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129 - Dr. Ben Cable - A Pediatric ENT Share Advice for Parents

Ben Cable

Emma Cooksey: [00:00:00] So thank you so much for joining me.

Ben Cable: Sure, it's good to be here.

Emma Cooksey: So do you want to just start off and give us a little bit about your background, like how you got into medicine in the first place and yeah, how you got here?

Ben Cable: No, I was determined to be a doctor, I think, since I was about six years old, not knowing much about it. I was determined to be a heart surgeon. I have no idea why I picked that. It turned out, thankfully, I did do that. Well, that's wonderful. It was not for me. But found my way into surgery. I just, I love working with patients and I love procedures.

So the mixture of the technology and the tools and fixing things and just working with people has always been a joy. And I've gravitated toward kids. My wife is a teacher. And I gravitated toward pediatrics because I love the group and the population and the ability to really make the vast majority of them better.

It's, it's a fun group. So, so in a room, you have a patient, you have parents, you have a family[00:01:00] and particularly in ENT, you can get to the bottom of things and, and, and make a difference. So I've done that for about 25 years now. I was after medical school, went to ear, nose and throat residency, which is about five years.

I did two more years subspecializing just in children. and some of the complex issues that they have and then have, have gone out and, and serve patients in multiple places, including continents. So

Emma Cooksey: Yeah. So there was some military service in there as well.

Ben Cable: Yes, so I was a military ear, nose and throat doctor for a couple of, the better part of two decades.

And that seems odd for a pediatric doctor but there are just a tremendous number of families in the military, as you can imagine, it's, it's, it's, it's mostly all young families. So I was one of. three pediatric ENTs in the U. S. Army. And we had patients all over the planet. So I was very, very busy and got a chance at the end to run [00:02:00] all of the ENTs.

I got a chance to be the leader of that group and I had ENTs literally all over the world. 

Emma Cooksey: Well, you are a terrific person to ask all my questions.

Ben Cable: good. Yeah. Fantastic.

Emma Cooksey: so far, as far as pediatrics has gone I had an ENT surgeon Dr. David McIntosh. He's based in Australia. 

Ben Cable: So when I was talking to Dr. McIntosh, he was talking a lot about there being this urgency. with kids with sleep disorder breathing, so whether that's snoring or sleep apnea, or even he was talking about mouth breathing, and he was talking about how he errs on the side of Urging parents to go for like tonsillectomies and doing surgery as quickly as possible.

Emma Cooksey: So since that interview, I've talked to many, many parents who, you know, have kind of sought different opinions and definitely have a lot of [00:03:00] reservations about doing a surgery. And. I've read a lot about it, and so there seems to be more of a difference of opinion to that, like some people have been advising, like, wait and see what happens, is also a way to go, so I just wondered where you were on that spectrum, and in your own experience, doing these kind of surgeries, what you're seeing, and what

Ben Cable: no, absolutely. And it's become even more confusing because the guidelines. So the guidelines that were originally developed in the early 2000s were fairly straightforward. But as with most guidelines over time, now the term is, you know, family centered decision making. Which often means terribly confusing things because we put everything in a parent's lap.

Without really giving them a structure. And I, I, it's, it's not uncommon at all that parents come in with questions saying, I understand that and I certainly want to be a part of the decision, but I need to know the advice and where this falls out in reality. And so I think. [00:04:00] You know, the, the idea that it's important from Dr.

McIntosh, I would agree with wholeheartedly. I mean, there's, you know, boy, we can fight in anything in science now, right? You can Google it and find an opinion, but sleep is not one of those things. I mean, if you look at the sleep literature in children Children that don't get a good night's sleep don't do as well as kids that do.

And that's not magic to tell to a mom or dad. Any parent knows that. But the key to that is there just is not a study that's been done that didn't show that poor sleep, and there's different versions of poor sleep, right? But poor sleep has tremendous implications to kids. So when you look at the testing that they've done, It impacts their ability to learn, to remember, to make decisions, to grow and eventually there's even some research that shows if it's severe enough that they can have long term consequences to their blood pressure and heart.

So I haven't actually seen a study that came out on the other [00:05:00] side. So, so you can't really get in an argument with people and say, well, you know, sleep doesn't matter. There's, it's resounding. So it does. The question is, is, is at what point does it need intervention, right? I mean, that's really your question.

And it's a spectrum, so breathing at night, and particularly obstructive breathing, is a complete spectrum. 90 percent of kids will breathe effortlessly at night and have no obstructive breathing. So, so

Emma Cooksey: So, effortlessly, just for parents who, you know, know nothing about this and have never even heard the terms sleep disorder breathing. So effortless breathing looks like mouth closed, breathing silently through their nose.

