1. PEDIATRIC SLEEP APNEAAND ITS CLOSE RELATIVEUPPER AIRWAY RESISTANCE SYNDROMEAllen J Moses, DDSAssistant Professor Rush Universityajmosesdds@sbcglobal.nethttp://www.kidsapnea.com

2. OBSTRUCTIVE SLEEP APNEA IN CHILDREN IS A SERIOUS PROBLEM ADHD ENEURESIS FAILURE TO THRIVE LEARNING DISORDERS COGNITIVE DISORDERS BEHAVIORAL DISORDERS DISRUPTED SLEEP CARDIOVASCULAR PROBLEMS HYPERTENSION HYPOTROPHIC FACES AND JAWS DELAYED DEVELOPMENT OF MOTOR SKILLS EXECUTIVE DYSFUNCTION ARE SOME OF THE COMORBID SYMPTOMS OF KIDS’ OSA

3. CHILDREN WITH OSA GENERATE 2.6 TIMES THE AMOUNT OF HEALTHCARE EXPENSES AS NON-OSA CHILDREN

4. THESE KIDS ARE NOSE BREATHERS, SLEEPING WITH THEIR MOUTHS CLOSED. THEIR TONGUE IS IN THE ROOF OF THE MOUTH FACILITATING NORMAL GROWTH OF THE PALATE, BROAD DENTAL ARCHES STRAIGHT TEETH AND BEAUTIFUL SMILES

5. THESE KIDS ARE SLEEPING WITH THEIR MOUTHS OPEN. NASAL BREATHING IS OBSTRUCTED. THEY ARE MOUTH BREATHERS. THE TONGUE IS IN THE FLOOR OF THE MOUTH . THIS WILL AFFECT THE POSITION OF THEIR DEVELOPING TEETH

6. THE AIRWAY COLLAPSES DURING AN APNEA EPISODE IN SLEEPCHILDREN WHO HAVE OSA HAVE SMALLER AND MORE OBSTRUCTED AIRWAYS THAN NON-OSA CHILDREN

7. THE SAME STRUCTURAL AND FUNCTIONAL PROBLEMS CREATED BY AIRWAY OBSTRUCTIONS DURING SLEEP RESULT IN INTERMITTENT HYPOXIAS AND HYPERCARBOXIAS IN CHILDREN

8. THESE SAME CONDITIONS EXIST DURING THE DAY AND AFFECT GROWTH, POSTURE, OROFACIAL STRUCTURE AND FUNCTION, NEUROLOGICAL AND CARDIOVASCULAR FUNCTION, LEARNING ABILITY AND BEHAVIOR

9. THE GOLD STANDARD FOR DIAGNOSIS OF SLEEP DISORDERED BREATHING IS A POLYSOMNOGRAPHIC STUDY PERFORMED AT A SLEEP LAB

10. 1. UARS IS MORE COMMON IN KIDS THAN OSA 2. FLOW LIMITATION (UARS) CAN BE MEASURED WITH NASAL PRONGS 3. MILD CRANIOFACIAL DEVELOPMENTAL ANOMALY IS OFTEN SEEN IN KIDS WITH UARS 4. EXAMINATION TO ASSESS THE NEED FOR ORTHODONTICS IS THE SUBJECT OF TODAY’S LECTURE

11. TODAY WE ARE DISCUSSING DIAGNOSTIC FACTORS FOUND ON EXAMINATION THAT SUGGEST CONSERVATIVE TREATMENT AND/OR PREVENTION

12. EARLY RECOGNITION AND PREVENTION ARE THE KEY WORDS

13. FAILURE TO TREAT SLEEP DISORDERED BREATHING IN CHILDREN PUTS THEM AT RISK FOR VERY SERIOUS HEALTH PROBLEMS LATER IN LIFE

14. THE EVIDENCE IS INDISPUTABLE THAT EARLY DIAGNOSIS AND TREATMENT OF SLEEP BREATHING DISORDERS IN KIDS IS MANDATED

15. THERE IS STRONG EVIDENCE THAT NO ONE TREATMENT MODALITY GETS 1OO% SUCCESSFUL RESULTSTHIS LECTURE EMPHASIZES MULTIDISCIPLINARY INVOLVEMENT PEDIATRICIAN SLEEP SPECIALIST ALLERGIST SURGEON NEUROLOGIST DENTIST MYOFUNCTIONAL THERAPIST PULMONOLOGIST

