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• Apnea is the medical term for the lack of breathing which lasts more than 10 seconds.
• Sleep apnea exists when more than 30 episodes of apnea occur in 7 hours of sleep.
• Obstructive sleep apnea occurs when there is a partial or complete obstruction of the airway.
  
  WHAT ARE THE CAUSES OF OBSTRUCTIVE SLEEP APNEA IN CHILDREN?
• Oropharyngeal Obstruction. This includes: enlarged tonsils, obesity, short neck, enlarged tongue, small lower jaw, or retruded lower jaw.
• Nasal Obstruction. This includes: enlarged adenoids, rhinitis (runny nose), or nasal septal deviation.
• Laryngeal Obstruction. This includes: subglottic stenosis or vocal cord paralysis.
• Irritative Obstruction. This includes: cigarette smoke, indoor allergens, or pollution.
• Pharmacologic Obstruction. This includes: antihistamines or medical sedation.
  
  WHAT ARE SOME COMPLICATIONS OF OBSTRUCTIVE SLEEP APNEA IN CHILDREN?
• Developmental and Behavioral: This includes: learning problems and failure to thrive.
• Gastrointestinal. This includes: gastroesophageal reflux.
• Neurologic. This includes: bed-wetting.
• Cardiovascular. This includes: cor pulmonale.
• Pulmonary. This includes: frequent airway infections.
• Dental. This includes: bruxism and open mouth posture.
• Other. This includes: mouth breathing and sleepwalking.
  
  WHAT ARE THE SIGNS AND SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA IN CHILDREN?
• Nighttime symptoms include: snoring, restless sleep, disturbed sleep, cessation of breathing (apnea), difficulty breathing, and inadequate oxygenation during sleep.
• Note that OSA can occur without snoring – so snoring alone is not diagnostic of OSA.
• Daytime symptoms include: mouth breathing, nasal obstruction, behavior problems, and excessive daytime sleepiness.
• Note that many children with mouth breathing do not have OSA.
  
  HOW IS OBSTRUCTIVE SLEEP APNEA DIAGNOSED?
• First, a complete physical examination should be performed in children with suspected OSA.
• The lungs and cardiovascular system should be examined for possible consequences of OSA. A thorough head and neck exam should include documentation of tonsil size.
• OSA is diagnosed in a sleep laboratory using polysomnography.
• Polysomnography is considered the gold standard for diagnosing obstructive sleep apnea. In this technique, multiple physiologic measurements are taken while the child is asleep in the laboratory.
• The physiologic parameters measured in a sleep study include: detection of rapid eye movement, electroencephalogram, chest movement monitors, nasal and oral air flow measurements, electrocardiogram, electromyogram, and pulse oximetry.
• Sleep laboratory studies cost between $800 and $1,400.
  
  WHAT IS THE TREATMENT FOR OBSTRUCTIVE SLEEP APNEA IN CHILDREN?
• The options for treating OSA include: observation, medical treatment, mechanical intervention, or surgical management.
• Medical treatment includes: treatment of infections of the tonsils and adenoids.
• Mechanical intervention includes: continuous positive airway pressure (CPAP). With CPAP, the child wears a snugly fitting nasal mask, which is attached to a device which blows air into the nostrils.
• Surgical management includes: tonsillectomy and adenoidectomy. Surgical removal of the obstructing tissue is the most common way of treating OSA in children. Adenotonsillar hypertrophy (enlarged tonsils) is the most common cause of obstruction.
  
  The American Family Physician presented an article on sleep obstruction in children. It discussed the various categories of sleep disorders, including: parasomnias, night terrors, sleepwalking, bed-wetting, obstructive sleep apnea, narcolepsy, and secondary sleep disturbances. It also offered anticipatory guidance for parents.
  
  Thiedke, CC: Sleep disorders and sleep problems in childhood. American Family Physician. January 15, 2001; 63:277-284.
  
  
  
  Could Your Child Have Gastroesophageal Reflux Disease? see photo
  Gastroesophageal reflux is the involuntary passage of gastric contents into the esophagus and mouth. Mild gastric reflux in infants is known as regurgitation. Around 40 percent of healthy infants regurgitate more than once per day.
  
  An infant’s high caloric requirements can easily overwhelm the stomach’s capacity to store food. Normal regurgitation probably acts as a “pop-off” valve, which prevents discomfort and illness in a rapidly growing infant. In most cases, this reflux is benign and will go away by 12 to 18 months of age.
  
  Some children, however, develop a pathologic form of reflux called gastroesophageal reflux disease. GERD is one of the most common disorders affecting the gastrointestinal tract of infants and children. Children who develop GERD need medical evaluation and treatment.
  
  Dental problems related to GERD are caused by the acidic gastric (stomach) contents which travel back up into the oral cavity. Both primary and permanent teeth can be affected by dental erosion. Dental erosion is the demineralization of enamel and dentin caused by chemicals, such as gastric acid. During a child's dental examination the dentist will see "dished-out" areas of lost enamel on the front of the incisors and eye teeth, near the gum line. These are also called cervical lesions of the labial surfaces, caused by chemical erosion. A flattening of the cusp tips of the primary molars may also be seen.
  
