Research Underway Explores
Surgery For Children With Sleep Apnea
May
Is Better Sleep Month
Although a restless night's
sleep typically leaves adults feeling drained and listless the next
day, that's not the case with many children, says Dr. Timothy Hoban,
a pediatric sleep specialist at the University of Michigan Health System.
These children "may
actually be inattentive, energetic or even hyperkinetic," Hoban
says.
And enlarged tonsils
that interfere with air flow in the breathing passages are frequently
the cause of the interrupted sleep that leads to behavioral
problems during the day.
There is a good chance
the child's tonsils may be to blame. And the problem may be
corrected with a new surgery that results in far less pain and
a much quicker recovery than traditional treatment of tonsillectomy.
Sleep apnea is a condition
that causes interrupted breathing during the night. While the
problem is typically associated with adults, particularly overweight
men, an estimated 1 percent to 3 percent of all children may
suffer from pediatric sleep apnea, University of Michigan researchers
say.
"Partial
Tonsillectomy" Reduced Recovery Time
Now physicians at
six hospitals in the US are performing what is called
a "partial tonsillectomy" on children who have sleep apnea or
other breathing problems.
Rather than a traditional
tonsillectomy, which includes the removal of the tonsil and
all the surrounding tissue, this procedure leaves a small layer
of tonsil tissue intact along the throat. This protects the
throat muscles and dramatically reduces the pain, bleeding,
and recovery time for the children, proponents say.
"We leave about 15
percent of the tissue in the throat so that no raw muscle is
exposed, which reduces bleeding, scarring and pain," says Dr.
Max April, of Lenox Hill Hospital in New York City, who with
other physicians in his practice has performed about 300
partial tonsillectomies since 2000.
Dr. Peter J. Koltai,
an otolaryngologist at the Cleveland Clinic, pioneered the operation
in 1996, when trying to help a colleague's 1-year-old infant
who had "enormous tonsils, an enlarged adenoid, and documented
sleep apnea.
"A tonsillectomy is
a terribly difficult procedure for young children," Koltai says.
So, he thought of using on the child the same technique he used
for removal of adenoids, which is shaving them down with a special
tool rather than cutting them out, leaving a protective covering
of tonsil tissue over the throat muscles.
The procedure is done
on an out-patient basis, takes about 15 minutes, and the results
are excellent, Koltai says. He says there is immediate improvement
in a child's breathing as well as a relatively speedy recovery
time.
He has performed about
400 of the operations to treat children's obstructed sleep or
disordered breathing, and says that post-operative bleeding
has been reduced by about half.
"Less pain medication
is used, and children can resume their normal diet and normal
activities much more quickly," in about two to three days compared
to seven to 10 days with a total tonsillectomy, Koltai says.
Koltai, April, and
the physicians who are performing the procedure in hospitals
in other cities - including Birmingham, Ala., Norfolk, Va.,
and Wilmington, Del. - are collecting information on the procedures
they have performed.
Koltai will present
data on 700 partial tonsillectomies at the annual meeting of
the American Society of Pediatric Otolaryngology
in May.
Koltai does not use
the procedure on children with tonsillitis, for which a complete
tonsillectomy is the standard treatment. Tonsillitis is an infection
in the tonsil and its surrounding tissue. By not removing all
the tissue, there is a risk of future infection, he says.
"I am concerned that
there could be tissue left that will become infected," Koltai
says, which would mean the child would need a second surgery.
Two of the children
on whom Koltai performed partial tonsillectomies for sleep apnea
or breathing obstruction did have their tonsil tissue grow back
and needed a second operation. He says regrowth of tissue can
happen to a small percentage of children, even with total tonsillectomies.
Some
Surgeons Look for More Results First
However, the possible
regrowth of tissue is a concern for some physicians who
have not adopted the partial tonsillectomy technique.
"I have reservations,
mainly that I don't know what the potential is for regrowth
of tissue, so that kids would be subjected to a second operation,"
says Dr. Earl Harley, an associate professor of otolaryngology
and pediatrics at Georgetown University Hospital.
"If I were convinced
that this would be a good operation, I'd do it," Harley says.
"I'd love to get kids up and back to school in a week, but there
is no long-term data on the procedure. The questions are still
out there, and I just want to wait."
Always consult your
child's physician for more information.
Botox
Helps Kids with Cerebral Palsy
Botox is being used
to treat everything from migraines to wrinkles, and researchers
from the Walter Reed Army Medical Center have now confirmed
another safe and effective use for the toxin: helping children
with cerebral palsy.
Lead researcher Dr.
Marc DiFazio reports that botulinum toxin type A helps improve
movement in youngsters who have the neurological disorder.
"The most important
part of the study was not so much that we were demonstrating
improvement in the kids, but that we demonstrated that this
medication is really safe," says DiFazio, who presented his
findings at the annual meeting of the American Academy
of Neurology.
