My daughter had a sleep study last summer and the conclusion drawn by the physician was that she had obstructive sleep apnea.  Following that, we had a T&A done, however it does not seem to have helped.  I am wondering if something else is going on and would greatly appreciate an interpretation of the sleep study.  I did not recieve any graphs but I do have the sleep study summary info:

Sleep duration - 458 minutes
Spontaneous arousals - 262
Tachycardia events - 119 for a duration of 28 minutes
Central apneas - 1 post sigh, in REM
Hypopneas - 54, 10 in REM (all obstructive) and 44 in NREM (1 central and 43 obstructive)
Index 7.2

Sleep efficiency - 88%

% time spent in different sleep stages
Stage 1 - 4.8%
Stage 2 - 46.56%
Stage 3 - 21.26%
Stage 4 - 14.61%
REM - 12.76%

Lowest SpO2 91%
Mean 97%

The narrative said her sleep was very fragmented.

My daughter had an earlier sleep study done when she was 4 but it did not reveal any hypopneas.  It did however reveal alot of arousals and fragementation.  We had the sleep study done because she had severe night terrors.  They started when she was about one and lasted nightly until she was about 7 1/2.  (Thank God they are over with now!)

She has always needed about 12 hours sleep at night and still napped at 5 years old.  Interestingly, she never snored and in fact is such a quiet sleeper I often have to put my hand on her back to feel her breathing because I cannot hear nor see her breath.

She does not seem to spend sufficient time in REM and I am wondering if that is contributing to her attention, learning and memory issues.

If the T&A did not solve the problem, where else could the obstruction be occuring.  Could her sleep troubles be caused by something other than an obstruction?

I would appreciate any input.

Hi T.O.:
Well, you've got 5 times as many arousals as you got hypopneas, so you're right, there's something else underfoot.  They could be RERAs, but given the results of the surgery tho, we're pretty close to throwing that idea out the window.

Need to know if she's on medications, any other underlying medical conditions, and if you can get those graphs, they can really be quite helpful.  They show the locations and durations of all the sleep stages and a bunch of other things that can really shed some light.

Any PLMs?

sleepydave

Hi SleepyDave - thanks for your reply.  

To address your questions:
Medication:
She was on ritalin at the time for her attention issues but at a very low dose of 7.5 mg in the morning.  She did not get an afternoon dose.  She was not on any other medication.

Other Health Issues:
She has alot of food allergies (carries an epipen), enurisis, poor digestion (ie. constipation) but other than that is in good health - she is 90th percentile for height and 50th for weight so there is no issue there.  From age 1 to age 7 1/2 she had night terrors - about 2-3 per night, every night.  You could set your watch by them.  The first would occur about 90 minutes after she fell asleep, the next about an hour after, and the next about 20 minutes after.  She would scream and cry, run around the house and remember nothing in the morning.  She did see an endocrinologist when she was about 5 for the bed wetting and she showed high levels of prolactin.  They repeated the blood test several times all with the same result.  They ended up dismissing it as likely being a problem with the assay.

Graphs:
I will try to get the graphs but when I requested the sleep study from the hospital they did not offer up any graphs.  I will ask specifically for them.

PLMs
I am unable to answer your question re:  PLMs as I don't know what they are.

Also, what is an RERA please?  I greatly appreciate the assistance that you are giving me SleepyDave.

Hi TO:

We talked about enuresis a little bit in your other post:

More on Enuresis

So I guess the food sensitivity now moves to the forefront.  Course, constipation is also high up on the list.

These guys usually have good clinical summaries about stuff, and their Enuresis article is pretty good:

Enuresis

But boy, sounds like you have the potential for 2 good causes already.

PLM is a Periodic Limb Movement, a movement of the lower leg that occurs rhythmically, and sometimes very frequently during parts or all of the night, that can create arousals and disturb sleep.  Their presence (or absence) should be listed on the complete report.

RERA is a Respiratory Effort Related Arousal.  Subtle respiratory events can cause arousals, so you can have a bunch of arousals with a respiratory cause without having apneas or hypopneas.  You can use devices during the sleep study to identify these subtle events, like pressure transducers or RIP (which they may have used, you can ask), but if they didn't. then the possibility of the arousals being RERAs remains.

I'd be looking very closely at the Ritalin, regardless of the dose or the time of the day, as the cause of the arousals.  Graphs of sleep architecture may afford a clue.

In February 2004, there was an article in the journal SLEEP pointing out that symptoms of OSA can mimic ADHD.  The article is copyrighted, but this is the group that did the study:

OSA and ADHD in Children

So the point is, there may be a whole bunch of kids out there being treated for "ADHD" who, in fact, had/have OSA.
sleepydave

Hi SleepyDave,

Thanks very much for the articles.

I have actually followed very strict elimination diets with Cassandra (my daughter) several times over the years to try and identify food allergies or intolerances.  We were never able to identify a food as a cause for the night terrors, enurisis or the behaviour.  I have volumes of diet diaries that we kept but no patterns.  Because of her digestion troubles, she has always eaten high fibre, low sugar, no caffeine, no food colouring etc.

