Saturday, April 29, 2006

The Impact of Undiagnosed Asthma On Children's Quality Of Life

Young girl on playround equipment with an ear to ear grin: she is an example of happiness through explorationAsthma can have a significant impact on children's quality of life. Researchers in the Netherlands have been looking into the impact of undiagnosed asthma on children's quality of life.

The researchers surveyed 1758 children, aged between 7-10 years old, in 41 schools. Researchers made a diagnosis of asthma on the basis of answers to core questions to the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire in combination with either airway obstruction or a provocation challenge to bronchial hyperresponsivity.

Typically, undiagnosed children are less willing to participate in activities or to explore their environment: they find it more difficult to engage with people or to participate in shared activities. Researchers administered the Paediatric Asthma Quality of Life Questionnaire to the children to assess their quality of life. Their preliminary findings are summarised below and indicate that in all domains, children with undiagnosed asthma have a lower quality of life compared to that of healthy children. Although these results need to be confirmed in a peer-reviewed publication, it seems as if undiagnosed asthma has significant consequences for children's quality of life. However, we need further detail from the researchers to establish whether there is a difference in the quality of life for those children with already-diagnosed asthma and those with previously-undiagnosed asthma.

Quality of Life Mean Score
Undiagnosed asthmaHealthy controls
Emotions domain mean score, (n)6.6 (103)7.0 (130) *
Activity domain mean score, (n)5.6 (90)6.9 (80) *
Symptom domain mean score, (n)6.2 (91)6.9 (104) *
Combined domain mean score, (n)6.1 (77)7.0 (77) *
* P < 0.05

Summary based on Quality of Life in Children with Undiagnosed Asthma, [Publication Page: A161, up-coming ATS conference in San Diego, May 2006]

Authors: R. van Gent, MD, G. de Meer, PhD, M. Rovers, PhD, J. Kimpen, PhD, C. van der Ent, PhD, L. van Essen-Zandvliet, Phd, Veldhoven, Utrecht, Hilversum,Groningen, Netherlands

Thursday, April 27, 2006

Will It Boost The Immune System?

Street advertisement promoting the services of a local herblist doctor: there is an unnerving drawing of a snake that raises the spectre of snake-oil and fails to reassure the passer-byA hat-tip to Orac for giving me a polite response for the next time somebody tells me that a product supports the immune system. Orac scrutinises the advertising claims for a herbal remedy that used to claim that it prevented colds until advertising regulations downgraded that claim to 'helps to support the immune system'. Orac hazards a guess that the people who make these products:
don't know an antibody from a T-lymphocyte, but now they're pushing a "boost the immune system" claim. What specific aspect of the immune system are they boosting? Cell-mediated immunity? What cell type? Neutrophils, T-lymphocytes, B-lymphocytes, natural killer cells?
I will make that set of enquiries the next time that I hear that claim.

Advertising board for an audio shop with a fascimile of the NASA logo and an artist's impression of a young man playing a guitar that is attached to a large speakerNow, if only Orac could help me out with an appropriate response to the next person I meet who tells me that an air-filter, smaller than a shoe-box, and that can run from the domestic power-supply, can clean the air in a warehouse-sized space of all "noxious smells, dust, dirt particles and even viruses like MRSA [sic]". The clincher for all of these air-filters is, "It was designed by NASA". I can't find the reference but I read a while ago that NASA emphatically denies being responsible for much of the technology that is attributed to it. It's a shame really; I, for one, would definitely take delivery of a NASA gift catalogue...With a nod to Rich Cook:
Health care today is a competition between scientists and doctors striving to create effective and better interventions to outwit ageing and to idiot-proof us against our lifestyle choices, and the Universe trying to produce bigger and better idiots. So far, the Universe is winning.

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Wednesday, April 26, 2006

The Duvet Diet: Lack Of Sleep And Hormone Disturbance

Cat lies on duvet: symbol of virtue and idleness and simple pleasure. Caption exhorts us to smell the duvet
When The Times ran an article provocatively entitled The Duvet Diet I feared that it was going to be one of those stupid puff pieces for a magnetised mattress pulling the fat from your body while you slept under the thermogenic stimulus of an essential-oils-impregnated-duvet or some such nonsense. So, I was both abashed and relieved that the article stressed that sleep is essential to our physical, cognitive and emotional well-being: and that it has a profound impact on our metabolism and physiology.

Young boy sleeps in the back of a carDr. Taheri of the University of Bristol is probably even now attaining cult status in playgrounds for his advice that children should be allowed to sleep uninterrupted (he wisely doesn't get into the argument of when the bedtime should be). Dr. Taheri is particularly interested in whether the sharp increase in teenage obesity is related to the fact that teenagers biologically need so much more sleep than modern lifestyles allow them to have. The article quotes Dr. Taheri:
How much sleep we have affects our IQ, our suicide risk, our chance of substance abuse and our weight...If we don’t take it seriously, we will pay the consequences.

Young man soundly asleep over his laptopA bald summary of the theoretical underpinning of the Duvet Diet is that lack of sleep affects the hormones that influence appetite: so, for some people
less sleep=hormone disruption=greater appetite=weight gain
Several hormones contribute to the rise in appetite. The stress hormone, cortisol, is probably the best-known of these. Cortisol levels follow a fluctuating rhythm throughout the day. Cortisol levels peak somewhere between late-morning and noon: thereafter they fall, and should reach low levels before falling asleep. There is some speculation that there is a substantial fall in cortisol levels between 2 and 4 a.m. that is linked to the number of asthma exacerbations that happen between midnight and 8 a.m.. However, the mechanism of nocturnal exacerbation of asthma is not clearcut: there are probably multiple (perhaps synergistic) factors that make a contribution.

