一瞬間己是三十五年的友情歲月
2018年10月22日星期一
2018年10月14日星期日
睡眠醫學二十九之兒童睡眠窒息症
今晚出席了振華小姨Vivian囝囝的百日宴，Vivian除了多謝我出席宴會外，因為她在懷孕期間患上了睡眠窒息症，而睡眠窒息症有可能會遺傳，因此她順道與我傾談了許多關於兒童睡眠窒息症的問題。
大概有一成兩歳至八歲的小朋友會習慣打鼻鼾，而兒童睡眠窒息症的發病率(Prevalence)約是2至5%(1,2)。不同民族有不同的發病率，亞洲的小朋友亦類似亞洲成人-有較高的發病率。其實睡眠窒息症最早可以在嬰兒時代就發病，尤以早產嬰為甚，大多數病人是在兩歳至十歲期間發病。睡眠窒息症的男女小朋友發病比例是1:1，但進入青春期後，男性患者的比例明顯增加。
肥胖，扁桃線(Tonsil)及腺樣(adenoid)肥大是兒童睡眠窒息症的主因(3)，但各種面部、口腔及喉部的異常結構同樣可以引發兒童睡眠窒息症的。甲狀腺功能減退症(hypothyroidism)及唐氏綜合症(Down syndrome)會令病人脷的體積過大，造成上呼吸道不暢通。其他與兒童睡眠窒息症的疾病多不勝數:chronic nasal obstruction, neuromuscular diseases; certain storage
diseases; marfarn syndrome; achondroplasia; chiari malformation, cerebral
palsy, laryngomalacia…。
兒童睡眠窒息症的病徵除了典型的日間嗜睡外、還有發噩夢、夜間遺尿、行為問題，甚至過度活躍等。若延醫可引致小朋友成長不良(failure to thrive)(4)、高血壓(5)、肺源性心臟病(cor pumonale)、胸腔發展異常(pectus excavatum)。更嚴重的可能影響兒童腦部發育及其功能(dysfunction in the prefrontal areas of the brain. Executive
dysfunction interferes with cognitive abilities and learning)(6)。雖然診斷兒童睡眠窒息症的黃金標準同是睡眠測試(polysomnography)，但箇中定議及細節卻與成人的完全不同!
處理方案大致有三大類:
第一
動手術(Adenotonsillectomy)切除肥大的扁桃線(Tonsil)及腺樣(adenoid)(7,8)，適用於扁桃線及腺樣過大、有病徵強烈及Apnoea and Hypopnea Index[AHI> 1] 的病人，但手術後睡眠窒息症可以殘存(9)或覆發的。
第二
若病人不宜或不願動手術，可選擇使用連續正氣壓機(continuous positive airway
pressure, CPAP)。手術後睡眠窒息症殘存(Residual OSA)者亦可使用CPAP治療其睡眠窒息症(10-13)。
第三
輕度睡眠窒息症病人可選擇觀望態度，但六個月內必須再小心評估病情(14)。
所有兒童睡眠窒息症的病人都應遠離過敏源(environmental allergen)及剌激源(irritant)，過肥兒童患者應減肥(15,16)，個別病人夜間亦有可能需要使用氧氣(17,18)，最後不能不提城中熱話- Myofunctional therapy (a form of
physical therapy consisting of exercise designed to strengthen the tongue and
orofacial muscles, with a goal of repositioning muscles to the appropriate
position)(19-21)。經治療後，多數小朋友都能回復正常成長，他們的腦功能及行為都會有所改善(22-24)。美國醫學界對兒童睡眠窒息症有非常詳盡的指引(25)。
最後我忍不住安慰Vivian，現在就擔心囝囝將來會否出現睡眠窒息症，實在過慮了，不如擔心能否入讀心儀的幼稚園更實際吧，明天就去排定隊!
參考文獻
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