Summer 2009

Sleep a Missing Link in Many Childhood Disorders

Gwynne D. Church, M.D.

"Sleep disorders are often overlooked, but in children, they can be a significant factor in processing and learning disorders, attention deficit hyperactivity disorder, and aggressive behavior," says sleep specialist Gwynne Church, M.D., director of the Pediatric Sleep Lab at UCSF Benioff Children's Hospital.

Missing the role of sleep in these disorders can be a dropped clinical opportunity because sleep problems are common. One in four children experiences a sleep disorder at some time during childhood. Obstructive sleep apnea alone may afflict as much as 1 to 3 percent of all children and a higher percentage of children who are obese, have craniofacial anomalies or have neuromuscular weakness.

"Moreover, treatments for sleep disorders have fairly high success rates and can often substantially alleviate academic problems, behavioral disorders or mood dysfunction," says Church.

Be Aware

The challenge for busy pediatricians is that parents rarely discuss their children's suspected sleep problems, and a wide variety of sleep disorders emerge from many causes and manifest in different ways. "Sleep problems can be caused by anything from enlarged tonsils to disorders that affect only 16 children in the world," says Dennis Nielson, M.D., Ph.D., chief of pediatric pulmonary medicine.

Nielson and Church believe, however, that heightened awareness among pediatricians can help uncover a suspected sleep disorder, after which physicians can refer the patient to an expert center.

Such centers have numerous advantages. At UCSF Benioff Children's Hospital, Church is board-certified in sleep medicine, pediatrics and pediatric pulmonology, which enables her to understand the full range of potential diagnoses and treatments. In addition, the Pediatric Sleep Lab has access to specialists that include pediatric neurologists, pediatric craniofacial surgeons, pediatric neurosurgeons, pediatric otolaryngologists-head and neck surgeons and pediatric anesthesiologists.

"We can diagnose the problem, and then work with the referring physician and the family to create an ideal treatment plan," says Nielson. "If, after something like a tonsillectomy, a sleep problem isn't improving, we can move people to CPAP therapy, with follow-up provided by experts."

Sleep Detectives

"In one case, a physician suspected that a patient with restless sleep and tonsillar hypertrophy had obstructive sleep apnea," says Church. "But a sleep study showed periodic limb movement disorder, which is often associated with iron deficiency. We discovered low ferritin levels, and treatment with iron supplementation solved this common problem."

In another instance, a child was admitted to UCSF Benioff Children's Hospital with carbon dioxide narcosis. He also had severe scoliosis, restrictive lung disease and a previously undiagnosed myopathy.

"A sleep study revealed severe nocturnal hypoventilation and obstructive sleep apnea," says Church. "Subsequent bi-level titration improved his nighttime ventilation sufficiently that his daytime carbon dioxide levels returned to normal, and he felt dramatically better." He then returned to his normal routine with the help of other members of the medical team, including pediatric intensivists, orthopedic surgeons and neurologists.

"These are clear examples of how a center can make a dramatic difference for children with sleep disorders," Church says.

When is a pediatric patient an appropriate candidate for a sleep study?

  • Difficulty falling asleep or maintaining sleep
  • Frequent or loud snoring
  • Apneic pauses, episodic choking, gasping and snorting during the night
  • Nocturnal enuresis
  • Restless sleep or frequent leg movements during sleep
  • Chronic mouth breathing or adenoid facies
  • Excessive daytime sleepiness (difficult to arouse in the morning, falling asleep in class, falling asleep easily while in the car or watching TV)
  • Sleep complaints in the presence of behavioral disorders, performance impairment or mood dysfunction
  • Sleep complaints in the presence of a family history of a primary sleep disorder

The UCSF Benioff Children's Hospital Pediatric Sleep Lab conducts studies every night of the week and on weekends. Clinical service is held every other Tuesday from 9 a.m. to 3 p.m. on the Second Floor of the Ambulatory Care Center at 400 Parnassus Ave.

For more information, contact the Pediatric Sleep Lab at (415) 353-1957 or Gwynne Church, M.D., at (415) 476-8629.

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