Middle-aged man with an apple tummy, asleep on a couch with small boy asleep against himEve Van Cauter has reported studies that show short sleep duration in young, healthy men is associated with decreased leptin levels, increased ghrelin levels, and increased hunger and appetite, and cortisol disturbances that influence the ability to cope with stress and also promote the laying down of a personal duvet of body fat. An interesting speculation here is that sleep apnoea is typically found in middle-aged, overweight men who have increased their collar-size (implying more body fat around the neck): if sleep disordered breathing (SDB) has been present for some time, it may have contributed to the weight gain, as well as being exacerbated by that weight gain. A similar hypothetical vicious circle may be present in morbidly obese children with SDB.

Cranky child with a barrage of speech bubbles saying, No; Whatever, Don't make me screamThere is a lot of evidence that highlights the importance of sleep's contribution to allostasis and therefore, wellbeing. Salvador Minuchin famously remarked that "behavioral events among family members can be measured in the bloodstream of other family members".* It seems as if that could also be adapted to "behavioural events among family members can be measured in the diagnoses of other family members". The Times carried a summary of El-Sheik's research into sleep quality in children. The more that children are exposed to parental conflicts, the worse they sleep. And, the worse children sleep, the more likely they are to be tired when awake, have difficulty focusing and be irritable and badly behaved. These are some of the behaviours that could make a contribution to a diagnosis of hyperactivity behaviour or ADHD. The tiredness-related behaviours would also mean that the children fulfil the diagnostic requirement of ADHD to have the behaviour documented in a variety of settings. And, as the children would be tired for most of the day, I think that that criterion would be met. Children with ADHD may have SDB as a separate issue, but there is increasing speculation that some of the children with SDB have been mis-diagnosed with ADHD or hyperactivity behaviour.

Recent sleep research in both adults and children shows that sleep quality has a tremendous impact on physical and emotional well-being and on our cognitive performance. The effects of poor sleep quality go beyond feelings of fatigue; they are said to encompass raised blood pressure, metabolic changes linked to metabolic syndrome, increased likelihood of diabetes etc.

Lack of sleep is a common complaint. So is the sense that sleep wasn't satisfying. Tony Plant of the Happystance Project runs workshops for carers. He observes that carers often report that they have difficulty sleeping. Many of them talk about their hypervigilance. And some of them have the raised blood pressure, raised heart rate, eating habits and even fat deposits around their middles that accompany this. Behavioural hypervigilance has strong physiological correlates that can have other impacts on health. The hypervigilance seems to be not only grounded in the need to listen out for or watch for significant changes in the person for whom they care but also in the social circumstances that go along with caring: financial problems, the benefit/allowance system, difficulties with socialising and relationships with other family members.
Glucose monitor and blood pressure monitor
Vast quantities of crisps and other savoury, salty snacksOne of the interesting predictions of allostasis is that raised blood pressure is related to hypervigilance, and that this can influence the foods to which people are attracted.* One of the contributions to raised blood pressure is the retention of sodium and water by the kidneys. Because hypervigilance is persistent, the body anticipates a continuing need for sodium and can increase the attraction to salty foodstuffs. When there is a perceived need for extra sodium, the body seems to assume that there will be a future demand for fuel. It's plausible that hypervigilance is linked to cravings for foodstuffs like fats and carbohydrates. van Cauter's research frequently reports that her sleep-deprived subjects crave carbohydrates: in the UK, crisps a.k.a. chips, are among the most popular snackfoods and offer salt, fat and carbohydrates-I just thought that might be relevant.

It is possible to argue that hypervigilance and sleep disturbance influence what people eat. And what we eat has its own impact on our health. Adults frequently wish that children ate more healthily (regardless of their own example). The Guardian carries the summary of a US study that reports:
Children consume nearly as many calories as are in a packet of crisps with every hour they spend watching television...Watching TV also encourages children to eat more junk foods, particularly soft drinks and takeaway fast food, the researchers found.
The article quotes one of the researchers as saying:
children and youth are encouraged to watch what they eat, many youth seem to eat what they watch.
It looks like allostasis would make all of these findings part of the same vicious circle of dysregulation. For the present, it does look like a Duvet Diet of adequate sleep and good nutrition might be of importance to establishing a firm foundation for children's health. Poor sleep quality and its plausible contribution to inactivity and poor food choices may mean that the foundation of good health is gradually eroded and may collapse over time.
A bank of sand has a large hole caused by wind erosion: only a small bridge of sand remains at the top to prevent collapse

*These examples are taken from Principles of allostasis: optimal design, predictive regulation, pathophysiology and rational therapeutics (pdf file) by Peter Sterling, in Allostasis, Homeostasis and the Costs of Adaptation, (ed) J. Schulkin. CUP. 2004.

For more information about the images used in the illustrations, click on them to see the detail about the contributors on Flickr (where they are from Flickr-the cartoon isn't)..

Tuesday, April 25, 2006

My Child Is Ill: But The Doctor's Prescribing Something For ME!?!

Cookie Monster smokes a cigarette

We have an extensive smoking ban in the UK. Anecdotally, some G.Ps claim there has been an increase in the incidence of asthma exacerbations in children as people spend more hours smoking at home, rather than doing this at their local pub. A number of the adults who attend the Breath Spa workshops with the children, tell me that at the last emergency visit for (typically) an asthma exacerbation, the doctor advised them to give up smoking: they shake their heads ruefully as they say, "My child is ill. And the doctor's prescribing something for me!". I don't know what to say.

Like most of their generation, my parents both smoked. A layer of tar and cigarette ash seemed to coat every surface in the house. All of the furnishings and most of my mother's clothing had at least one cigarette burn in it. Until I moved away from home I'd never had a meal without at least one person smoking as we ate. Of course, it wasn't until I moved away that my 'putrid ears' (as my ENT consultant so aptly referred to them) started to clear up. And I realised that my sinuses did not have to feel as if they were being scoured with a drain cleaner and wire brush.

