Pediatric obstructive sleep apnea: complications, management, and long-term outcomes

Diagnostic accuracy of the Belun ring in children at risk of obstructive sleep apnea

STUDY OBJECTIVES

The Belun ring is a new home sleep apnea testing device using a pulse oximeter sensor and a neural network algorithm, but its data in children are limited. This study aims to evaluate the correlation and agreement of the Belun ring, compared with polysomnography (PSG) and determine the diagnostic accuracy of the Belun ring for moderate-to-severe obstructive sleep apnea (OSA).

METHODS

This is a cross-sectional observational study in children aged 5-18 years with suspected OSA between June 2023 and February 2024. The Belun ring and PSG were undertaken on eligible participants to assess apnea-hypopnea index (AHI) in the same sleep test session.

RESULTS

Of 75 children enrolled, OSA was diagnosed in 74 children by PSG. The Belun AHI (B-AHI) was moderately correlated with the PSG AHI (P-AHI) (r = .63, P < .001) with mean difference (standard deviation) -7.8 (13.91) events/h. The area under the receiver operating characteristic curve of the B-AHI to identify moderate-to-severe OSA (P-AHI > 5 events/h) was 0.66, and the B-AHI cut-off of 3 events/h yielded 74.1% sensitivity and 52.4% specificity. The B-AHI cut-off of 2 events/h yielded 92.6% sensitivity, and 7 events/h yielded 95.2% specificity.

CONCLUSIONS

Despite the correlation, the difference in AHI between the Belun ring and PSG in children was noted. Either single or multiple B-AHI cut-offs to diagnose, include or exclude moderate-to-severe OSA may be valuable, but their implementation must be approached with caution.

CLINICAL TRIAL REGISTRATION

Registry: Thai Clinical Trials Registry; Name: Diagnostic Accuracy of the Belun Ring in Children at Risk of Obstructive Sleep Apnea; URL: https://www.thaiclinicaltrials.org/show/TCTR20240604003; Identifier: TCTR20240604003.

CITATION

Panichapat N, Niyomkarn W, Boonjindasup W, Thiamrakij P, Sritippayawan S, Deerojanawong J. Diagnostic accuracy of the Belun ring in children at risk of obstructive sleep apnea. J Clin Sleep Med. 2025;21(1):123-128.

Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Children Under 3 Years of Age

Objectives: To identify predictors of obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) in children under 3 years of age and to describe the characteristics of children with OSA under 3 years of age undergoing T&A in an ethnically diverse population. Methods: We examined 87 children under 3 years with T&A and pre- and post-operative polysomnography (PSG) between 8/2012 and 3/2020 at a large tertiary care hospital. Differences were compared for covariates including demographics, comorbidities, and respiratory parameters. Regression was used to identify predictors of persistent severe OSA. Significance was set at P < .05. Results: Of the 87 children in the study, 64 (74%) were male, 26 (30%) were obese, 34 (39%) were Hispanic, and 35 (40%) were Black. Most children (94%) had improvements in OSA severity as measured by the apnea-hypopnea index (AHI) after T&A, but 78% had persistent OSA (AHI ≥1) after surgery. Children with persistent mild, compared to moderate-severe OSA, were more likely to have gastroesophageal reflux disease (GERD) (50% versus 24%, P = .025), a craniofacial disorder (30% versus 10%, P = .025), Down syndrome (20% versus 5%, P = .031), or pre-operative severe OSA. Conclusions: This study of an ethnically diverse population found that T&A is an effective procedure at improving, but not resolving, OSA in children under 3 years. Children with Down syndrome, craniofacial abnormalities, GERD, or pre-operative severe OSA who are under 3 years old are at high risk for persistent OSA and may benefit from post-operative PSG. Future study should examine complications and long-term outcomes of T&A in this age group.

Airway management in infants with Robin sequence in the United Kingdom and Ireland: A prospective population-based study

OBJECTIVE

There is currently no consensus about managing upper airway obstruction (UAO) in infants with Robin sequence (RS), in terms of treatment efficacy or clinical outcomes. This study describes UAO management in UK/Ireland, and explores relationships between patient characteristics, UAO management, and clinical outcomes in the first 2 years of life.

METHODS

Active surveillance of RS throughout UK/Ireland via the British Paediatric Surveillance Unit and nationally commissioned cleft services. Clinical data were collected at initial notification and 12-month follow-up.

RESULTS

173 infants with RS were identified, of which 47% had additional congenital anomalies or an underlying syndrome (non-isolated RS). Two-thirds (n = 119) required an airway intervention other than prone positioning: non-surgical in 84% and surgical (tracheostomy) in 16%. Nasopharyngeal airway (NPA) was the most common intervention, used in 83% (n = 99) for median 90 days (IQR 136). Surgical UAO management was associated with prolonged hospital admission, higher prevalence of neurodevelopmental delay (NDD), lower weight-for-age z-scores, and delayed oral feeding. These findings were not attributable to a higher prevalence of non-isolated RS in this group. Although more commonly associated with non-isolated RS, growth faltering was also identified in 48%, and NDD in 18%, of cases of isolated RS.

CONCLUSIONS

In UK/Ireland, most infants with RS are managed with NPA, and tracheostomy is reserved for refractory severe UAO. Clinical outcomes and duration of use indicate that NPA is a safe and feasible first-line approach to UAO. Longitudinal assessment of neurodevelopment and growth is imperative, including in children with isolated RS. Current variations in practice reinforce the need for evidence-based treatment guidelines.

Role of endothelial dysfunction in sleep-disordered breathing in egyptian children with sickle cell disease

BACKGROUND

Endothelial dysfunction is an integral pathophysiologic mechanism in sickle cell disease (SCD), and can lead to many complications. Sleep-disordered breathing (SDB) is a SCD complication with diverse incidence and pathophysiology. This study aimed to determine the prevalence of SDB in children with SCD and to assess its relation to endothelial dysfunction.

METHODS

Sixty children with SCD and 60 healthy controls were enrolled. The levels of TNF-α, IL-6, and IL-17A were evaluated in the entire cohort using enzyme-linked immunosorbent assay (ELISA) kits. Polysomnography (PSG) was performed for all SCD patients after completion of the Pediatric Sleep Questionnaire (PSQ).

RESULTS

TNF-α, IL-6, and IL-17A levels were significantly greater in children with SCD than in controls (p-values < 0.001, < 0.001, and 0.006, respectively). The PSQ revealed symptoms suggestive of SDB in 50 children with SCD (83.3%), and PSG revealed obstructive sleep apnea (OSA) in 44 children with SCD (73.3%); 22 patients had mild OSA, and 22 had moderate-to-severe OSA according to the apnea-hypopnea index (AHI). TNF-α was significantly greater in SCD children who reported heavy or loud breathing, trouble breathing or struggle to breathe, and difficulty waking up in the morning (p-values = 0.002, 0.002, and 0.031, respectively). The IL-6 levels were significantly greater in SCD children who stopped growing normally (p-value = 0.002). The levels of IL-6 and IL-17A were significantly greater in SCD children with morning headaches (p-values = 0.007 and 0.004, respectively).

CONCLUSION

Children with SCD showed a high prevalence of SDB with significantly elevated levels of markers of endothelial function, highlighting the interplay of SDB and endothelial dysfunction in SCD.

