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Children and sleep-disordered breathing.

As one principle of the highest standards of health in the clinical areas covered by this journal, I would insist that breathing during sleep should always be effortless and silent. This is tantamount to saying that when an individual falls asleep, airway resistance will remain at the level of the prior waking state, at which time breathing was presumably effortless and silent.


It is well-known that the foregoing is not true. However, a very modest rise in airway resistance is not necessarily a cause or even a likely prelude to eventually developing sleep-disordered breathing. On the other hand, loud snoring or other signs of substantially increased airway resistance should never be ignored. Something must be done as soon as possible, and that something should be done by a sleep specialist who, in turn, should be doing that something at a sleep disorders clinic.

Getting back to the highest standards of health care, I want to suggest very strongly that all parents should apply the silent, effortless breathing standard to all of their children, possibly even beginning in the first year of life. It should be noted that although sleep-disordered breathing is no longer the prime suspect as a cause of Sudden Infant Death Syndrome, it may occasionally be a cause.

In the early 1970s, Christian Guilleminault and I at Stanford began to carry out polysomnographic observations not only on infants but also on children and adolescents. The clear-cut results were that severe obstructive sleep apnea syndrome occurred at every age. However, as we all know, effective clinical approaches to sleep-disordered breathing have not yet fully permeated society and the medical profession, and this is particularly true in children.

Studies of the negative consequences of sleep-disordered breathing on daytime wakefulness in non-adult age groups are relatively sparse. However, we know that obstructive sleep apnea can have a very severe negative impact on the ability to study and learn in children and adolescents. Therefore, it would seem mandatory for the benefit of society at large that every young American should be screened for sleep-disordered breathing.

If there is any hint of its presence, children should be carefully tested and, if indicated, effectively treated. It is likely that treatment in the majority of children and adolescents would involve tonsillectomy and adenoidectomy alone, of course with meticulous follow up.

As alluded to earlier, my personal experience has resulted in the very firm opinion that a diagnosis of impaired breathing during sleep can be made simply by listening to a sleeping child breathe. This is best done if the child is sleeping on his or her back. The listener should be quite close, and there should be no competing noise in the bedroom. Breathing should be noiseless and unambiguously without effort. Obviously, this "test" is not valid if the child is suffering an upper airway infection.

To enumerate the benefits of early identification, they are:

* Prevention of the impaired learning and memory that would prevent growing children and adolescents from achieving their full potential,

* Lowering long-term risk for developing cardiovascular problems

* Likelihood that treatment at an early age will be less complicated and less expensive, and

* Improvement of interpersonal and family relationships.

When undetected obstructive or central sleep apnea is very severe, the consequences can be serious and potentially permanent, for example lower IQ.

It is my relatively uninformed impression that at the present time, identification and treatment of sleep-disordered breathing at all ages is not truly mainstream or indeed not an absolutely required component of pediatric clinical practice. It seems likely that the idea of early diagnosis and treatment would be resolved by making sleep medicine an essential component of standard pediatric training. This development continues to remain long overdue.

The most elegant representative population study of the prevalence of obstructive sleep apnea in adults was reported by Professor Terry Young in 1993. Obstructive sleep apnea defined as five or more respiratory events per hour of sleep occurred in 24 percent of adult males and 9 percent of adult females (18 years of age and older). In addition, Young and her colleagues and other groups have documented that obstructive sleep apnea progresses.

Finally, a number of risk factors for both the actual occurrence and the rate of progression have been identified. In a comprehensive study that included all adults in a typical family practice clinic, the prevalence of sleep-disordered breathing was 32.3 percent in adult males and 16.3 percent in adult females. At the time of the study (1997-1998), these high levels were very surprising. They have subsequently been substantiated by other groups.

The prevalence of obstructive sleep apnea in children is less well-established, but it has been estimated at 10 percent or even higher. The point of mentioning the very high numbers in adult clinical practice in the immediately foregoing paragraph is to subvert skepticism about the likelihood that very substantial numbers of children are also afflicted with sleep-disordered breathing problems.

No one goes from completely normal breathing to unambiguous obstructive sleep apnea overnight.

William C. Dement is the director of the Stanford University Center of Excellence for the Diagnosis and Treatment of Sleep Disorder in California.

William C. Dement, MD, PhD
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Title Annotation:SLEEP MEDICINE
Author:Dement, William C.
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Geographic Code:1USA
Date:Jan 1, 2010
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