Merry Christmas scene of a loving, happy couple and the ideal gift of festively wrapped cigarettesThe sophistication of tobacco advertising was extraordinary. Cigarettes and alcohol were socially approved methods of self-medication. Everybody smoked back then. Even people like my parents who had both had several bouts of tuberculosis. People were admired for their stoicism and their power to endure. Psychotropic drugs were unheard of and the notion of stress was disdained no matter how hard the routine of your life or the blows that threatened to fell you to the ground and break up your family.

When the public health message about the personal health impacts of smoking gained credence, my mother tried to give up. She may have lasted longer when I was very young; but, as I grew older, her attempts at smoking cessation did not go beyond three hours. And, yes, I mean that. She always did wake up during the night and smoke. But when she was "giving up smoking" her anxiety level was so great that she would wake up even more frequently and need to soothe herself with 'just one more'.

My mother did stop smoking eventually, but it was almost by default. She had had surgery but something had gone awry and she spent almost five weeks in an intensive care unit. She was unconscious for most of that time. She said afterwards that she must have gone cold turkey because by the time she remembered anything again, she had been without a cigarette for more than a month and had lost her craving. She never did start smoking again. When she returned to her home, she couldn't believe the smell, or the stains on the ceiling over her favourite armchair. She was so angry that at one point she accused us of putting cigarette burns over her furniture just to embarrass her.

Little girl sleeping on her father's shoulder: holding on tight, secure in her trust of himSo, I have every sympathy for people who find it hard to give up smoking. I witnessed the struggle for many years and I know the heartache it causes. But it is because of this that I don't know what to say when adults accompany children to the Breath Spa workshops, give me an overview of the child's sleep problems, ENT issues or respiratory conditions, say "I'd do anything for my kids", but then reveal that they are smokers. They hold the children tight to protect them from all other sources of harm, but either they can not bring themselves to accept that smoking really has that much of an impact on the child or their lives are so chaotic that smoking seems better than any alternative. Some of the adults have made repeated attempts to give up. A fair number claim that they don't smoke in the house, or "never upstairs": or they smoke in some subtle way that defies the law of physics and means that children never come into contact with the smoke. It's usually at this point that the listening child makes some artless comment that contradicts the adults' account.

It's not political correctness or a fear of causing offence that puts a scold on my tongue: it's the memory of my mother's struggle and the awfulness of the solution to it. Plus, much as I believe that a smoke-free home is in the best interest of the children with whom I work, it is really not appropriate for me to comment. But I admire the doctors who do address the issue. Researchers interviewed parents in four paediatric practices in the US and asked them what their reaction would be if a paediatrician addressed the issue of parental smoking in the outpatient setting.
Only 3% of the sample felt their smoking status was not the pediatrician's business, 89% stated they believe it is an important part of a pediatrician's job to ask about their smoking status, and 8% stated it wouldn't matter if the pediatrician asked...Among 187 smokers, 177 (95%) would appreciate or feel okay about the physician's concern if advised to quit and 57% reported wanting some kind of smoking cessation help from the pediatrician's office.

However, another study reports that when smoking parents accompanied a child on a visit to the doctor, only 15% had pharmacotherapy recommended to them and only 8% received a prescription for a smoking cessation medication although smokers who use such medication double the likelihood of their success.

A study of diabetic children with uncontrolled ketoacidosis prompted Salvador Minuchin to say that "behavioral events among family members can be measured in the bloodstream of other family members". The notion that when one family member is ill, it may be another family member that needs a psychosocial or pharmacological prescription is a poignant example of allostasis and allostatic load. I've borrowed this following explanation of allostasis from Dr. Salt's summary of a classic paper:
[stress has] many mechanisms, but among the most prominent are the manifestations of physiological stress responses as a result of living and working conditions, inter-personal conflict, as well as the sense of control of one’s environment and optimism/pessimism toward the future. "Allostatic load" refers to the cost of adaptation to a stressful environment, which elicits repeated and sometimes prolonged adaptive responses ("allostasis") that preserve homeostasis in the short run but can cause wear- and-tear on the body and brain...We have powerful ways of modulating the harmful output of the stress response systems that include belief systems and behaviors. An important quote attributed to Dr. McEwen is, "We must also remember that the biggest problems for the human race in the future are those associated with our own behavior and misbehavior and the impact of the social and physical environment on our bodies and brains."

There can be a significant improvement in children's health as a result of a successful intervention with people other than themselves. Helping children by helping adults to give up smoking is a lot like a first attempt at balancing pebbles. It takes a lot of consideration as to:
  • the opposing forces (gravity, the wind)

  • the suitability of the environment (are some sources of stress adequately controlled?)

  • the correct support (do you know what support you can scrape together from the surrounding resources?)

Pebble balancing: vertical column of finely balanced pebbles withstanding gravity and windA recommendation to a quit smoking clinic or a prescription for smoking cessation aids might be the successful placement of that first pebble. Over time, people become remarkably adept at balancing rocks and pebbles: they even manage to make it look like an artform.

Monday, April 24, 2006

Paediatric Grand Rounds 1 Is Up!

Paediatric Grand Rounds Volume 1:1 is up at the splendidly entertaining Clark Bartram's Unintelligent Design. There is an interesting mix of posts and this first edition has set the bar for future collections.

Reading Clark Bartram's robustly sceptical posts reminds me of a family friend who is a prosecutor for the Crown Prosecution Service. A while ago, his son was prattling on about the huge 'incey-wincey' in the bath and explaining that this was why his bed-time was delayed. Scenting rannygazoo, his father refused to buy into this explanation and in all seriousness said, "I put it to you that this alleged spider is no more than an artifice". His wife intervened after about a minute of the remorseless cross-examination: "He's 2 years old. 2 year-olds aren't capable of alleging anything. He believes in talking steam trains". The father was abashed, but I feel that in a similar position, Clark would have replied, "Name your source that 2 year-olds can't allege. And, what's your point?".