Quality of life of elementary school students with sleep-disordered breathing and allergic rhinitis: A population-based study in Thailand

BACKGROUND

Sleep-disordered breathing (SDB) and allergic rhinitis (AR) are common problems that can lead to worsening quality of life (QOL) in children with these conditions. There is scarce evidence on the QOL of children with SDB outside of the hospital setting with inconsistent evidence on the association of AR and QOL concerning the SDB in children. Thus, the primary objective of this study is to determine the QOL concerning the SDB of elementary school students by using OSA-18. We also aim to provide the relationship of allergic rhinitis to the QOL.

METHODS

A cross-sectional study was conducted on all elementary school students, aged 6-12 years, from 10 elementary schools. The QOL of all participants was evaluated by the Thai version of the caregiver-administered OSA-18 questionnaire. The simple and multiple linear regression models were used to determine the effect of allergic rhinitis on the OSA-18 total scores.

RESULTS

A total of 3,053 children were included in the final analysis, 50.1% male. At least a moderate impact on QOL from SDB was observed in 9.4% of the population. Children with AR had significantly higher mean total OSA- 18 scores than the children without AR (47.5 ± 15.0 VS 38.5 ± 13.1, p < 0.001). After the adjustment for age, gender, body mass index, household income, and history of asthma, the point estimate of the adjusted beta regression coefficient on the OSA-18 total score in children with AR was 7.82 (95% CI: 6.00-9.65, p < 0.001). Significant associations were observed between AR and all domains except for emotional distress.

CONCLUSIONS

A substantial number of elementary school children had at least a moderate impact on the QOL from SDB, especially those with AR. Thus, effective screening of SDB in children with AR should be done to improve the QOL of these children.

Cephalometry as an aid in the diagnosis of pediatric obstructive sleep apnoea: A systematic review and meta-analysis

Background

Obstructive sleep apnoea (OSA) is part of a spectrum of sleep disorders causing snoring, gasping, and choking while sleeping. In children, OSA can also lead to behavioural issues, hyperactivity, and poor academic performance. Thus, early identification and management of OSA in children is crucial in preventing long-term health problems. The gold standard test for diagnosis is an overnight in-lab polysomnography (PSG). However, due to certain constraints associated with PSG, such as lack of accessibility, high expenses incurred, as well as the need for hospitalization, alternative diagnostic tools are needed. Cephalometry is a non-invasive, affordable diagnostic tool that may offer useful information in the evaluation of OSA. The present systematic review and meta-analysis aimed to evaluate the various cephalometric parameters associated with the diagnosis of OSA in children.

Methods

A structured literature search was performed using the search engines PubMed, Scopus, Web of Science, Cochrane, and Google scholar from inception till July 2022. The weighted mean difference (z-test) was calculated using a random effects method (REM).

Results

16 studies were included in the review and meta-analysis was executed for each cephalometric parameter. The parameters of significance (p < 0.05) in Pediatric OSA with lower heterogeneity were associated with McNamara's and Linder-Aronson's analysis, the hyoid bone position, a retrognathic mandible, and an acute cranial base angle.

Conclusions

Certain parameters in craniofacial morphology may be reliable diagnostic parameters. Further long-term studies are needed in order to shed more light in this area.

'Personalized medicine': phenotyping pediatric obstructive sleep apnea

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) is common in children. Phenotyping pediatric OSA has a crucial role in personalized diagnosis and treatment to improve outcomes for this population. This review sets forth a clinical approach that allows for phenotyping pediatric OSA.

RECENT FINDINGS

The emerging concept of phenotyping pediatric OSA is based on identifying a primary cause, which leads to a more precise understanding of the pathogenesis in any individual patient. Phenotyping enables treatment focusing on the primary cause, but does not exclude the need for supplemental management strategies based on other recognizable traits. The identification of pediatric OSA phenotypes (POP) relies on observable characteristics with significant prevalence. This review will concentrate on the most important phenotypes seen in clinical practice: pediatric OSA with craniofacial abnormalities (POPCA); OSA with upper airway disease (POPUAD); OSA with obesity (POPO), and OSA associated with neuromuscular disease (POPNED).

SUMMARY

Phenotyping pediatric OSA is a form of personalized medicine. By identifying clinical subtypes, individualized treatment plans can be devised in order to choose therapies that are associated with predictable responses. Moreover, it is rare that a therapeutic modality is devoid of possible complications; knowledge of the phenotype being treated can enable early intervention should those occur. Finally, all of the aforementioned phenotypes require personalized support incorporating individualized care plans so as to optimize the quality of life and overall sleep health of children with OSA.

Awareness and Knowledge of Parents and Caregivers Regarding Pediatric Obstructive Sleep Apnea in Jazan, Saudi Arabia: A Cross-Sectional Study

Background Pediatric obstructive sleep apnea (POSA) is a common sleep disorder that can cause major health problems if untreated. Parental knowledge and awareness are critical for early detection and management of POSA in children. This study sought to measure parents' and caregivers' knowledge and awareness of pediatric POSA in Jazan, Saudi Arabia, as well as to uncover sociodemographic correlates of knowledge levels. Methods This cross-sectional study was conducted in Jazan, Saudi Arabia. A structured survey was used to collect data on sociodemographic factors and knowledge of pediatric OSA. Data were examined using descriptive statistics, ANOVA, and multivariate logistic regression analysis. Results The study included 393 parents and caregivers, 36.4% of whom were in the 18-30 year age group. Most were Saudis (n=385; 98%), and 212 (53.9%) were men. Most parents (n=378; 96.2%) had limited knowledge of pediatric OSA. Significant knowledge gaps were observed in recognizing POSA symptoms, understanding its impact on children's academic performance, and their association with mental health issues. Internet and social networking sites were the most common sources of knowledge about POSA (n=131; 33.33%), followed by knowing someone with OSA (n=103; 26.21%). Parents with more than eight children had a significant association with more knowledge than those without children (adjusted OR = 10.661, 95% CI: 1.367-83.139, p = 0.024). Conclusion The study identified significant gaps in the recognition of POSA symptoms and understanding its impact on their children's academic performance and mental health. Despite their limited knowledge, parents were receptive to early intervention for POSA. The study suggests that parents with more children had better knowledge of POSA, indicating that experiential learning may contribute to their understanding. The study recommends developing and assessing targeted education and awareness programs for parents, healthcare providers, and the public to improve POSA diagnosis, care, and outcomes.

Allergic rhinitis as a predictor of moderate-to-severe paediatric obstructive sleep apnoea

PURPOSE

Obstructive sleep apnoea (OSA) is a common sleep-related breathing disorder affecting children. This study aims to characterize factors associated with the development and progression of severe forms of paediatric OSA.

METHODS

This study included children admitted to Children's Hospital of Chongqing Medical University, a tertiary children's hospital in southwest China between January 2020 and December 2020 with a discharge diagnosis of OSA. Each patient underwent polysomnography examination, following assessments of apnoea-hypopnea index (AHI) and lowest oxygen saturation (LSaO2) by standardized techniques. Demographic and clinical information was collected from the hospital's electronic medical records. Associations between OSA severity and various factors were first examined in a univariate logistic model, with subsequent multivariate analysis to further identify independent risk factors.

RESULTS

A total of 263 children were identified during the study period. Among patients presenting with OSA, 51.3% had mild and 48.7% had moderate to severe symptoms according to standardized guidelines. The incidence of mild and moderate to severe hypoxemia in our population was 39.2% and 60.8%, respectively. Allergic rhinitis (AR; adjusted odds ratio (aOR) = 1.75, 95% CI 1.03-2.96) and male gender (aOR = 1.77, 95% CI 1.03-3.06) were significantly associated with moderate-to-severe OSA (all P-values < 0.05) after adjustment for covariates. AR was also the only significant predictor of hypoxemia (P < 0.05).

