Postoperative Respiratory Compromise in Children With Obstructive Sleep Apnea Syndrome: Can It Be Anticipated?

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Postoperative

Respiratory

Compromise

in

Children

With

Obstructive

Sleep

Apnea

Syndrome:

Can

It Be

Anticipated?

Gerald M. Rosen, MD*; Robert P. Muckle, MD4; Mark W. Mahowald, MD;

George

S. Goding, MDX; and Connie Ullevig, RN

ABSTRACT. Objective. The aim of this research was

to describe the postoperative respiratory complications after tonsillectomy and/or adenoidectomy (T and/or A) in children with obstructive sleep apnea syndrome (OSAS), to define which children are at risk for these complica-tions, and to determine whether continuous positive air-way pressure (CPAP) is an effective strategy for dealing with these complications.

Methods. The data for this study were gathered

through a retrospective chart review of all children 15

years of age or younger with polysomnographically (PSG) proven OSAS who had a T and/or A at Hennepin County Medical Center between January 1985 and September 1992. Particular attention was paid to factors that contrib-uted to the OSAS, postoperative respiratory complica-tions, and intervention strategies for dealing with these complications.

Results. The charts of 37 children with OSAS

docu-mented by preoperative PSG who later had a T and/or A were reviewed retrospectively. Ten of these children had significant postoperative respiratory compromise

second-ary to OSAS that prolonged their hospital stay from 1 to

30 days and caused symptoms ranging from 02

desatu-ration <80% to respiratory failure. These children were younger and had significant associated medical problems that contributed to or resulted from their OSAS in addi-tion to large tonsils and adenoids. The associated medical problems included craniofacial anomalies, hypotonia, morbid obesity, previous upper airway trauma, cor pul-monale, and failure to thrive. The children with postop-erative respiratory complications also had more severe ap-nea on their preoperative P5G. One child had a

uvulopalatopharyngoplasty (UPPP) in addition to the T &

A. Taken together, the history, physical and neurological examination, and the PSG were able to identify success-fully the children who subsequently developed

respira-tory compromise secondary to OSAS after a T and/or A. Nasal continuous positive airway pressure (CPAP) and bilevel CPAP was used successfully to manage the

pre-operative and/or postoperative upper airway obstruction

in five of these children.

Conclusions. Based on these findings, overnight

ob-servation is recommended with an apnea monitor and oximeter for patients undergoing a T and/or A who have

OSAS and meet any of the following high-risk clinical

criteria: (1) <2 years of age, (2) craniofacial anomalies

af-fecting the pharyngeal airway particularly midfacial hy-poplasia or micro/retrognathia, (3) failure to thrive, (4)

hy-From the Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, Departments of *pediatrics, Otolaryngology, and Neu-rology and the University of Minnesota Medical School, Minneapolis. MN.

Received for publication May 3, 1993; accepted Sep 15, 1993.

Reprint requests to (G. M. R.) Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, 701 Park Ave. Minneapolis, MN 55415.

potonia, (5) cor pulmonale, (6) morbid obesity, and (7) previous upper airway trauma; or high-risk PSG criteria: (1) respiratory distress index (RDI) >40 and (2) Sa02 nadir

<70%; or undergoing a UPPP in addition to the T and/or

A. Nasal CPAPlbilevel CPAP can be used to manage the

preoperative and/or postoperative upper airway obstruc-tion in patients with OSAS undergoing a T and/or A.

Pediatrics 1994;93:784-788; postoperative respiratory

com-promise, craniofacial anomalies, hypotonia, obesity, cor

pulmonale, CPAP.

ABBREVIATIONS. T and/or A, tonsillectomy and/or adenoidec-tomy; OSAS, obstructive sleep apnea syndrome; FIT, failure to thrive; PSG, polysomonogram; UPPP, uvulopalatopharyngo-plasty; RDI, respiratory distress index; CPAP, continuous positive airway pressure; BIPAP, bilevel positive airway pressure; BRA, breathing-related arousal.

Tonsillectomy and adenoidectomy (T&A) have

been and continue to be one of the most commonly

performed surgical procedures for children.1

Al-though recurrent tonsillitis is the most common

in-dication for surgery, upper airway obstruction is

be-coming an increasingly important indication for

surgery, especially in young children.1 T&As are

rou-tinely performed as an outpatient procedure at many

centers.2’3 There are obvious social and financial

ad-vantages to this as long as the shorter period of

ob-servation does not preclude detection of serious

post-operative complications.

