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Pediatric OSA

Mouth breathing, “nasal dis-use” and pediatric sleep-disordered-breathing

Seo-Young Lee* , Christian Guilleminault, Hsiao-Yean Chiu,**, Shannon S. Sullivan

In Press: Sleep and Breathing (2015)

Abstract: Background: Adenotonsillectomy (T&A) may not completely eliminate sleep-disordered-breathing (SDB ) and residual SDB can result in progressive worsening of abnormal breathing during sleep. Persistence of mouth breathing post -T&As plays a role in progressive worsening through an increase of upper airway resistance during sleep with secondary impact on orofacial growth.

Methods: Retrospective study on non-overweight and non-syndromic prepubertal children with SDB treated by T&A with pre and post surgery clinical and polysomnographic(PSG) evaluations including systematic monitoring of mouth breathing (initial cohort). All children with mouth breathing were then referred for myofunctional treatment (MFT), with clinical follow-up 6 months later and PSG one year post surgery. Only a limited subgroup followed the recommendations to undergo MFT with subsequent PSG (follow-up subgroup).

Results: 64 pre-pubertal children meeting inclusion criteria for the initial cohort were investigated. There was significant symptomatic improvement in all children post T&A, but 26 children had residual SDB with an AHI>1.5 events/hour and 35 children (including the previous 26) had evidence of “mouth breathing” during sleep as defined [ minimum of 44% and a maximum of 100% of total sleep time, mean 69 ± 11%.” mouth breather”subgroup and mean 4±3.9 %, range 0 and 10.3% “non-mouth breathers”]. Eighteen children (follow-up cohort), all in the “mouth breathing” group were investigated at 1 year follow-up with only 9 having undergone 6 months of MFT. The non- MFT- subjects were significantly worse than the MFT treated cohort.  MFT led to normalization of clinical and PSG findings.

Conclusion: Assessment of mouth breathing during sleep should be systematically performed post T&A and the persistence of mouth breathing should be treated with MFT.

 

Sleep Science Volume 7, Issue 4, December 2014, Pages 225–233

Abstract: Rapid maxillary expansion (RME) is a widely used practice in orthodontics. Scientific evidence shows that RME can be helpful in modifying the breathing pattern in mouth-breathing patients. In order to promote the restoration of physiological breathing we have developed a rehabilitation program associated with RME in children. The aim of the study was a literature review and a model of orofacial rehabilitation in children with obstructive sleep apnea undergoing treatment with rapid maxillary expansion. Muscular training (local exercises and general ones) is the key factor of the program. It also includes hygienic and behavior instructions as well as other therapeutic procedures such as rhinosinusal washes, a postural re-education (Alexander technique) and, if necessary, a pharmacological treatment aimed to improve nasal obstruction. The program should be customized for each patient. If RME is supported by an adequate functional rehabilitation, the possibility to change the breathing pattern is considerably amplified. Awareness, motivation and collaboration of the child and their parents, as well as the cooperation among specialists, such as orthodontist, speech therapist, pediatrician and otolaryngologist, are necessary conditions to achieve the goal.

 

Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences

Yu-Shu Huang and Christian Guilleminault

Front. Neurol., 22 January 2013 |

Conclusion

The different data accumulated over time on SDB children and the experimental data obtained from infant monkeys years ago are indicative of a strong association between normal oral-facial muscle tone and the normal development of the nasomaxillary complex and mandible. Presence of abnormal muscle tone, either experimentally induced by creation of abnormal nasal resistance or due to premature birth, is associated with mouth breathing particularly during sleep, abnormal placement of the tongue, and either development or worsening of the oral-facial anatomy. In humans, SDB is noted in association with pathological hypotonia of the tongue muscles. In a small group of infants seen at birth with a normal hard palate, development of a high and narrow hard palate and SDB was documented in children with oral-facial hypotonia. When the high and narrow hard palate was noted at birth in these cases, hypotonia also was present, and SDB was noted. In rare cases efforts very early in life to counteract oral-muscle hypotonia and reverse the high and narrow hard palate may lead to normal development and absence of SDB at follow-up. As suggested by Swedish investigators, tonsillar enlargement appears to be a secondary phenomenon that further impacts nasal resistance. No information on adenoids had been collected in our infant studies, but was obtained in the long-term follow-up of older children with 3D-CT scans. Adenotonsillectomy often is insufficient to achieve complete and lasting resolution of breathing problems.

Understanding the continuous interaction between muscle activity of the tongue and other oral-facial muscles, as well as the development of normal anatomic structures supporting the upper airway may lead to expansion of myofunctional reeducation as a therapeutic tool. We still do not know when the interaction between the potential airway-limiting oral-facial anatomic structures and its musculature begins. Interruption of normal development with premature birth may explain the frequency of sleep-related breathing problems in premature infants. However, these events also can be seen in full-term infants, leading to negative consequences (Rambaud and Guilleminault, 2012). It is possible that the abnormality leading to oral-facial hypotonia begins in utero. Investigation of facial expression and movements shows that beginning in early pregnancy, the fetus exhibits regular movements of the mouth and face. For example, the most frequent movement seen during the second trimester is sucking (Kurjak et al., 2005). Abnormal pregnancy and/or impairment of these movements may impede normal muscle activity at birth.