Ben Cable: yes, consistently. And that doesn't mean, when kids get sick, they're going to mouth breathe, right? I mean, we were just talking, your child has a cold. When kids are actively ill, I won't say that doesn't count, but that's not the assessment. It's when they're well. Assuming they're consistently well if they're breathing smoothly at night with their mouth closed[00:06:00] that is, we would consider there to be no obstructive impacts to their breathing.

And thankfully that's about 90 percent of children. But then you have the other 10%. And that almost always starts with snoring. So snoring is our is our screening question. So the American Academy of Pediatrics and ENT all agree that a well child visit, that's a pretty good question to start the conversation is, do you hear your child audibly snoring at night?

So one in 10 kids will do that. There's arguments whether that causes significant problems, but I would say most of the research That's out there would argue that that by itself without any other issues, just, just noise, smooth breathing with noise by itself. We don't see tremendous implications and we don't jump to surgery.

So it's a, and we'll go deeper into this, but as a generalization, most certainly in the ENT community. [00:07:00] Sleep medicine, I would say, too, would not advocate certainly a surgical procedure or anything invasive for snoring by itself. Now, when we go to sleep, and the reason snoring happens is that we lose muscle tone, right?

I mean, we We fall asleep and our muscles relax, our tongue falls backward a bit, in all of us, kids and adults, the side of our throat, whether we have tonsils or not, comes together a bit. And when that comes together enough that the airflow becomes turbulent, when it actually moves through not in a smooth fashion, that's what a snore is, is turbulent airflow.

And that's from collapse of the airway. So as kids do that, you start to see turbulent airflow and they make noise. It's the kids that go beyond that. It's the kids that then really get in the deep restful sleep where we lose all muscle tone, some of the deeper sleep, where those tissues actually fall together.

and create pauses in breathing that we call sleep apnea or, or interruptions in sleep, which would be [00:08:00] sleep disturbed breathing. But in those cases, those children get in that deep, restful sleep they need. And that's where a lot of things happen. That's where learning becomes more concrete. Neurons put together things we learn during the day.

Growth hormone is secreted at night, that's all in those really deep phases, so when those kids go in the deep phases of sleep where they lose muscle tone and they collapse, the brain says breathe, the chest goes to rise to pull air in. But it can't get in, so it's either obstructed enough, you can breathe a little, but they're pulling so hard they wake themselves up, or it literally stops.

The brain says breathe, the chest goes to rise, and it just, the garage door is shut, nothing happens. No matter how asleep a child is, their brain is always monitoring. That child will never suffocate, assuming they're not premature and really, really little. That's a different story. But their brain's going to wake them up, and the brain kind of pokes and says, Hey![00:09:00] 

You gotta wake up. And so what you're gonna see is the child's gonna come out of sleep usually either startle or a little bit of a gasp sensation and they're gonna come up out of that deep restful sleep where they're trying to grow and learn and recover and they go in the lighter stage where they get muscle tone back and they literally open their airway, but very quickly They're tired, the brain goes, and so they porpoise.

And those children can be asleep for 8 or 10 hours, but when you look, they're not getting the deep stages of sleep that they really need to, to, to function in a classroom. And so that's ultimately what parents are looking for. So that's where I start, is people jump to all sorts of testing and consults and do you need a sleep study?

Most of the time, kids should largely be sleeping in their own rooms. Long discussion, but assuming that's the case, I always ask parents just spend 15 or 20 minutes either inside the child's room or right outside the room, bring your phone, bring abook and just listen and [00:10:00] sample their sleep 

Emma Cooksey: recordings 

Ben Cable: inspiratory, 

Emma Cooksey: Yeah. Mm-Hmm.

Ben Cable: inspirational, But parents are actually pretty good at that. And, and we'll talk about parent versus sleep study because it turns out the parents in some cases may be better at screening for some of the things we're looking for than a sleep study.

Because a sleep study really isn't, it's about, it's about breathing and heart rate. But, but that interruption and its impact on the child's behavior, it turns out mom and dad are pretty good at picking that

Emma Cooksey: So, I don't wanna interrupt your flow 'cause I think you're about to get there, but one of the things I hear all the time is from people saying that they've gone to their pediatrician and. The pediatrician, I mean, I wouldn't say doesn't know what to look for, but they aren't necessarily trained in sleep, right?

So, the parent's saying, like, they have kind of [00:11:00] disturbed sleep, and the pediatrician's like, well, it seems fine. And so, who should Those parents be pushing to go and see,like, I've heard of people going directly to ENTs and I've heard other people going to a pediatric sleep specialist, having a sleep study, but then they end up at the ENT.