The two most common serious complications after

T&A are local bleeding and upper airway

obstruc-tion.4’5 The timing of serious postoperative bleeding

after T&A’s has been studied in several large

reviews. These studies suggest that in children

without a history of significant medical or

hemato-logical problems, serious postoperative bleeding,

re-quining surgical intervention and/on transfusion, is

unlikely to begin later than 10 hours after surgery.

Because the interval between surgery and onset of

serious bleeding is generally brief, the 6 to 8 hour

postoperative observation period in most short stay

units appears adequate to allow for identification and

intervention in the rare child with this complication.

Upper airway obstruction is the most serious

res-piratory complication after a T&A.5’7 In children with

OSAS, upper airway obstruction is state-dependent.

It is present only during sleep and is generally worse

during rapid eye movement sleep.8 Because most of

these children have surgery in the morning and most

rapid eye movement sleep occurs in the later part of

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ARTICLES 785

may not be apparent until 18 hours postoperatively.

This consideration has led us to routinely monitor all

children undergoing T and/or A for OSAS in an

in-tensive care unit for 24 hours postoperatively,

through an entire sleep period. This study was

undertaken to evaluate whether this approach is

justified.

METHODS

The charts of all patients I 5 years of age or younger undergoing T and/or A for PSG-proven OSAS between January 1985 and September 1992 at Hennepin County Medical Center were re-viewed. Data collected were: age, sex, results of preoperative poly-somnography, past medical history, surgical procedure, and post-operative complications.

All patients were evaluated at the Minnesota Regional Sleep Disorders Center and had an all night PSG usIng standard tech-niques. A 16-channel Grass polygraph recorded electroencephalo-gram, electrocardiogram, oral/nasal airflow, electrooculogram, chin electromyogram, respiratory inductive plethysmography, in-tercostal electromyogram, and arterial oxyhemoglobin saturation measured by a Ohmeda pulse oximeter, Model 3700 with a Flex probe and a 6-second response time. All PSGs were scored using standard Rechtschaffen & Kales sleep stage scoring criteria,9 and records were interpreted by a board certified sleep specialist.

The criteria for the diagnosis of OSAS is well-defined in adults but not so in infants and children. The adult criterion is based on total number of apneas and hypopneas per hour. The same crite-non has been used in a pediatric population.7”#{176} However, a recent study of OSAS in children has shown that the standard adult criterion does not identify all children with clinically significant sleep-disordered breathing)”2 The retrospective design of this study limited us to collating data that had been previously gath-ered. Consequently, only children that meet the adult definition of OSA and/or breathing-related arousal (BRA) are included in this

report. OSA was defined as an event marked by a 50% or greater

decrease of airflow at the nose and mouth associated with

con-tinuation of respiratory effort lasting at least 10 seconds associated with an 02 desaturation of at least 2%. BRA were defined as events marked by a 30 to 50% reduction of airflow at the nose and mouth associated with a change in respiratory pattern leading to an arousal and associated with a 1 to 2% decrease in 02 saturation. The RDI is the number of OSA and BRA events occurring per hour

of sleep. CO2 measurements were not available in the sleep

labo-ratory during the interval in which data were gathered for this

study.

The data were analyzed to determine whether features of the history, physical examination, neurologic examination, and the preoperative PSG were able to predict which patients were at risk for postoperative respiratory compromise.

Data Analysis

For age, RDI, and 02 saturation, the Mann-Whitney-U two-tailed test was used. For sex and medical problems, the two-tailed Fisher’s exact test was used.

RESULTS

Between January 1985 and September 1992, 174

children 15 years of age or younger had a T & A, one

child had a T & A and a UPPP, 138 children had an

adenoidectomy, and three children who had an

ad-enoidectomy alone subsequently had a T & A or a

repeat adenoidectomy. Of these 312 children, 37 had

an all-night PSG before surgery documenting the

presence and severity of OSAS. It is this group that is

discussed in this report. Twenty-seven of these

chil-dren had no postoperative complications and were

discharged home on day I or day 2 postoperatively.

Ten had significant postoperative upper airway

ob-struction that was apparent within hours of surgery.