16. ADENOTONSILLECTOMY IS THE FIRST LINE TREATMENT FOR KIDS’ OSA CURE RATE 80% DEFINED AS DISAPPEARANCE OF SIGNS AND SYMPTOMS, NORMALIZATION OF RESPIRATORY MEASURES 20% PERSISTANCE OF OSA T&A DOES NOT ADDRESS ACCOMPANYING SYMPTOMS SUCH AS ALLERGIES, DYSFUNCTIONAL REFLEX PATTERNS OF SWALLOWING, MOUTH BREATHING AND OROFACIAL HYPOPLASIA,

18. INFLAMED, ENLARGED, INFECTED TONSILS AND ADENOIDS ARE NOT THE CAUSE OF OSA KIDS WITH OSA AT NIGHT DO NOT OBSTRUCT DURING THE DAY REPEATED STUDIES HAVE NOT BEEN ABLE TO RELATE THE SIZE OF T & A TO INCIDENCE OF OSA ALL KIDS WITH ENLARGED T & A DO NOT HAVE OSA THERE ARE KIDS WITH VERY SMALL T & A WHO HAVE OSA THERE ARE KIDS WITH OSA WHOSE OSA PERSISTS AFTER T & A

19. FAILURE TO THRIVE DYSPHAGIA DUE TO HYPERTROPHIC TONSILS AND ADENOIDS MAY CAUSE OLFACTORY CHANGES INCREASED RESPIRATORY EFFORT LEADS TO INCREASED METABOLIC EXPENDITURE HORMONAL BINDING FACTORS SUCH AS INSULIN GROWTH FACTOR-1 DECREASE APPETITE EARLY DIAGNOSIS AND TREATMENTAVERT SERIOUS MORBID AND IRREVERSIBLE CONSEQUENCES

20. KIDS WITH OSA ARE 3X MORE LIKELY TO HAVE HYPERTENSION THE ELEVATION OF B.P. IN KIDS IS PROPORTIONATE TO THE SEVERITY OF OSA OSA IN KIDS PREDICTS CARDIOVASCULAR RISKS LATER IN LIFE C-REACTIVE PROTEIN INCREASES IN KIDS WITH OSA, IS SENSITIVE MARKER FOR SYSTEMIC INFLAMMATION INFLAMMATION CONTRIBUTES TO ENDOTHELIAL DYSFUNCTION, VASO CONSTRICTION, AND ATHEROSCLEROSIS CARDIOVASCULAR CONSEQUENCES OF OSA

21. BY AGE 4, 60% OF FACIAL GROWTH IS COMPLETEBY AGE 6, 80% OF FACIAL GROWTH IS COMPLETEBY AGE 11, 90% OF FACIAL GROWTH IS COMPLETE(WHEN THE SECOND MOLARS HAVE ERUPTED) ORTHODONTIC TX AFTER AGE 12 VIRTUALLY ASSURES RELAPSE EARLY ORTHODONTICS ADDRESSES BREATHING, SWALLOWING AND POSTURE PROBLEMS AS WELL AS MAKING MORE BEAUTIFUL FACES

22. APNEIC KIDS CANNOT WAIT UNTIL AGE 12 OR OLDER TO BREATHE PROPERLYKIDS ARE HAPPIER, SMARTER AND BETTER BEHAVED WHEN THEY SLEEP WELLORTHODONTICS AT AS EARLY AN AGE AS POSSIBLE TAKES ADVANTAGE OF GROWTH AND REAPS HUGE PSYCHOLOGICAL AND PHYSIOLOGICAL GAINS FOR THE CHILD

24. PALATAL EXPANSION CREATES MORE SPACE IN THE MOUTH FOR THE TONGUE FACILITATES POSITIONING THE TONGUE ANTERIORLY AND IN THE ROOF OF THE MOUTH WIDENS THE NASAL PASSAGE & FACILITATES NASAL BREATHING (ROOF OF THE MOUTH IS THE FLOOR OF THE NOSE) DECREASES NASAL RESISTANCE AND COLLAPSIBILITY OF THE NASAL PASSAGES KIDS WHOSE AIRWAYS DO NOT COLLAPSE AT NIGHT AS A RESULT OF PALATAL EXPANSION ALSO ENJOY IMPROVED BREATHING DURING THE DAY

30. TEETH AND DENTAL ALVEOLI LIE IN A POSITION OF BALANCE BETWEEN CHEEKS LIPS AND TONGUE • IDEALLY THE TONGUE IS IN CONTACT WITH THE ROOF OF THE MOUTH AT REST, DURING SWALLOWING AND NASAL BREATHING • INTERVENTIONS THAT DISRUPT NASAL BREATHING CAUSE OPENING OF LIPS, LOW TONGUE POSITION, HEAD FORWARD POSTURE AND MALOCCLUSIONS