CONCLUSION

Our results suggest that male gender and presence of AR may be associated with an increased likelihood of moderate-to-severe OSA in children. These findings underscore the importance of timely intervention and individualized management for at-risk individuals.

Sleep-Disordered Breathing and Associated Comorbidities among Preschool-Aged Children with Down Syndrome

Children with Down syndrome (DS) are at high risk of sleep-disordered breathing (SDB). The American Academy of Pediatrics recommends a polysomnogram (PSG) in children with DS prior to the age of 4. This retrospective study examined the frequency of SDB, gas exchange abnormalities, co-morbidities, and surgical management in children with DS aged 2-4 years old at Seattle Children's Hospital from 2015-2021. A total of 153 children underwent PSG, with 75 meeting the inclusion criteria. The mean age was 3.03 years (SD 0.805), 56% were male, and 54.7% were Caucasian. Comorbidities included (n, %): cardiac (43, 57.3%), dysphagia or aspiration (24, 32.0%), prematurity (17, 22.7%), pulmonary (16, 21.3%), immune dysfunction (2, 2.7%), and hypothyroidism (23, 30.7%). PSG parameter data collected included (mean, SD): obstructive AHI (7.9, 9.4) and central AHI (2.4, 2.4). In total, 94.7% met the criteria for pediatric OSA, 9.5% met the criteria for central apnea, and 9.5% met the criteria for hypoventilation. Only one child met the criteria for hypoxemia. Overall, 60% had surgical intervention, with 88.9% of these being adenotonsillectomy. There was no statistically significant difference in the frequency of OSA at different ages. Children aged 2-4 years with DS have a high frequency of OSA. The most commonly encountered co-morbidities were cardiac and swallowing dysfunction. Among those with OSA, more than half underwent surgical intervention, with improvements in their obstructive apnea hypopnea index, total apnea hypopnea index, oxygen saturation nadir, oxygen desaturation index, total arousal index, and total sleep duration. This highlights the importance of early diagnosis and appropriate treatment. Our study also suggests that adenotonsillar hypertrophy is still a large contributor to upper airway obstruction in this age group.

Adenotonsillectomy for the treatment of OSA in children with mucopolysaccharidosis: A systematic review

OBJECTIVE

To study the role of adenotonsillectomy (ADT) for obstructive sleep apnea (OSA) in children with mucopolysaccharidosis (MPS).

METHODS

A systematic review were performed following the PRISMA guideline. PubMed and Embase were searched for studies regarding adenotonsillectomy for OSA in children with MPS. The MINOR Score were applied for quality assessment of the included studies.

RESULTS

Nineteen studies were eligible for inclusion: fifteen were retrospective and four prospective. A total of 1406 subjects were included. The samples size varied from 2 to 336, the male to female ratio is 1.2 and mean age varied from 2.4 to 11 years. Overall, 56.2 % (IC 95%: 53.6-58.8) of the included subjects underwent ADT. MPS I and II are the two most operated types. Three studies, including 50 children, reported improvement in polysomnographic parameters after surgery. Two authors described the duration of follow-up: 8.4 and 9.8 years, respectively.

CONCLUSIONS

More than half of children with MPS underwent ADT for the treatment of OSA, although few evidence demonstrated improvement in term of polysomnographic parameters. The two types of MPS most involved are type I and II. Considering the disease progression and anesthetic risks, multidisciplinary management may help identify the subgroup of children with MPS who benefit from ADT for the treatment of OSA.

Identification of novel loci in obstructive sleep apnea in European American and African American children

STUDY OBJECTIVES

To identify genetic susceptibility variants in pediatric obstructive sleep apnea in European American and African American children.

METHODS

A phenotyping algorithm using electronic medical records was developed to recruit cases with OSA and control subjects from the Center for Applied Genomics at Children's Hospital of Philadelphia (CHOP). Genome-wide association studies (GWAS) were performed in pediatric OSA cases and control subjects with European American (EA) and African American (AA) ancestry followed by meta-analysis and sex stratification.

RESULTS

The algorithm accrued 1486 subjects (46.3% European American, 53.7% African American). We identified genomic loci at 1p36.22 and 15q26.1 that associated with OSA risk in EA and AA, respectively. We also revealed a shared risk locus at 18p11.32 (rs114124196, p = 1.72 × 10-8) across EA and AA populations. Additionally, association at 1q43 (rs12754698) and 2p25.1 (rs72775219) was identified in the male-only analysis of EA children with OSA, while association at 8q21.11 (rs6472959), 11q24.3 (rs4370952) and 15q21.1 (rs149936782) was detected in the female-only analysis of EA children and association at 18p11.23 (rs9964029) was identified in the female-only analysis of African-American children. Moreover, the 18p11.32 locus was replicated in an EA cohort (rs114124196, p = 8.8 × 10-3).

CONCLUSIONS

We report the first GWAS for pediatric OSA in European Americans and African Americans. Our results provide novel insights to the genetic underpins of pediatric OSA.

Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea

RATIONALE

Lower respiratory tract infections (LRTI) during the first 2 years of life increase the risk of pediatric obstructive sleep apnea (OSA), but whether this risk varies by LRTI severity is unknown.

METHODS

We analyzed data from 2962 children, aged 0-5 years, with early-life LRTI requiring hospitalization (severe LRTI, n = 235), treated as outpatients (mild LRTI, n = 394) and without LRTI (reference group, n = 2333) enrolled in the Boston Birth Cohort. Kaplan-Meier survival estimates and Cox proportional hazards models adjusted by pertinent covariables were used to evaluate the risk of pediatric OSA.

RESULTS

Compared to children without LRTI, those with mild LRTI were at a higher risk of having OSA (hazard ratio [HR] 1.44, 95% confidence interval [CI]: 1.01-2.05), and those with severe LRTI were at the highest risk (HR 2.06, 95% CI: 1.41-3.02), independently of relevant covariables (including maternal age, race, gestational age, and type of delivery). Additional risk factors linked to a higher risk of OSA included prematurity (HR 1.34, 95% CI 1.01-1.77) and maternal obesity (HR 1.82, 95% CI 1.32-2.52). The time elapsed between LRTI and OSA diagnosis was similar in mild and severe LRTI cases, with medians of 23 and 25.5 months, respectively (p = .803).

CONCLUSION

Infants with severe early-life LRTI have a higher risk of developing OSA, and surveillance strategies to identify OSA need to be particularly focused on this group. OSA monitoring should continue throughout the preschool years as it may develop months or years after the initial LRTI hospitalization.

Obstructive sleep related breathing disorders and cardiometabolic risk factors - A Portuguese birth cohort

BACKGROUND

Pediatric obstructive sleep related breathing disorders (SRBD) are an important under-diagnosed health problem with associated cardiometabolic comorbidities, demonstrated with polysomnographic studies in selected samples. Our main goal was to assess the prevalence of SRBD in a population-based cohort and to analyze its association with cardiometabolic risk factors, in general and by sex.

METHODS

Pediatric Sleep Questionnaire (PSQ) was applied to parents of 7-years-old children evaluated in the birth cohort, Generation XXI. Sex, anthropometrics, blood pressure (BP), lipid profile, glucose, insulin, HOMA-IR, and high-sensitivity C-reactive protein were compared among children with/without SRBD, using Chi-square, Mann-Whitney tests and logistic regression models.

