Albert Einstein School of Medicine study: Abnormal breathing during sleep can lead to behavior problems in children

25 Mar

A physical examination is important for children to make sure that there are no health problems. The University of Arizona Department of Pediatrics has an excellent article which describes Pediatric History and Physical Examination  A physical examination is important to discover any problems which might affect a child’s ability to learn or which might affect the child’s future health.

Albert Einstein School of Medicine announced the study, “Sleep Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years.”

A study of more than 11,000 children followed for over six years has found that young children with sleep-disordered breathing are prone to developing behavioral difficulties such as hyperactivity and aggressiveness, as well as emotional symptoms and difficulty with peer relationships, according to researchers at Albert Einstein College of Medicine of Yeshiva University. Their study, the largest and most comprehensive of its kind, published online today

“This is the strongest evidence to date that snoring, mouth breathing, and apnea [abnormally long pauses in breathing during sleep] can have serious behavioral and social-emotional consequences for children,” said study leader Karen Bonuck, Ph.D., professor of family and social medicine and of obstetrics & gynecology and women’s health at Einstein. “Parents and pediatricians alike should be paying closer attention to sleep-disordered breathing in young children, perhaps as early as the first year of life.”

Sleep-disordered breathing (SDB) is a general term for breathing difficulties that occur during sleep. Its hallmarks are snoring (which is usually accompanied by mouth breathing) and sleep apnea. SDB reportedly peaks from two to six years of age, but also occurs in younger children. About 1 in 10 children snore regularly and 2 to 4 percent have sleep apnea, according to the American Academy of Otolaryngology–Health and Neck Surgery (AAO-HNS). Common causes of SDB are enlarged tonsils or adenoids.

“Until now, we really didn’t have strong evidence that SDB actually preceded problematic behavior such as hyperactivity,” said Ronald D. Chervin, M.D., M.S., a co-author of the study and professor of sleep medicine and of neurology at the University of Michigan. “Previous studies suggesting a possible connection between SDB symptoms and subsequent behavioral problems weren’t definitive, since they included only small numbers of patients, short follow-ups of a single SDB symptom, or limited control of variables such as low birth weight that could skew the results. But this study shows clearly that SDB symptoms do precede behavioral problems and strongly suggests that SDB symptoms are causing those problems.”

The new study analyzed the combined effects of snoring, apnea and mouth-breathing patterns on the behavior of children enrolled in the Avon Longitudinal Study of Parents and Children, a project based in the United Kingdom.

“We found that children with sleep-disordered breathing were from 40 to 100 percent more likely to develop neurobehavioral problems by age 7, compared with children without breathing problems….”

— Karen Bonuck, Ph.D.

“We found that children with sleep-disordered breathing were from 40 to 100 percent more likely to develop neurobehavioral problems by age 7, compared with children without breathing problems,” said Dr. Bonuck.  “The biggest increase was in hyperactivity, but we saw significant increases across all five behavioral measures.”

Children whose symptoms peaked early—at 6 or 18 months—were 40 percent and 50 percent more likely, respectively, to experience behavioral problems at age 7 compared with normally-breathing children. Children with the most serious behavioral problems were those with SDB symptoms that persisted throughout the evaluation period and became most severe at 30 months.

Researchers believe that SDB could cause behavioral problems by affecting the brain in several ways: decreasing oxygen levels and increasing carbon dioxide levels in the prefrontal cortex; interrupting the restorative processes of sleep; and disrupting the balance of various cellular and chemical. Behavioral problems resulting from these adverse effects on the brain include impairments in executive functioning (i.e., being able to to pay attention, plan ahead, and organize), the ability to suppress behavior, and the ability to self-regulate emotion and arousal.

“Although snoring and apnea are relatively common in children, pediatricians and family physicians do not routinely check for sleep-disordered breathing,” said Dr. Bonuck. “In many cases, the doctor will simply ask parents, ‘How is your child sleeping?’ Instead, physicians need to specifically ask parents whether their children are experiencing one or more of the symptoms—snoring, mouth breathing or apnea—of SDB.”

