An Alternative Therapy Developed for Mild Sleep-Disordered Breathing in Children

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Sleep Disorders in Children

Research investigators have shown that there is an alternative therapy to the removal of tonsils and adenoids for the relief of mild sleep disordered breathing in children.

In a 16-week study involving 24 young children, researchers employed montelukast, an anti-inflammatory agent used in asthma and allergic rhinitis. They found that the oral therapy resulted in significant reductions in the children's adenoid size, as well as decreases in respiratory sleep disturbances.

Writing in the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine, David Gozal, M.D., along with three associates from Kosair Children's Hospital Research Institute at the University of Louisville in Louisville, Kentucky, pointed out that the major concept emanating from this study supports the existence of a chronic inflammatory process in children with sleep-disordered breathing.

"Systemic anti-inflammatory agents with safe therapeutic profiles for use in children with sleep-disordered breathing could serve as an alternative intervention to removal of tonsils and adenoids," said Dr. Gozal.

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The 24 children recruited for the study, as well as the 16 controls, were older than age 2, but younger than 10. Each child was a habitual snorer who had been found to have an obstructive apnea-hypopnea index of more than 1, but less than 5 events per hour during overnight polysomnography evaluations at the sleep center.

In obstructive sleep apnea, the sleeping person temporarily stops breathing long enough to decrease oxygen in the blood and build up carbon dioxide. After a breathing pause of 10 seconds or more, the person awakens and resumes breathing.

Obstructive sleep apnea affects 2 to 3 percent of children in the United States. It is usually associated with a blockage in the throat or upper airway. A common symptom is snoring in between pauses in breathing and episodes of awakening. An apnea-hypopnea index (AHI) between 1 and 4 breathing pauses (called "events") an hour constitutes mild sleep-disordered breathing. Removal of tonsils and adenoids is usually reserved for children whose respiratory index (AHI) during sleep exceeds 5 events per hour of sleep.

In reviewing the research in an editorial in the same issue of the journal, Raanan Arens, M.D., of the Albert Einstein College of Medicine's Children's Hospital at Montefiore in Bronx, New York, wrote: "These results, although preliminary, support the notion that obstructive sleep apnea syndrome (OSAS) in children with adenoid and tonsillar hypertrophy has an immunologic/inflammatory component, and that new approaches in reducing inflammation should be considered in children with some forms of OSAS."

He continued: "If adenotonsillar hypertrophy associated with OSAS is indeed an inflammatory disorder and not just a consequence of excessive physiologic development of these tissues, there is a rationale to use anti-inflammatory modalities for some forms of the disorder. Leukotriene modifiers are especially attractive because they are both safe and effective in other forms of common inflammatory disorders of childhood such as asthma and allergic rhinitis. However, more controlled studies are indicated to assess the efficacy of this group of medications with and without nasal corticosteroids. These future studies will need to address the clinical indications, doses, duration of therapy and recommendations for follow-up of these patients once treatment is discontinued. At this time, the current recommendations to treat children with OSAS remain unchanged and adenotonsillectomy continues to be indicated when adenotonsillar hypertrophy is present. However, it is possible that anti-inflammatory modalities will be introduced in the future for children with mild forms of the disorder as a bridge until surgery is performed, or for a period of time after adenotonsillectomy to suppress any residual inflammation that could continue OSAS symptoms."

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