 

Update on Paediatric Obstructive Sleep Apnea

Dehlink E, Tan H-L

Journal of Thoracic Disease 2016; 8:224-235

Abstract: Obstructive sleep apnoea (OSA) is one of the most common causes of sleep-disordered breathing (SDB) in children. It is associated with significant morbidity, potentially impacting on long-term neurocognitive and behavioural development, as well as cardiovascular outcomes and metabolic homeostasis. The low grade systemic inflammation and increased oxidative stress seen in this condition are believed to underpin the development of these OSA-related morbidities. The significant variance in degree of end organ morbidity in patients with the same severity of OSA highlights the importance of the interplay of genetic and environmental factors in determining the overall OSA phenotype. This review seeks to summarize the current understanding of the aetiology and mechanisms underlying OSA, its risk factors, diagnosis and treatment.

 

Clinical Signs of Temporomandibular Disorders and Various Pain Conditions Among Children 6 to 8 Years of Age: The PANIC Study

Vierola A, Suominen AL, Ikavalko T, et al.

Journal of Orofacial Pain 2012; 26:17-25

Abstract: AIM: To examine the prevalence and significance of clinically determined signs of temporomandibular disorders (TMD) and pain in different parts of the body as well as the frequency, intensity, and other features of pain in children. METHODS: The subjects were a population-based sample of children 6 to 8 years of age. Complete data on clinical signs of TMD were available for 483 children. Data on pain during the past 3 months, assessed by a questionnaire administered by parents, were available for 424 children. Differences between the prevalence of at least one sign of TMD and the location or frequency of pain were evaluated using the chi-square test, as well as the associations between the prevalence, frequency, and location of pain and gender, the use of medication, and visits to a physician. The relationship of various pain conditions with the risk of having clinical signs of TMD was analyzed using logistic regression. RESULTS: Of the 483 children, 171 (35%) had at least one clinical sign of TMD. Of the 424 children, 226 (53%) had experienced pain during the past 3 months. Pain was most prevalent in the lower limbs (35%) and head (32%). Of the 226 children with pain, 119 (53%) had experienced frequent pain (>/= once a week). No gender differences were found. The risk of having at least one clinical sign of TMD was 3.0 (95% confidence intervals [CI]: 1.1-8.5, P < .05) times higher in children with back pain, 2.7 (95% CI: 1.2-6.0, P < .05) times higher in children with neck-shoulder pain, and 1.6 (95% CI: 1.1-2.5, P < .05) times higher in children with headache compared to children without these pain symptoms. The risk of having at least one clinical sign of TMD was 12.2 (95% CI: 1.4-101.8, P < .01) times higher among children with palpation tenderness in trapezius muscles than among those without it. CONCLUSIONS: Clinical signs of TMD and pain symptoms are common in children. The relationship of back pain, neck-shoulder muscle palpation tenderness, and headache with clinical signs of TMD suggests that more attention should be paid to stomatognathic function in children with such pain problems.

 

Headache Associated with Temporomandibular Disorders Among Young Brazilian Adolescents

Franco AL, Fernandes G, Goncalves DA, et al.

The Clinical Journal of Pain 2013; 30:340-345

Abstract: OBJECTIVE: To verify whether headaches (HAs) are associated with temporomandibular disorders (TMD) in young Brazilian adolescents. METHODS: From a population sample, 3117 public school children (12 to 14 y) were randomly invited to participate in this study. TMD was assessed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I, in addition to questions #3, #4, and #14 of Axis II history questionnaire. HAs were investigated with question #18 of RDC/TMD Axis II. Chronic TMD pain was considered as pain that has persisted for 6 months or more, as proposed by the International Association for the Study of Pain. The statistical analysis consisted of chi tests, odds ratio (OR), and logistic regression models, adopting a significance level of 5%. RESULTS: The sample included 1307 individuals (a response rate of 41.93%), and 56.8% (n=742) were girls. Overall, 330 adolescents (25.2%) were diagnosed with painful TMD and 595 (45.5%) presented with HAs. Individuals presenting with HAs were more likely to present painful TMD (OR=4.94; 95% confidence interval [CI], 3.73-6.54, P<0.001), especially combined muscle and joint painful TMD (OR=7.58; 95% CI, 4.77-12.05, P<0.001). HAs also increased the risk to a higher magnitude for chronic TMD pain (OR=6.12; 95% CI, 4.27-8.78, P<0.0001). All estimated ORs remained essentially unchanged after adjusting for sex. DISCUSSION: HAs were a potential risk factor for TMD in adolescents, and the risk was particularly higher for painful and chronic TMD. When HAs are present in young adolescents, a complete examination is strongly recommended with regard to the presence of painful TMD, and vice versa.

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