As many as 500,000
Americans have cerebral palsy, according to the National
Institute of Neurological Disorders and Stroke, and
4,500 babies are diagnosed with the disorder every year. Symptoms
vary from person to person, but cerebral palsy generally causes
stiff, spastic muscles. Children with severe cases may be unable
to walk or control the movement of their limbs.
Botox helps, says
DiFazio, by interrupting the communication between the nerves
and the spinal cord, which lets muscles relax.
Two hundred and fifty
children who had already received at least one treatment of
botulinum toxin were enrolled in this study. They were between
the ages of one and 16. Two hundred and six youngsters
received more than one treatment, and 148 were followed for
an average of two years.
Significant improvement
in movement was seen in 86 percent of the children. Only 2 percent
had side effects, which included flu-like symptoms and mild
weakness in the legs. Many older medications used to treat muscle
spasms and stiffness have significant side effects, such as
drowsiness and cognitive impairment, DiFazio notes.
The results also appear
to last longer than the medication does. Even though Botox wears
off in about three to four months, DiFazio says many of the
children were still seeing improvements six-to nine-months later.
He says this is probably because once they were able to use
their muscles, those muscles became stronger and more flexible.
Always consult your
child's physician for more information.
Online Resources
American
Academy of Neurology
American
Academy of Otolaryngology
American
Academy of Pediatrics
American
Society of Pediatric Otolaryngology
National
Institute of Neurological Disorders and Stroke
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May 2003
May
Is Better Sleep Month
"Partial
Tonsillectomy" Reduced Recovery Time
Some
Surgeons Look for More Results First
What
Is Obstructive Sleep Apnea?
Botox
Helps Kids with Cerebral Palsy
Toilet
Training Goes Faster if the Time Is Right
Online
Resources
What
Is Obstructive Sleep Apnea?
Obstructive sleep
apnea occurs when a child stops breathing during periods of
sleep. The cessation of breathing usually occurs because of
a blockage (obstruction) in the airway.
Tonsils and adenoids
may grow to be large relative to the size of a child's airway
(passages through the nose and mouth to the windpipe and lungs).
Inflamed and infected glands may grow to be larger than normal,
thus causing more blockage.
The enlarged tonsils
and adenoids block the airway during sleep, for a period of
time. The tonsils and adenoids are made of lymph tissue and
are located at the back and to the sides of the throat.
During episodes of
blockage, the child may look as if he/she is trying to breath
(the chest is moving up and down), but no air is being exchanged
within the lungs.
Often these episodes
conclude with a period of awakening and compensation for lack
of breathing. Periods of blockage occur regularly throughout
the night and result in a poor, interrupted sleep pattern.
Always consult your
child's physician for more information.
Toilet
Training Goes Faster if the Time Is Right
Starting to toilet
train your children before the age of 27 months probably isn't
a good idea because it takes longer and offers no real benefit,
a new study says.
Most parents seem
to know that already, according to physicians at Children's
Hospital of Philadelphia. In their study of 378 parents of toddlers,
the average age when intensive toilet training was started was
28.7 months.
"For those children
starting toilet training before 27 months, the process took
a year or more, but if they were started between 27 and 36 months,
it took five to 10 months," says Dr. Nathan Blum, a developmental
pediatrician at Children's Hospital and lead author of the study.
The research appears
in the medical journal Pediatrics.
The optimal time for
speedy toilet training, the study found, was when children started
training just shy of their third birthdays. It took five months
to train them if they started between the ages of 33 and 36
months, Blum says.
For the study, Blum
and his colleagues followed the parents of 17- to 19-month-old
babies, interviewing them every several months to track their
babies' toilet training until it was completed.
The authors defined
the beginning of toilet training as when the parents first took
out a potty chair and started initial discussions. Intensive
toilet training was defined as asking the child to use the potty
more than three times a day.
The researchers found
that while starting training earlier than 27 months was not
harmful to the child - there was no increase in constipation
or withholding stool - it took longer than if the training started
when the children were older.
The average age when
the children were toilet-trained was 36.8 months, with girls
completing toilet training, on average, sooner than boys, at
35.8 versus 38 months, respectively.
Dr. Marcia M. Wishnick,
a New York City pediatrician, says, "It is generally accepted
that most toilet training takes place between two and three
years."
She says there are
ways to assess when your child is ready for toilet training,
including asking parents how many diapers a day they change.
"If they're down to
four-plus diapers during the day, we know the child is using
sphincter control," she says. "Also, if the child is communicating
in some fashion that they don't like being soiled, we know that
the development is there, and it's time for a parent to take
a proactive role in toilet training."
Once that time is
at hand, she says, toilet training happens quickly, "from one
week to three or four months."
Blum adds, "This study
suggests a range where people should be looking for optimal
toilet training, but if you think your child is ready before
27 months, or, on the other hand, if you think they're ready
at 3 years old, then do what you think."
Always consult your
child's physician for more information.
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