Sleep Apnea: A Review of the Permanente Medicine Today Videoconference, October 12, 2012

Moderator: Charles Wibblesman, MD, Chief Adolescent Medicine, Kaiser San Francisco
Speakers: Mujahid Mahmood, MD, Neurologist and Sleep Specialist, Kaiser South San Francisco and Andrew Wen, MD, Pediatric Pulmonologist, Kaiser Oakland


This videoconference can be viewed in its entirety here:
http://insidekp.kp.org/ncal/tpmgphysicianed/media/video/pedi_sleepapnea/index.html


The American Academy of Pediatrics recommends screening for snoring and sleep apnea at all well child visits. Recently, there guidelines for sleep apnea were published in Pediatrics.

Key points highlighted in the videoconference include:

• Up to 4% of all children may have sleep apnea.
  
   
• Sleep apnea can lead to many problems including neurocognitive delays, behavior and learning problems, enuresis, attention problems and fatigue.
  
   
• A thorough history should be taken at every well child visit. A questionnaire guiding the pediatrician's history, written by Dr. Myrza Perez, Pediatric Pulmonology, Kaiser Roseville and was provided in the handout for this videoconference.
  
   
• Pediatricians should ask if about the frequency of a child's snoring, if enuresis is an issue, restless sleeping, and interruptions or gasps in the rhythmic breathing cycle. In addition, the pediatrician should inquire about daytime symptoms such as fatigue, irritability and learning and behavior problems.

• A polysomnogram (PSG) is not always needed in an otherwise healthy child with overt symptoms of obstructive sleep apnea (OSA).
• Parents can videotape a child during sleep attempting to capture moments of apnea in their child. This can be diagnostic and these patients may be referred directly to an otolaryngologist.
  
   
• 70 to 80 % of patients without pre-existing risk factors will be cured of OSA with an adenotonsillectomy.
  
   
• PSG are mostly performed at Kaiser San Jose and Kaiser Sacramento.
  
   
• PSG is helpful in patients where the diagnosis of OSA is unclear, for patients with high risk factors, for patients who have contraindications to surgery, or for patients who have undergone an adenotonsillectomy yet have persisting symptoms of OSA.
  
   
• A PSG study is videotaped while air flow, oxygen saturation, chest and abdominal movement are measured. An EEG and EKG are also performed and a specialized technician is in attendance. If OSA is identified by this study, a referral to an ENT specialist will be made by the sleep study department.
  
   
• All high risk patients with suspected OSA should be referred to a center where there is a pediatric otolaryngologist and pediatric anesthesiologists.
  
  
  
  
  High risk factors include:
  
   
• Children under 4 years of age
• BMI > 95th % tile
• Children with Neuromuscular disorders
• Down Syndrome
• Achondroplasia
• Chronic lung disease
• Pulmonary Hypertension
• Central apnea
• Craniofacial abnormalities

A home ambulatory sleep study that measures air flow, hear rate, respiratory rate, oxygen saturation, and chest and abdomen movement is available from most Kaiser sleep labs and may be considered.
Ambulatory home sleep studies are helpful if the results are abnormal, but offer no information if the results are negative.
If a child undergoing a PSG is found to have overt OSA, the sleep lab will facilitate the referral to an ENT specialist.
If this PSG shows OSA, often times CPAP will be the treatment of choice. This benefit is covered only for those Kaiser members with DME coverage.

Commentary by Luke Schloegel, MD, Pediatric Head & Neck Surgery

Kaiser Permanente Oakland

Diagnosis and Management of Childhood Obstructive Sleep Apnea

When evaluating a child with snoring, this revised guideline by the AAP recommends a thorough investigation to ensure that children with obstructive sleep apnea (OSA) are identified.  No longer can we be sure that a child with OSA is being identified if we only ask about pauses/gasps in breathing at night or daytime tiredness.   Further understanding of the effects of sleep apnea in children has shown that OSA can have a wide-range of manifestations such as enuresis, attention-deficit hyperactivity disorder, poor school performance, poor quality of life, behavioral problems, and growth failure.  It is important to link these problems to OSA in order to enhance diagnostic accuracy for OSA but also provide appropriate treatment for these behavioral and neurocognitive problems.

