The child with obstructive sleep apnea may be admitted to the hospital for a T&A (tonsillectomy
                     and adenoidectomy). One may think that this procedure is a rather minor one, but in this type of
                     child, the initial recovery may actually involve additional airway obstruction. Sleep apnea patients
                     who undergo T&A's sometimes are kept intubated for a day or more, and steroids such as
                     Decadron are used to reduce airway swelling. In many cases, because these children often are
                     active toddlers, they are placed in mist tents even though they are intubated. Nothing is placed on
                     the endotracheal tube adapter so that movement of the tube and tension on it is minimized. I told
                     you that we do this with patients who have croup and epiglottitis. We also occasionally do it with
                     the T&A patients as well for the same reasons. Many of these patients are taken to the operating
                     room to be extubated. In the OR, the ear, nose, and throat (ENT) specialists have better access
                     to instruments such as the fiber optic laryngoscope and other items that might facilitate a difficult
                     emergency reintubation. Our people have learned from experience that the worst airway
                     emergencies can occur with these patients.

                     In some cases, surgical intervention is not a solution to OSA in a child. As in the adult, the use of
                     nasal CPAP and BiPAP may greatly reduce airway obstruction and apneic periods during sleep.
                     It is not too often that nasal BiPAP/CPAP is used in the infant under one year of age, but we are
                     moving in this direction.

                     Sudden Infant Death Syndrome (SIDS) is of course the most tragic of apnea syndromes. It is not
                     my intention in mentioning it here to say that it has anything to do with chronic obstructive sleep
                     apnea. It doesn't really. SIDS reportedly occurs most often in children less than one year of age
                     and commonly occurs during the time that the child is thought to be asleep. Also called "crib
                     death," more than 5,000 infants fall victim to the syndrome in the United States every year. The
                     definition of SIDS is the unexpected death of an infant for which sufficient cause cannot be found
                     by a death scene investigation, review of the history, and a post-mortem examination. SIDS is
                     diagnosed by exclusion - when there is no other explanation for the death. It is probable that the
                     syndrome has several causes. SIDS is sometimes called a development disorder, although many
                     of us have the impression that it affects the youngest of infants.

                     SIDS is sometimes called a development disorder. Actually, infants in the first month of life are
                     rarely affected by it: the incidence of SIDS peaks at 1 to 4 months. Its incidence then drops off
                     until about six months of age. Ninety per cent of deaths are in infants less than six months of age.
                     And after the first birthday it is very rare.

                     There are quite a few risk factors for SIDS. They are as follows:

                     Male sex// Bottle-feeding// African-American race// Prematurity// Teenaged mother// Low birth
                     weight// Exposure to opiates and cocaine in utero// Prone position// Anemia during pregnancy//
                     Winter season// Late or no prenatal care// Passive smoking// Maternal smoking during pregnancy

                     But take a look at these risk factors. Some seem pretty innocuous. Many children have some of
                     these risk factors and never have a problem. Obviously many of these risk factors cannot be
                     eliminated, but there are some in which intervention is possible. For example, bottle-feeding can
                     be eliminated in some cases. And because infections have been implicated, it is thought that the
                     higher immunity that a baby receives through breast-feeding can reduce the risk of SIDS Because
                     maternal smoking and passive smoking are very high risk factors, mothers are warned of these
                     risks routinely. There have been a number of studies in Europe and Australia pointing to an
                     increased risk of SIDS when infants are put to bed in the prone position. Apparently it is thought
                     that there is a sub-group of infants who burrow their faces into the bed clothing and die either
                     because of suffocation or rebreathing. Sleeping in the prone position has not been tested
                     scientifically, so there is no direct evidence that it contributes to SIDS. There are only
                     epidemiological studies, and they are not consistent. In fact, all of the risk factors above are
                     based on epidemiological studies. None of them have been linked with any certain mechanism for
                     causing SIDS.

                     SIDS, like some apnea of prematurity, could be precipitated by a disorder at the level of the
                     brain stem. This seems logical since heart rate also is controlled here. It is postulated that apnea
                     and bradycardia both give rise to sudden death if severe enough. At autopsy, many SIDS victims
                     show gliosis (scarring) of the brain stem. Much of this gliosis has been found within the nuclei of
                     cells that control respiratory and cardiac function.

                     Why would be discussing SIDS since it usually occurs at home and results in death? One reason
                     is that sometimes there is an apparent life-threatening event (ALTE) that usually is characterized
                     by some combination of apnea, color change, marked change in muscle tone, choking or gagging.
                     The result of an ALTE could be a post-asphyxia infant who requires airway management and
                     assisted ventilation. In other cases, the infant may have survived the ALTE with no complications
                     but may be admitted for observation and work-up. Sleep studies sometimes are performed on
                     such infants, and complete examination of the airway is recommended.

                     Infants who are considered high risk for any apnea syndrome because of their history often are
                     monitored at home with a combination impedance/EKG monitor. These usually require only three
                     small chest electrodes and are simple for a parent to use. They usually have memory software in
                     them so that the child's sleeping periods can be reviewed to see if there were any suspicious
                     events.

                     Teaching CPR to parents in high risk groups is a very high priority. While there is evidence that
                     parents forget CPR techniques in a matter of weeks, this can be remedied by a follow up training
                     session two to four weeks after the patient is discharged to home.