Let the Paediatric Grand Rounds flourish!

Sunday, April 23, 2006

Nose Breathing: The Why (If Not Yet The Dao)

Gargoyle-like structure with large nose With very young children, we start the Breath Spa workshops by pointing to the legs and asking, "What are your legs for?". The children shout out their responses, "Walking", "Running", "Football". We continue through, asking about the arms, tummy, ears, eyes and mouth. Finally, we point to the nose and ask, "What is your nose for?". From time to time, a child will answer, "Breathing" but it is unusual to hear anything other than "Smelling" or "Bogies" (they are very young children but this reply is also popular with teenagers).

Darth Vader holds a cardboard sign: Noisy Breather. Please Help.Through a cunning mix of perseverance, bubble-blowing, Darth Vader masks and voice-changers, ruthlessness in the face of pleading by pre-schoolers, stories, games, playing with balloons, plus a remorseless dedication to our mission, we persuade the children to breathe through their noses (apologies to any Python fans who were expecting comfy cushions but not expecting the Spanish Inquisition). The children have their own revenge. We've given up any attempt to salvage the clothing we wear on workshop days. If the children weren't quite so young, we would try and wear the paper suits that ill-become the actors in countless forensic science dramas. But children scream in horror at the sight of adults in protective coveralls although they scream with enthusiasm at the sight of Wiggles, so what can you do?

Why this remorseless dedication to the cause of breathing through the nose? It's good for you! We strongly recommend that wherever practical, people should breathe in and out through the nose. If the nose is blocked, there are several options for clearing it: we tend to use simple exercises with children but nasal irrigation is also a popular technique. It is essential for children to feel comfortable breathing through the nose. Nose-breathing:
  • filters
  • warms
  • humidifies
the air before it reaches the lungs: on exhalation, it contributes to an efficient heat and moisture exchange. So, the nose not only contributes to our sense of smell, it is involved in respiration, speech production, heat exchange, humidification, filtration and antimicrobial defence.

The nose has a very rich blood supply, so when we breathe in through the nose, the airstream is exposed to the protective mucus and serous defence mechanisms. We've read that an adult produces 30 gloriously gloopy fluid ounces of mucus per day. We're still trying to find an estimate for mucus production in children-any references that would remove the need for direct research would be gratefully received.

Cute toddler with snuffly, twitchy nose

In a recent experiment, the volunteers took their shoes and socks off and half had their feet chilled in ice cold water for 20 minutes while the others sat with their feet in an empty bowl. 29% of the chilled volunteers developed cold symptoms over the next 4-5 days compared to only 9% in the control group.

One of the research authors, Professor Ron Eccles said:
A snuffle of soft-toy viruses: mostly upper-respiratory tract
When colds are circulating in the community many people are mildly infected but show no symptoms. If they become chilled this causes a pronounced constriction of the blood vessels in the nose and shuts off the warm blood that supplies the white cells that fight infection. The reduced defences in the nose allow the virus to get stronger and common cold symptoms develop. Although the chilled subject believes they have "caught a cold" what has in fact happened is that the dormant infection has taken hold.

The assumption that we should be breathing through the nose is implicit in Eccles' comments. Eccles speculates that the research indicates the importance of keeping the nose warm, and the blood supply circulating freely:
A cold nose may be one of the major factors that causes common colds to be seasonal. When the cold weather comes, we wrap ourselves up in winter coats to keep warm, but our nose is directly exposed to the cold air. Cooling of the nose slows down clearance of viruses from the nose and slows down the white cells that fight infection.

Anybody who has ever told someone to wrap up warmly against the cold was only part right if they didn't encourage them to wear a scarf to protect the nose. We need to continue nose breathing even in warm weather. Although the blood supply should be circulating freely because the nose is warm, breathing in through the nose allows the air to be adjusted to the correct humidity. Breathing out through the nose allows the moisture from the airstream to be recycled and use to humidify the inhaled breath.

Interestingly, nose-breathing also exposes the air to nitric oxide. Nitric oxide is a potent vasodilator and anti-microbial that also improves the free movement of the fine hairs that allow the efficient removal of detritus and mucus. So nose-breathing offer a number of benefits, including the efficient killing of harmful organisms and better gas-exchange in the lungs and more increased oxygenation of the blood (estimated at 10%). Nitric oxide is an important defence mechanism even when the nose and sinuses are blocked.

Some researchers suggest that the long-term cardiac and circulatory consequences of obstructive sleep apnoea might be attributable to the lack of the vasodilatory properties of nitric oxide, secondary to the lack of oxygen. The comparative constriction of the blood supply to the heart and brain is thought to contribute to raised blood pressure which is linked to both heart problems and strokes in adults.

We have a number of colleagues who teach that all newborns breathe through the nose and that's why we should continue to do so. Additionally, nose breathing is typically associated with diaphragmatic breathing which is typically A Good Thing. Now, there are a number of natural behaviours for a newborn that I couldn't wait to shed as a toddler. However, the health benefits of nose breathing are so significant that is a habit that should be cultivated if it has been lost.

Friday, April 21, 2006

Why A Breath Spa For Kids?

Young man in a hooded top: with attitude A Breath Spa? Quis-quis. What-E-ver. Attitude before platitudes.

Long ago, in a Latin class, by way of distracting us from the endless rote learning of verb conjugations, my teacher introduced us to an early TLA, the spa, or sanitas per aqua. Said Latin teacher also had a cough that made the average classroom into a Sensurround version of any disaster film that involves shaking, quaking, and the sudden appearance of vast fissures in the ground. That was the first time that I wondered if it was possible to have a breath spa: spiritus per anima or sanare per anima.

I remembered this experience the first time that I wondered whether breathing re-training could help children to correct disordered breathing and to improve their physical, mental and emotional wellbeing.