Symptoms and findings of postoperative upper

air-way obstruction included snoring; increased work of

breathing during sleep; consistently low 02 saturation

(<80%) requiring continued repositioning,

supple-mental 02, nasal continual positive airway pressure

(CPAP, Respironics, Murrysville, PA) or bilevel

posi-tive airway pressure (BIPAP, Respironics,

Murrys-ville, PA). Two children required prolonged

intuba-tion, and one required reintubation (Table 1).

Five children received nasal CPAP/BIPAP to treat

their upper airway obstruction either preoperatively,

postoperatively, on both (Table 2).

TABLE 1. Clinical and PSG Characteristics in Children with Postoperative Upper Airway Obstruction After Tonsillectomy and/or Adenoidec tomy for OSAS

Patient Age Sex Associated Medical Problems Surgery PSG Postoperative Complications RDI 02 Nadir

I 4 y M Airway burn T&A 44 53% Desaturations to 40%, required 02

2 2.75 y M Chondrodysplasia puntata,

mid-facial hypoplasia, low muscle tone

T&A 91 24% Desaturations to 50%, required 02 and BIPAP postoperative

3 8 mo M Midfacial hypoplasia, FTT, bron-chotracheomalacia, low muscle tone

A 28 39% Desaturations, required 02 and CPAP postoperative

4 12 mo M Midfacial hypoplasia, FTT, developmental delay, fetal alcohol syndrome

T&A 149 3% Desaturations to 50%, required 02

5 4.25 y F Obesity A 48 78% Desaturations to 60%, required 02

6 14 mo M F1F, low muscle tone T&A

UPPP

27 0% Respiratory failure, required reintubation

7 19 mo F FTT, developmental delay, low

muscle tone

T&A 53 85 Desaturations, required 02

8 9 mo F Rubinstein-Taybi syndrome,

FTf, midfacial hypoplasia

T&A 59 26 Prolonged intubation (36 h) required 02 and BIPAP after extubation

9 15 mo F FIT T&A 39 61 Desaturation to 70%, required 02

10 17 mo M Cor pulmonale, recurrent pneumonia

T&A 33 53 Prolonged mtubation (4 d) required CPAP and 02 postextubation

* PSG, polysomnogram; OSAS, obstruction sleep apnea syndrome; RDI, respiratory disturbance index = (# of apnea + breathing-related arousals)/total hours of sleep; M, male; F, female; T&A, tonsillectomy and adenoidectomy; BIPAP, bilevel positive airway pressure; FTT, failure to thrive; A, adenoidectomy; CPAP, continuous positive airway pressure; UPPP, uvulopalatopharagoplasty.

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TABLE 3. Clinical and PSG Characteristics of Children With and Without Postoperative Upper Airway Obstruction After Tonsillectomy and/or Adenoidectomy for OSAS

No. Age

P

.Oolt

RDI

Mean: 67/h (SD = 44) Range: 27-149/h 02 saturation nadir

Mean: 42% (SD = 29) Range: 0-85%

* PSG, polysomnogram; OSAS, obstructive sleep apnea syndrome; RDI, respiratory disturbance index

= (total # of apnea + breathing-related arousals)/sleep duration in hours.

1Statistical significance.

TABLE 2. Nasal CPAP/BIPAP* for Upper Airway Obstruc-tion Pre- and Post-tonsillectomy and/or Adenoidectomy for OSAS

Patient Age Preoperative Postoperative

2 2.75 y BIPAP 7/5 (9 d) BIPAP 7/5 and 02

(4 d)

3 8 mo CPAP 7.0 (4 d) CPAP 8.0 and 0, (1 d)

8 9 mo 02 (2 d) Intubation (36 h)

BIPAP 10/8 and #{176}2

(2 d) 10 17 mo CPAP 8.0 and Intubation (4 d)

02 ‘1 d) CPAP 8.0 and 0, (6 d)

11 9 mo CPAP 8.0 (4 d) None

CPAP, continuous positive airway pressure; BIPAP, bilevel posi-tive airway pressure; OSAS, obstructive sleep apnea syndrome.