If sleep disordered breathing is suspected, the AAP guideline recommends obtaining a polysomnogram (PSG) as the most accurate way to diagnose sleep apnea.  I agree that overnight PSG is the most reliable and objective test to measure the presence and severity of OSA.  However, I do not think that PSG is necessary in otherwise healthy children with clinical evidence of OSA.  In these cases, a referral for adenotonsillectomy can be made without a sleep study.  PSG is helpful in patients when the clinical diagnosis is indeterminate, when there is a complex medical history making surgery contraindicated, or if there is a high likelihood that the child’s sleep apnea will not resolve following adenotonsillectomy. 

A polysomnogram is also useful in the postoperative period for reassessment.  Children in whom OSA fails to resolve after adenotonsillectomy should be managed with CPAP.  In select patients, additional surgical procedures can be helpful such as lingual tonsillectomy, turbinate coblation, supraglottoplasty and maxillary advancement.

In otherwise healthy children of normal weight, adenotonsillectomy will resolve OSA in 70 to 80% of patients.  In obese children, children with craniofacial and neuromuscular abnormalities, and/or severe OSA, the resolution of OSA drops significantly to only 10 to 25% after surgery.  Therefore, it is important to counsel families about realistic expectations concerning adenotonsillectomy.  This group of patients should be managed by a pediatric ENT specialist and pediatric anesthesiologist.  All high risk patients should be observed overnight in the hospital for complications after adenotonsillectomy.  This guideline along with additional compelling research on pediatric sleep disorders and special educational need remind us of the importance of diagnosis and treatment of sleep apnea in children.         

 

Editor’s Commentary:

Sleep disordered breathing, when left untreated, can result in both short term and long term consequences for children.  Short term issues include enuresis, attention problems, learning and behavior problems, and potential neurocognitive delays.  Long term problems may include pulmonary hypertension, right ventricular hypertrophy and cor pulmonale.  These 2 articles and the videoconference advocate early intervention with a sleep study and adenotonsillectomy as a first-line therapy for patients with OSAS.

Patients under age 4 years or with special risk factors such as obesity, neuromuscular disorders, Down syndrome, achondroplasia, chronic lung disease, pulmonary hypertension, or craniofacial abnormalities should be managed by a pediatric otolaryngology specialist and pediatric anesthesiologist.

Any child who presents with enuresis, headaches, and learning or behavior concerns as primary complaints should have a thorough history looking for signs of snoring and/or OSAS.   Certainly, this diagnosis should be ruled out prior to initiating medications for ADHD in any child.

Sleep Apnea: New Guidelines from the American Academy of Pediatrics

 
Link to full article: http://pediatrics.aappublications.org/content/130/3/576.full

Article Review:
In August 2012, the AAP published an online report titled Diagnosis and Management of Childhood Obstructive Sleep Apnea. This report, written for the primary care pediatrician, provides guidelines for the diagnosis and management of uncomplicated children with signs and symptoms of obstructive sleep apnea syndrome (OSAS). It is an evidence-based review derived from 350 published reports over the past eleven years on OSAS.

 These new guidelines involve "key action statements" and include the following:

1. During all well child visits, the pediatrician should ask if the child snores. If the child does snore, then further history should include:
   
    

• Frequency of snoring (nights per week)
• Labored breathing while sleeping
• Choking on breath or brief cessation of breathing that interrupts the normal respiratory rhythm
• Daytime symptoms such as fatigue or headache
• Learning or behavior problems

 

2.  A child who snores and has signs of sleep apnea should be referred for a sleep study or to an Otolaryngologist for further evaluation.

3.  A child with documented OSAS and adenotonsillar hypertrophy on exam should be referred for an adenotonsillectomy.

4.  Patients whose symptoms do not improve after surgery, or who have contraindications for surgery, should be referred for CPAP management.

