Raising hope

Dr Vandana Katyal
Dr Vandana Katyal

Dr Vandana Katyal is breaking new ground in the research of sleep apnoea in children and aims to raise awareness about the cause and treatment. By Nick Carne

Vandana Katyal was inspired by a number of teachers, but it was a friend who helped set her career direction. That friend happened to be a paediatrician who had an interest in childhood sleep disorders and was astounded at the paucity of literature looking at the problem from an orthodontic perspective. She also knew the people in Adelaide to talk with.

For an orthodontics student who was looking for a research project—and had an abiding interest in working with young people—that was too good an opportunity to pass up. And it appears to have been a sound decision all round.

In little more than a year, Dr Katyal has graduated from the University of Adelaide, won the ABOS/NZAO prize for best postgraduate presentation, co-authored two papers in the American Journal of Orthodontics and Dentofacial Orthopedics and another in the Australian Orthodontic Journal, and presented at Australian and international orthodontic conferences. She has also worked as an adjunct lecturer for the University of Western Australia’s online Graduate Diploma in dental sleep medicine and was awarded the prestigious Sam Bulkley–AB Orthodontics Travelling Fellowship to continue her research in Germany later this year.

More importantly from her perspective, however, she has been part of developing a multi-disciplinary approach to studying paediatric sleep disorders in Adelaide that is gaining some traction, and is now involved with a similar initiative in Sydney.

That should make her uncle back in India pretty proud. It was while helping out in his New Delhi dental surgery as a schoolgirl that Dr Katyal decided dentistry was the way her interest in science should be directed. “I just found the whole thing fascinating,” she says.

Arriving in Australia with her parents as an 18-year-old, she started applying to dental schools, and the University of Sydney said yes. After graduating in 2001 she spent nine years in a private practice while also studying part-time for two of those years to earn a Master of Science in Medicine (Clinical Epidemiology).

“I really enjoyed general dental practice and I think it was valuable having that experience before moving to orthodontics because by then I knew that was what I really wanted to do and I had a better idea of what the possibilities were,” she says.

This time the University of Adelaide said yes to her application (the “best thing that could have happened”, Dr Katyal says, thanks to a supportive professor and Adelaide’s collaborative nature) and the possibilities for her emerged when the paediatrician friend urged her to read more about obstructive sleep apnoea (OSA).

“I was shocked by what we know about its impact on young people and by how little research had been done on possible treatments,” she says. “There were lots of studies into adults but no more than a handful of papers on children, even though we’d known children have it for 10 years.”

Dr Katyal’s contribution to expanding that body of literature has come in collaboration with the Sleep Disorders Unit at Adelaide’s Women’s and Children’s Hospital and paediatricians at the University of Adelaide, led by Associate Professor Declan Kennedy.

Their recent published work has focused on craniofacial and upper airway morphology in paediatric sleep-disordered breathing (SDB), an area that to date has been, in their own words, “poorly understood and contradictory”.

The first aim was to evaluate the prevalence of children at risk for SDB, particularly OSA, and to examine associations with their craniofacial and upper airway morphologies.

In a case-control study, 81 children aged eight to 17 were grouped as either high risk or low risk for SDB based on the scores from a validated 22-item paediatric sleep questionnaire and the ‘Obstructive Sleep Apnoea—18 Quality of Life’ questionnaire.

Results showed the frequency of palatal crossbite involving at least three teeth (suggesting a transversely narrow maxilla) was 68.2 per cent in the high-risk group, compared with just 23.2 per cent for the low-risk group.

Average quality of life scores in the high-risk group indicated reduced quality of life related to sleep-disordered breathing by 16 per cent compared with children in the low-risk group.

That snoring and SDB are strongly linked to a narrow palate is an important finding, one Dr Katyal acknowledges “is obvious when you think about it.

“I’m not sure why this has not been looked at before,” she says. “It might be because most research to date has been retrospective and based around the use of X-rays, which only show two dimensions—the vertical and the anterior/posterior.

“Our work is prospective, studying children in a clinical setting, and this has allowed us to take account of the transverse dimension, where we have found an even greater correlation.

“A lot more work is still needed, but this is an important step up the ladder.”

So, too, were the results from the second phase of the study, which was designed to assess the change in quality of life for affected children undergoing rapid maxillary expansion (RME) to correct a palatal crossbite or widen a narrow maxilla.

Ten children from the study group who underwent RME were followed longitudinally until the appliance was removed about nine months later. Children in the high-risk group showed an average 14 per cent improvement in quality of life compared with those in the low-risk group.

Again this is just another step up the ladder, but it raises hope that an orthodontic approach may be an alternative to surgery for children with a narrow palate. Preliminary results from subsequent research in Sydney and Italy add weight to this proposition.

“While removing the tonsils is the first line of treatment for children with OSA, up to half of those who have their tonsils out continue to suffer,” Dr Katyal says. “Exploring RMEs first in appropriate malocclusions could be a valuable option.”

She cautions, however, that it is too early to claim RMEs could be “a cure” and that orthodontists have to be wary of overstating its value until more research has been completed.

Dr Katyal says while the robust nature of the Adelaide team’s research was one of its strengths, it had also created the main complications.

“It was easy to enrol people and easy to get ethics approval because our research was not invasive. The hardest part was keeping all the records and keep everything on track,” she says. “Children don’t always co-operate and we had to bring them back in to see us, which can be quite draining for them.”

The research sample was primarily orthodontic patients who were referred by their local school dentists. Orthodontic data and sleep screening questionnaires were collected over a year, the 10 children who had RME were followed for an additional nine months.

With the research required for her degree completed, Dr Katyal returned to Sydney late last year and is now working as an orthodontist in private practice. However, she stays in regular contact with her former colleagues who are continuing the study, and is excited to be a part of a new multi-disciplinary paediatric sleep clinic planned for Westmead Children’s Hospital.

Again a friend helped make it happen. Associate Professor Kennedy put her in touch with the hospital’s Professor of Paediatrics & Child Health, Karen Waters, who is the driving force behind creating a team that will include orthodontists, speech pathologists and respiratory, sleep and ENT physicians.

While the research gains momentum, Dr Katyal believes an important priority is to raise awareness among the medical and dental communities and the broader population.

Estimates are that 10 to 12 per cent of Australian children have either chronic snoring or sleep apnoea, she says, with some research suggesting it is as high as 25 per cent.

The message for parents is that snoring is not normal for children, unless they have a cold or some other influences are at play, so if their children snore regularly—more than three times a week—this may be an indication of OSA.

“They need to speak up,” she says. “Research shows that 80 per cent of kids with these problems aren’t diagnosed or reported.”

The message for doctors, dentists and orthodontists is that they are on the front line and have an obligation to do a thorough assessment if they have any reason to believe their young patients may be suffering from SDB.

She believes the aim should be to screen every child who shows signs of air obstruction, with a view to insuring that each child is assessed and treated individually.

“What we really need is to develop a protocol—a consensus on what to do first and who should do it,” Dr Katyal says. Perhaps that’s the cue for a future PhD.

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