Four children were inpatients for a period of 2 days

to 5 months before the T and/or A. One child (patient

1) was admitted 5 months previously to the Burn Unit,

and two children were admitted after the PSG

be-cause of the severity of the OSAS. Patient 2 was

treated with BIPAP for 9 days before surgery, and

patient 8 was treated with 02 for 2 days

preopera-tively. One child (patient 10) was admitted to the

hos-pital because of pneumonia and was noted to have

OSAS during the first hospital night. A PSG on day

2 confirmed the OSAS. The child was on CPAP for I

night before surgery. The hospital stay for the

chil-dren with postoperative respiratory complications

was extended from I to 30 days after the day of the

surgery. Two of the children required prolonged

in-tubation, patient 8 for 36 hours and patient 10 for

4 days followed by nasal CPAP or BIPAP and 02

(patient 8, BIPAP and 02 for 2 days; patient 10, CPAP

and 02 for 6 days) to manage persistent upper airway

obstruction. One child (patient 6) had both UPPP and

T & A. This child required neintubation during the

first postoperative night for respiratory failure

sec-ondary to upper airway obstruction. The child

re-mained intubated for 4 days. (Nasal CPAP/BIPAP

was not available for children at that time in our

in-stitution, and it was thus not used.)

Two other children (patients 2 and 3) received

BIPAP from I to 4 days postoperatively to manage

upper airway obstruction. All of the children for

whom CPAP/BIPAP was used during their

post-operative recovery had previously been titrated for

CPAP/BIPAP during their diagnostic PSG. The

CPAP/BIPAP was delivered through a Respironics

prototype pediatric nasal mask (Respironics,

Murrys-ville, PA) with an inspiratory pressure of 4 to 10 cm

and an expiratory pressure of 4 to 8 cm. There were

no complications from use of the nasal CPAP/BIPAP.

Patient I I (Table 2) was a 9-month-old boy who had

a history of recurrent pneumonia and FTT. The PSG

revealed severe OSAS with an RDI of 65/h and an 02

saturation nadir of 61 %. After the PSG, the child

re-mained in the hospital and was treated with nasal

CPAP 8 cm water pressure for four nights before T &

A. Postoperatively, there were no complications, and

the child was discharged home on postoperative day

2. This child was not included in the statistical

analy-sis of the no complication group because the 4 days

of CPAP appeared to play a significant role in the

child’s clinical course and clearly distinguished this

child from others in that group.

The children with respiratory complications after T

and/or A were different from those who did not have

postoperative complications (Table 3). Those with

respiratory complications were younger (mean age of

I .8 years versus 5.2 years [P = .001]) had more severe

apnea on the preoperative PSG (RDI = mean 67/hour

with an 02 saturation nadir of 42% versus RDI =

mean 32/hour [P = .0003] with an 02 saturation nadir

of 81% [P = .0001]) and were more likely to have

as-sociated medical problems (100% versus 23% [P =

.0001]). All of the children who subsequently

devel-oped postoperative upper airway obstruction had

medical problems that either directly contributed to

or resulted from the OSAS in addition to enlarged

tonsils and/or adenoids. The medical problems that

contributed to the OSAS were craniofacial anomalies,

hypotonia, morbid obesity, and an upper airway

burn. Six of the 10 children with postoperative

com-plications had ITT, secondary to the OSAS and one

had cor pulmonale secondary to the OSAS. Children

without postoperative upper airway obstruction also

Sex Associated Medical Problems, % PSG Complications 10 8 mo to 4.25 y Mean = 1.8 y (SD = 17 mo) Male (7) Female (3) 10/10 (100%) No Complications 26 1.0 to 15 y Mean = 5.2 y (SD = 36 mo) Male (15) Female (11) 6/26 (23%)

RDI

Mean: 32/h (SD = 19) Range: 4-95/h

02 saturation nadir Mean: 81% (SD = 12) Range: 39-97%

.71

<.000lt

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ARTICLES 787

had medical problems but less often: 3/26 had

mid-facial hypoplasia, I /26 had morbid obesity, I /26 had

sickle cell disease, I /26 had hypotonia, and I /26 had

VFT. The sex of the child was not a significant factor

in the development of postoperative upper airway obstruction.

DISCUSSION

Upper airway obstruction during sleep in children

is the final common pathway for a multifacted,

mul-ticausal problem.8”#{176} The obstruction can be either

par-tial or complete and causes symptoms that vary from

simple snoring without evidence of clinical effect to

life-threatening respiratory failure. The mechanisms

responsible for upper airway obstruction in children

are both anatomic and neuromuscular in nature.