5.  Obese children with symptoms of OSAS should also be followed closely and counseled on dietary and lifestyle changes.

6.  A trial of intranasal corticosteroids (Fluticasone) may be indicated for children who have contraindications for surgery, or who have persistent symptoms after an adenotonsillectomy is performed.

Children With Sleep Disorders Have High Risk of Special Education Needs by age 8 years

Link to article: http://pediatrics.aappublications.org/content/early/2012/08/28/peds.2012-0392.full.pdf+html


Article Review:
Karen Bonuck, PhD, from the Department of Family Medicine, Albert Einstein College of Medicine, New York, and her colleagues recently published a study reporting on data from the Avon Longitudinal Study of Parents and Children (ALSPAC) in southwestern England. Since 1991, this institution has tracking the development over 14,000 children from birth through age 8 years. This specific study focuses on the relationship between sleep disorders and special education needs (SEN) at age 8 years. SEN categories include communication disorders, learning disabilities and behavioral and emotional difficulties.
Parents enrolled in this study responded to questionnaires when their children completed the ages of 6, 18, 42 and 57 months. These surveys included questions about snoring, mouth breathing and apnea. In addition, the surveys included questions on behaviors around sleep, such as refusal to go to bed, patterns of awakening, and inability to sleep through the night.


After controlling for 16 confounding variables, this study demonstrated a 7% increased risk for special education needs for each year a behavioral sleep disorder was reported. Overall, children with sleep disordered breathing had a 40 to 60% increased need for SEN, depending on the severity of their sleep disordered breathing.

Pediatric Sleep Apnea Questionnaire

Instructions:


Please answer the questions on the following pages regarding the behavior of your child during

sleep and wakefulness. The questions apply to how your child acts in general, not necessarily

during the past few days since these may not have been typical if your child has not been well. If

you are not sure how to answer any question, please feel free to ask your husband or wife, child, or

physician for help. When you see the word "usually" it means "more than half the time" or "on more

than half the nights."



Name of person completing this questionnaire: __________________________________________

Relationship to the child? ____________________________________________________________



A. Nighttime and sleep behavior:

WHILE SLEEPING, DOES YOUR CHILD … Yes No Don't Know

… ever snore?

… snore more than half the time?

… always snore?

… snore loudly?

… have "heavy" or loud breathing?

… have trouble breathing, or struggle to breathe?



HAVE YOU EVER … …

seen your child stop breathing during the night?

If so, please describe what has happened:



… been concerned about your child's breathing during sleep?

… had to shake your sleeping child to get him or her to breathe, or wake

up and breathe?

… seen your child wake up with a snorting sound?





DOES YOUR CHILD

… have restless sleep?

… describe restlessness of the legs when in bed?

… have "growing pains" (unexplained leg pains)?

… have "growing pains" that are worst in bed?





WHILE YOUR CHILD SLEEPS, HAVE YOU SEEN

… brief kicks of one leg or both legs?

… repeated kicks or jerks of the legs at regular intervals

(i.e., about every 20 to 40 seconds)?







AT NIGHT, DOES YOUR CHILD USUALLY



… become sweaty, or do the pajamas usually become wet with

perspiration?

Does your child usually sleep with the mouth open?

Is your child's nose usually congested or "stuffed" at night?

Do any allergies affect your child's ability to breathe through the nose?



DOES YOUR CHILD

… tend to breathe through the mouth during the day?

… have a dry mouth on waking up in the morning?

… complain of an upset stomach at night?

… get a burning feeling in the throat at night?

… grind his or her teeth at night?

… occasionally wet the bed?





B. Daytime behavior and other possible problems:

DOES YOUR CHILD … Yes No Don't Know

… wake up feeling unrefreshed in the morning?

… have a problem with sleepiness during the day?

… complain that he or she feels sleepy during the day?



Has a teacher or other supervisor commented that your child appears

sleepy during the day?

Does your child usually take a nap during the day?

Is it hard to wake your child up in the morning?

Does your child wake up with headaches in the morning?

Does your child get a headache at least once a month, on average?