Ben Cable: Yeah. And, and that's the confusion because the guideline actually says at this point, if, if you as a parent are seeing. Interruptions like that with the, with the breathing. And the second thing that I'll add before we leave that is called secondary enuresis, and that's bedwetting after bedwetting goes away for six months and comes back, that's, that's another very strong sign of potential sleep apnea.

So bedwetting is normal up to quite a few years of age, but if it goes away and a child is not wetting the bed for six months, but develops that. Say, 4, 5, 6, and it returns, [00:12:00] that's another big flag and I think that's a good one to list. But, but if you see either of those things, if the parent is, is on multiple nights when the child is well, noticing obstructive breathing, it's really either.

I would go to one or the other I'm obviously biased. I would say start with an ENT and I'll tell you why, but the guideline is there that you can visit a sleep medicine doctor as well. And the reason I would, I would say with bias is, is as you know, the most common treatment if we do confirm sleep apnea by the recommendations in an otherwise healthy child is taking the tonsils and adenoids out which, which is in most all cases at least improves the situation and of course in many cases solves it.

So I, I think if the parent is not averse to surgery for some reason. And we certainly don't jump to it. We're going to have a discussion with them and go through the pros and cons. If we don't think surgery is right, we can get them in the other direction. But I think that direction is usually a pretty reasonable one [00:13:00] to start.

And the evidence bears that out. Most kids don't need a formal sleep study. And we can go into that and talk about that in detail. But the initial guideline did recommend that and it just, it doesn't work out and it turns out parents can screen pretty effectively for those kinds of things. And then the expensive sleep study doesn't necessarily add value to that process.

Now if a child has any type of significant medical issue and, and by that syndromic children that have changes in their facial features, children with down syndrome, children with any disease that affects their muscular strength. If they have weakness or muscle tone issues or kids two and under, all of those kids would ultimately need a sleep study first.

So I think in that case, if the child is two or under, I think it'd be very reasonable to start with a sleep medicine physician because those kids need sleep studies, no matter what. And

Emma Cooksey: In order to, to even go see an ENT and talk about surgery,

Ben Cable: [00:14:00] you could still, you could still talk to an ENT, but the ENT is going to send you for a sleep study. And so I think I'm just trying to simplify and streamline for the process. So

Emma Cooksey: Because it, it can be so frustrating for

Ben Cable: Yep. So I would,

Emma Cooksey: in circles.

Ben Cable: do go around in a circle. So I would really boil it down. If your child is two or under or has any of those other.

medical issues that we just mentioned or that affect the facial features or anatomy or tone, I would start with sleep medicine. I think if they're over two years old, and again, there aren't reasons, specific reasons, the family has concerns with surgery or want to go the other route, we can start with a sleep study.

And so that's how I would do it. So for the child over, I would head toward ENT, for the child under or with disease process, I would head to pediatric sleep medicine.

Emma Cooksey: that's super helpful. I just already know that I'm going to send a bunch of people to email me to this episode.

Ben Cable: good, good, yeah.

Emma Cooksey: Okay, I'm super interested in Dr. Audrey [00:15:00] Yoon did that paper about palate expansion in kids.

So I think, correct me if I'm not a clinician of any kind or a researcher. So, just from having read the paper, they looked at kids who during the pandemic were supposed to be having tonsillectomies and They were canceled because of the pandemic. And so they put some of those kids into palate expanders and then they looked at the results of that.

So I just kind of wanted to hear your take on it.

Ben Cable: Yeah, no, and so, you know, COVID opened up a whole area of trying to think outside the box, right? To take care, to take care of kids, and we actually kept our clinic open for You know, obviously patients with cancer and other things, but one of the things that we continue to treat was peds sleep apnea. We felt so strongly.

So we continued to do tonsillectomies and adenoidectomies just with precautions because sleep apnea is so important in kids, but, but a lot of places just didn't allow that. So I certainly understand that. And [00:16:00] so. The whole idea of that airway crowding at night is the concern, is during the day when we have muscle tone, everything's open, we have muscle, we're sitting upright, you know, kids aren't snoring when they're awake obviously, and so it's all about the real 

Emma Cooksey: estate

they're on their phones,

Ben Cable: unless they're on their phone.

Emma Cooksey: a whole nother

Ben Cable: And mouth, and mouth breathing is a little different. We'll talk about, it's right heavy breathing there, but I, I think it's a matter of room in the throat and the tonsils and adenoids are just part of a ring. It's a circle all the way around that involves the tongue, the tonsils on the sides, The palate with the uvula that hangs down and the adenoids, which are right behind the palate.