Ob-struction caused by anatomic factors include age,3

which determines the size of the pharyngeal airway,

soft tissue obstruction caused by enlarged tonsils

and/or enlarged adenoids, fat, macroglossia, and

craniofacial anomalies that affect the shape and size

of the pharyngeal airway-such as midfacial

hyp-oplasia on retro/micrognathia. In infants,

bronchotra-cheomalacia is another anatomic factor that can cause

upper and lower airway obstruction. The most

com-mon neuromuscular factor affecting the upper airway

is abnormal muscle tone.

It is the interplay of the various anatomic and

neu-romuscular factors that appears to distinguish

chil-dren with OSAS who are likely to have postoperative

respiratory complications after a T & A from those

who will not. All of the children who had

postopera-tive upper respiratory obstruction after T & A had

some factor in addition to enlarged tonsils and

ad-enoids that played a role in the development of their

OSAS. These factors include craniofacial anomalies,

hypotonia, young age, obesity, on previous upper

air-way trauma. All these factors affect the size and shape

of the pharyngeal airway. Consequently, it is not

sur-prising that in these children removing the tonsils and

adenoids with the attendant bleeding and edema is

associated with significant postoperative risks.

CPAP/BIPAP was used successfully in five

chil-dren to manage either preoperative on postoperative

upper airway obstruction. Nasal CPAP is a

well-accepted intervention for adults with OSAS,14 and has

been used to manage the postoperative upper airway

obstruction in adults undergoing a UPPP.’5 There is

only limited published experience with its use in the

pediatric literature.16 In this small group, CPAP/

BIPAP was well-tolerated in an inpatient hospital

set-ting by children as young as 9 months of age.

Patient I 1 (Table 2) is of particular interest because

one might have expected this child to have some

post-operative respiratory complications based on age,

as-sociated medical problems and PSG, but none

oc-curred. Although one can not attribute the benign

postoperative course of this child to the 4 days of

pre-operative CPAP, it does raise some intriguing

ques-tions that are currently under investigation.

Although this study is limited by small number and

a retrospective design, the implications are clear and

important. Postoperative respiratory compromise,

particularly upper airway obstruction, after upper

TABLE 4. High-Risk Profile for Postoperative Upper Airway Obstruction After T and/or A* for OSAS

Clinical Age <2 y

Craniofacial anomalies Failure to thrive Hypotonia Morbid obesity

Previous upper airway trauma Cor pulmonale

Surgical UPPP PSG

RDI >40

02 saturation nadir <70%

* T and/or A, tonsillectomy and/or adenoidectomy; OSAS, ob-structive sleep apnea syndrome; UPPP, uvulopalatopharyngo-plasty; P5G. polysomnogram; RDI, respiratory disturbance index.

airway surgery should be anticipated in high-risk

children with OSAS. The severity of the respiratory

complications range from relatively minor oxygen

de-saturation to life-threatening respiratory failure.

Chil-dren who are at high risk for these complications

al-most always have some problem in addition to

enlarged tonsils and adenoids to explain the presence

of the OSAS. These high-risk children can be

identi-fled by physical and neurological examination, and

preoperative polysomnography. The high-risk

clini-cal characteristics are young age, craniofacial

anoma-lies, FTT, hypotonia, con pulmonale, morbid obesity,

and previous upper airway trauma. The preoperative

PSG features associated with postoperative

respira-tory compromise are RDI >40 or 02 saturation nadir

<70%. A UPPP may pose additional risks of

postop-erative complication in the young child (Table 4).

This study extends and confirms the findings

ne-ported by McColley et al.7 The high-risk criteria they

identified for predicting postoperative respiratory

compromise were identical to this study’s: age,

weight <5th percentile, craniofacial anomalies,

abnor-mal electrocardiogram or echocardiogram, and

sever-ity of OSAS as defined on the P5G. Their

recommen-dations are the same: that children who meet these

high-risk criteria be monitored for at least the first

postoperative night after upper airway surgery.

Until a large, prospective study can more fully

de-lineate the profile of patients at high-risk for

post-operative respiratory complications after T and/or A,

great caution must be exercised when performing

up-per airway surgery in these high-risk children.

Post-operatively, these children should be monitored

over-night with an oximeter and apnea monitor in a setting

that can quickly respond to respiratory compromise.

If upper airway obstruction occurs postoperatively,

nasal CPAP/BIPAP should be considered as a

thena-peutic intervention. These children should not be

con-sidered candidates for outpatient upper airway

sun-gery at the present time.