The way that children breathe can have a significant impact on their health. Conditions such as asthma are familiar to us: throughout the UK, an estimated 1 in 10 children has this condition. However, a lot of research reports that disordered breathing is also found in a number of other less obvious conditions. This raises the interesting question as to whether disordered breathing contributes to a number of physical, cognitive, emotional and behavioural disorders, or whether it is an epiphenomenon and no more than an interesting feature that occurs independently but is of no clinical significance.

Children’s sleep can be disrupted by irregular breathing patterns causing a condition known as sleep-disordered breathing (SDB). One of the main signs is frequent snoring: around 10% of children snore habitually and would be classified as having SDB.
Child snoring in bed. 2 soft-toys listen to sounds and say, The allergen avoidance people blame us for this, you knowSDB can also involve hundreds of episodes during the night where the breathing stops for brief periods and the child jolts awake to start breathing again: the estimate for children affected by this is 1%.

Like many other habits, breathing patterns are often learned unconsciously. Simple breathing exercises and techniques can break these patterns and reduce the symptoms of disordered breathing in both adults and children. Practising the exercises restores healthy breathing habits. I am interested to learn whether for some children, restoring healthy breathing habits can reduce SDB sufficiently to help bring the benefits of refreshing sleep. Beyond that, I would hope to offer some findings that would contribute to a discussion about whether SDB is an epiphenomenon or sometimes, a clinically significant finding.

Research has linked SDB to: Cranky child with a barrage of speech bubbles saying, No; Whatever, Don't make me screamSnoring is so common among children that it was thought to have no ill effects for them. Recently, however, research links SDB in children to how they perform at school and how they behave [1-3]. The same research links SDB to Attention Deficit Disorder. SDB has been shown to cause problems in later life such as raised blood pressure, obesity, diabetes and heart disease [4-6].

SDB & impaired thinking

Because of the disruption to the breathing, one of the features of SDB can be a significant drop in oxygen levels, known as hypoxia. Research indicates 71 ways in which hypoxia can adversely affect the well-being of children [3]. These include impaired thinking and difficulty in performing tasks that involve planning or problem-solving [7].

SDB and educational performance

A study of primary school children [1] revealed a significant link between regular snoring and hyperactivity, a lack of attention, poor behaviour and difficulties with friends. It also found that the children who were snoring were more likely to feel tired and sleepy during the day and were more likely to under perform at school.

Lower oxygen levels in children have been shown to reduce their IQ scores by as much as 8-9 points [8-10]. One study found that IQ was 12 points lower in children who snored [11]. This affect on IQ is attributed to a general impact on the body of lower oxygen levels and snoring. The most noticeable signs of this range from feeling tired during the day to physical changes that can subtly or dramatically affect a child’s health.
Teen boy at desk, poring over books and papers: head in hands
Inattentive behaviour is one of the most frequently reported features of SDB [11]; it affects both memory capacity and intelligence. Children can not work to their full potential when their concentration is reduced. The children can not be taught to their true level and thus they underperform: this effect is cumulative throughout their educational career.

SDB, Hyperactive Behaviour and Attention Deficit Hyperactivity Disorder (ADHD)

Research links snoring and symptoms of hyperactive behaviour (HB) [19] or Attention Deficit Hyperactivity Disorder (ADHD) [11-13]. The conditions are a combination of behaviours: inattention, impulsiveness, outbursts such as tantrums, over-activity, restlessness, poor co-ordination and social difficulties. Hyperactive-inattentive behaviour is common among children who snore frequently [1, 19]. Some researchers argue that it is possible that some children with SDB are mis-diagnosed with HB or ADHD because of a similarity in the symptoms (estimates range from 15% to 39% depending on the demographics of the group under consideration [19]). One study analysed children’s breathing during sleep, and assessed their educational performance and behaviour. In a follow-up one year later, those children who no longer snored frequently showed improved behaviour. The report concludes that:
Habitual snoring was common among these primary school children and was associated with hyperactive and inattentive behavior and daytime tiredness and sleepiness...Considering its high prevalence and assuming a causal link to disturbed behavior, habitual snoring seems to be a substantial public health problem in school-aged children. (my emphasis) [1]

SDB and health in later life

A recent review highlights the potential link between SDB and chronic health conditions in later life (e.g., diabetes and heart disease) [14].
Glucose monitor and blood pressure monitor
The physical changes caused by SDB are thought to lead to raised levels of blood sugar and cholesterol. The disturbed sleep pattern and hypoxia associated with SDB may also be involved in a chain of physical reactions that contribute to later cardiovascular, cognitive and behavioural problems [15].

SDB & Sleep Apnoea

Obstructive sleep apnoea (OSA) is a serious form of SDB where the sleeper can stop breathing several hundred times a night. OSA is less common in children than adults but the statistics are increasing because of contributory lifestyle factors such as obesity and lack of exercise. At least a third of children with severe OSA show significant physical or behavioural disorders [16-18]. OSA has related secondary symptoms that include morning headaches, blood pressure fluctuations, weight gain, heartburn and insomnia.

SDB And Sleep Assessments

SDB in children is reportedly underdiagnosed in general practice [20]. In a survey of children attending a general practice, 18% were frequent snorers, and 0.6 to 5% not only snored, but displayed at least one other symptom of OSA. Sometimes, parents don't know whether their children snore, particularly if a child doesn't share a room. Or, it may be that everyone in the family snores habitually, and snoring is considered a normal part of sleep. Parents who are aware that their children are habitual snorers or have frequently observed signs of daytime sleepiness etc. that do not correlate with the child's time asleep, should consult their family doctor.
Young girl rubs her eyes and yawns: tired in the daytime
The doctor can check for over-developed adenoids or tonsils that may be contributing to SDB, and make a referral, if appropriate. The family doctor would also be able to assess the child for other medical conditions or lifestyle factors that may be contributing to SDB. Sometimes, it may be necessary to refer a child for a more formal sleep assessment although access to this varies throughout the UK.