RESULTS

A total of 1931 children (51.2 % boys) were included; 17.5 % were overweight and 15.7 % obese. The prevalence of SRBD was 13.4 %, more frequent among boys (15.7 % vs.10.9 %, p = 0.002) and in overweight/obese children (22.0 % vs.13.6 % vs.11.3 % in obese, overweight and normal weight group, respectively, p < 0.001). Children with SRBD had higher systolic BP (107 ± 8 vs.105±9 mmHg; p = 0.001) and lower HDL-cholesterol levels (54 ± 11 vs.56 ± 11 mg/dL; p = 0.04) than children without SRBD. After adjustment for sex, age, birthweight-for-gestational age and maternal age, children with SRBD had higher BMI-z-score, systolic BP, insulin and HOMA-IR levels, and lower HDL-cholesterol, when compared to those without SRBD, but these associations were lost when adjusting to BMI z-score. Analyzing obese children with the same regression model, those with SRBD presented lower HDL-cholesterol than those without SRBD.

CONCLUSIONS

Our results identified a male predominance of SRBD in pre-pubertal children and highlighted the potential contribution of SRBD to cardiovascular risk in obese children.

Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance

Obstructive sleep apnea (OSA) is the most common respiratory sleep disorder in the United States in preschool and school-aged children. In an effort to continue addressing gaps and variations in care in this patient population, the American Academy of Sleep Medicine (AASM) Quality Measures Task Force performed quality measure maintenance on the Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea (originally developed in 2015). The Quality Measures Task Force reviewed the current medical literature, including updated clinical practice guidelines and systematic literature reviews, existing pediatric OSA quality measures, and performance data highlighting remaining gaps or variations in care since implementation of the original quality measure set to inform any potential revisions to the quality measures. These revised quality measures have been implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous quality improvement, specifically in outcomes associated with diagnosing and managing OSA in the pediatric population.

CITATION

Lloyd RM, Crawford T, Donald R, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance. J Clin Sleep Med. 2024;20(1):127-134.

A review of uvulopalatopharyngoplasty for pediatric obstructive sleep apnea

OBJECTIVES

To evaluate existing literature to understand the utility and safety of uvulopalatopharyngoplasty (UPPP) for treatment of pediatric obstructive sleep apnea (OSA).

METHODS

A literature review was conducted by two authors to search for studies from the inception of two databases until March 1, 2023. Studies in which participants were under 18 years of age and underwent UPPP for OSA or upper airway obstruction were selected. Data on variables such as pre- and postoperative severity, efficacy, complications, and follow-up were collected from all studies.

RESULTS

After applying inclusion criteria to the initial 91 abstracts that were screened, 26 studies remained that included 224 patients who underwent UPPP. Most children who underwent UPPP had neurologic impairment, developmental delay, craniofacial abnormalities, or were obese, and underwent several procedures for OSA treatment. Of the studies that reported outcomes, 85.6 % of patients had subjective improvement, and 25.6 % of patients had a reported complication.

CONCLUSIONS

Most children who underwent UPPP had serious medical comorbidities with moderate or severe OSA and a multi-procedural treatment plan. Although most patients had subjective improvement and there were low complication rates, the heterogeneity of existing literature makes it difficult to draw conclusions. Future multi-center, prospective studies should be conducted to analyze the true safety and efficacy of UPPP in pediatric patients.

Computational fluid dynamics study in children with obstructive sleep apnea

OBJECTIVES

This study aims to identify characteristics in image-based computational fluid dynamics (CFD) in children with obstructive sleep apnea (OSA).

DESIGN

Diagnostic study.

SETTING

Hospital-based cohort.

PARTICIPANTS

Children with symptoms suggestive of OSA were recruited and underwent polysomnography.

MAIN OUTCOME MEASURES

Three-dimensional models of computational fluid dynamics were derived from cone-beam computed tomography.

RESULTS

A total of 68 children participated in the study (44 boys; mean age: 7.8 years), including 34 participants having moderate-to-severe OSA (apnea-hypopnea index [AHI] greater than 5 events/h), and 34 age, gender, and body mass index percentile matched participants having primary snoring (AHI less than 1). Children with moderate-to-severe OSA had a significantly higher total airway pressure (166.3 vs. 39.1 Pa, p = .009), total airway resistance (9851 vs. 2060 Newton-metre, p = .004) and velocity at a minimal cross-sectional area (65.7 vs. 8.8 metre per second, p = .017) than those with primary snoring. The optimal cut-off points for moderate-to-severe OSA were 46.2 Pa in the total airway pressure (area under the curve [AUC] = 73.2%), 2373 Newton-metre in the total airway resistance (AUC = 72.5%) and 12.6 metres per second in the velocity at a minimal cross-sectional area (AUC = 70.5%). The conditional logistic regression model revealed that total airway pressure, total airway resistance and velocity at minimal cross-sectional area were significantly associated with an increased risk of moderate-to-severe OSA.

CONCLUSIONS

This study demonstrates that CFD could be a useful tool for evaluating upper airway patency in children with OSA.

Pediatric obesity education and counseling in otolaryngology clinics: A survey of ASPO members

BACKGROUND

Adenotonsillectomy can cure pediatric obstructive sleep apnea (OSA) in 80% of children without obesity but only 20-30% of children with obesity. Despite this, there is a current lack of consistent guidelines and practices around pediatric obesity management in otolaryngology. This study evaluated the extent of counseling, referrals, confidence, and barriers in addressing childhood obesity in pediatric otolaryngology.

METHODS

A 20-question electronic survey assessing pediatric obesity practice patterns regarding sleep-disordered breathing (SDB) and OSA was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were performed. Pediatric otolaryngologists were compared using logistic regression models based on their practice type and frequency of counseling and referral.

RESULTS

Of all ASPO members, 19.6% (114/583) completed the survey. Half (50.0%) of physicians counsel and 14.0% refer to obesity management >75% of the time. Only 8.8% of physicians are confident their counseling helps reduce their patient's obesity, and 35.9% of physicians are satisfied with their services available for referral. Most physicians cite time/clinical workload (81.6%) and parent/rearing habits (50.0%) as barriers to obesity counseling. Non-academic physicians had lower odds of counseling and referring their patients >50% of the time (aOR 0.23 [95%CI 0.06-0.81], aOR 0.23 [95%CI 0.06-0.83]). Almost all (92.1%) physicians counsel on residual SDB or OSA after adenotonsillectomy >75% of the time if the child is obese.

CONCLUSIONS

Most pediatric otolaryngologists do not regularly counsel or refer patients to available obesity management programs, with differences seen between academic and non-academic surgeons. Confidence is low in currently available measures to reduce pediatric obesity. These results highlight the challenges of pediatric obesity and provide context for guideline implementation and additional resource development for pediatric otolaryngologists.

Analysis of possible risk factors for the severity of paediatric obstructive sleep apnoea syndrome

PURPOSE

This study aimed to determine the effect of body mass index (BMI) percentile, asthma, sex, and age on the paediatric obstructive sleep apnoea (OSA) severity. Furthermore, to determine the possible predictive role of the BMI percentile and age in severe OSA.

METHODS

This retrospective study included 921 children aged 2-18 years diagnosed with OSA by polysomnography. Analysis of Covariance (ANCOVA), Spearman's correlation, Receiver Operating Characteristics (ROC) analyses were performed and area under the curve (AUC) was determined.