31. BREATHING IS A PRIMAL FUNCTION NECESSARY FOR SURVIVALTHE RESPIRATORY CENTRAL PATHWAY MAINTAINS THE PATENT AIRWAY AND DOMINATES REFLEX CONTROL OF THE OROPHARYNXIT SUPERCEDES ALL OTHER REFLEXES

32. HUMAN BEINGS ARE OBLIGATE NASAL BREATHERS THE MOUTH IS MERELY A BACK-UP BREATHING ORGAN THE NOSE IS IDEAL FOR WARMING, FILTRATION AND HUMIDIFICATION OF INHALED AIR WITH NASAL OBSTRUCTION THE LIPS MUST PART TO ALLOW AIR TO ENTER THE MOUTH THE TONGUE MUST LOWER ITSELF TO ALLOW AIR INTO THE PHARYNX HYOID BONE LOWERS MANDIBLE BECOMES RETROGNATHIC AIRWAY NARROWS HEAD ASSUMES A MORE FORWARD POSITION ON SPINAL COLUMN

33. NOSE BREATHER VS MOUTH BREATHERSNIFF TEST: CLOSE YOUR LIPS TAKE A BREATH THROUGH YOUR NOSE AS DEP AND AS FAST AS YOU CAN MOUTH BREATHER: NARES CONSTRICT NOSE BREATHER: NARES FLARE

34. THE LOW TONGUE POSITION AND MOUTH BREATHING, ONCE LEARNED BECOME THE DOMINANT REFLEXCHILD’S HABITUAL OPEN MOUTH AND DYSPHAGIA ARE DYSFUNCTIONAL STRUCTURAL AND POSTURAL CHANGES OCCUR AS A RESULT

35. THE LOWERED TONGUE POSITIONTHE NARROWING OF THE AIRWAY AND SUBSEQUENT INCREASED COLLAPSIBILITY DURING SLEEP PREDISPOSE TOPEDIATRIC OSA, SNORING AND UARS

36. REFLEXES FROM THE OROPHARYNGEAL AREA PROTECT THE ANTERIOR PORTAL OF THE GASTROINTESTINAL TRACT TRANSPORT OF FOOD AND LIQUIDS AIRWAY FOR GASEOUS EXCHANGE BY THE LUNGS PROTECTION OF LUNGS FROM ASPIRATION OF FOOD AND LIQUIDS

37. THE SWALLOW IS THE MOST COMPLEX REFLEX ACTIVITY THE HUMAN NERVOUS SYSTEM PERFORMS THE TEETH TOUCH IN A POSITION OF MAXIMUM OCCLUSION THE LIPS ARE SEALED AND THE TONGUE PROPULSES THE BOLUS DISTALLY AGAINST THE PALATE THE HEAD IS BRACED ON THE SPINAL COLUMN AND DOES NOT MOVE

38. KIDS HAVE COMPENSATORY REFLEXES IN ADDITION TO MOUTH BREATHING THAT RESPOND TO OBSTRUCTED NASAL BREATHINGTHEY INVOLVE ABNORMAL ADAPTIVE LIP, TONGUE AND HEAD POSTURES THAT ALTER NORMAL FACIAL GROWTH

39. MOUTH BREATHER, LIPS APART AT REST, CHRONIC DRY CHAPPED LIPS

40. STRAINED FACIAL MUSCLES TO ATTAIN LIP CLOSURE. NOTE LOWER LIP PUSHING IN

41. MALOCCLUSION EVIDENT ON SMILE

42. LIPS PUSHED LOWER TEETH IN. TONGUE PUSHED UPPER TEETH OUT

43. NATURAL REST POSITION

44. SWALLOWING – NOTE LIPS

45. ANTERIOR TONGUE THRUST

47. REST POSITION

48. SWALLOWING NOTE STRAINED LIPS

50. THERE IS MORE TO LOOK AT IN KIDS’ BREATHING THAN PSG LIP POSTURE – RELATES TO SPEECH, SWALLOW AND BREATHING SWALLOW – RELATES TO HEAD MOVEMENT AND TOOTH POSITION HEAD POSTURE – RELATES TO SWALLOW AND BREATHING TEETH – REFLECT LIP POSTURE, ORAL/MOUTH BREATHING, SWALLOW TONGUE POSTURE, HEAD MOVEMENT TONGUE POSTURE - RELATES TO BREATHING, FACIAL GROWTH , AND SWALLOWING