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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 1  |  Page : 6-10

The effect of sleep disordered breathing on children’s behavior


1 King Faisal University, College of Medicine, Al-Ahsa, Saudi Arabia
2 King Faisal University College of Medicine, Al-Ahsa, Saudi Arabia

Date of Web Publication7-Jan-2020

Correspondence Address:
Alaa Ali Al Ghanim
PO. Box 36342, Al Ahsa 31982
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.275312

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  Abstract 


Objective: To evaluate the effect of adenoton-sillectomy, adenoidectomy, or tonsillectomy on improvement of attention deficit, hyperactivity, conduct, and oppositional defiant disorders in patients with sleep disordered breathing (SDB) secondary to adenotonsillar hypertrophy.
Methods: This was a prospective observational study. It was conducted in Al-Ahsa City in Saudi Arabia, from 10 June 2015 until 25 December 2015. A total of 28 children from a tertiary hospital underwent adenotonsillectomy, adenoidectomy, or tonsillectomy for treatment of SDB. The Turgay DSM-IV-Based Child and Adolescent Disruptive Behavioral Disorders Screening and Rating scale was distributed to parents before the surgery and 3 months after the surgery. Data were analyzed with SPSS Mac’s software version 20.0.
Results: Of the 28 children, 17 (60.7%) were boys and 11 (39.3%) were girls. The age range was from 3 to 11 years; the mean age ±standard deviation was 6.1±1.97. A statistical significant difference (P<0.05) was found when the mean scores of the T-DSM-IV-S for oppositional-defiant, inattention, and hyperactivity disorders were compared before surgery and three months after surgery, while there was no statistical significant difference in the mean scores of conduct disorder (P=0.805).
Conclusion: SDB is shown to be associated with many psychiatric symptoms and illnesses. The presence of SDB may even worsen the already present psychiatric illness. Treatment of pediatric patients with SDB secondary to adenoid and/or tonsillar hypertrophy will improve the severity of these psychiatric symptoms. It will also improve learning, behavior and overall quality of life.

Keywords: SDB, adenotonsillar hypertrophy, adenotonsillectomy, attention-deficit hyperactivity, conduct disorder


How to cite this article:
Aljabr IK, Al Ghanim AA, Buhaimed BM. The effect of sleep disordered breathing on children’s behavior. Saudi J Otorhinolaryngol Head Neck Surg 2017;19:6-10

How to cite this URL:
Aljabr IK, Al Ghanim AA, Buhaimed BM. The effect of sleep disordered breathing on children’s behavior. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2023 Jan 30];19:6-10. Available from: https://www.sjohns.org/text.asp?2017/19/1/6/275312