And all of that together crowds as we fall asleep. And so in the idea where you're just trying to create room and that's what an adenotonsillectomy does is we're just taking out the tissue that can be taken out. Without long term consequence that makes more room. It doesn't mean they're not still falling together, they just don't fall together [00:17:00] enough, they obstruct.

So in the, in the area where you couldn't do that with the dental folks thought, well, why don't we kind of make more room by literally expanding the mouth? And so a palatal expander, particularly rapid palate expansion, puts in a device that bridges across the back of the palate and literally a screw, and as they turn it, it puts pressure and forces very slowly the jaw to open up around it.

And medicine's been doing that for a long time. There are people that break their leg and one leg is shorter than the other. You can literally put. It's pins and screws, but you extend the leg. If you do it slowly enough, the bones will keep up and knit and that's kind of what you're doing. And, and it turns out when they did the, the post op studies, there was more room and, and they, they, what they said is the tonsils and adenoids were smaller.

They weren't actually smaller. They just took up. They weren't taking up as much real estate as they would 'cause now they're, they were here, now they're sitting out here. 'cause the whole mouth is

Emma Cooksey: Right.

Ben Cable: And I, and I think that, [00:18:00] that there was not data to show that that cured sleep apnea, what their paper's conclusion was.

There was more room in the back. And I think that that would be a potential approach, but the problem with it, and what I worry, I worry about two things, and you don't see that, that's not something that's in any of the mainstream guidelines, and I think probably shouldn't be for two reasons. One, we know if you push a growing surface, It will respond but it may stop growing after that.

So you, we know in the nose, for instance, when kids have deviated septums or things inside their nose, we don't operate on them until they're 16 or 18 because if you do, the growth in the face will stop growing and their face expansion, there are very clear studies that show that you can expand it or fix it right there when they're four or five or seven but you may arrest their growth.

that they would have gone through from [00:19:00] 10 to 18. When we speak, as we make words, we use the back of our mouth quite a bit. You know, your palate, if you put your finger in your mouth, is bone, but further back is soft, and our palate moves up and down, and from the side, it closes our nose off when we make specific sounds.

So, P or T. T. You have to build up pressure. You have to close your nose off, build up pressure, and let it go. Sometimes if you really expand the back too quickly, you can give kids speech problems where they can't make those sounds, and that's called velopalatal insufficiency. It's a mouthful, but what that means is there's so much room, their palates can't keep up with the speech aspect.

And so we do worry about that. We don't take adenoids out in children with palate problems because you can give them severe [00:20:00] speech problems from that. So I, I, I think that would be my other concern. If you very rapidly change the size of the bone in a way that they can't keep up with, that may be a risk for, for VPI is the acronym there.

So. I think it's interesting and we know palatal expansion is done in a lot of kids when they're older before they go in braces where the growth just didn't, you know, some people have a narrow mouth and they just literally can't fit their teeth in there and the orthodontists expand and then move the teeth in and I think in the teen years that's probably fine but I think in the years we're talking about and the kids who are kind of the three, three to six or

Emma Cooksey: I, I hear a lot, like, just having done this for, you know, three and a half years or whatever, I've heard a lot from medical doctors, just they don't see enough data around palate expansion and myofunctional therapy and all of this for kids, but do you work, like, do you refer to any of those people and what would be the [00:21:00] circumstance?

Ben Cable: Yeah, no, it's a great question. And we're very, in medicine in general, we don't read each other's literature enough. There's just, there's too much out there, but, but I will,

Emma Cooksey: so here's the thing I feel like for months I was banging on about like people need to be collaborative and they need to talk to each other more and then I interviewed one sleep specialist about six weeks ago and It kind of gave me pause because she was explaining, she's now in private practice and can set her own schedule but she was explaining how much time she has with patients, how long it takes to chart, how long she's,like caught up in the admin of actually being in a practice and she, she was saying like, you know, I would have loved to have collaborated with people, when am I going to these lunches or, you know, she just was trying to get that conversation going.

her job done as a doctor. So that kind of made me go, well, that is a good point.

Ben Cable: it is, it is, but it doesn't take away from the fact that you, you [00:22:00] do, you know, sleep is not a one specialty practice. Right. So, so I do, and I've used, I've had collaborations and it's not that you collaborate with. Like one single patient on the phone with everything. But what you do is you develop a network and you have a sense of what everybody's good at.

And, and so

Emma Cooksey: referring

Ben Cable: Yeah. Right. And, and that's what we do. So I, I used to not, and this is a great, it, it's an aside, but it fits back in. I used to get consults all the time saying, please take out the adenoids. 

