Growing up angry: How nighttime breathing battles hurt our children: the sleep apnea-ADHD connection

Sleep apnea is not just an adult problem. Far from it. Between 1- 3% of young children have sleep apnea/disordered breathing, and if untreated, can grow up with lasting scars. Habitual nighttime battles for adequate air can set a child up for ADHD sym

By Dr. James E. Metz

Published: Thursday, Apr. 18, 2013 - 2:14 pm

Read more here: http://www.sacbee.com/2013/04/18/5353670/growing-up-angry-how-nighttime.html#storylink=cpy

COLUMBUS, Ohio, April 18, 2013 -- /PRNewswire/ -- People lobbying for gun control may want to consider another culprit in the post-Newtown search for the answer to our unfathomable questions.  In Adam Lanza, with his classic adenoidal face structure, have we overlooked a possible root cause as simple as the very air we breathe…or more accurately, don't breathe?  Failure to free a compromised child's breathing, usually through tonsil and adenoid removal, can have tragic repercussions which extend beyond the life of that individual. 

(Photo: http://photos.prnewswire.com/prnh/20130418/CL97507 )

Parents today tend to view tonsillectomies with skepticism.  Aren't we smarter now than when tonsils were routinely removed for a few stubborn sore throats?   What about our president's well-publicized implications that surgeons fall prey to financial incentives to remove tonsils, limbs and anything else that can be severed?  Shouldn't we be wary? 

Evidence is mounting that if a child's tonsils are causing him or her to snore or breathe abnormally, there are more serious things to be wary of than the knife.   

The politicization of medical decisions is particularly regrettable fallout from Washington's debate over how to control one-fifth of our economy.  After President Obama made his "cash for tonsils" gaffe at a health care overhaul rally, The American College of Surgeons reacted strongly, and rightly so.  Their official statement made it clear that the College still thinks its members take the Hippocratic Oath seriously, and are not knife-happy because of the current reimbursement schedules President Obama promises to convert into a greed-deterring system:  "That remark (that a surgeon's decision to remove a child's tonsils is based on the desire to make a lot of money) was ill-informed and dangerous, and we were dismayed by the characterization of the work surgeons do."

Aside from the insult to physicians, who still rank #2 on Forbes' "Most Respected Professions" list, is it a big deal to raise public doubt about the necessity of tonsillectomies and the motives of those we have traditionally trusted to do the right thing for our children? 

Changing trends in tonsillectomy

Let's start by noting that two generations ago, tonsillectomies were routine, not due to snoring, but due to throat infections.  Tonsillectomies were an inpatient procedure, and over one million American children had their tonsils removed in the 1950's alone!  At that time 90% of tonsillectomies were performed because of recurrent infections, but superior antibiotics and a generally cautionary approach to surgery reversed the tide.   Today, only 20% of the tonsillectomies performed are due to recurrent infection.  80% are due to sleep-disordered breathing, which is the spectrum that extends from primary snoring, which is often benign, through obstructive sleep apnea (OSA).¹

The brain remembers every insult

The message that surprisingly hasn't been shouted from the rooftops is that we have significant evidence that sleep-related breathing disorders are associated with cognitive and behavioral impairment in children (which improve after tonsillectomy).  What, then, if OSA is ignored and the child grows up with these "cognitive and behavioral impairments" becoming firmly rooted?  Do we then have an adult with ADHD, with anxiety or depression, and often some very severe anger issues? 

It is safe to say that ADHD has been routinely misdiagnosed, undertreated and overtreated, and the medical and psychological communities are still stabbing in the dark about root causes and defining physiological characteristics.  The closest we have come to finding these is through PET scans, which have demonstrated abnormal glucose uptake patterns in the brains of symptomatic individuals.   Why that happens and whether the reduced glucose uptake causes symptoms or simply coexists with them is as yet unclear.  

One thing that is clear is that a child diagnosed with ADHD will exhibit symptoms that mimic the very natural consequences of other infirmities or unmet physiologic needs -- like quality sleep.  The adult with ADHD is different from the child in that the pattern of behavior --> response to behavior --> negative reinforcement of self-image has been in place since childhood.  Chronic inability to engage in social banter, listen attentively, keep to a calendar and be prompt, plan and organize….all these basic necessities of a civilized lifestyle can be daunting to the adult with ADHD, and the reactions from the world are often emotionally debilitating. 