  Introduction Top


Sleep-disordered breathing (SDB) in children represents a spectrum of sleep disorders, which ranges in severity from snoring to upper airway resistance to obstructive sleep apnea syndrome (OSAS) [1]. Pediatric SDB may be the result of various factors, but the most frequent etiology is adenotonsillar hypertrophy [2].Childhood OSAS is characterized by a combination of prolonged partial upper airway obstruction (obstructive hypopnea) and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns. The prevalence of OSAS in children is estimated to be approximately 2% and it occurs equally among boys and girls [3].Adenotonsillar hypertrophy has a major role in the pathogenesis of childhood OSAS. The abnormal growth of adenoid and tonsillar tissues can lead to narrowing of the upper respiratory tract which can lead to snoring, mouth breathing, frequent arousals during sleep, and sleep apnea in untreated advanced cases [2]. The size of the tonsils and adenoids increases during childhood; thus, all children have some degree of adenotonsillar hypertrophy. The tonsils and adenoids are made of lymphoid tissues, which increase in volume from birth to approximately 12 years of age. Simultaneously there is gradual growth in the size of the skeletal boundaries of the upper airway. Thus, between 3 and 6 years of age, the tonsils and adenoids are largest in relation to the underlying upper airway size, resulting in a relatively narrow upper airway. Other causes of OSAS in children include obesity, craniofacial and neuromuscular disease [4]. Untreated OSAS in children can lead to many serious complications such as maxillo-mandibular anomalies, failure to thrive, nocturnal enuresis, corpulmonale, and/or systemic hypertension [5]. Patients with SDB do not sleep efficiently enough to rest; therefore, they may experience neurocognitive disorders, behavioral disturbances and a decline in quality of life scores [2]. These changes are due to reduction in oxygen supply to the most sensitive organ, which is the brain. Even though it constitutes only 2% of the whole body, it utilizes 20% of the total metabolic oxygen [6]. The precise mechanism(s) responsible for neurocognitive impairment in SDB is unknown but several factors may be involved, such as intermittent hypoxia, repeated arousal, and alveolar hypoventilation resulting in hypercapnia [7]. These factors together lead to damage to cells in the prefrontal region of the brain, since any cortical dysfunction in this region results in behavioral and cognitive disturbances [8]. Researches have shown that both externalizing symptoms, such as impulsivity, hyperactivity, aggression, oppositional behavior, conduct problems and somatization, frequently occur in children with SBD, in addition to internalizing symptoms, such as anxiety, depression and social withdrawal [2]. From the 1950s until the 1980s, the primary and the most frequent indication for adenotonsillectomy and adenoidectomy were recurrent infections. Since the introduction of antibiotics, SDB became a more common indication for adenotonsillectomy and adenoidectomy [2]. Recently conducted studies have reported that attention deficit hyperactivity disorder frequently accompanied adenotonsillar hypertrophy in children. In the postoperative period, positive changes in their attention and behavioral problems were observed [9],[10]. The aim of this study was to evaluate the effect of adenotonsillectomy, adenoidectomy, or tonsillectomy on improvement of attention deficit, hyperactivity, conduct, and oppositional defiant disorders in patient with SDB secondary to adenotonsillar hypertrophy.


  Materials and Methods Top


This was a prospective observational study. It was conducted in Al-Ahsa city in Saudi Arabia, from 10 June 2015 until 25 December 2015. Ethical approval for the research was received from the institutional review board of College of Medicine at King Faisal University. A total of 28 pediatric patients between the ages of 3 and 11 years from a tertiary hospital were enrolled in this study. Physical examinations were done for all patients by an ENT physician and showed one of the following: adenoid hypertrophy, tonsillar hypertrophy or adenotonsillar hypertrophy. The inclusion criteria for this study were: patients who underwent adenotonsillectomy, adenoidectomy, or tonsillectomy for one or more of the following: sleep disturbance, snoring, and mouth breathing as shown in [Figure 1]. The method of surgery for adenoid hypertrophy was removal by curettage and in tonsillar hypertrophy the method was removal by cold dissection technique. The exclusion criteria from this study were: patients with psychiatric disorders, mental retardation, neuromuscular disorders, craniofacial anomalies, and patients who were on medications for any chronic disease. Also, patients treated with adenotonsillectomy with indication of recurrent infections without airway obstruction were excluded as well. We used the Turgay DSM-IV-Based Child and Adolescent Disruptive Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S). It was translated into Arabic and distributed to parents before surgery and 3 months after the surgery. A verbal consent was obtained from the parents after explaining the objectives and benefits of the study. The parents were asked to observe any behavioral changes in their children after surgery. T-DSM-IV-S is based on the DSM-IV diagnostic criteria and assesses four disorders: hyperactivity-impulsivity (9 items), inattention (9 items), opposition/defiance (8 items), and conduct disorder (15 items). The responses to each disorder were based on a four-point Likert-type scale (i.e., 0= never, 1= little bit, 2=often, and 3=very much). Data were analyzed with SPSS Mac’s software version 20.0. Frequencies and percentages were obtained for gender, patient’s complaints, and surgical procedures. Means and standard deviations were calculated. A paired Samples t-test was used to evaluate the mean scores before and after surgery. P<0.05 was considered statistically significant.
Figure 1: Indications for surgery (%)

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  Results Top


A total of 28 children were involved in this study. The age range was from 3 to 11 years of age, the mean age ±standard deviation was 6.1±1.97. Of these, 17 (60.7%) were boys and 11 (39.3%) were girls. Before surgery, patients complained of snoring (n=19, 67.9%), recurrent sore throat (n=17, or 60.7%), mouth breathing (n=15, or 53.6%), cessation of breathing (n=7, or 25%), and\or halitosis (n=1, or 3.6%). 19 patients (67.9%) underwent adenotonsillectomy, 5 patients (17.9%) tonsillectomy, and 4 patients (14.3%) adenoidectomy as shown in [Figure 2].
Figure 2: Surgical Procedures (%).