RESULTS

We observed a significant association between a higher BMI percentile and the severity of OSA (p < 0.001, ρ = 0.15). The correlation also was significant under (p = 0.007, ρ = 0.11) and over 7 (p = 0.0002, ρ = 0.23) years of age. There was no association between the severity of OSA and the presence of asthma (p = 0.9) or sex (p = 0.891), respectively. Age was significantly related to OSA severity (p = 0.01, ρ = 0.08). Although both the BMI percentile (0.59 AUC [0.54-0.65]) and age (0.58 AUC [0.52-0.63]) predicted severe OSA, according to the sensitivity and specificity values of the ROC curve, the association presents a slight clinical relevance.

CONCLUSIONS

OSA severity is determined by the BMI percentile and age in children; however, these factors are unsuitable for predicting severe OSA in clinical practice. Based on our results, obesity is also a significant risk factor for OSA in younger children. Our study highlights that older, overweight, and obese children have a higher risk for severe OSA.

Pediatric pulmonology year in review 2022: Sleep medicine

Pediatric pulmonology publishes original research, review articles, and case reports on a wide variety of pediatric respiratory disorders. In this article, we summarized the past year's publications in sleep medicine and reviewed selected literature from other journals in this field. We focused on original research articles exploring aspects of sleep-disordered breathing in patients with underlying conditions such as asthma, neuromuscular disorders, and Down syndrome. We also explored sleep-disordered breathing risk factors, monitoring, diagnosis, and treatment; and included recent recommendations for drug-induced sleep endoscopy and ways to monitor and improve PAP adherence remotely.

Management of obstructive sleep apnea syndrome type 1 in children and adolescents - A French consensus

This document is the outcome of a group of experts brought together at the request of the French Society of Sleep Research and Medicine to provide recommendations for the management of obstructive sleep apnea syndrome type 1 (OSA1) in children. The recommendations are based on shared experience and published literature. OSA1 is suspected when several nighttime respiratory symptoms related to upper airway obstruction are identified on clinical history taking. A specialist otolaryngologist examination, including nasofibroscopy, is essential during diagnosis. A sleep study for OSA1 is not mandatory when at least two nighttime symptoms (including snoring) are noted. Therapeutic management must be individualized according to the location of the obstruction. Ear, nose, and throat (ENT) surgery is often required, as hypertrophy of the lymphoid tissues is the main cause of OSA1 in children. According to clinical findings, orthodontic treatment generally associated with specialized orofacial-myofunctional therapy might also be indicated. Whatever treatment is chosen, follow-up must be continuous and multidisciplinary, in a network of trained specialists.

Mental Health and Cognitive Development in Symptomatic Children and Adolescents Scoring High on Habitual Snoring: Role of Obesity and Allergy

BACKGROUND

Obstructive sleep apnea can have a negative impact on children's and adolescents' neurocognitive abilities and hinder their academic and adaptive progress in academic, social, and/or behavioral dimensions. In this retrospective cross-sectional study, we investigated the influence of body weight conditions and allergy status on long-term mental health, cognitive development, and quality of life in children and adolescents who snored.

METHODS

The study sample included 47 subjects (age range 4.1 to 15.3 years) who exhibited high levels of snoring and underwent home-based polysomnography between 2015 and 2019. Follow-up assessments (3 years on average between baseline and follow-up) entailed phone interviews with the subject's parents/caregivers who completed three validated questionnaires investigating sleep, quality of life, and parental ratings.

RESULTS

We found a correlation between age at diagnosis and being retrospectively overweight and high levels of snoring. In addition to a higher risk of developing emotional symptoms (8.2% increase in retrospective overweight status for each unit increase in the emotional score at follow-up) and oppositional behavior (9% increase in retrospective overweight status for each unit of oppositional T points at follow-up), we also noted reduced long-term social symptoms (11% decrease in retrospective overweight status for each unit increase in the social score at follow-up) and cognitive symptoms (10.6% decrease in retrospective overweight status for each unit increase in the cognitive score at follow-up), as well as a 6.1% increase in retrospective allergy status for each unit increase in academic performance at follow-up.

CONCLUSIONS

Snoring can have negative impacts on mental health and cognitive development in the long term. Early detection and intervention for neuropsychological disorders is important in children and adolescents who score high on snoring. In the long term, the effects of snoring on neuropsychological disorders may vary based on previous body weight and allergy status.

Topological Data Analysis of Electroencephalogram Signals for Pediatric Obstructive Sleep Apnea

Topological data analysis (TDA) is an emerging technique for biological signal processing. TDA leverages the invariant topological features of signals in a metric space for robust analysis of signals even in the presence of noise. In this paper, we leverage TDA on brain connectivity networks derived from electroencephalogram (EEG) signals to identify statistical differences between pediatric patients with obstructive sleep apnea (OSA) and pediatric patients without OSA. We leverage a large corpus of data, and show that TDA enables us to see a statistical difference between the brain dynamics of the two groups.Clinical relevance- This establishes the potential of topological data analysis as a tool to identify obstructive sleep apnea without requiring a full polysomnogram study, and provides an initial investigation towards easier and more scalable obstructive sleep apnea diagnosis.

Real-world data evaluation of PAP responsiveness in pediatric obstructive sleep apnea

STUDY OBJECTIVES

The use of positive airway pressure (PAP) in children is a complex process determined by multiple factors. There are limited data on the response of the pediatric population to PAP therapy at home. The goal of the study was to examine real-world responses using PAP home monitoring in children with obstructive sleep apnea.

METHODS

The study included PAP therapy data for 195 children aged between 1 month and 18 years with obstructive sleep apnea and polysomnogram baseline study. We collected demographics, clinical variables, and polysomnogram parameters in all study participants. The individual response to PAP therapy was calculated comparing the apnea-hypopnea index (AHI) in the initial polysomnogram with the mean AHI provided by the download of PAP devices. Multivariate models (logistic regression) were used to examine the predictors of positive PAP response defined as a reduction in AHI ≥ 75%.

RESULTS

We found excellent responses to PAP therapy in children (median 85% AHI reduction). However, there was substantial heterogeneity in AHI reductions while on PAP therapy. The best PAP responses were linked to more severe obstructive sleep apnea and higher PAP levels. We also identified that the response to PAP was higher in obese children and lower in males. The best predictive model for individual PAP response was biological sex, obesity, and obstructive AHI ≥ 20 events/h (area under the receiver operating characteristic curve of 0.791).

CONCLUSIONS

Real-world data show that PAP is overall an effective therapy in children but the response is heterogeneous. Obstructive sleep apnea parameters and individual factors can be used to predict individual AHI reductions while on PAP and optimize PAP responses at home.

CITATION

Aguilar H, Kahanowitch R, Weiss M, et al. Real-world data evaluation of PAP responsiveness in pediatric obstructive sleep apnea. J Clin Sleep Med. 2023;19(7):1313-1319.