10 Symptoms of Adult ADHD
1.	Difficulty Getting Organized
2.	Reckless Driving and Traffic Accidents
3.	Marital Difficulties
4.	Extreme Distractibility
5.	Poor Listening Skills
6.	Restlessness, Difficulty Relaxing
7.	Difficulty Starting a Task
8.	Chronic Lateness
9.	Angry Outbursts
10.	Prioritizing Issues

So tonsils are connected with mental health?

Strong correlations have been established and causal relationships are beginning to emerge from the research, but aside from this, there is something very fundamental we know:  breathing matters.  Oxygen matters.  Acute lack of oxygen is a death sentence, a chronic shortage of oxygen is going to lead to a suboptimal life, and the little throats of children have disproportionately large organs around which to negotiate the air they need.   Here's something else we do know:  10% of children snore regularly, and it is estimated that 10-30% of these children have obstructive sleep apnea.^2,3,4,5

But wait - it gets worse!  Untold numbers of children suffer from other upper airway restrictions that mimic OSA but which are not considered a problem by many people in the medical community.   In total, that is a lot of children to put at risk for permanent damage from dysfunctional breathing.

In children who have moderate to severe OSA, the airway is so compromised that the body is in continual "fight or flight" mode, as the primitive brain struggles for oxygen.   A child will snore, repeatedly stop breathing, and then arouse to recover, only to fall back into the cycle.  Not only is there an oxygen deficit, but the "fight or flight" mode causes surges of sympathetic system hormones (adrenaline and cortisol) to be delivered throughout the bloodstream.  In the short term, the child will simply be exhausted, "fuzzy", distracted by day.  Over time, however, as the barrage of hormones habitually attacks the nervous system and organs, permanent changes take place.  Anxiety, depression and other psychological disorders are among the consequences of this unremitting hormonal onslaught.

Disappearing ADHD

In fact, researchers are accruing evidence that much of the behavior we call ADHD is a result of chronic struggle for oxygen from obstructive sleep apnea, and a significant percentage of the time, this is something that can be resolved by tonsil removal.    Multiple studies have demonstrated that ADHD symptoms subside substantially post-surgery, and some studies even indicate that 20-30% of the participants who were diagnosed with ADHD became completely asymptomatic for ADHD.⁶If OSA is caught and treated early, we can mitigate damage and the toll that living with ADHD takes on the psyche.   

The "adenoidal face" reflects childhood struggle

Any dentist, orthodontist or physician can recognize the characteristics of what is called "adenoid facie" – a face that has developed an abnormally long, narrow bone structure due to chronic mouth-breathing over the growth years.  The "dumb look" may belie an intelligence that is often dwarfed or subverted by years of others' negative responses to a tired, forgetful, distracted demeanor.  Loneliness, rejection, failure in others' eyes, eventually converts to anger – at self or others.  

The brain is permanently damaged by the struggle with airway incompetence.  An indelible mark is left.  Generally, only the person's close relationships suffer from the damage, but sometimes a missed diagnosis may have had repercussions way beyond that small circle.  While we will never know the etiology of Adam Lanza's tragic rampage, he exhibits the classic "adenoidal face", and one can't help but wonder if he wasn't, as a child, victim to his own nighttime battles for air, and what kind of impact that made on his mental state over time. 

Spare the knife, risk the outcome

Tonsillectomies are still painful and still carry the attendant risks of major surgery.  However, the risk of morbidity or misplaced trust in a surgeon are very low, and to let fear blind us to the enormous benefits children receive from relieved airways, improved oxygenation, peaceful sleep and potential prevention of long-term mental health problems is far riskier.

What if my child snores or exhibits ADHD symptoms?

A one to two night polysomnic sleep test at a certified sleep laboratory will enable a sleep medicine professional to rule out sleep disordered breathing or recommend surgery (primary recommendation for children), CPAP or oral device treatment.