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As shown in [Table 1], a statistical significant difference (P< 0.05) was found when the mean scores of the T-DSM-IV-S for oppositional-defiant, inattention, and hyperactivity disorders were compared before surgery and three months after surgery. There was no statistical significant difference in the mean scores of conduct disorder (P=0.805).
Table 1: Mean ±SD scores of the T-DSM-IV-S for oppositional defiant, hyperactivity, inattention, and conduct disorders before surgery and three months after surgery:

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  Discussion Top


The aim of our study was to review the available lAdenotonsillar hypertrophy is the most common cause of SDB among children, which can be cured by doing an adenoidectomy and/or tonsillectomy. It is effective in resolving SDB in over 85% of children [1]. Untreated SDB in children is associated with various disorders such as attention deficit/hyperactivity disorder, poor academic achievement, and behavioral changes. Also, it can lead to more serious morbidities, such as growth failure, corpulmonale, and systemic hypertension [11]. In the past few years many reports also indicated an association between SDB and some psychiatric disorders. The exact mechanism of such relationship is not known yet although it is reported in many studies [12],[13],[14],[15],[16],[17],[18]. In this study, we compared the mean scores of T-DSM-IV-S pre-operatively and 3 months postoperatively. The T-DSM-IV-S is assessing the diagnostic criteria of 4 psychiatric disorders, which are hyperactivity-impulsivity, inattention, opposition/ defiance, and conduct disorder. We found a statistically significant reduction in the mean scores of the diagnostic criteria in 3 out of 4 disorders [Table 1]. These findings stress the importance of early diagnosis and treatment of SDB in pediatric patients who are otherwise healthy and also in patients who are diagnosed to have psychiatric illness. Children with ADHD, for example, may suffer from fragmented sleep, motor restlessness, confusional arousals, snoring and leg discomfort at night [19]. These manifestations worsen in the presence of SDB. On the other hand, it was shown that children with adenotonsillar hypertrophy who only complain of snoring may suffer from behavioral changes [8]. It was reported that adenotonsillectomy, by resolving the airway obstruction and consequently improving oxygenation, decreases the severity of psychiatric symptoms in children and improves behavior [20][Figure 3].
Figure 3: The mean scores before surgery and 3 months after surgery.

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Adenotonsillar hypertrophy should be looked for in any child with snoring, mouth breathing, hyponasal voice, chronic nasal discharge, dysphagia, halitosis and apnea. According to the American Academy of Pediatrics, polysomnography should be done to all children before performing adenotonsillectomy for the indication of SDB. But in real practice, most cases in North America are being done without a prior polysomnography [21]. We suggest a lower threshold for doing adenoidectomy and/or tonsillectomy in pediatric patients who are known to have the aforementioned psychiatric disorders and having the symptoms and signs of SDB after confirmation by clinical examination.

The limitations of this study were small sample size, short follow up period, and no direct psychiatric observation.

In conclusion, SDB is shown to be associated with many psychiatric symptoms and illnesses. The presence of SDB may even worsen the already present psychiatric illness. Treatment of pediatric patients with SDB secondary to adenoid and/or tonsillar hypertrophy will improve the severity of these psychiatric symptoms. It will also improve learning, behavior and overall quality of life. Adenoidectomy and/or tonsillectomy is not suggested as an alternative treatment for psychiatric diseases, but as shown previously, it will ameliorate the clinical features of some psychiatric diseases.



 
  References Top

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  [Figure 1], [Figure 2], [Figure 3]
 
 
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