Knowledge and Awareness of Parents About Pediatric Obstructive Sleep Apnea in Jeddah: A Cross-Sectional Study

Background Obstructive sleep apnea (OSA) is relatively common in childhood and is characterized by repeated partial or complete blockages of the upper airway during sleep. Children affected by OSA can experience various symptoms including snoring, restless sleep, and behavioral issues such as hyperactivity, impulsivity, and aggression, which interfere with their quality of life. Additionally, OSA can result in serious conditions such as cardiovascular and metabolic diseases. This study aims to determine the level of knowledge and awareness of OSA among parents in the Jeddah region. Methodology An observational cross-sectional study was conducted to determine the level of awareness of OSA among all parents in Jeddah, Saudi Arabia. Participants were recruited through social media platforms. The online survey assessed the knowledge regarding the OSA definition, risk factors, associated symptoms, and treatment. Results A total of 462 participants were included. Only 16% of participants had a good level of knowledge of OSA, while the remaining 84% had a poor level of knowledge. The mean knowledge score was 15.39 ± 5.8, with a significant difference between occupations (P=0.039). Conclusion Our study reveals that parents in Jeddah, Saudi Arabia have a low level of knowledge about pediatric OSA, with only 16% demonstrating good knowledge and less than half recognizing the definition of OSA. This lack of knowledge could lead to delays in diagnosis and treatment, negatively impacting children's health and academic performance. Common symptoms of OSA reported by parents were restless sleep, mouth breathing, and snoring, but bedwetting and hyperactivity were poorly recognized. Adenoids, allergic sinusitis, enlarged tonsils, asthma, and obesity were identified as risk factors for OSA. Improving parental awareness of OSA through public campaigns, doctor consultations, and education programs is crucial. Further studies are needed to assess the effectiveness of these interventions.

Drug-Induced sleep endoscopy in children: NAVOTEL scoring system development

OBJECTIVES

Pediatric drug-induced sleep endoscopy (DISE) lacks a universal and easy-to-use scoring system. The velum, oropharynx, tongue, epiglottis (VOTE) scoring system is widely used but needs to be completed in pediatrics. The main objective of this study was to investigate the distribution of obstructive sites in DISE and to propose an appropriate pediatric scoring system. The secondary objective was to evaluate the changes in surgical management induced by the proposed scoring system.

METHODS

A single-center prospective 5-year study was conducted from March 2016 to December 2021, including 99 children with a mean age of 7.2 years (±3.7), with pathological preoperative sleep recordings and undergoing DISE. The distribution of all upper airway obstructive sites was studied.

RESULTS

Adenoids (A) were the most frequent obstructive site (63% of patients), and the nasal cavities (N) and the larynx (L) were other frequent obstructive sites. These sites are not explored by the VOTE scoring system, leading to the creation of the nose, adenoids, velum, oropharynx, tongue, epiglottis, larynx (NAVOTEL) scoring system. NAVOTEL was significantly correlated with the severity of obstructive sleep apnea-hypopnea syndrome (OSAS) (ρ = 0.2; p = 0.04) and highlighted obstructive sites in 6/9 patients with VOTE = 0. Of these patients, 4 had a complete obstructive site, and 3 had a multisite obstruction. VOTE indicated 8 additional surgical actions; NAVOTEL indicated 50 other actions compared to clinical examination. The NAVOTEL scoring system was exhaustive regarding surgical indications for OSAS.

CONCLUSIONS

The NAVOTEL scoring system is exhaustive in pediatric DISE and correlated to OSAS severity. It should be preferred in pediatric DISE.

[Research progress on correlation between childhood obesity and obstructive sleep apnea]

Prevalence of childhood obesity is progressively increasing, reaching worldwide levels of 5.6% in girls and of 7.8% in boys. This also leads to a corresponding increase in the prevalence of obesity-associated morbidities particularly those involving obstructive sleep apnea（OSA）. Obesity is an independent risk factor and regulator of OSA in children. There is a bidirectional causal relationship between OSA and obesity in children. The factors involved in the association between OSA and obesity are systemic inflammation, oxidative stress, and gut microbiota etc. However, a causal link between obesity-related inflammatory state and OSA pathogenesis still needs to be properly confirmed. The present review aimed to investigate the links between childhood obesity and OSA.

The burden of sleep disordered breathing in infants with Down syndrome referred to tertiary sleep center

INTRODUCTION

Children with Down Syndrome (DS) are at high risk of sleep disordered breathing (SDB). We aimed to examine the burden of SDB in infants with DS referred to tertiary sleep center.

METHODS

Infants (≤12 months old) with DS who underwent consecutive polysomnography (PSG) at a single academic sleep center over a 6-year period were included. obstructive sleep apnea (OSA) (obstructive apnea hypopnea index [oAHI]>1/hr), central sleep apnea (central apnea index > 5/h) and the presence of hypoventilation (% time spent with CO2  > 50 mmHg either by end-tidal or transcutaneous> 25% of total sleep time) and hypoxemia (time spent with O2 saturation <88% >5 min) were ascertained.

RESULTS

A total of 40 infants were included (Mean age 6.6 months, male 66%). PSGs consisted of diagnostic (n = 13) and split night (n = 27, 68%) studies. All met criteria for OSA with mean oAHI 34.6/h (32.3). Central sleep apnea was present in 11 (27.5%) of infants. A total of 11 (27.5%) had hypoxemia. Hypoventilation was present in 10 (25%) infants.

CONCLUSION

This study highlights the high prevalence of SDB in infants with DS referred to a sleep center, and supports early PSG assessment in this patient population.

Pediatric Obstructive Sleep Apnea and Sickle Cell Disease: Demographic and Polysomnographic Features

OBJECTIVE

Obstructive sleep apnea (OSA) is prevalent in children with sickle cell disease (SCD). We compared the demographic, clinical, and polysomnographic characteristics of children with and without SCD.

METHODS

This retrospective chart review included children with SCD (n = 89) and without SCD (n = 192) ages 1-18 years referred for polysomnography (PSG) for OSA.

RESULTS

Children with SCD were predominantly African American when compared to the non-SCD group (95% vs. 28%, p < 0.001). The non-SCD group had a higher BMI z-score (1.3 vs. 0.1, p < 0.001) and a higher percentage of patients classified as obese (52% vs. 13%, p < 0.001). In children with SCD, 43% had severe OSA and 5.6% had no OSA. In the non-SCD group, 67% had severe OSA and 4.7% had no OSA. The SCD compared to the non-SCD group had a lower mean apnea-hypopnea index (AHI) (13.6 vs. 22.4, p = 0.006) but a higher percent sleep time below 90% oxygen saturation (10.5% vs. 3.5%, p < 0.001). Predicted probability for severe OSA in children with SCD decreased with increasing age (OR = 0.81, 95% CI: 0.70-0.93).

CONCLUSION

Children with SCD referred for PSG are at risk for severe OSA. Compared with the non-SCD group, most children were African American with lower rates of obesity and lower AHIs but longer periods of nocturnal hypoxemia. Likelihood for severe OSA decreased with increasing age for the SCD group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study Laryngoscope, 2023.

Effectiveness of functional orthopedic appliances as an alternative treatment among children and adolescents with obstructive sleep apnea: Systematic review and meta-analysis

INTRODUCTION

The objective here was to review the efficacy of functional jaw orthopedic appliances for treating children/adolescents with obstructive sleep apnea (OSA), through correlating the apnea/hypopnea index (AHI) and oxygen saturation (SaO₂) in polysomnography (PSG), in addition to questionnaire scores from the obstructive sleep apnea-18 (OSA-18).

METHODS

The PRISMA 2020 guidelines¹ were followed. A search was conducted in October 2021, with updating to May 2022, in the MEDLINE/PubMed, BVS (LILACS/BBO), ISI, SciELO (Web of Science), COCHRANE, EMBASE, SCOPUS and WHO databases and the gray literature. Data selection and extraction were performed by two independent reviewers, with Cohen kappa testing. All articles included in the meta-analyses showed good quality and low risk of bias. Statistical analyses were performed in the "R" software, using means with standard deviations, and differences in the means were represented graphically in forest plots. Heterogeneity was tested using I², in random-effect models.

