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"The recognition of red flags in our pedi- atric populations is a vital first step that requires educating parents and caregivers as well as astute screening by frontline primary care providers." One example of a sleep-apnea red flag in children is snoring, which Dr. Krishna says should not be glossed over. Snoring in children merits a focused set of ques- tions to a ssess n ig ht ti me sleep a nd breathing problems as well as daytime inattentive behaviors, moodiness, fatigue and sleepiness. In fact, poor sleep can exacerbate behavioral disorders. Some studies indicate that up to 25 percent of children diagnosed with attention-deficit hyperactivity disorder may a lso have symptoms of obstructive sleep apnea, which may further contribute to learning and behavioral di¨culties. Other nighttime red f lags, such as insom nia , rest less sleep, w itnessed pauses in breathing, bedwetting, sleep- walking or sleep terrors also warrant a sleep screening. Failure to thrive, obesity and other metabolic problems may also be associated with sleep disorders. T hat 's why, i n Sept ember of la s t y e a r, A k r o n C h i l d r e n 's u n v e i l e d it s mo der n , s t a t e - of-t he -a r t s le ep lab desig ned to tack le t his ongoing health threat. Focusing exclusively on pediatric patients, the renovated, AASM- accredited sleep lab o€ers larger, cozier rooms, a n upgraded TV system with educational on-demand content, accom- modations for caregivers or parents and more. High-definition video cameras and transcutaneous carbon dioxide monitors give the sleep technicians and physicians greater levels of information while safely monitoring patients' sleep. Mobile units can reach inpatients as well. The nearly 3,000 square-foot suite o€ers private bathrooms and showers allowing children and family members to shower and go directly to work or school the morning after their sleep test. " We run a busy clinica l service too, with the help of a sleep psychologist to assist the three board-certified sleep physicians on sta€. Our physicians have training in general pediatrics, pulmonol- ogy and neurology as well. In short, we are a full-service pediatric sleep center." Thus, aside from a sleep test, patients may be directly referred to the clinic where they undergo thorough evalua- tion including a detailed sleep-focused h istor y a nd physica l exa m i nat ion . Decisions for sleep disorders treat- ment, for example, ta ke into account body mass index, bony and soft tissue anatomy of the head and neck, such as large tonsils, and co-morbid medica l conditions, parental choice and family circumstance. "Educating parents is part of what we do," says Dr. Krishna. T he sleep specia l ist s work closely with experts in other areas such as ENT, endocrinology, developmental pediatrics, and plastic surgery to optimize manage- ment of a wide spectrum of cases. These could include children with insomnia, hypersomnia, circadian rhythm disorders, sleep-related movement and breathing disorders, and parasomnias. The results of timely intervention can have a marked impact in everyday life for children and their families. ANSWERS TO COMPLEX EXERCISE QUESTIONS For children who become easily winded or su€er from di¨culty breathing during or after exercise, the center's team relies on its Clinical Exercise Physiolog y lab to find answers. The lab, which is part of the pulmona r y function lab, helps children a nd their fa milies discover what may be a€ecting a child's breathing during exercise and how to overcome various conditions that result in exer- cise intolerance. Phy sicia n s u se ca rd iopu l mona r y exercise testing (CPET), a non-invasive method that assesses the performance of the heart and lungs during exercise and at rest, to determine the cause of exercise intolerance and exercise-induced dyspnea (EID). The test helps physicians di€erenti- ate causes for the shortness of breath. For instance, is a patient asthmatic? Is there another condition at play on top of the asthma, or some other physiological or psychological limitation? These are the kinds of questions that CPETs help physicians answer, providing valuable insights on appropriate treatments and management methods. Rajeev Bhatia, MD, a pediatric pul- monologist and Medical Director of the Clinical Exercise Physiology lab, has used CPETs many times to improve patient outcomes in complex cases. One patient, an adolescent with EID, wasn't improving with asthma therapy. Based on the CPET results, Dr. Bhatia and his team diagnosed the patient with vocal cord dysfunction and exercise-induced hyperventilation. The patient ceased asthma therapy and bega n speech therapy for breathing techniques, which improved the patient's condition. Dr. Bhatia says this is a relatively common scenario at the exercise lab. "In otherwise healthy children, EID is commonly attributed to exercise-induced Rajeev Bhatia, MD, is Medical Director of Akron Children's Clinical Exercise Physiology lab where cardiopulmonary exercise testing is used to determine the cause of exercise intolerance and exercise-induced dyspnea. M D N E W S .C O M /// M D N E W S C L E V E L A N D /A K R O N / C A N T O N 2 017 0 7