- Pediatric Sleep Medicine
- Pediatric Pulmonary
Clinical Associate Professor, Pediatrics - Pulmonary Medicine
Board Certification: American Board of Pediatrics, Pediatric Pulmonary (2021)
Board Certification: American Board of Pediatrics, Sleep Medicine (2021)
Board Certification: American Board of Pediatrics, Pediatrics (2021)
Medical Education: University of the East (1992) Philippines
Fellowship: Children's Hospital Los Angeles Div of Ped Pulmonology (2005) CA
Residency: Overlook Hospital (1997) NJ
The Link between Pediatric Obstructive Sleep Apnea (OSA) and Attention Deficit Hyperactivity Disorder (ADHD)
2021; 8 (9)
Obstructive sleep apnea (OSA) is a form of sleep-disordered breathing that affects up to 9.5% of the pediatric population. Untreated OSA is associated with several complications, including neurobehavioral sequelae, growth and developmental delay, cardiovascular dysfunction, and insulin resistance. Attention-deficit/hyperactivity disorder (ADHD) is among the neurobehavioral sequelae associated with OSA. This review aims to summarize the research on the relationship between OSA and ADHD and investigate the impacts of OSA treatment on ADHD symptoms. A literature search was conducted on electronic databases with the key terms: "attention deficit hyperactivity disorder" or "ADHD", "obstructive sleep apnea" or "OSA", "sleep disordered breathing", and "pediatric" or "children". Review of relevant studies showed adenotonsillectomy to be effective in the short-term treatment of ADHD symptoms. The success of other treatment options, including continuous positive airway pressure (CPAP), in treating ADHD symptoms in pediatric OSA patients has not been adequately evaluated. Further studies are needed to evaluate the long-term benefits of surgical intervention, patient factors that may influence treatment success, and the potential benefits of other OSA treatment methods for pediatric ADHD patients.
View details for DOI 10.3390/children8090824
View details for Web of Science ID 000699406500001
View details for PubMedID 34572256
View details for PubMedCentralID PMC8470037
Neonatal Coccidioidomycosis: A Single-center Experience and Review of the Literature.
The Pediatric infectious disease journal
BACKGROUND: Coccidioidomycosis is common in adult and pediatric populations living in endemic areas of the United States but has rarely been reported in neonates. We reviewed recent cases of neonatal coccidioidomycosis treated at a tertiary care children's hospital in an endemic area and compared them with previously reported cases in the literature.METHODS: We performed a retrospective chart review of infants 1 month old or less hospitalized with a diagnosis of coccidioidomycosis from January 1, 2014, to December 31, 2019. Additionally, we performed a literature review of all reported cases of neonatal coccidioidomycosis over the past 7 decades through PubMed. Infants born to mothers with confirmed or suspected active coccidioidomycosis were excluded.RESULTS: Three cases of neonatal coccidioidomycosis were identified at our institution. Each presented in a unique manner and had an alternative diagnosis at the time of initial presentation. Two patients had negative coccidioidal screening tests upon admission but later seroconverted. All patients had extrapulmonary involvement, and all recovered after appropriate treatment. A review of the literature reveals that the presentations and outcomes of neonatal coccidioidomycosis vary widely.CONCLUSIONS: There is significant variability in the presentation of coccidioidomycosis in the neonatal period, and diagnosis may be challenging. In endemic regions, healthcare providers should consider coccidioidomycosis in their differential diagnoses of ill-appearing neonates that do not respond to treatment.
View details for DOI 10.1097/INF.0000000000003281
View details for PubMedID 34310505
- Normal Sleep in Childhood Integrative Sleep Medicine Oxford University Press. 2021: 33-48
Coccidioidomycosis in infants: A retrospective case series.
2016; 51 (8): 858-62
In contrast to adults, coccidioidomycosis is a rare disease in infants and the mechanisms of disease acquisition are not well described in infants. The purpose of this study was to describe the clinical presentation, treatment, and outcome of pulmonary coccidioidomycosis in infants in an endemic area.We performed a retrospective observational study of all patients less than 12 months of age admitted to a tertiary free standing children's hospital from 2003-2012 diagnosed with coccidioidomycosis.Thirteen infants were hospitalized during the study period. The majority of the patients presented with upper and/or lower respiratory tract infection. The most common presenting symptoms included fever (77%), cough (61%), and respiratory distress (38%). Disseminated disease, included pericardial effusion, neck abscess, and lesions in the cerebellum, basal ganglia and left temporoparietal skull. Fluconazole was the initial, antifungal agent used. Amphotericin B was reserved for significant lung disease and disseminated cases. Failed response to fluconazole and amphotericin B were treated with a combination of voriconazole and caspofungin. Average length of treatment was 4 years. All patients survived to hospital discharge. The majority of the patients had resolution of chest radiograph and coccidiodal complement fixing antibody titers.Infant coccidioidomycosis has a non-specific presentation and can mimic common infant respiratory illnesses. In endemic areas, coccidioidomycosis should be considered in the differential diagnosis of infants with pulmonary symptoms unresponsive to conventional treatment. Pediatr Pulmonol. 2016;51:858-862. © 2016 Wiley Periodicals, Inc.