Since she was dry for the 10 days following the T&A surgery, I went back to the food angle and kept her off wheat.  In my view, she seems more calm, more rested when she is off wheat, however she does not think so, and wants her wheat back!  I am wondering if perhaps past diet intervention did not help due to the OSA, but now that the OSA has been treated (successfully I hope), diet intervention will make a difference.  

Thanks also for your article re:  ADHD and OSA.  When I recieved the OSA diagnosis last May, I researched everything I could find and removed her off meds (which I felt were not helping her very much anyway).  We were hoping so much that the T&A would help, given the improvement sited in so many papers on OSA and surgery.  As mentioned in my other post, we are three month post op now, but she seems the same (except when off wheat and that is very subjective).  SleepyDave - Is it possible that improvement could still be pending?  Does it sometimes take 5-6 months after surgery for children to experience changes or is it usually within months?  

As for the ADHD meds impacting the arousal indicator in her sleep study, I am thinking not, because her first sleep study at age 4 also showed many arousals, and she was not on any meds at that time.  That sleep study did not reveal any apneas, so now I need to research what can cause arousals - SleepyDave can you shed some more light on that one please?  Her last sleep study showed no PLM's and no respiratory related arousals.  Although I do not have the graphs, I can tell you that the study verbage indicated that her last periods of REM were very fragmented with numerous arousals.  (They woke her at 5:30, and she usually does not wake up until 7:30, so the last periods of REM in the sleep study would be when she was nowhere near ready to wake up.)  Could this be a hormone thing?

As for enurisis, I had been using that as my objective meter for sleep improvement.  I was hoping that once her sleep improved, the enurisis would go away and that would let me know her sleep has improved.  But as you have pointed out, there are many causes of enurisis, and so OSA may not be the only one in her case.

All to say, I will have to rely on the next sleep study at the end of March to see if the OSA is better.  If the study still shows frequent arousals, I guess I will still have a sleep problem to pursue - again any light you can shed on this would be very helpful  ie. causes and treatment available.  I would like to be prepared before the next sleep study so that I can make sure to ask the right questions.
Thank you for all of your input so far.  It is greatly appreciated.

tuckeredout wrote:

she seems more calm, more rested when she is off wheat
improvement could still be pending?
her first sleep study at age 4 also showed many arousals.. not on any meds at that time.  That sleep study did not reveal any apneas
Her last sleep study showed no PLM's and no respiratory related arousals...   her last periods of REM were very fragmented with numerous arousals.
Could this be a hormone thing?
I will have to rely on the next sleep study to see if the OSA is better

OK, in no particular order:
We are taking the report at face value right now, which is probably fine, but subtleties may appear in the graphs, which although highly condensed, still may offer clues.

Wheat, huh?  What's left after you get rid of wheat?  Rice Krispies?  GI disturbance, maybe.  Respiratory involvement?  Seems like you'd see that, exhibited as wheezing, a mile away.  But I guess if you think she seems better, you gotta go with that.

Once you remove the obstruction and the swelling goes down, you should kinda see improvement fairly quickly, we retest at 2-3 months.

If you do the literature search, and in the article from eMedicine, you kinda find stuff like this:

Quote:

The dramatic resolution of NE following surgical treatment of airway obstruction suggests SDB influences a critical pathophysiologic factor. A disorder of sleep arousal is suggested as the most likely factor. Nocturnal polyuria is reported in individuals with OSA and is another possible causative factor. A decrease in nocturnal secretion of ADH and increase in ANP are possible explanations for nocturnal polyuria.

By dramatic, they're talking days.

But I guess you could go to the Weider study:

OSA and Enuresis

So, hey, who knows, maybe.

The difference between 4 and 9, and so many variables, at this point, I don't know what conclusions you can draw.  But you're gonna have a hard time making a sentence with "Ritalin" and not include "arousals" in there somewhere.

Which hormone are you thinking of, like ADH?  I don't think that creates sleep fragmentation like that.

And while there is a high success rate for OSA in kids, it's not 100%, it might be more like 80%.

Yeah, the sleep study, it all boils down to that.  Cause facts will be facts.
sleepydave

Hi SleepyDave,

A lot of variables is an understatement.  Thanks for the Weider study.  I guess there is still a remote possibility of T&A success ... very remote at this point.

As for wheat, no, there is not alot left ... fortunately she enjoys rice krispies.  I'm going to be very vigilent about it for the next few weeks (cause she cheats at school - eats her pals crackers and cheerios) to either confirm it as a factor or rule it out.

I hear you re:  ritalin and arousals.  She has been off it since last June (was only on it for 8 months total) so the sleep study we do in March should not be influenced by medication in any way.  (I am so hoping her issues are sleep related - and curable/treatable, and not ADHD afterall - you probably have gathered that.)

But as you said, facts is facts, so I'll be patient and wait for the study.  I'll deal with the outcome when I know it.  Thanks again for your comments and references to papers.  I truly appreciate your input.

Hello! I have been reading your posts about Cassandra, I am in Neurophysiology and wanted to know out of interest if she has had an EEG done or if she has been monitored in Video Telemetry in order to observe her full brain activity during sleep.