Emma Cooksey: I used to get consults from dentists saying, please take out the adenoids, this child's mouth breathing, I need room. And I didn't have the literature, so I would just kind of say it's not in my literature, so I wouldn't. So, they finally sat me down and said, here is our literature. Let me give you half

the dental

Ben Cable: From the dental side and, and they have tremendously good literature that chronic mouth breathing isn't necessarily, if it's not obstructive at night, it's not as much worry, but it causes all sorts of problems with the teeth and it causes malocclusion. And there's no,

Emma Cooksey: If your tongue is not where it's supposed to be,

Ben Cable: Right.

Emma Cooksey: it just really affects the way [00:23:00] everything develops.

Ben Cable: that turned around everything for me.

Cause I, I still, not only do I, do they show me the literature and I take those consults very seriously, but that really got me involved with the two way because I see malocclusion as well and I'll get them to the dentist. And you mentioned myofascial, I've, I've used multiple in my last, I was in Virginia for about six years and we had a wonderful myofascial team where tongue positioning, if it was high and high arched palates, and, and I did involve them.

And, and I don't think it. In, in a lot of cases it wouldn't change the need to probably take tonsils, but there were other issues going on and if you just treat one thing and it's multiple, you're not really helping the patient. So we had a two way, you know, he would send all the time saying, this isn't really for me, this is, this is just big tonsils, please take them out.

 so I think you, you don't necessarily in a single day with short time have those conferences. You'd love to have a conference every Friday and go over everybody and chat. Those days are gone, but having those collaborations are still there, so I absolutely work with [00:24:00] pediatric dentists consistently and the myofacial folks I've had good relationships with in the past.

I haven't found a good one, not that there aren't lots of good ones here yet, I'm learning, but I'm learning those teams here and I'm sure I'll find them as well, so I think,

Emma Cooksey: I think, I mean, with my functional therapy, I feel like it would be really nice to have more of a national specific, like they do have credentials, but I feel like there's a vast range of different levels of training.

Ben Cable: that's why we mentioned that when we were talking on email, there is a huge broad spectrum of what. is offered in them. And it is, it's new. It's not standardized. That's not always a bad thing, but I think you just have to pick the ones you're working with. And that's hard for parents. So that's, that's where I would really make sure from a parent's perspective, I wouldn't just Google that.

I would talk with a pediatrician or a local ENT or sleep doc, because they're going to know 

 [00:25:00] everybody's Google's doctors now and it's all about star where you can have a star rating and just be very nice It doesn't that doesn't always imply you're gonna really get things fixed or know what's going on So I think you want you always want a doctor with good star ratings, of course But I think you got to look a little deeper you should always look deeper than that, but, but I think in those cases, you really need to find somebody in the community and get, get a reference because they're going to help.

They're going to help you guide through that process. So

Emma Cooksey: so I think most of the time now where the, the guidelines from the American Academy of Pediatrics, I think are very reasonable. They've always been good at guidelines. In 2002, they said to every pediatrician, you have to ask every visit. of your 150 questions you have to ask every child, does your child snore?

Ben Cable: And if the answer is yes, they need a sleep study. That was in 2002. That was a disaster. And it turns out less than, I think, eight percent of pediatricians followed it. And they first looked and said, well, gosh, they're just not reading our guidelines. We'll educate. They educated.

Emma Cooksey: or, to be quite honest with you, just being [00:26:00] out here in the real world, and all of the people that I talk to, a lot of that can be pediatricians saying, I'd really recommend you having a sleep study, and not everybody has great insurance. So you're looking at out of pocket costs of like thousands of dollars.

Ben Cable: so the average sleep study is about 4, 000 and they can be up to 12, 000 and, and that's a great question if we have a couple minutes to talk about that. So to sleep study or not sleep study is a, is a fantastic question and I, I think that guideline didn't work and it, it morphed away from that for very good reasons.

It's important to talk about that. So, The big question at the time, and the reason that guideline came out, it was interesting is there was a little asterisk at the end of that that said, get a sleep study on all those kids. There was an asterisk that wasn't in the guideline, it was in the addendum that you had to read.

And the American Academy of Pediatrics is wonderfully honest. They said, We don't really have any evidence to support this. It's just the best test we have, so you should do it. And, and again, they just laid it right out there. It should be the gold [00:27:00] standard because it's the only test we have. And the argument at the time was, there's no question you can ask a mom or dad that will predict what the sleep study will say.

Right? And that was true. You still can't have a questionnaire. You can't have a conversation with a, with a mom or dad and have a really accurate prediction of what a sleep study would say. And so the logic there was, well, you have to get a sleep study because mom and dad don't know what they're talking about is the implication.

The problem with that is, is a sleep study was designed, I mean, we made up. the term sleep apnea. Obstruction is real, but sleep apnea is just a statistical term. So we look, we looked at hundreds, it wasn't thousands, we looked at hundreds of kids and we put them in boxes and the worst, the worst box over here, we made a line and it said if your child stops breathing more than once an hour for a specific period, your child has a disease called obstructive sleep apnea, right?

