Sweet Dreams
By Jen DeLaney, MSPT, MPH, CHE
Monday June 8, 2009
Noisy mouth breathing. Excessive snoring. Disruptive sleep patterns. Difficulty awakening. Sound familiar? Or perhaps a child complains of morning headaches, has unexplained bedwetting, or falls asleep during daytime hours, factors that translate into mood and behavioral changes, learning problems, and classroom challenges. These sleep-related symptoms, combined with childhood obesity, a lack of exercise, and too much indoor screentime, may be signs of a serious and potentially life-threatening disorder known as obstructive sleep apnea.OSA is characterized by the inability to keep airways open during sleep, which causes repeated episodes of breathing cessation, or apnea. Upper airway obstruction may stem from physical causes such as congenital anomalies or anatomical obstruction due to nasal polyps, septal deviation, or enlarged tonsils. In children who are overweight, upper airway obstruction often is attributed to excess body mass in the throat that results in impaired oxygen flow during sleep.Although the National Sleep Foundation reports equal occurrences of OSA in girls and boys, there is a higher prevalence in blacks, Hispanics, and those from lower socioeconomic classes. OSA occurs in 4% of normal-weight youth, but the incidence in obese children rises to approximately 25%.Family Affair
Routine measures to treat children with OSA who have no visible nasal or throat obstructions rely strongly on family participation. It is important to establish regular bedtime and wake-up times, encourage side-lying sleep postures, and limit excitatory activities at bedtime such as watching television, exercising, eating, and using the computer or telephone.Stacy Bernstein, MD, who practices adolescent medicine and pediatrics in Westfield, N.J., points out that daily exercise, a balanced diet, and a controlled schedule of activities that minimizes overload is strongly advised to improve overall health and sleep patterns. But when OSA fails to respond to exercise and an anatomical obstruction is detected in normal-weight children with the disorder, surgery to remove enlarged tonsils may be necessary. Bernstein affirms that postoperative outcomes of improved growth, mood, and school performance occur in children of normal weight with OSA; unfortunately, children who are overweight are less likely to respond to surgery.“Removal of tonsils in an overweight child is less definitive in resolving OSA,” Bernstein says, perhaps because the surgery cannot resolve the obesity factor typically responsible for OSA in that population. Josh Needleman, MD, Director of Pediatric Pulmonology Function Testing at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City, agrees with Bernstein. “When obesity is a factor in OSA, the main change that needs to occur is a lifestyle change at both the family and community level,” he emphasizes.Team Effort
Lifestyle change implies family-wide modifications in diet and exercise. “To effectively treat obesity and complications from it [such as OSA], we recommend sustained activity at minimum four times weekly for 20 to 40 minutes,” Bernstein says. NYPH’s approach that emphasizes exercise is in keeping with research findings that aerobic activity can result in a marked reduction in sleep-disordered breathing and snoring in overweight children.Exercise can be any continuous movement such as walking, hiking, playing outside, doing chores, or cycling, says Eric Schwabe, PT, MS, supervisor of inpatient rehabilitation at New York-Presbyterian Hospital/Weill Cornell Medical Center.
Schwabe recommends that PTs treat the patient and the family using incremental steps, such as incorporating breathing activity, completing daily activity logs, and implementing pedometer use. “Active parents help raise active kids,” Schwabe says.Resources
* National Sleep Foundation: www.sleepfoundation.org
* Bonuck KA, Freeman K, Henderson J. Growth and growth biomarker changes after adenotonsillectomy: systematic review and meta-analysis. Arch Dis Child. 2009;94(2):83–91.
* Davis CL, Tkacz J, Gregoski M, Boyle CA, Lovrekovic G. Aerobic exercise and snoring in overweight children: a randomized controlled trial. Obesity (Silver Spring). 2006;14(11):1985–91.
* Kohler M. Risk factors and treatment for obstructive sleep apnea amongst obese children and adults. Curr Opin Allergy Clin Immunol. 2009;9(1):4–9.
* Meletis C, Zabriskie N. To sleep, perchance to breathe: sleep apnea, snoring, and sleep-disordered breathing. Alt Comp Med. 2006;12(3):113-20.
Jen DeLaney, MSPT, MPH, CHES, is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.
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