RESULTS

From before to after treatment, treated individuals showed improved AHI, SaO₂ and OSA-18 scores². Comparing treated individuals and controls, AHI decreased in treated individuals and increased in controls. For SaO₂, the increase in treated individuals was greater than in controls. For OSA-18, daytime/nighttime symptoms decreased in treated individuals and increased in controls.

CONCLUSION

Functional jaw orthopedic appliances are appropriate and effective for children/adolescents with OSA whose etiology is deficient maxillomandibular growth and development. Functional jaw orthopedics treats the form and function of the stomatognathic system, thereby enhancing quality of life.

PROSPERO REGISTRATION PROTOCOL

CRD42021253341.

Knowledge and Awareness of Parents Attending Pediatric Clinic Regarding Pediatric Obstructive Sleep Apnea in Jeddah: A Cross-Sectional Study

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by chronic, recurrent episodes of partial or complete airway obstruction during sleep. It has a negative impact on quality of life and behavior and can lead to adverse neurological and cardiovascular outcomes if left untreated. This study aims to assess the awareness and knowledge of pediatric OSA among parents attending a general pediatric clinic in Jeddah, Saudi Arabia.

METHODS

An observational cross-sectional study was conducted from October 2022 to December 2022, on parents who attended the pediatric clinic at Dr. Soliman Fakeeh Hospital in Jeddah. Participants were asked to complete a self-administered questionnaire, either using a tablet or a paper-based survey. The questionnaire consisted of sociodemographic information and questions assessing the parents' knowledge and awareness of pediatric OSA.

RESULTS

The study included 146 participants. The mean knowledge score was 15.38 ± 6. Only 20% of the participants had a good knowledge level, while 80% had a poor level of knowledge. Furthermore, regarding the definition of OSA, 60 out of 146 participants answered correctly. Enlargement of adenoids was the most recognized risk factor, and restless sleep was the most recognized symptom. The majority of participants agreed that consulting an expert doctor was the best method to raise awareness about childhood OSA.

CONCLUSION

The result of our study reveals the low level of awareness and knowledge of pediatric OSA among parents attending a pediatric clinic in Jeddah. This highlights the need for health education programs and sensitization campaigns to improve awareness of pediatric obstructive sleep apnea.

Clinical Characteristics Combined with Craniofacial Photographic Analysis in Children with Obstructive Sleep Apnea

Purpose

Distinguishing obstructive sleep apnea (OSA) in a high-risk population remains challenging. This study aimed to investigate clinical features to identify children with OSA combined with craniofacial photographic analysis.

Methods

One hundred and forty-five children (30 controls, 62 with primary snoring, and 53 with OSA) were included. Differences in general demographic characteristics and surface facial morphology among the groups were compared. Risk factors and prediction models for determining the presence of OSA (obstructive sleep apnea-hypopnea index>1) were developed using logistic regression analysis.

Results

The BMI (z-score), tonsil hypertrophy, and lower face width (adjusted age, gender, and BMI z-score) were showed significantly different in children with OSA compared with primary snoring and controls (adjusted p<0.05). The screening model based on clinical features and photography measurements correctly classified 79.3% of the children with 64.2% sensitivity and 89.1% specificity. The area under the curve of the model was 81.0 (95% CI, 73.5-98.4%).

Conclusion

A screening model based on clinical features and photography measurements would be helpful in clinical decision-making for children with highly suspected OSA if polysomnography remains inaccessible in resource-stretched healthcare systems.

Personalized Medicine and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease that is often under-diagnosed and under-treated in all ages. This is due to differences in morphology, diversity in clinical phenotypes, and differences in diagnosis and treatment of OSA in children and adults, even among individuals of the same age. Therefore, a personalized medicine approach to diagnosis and treatment of OSA is necessary for physicians in clinical practice. In children and adults without serious underlying medical conditions, polysomnography at sleep labs may be an inappropriate and inconvenient testing modality compared to home sleep apnea testing. In addition, the apnea-hypopnea index should not be considered as a single parameter for making treatment decisions. Thus, the treatment of OSA should be personalized and based on individual tolerance to sleep-quality-related parameters measured by the microarousal index, harmful effects of OSA on the cardiovascular system related to severe hypoxia, and patients' comorbidities. The current treatment options for OSA include lifestyle modification, continuous positive airway pressure (CPAP) therapy, oral appliance, surgery, and other alternative treatments. CPAP therapy has been recommended as a cornerstone treatment for moderate-to-severe OSA in adults. However, not all patients can afford or tolerate CPAP therapy. This narrative review seeks to describe the current concepts and relevant approaches towards personalized management of patients with OSA, according to pathophysiology, cluster analysis of clinical characteristics, adequate combined therapy, and the consideration of patients' expectations.

Effect of Otolaryngology Residency Program Training on Obstructive Sleep Apnea Practice

According to the importance of management of obstructive sleep apnea syndrome by otolaryngologists, this study was designed to investigate knowledge, attitudes and practice of junior and senior residents of otolaryngology and evaluate the effect of current residency training program on choosing the first lines of treatment. A total of 110 residents of otolaryngology were selected. Our study tools were obstructive sleep apnea knowledge and attitudes (OSAKA and OSAKA-KIDS) questionnaires. The participants were classified as junior and senior. Senior residents had significantly higher total knowledge score for OSAKA based on independent t test (12.73 Vs. 10.52). No significant difference was observed for OSAKA-KIDS (11.31 Vs. 10.69). The most frequent choice for the first line was CPAP (63.8%) and weight loss (41.5%) among junior and senior residents, respectively. Although the knowledge of otolaryngology residents increased during their program, the choice of first line treatment in obstructive sleep apnea was different between junior and senior residents. We found a need for further multidisciplinary education for residents especially in the management of sleep apnea particularly toward CPAP usage and this syndrome in pediatrics.

Ambulatory Blood Pressure Variability after Adenotonsillectomy in Childhood Sleep Apnea

OBJECTIVE

To investigate the influence of adenotonsillectomy (T&A) on ambulatory blood pressure (BP) variability in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective, interventional study.

METHODS

Children with OSA symptoms were recruited from a tertiary center. After OSA diagnosis was confirmed (ie, apnea-hypopnea index [AHI] > 1), these children underwent T&A for treatment. We performed polysomnography and 24-hour recordings of ambulatory BP before and 3 to 6 months postoperatively. Ambulatory BP variability was presented as the standard deviation of mean blood pressure in the 24-hour monitoring of ambulatory BP. Differences in BP variability among different subgroups were tested using a multivariable linear mixed model.

RESULTS

A total of 190 children were enrolled (mean age: 7.8 ± 3.3 years; 73% were boys; 34% were obese). The AHI significantly decreased from 12.3 ± 17.0 to 2.7 ± 5.5 events/hr after T&A. Overall, daytime, and nighttime ambulatory BP did not significantly change postoperatively, and overall, daytime, and nighttime ambulatory BP variability did not differ significantly preoperatively and postoperatively. In the subgroup analysis, children aged <6 years demonstrated a significantly greater decrease in ambulatory BP variability postoperatively than those aged >6 years (nighttime diastolic BP variability: 9.9 to 7.7 vs. 8.9 to 9.4). Children with hypertension also showed a significantly greater decrease in ambulatory BP variability than those without hypertension.