“As for parents,” said Dr. Bonuck, “if they suspect that their child is showing symptoms of SDB, they should ask their pediatrician or family physician if their child needs to be evaluated by an otolaryngologist (ear, nose and throat physician) or sleep specialist.”

According to the AAO-HNS, surgery is the first-line treatment for severe pediatric SDB in cases where the tonsils and adenoids are enlarged. Another option is weight loss for overweight or obese children.

Dr. Bonuck’s paper is titled “Sleep Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years.” In addition to Dr. Bonuck, other Einstein contributors were Katherine Freeman, Dr.P.H., and Linzhi Xu, Ph.D.

The study was supported by grants from the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.                                       


Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years


Karen Bonuck, PhDa, Katherine Freeman, DrPHb, Ronald D. Chervin, MD, MSc, and Linzhi Xu, PhDa

  1. 1.    Published online March 5, 2012(doi: 10.1542/peds.2011-1402)
  2. » AbstractFree
  3. Full Text (PDF)
  4. Supplemental Information

The Cincinnati Children’s Hospital describes the Process of the Physical Examination

Process of the Physical Exam

A thorough history often precedes the physical examination and allows the cardiology staff to determine the reason for referral, significant family and medical history, and symptomatic status with respect to the cardiovascular system.

The history also provides the first interaction of our staff with the patient’s family so that some familiarity can be achieved prior to the performance of the physical examination.

The history is likely to vary somewhat based not only on the age of the patient, but also on the reason for referral.

A detailed history also allows us to tailor the physical examination and, if needed, subsequent testing to deal precisely and thoroughly with the patient’s suspected problem.

The first portion of the physical examination is performed by the screening clinic nurse. Height, weight, blood pressure and oxygen saturation determinations are made in the clinic at the time of being checked into the examination room.

Although these tests are painless, on occasion smaller children are anxious at the performance of blood pressure and pulse oximetry.

Rarely, however, are these tests difficult to obtain. The physical examination performed by the physician can be broken down into three separate parts, all of which are important in the accurate assessment of the patient.

  • Observation: The simple act of observing a patient is often very revealing. Patients are observed for their general sense of distress / discomfort, possible associated abnormalities (for example, orthopedic deformities or Down syndrome) and for any more subtle abnormalities that might be a clue to more serious underlying heart disease, for example, cyanosis or chest asymmetry.
  • Palpation (examination by touching): Using the fingers and hands, the physician in the clinic can gain insight into peripheral circulation (arms and legs) as well as overall heart muscle performance. Signs of peripheral fluid buildup (edema) can also be noted.

The chest is often palpated to determine the location of the heart and its overall degree of activity.

Additionally, some murmurs often create a loud enough noise to be felt through the chest, and the location of these “thrills” can pinpoint a structural heart abnormality.

  • Auscultation (examination by listening): The final portion of the physical examination involves the use of the stethoscope to listen to various sounds that a heart makes.

During the auscultation process, valve closure and opening sounds are determined. We attempt to determine how many valve closure sounds there are, how loud they are, and where they are best heard.

Heart murmurs are characterized by timing in the heart cycle, loudness, pitch, and location. The entire chest and often the back are inspected with the stethoscope during this process.

In addition, extra sounds such as rubs, gallops and clicks are listened for. These, if present, can lead to a precise bedside diagnosis of a cardiac abnormality.

Finally, the lungs and abdomen are examined both by auscultation and palpation so as to determine position and size of abdominal organs, abnormal lung findings and possible murmurs in the abdomen or back.

During the course of the physical examination process, the pulse rate (heart rate) and respiratory rate are determined often by several observers.

The Albert Einstein study should be taken seriously because of the implications for future behavior issues of children. See, Babies’ snoring linked to later behavior problems .–143398676.html

Our goal as a society should be:

A Healthy Child In A Healthy Family Who Attends A Healthy School In A Healthy Neighborhood. ©

Dr. Wilda says this about that ©

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