Dr. Metz is a Diplomate and Board member of the American Association of Dental Sleep Medicine.  Having treated over 2,500 sleep disordered patients, his outreach to colleagues, physicians and the public is part of his mission to raise health risk awareness and improve treatment for sufferers of TMD and OSA.  He brings a soft-spoken style and visionary approach to educating others in "Medistry" (a term he coined for medically-informed dentistry).  Since shedding 100 pounds in 2004 and alleviating his own case of sleep apnea, Dr. Metz relates readily to those struggling with OSA, obesity and their attendant health problems. 

www.themetzcenter.com

References

1. Head and Neck Surgery web site  http://www.entnet.org, 2013.
2. Newacheck P. W.  Am. J Public Health , 1992.
3. Rosen, C. Sleep, Yale University School of Medicine, 1996.
4. Chang, S., Chae K., J Pediatrics, Oct, 2010.
5. National Sleep Foundation web site  http://www.sleepfoundation.org, 2013.
6. Oguzturk O.  J Clin Psychological Medical Settings, 2012

Contact

Margy Rockwood 614-252-4444 drmetz.margy@yahoo.com

SOURCE Dr. James E. Metz

• Read more articles by Dr. James E. Metz

Read more here: http://www.sacbee.com/2013/04/18/5353670/growing-up-angry-how-nighttime.html#storylink=cpy

Read more here: http://www.sacbee.com/2013/04/18/5353670/growing-up-angry-how-nighttime.html#storylink=cpy

Forty percent of snoring patients are women

4/5/2013 10:30:00 AM

Philippa Lees

We can't point our finger at old, obese men as the only snoring culprits —these days up to 40 percent of patients being treated for snoring are women.

A UK study found the number of women seeking treatment was rising, with drinking, smoking and obesity worsening the problem.

Dr Sean Tolhurst, a respiratory and sleep physician said weight gain is to blame, plus snoring often worsens around menopause.

"Weight gain in the peri- and post-menopausal women is different to weight gain in their pre-menopausal period," he said.

"Post-menopausal women gain weight in a much more male pattern because they don't have the effect of oestrogen. Most of the weight gain that has an impact on sleep apnoea is on the chest and the back of the airway."

Women with large breasts can also have problems.

"To expand their lungs to breathe, they have to lift whatever weight is on their chest up and out," Dr Tolhurst said.

"When they're upright, the extra breast tissue doesn’t make a big difference, but when they are asleep at night, particularly on their back, the extra weight of very large breasts can make a big difference to the amount of pressure they have to generate."

Many women don't realise the broader health and emotional consequences of snoring.

"Snoring has been linked with increased high blood pressure and increased stroke," Dr Tolhurst said.

A study from the Snoring Center in Chicago last year found snoring was causing relationship issues in 30 percent of couples. Forty-six percent of people involved in the study said they would consider breaking up with somebody whose snoring interrupted their sleep.

"It can lead to two tired and cranky patients in the relationship. They feel guilty when one has to move to another room, and can have a negative impact on the intimacy. It's no wonder that that on top of all of life's normal stress is enough to break," Dr Tolhurt said.

"Snoring in women is becoming a really big issue, especially for single women who might be looking for a new life partner — it can be a real deal-breaker for some of them."

But Dr Tolhurst said treatment is often quite simple.

"One treatment is called the Theravent, which is a band aid-looking thing that sits on the outside of the nostril," he said.

"It works by holding up some of the flow when a patient breathes out, which increases the pressure. It's not particularly ugly and can make a huge difference."

A child's snoring is nothing to joke about

SATURDAY, JANUARY 19 2013 04:51

WRITTEN BY JENNIFER RICH

If your child snores, tell your pediatrician. Snoring may be a symptom of an underlying condition that can have serious health consequences later in life.

Even though snoring in children is frequently trivialized and even joked about by family members, it can be a sign of a serious medical problem or condition. 

Many parents will casually report that their son or daughter snores so loudly that they “sound like grandpa” or even “wake the entire house up.” But these casual reports just reinforce the need for practitioners to screen all children at routine visits for a history of snoring and especially those children with large tonsils on physical exam.

It is important that a report of snoring is not only when a child has seasonal allergies or is sick with a cold to be considered persistent. Almost 80 percent of children will snore when they are congested with a cold or allergies and this is predictable, normal and not pathologic.

When there is a report of persistent snoring even without congestion, then further testing and evaluation is important and indicated. This is because a child’s snoring can be an early sign of obstructive sleep apnea. OSA is a complicated condition but essentially, a child’s snoring is an audible sign that there may be multiple, short, 2-3 second episodes of apnea (stopped breathing) during sleep. All children continue breathing normally between these episodes, but their sleep is interrupted.