ACKNOWLEDGMENTS

The authors wish to acknowledge Dr Alfred Pheely, Depart-ment of Medical Epidemiology, Hennepin County Medical Cen-ter, for his help with the statistical analysis and to Traci Oletzke for her help with the preparation of this manuscript.

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2. Helmus C. Grin M, Westlall P. Same-day stay adenotonsillectomy. Laryngoscope. 1990;100:593-596

3. Guida RA, Mattucci KF. Tonsillectomy and adenoidectomy: an inpa-tient or outpatient procedure? Laryngoscope. 1990;100:491-493

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following tonsillectomy nd adenoidectomy-who is at risk? Int I

Pediatr Otolani,ingol. 1987;13:1 17-124

6. Crysdale WS. Complications of tonsillectomy and adenoidectomy in

9409 children observed overnight. CMAJ. 1986;135:1 139-1142

7. McColley 5A, April MM, Carroll JZ, Naderio RM, Loughlin GM.

Res-piratory compromise after adenotonsillectomy in children with obstruc-tive sleep apnea. Arch Otolaryngol Head Neck Surg. 1992;118:940-943

8. Loughlin GM. Obstructive sleep apnea in children. Ado Pediatr. 1992;

39:307-336

9. Rechtschaffen A, Kales A, eds. A Manual of Standardized Terminology,

Techniques, and Scoring System for Sleep Stages of Human Subjects. Los

Angeles, CA: Brain Information Service; 1971

10. Brouillette R. Assessing cardiopulmonary function during sleep in in-fants and children. In: Beckerman R, Brouillette R, Hunt C, eds. Respi-ratory Control Disorders in Infants and Children. Baltimore, MD: Williams and Wilkins; 1992:125-141

11. Rosen CL, IYAndrea L, Haddad T. Adult criteria for obstructive sleep apnea do not identify children with serious obstruction. Am Ret’ Respir Dis. 1992;146:1231-1234

12. CarrollJL, Loughlin GM. Diagnostic criteria for obstructive sleep apnea syndrome in children. Pediatr Pulmonol. 1992;14:71-74

13. Betancourt D, Beckerman RC. Craniofacial syndromes. In: Beckerman R,

Brouillette R, Hunt C, eds. Respiratory Control Disorders in Infants and Children. Baltimore, MD: William and Wilkins; 1992:294-305

14. Iber C, O’Brien C, Schluter J, Davies 5, Leatherman J, Mahowald MW.

Single-night studies in obstructive sleep apnea. Sleep. 1991;14:383-385

15. Katsantonis GP. Complications of surgical treatment for obstructive sleep apnea. Oper Tech Otolaryngol Head Neck Sung. 1991;2:143-147 16. Guilleminault C, Nino-Murcia G, Heldt G, et al. Alternative treatment to

tracheostomy in obstructive sleep apnea syndrome: nasal continuous

positive airway pressure in young children. Pediatrics 1986;78:797-802

REPORT CARDS: SOME SAY THERE MUST BE A BETTER WAY

Despite decades of improvements in education, report cards have hardly

changed; educators see them as necessary evils that add little to a student’s

edu-cation but fear. Increasingly, though, some schools are trying new ways of

com-municating with parents that can reduce violence at home and actually enhance

learning.

In Attleboro, report cards now include a warning to parents not to let their

frustration over grades turn into violence. In Baltimore, middle-school students

earn “improvement points” and compete against themselves, not their peers.

Setting Their Own Goals

A school in Manhattan, Kan., has replaced report cards with triangular

parent-student-teacher

conferences in which the children set their own educational goals

and then assess how well they have done ...

While scattered schools around the country are experimenting with alternatives

to the report card-portfolios of work, evaluations by the teacher or parent

conferences-report cards remain the most important communication between

school and home in a vast majority of schools ...

The biggest problems arise when parents overreact. Child advocates in several

cities say that when report cards are issued, reports of child abuse go way up. The

National Committee for Prevention of Child Abuse, a group in Chicago, has a

national awareness campaign, with advertisements that read, “Stop the Report

Card Reflex.”

DePalma A. Report cards: Some say there must be a better way. The New Yonk Times. December 9, 1992.

Noted by J.F.L., MD

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1994;93;784

Pediatrics

Ullevig

Gerald M. Rosen, Robert P. Muckle, George S. Goding, Mark W. Mahowald and Connie

Syndrome: Can It Be Anticipated?