Category Archives: Child Growth & Development
Children grow and develop differently at high altitudes than they do at sea level
Going Public at the American Thoracic Society meeting in SF
For seven years I have been writing and speaking about what I call Resident High Altitude Pulmonary Edema- a clinical diagnosis I apply to children with hypoxia during a respiratory illness with no recent travel. Now I have an opportunity to present my theory to a wider professional audience. I have been invited to present a poster at the American Thoracic Society annual meeting in San Francisco on May 15. This will be a forum to bring attention to a problem I see frequently in children living in the mountains that is not widely recognized or described in the scientific literature. I expect to be challenged and hopefully form working relationships with other researchers who can help us further define this condition. See post on 1/9/15 for further details. I will share the poster here when it is finished.
Pulmonary hypertension may be common in high altitude residents
Summit County cardiologist Warren Johnson is impressed by the numbers of people with elevated pressures in their lungs. “It could be as high as 30 per cent of adults,” he told local physicians gathered at a presentation this week. Symptoms are subtle: decreased exercise tolerance, mild shortness of breath, trouble sleeping, high red blood cell counts. Most people just think they are out of condition or aging.
A study in SpitiValley India of residents living at 9000-13000 ft found an incidence of three per cent with PH. Dr Johnson suspects this is a highly adapted population with centuries of mountain living.
Diagnosing this condition early with Echocardiogram can prevent serious disability. Treatment is as simple as sleeping on oxygen
SIDS incidence double above 8000 ft
Dr. David Katz at the University of Colorado reviewed 393000 births between 2007-2012. Of these 80% live between 3000-6000 ft. Only 1.9% live over 8000 ft. Death rates from Sudden Infant Death Syndrome state-wide was 4.2 per 10,000 but over 8000 ft the rate was 7.9/10000.
it is possible that hypoxia is a contributing factor, but there is no research on this. Meanwhile parents are urged to place their babies on their backs to sleep and remove all soft material from the sleep area.
School problems and orthodontics
My nurse practitioner Laura Amedro and I met with local orthodontist Al Bishop yesterday. Sleep problems are more common at high altitude, and providers caring for children know that poor sleep can cause difficulties with learning and behavior, including ADHD. Dr. Bishop listed ten diseases made worse by poor sleep, including obesity, diabetes, high blood pressure, depression and others.
How does this tie in with the person who provides braces? Dr. Bishop showed us photos of mouths and teeth that can cause airway constriction. Expanders inserted inside the mouth (no more “head gear”) correct these problems but are more effective when started earlier. Some children can be identified and treated as early as 7 years.
Dr. Bishop has offices in Edwards and Summit County, so he is familiar with altitude issues. Night time oximetry is the recommended screening test for airway problems. This has to be ordered by a health care provider such as Laura or myself.
Sleeping at altitude
Most people will agree they do not sleep as well at high altitude, especially over 9000 ft/2500 m. In sleep, the drive to breathe is blunted, which may lower the oxygen and raise carbon dioxide in the blood. This causes high blood pressure in some adults and children but what else does it cause? Pediatric pulmonologist and sleep specialist Ann Halbower wonders if it effects growth and development in children. Family practice physician Lisa Zwerdlinger has many years of experience treating patients in Leadville and sometimes has babies that need oxygen for a year to gain weight.
A study published in the Archives of Diseases of Children in February this year analyzed previously published studies of oxygen levels in awake children at altitudes between sea level and 4000 meters, including Summit County. We are in the early phase of formulating a study on night time oxygen levels at various ages. since it takes years for research to be completed we recommend anyone with health issues that may be related to altitude to have a sleep study. this is very simple: a finger clip connected to a wrist band where data is collected.
when to stop using oxygen after an illness
Several parents returned to the clinic this week with their children on oxygen after respiratory illness. Our protocol has been to discontinue the oxygen when their saturation is above 89 in clinic. Now that many parents have a home pulse oximeter, children are using oxygen for longer periods. Measurements at home may be fine during the day, and the child attends school, then decreases at night so parents continue oxygen. since most oxygen equipment is rented by the month, this is not more expensive. I think it helps the lungs to heal, possibly reducing future problems such as pulmonary hypertension.
New information comes from one of the students rotating here at Ebert Family Clinic: Justin Lockwood, a pediatric resident. He reports that even in Denver some children require oxygen during respiratory illnesses that do not get a diagnoses of asthma or pneumonia.
When Should Oxygen Be Given To Children At High Altitude?
This article was published in the Archives of Disease in Childhood in 2009.
The authors reviewed 14 studies in the scientific literature for normal oxygen values for children ages 1 week to 12 years.
Hypoxemia (low oxygen) was defined as oxygen saturation at or below the 2.5th% for healthy children at a given altitude.
At 8,200 feet (2,500 meters) elevation 97.5 % of children had oxygen concentrations above 90%
At 10,498 feet (3,200 meters) elevation this decreased to 85%, with 2.5 % of children were below this.
Should children living in Leadville, Alma and Fairplay be allowed to go untreated when their oxygen levels are 85-89%?
Now that many families have a pulse oximeter parents are measuring their children’s oxygen levels when they are sick, and presumably when they are well.
Therefore deciding when a child has a low oxygen that needs treatment can be based on the child’s levels when healthy. Unfortunately, these oximeters are not accurate in infants.
Adaptation v.s. Aclimatization
Why don’t babies in Nepal and La Paz need oxygen?
Research comparing ethnic groups that have lived at high altitude for centuries, such as native Tibetans, and more recent immigrants such as the Han Chinese in Tibet, showed changes in adaptation. People living in the Andes, Himalayas and mountains of Ethiopia have higher lung volumes, more nitric oxide in the blood, high oxygen-carrying hemoglobin levels and increased respiratory rates which are genetic.
Those of us living in the mountains of Colorado have been here at the most 150 years, not long enough to establish gene-based adaptation. We do acclimatize over weeks and months with changes in hemoglobin levels, respiratory rates and lung volumes but not to the extent of the above populations.
During my travels to La Paz Bolivia and Cuzco, Peru I noticed the people were smaller. At Ebert Family Clinic we analyzed over 10,000 pieces of growth data on children up to four years old from our electronic medical record. A high percent are below the standard growth chart: seven percent compared to three percent. Most catch up by age two years.
How to keep oxygen on your young child
Both tourist and local children may need supplemental oxygen during illnesses at high altitude. There are excellent providers available 24 hours a day to set up tanks and concentrators so most don’t have to stay in the hospital, but can be comfortable at home with the family. It is a mistake to admit these children to the hospital just because they won’t keep the nasal cannula in their nose. Hospital guidelines make it difficult for nurses to implement adequate control measures over these fiesty little ones.
At Ebert Family Clinic we have found a very effective method: magazines. Tape a magazine around both child’s arms so that they cannot bend their elbows to pull off the cannula. After 30 minutes of not being able to use their arms, most children will accept the oxygen.