The Breath Spa Project

I run breathing retraining workshops for children who have SDB. I applied to UnLtd for funding to cover the cost of the workshop materials and also some travel expenses. I was fortunate enough to be awarded a small grant and I am grateful to UnLtd for their support. I am happy to deliver presentations to interested groups of teachers, parents, community or health workers. I've worked with children in pre-school groups who were as young as two years old. I'm in the south of England, half-way between London and Cambridge. However, with the sometimes amazing travel deals that are available in the UK, please email me if you are interested in the project and might be interested in hosting a course.

Breathing Techniques

Depending on the age of the child, I sometimes use capnometry as a biofeedback mechanism: older children enjoy the gadgetry and even young children have a surprising interest in it. I've demonstrated biofeedback and the impact of breathing techniques in both science and PSHE (personal, social and health education) classes for different ages in both school and community outreach settings.

The breathing techniques are based on accepted principles of respiration and physiology. The techniques are not something that are to be practised for only a few minutes a day. We are looking to re-train the breathing habits so that children breathe appropriately, all of the time. For example, we emphasise the importance of breathing in and out through the nose most of the time. Children learn these techniques in simple exercises and activities to practise at school and at home with their parents. The techniques can also be easily integrated into many existing activities, such as walking, playing games, watching television and reading stories.


[1] Urschitz, M.S., Eitner, S., Guenther, A., Eggebrecht, E., Wolff, J., Urschitz-Duprat, P.M., Schlaud, M. & Poets, C.F. (2004). Habitual Snoring, Intermittent Hypoxia and Impaired Behavior in Primary School Children. Pediatrics 114 (4), pp 1041-1048.

[2] Urschitz, M.S., Wolff, J., Sokollik, C., Eggebrecht, E., Urschitz-Duprat, P.M., Schlaud, M. & Poets, C.F. (2005). Nocturnal Arterial Oxygen Saturation and Academic Performance in a Community Sample of Children. Pediatrics 115 (2), e 204-209.

[3] Bass, J.L, Corwin, M., Gozal, D., Moore, C., Nishida, H., Parker, S., Schonwald, A., Wilker, R.E., Stehle, S. & Kinane, T. B. (2004). The Effect of Chronic or Intermittent Hypoxia on Cognition in Childhood: A Review of the Evidence. Pediatrics 114 (3), pp 805-816.

[4] Marcus, C.L., Greene & M.G., Carroll, J.L. (1998). Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med, 152: 1098-1103.

[5] Kohyama, J. Ohinata, J.S. & Hasegawa, T. (2003). Blood pressure in sleep disordered breathing. Arch Dis Child, 88: 138-42.

[6] Enright, P.L., Goodwin, J.L. Sherrill, D.L., Quan, J.R. & Quan, S.F (2003). Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: The Tucson Children’s Assessment of Sleep Apnea study. Arch Pediatr Adolesc Med, 157: 901-4.

[7] Menkes, J.H., Hurvitz, C.G.H., McDiarmid, S.V., Williams, R.G. (1995). Neurologic manifestations of systemic disease. In: Menkes, J.H Textbook of Child Neurology. 5th ed. Baltimore, MD: Williams & Wilkins; 873–874.

[8] Aram, D.M., Ekelman, B.L., Ben-Schachar, G., Levinsohn, M. (1985). Intelligence and hypoxemia in children with congenital heart disease: fact or artifact? J Am Coll Cardiol. 6: 889 –893

[9] Linde, L.M., Rasof, B., Olive, J.D. (1967). Mental development in congenital heart disease. J Pediatr. 71: 198 –203

[10] Wright, M., Nolan, T.(1994). Impact of cyanotic heart disease on school performance. Arch Dis Child. 71 :64 –70

[11] Blunden, S., Lushington, K., Kennedy, D., Martin, J., Dawson, D. (2000). Behavior and neurocognitive performance in children aged 5–10 years who snore compared to controls. J Clin Exp Neuropsychol. 22 :554 –568

[12] Stradling, J.R., Thomas, G., Warley, A.R.H., Williams, P., Freeland, A.(1990). Effect of adenotonsillectomy on nocturnal hypoxaemia sleep disturbance and symptoms in snoring children. Lancet. 335 :249 –253

[13] O'Brien, L.M., Holbrook, C.R., Mervis, C.B., et al. (2003). Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention-deficit/hyperactivity disorder. Pediatrics,111 :554 –563

[14] Waters, K. & Gozal, D. (2004). Developmental and metabolic implications of the hypoxic ventilatory response. Paediatric Respiratory Review, 5 (3): 173-81.

[15] Tauman, R., Ivanenko, A., O’Brien, L.M. & Gozal, D. (2004). Plasma C-Reactive Protein Levels Among Children With Sleep-Disordered Breathing. Pediatrics, 113: e564-69.

[16] Owens, J., Spirito, A., Marcotte, A., McGuinn, M., Berkelhammer, L. (2000). Neuropsychological and behavioral correlates of obstructive sleep apnea syndrome in children: a preliminary study. Sleep Breath. 4 :67 –77

[17] Lewin, D., Rosen, R., England, S., Dahl, R. (2002). Preliminary evidence of behavioral and cognitive sequelae of obstructive sleep apnea in children. Sleep Med. 3 :5 –13

[18] Goodwin, J.L., Kaemingk, K.L., Fregosi, R.F., Rosen, G.M., Morgan, W.J., Sherrill, D.L. & Quan, S.F. (2003). Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children–the Tucson Children's Assessment of Sleep Apnea study (TuCASA). Sleep. 26: 587 –59

[19] Chervin, R.D., Hedger Arcbold, K., Dillon, J.E., Panahi, P., Pituch, K.J., Dahl, R.E. & Buillenimault, C. (2002). Inattention, Hyperactivity, and Symptoms of Sleep-Disordered Breathing. Pediatrics, 109: 449-456.