Infantile Hemangiomas: Permanente Medicine Today Videoconference August 10, 2012

 

On August 10, 2012, Zoey Goore, MD moderated a videoconference on Infantile Hemangiomas. The speakers were Erin Mathes, MD, Assistant professor of Dermatology and Pediatrics at UCSF, and Deborah Goddard, MD, Pediatric Dermatologist at Kaiser San Jose.

 
This videoconference can be viewed in its entirety here:
http://insidekp.kp.org/ncal/tpmgphysicianed/media/video/pediatric_hemangiomas/index.html


 
Also, one may wish to review this newsletter's previous article on the use of Propranolol for Infantile Hemangiomas.

 
Some important highlights of the videoconference include:

 

• Infantile hemangiomas grow most rapidly 2 to 6 weeks of life. Early referral to a pediatric dermatologist is important.

 

• Most Infantile Hemangiomas are just observed closely. However, hemangiomas that could lead to disfigurement, functional impairment or life threatening complications are treated. Topical and systemic Propranolol are now first line therapies.

 

• The key window for optimal intervention is 2 to 4 weeks of age. Pediatricians are encouraged to take a photo of their patient's lesion and upload it to the Health Connect chart. The Pediatric Dermatologist can view this photo prior to referral.

 

• All children with hemangiomas on the face should be referred for early evaluation.

 

• In general, 16% of all hemangiomas will ulcerate. Locations at risk for ulceration include the perioral area, flexion areas such as the elbow and groin, and areas of friction (such as the diaper region).

 

• Ulcerations tend to occur at 4 to 6 months of age. Early whitening of the hemangioma may be a precursor to ulceration.

 

• Hemangiomas in the diaper area are exposed to friction, urine and feces. These lesions should be generously lubricated with emollients to avoid abrasions. In addition, diapers should be changed frequently. Lesions in this area are painful and can ulcerate readily and should be referred for early evaluation.

 

• Pain management can include topical emollients, oral Tylenol and a small amount of 5% Lidocaine gel (max 5 times per day). Lidocaine gel will relieve pain for only a short while, but can be useful on lip hemangiomas for feeding, and lesions in the groin during bathing. Covering lesions with xeroform gauze will also help control pain.

 

• Eyelid hemangiomas can cause functional impairment leading to amblyopia and should be watched carefully.
  
   
  
   
• Babies who have more than 5 hemangiomas anywhere on their body have an increased risk of liver involvement. These patients should have an ultrasound with doppler flow of the liver.
  
   
  
   
• If liver hemangiomas are seen ultrasound, a referral to pediatric dermatology for possible systemic propranolol treatment is indicated.
  
   

 

 
Segmental Hemangiomas, which involve more than one entire segment of the face or body, pose high risks of complications.
Segmental hemangiomas tend to grow more rapidly and for a longer period of time than do simple hemangiomas. Approximately 30% of segmental hemangiomas are associated with PHACE syndrome. PHACE syndrome includes one or all of the following:

 

• Posterior fossa malformations, usually present at birth
• Hemangioma that covers a large area, generally on the face, neck or head and extends more than 5 cm (also called "segmental hemangiomas").
• Cerbral artery lesions
• Congenital cardiac defects, most commonly coarctation of the aorta
• Eye abnormalities

 

 
Infants with a "beard" distribution hemangioma on the face have increased risks of airway hemangiomas. These infants will need an ENT evaluation and appropriate imaging. Families should be trained to recognize symptoms of airway obstruction such as stridor, respiratory distress, and swallowing difficulties.

 
The treatment of Infantile Hemangiomas has changed dramatically over the past few years. In 2008, propranolol was identified as a medication that can prevent growth of the lesions as well as promote their involution. Timolol, an ophthalmic preparation of propranolol, is used topically for small and superficial hemangiomas anywhere on the body.

 
Oral propranolol, used for deeper and more serious lesions, can cause cardiovascular side effects such as bradycardia and hypotension. Small infants receiving systemic propranolol are also at risk for hypoglycemia.

