The Sleepy Child Conundrum: What to consider when SDB is ruled out

Stating that this is the common practice at her clinic, Stacey Ishman, MD, assistant professor of Otolaryngology-Hed and NEck Surgery within the Division of Pediatric Otolaryngology at Johns Hopkins University in Baltimore, emphasized that the importance of recognizing manifestations of narcolepsy and doing the follow-up MSLT is highlighted by the fact that this disorder remains largely under-recognized among otolaryngologists.

“Part of the problem with diagnosing narcolepsy is that we are not attuned to it,” said Dr. Ishman, adding that it is not uncommon for people to go without a proper diagnosis for a couple of years, because it is a disorder that tends to become more apparent in older adolescents and adults. Yet she has diagnosed and treated kids as young as 10 or 11 with narcolepsy.

Narcolepsy is suggested as the diagnosis on the MSLT by objective measures that show short sleep latency and sleep fragmentation, as well as the presence of rapid eye movement (REM) sleep at the onset of sleep, which, according to Dr. Ishman, is the defining feature seen on the MSLT.

Further evaluation may also be necessary for children with suspected restless leg syndrome. Although restless leg syndrome is predominately diagnosed by clinical symptoms, a sleep study may be helpful when there is doubt, according to Dr. Marcus. “This is especially true in young children in whom it is hard to get a good history,” she said, adding that a sleep study can help differentiate between normal restless sleeping movements and the periodic limb movements that are usually associated with restless leg syndrome.

Dr. Ishman also suggested getting an iron profile on children with suspected restless leg syndrome; this treatment may control symptoms in children whose serum iron, transferrin, and ferritin levels are on the low end of normal or below the normal range. “It has been shown that people with low iron levels can be treated with iron, and their restless leg symptoms will go away or be controlled,” she said.

Dr. Gozal urged otolaryngologists to take symptoms of sleepiness very seriously and not rule out persistent sleep problems, even in children surgically treated for sleep apnea. “If there are ongoing symptoms, it should not be assumed that just because surgery was performed it was effective,” he said, adding that surgery can take away the snoring but not the disease. ENTtoday

Mary Beth Nierengarten is a medical writer based in St. Paul, Minn.