[20] Blunden, S., Lushington, K., Lorenzen, B., Wong, J., Balendran, R. & Kennedy, D. (2003). Symptoms of sleep breathing disorders in children are underreported by parents at general practice visits. Sleep Breath. 7(4) :167 –76

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Community Trauma and Its Impact on Children's Health

Blue-feeling teen in a blue shadow
Happystance has posted an overview of a study that suggests that chronic stress as a precursor of anxiety may be a trigger for -- rather than a symptom of -- depression. He argues that this research fits in with the concept of allostasis and, as such, highlights the many factors that contribute to declining health in the evacuees of Hurricane Katrina who are still living in temporary housing.

Dr. Salt describes allostasis by explaining that:
[stress has] many mechanisms, but among the most prominent are the manifestations of physiological stress responses as a result of living and working conditions, inter-personal conflict, as well as the sense of control of one’s environment and optimism/pessimism toward the future. "Allostatic load" refers to the cost of adaptation to a stressful environment, which elicits repeated and sometimes prolonged adaptive responses ("allostasis") that preserve homeostasis in the short run but can cause wear- and-tear on the body and brain. Functional symptoms and syndromes, decreased cognitive function during aging, abdominal obesity, increased risk for hypertension and cardiovascular disease, insulin-dependent diabetes and decreased immune responses are all manifestations of allostatic load.
The researchers carried out face-to-face interviews with more than 650 displaced families living in trailers or hotels. The findings show that people displaced by Hurricane Katrina are displaying higher rates of asthma, emotional and behavioural disorders. 37% of parents and guardians describe their health as fair or poor compared with 10% before the hurricane. More than half of the mothers and other female caregivers scored "very low" on a mental health screening exam: the score is consistent with clinical disorders like depression or anxiety.

Children's health was assessed against the results of the same survey that was conducted among the urban Louisiana population in 2003. 34 percent of displaced children suffer from conditions like asthma, anxiety and behavioral problems, compared with 25 percent of children in urban Louisiana before the storm. Of the first 1,000 children who were screened by researchers, 27 percent displayed symptoms of trauma, including nightmares, flashbacks, heightened anxiety and bedwetting. 18 per cent of children have asthma, contrasted to 14 per cent for the urban survey. Learning disabilities were assessed at 18 v. 10. Behavioural or conduct problems were 15 v. 7. Depression or anxiety were 9 v. 4.

The study's findings do support the view that chronic exposure to stress following the trauma of Hurricane Katrina is having a demonstrable impact on the wellbeing of the displaced children. Dr. Irwin Redlener, the director of the National Center for Disaster Preparedness at Mailman and co-founder of the Children's Health Fund, expressed his concern about the physical and emotional problems reported by the children displaced by the hurricane.
Children do not have the ability to absorb six or nine months of high levels of stress and undiagnosed or untreated medical problems [without long-term consequences].

The community trauma has exacted a significant toll on the health of the evacuees. Allostasis would predict some of this declining health from the severe levels of emotional, social, environmental and financial distress. It will be interesting to see if the study's findings stimulate the implementation of the promised aid packages that might do so much do relieve the stress of the displaced households. Until then, the wellbeing of these children may be as fragile as a sandcastle.

Elaborate Inca-style structures built in sand, perilously near the sea

Peck of Dirt: Exposure To Dust And Microbials Protects Children From Early Development Of Asthma

Anyone watching a young child cram anything and everything into its mouth has probably heard an internal voice, channelling the wisdom of previous generations, "You eat a peck of dirt before you die". There's been a lot of publicity given to the hygiene hypothesis as an explanation for the dramatic rise in autoimmune and allergic diseases in western and industrialised countries. The suggestion is that our prevailing standards of hygiene lead to a lack of contact with bacteria in early life. Similarly, the hypothesis suggests that children have less exposure to viruses. The reduced opportunities for challenge compromises the robust development of an immune system that is protective against the development of asthma and other allergic diseases.

There is a new study that lends some support to this dirt exposure part of the hygiene hypothesis. Exposing children early in life to dust and other microbial agents may protect them from developing asthma, according to new research in the Journal of Allergy and Clinical Immunology (JACI). Microbials are small, inhalable particles that are, or have been living agents.

Researchers report the results of their four-year study in the paper, Does early indoor microbial exposure reduce the risk of asthma? The Prevention and Incidence of Asthma and Mite Allergy birth cohort study. The subjects were all children of atopic mothers and living in the Netherlands. Researchers initially assessed childrens’ exposure to microbials at three months of age. They conducted a long-term assessment of the children to the age of four. For four years, the researchers monitored the development of atopic sensitisation (which can lead to allergies), doctor-diagnosed asthma and wheeze in the children.

The researchers measured:
  • dust on living room floors and infants’ mattresses at three months of age
  • serum IgE levels for common allergens at one and four years of age

They collected yearly information as to whether or not the children had developed asthma. A random group of participants received mite-impermeable mattress and pillow covers; the control group received a placebo of cotton mattress and pillow covers.

The research findings reported that:

  • microbial levels in mattresses were low and not associated with allergy, doctor-diagnosed asthma or wheeze
  • levels of dust and other microbials on the floor correlated to a lower level of asthma development by age four
  • the highest exposure group had a lower level of asthma and wheeze, even after adjustments for the presence of animals in the home, antibiotic use, dampness, etc.

Parents may be relieved to learn that antibiotic use in early life is not shown to be a risk factor for asthma in this study. A recent review of the hygiene hypothesis and asthma cautioned that:

For every exposure studied with regard to the hygiene hypothesis, there are inconsistent findings in relation to asthma. The hygiene hypothesis is not likely to be the sole explanation for the ongoing asthma epidemic in industrialized nations.

