June 09, 2004

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Publication Date: Wednesday, June 09, 2004

Health & Fitness: The nighttime culprit

By Rebecca Wallace
Almanac Staff Writer

The symptoms are often unexpected. A child may get bursts of restless energy in the afternoon, becoming angry and unable to concentrate in school. There may be bed-wetting. And, the child might always seem too small for his or her age.

The answer may come deep in the night.

More and more, doctors are saying that disrupted sleep may be the culprit behind behavioral and developmental problems in children. Many times, they point the finger at obstructive sleep apnea.

Derived from the Greek apnoia , apnea means "without breath." Those stark words sum up why the sleep disorder can be so worrisome.

For people with apnea, soft tissue in the back of the throat collapses during deep sleep, narrowing the airway. Many patients, mostly adults, repeatedly stop breathing altogether. Others emerge from deep sleep when the obstruction begins. Either way, their sleep is disturbed over and over.

Asthma and allergies that cause congestion can worsen the situation, as can smoking and obesity.

The classic sign of sleep apnea is when an adult or child regularly snores "heroically," as sleep specialists put it. Unsurprisingly, the disorder also often makes a person lethargic during the day.

But the signs and consequences can be less intuitive -- and more serious. Adults with untreated sleep apnea can develop high blood pressure and heart problems, doctors say. In addition, their risk of getting in a car accident goes up due to driving while drowsy.

Kids can get irritable and have trouble in school, wet their beds, and even not secrete enough growth hormone, a process that happens during sleep.

Dr. Jerome Hester of Menlo Park, a clinical faculty member at Stanford Hospital whose physicians' group specializes in diagnosing and treating sleep apnea, says people -- particularly parents -- should pay more attention to the value of shut-eye.

Before electricity, people knew to sleep when it was dark. But in the technological, workaholic present, those who like to sleep can be seen as lazy, he says.

"It doesn't make sense that something you do for a third of your life wouldn't be important," he says.

Many people think of sleep apnea as something that happens to overweight adult men. Doctors say that is the most common scenario, perhaps because fat deposits can encroach on the airway and estrogen may protect against apnea.

But awareness is growing about the disorder in children, Dr. Hester says. About 10 percent of all children snore, and perhaps half of those have sleep apnea, he says.

Dr. Judith Owens, director of the pediatric sleep disorders clinic at Hasbro Children's Hospital in Rhode Island, says sleep apnea has been recognized as a problem in children in only about the last 25 years. In the last five years, she says, there has been "an explosion in interest for parents and researchers."

"We're realizing that many of the daytime symptoms in children are similar to those you might see in attention deficit disorder and mood-related problems," she says. "But pediatricians don't screen children (for sleep apnea) as much as they should."

Treating sleep apnea

When is a chair not a chair? When you're 4-1/2 years old. Then it's a slide.

Olivia Leupold can't resist the inviting slope of the long doctor's chair, slipping all the way down, then clambering up to do it all over again.

It's been about two months since the Menlo Park youngster underwent "the whole blue plate special" of sleep apnea surgery, as Dr. Hester, her physician, dubs it. Olivia seems perky and at ease in the doctor's office at the Facial Reconstructive Surgical and Medical Center in Palo Alto.

Sleep studies measuring heart rate, depth of breathing and other factors are often used to diagnose sleep apnea. But in Olivia's case, a study was not needed because her symptoms were so marked, Dr. Hester says. She had snored "significantly" since birth, would wake up in the night whimpering, and sometimes wet the bed.

In addition, Dr. Hester examined Olivia and found that her tonsils and adenoids were enlarged and that she had excess tissue in her nasal area, all potential breathing obstructions.

So Olivia's tonsils and adenoids were removed, a common treatment for sleep apnea. In addition, Dr. Hester used radiofrequency, a treatment that uses controlled thermal energy to shrink excess soft tissue in her airway.

In his office, he looks in Olivia's mouth and jokes, "Someone took out your tonsils! Where'd they go?"

Olivia giggles and says with a jaunty point, "You!"

Alison, Olivia's mother, says her daughter's snoring had made her suspicious, but that her behavior also made her think something was wrong.

"She got very hyper in the afternoon. She's spirited, but this was extreme," she says.

But Ms. Leupold says she didn't think lack of sleep was a problem because her daughter seemed to have lots of energy, rather than being drowsy. Then Ms. Leupold had a conversation with another mother who was experiencing the same things and had been told her child had sleep problems. Olivia's pediatrician referred her to Dr. Hester.

Recovery from the surgery was painful for Olivia ("I ate a lot of popsicles," she says), but so far the results have been impressive, Ms. Leupold says. Her daughter no longer snores and doesn't wake up at night, she says. During the day, she's calmer.

Dr. Hester says all children who snore should be evaluated for sleep apnea. But not everyone with the disorder snores, he says, and symptoms can be more subtle in children. Very young kids, for example, may go to school only in the morning, so afternoon restlessness may go undetected.

Still, Dr. Hester adds, "A lot of parents have a gut feeling about this: 'I've never thought they slept well.' Or they say, 'When I see my child in the afternoon, that's just not my child.'"

Other treatments

Dr. Hester says surgery often has positive results for children, simply because it removes obstructions. Snoring and behavioral problems frequently go away, and children who were small for their age can begin growing more quickly. Surgery can be successful in adults as well.

Apnea can return, though. Sometimes adenoids grow back, or people develop other risk factors such as obesity, asthma, or allergies, Dr. Owens says.

Some people are leery of surgery or may have other conditions that make it inadvisable. Another common treatment is CPAP, or nasal continuous positive airway pressure.

With CPAP, a person wears a mask with a pump attached to it that pushes air into the nasal passages, using pressure high enough to get past obstructions.

Dr. Owens has seen much success with CPAP, she says. One 17-year-old patient was on anti-depressant medication but still kept saying, "I should feel happier, more energetic, and I don't," she says.

Now the girl uses CPAP regularly and is "dynamic, funny and really outgoing," Dr. Owens says.

Dr. Hester is skeptical that most patients, especially children, will tolerate CPAP, saying it can be uncomfortable or embarrassing. It's also not a cure and must be used all the time, he adds.

But Dr. Owens, who also performs tonsil and adenoid removal surgery, says the treatment shows promise. These days, manufacturers are making CPAP devices that are smaller, quieter, and more comfortable, with air that's heated and humidified.

When parents are deciding what treatment is best for their children, there's one thing they shouldn't neglect -- themselves. Researchers don't yet know if there's a real genetic component, but apnea often runs in the family, doctors say.

"Often parents will bring in their children for an evaluation, but they haven't gotten an evaluation themselves," Dr. Owens says. "These are people who are snoring up a storm and falling asleep at the wheel. It's funny how used people get to feeling exhausted all the time."

For more information about the Facial Reconstructive Surgical and Medical Center, go to www.sleepsurgery.com. The American Sleep Apnea Association also has fact sheets and articles about the disorder; its Web site is www.sleepapnea.org.

Common signs of sleep apnea in children

** Excessive sleepiness during the day
** Hyperactivity or trouble concentrating at school
** Mouth breathing
** Trouble sleeping or restless sleep
** Enlarged tonsils and adenoids

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