressure in the lungs as the body tries to get more oxygen. This “pulmonary hypertension” can cause the right side of the heart to become enlarged and other cardiac complications can follow. The incidence of death due to OSA is unknown.
Financial support for this study came from Philips Respironics, as well as from the National Institutes of Health. Co-authors with Marcus were Jerilynn Radcliffe, Ph.D., Sofia Konstantinopoulou, M.D., Suzanne E. Beck, M.D., Mary Anne Cornaglia, Joel Traylor, RPsgT, Natalie DiFeo, CRNP, Laurie R. Karamessinis, RPFT, and Paul R. Gallagher, M.A., all of The Children’s Hospital of Philadelphia; and, Lisa J. Meltzer, Ph.D., previously from CHOP, now at Denver National Health, Denver, Colo.
“Effects of Positive Airway Pressure Therapy on Neurobehavioral Outcomes in Children with Obstructive Sleep Apnea,” the American Journal of Respiratory and Clinical Care Medicine, published online ahead of print Feb. 10, 2012.
About The Children’s Hospital of Philadelphia: The Children’s Hospital of Philadelphia was founded in 1855 as the nation’s first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children’s Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking third in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 516-bed hospital recognition as a leading advocate for children and adolescents.
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Source: Children’s Hospital of Philadelphia