And And parents can't predict that, yes or [00:28:00] no. But the problem is, what a mom's worried about, or a dad, is not whether they stop breathing one time an hour, it's whether they're having trouble in school because they're not sleeping well, right?

Emma Cooksey: Or they're not growing

Ben Cable: Or they're not growing, or they're wetting the bed. Right. And so the, the catch to that is, and the magic in that is the sleep study doesn't predict that.

 so that was the catch is now you're saying the gold standard study we have to do, but it turns out it doesn't really test for what mom and dad are worried about. Wait a minute, right? And, and so then everybody backed up and

Emma Cooksey: I feel like going to a sleep specialist and having that test is a great plan for very severe kids where they're, you can see like they're, they have pauses in their breathing, you know, multiple, multiple times. And we're not really talking about that. We're talking about the rest of most of the other kids.

Ben Cable: Right. And then here's just a very quick, I won't drag you through a bunch of studies, but the one that I think was a

Emma Cooksey: Oh, I think you know that. [00:29:00] I love it.

Ben Cable: oh, okay, well let's do it. There was a, there was a study done out of Michigan where they took a hundred kids, about 75 of them that were sent from their pediatrician to an ENT for, for sleep apnea.

This child has sleep apnea. Please consider taking out his or her tonsils and they took 25 age matched kids normal and before they got to the ENT they snuck them off to the side and they did a sleep study and they did a huge battery of neurocognitive testing which takes a tremendous amount of time all validated learning executive function memory behavior extensive of the stuff that mom and dad are worried about and validated and then they let the process continue.

Most of those kids, not all of them, went and got a tonsillectomy, adenotonsillectomy and then three months later, they snuck them off again without the pediatrician or the ENT knowing and they retested, right? They did a follow up sleep study and

Emma Cooksey: did a repeat at all those other [00:30:00] tests.

Ben Cable: what was fascinating is 50 percent of the kids that went to get surgery did not have sleep apnea.

And so you say, Oh my gosh, we operated on twice the number of kids, but the catch is. Both of those groups equally had neurocognitive deficits when compared to normal kids. They were abnormal. They had problems in learning behavior and mom and dad picked it out. And the sleep study, I won't say missed because it's easy to say the sleep study missed, but the sleep study is not designed to do that.

The sleep study didn't call the other half. And what was, not only were they both abnormal equally. They both got better, and they both went back to normal in aggregate. Of course, not every child, but in aggregate, when you looked at the total numbers, both groups went back to baseline equally. So that's the answer.

That's just what you said. For the normal, healthy child who's got obstructive breathing that mom and dad can pick up on, the answer is the sleep study didn't add value, it added [00:31:00] 4000 dollars twice, and, and so that is not required in

Emma Cooksey: And I think that that's, it's so interesting. Cause I think that that's so much of what we're dealing with with a lot of adults as well, just because The way that somebody has chosen, you need to pause breathing, you know, for adults for 10 seconds and this number of times an hour, and I really feel like there's so many people I've interviewed where their AHI is not So, Very high, but they're having significant symptoms and they're helped by treatment.

So it's kind of one of those things where I know that there has to be some sort of test, but I think maybe for kids especially, I'm not sure that it's picking up

Ben Cable: Yeah, and it's just not ideal yet. I mean there's, there's probably other tests out there and we're refining it. I mean they are getting better at it. You know, you look at if it's interrupting the sleep stage. A true sleep study of course is looking at sleep staging and we're seeing how intact their sleep is.

 and they're adding metrics to that and we're starting to [00:32:00] see more of that coming. But the truth is mom and dad are pretty good at it. And, and I think that's where most pediatricians even with that original guideline fell out and that's ultimately where the guideline went is in a child who's over two, who you are seeing Sleep disturbed breathing and some of these implications, right, so behavior problems, learning problems, tired, bedwetting after not bedwetting, that's worth treating and so I think going in that direction just makes sense.

Now I, I send kids for sleep studies all the time. Kids who are under two really need a cardiopulmonary test and a sleep study because that matters. the risks to those kids. We do surgery, I've done tonsillectomy on 12 month old kids? Rarely, very rarely.

Emma Cooksey: they've had a sleep study and you've

Ben Cable: oh yeah, absolutely. Yes. And so kids under 2, you absolutely have to have a sleep study before you consider any form of treatment.

It doesn't mean they all need surgery. And, and there are, there are other treatments along the way too. CPAP is not great in many kids, but it can be done particularly in younger kids. But, but those kids have to have a sleep study. For our [00:33:00] Downs, our trisomy population, my Downs patients, they need sleep studies because they have tremendous heart and lung issues to start with.

