Sleep Hygiene Linked to Post-op Behavior Problems in Peds

by Michael Vlessides

Chicago—Children who experience sleep-disordered breathing are significantly more likely to exhibit maladaptive behaviors following surgery than those without the respiratory problem, a new study has found.

The investigators, from the University of Michigan, in Ann Arbor, said they were intrigued by the fact that postoperative behavioral problems—like fussiness, disobedience and introversion—also seem to be mitigated by daytime sleepiness.

“All of us have taken care of obstructive sleep apnea patients at one time or another,” said Robert E. Christensen, MD, clinical lecturer in anesthesiology at the institution. “Sleep-disordered breathing represents the full spectrum of disorders, not just those patients who qualify for the full diagnosis of obstructive sleep apnea. We were interested in those patients, specifically in their postoperative behavior and the impact of anesthesia there.”

Although children with sleep-disordered breathing are known to be at increased risk for airway complications after surgery, information regarding postoperative behaviors in this population of patients is scarce.

Dr. Christensen and his colleagues enrolled 337 children, aged 2 to 14 years, scheduled for elective surgery in their study. Before the procedures, parents of the subjects completed the Sleep-Related Breathing Disorders subscale (SRBD) of the Pediatric Sleep Questionnaire. Children with scores of 0.33 or higher on the SRBD were considered to have sleeping trouble, including sleep-disordered breathing, snoring and daytime sleepiness.

One week after surgery, the Michigan researchers readministered the SRBD scale to parents, who also completed a questionnaire about their child’s behavior after discharge. A behavior was considered maladaptive if parents rated it as “more/much more” than normal.

The investigators, who reported their results at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 049), found that 26.7% of children had sleep-disordered breathing. Those who did were significantly more likely to exhibit maladaptive behaviors following surgery than children with healthier sleep hygiene.

Several other factors were significantly associated with maladaptive behaviors, including being overweight or obese, having had an adenotonsillectomy, preoperative and postoperative snoring and daytime sleepiness before and after surgery (P<0.01). Adenotonsillectomy (odds ratio [OR] 9.89; P<0.01) and postoperative daytime sleepiness (OR 2.8; P<0.01) also were independent risk factors for maladaptive behaviors.

“Where it got really fun was when we started breaking down the elements of sleep-disordered breathing subscales,” Dr. Christensen noted. “And when we looked at the entire group—those with and without sleep-disordered breathing—those with daytime sleepiness had more behavioral problems.”

This finding suggests that sleep hygiene, and the underlying sleepiness, might be leading to the increased behavioral problems, not simply the sleep-disordered breathing itself, Dr. Christensen said. If the link holds up in future studies, clinicians could alert parents to the importance of good sleep hygiene before and after surgery.

Mehernoor Watcha, MD, associate professor of pediatric anesthesiology at Baylor College of Medicine in Houston, congratulated the researchers for following their patients beyond the recovery room.

“Most of us think ‘Hey, I got them out of the PACU [postanesthesia care unit], my job’s done,’” Dr. Watcha said. But the new data show that “patients who have what is considered a normal recovery still continue to have behavioral problems for some time at home, and this is a problem as far as the parent is concerned.

“I wonder if any particular type of anesthetic intervention is going to change this,” Dr. Watcha added. “Either way, I think it’s very important to continue this type of work.”

Clinical Anesthesiology

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