View details for DOI 10.1002/ppul.23387
View details for PubMedID 26829719
Supine sleeping position does not cause clinical aspiration in neonates in hospital newborn nurseries.
Archives of pediatrics & adolescent medicine
2007; 161 (5): 507-10
To determine the frequency and severity of clinically significant events of spitting up in normal newborns during the first 24 hours of life and to correlate the events with sleeping position.Prospective observational study.Children born between August 2003 and October 2004 in newborn nurseries at 2 hospitals.Healthy full-term newborns (n=3240) (>or=37 weeks estimated gestational age) during the first 24 hours of life.Frequency of, and intervention required for, spitting up in supine, side-lying, and prone positions while asleep and awake.Of the 3240 infants, 96.6% did not spit up during sleep. A total of 142 episodes of spitting up were documented in 111 newborns during sleep. While the newborns were supine and asleep, there were 130 episodes of spitting up. Of these episodes, 55% did not require any intervention, 37% only required brief suctioning with a bulb syringe, 6% required gentle stimulation, and 2% required wall suction. Both nurseries had a policy that newborns should sleep supine; therefore, only 6 newborns were noted to have spitting up episodes while lying on the side, with 66.7% requiring no intervention and 33.3% requiring bulb syringe. No episodes of apnea, cyanosis, documented aspirations, neonatal intensive care unit admissions, or deaths from spitting up were noted.We conclude that clinically significant spitting up occurs infrequently in hospital newborn nurseries while the newborns are asleep. Fewer than 4% of newborns spit up while sleeping in the supine position in the first 24 hours of life, and none required significant intervention or experienced serious sequelae.
View details for DOI 10.1001/archpedi.161.5.507
View details for PubMedID 17485629
- Lung Transplantation in Pediatric patients Clinical Application of Pulmonary Function Testing in Common Pediatric Respiratory Disease 2005: 224-232
Diaphragm pacers as a treatment for congenital central hypoventilation syndrome.
Expert review of medical devices
2005; 2 (5): 577-85
Congenital central hypoventilation syndrome is a rare syndrome present from birth, and is defined as the failure of automatic control of breathing. All patients with congenital central hypoventilation syndrome require life-long ventilatory support during sleep, although approximately a third of patients require ventilatory support 24 h per day. Diaphragm pacers offer a modality of ventilatory support that affords congenital central hypoventilation syndrome patients with maximal mobility for full-time ventilatory patients, and they may allow for a more normal lifestyle in the appropriate patient. They may permit tracheostomy decannulation in those requiring only support during sleep. Diaphragm pacing entails surgical placement of an electrode onto the phrenic nerve, connected to a subcutaneous receiver. There is an external battery-operated transmitter and antenna placed on the skin over the receiver. The transmitter emits energy, similar to radio transmission, which is converted into an electrical current by the receiver. This stimulates the phrenic nerve resulting in a diaphragmatic contraction. Settings on the transmitter include respiratory rate and electrical voltage, and are adjusted to give enough tidal volume to allow for adequate oxygenation and ventilation. Therefore, diaphragm pacing is an attractive alternative mode of mechanically assisted ventilation for many patients with congenital central hypoventilation syndrome.
View details for DOI 10.1586/174344188.8.131.527
View details for PubMedID 16293069
Disordered respiratory control in children with partial cerebellar resections.
2005; 40 (1): 88-91
While the cerebellum is not traditionally thought of as having an important role in respiratory control, breathing involves cyclic motor acts that require cerebellar coordination. We postulate that children with partial cerebellar resections have disordered respiratory control due to altered synchronization of ventilatory muscles. We reviewed the records of 36 children following partial cerebellar resections due to neoplasms confined to the cerebellum. P aCO2 values were elevated in 19% of patients. Six patients had apneic or bradypneic events documented within the first month after resection. Two patients required intubation with assisted ventilation, and one needed assisted ventilation for 7.3 weeks. Those with apnea had lower oxygen saturations, and a longer need for supplemental oxygen. Patients with apnea were older than those without apnea. Swallowing, which uses many of the same muscles as those needed to maintain upper airway patency, was dysfunctional in 50% of those with apneas. We conclude that children with cerebellar resections have an increased incidence of apnea, hypoventilation, and hypoxemia not otherwise explained by pulmonary disease, and some require prolonged assisted ventilation. We speculate that these abnormalities are manifestations of altered respiratory control caused by dysfunctional cerebellar coordination of ventilatory muscles.
View details for DOI 10.1002/ppul.20225
View details for PubMedID 15880401