It will be interesting to learn if the children with the higher exposure to dust and other microbials continue to maintain the lower level of asthma and wheeze. These findings do present an interesting contrast with the results of the allergen avoidance experiment. An obvious difference is that the Netherlands study was a long-term cohort observation, rather than a comparatively brief made-for-TV experiment. The age-groups of the children are also very different.

However, it does seem clear that there is no definitive advice to offer concerned parents. Clean water and high standards of food hygiene protect children, nobody would suggest that children should be exposed to harmful microbes.

As Dr. Wiess, Professor of Medicine at Harvard Medical School, wryly remarked in an editorial for the New England Journal of Medicine:

Eating dirt or moving to a farm are at best theoretical rather than practical clinical recommendations for the prevention of asthma...However, a number of environmental factors are known to be associated with a lower incidence of allergic disease early in life...The challenge will be … to determine the extent of exposure that will ensure safety and have the desired outcome—the development of a healthy child with a very low risk of autoimmune disease.

Thursday, April 20, 2006

Allergen Avoidance: How To Beat Your Kid's Asthma

Assorted animal toys sitting on stairs, dogs, lions, zebra and weird Made homeless by the heartless? Innocent victims
of allergen avoidance or reservoirs of dust-mite droppings and
saboteurs of children's health? You decide.

It's been a rough week for Teddy and other pets. Channel 4's Dispatches recently televised an allergen avoidance experiment. The allergen avoidance regime was implemented to see if it could improve the asthma symptoms of ten young people. The Guardian gives an overview of the regime, but in summary, it consisted of:
  • skin-prick testing

  • removing the soft-furnishings from children's bedrooms

  • reducing the clutter in the bedrooms

  • using mite-impermeable bed covers

  • intensive steam-cleaning of the home

  • removing animals

  • giving the families a cleaning kit, including a filter vacuum cleaner.

  • attending an education seminar that explained the cleaning sequences and how to:
    • air the bedroom and bedclothes every day.

    • vacuum and dust the bedroom every day.

Soft-toys packed into lidded plastic crate. Toys in various aspects of pleading.
Won't we suffocate in here?

The skin-prick tests identified dust-mite droppings as the number one menace for the children. There were nauseating close-ups of grime, courtesy of the deep, steam-cleaners. Soft-toys and soft-furnishings were identified as reservoirs of dust-mites (or perhaps, more appropriately, the sewage tanks of dust-mites).

The children were allowed one soft-toy on their beds: other faithful companions were banished to a plastic storage box. If you've seen any clutter-busting programme where the dominatrix of the clean and clutter-free insists on a similar down-sizing of soft-toy numbers, then you will have a rough idea of the Sophie's Choice scenes that typically ensue when children are asked to choose between Teddy and their favourite dog. Other families failed to board out their pets until partway through the experiment because of their affection for these family members (although, in at least one case, there seemed to be some controversy over the results of the skin-prick test).

Teddy bear and Old English Sheepdog plead for prime spot on the bed
Keep me on your bed! Please, don't send me away!

Overall, the results were that there was a 70% reduction in the use of reliever medication by the children over the (comparatively brief) duration of the experiment. The parents reported dramatic improvements in their children. Interviewed for the Guardian, one mother said, of her son:

Dominic would rarely have a good night's sleep, and he'd always wake up coughing and wheezy. But the changes in his room and the cleaning made a huge difference literally overnight: suddenly he was able to sleep through and he was waking up able to breathe normally. It's made a difference to everything: he's a lot more relaxed, he's sleeping better so he's more rested and in a better mood, and most of all he isn't coughing and wheezing and bringing up phlegm.

In a web-chat that followed the programmes, Dr. Scadding, the consultant allergist who was in charge of the experiment, stressed the need for the children to continue to use their medication as appropriate. In response to a question about medication use and breathing techniques, Dr. Scadding replied:
there is evidence that some breathing techniques such as yoga and possibly the Buteyko method can hep [sic] asthma, possibly because many asthmatics also hyperventilate (that is breath [sic] too fast and too shallowly). The over-use of blue inhalers can be detrimental. If the blue inhaler is needed several times a week then preventive asthma treatment should be increased. Inhaled corticosteroids are very effective and safe in the vast majority of patients, even children.

It is good to see a favourable mention of the usefulness of breathing techniques like Buteyko for the improvement of asthma symptoms.

What was missing from the programme and follow-up was any discussion of the Hawthorn Effect or Pygmalion Effect that might have influenced the behaviour of the participants in the programme and made it more likely that they would comply with the onerous cleaning regime. In the second programme we saw the follow-up of the implementation of the avoidance regime. We saw a couple of the households being upbraided by the supervising asthma nurse for failing to adhere to the cleaning regime. The nurse repeatedly explained that the avoidance regime was something that could not be only partially implemented: the whole programme needed to be implemented in order to be effective.

There was a striking reduction in the use of reliever medication. However, one of the boys in the programme was using around 100 puffs of Ventolin a week at the start of the experiment: there was some suggestion that other children were over-medicating with relievers. Unfortunately, there wasn't much discussion of the children's use of inhaled corticosteroids or other preventer medication, so it is not possible to comment on changes in the use of all medications.

Some of the children experienced a remarkable improvement in their symptoms overnight-literally after their bedrooms had been de-cluttered, stripped of soft-furnishings etc. Several of the children slept through the night, without any asthma exacerbations, and woke in the morning without itchy eyes or a blocked nose. It would be expected that any improvement as a result of reduction to allergens would take longer to become apparent. It is plausible that some of the improvement can be attributed to the placebo effect. However, improvement continued for the duration of the programme, during which time the children's lessened exposure to irritant materials may have continued the reduction in symptoms.

Allergen avoidance looks like an interesting strategy, but I have no feel for the long-term practicality of sustaining the regime within the average family home. Actually, I do have an opinion, but I wouldn't want you to think that I'm less than a domestic goddess.