And we actually guide therapy based on the sleep study because Taking out tonsils and adenoids in children with Down's doesn't solve it in almost any case. It helps, but it doesn't solve it and we have to look at other ways and what we're really trying to make sure is that we're not having a strain on their heart, which is creating heart failure, which can happen.

So that population and some of the other more complex ones, sleep studies are absolutely critical and, and we guide all of our decision making because they're the cardiopulmonary, the heart and lungs and the blood pressure are really what we're worried about more. As well as the learning. So, so in that case, we use them.

So I, I, please don't hear that I don't use peds sleep studies. I do, but it's in that subset of, of patients. And in those kids, you have to spend those, you know, that makes sense to do that. Cause it helps me guide a mom and dad. on the right ways to approach things. I mean, we used to do tracheostomies in kids with [00:34:00] trisomy because we initially said no sleep apnea was okay.

And, and we don't say that any, I mean, we don't tolerate sleep apnea, but we certainly don't jump to that. We were taking out parts of tongues in kids with sleep with trisomy to decrease the size of their tongues. It was very aggressive because initially the answer was.

Emma Cooksey: recovery.

Ben Cable: painful. And our, our goal was no sleep apnea in those kids.

And in the end, that's probably not realistic, but we manage it. So they're doing the best they can without being in super invasive and, and, you know, with consequences. So, so sleep studies have their place, but I do agree. And my opinion is in general for the otherwise healthy over two year old child, they're not required.

foR treatment.

Emma Cooksey: What do parents need to know about just the, I know I've talked to a bunch of people and I also went through this myself because my now 11 year old had her tonsils and adenoids out when she was five. And. I think it's one of those things where people can tell [00:35:00] you the statistics and how safe this procedure is, but when you're a parent and it's your kid, you're kind of like, oh, yikes, like, this is kind of scary.

So, what, what do you say to parents who have a lot of anxiety around it?

Ben Cable: No. We, we absolutely, I mean, we, we joke about the only minor procedure is one that somebody else's child is having and, and tonsillectomy is not a minor procedure, right? I mean, so it should be weighed very carefully. And that's where I'd start by saying that all children that snore, I would definitely not race to tonsillectomy because it's, it's surgery.

And so I would, I, I want to have good reasons that make sense where we're going to. say this is what we're treating and this is what we hope to achieve and, and, and have a very reasonable expectation that you will. But what I tell parents now when we talk in about surgery in general is modern anesthesia has come a long way.

That certainly was a pretty big concern, particularly in young children for a long time. There are certainly still risks, but the, the risk of having a [00:36:00] significant problem from anesthesia is about the same as driving on a busy road for four hours. Which most families do two or three times a week around here.

And it's not to make light of it, but, you know, we take risk every day. Driving is certainly not safe, but it's manageable. And I think from anesthesia standpoint, that's why you do it with in, in my operating room, we have, you know, physician anesthesiologist whose job is to be there. If there is a very rare incident, they handle it.

And, and it's very rarely. An issue even when those times come up in those cases, but we need to make absolutely sure the children are well. Children who are actively sick, particularly with their lungs being reactive or any kind of wheezing, we need to avoid surgery because that raises the risks, but assuming the lungs are clear and they're otherwise healthy, the risk of a 20 to 25 minute anesthesia, which is what it is, is extremely low.

From a tonsil standpoint the most significant reason to, or risk to get tonsils out is bleeding.[00:37:00] In surgery, it's usually like giving a small tube of blood at the lab. It's in children rarely more than that, but we're prepared if there is, it's, that's rarely the issue. 

about one in 80 children in anyone's hands, and no one has beat this, will have bleeding after surgery because the tonsils sit in pockets and the tonsil comes out of a pocket. That pocket can't be sewed closed. It can, but it just opens back up.

So you have a raw spot about that big where you form a scab. And it's no different than a scab on a child's knee when he or she skins up their knees. But a scab, when it's wet like that, as if the child's bathing, it turns kind of whitish gray and wet, can come off a little early. And it's no different than a scab on the knee.

But in the mouth, you can't put a bandaid on it like you do in the knee. So if children do have a scab come off early and they spit blood, it doesn't hide. We always tell them night or day, they must come in and see us in the emergency room. And most of those kids have to go back to the operating room for a few minutes.

And we [00:38:00] cauterize. It's usually one very small spot. It often takes less than. Two minutes. And it's sealed, but the key is there. We don't wait. And so those cases can become severe if families sit at home and wait and kind of watch that very few do that, obviously. But we always make sure and counsel them.