When snoring is a sign of OSA and remains untreated or unaddressed for years, it may lead to cardiac problems (primarily right heart enlargement), in early adulthood. But long before any heart problems potentially arise, snoring and OSA are frequently associated with some of the following symptoms and signs: gasping or snorting during sleep, prolonged nocturnal enuresis (bedwetting), chronic mouth breathing with sleep, daytime somnolence (sleepiness) even after a full night’s sleep, and even behavioral and attention problems.

If your child has persistent snoring with or without some of these other signs, then after initial pediatric evaluation and exam, a referral to a pediatric ear-nose-throat specialist may be needed. A pediatric ENT can use a flexible endoscope to check for hypertrophy — enlargement — of a child’s adenoids and tonsils. Enlargement of tonsils and adenoids is the most common cause of persistent snoring in children.

So, once snoring has been confirmed by both a practitioner and specialist to be a sign of OSA, what is the next step(treatment)? Rarely, when the swelling of the tonsils and adenoids is mild, intranasal steroids at bedtime used for 4-6 weeks can decrease swelling and minimize snoring. But the majority of the time, the gold standard and definitive treatment for OSA is surgery to remove the tonsils and adenoids.

In summary, because of the proven available treatment and clear significant health consequences of OSA, it is important for parents to always mention their child’s persistent snoring at any pediatric office visit.

Jennifer Rich, MD is a board-certified pediatrician and is an associate professor of pediatrics at Albert Einstein College of Medicine, of which she is an alumna. She continued her pediatrics residency at the same institution and went on to serve as chief resident at the Children’s Hospital at Montefiore. Rich has a special interest in the prevention and treatment of childhood obesity, medical education and biomedical ethics. She is a physician at Peconic Pediatrics in Riverhead.

Is snoring more dangerous to your heart than smoking?

Tuesday, February 05, 2013 by: David Gutierrez, staff writer

(NaturalNews) People who snore are at higher risk for cardiovascular disease than smokers, the overweight, or people with high cholesterol, according to a study conducted by researchers from Henry Ford Hospital in Detroit and presented at the 2013 Combined Sections Meeting of the Triological Society in Scottsdale, Ariz. The study has been submitted for publication to the journal The Laryngoscope.

"Snoring is more than a bedtime annoyance and it shouldn't be ignored," lead author Robert Deeb said. "Patients need to seek treatment in the same way they would if they had sleep apnea, high blood pressure or other risk factors for cardiovascular disease."

Scientists have known for some time that the sleep disorder known as a obstructive sleep apnea - in which a collapse of the airway in the throat causes snoring and cessation of breathing during sleep - significantly increases a person's risk of cardiovascular disease and other serious health problems. Yet until now, there has been no evidence suggesting that even in the absence of obstructive sleep apnea, snoring itself might be a risk factor.

The researchers reviewed medical data on 54 patients between the ages of 18 and 50 who did not have sleep apnea and who had participated in a diagnostic sleep study at the hospital between December 2006 in January 2012. All the participants had completed a survey about their snoring habits and had undergone a test known as a carotid artery duplex ultrasound.

This procedure measures the thickness of that critical artery's two inner layers, known as "intima-media thickness." Thickness of these two layers is considered an early sign of carotid artery disease, and can be used to detect and track the progression of atherosclerosis, or hardening of the arteries. Atherosclerosis can deprive the brain of oxygenated blood, leading to stroke.

Snoring not "benign"

The researchers found that people who snored had a significantly higher carotid intima-media thickness than people who did not snore. No such difference was found between smokers and non-smokers or people who did and did not suffer from diabetes, high blood pressure or high cholesterol.

The damage to the carotid artery may come from trauma and inflammation caused by the vibration of chronic snoring, the researchers speculated.

"Our study adds to the growing body of evidence suggesting that isolated snoring may not be as benign as first suspected," Deeb said. "So instead of kicking your snoring bed partner out of the room or spending sleepless nights elbowing him or her, seek out medical treatment for the snorer."

A 2012 study published in October 2012 in the American Journal of Obstetrics found that women who began snoring during pregnancy were significantly more likely to develop hypertension.

The Ford researchers are now planning to conduct a long-term study to see if people who snore suffer from a higher rate of cardiovascular events.

"Snoring is generally regarded as a cosmetic issue by health insurance, requiring significant out-of-pocket expenses by patients," Deeb said. "We're hoping to change that thinking so patients can get the early treatment they need, before more serious health issues arise."


Learn more: http://www.naturalnews.com/038955_snoring_smoking_heart_health.html#ixzz2PPvWTaiG