 

 
Differential Diagnoses for Infantile Hemangiomas:

Port wine Stain > flat telengatatic vessels occupying a trigeminal nerve distribution (dermatomes)

Venous malformation > abnormally formed vessels that will not proliferate rapidly, yet grow over time

Congenital tumors > rare hemangiomas, fully formed at birth

 
Editors Commentary:
While most infantile hemangiomas require no intervention, those infants with lesions on the face, groin, or whose lesions are greater than 5 cm in size should all be referred early to a pediatric dermatologist. The pediatrician should anticipate those at risk of ulceration and treat with emollient skin barriers. Photos of the hemangiomas can be taken and uploaded into health connect at various visits, documenting their progression.
Any facial segmental hemangiomas greater than 5 cm and/or in the beard distribution qualify for a PHACES workup.

 
The Children's Hospital of Wisconsin's website describes segmental hemangioma lesions and PHACE Syndrome: https://www.chw.org/display/PPF/DocID/28483/router.asp

 
Patients can be referred to any of the following Pediatric Dermatologists:

 

Dr. Deborah Goddard at San Jose
Dr. Pristine Lee at San Rafael
Dr. Linda Beets-Shay at Oakland
Dr. Glenda Swetman at Pleasanton / Walnut Creek

Patient Information Handout: Hemangiomas

Modified from Pristine Lee, MD, Pediatric Dermatologist, Kaiser San Rafael



WHAT ARE HEMANGIOMAS?


Hemangiomas are collections of immature blood vessels in the skin.  They are a common birthmark and are present in ~5% of newborns.  They may not be visible at birth, but often develop in the first few weeks of life.  Initially they may look like a reddish-blue skin marking before they grow and become more apparent.


Hemangiomas have a unique natural course: once they are present, they show rapid growth for 6-12 months (proliferative phase).  They grow most rapidly from 3 – 8 weeks of age, but can continue to grow until 6-9 months, at which time they slow down their growth.  By 12 months, they tend to stay stable with very little change for several months (plateau phase), before they slowly start to shrink (involution phase).


Though it is difficult to predict how one particular hemangioma is going to behave, it is important to remember this natural course, especially during the time of rapid growth.  We understand that this is very worrisome to parents, and we would like to follow your child closely during those months and provide the needed support!  The first signs noted when the hemangioma starts to resolve are a change of color from bright red/blue to grayish and no further increase in size.  It may take months or years for the hemangioma to shrink, but the cosmetic result at the end is usually excellent without any treatment.  As a rule of thumb, clinical experience has shown that by age 3 years, 30% of hemangiomas have completely shrunk; by age 5 years, 50% and by age 9 years, 90% will have shrunk.  It is important to remember that when the hemangioma has fully shrunk on its own, it will not necessarily be "completely gone" as they can sometimes leave behind stretched skin or discoloration.


CONCERNS ABOUT HEMANGIOMAS

Since hemangiomas can occur anywhere on the body and come in all shapes and sizes, there are some situations when they may cause problems and may need treatment.


Location is an important factor.  If a hemangioma is found near the eye, nose, mouth, ear or groin/buttocks, it may cause pressure and interfere with the normal function of important body parts.  It may cause problems with vision, breathing, feeding and toileting.


Ulcerationcan occur during the rapid growth phase of a hemangioma. If this happens, it is often painful, will leave a scar and may get infected.
Bleedingof the hemangioma may happen, particularly if the area has been accidentally hit.  If the hemangioma bleeds, hold firm pressure for 10-15 minutes.
If any of the situations mentioned above occur, we would like to hear about

There are different treatment optionsand combination of treatments available, which we would discuss with you given your child's unique situation

Epinephrine for bronchiolitis. Cochrane Database of Systematic Reviews

2011,Issue 6. Art. No.: CD003123. DOI: 10.1002/14651858.CD003123.pub3. Accessed October 27, 2011.Hartling L, Bialy LM, Vandermeer B, et al.