And, and then I go back in 79 out of 80 kids don't have that happen. Most of the kids that do are a bit dehydrated. So we always emphasize fluids, fluids and fluids. And then soft foods for two weeks. And again, 79 out of 80 kids really don't. have that issue. There are parents where that risk alone just scares them so much.

we need to look at other things and that's a decision they just need to make. In very rare cases, those can be severe and, and there are world case reports where children have had bad outcomes from that, particularly when they're not treated, but they're extremely rare. 

Emma Cooksey: Okay. Thank you for clearing all that up, because I think that's one thing that I get asked the most if parents are in that situation.[00:39:00] Anything else you want to talk about? I feel like it's our favorite subject and we could talk all day,

Ben Cable: yeah, no, I, I would mention mouth breathing because you had mentioned that as well. Mouth breathing is kind of its own animal and, and, and certainly can lead to sleep apnea, but children that just walk around with their mouth open and just do not breathe through their nose often have that for a couple of very fixable reasons.

And the dentists are the ones that really Push me on this and I believe it now is that does when your mouth is constantly open. The thought is the teeth hyper erupt. They come in too far is our teeth when they grow in, have to contact to stop. And if you think about it, we don't have our teeth together much of the time.

We probably haven't for most of this conversation, but they do touch from time to time. But if they never touch the teeth and come in and go off and so malloclusion, is that term and chronic mouth breathing really setschildren up for dental issues. So I do think that's worth treating and there's two reasons. Allergies are a huge one in kids [00:40:00] 4,5 and up

Emma Cooksey: Oh, that is one thing I was going to ask you about with allergies, so I'm

Ben Cable: Yeah, so 18 month old children really don't have allergies.

So people come in all the time and say, my 13 month old has allergies. Not in the, almost certainly not in the way we think about it. Kids don't develop allergies in the way we think about them until right before grade school. So most people, and we're, we treat allergy as well, wouldn't think about allergy testing and kids are at least four and probably five, six.

So really young kids don't have that. In the nose for the grade school children, allergies can increase the swelling in the nose with small fins in the nose, the septums in the middle, and there are turbinates that hang down from the sides, little fins. Those get bigger with allergy and can really act like corks in the nose.

It's very easy to see. It's treatable with topical nasal steroids like Flonase and Nasonex and those kind of things in most kids. And in the rare ones where it doesn't treat, they can be treated now. We shrink turbinates in the operating room, but that's rare. Most of the time medicine will take [00:41:00] care of that.

The other big reason is adenoid growth. And so adenoids are like tonsils, but they're in the back, back of the nose, and they can be an absolute cork in the back of the nose. Kids are not born with adenoids. If you look at a newborn baby, they don't have adenoids. The adenoids grow faster than the child does until she's probably three or four or five, and then they're at peak size.

And then they, over time, stay about the same and then they go away when we're adolescents. So adults don't have adenoids or shouldn't have adenoids. And so that's the time where kids start having the mouth breathing. And if that's adenoids, then you can try topical steroids. They've been shown to decrease with the spray about 20%, but as soon as you come off, it comes back.

If it's big enough, it usually requires taking them out. And that evaluation to figure out which that is, is going to be done probably in an ENT doctor's office. or a pediatrician can get an x ray from the side. It's a lateral, just one x ray, and you can see the adenoid beautifully with that. [00:42:00] And I have a lot of pediatricians that'll do that in the clinic, and that's very reasonable because that gets a good look in the back of the nose.

And if you see those things, both for breathing during the day so they can just resonate and sound better and communicate, and to help dental issues over time improve. So I think that

Emma Cooksey: craniofacial development as well,

Ben Cable: Yeah, I mean that's where the,

Emma Cooksey: doesn't go well if

Ben Cable: no, your midface, so it's called adenoid

Emma Cooksey: end up like me.

Ben Cable: well you've heard adenoid faces probably, that's where the whole mid part of the face doesn't grow as well as it could if you have chronic mouth breathing, and that's true as well, and that's that term that we come up with for that.

So getting that treated, I, I think. And a lot of those kids will have sleep disorder breathing as well, but some of them don't. Some of them, they just mouth breathe. They open mouth at night and no issues. I would still investigate treatment for those kids because it's, it's going to, like you said, facial growth, voice, communication, and dental development.

There's tremendously good research

Emma Cooksey: even kids who really aren't having that many problems, like, [00:43:00] it doesn't hurt to have them breathing properly, right? Like, you know, you don't really want, you're not supposed to be breathing through your mouth. So if we can just like re educate them to, to be aware of it, you know, it's good.

Well, listen, thank you so much for your time. I feel like we covered everything.

Ben Cable: covered a lot of ground. 

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