  WHAT ARE THE CAUSES OF GERD IN CHILDREN?
• The primary cause of GERD in children is inappropriate relaxation of the lower esophageal sphincter (LES) muscle. This process is called transient LES relaxation.
• The LES is a muscular sphincter (band of muscle tissue) which allows food and nourishment to pass down the esophagus and into the stomach. When this sphincter does not remain tightly closed, the harmful stomach contents travel back up the esophagus and sometimes into the mouth. During this pathologic reflux, the lining of the esophagus is irritated, and the dental enamel may be chemically eroded.
• GERD can also be caused by increased abdominal pressure or increased acid production by the stomach.
• Factors which contribute to pathologic gastric reflux in children include: the frequency of reflux episodes, the rate of esophageal clearance, and the composition of the refluxed gastric contents. Gastric contents such as acid, digestive enzymes (pepsin and trypsin), and bile salts can irritate the lining of the esophagus and airway, and decrease the function and motility of the esophagus.
  
  WHAT ARE THE SIGNS AND SYMPTOMS OF PEDIATRIC GERD?
• Crying, irritability, sleep disturbances, sore throat, bad breath, vomiting, abdominal discomfort, bruxism, failure to gain weight, and decreased appetite are some of the nonverbal cues for gastroesophageal reflux in children.
• Respiratory disorders such as recurrent pneumonia or sleep apnea might be the only symptoms in a child with GERD.
• In older children, reflux can cause respiratory disease such as pneumonia – especially in neurologically impaired children.
  
  HOW IS GERD DIAGNOSED IN CHILDREN?
• Gastroesophageal reflux disease is diagnosed in most cases on the basis of medical history and physical examination.
• Diagnostic tests for GERD include: upper gastrointestinal series (UGI), gastric emptying study (gastric scintiscan), esophagogastroduodenoscopy (EGD) with biopsy, esophageal pH probe monitoring, and manometry (pressure measurement).
• Barium radiography (UGI) evaluates whether a child’s digestive anatomy is normal.
• Scintigraphy (gastric scintiscan) determines the potential role of delayed gastric emptying. It can: detect gastric reflux after a meal, detect unusually slow gastric emptying, and detect aspiration (into the lungs) of gastric contents.
• Endoscopy (EGD) is also useful for diagnosing GERD, because it allows visual examination of the lining of the esophagus (mucosa). EGD is useful in children who do not respond to medical therapy for GERD. The endoscope is a thin, flexible tube which is placed into the child's mouth, and is passed down the esophagus. A tiny camera in the endoscope allows a physician to view the esophagus for indications of gastric reflux. Evidence of esophageal inflammation such as bleeding, ulceration, or exudate, may be seen. Esophagogastroduodenoscopy (EGD) also facilitates taking biopsies.
• Diagnosis of childhood GERD may be facilitated with the 24-hour esophageal pH monitoring study. Esophageal pH probe monitoring quantifies the amount of acid in the esophagus. This procedure uses a flexible indwelling esophageal probe, and is 100% accurate in diagnosing gastric reflux when the esophagus pH is less than 4.0 for at least 6 hours during the 24-hour testing period.
  
  HOW IS PEDIATRIC GERD TREATED?
• Treatment of reflux generally begins with conservative measures, which include: close follow-up by a physician, upright positioning after feeding, prone (face down) sleeping position if recommended by a physician, small/more frequent feedings, thickening of milk and formula, and avoiding substances that decrease lower esophageal sphincter tone (such as chocolate).
• For infants with functional (benign) GER, the prone sleeping position decreases aspiration of stomach contents, and improves emptying of the stomach.
• Thickening of an infant’s food, by adding rice cereal to formula, may reduce the time spent crying or vomiting.
• The next step is pharmacologic treatment. Pharmacologic options include: acid neutralization/suppression with: Prilosec - a proton pump inhibitor, or Tagamet - an antacid. Another option is the use of a prokinetic agent: Cisapride - which improves motility.
• Surgical procedures are the final option when medical management fails to control GERD. Surgical correction, such as fundoplication, attempts to increase the barrier in the lower esophageal sphincter region.
• The Nissen fundoplication procedure uses the fundus of the stomach to perform a 360 degree “surgical wrap” around the most distal 3.5 cm of the esophagus.
• The most common complication of the Nissen fundoplication is gas-bloat syndrome, which can be life-threatening.
  
  An article in Oral Surgery, Oral Medicine, Oral Pathology investigated the effects of gastroesophageal reflux disease on the teeth, salivary function, and the oral mucosa. The results of the study showed no relationship between GERD and changes in the oral cavity. The study also used morphometry, which did detect microscopic alterations in the palatal mucosa, however.
  
  The study’s findings are interesting, since they contradict conventional dental wisdom concerning the cause and effect relationship between GERD and dental erosion. The results regarding dental erosion did not agree with those reported by most other clinical investigators.
  
  Silva, MA et al.: Gastroesophageal reflux disease: New oral findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. March 2001; 91:301-310.
  
  
  

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