In any study exploring the effects of otitis media on attention-
related behavior, it would be important to screen patients for the
presence of a sleep-related breathing disorder (SBD) beforehand. Upper
airway congestion which would predispose a patient to otitis media would
also be a risk factor for SBD, and the links between disordered sleep and
attention problems are well-established. If sleep is being affected, then
the sleep disorder - not the otitis media - would be the more likely cause
of any problems with attention the child is experiencing, and unless this
is controlled for, it would be difficult to say anything about the effects
of OM.
It is important for physicians to take detailed sleep histories in
any child, but it may be especially important and useful when seeing
children with recurrent otitis media. Children with congested upper
airways are at high risk for SBD, and any sleep problems they are
experiencing should not be written off as "behavioral" problems caused by
the parents until a thorough investigation for an underlying SBD has been
performed. From my interpretation of the present guidelines from the
American Academy of Sleep Disorders, this would mean a polysomnogram
should be performed. The guidelines are not easy to interpret, but it
would appear that risk factors for SBD put children in a category of
having a sleep disorder until proven otherwise, and the only way to do
this is by using polysomnography. Clinical information alone is
insufficient to rule out the diagnosis. How often physicians follow these
guidelines is unclear. My personal impression from talking to other
pediatricians, sleep specialists, and reading articles such as this one,
is that rarely, if ever, do children with a history of upper airway
problems get adequately investigated for SBD. Physicians tend to ignore
sleep problem, and if present, treat all of them as behavioral sleep
disorders and advise behavioral interventions. If these interventions
don't work, they simply advise they be tried again, assuming that if they
aren't working, it is the parents fault. How parents can be expected to
succeed with interventions that don't work is never considered, and
polysomnography - the only means available of knowing what we are dealing
with - is rarely considered as an option. This is a horrendous mistake
on the part of physicians caring for children, and one parents are
repeatedly blamed for.
When one considers the consequences of an untreated sleep disorder on
the developing central nervous system, and the high incidence of both
sleep problems and respiratory problems that put children at risk for SBD,
one can only shudder and wonder how many children with so called
"behavioral sleep disorders" are really experiencing symptoms of SBD.
Without polysomnography or some other screening test, we don't know what
these children really have, and if symptoms improve, all we really know is
that the parents are sleeping better because the child isn't waking them.
Is the child sleeping better? No data exists indicating this is true. No
studies using polysomnography have ever been performed on children with a
diagnosis of behavioral sleep disorder, so to date, the very existence of
behavioral sleep disorders and the effects of behavioral interventions on
the quality of a child's sleep is at question. No matter how well-
established the concept is in medical training programs, all we really
know is that children eventually stop bothering their parents.
No matter how expensive or unwieldy polysomnography seems, medico-
legally, we are obligated to use it to investigate any child with signs of
upper airway congestion and sleeping problems. Until some other more
suitable screening test is available, our duty is to make sure we know
what we are treating before we advise a parent to let a child "cry it
out." Certainly, we should do this before we "readvise" a parent to try
"crying it out" again. Before we give parents pep talks about how not to
attend to a crying child at night, especially a child with a history of
recurrent upper airway infections that put them at risk for SBD, we should
know what we are treating.
The authors of this study mention that severity of OM may correlate
positively with attention problems, and perhaps the reason why is that the
more severe the OM, the more likely the child also has SBD. Further
investigations would be helpful before we dismiss the possibility OM is
linked to attention problems. If nothing else, it's presence should serve
as a reminder for physicians to look for SBD.
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