Link to article:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003123.pub3/pdf

Article Review:

Hartling et al reviewed 19 publications that collectively investigated more than 2,200 infants with bronchiolitis. The studies focused on therapies for outpatients and inpatients, but excluded severe cases requiring ICU admission and intubation.  Two main clinical factors were evaluated: rate of admission on day 1 and day 7 of presentation, and length of stay (LOS) for inpatients on the pediatric ward. Secondary outcomes studied included respiratory rate, retractions, oxygen saturation, heart rate, rate of readmission, pulmonary function tests, adverse events, and quality of life.

Overall, their findings showed that when administered to infants upon early presentation with bronchiolitis, inhaled epinephrine greatly reduced the likelihood of hospitalization.

Highlights of the review:

• Inhaled epinephrine versus placebo among outpatients showed a significant reduction in admission rates at Day 1, but not at Day 7 of illness.
• Repeated dosing of inhaled epinephrine offered no increased benefit over a single dose.
• Epinephrine markedly decreased the length of hospital stay when compared with salbutamol.
• There were no adverse effects seen with short-term use of epinephrine.
• One study suggested benefits of epinephrine and dexamethasone in reducing outpatient admissions.
• More research is needed to confirm if steroids combined with epinephrine are beneficial.

Epinephrine showed a significant reduction in length of hospital stay as compared to salbutamol. But a confounding finding demonstrated no differences in length of stay for epinephrine versus placebo.

 

 

Reviewer’s commentary

Bronchiolitis is a common reason for infant hospitalization during the winter months. While bronchodilators such as albuterol are routinely used, there is no clear evidence that this intervention is effective.

This review demonstrates the effectiveness in reducing hospitalization rates in infants with bronchiolitis who received inhaled epinephrine upon presentation in the outpatient setting. If an infant presents to the outpatient setting with clinical signs of bronchiolitis, inhaled epinephrine should be considered.  If their respiratory status and general state of health are favorable following this treatment, the infant can be safely sent home if close follow-up is arranged.

Newborn Male Circumcision: AAP Guidelines Revisited

Links to articles:  http://pediatrics.aappublications.org/content/130/3/585.full.pdf+html


 
                               http://aapnews.aappublications.org/content/33/9/1.2.full.pdf+html


 
Article Review:

 
In 1999 and 2005, the American Academy of Pediatrics reviewed data on hundreds of studies on circumcision but did not make a definitive recommendation.  That is, the AAP stated that there are health benefits to circumcision, but these benefits do not outweigh a parent's choice to leave their baby's foreskin intact.  Now in 2012, after reviewing over 1,000 studies dating back to 1995, the AAP maintains their position in leaving this decision up to parents, allowing their decision to be predicated on cultural, religious and personal reasons.  However, this report documents an increasing amount of data showing circumcision offers more health benefits than previously recognized.


 
Studies in Africa have shown a 40 to 60% reduction in HIV in circumcised heterosexual males.  Overall in the United States, the incidence of herpes simplex virus type II was reduced by 28 to 34 % in circumcised males as well as a 30 to 40% reduction in male human papilloma virus infection.  And, there was no data in this study to support the current belief that circumcision reduces sexual satisfaction due to decreased sensitivity.  In many studies, circumcised men report a higher degree of sexual sensitivity and satisfaction.  And, a significantly reduced incidence of urinary tract infection in the first year of life in circumcised boys was reconfirmed in this report.


 

 
Editor's Commentary:

 
In September 2011, the Centers for Disease Control reported a decline in rates of in-hospital male circumcisions in the United States.  Rates reported from 1997 to 2000 at 61.1% declined to 54.7% in 2010.  These rates do not account for out of hospital circumcisions performed.   Many families are deciding to forego circumcising their male newborns.  However, the pediatrician is often faced with questions from families asking their opinion.  While circumcised males have a lower incidence of sexually transmitted diseases and a lower incidence of urinary tract infections in the first year of life, the AAP does not feel that these benefits are compelling enough to routinely recommend the procedure for parents.  Pediatricians should share this objective data with families who are undecided about the procedure, and encourage them to make a decision for their baby they personally feel is best.

 

References:  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a4.htm?s_cid=mm6034a4_e%0D0a