Tonsillectomy or Adenoidectomy May Resolve Sleep Disorders in Children

January 10, 2003

Sid Kirchheimer

Jan. 10, 2003 — Frequent episodes of sleepwalking and sleep terrors may result from allergies, swollen tonsils, and other factors that interfere with nighttime breathing, and may be cured with surgery to remove the tonsils and adenoids, according to Stanford University researchers in a breakthrough study.

Sleep disturbances are often attributed to stress or anxiety, although it's not clear what triggers these problems, how to treat them, or why they can persist for months or years.

In a study published in the January issue of Pediatrics, the researchers found that nearly all of the 84 children with recurring sleepwalking and/or sleep terrors suffered problems that affected sleep such as habitual snoring, a history of upper respiratory infection or earaches, or mouth breathing. Meanwhile, virtually none of 36 control children without parasomnias experienced such sleep problems.

Of the 84 children with parasomnias, 51 (61%) had an additional sleep disorder: 49 had sleep-disordered breathing, two had restless leg syndrome. Twenty-nine of the 49 children with parasomnias had a family history of sleep disorder.

Of the 51 children with sleep disorders, 45 were treated: 43 children with sleep-disordered breathing received tonsillectomy, adenoidectomy, and or turbinate revision. The two children with restless leg syndrome received pramipexole.

"They were all cured of their sleep disturbances," said Christian Guilleminault, MD, BiolD, director of clinical research at the Stanford University Sleep Disorders Clinic.

Polysomnography in all 43 children receiving surgery revealed an absence of sleep-disordered breathing, and recordings showed an absence of confusional arousals. EEG arousals or 3 seconds per hour or more decreased from a mean of 9 seconds to 3 second. Parents also reported a subsequent absence of the parasomnia.

The two children treated with pramipexole had a complete absence of confusional arousals on follow-up and reported no parasomnia since treatment. The periodic limb movement syndrome arousal index decreased from 11 and 16 to 0 and 0.2 in the children.

The parasomnias persisted in six children who did not receive surgery. They were refused the operation because of surgeons who cited a lack of data on the relationship between parasomnias/sleep-disordered breathing and tonsil or adenoid enlargement.

"Now, it's a matter of convincing the pediatricians and surgeons that persistent sleepwalking and sleep terrors may be related to breathing problems and not just anxiety," said Dr. Guilleminault.

While it's well-documented how breathing difficulties can affect adult sleep patterns and quality, this study marks some of the first research on the impact they may have on children.

"To bring this into the pediatric arena, where there is less awareness of some of these relationships, is really important," says Carl E. Hunt, MD, a pediatrician and the director of the National Center on Sleep Disorders Research, part of the National Institutes of Health. "It's also a call for parents to know that it's not normal for children to snore loudly and frequently. If your child is developing or already having recurring problems with sleepwalking or night terrors and he or she frequently snores, it certainly increases the need to be evaluated."

Dr. Guilleminault told Medscape that he first noticed a relationship between breathing problems and the baffling sleep disturbances in 1996, while conducting another study. "We did a very large survey on sleep disturbances and we noticed that frequent, recurrent sleepwalking and sleep terrors were much more common in those with abnormal breathing," he says. "But when we published the paper in Pediatrics, we didn't emphasize that finding enough. It was nagging at us, so we wanted to test it."

The new finding could not only bring answers to medical experts, but relief to parents. Sleep terrors can be particularly frightening, since these episodes often include screaming and crying, yet children are unresponsive to efforts to comfort them. Unlike nightmares, terrors are usually not remembered. Both sleep terrors and sleepwalking occur in the deepest stage or slow-wave sleep — usually within three hours after falling asleep; nightmares typically happen closer to rising.

"It certainly makes sense," said J. Catesby Ware, PhD, director of the Sleep Disorders Center at Eastern Virginia Medical School. "The thing that we do know about sleep terrors in children is that there must be something to produce a partial arousal from sleep. If someone placed a pillow on your face while you were sleeping, you would wake up because a cessation of breathing — even partial — produces an arousal."

These "arousals" prevent children from transitioning from slow wave sleep to a lighter sleep stage. External factors like noise and light also cause arousals, along with physiologic conditions such as being "overtired" from lack of sleep and anxiety. "Normally, when we sleep, there's a very sharp distinction between awake and the different stages of sleep. With some of these disorders, the boundaries between those states are blurred," explained Dr. Hunt. "That is why with these conditions there are some behaviors that are typically awake-related occurring during sleep."

Dr. Guilleminault isn't suggesting that surgery be done to prevent these sleep disturbances in all children. "When they occur once in great while, or even in occasional bursts and then they disappear, that is perfectly normal and probably not because of breathing difficulties," he said. "The children in our study had persistent sleepwalking and terrors — occurring once or several times a week, every few weeks or so." These children should be evaluated for breathing disturbances and other sleep disorders.

Pediatrics. 2003;111(1):e17-e25

Reviewed by Gary D. Vogin, MD

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