CONCLUSIONS

We concluded that overall ambulatory BP variability does not significantly change after T&A in children with OSA. Moreover, young-aged and hypertensive children demonstrate a significant decrease in BP variability after T&A.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2491-2497, 2022.

Evaluating symptoms and polysomnographic findings among male and female children with obesity with and without obstructive sleep apnea

OBJECTIVE

Limited data regarding sex-based differences in the presentation and phenotype of obstructive sleep apnea (OSA) exists among children with obesity. The study objectives were to compare reported symptoms and polysomnogram (PSG) findings between children with obesity 1) with and without OSA and 2) males and females with OSA.

PATIENTS/METHODS

This cross-sectional study included children with obesity, aged 8-18 years, with a diagnostic PSG between 2015 and 2021, referred for evaluating sleep-related breathing. Patient demographics, anthropometrics, and PSG data were recorded. Symptoms were evaluated using Epworth Sleepiness Scale and Pediatric Sleep Questionnaire. Pubertal staging was collected using Tanner Stage questionnaire. PSG parameters, symptoms and pubertal stage were compared between sexes with and without OSA.

RESULTS

Of 148 children, 61 (41%) had OSA. Within the OSA group, 41/62 (69%) were male (p = 0.002). Males with OSA reported higher Pediatric Sleep Questionnaire scores compared to males without OSA (0.38 ± 0.2 vs 0.23 ± 0.1; p = 0.002). Males with OSA reported more trouble breathing (p = 0.04) and mouth breathing (p = 0.008) compared to females with OSA. Females with OSA showed longer sleep onset latency (45.8 ± 40.6 min vs 22.4 ± 26.7; p = 0.02) and higher supine obstructive-apnea hypopnea index (32.9 ± 31.1 vs 20.4 ± 18.4 events/hour; p = 0.02) compared to males with OSA. A significant interaction was found between male sex and waist-to-height ratio (β = 15.34, R² = 0.18, p = 0.05).

CONCLUSIONS

Sex differences in symptoms and phenotype of OSA exist among children with obesity. Such information is beneficial for early diagnosis and management to mitigate adverse outcomes and comorbidities.

Adverse Drug Reactions (ADRs) of Montelukast in Children

Montelukast is a leukotriene receptor antagonist (LTRA) commonly prescribed for asthma, allergic rhinitis and sleep-related breathing disorders. Recently, some studies have reported several adverse events, such as neuropsychiatric disorders and sleep disturbances, among children.

OBJECTIVE

To obtain more insight into the safety profile of montelukast for children with asthma, allergic rhinitis and sleep-related breathing disorders.

METHOD AND RESULTS

We retrospectively studied all adverse drug reactions to montelukast among 385 children 6 months or older in six tertiary centers over a two-year period. A total of 89.6% were asthmatic, 50% had allergic rhinitis and 13.6% had sleep-related breathing disorders; Singulair was the most common type of montelukast used (67.9%). This study reported a high prevalence of adverse drug reactions among 123 patients (31.9%), predominantly in those aged 4-9 years (52.8%), followed by adolescents (24.4%) and toddlers (22.8%). Two (ADRs) were reported in 9.8% of the children, while three or more were reported in 5.5%. Sleep disturbance was the most common (ADRs), affecting 15.1% of participants (overlap was common; 5.5% of children experienced sleep difficulties, 4.4% experienced sleep interruption and decreased sleep, and 1.82% experienced nightmares), followed by agitation (10.4%), pain (9.4%) and hyperactivity (6.8%). No serious (ADRs) were reported. Eleven percent of families faced difficulties in purchasing montelukast, and only 57% of families had insurance. Misconceptions were common (9.8% reported it to be a steroid, while 30.6% believed it to be a bronchodilator). Although 81% of the families believed it was an effective and preventive medication, 5.3% stopped the drug due to concern about side effects, especially agitation (3%) and nightmares (0.6%).

CONCLUSION

These data demonstrate that montelukast is effective, but the associated adverse neuropsychiatric drug reactions are more prevalent than those reported in the literature. In particular, sleep disturbance, agitation, pain and hyperactivity were observed. Pediatricians should be aware of such (ADRs). Misconceptions about montelukast are still common, and parental counseling and urgent epidemiological studies are needed to quantify the risk for management plans.

Reliability of a pediatric sleep endoscopy scoring system

INTRODUCTION

The surgical management of Obstructive Sleep Apnea (OSA) may be guided by Drug Induced Sleep Endoscopy (DISE), but there is no universally accepted scoring system for DISE in children. The purpose of this study is to compare a novel system to the more commonly used VOTE (Velum, Oropharynx, Tongue base, Epiglottis) system.

METHODS

A total of thirty pediatric DISE videos were reviewed and scored twice by 5 raters with a range of experience levels. The videos were scored using both the VOTE and the new scoring systems. The raters were also asked to recommend surgical intervention based on the DISE exam alone. Intra-rater test-retest analysis of the responses was conducted using weighted kappa (WK) statistic and percentage agreement (PA), respectively. Inter-rater reliability analysis of responses was evaluated using Krippendorff's alpha reliability coefficient (KA). Using a proportional odds model, a comparison of the weighted kappa statistic for the VOTE and the novel scoring systems was conducted.

RESULTS

For the novel scoring system, the intra-rater test-retest WK coefficient was 0.62 and 0.87 and the PA was 64% and 82% at the 25th and 75th percentiles, respectively. For the VOTE system, the intra-rater test-retest WK coefficient was 0.50 and 1.00 and PA was 75% and 100% at the 25th and 75th percentiles, respectively. KA was 0.36 and 0.77 at the 25th and 75th percentiles. In addition, responses to the surgical intervention survey analysis yielded a test-retest WK coefficient of 0.40 and 1.00 and a PA 71%-100% at the 25th and 75th percentiles, respectively. KA was 0.40 and 0.61 at the 25th and 75th percentiles, respectively. There was no significant difference between the 2 scoring systems on the WK statistic (p = .15), but significant difference on PA (p = .01).

CONCLUSION

Our novel scoring system demonstrated intra-rater test-retest and inter-rater reliability similar to the VOTE system, includes more sites of potential airway obstruction, and has potential for widespread use.

Clinical Characteristics and Post-Operative Outcomes in Children with Very Severe Obstructive Sleep Apnea

Available information on clinical characteristics and post-operative outcomes in children with very severe obstructive sleep apnea (OSA) is limited. Our study evaluates the clinical features and polysomnographic (PSG) variables that predict post-operative outcomes in children with an obstructive apneal hypopnea index (AHI) of more than 25 events/hr. In this study from a single tertiary care center, we performed a retrospective chart review of patients with an AHI > 25/hr, who underwent tonsillectomy and adenoidectomy (T&A) between January 2016 and September 2021. In total, 50 children were included in the study: 26.0% (13/50) of children experienced post-operative respiratory events and four children needed intubation and ventilator support. Compared with children without respiratory events, children requiring post-operative respiratory interventions were younger (4.4 ± 5.2 vs. 8.0 ± 5.2 years; p = 0.04), had higher pre-operative AHI (73.6 ± 27.4 vs. 44.8 ± 24.9; p < 0.01), lower oxygen nadirs (70.0 ± 13.0% vs. 83.0 ± 7.0%; p < 0.01), and had lower body metabolic index Z-scores (−0.51 ± 2.1 vs. 0.66 ± 1.5; p < 0.04). Moderate to severe residual OSA was identified in 70% (24/34) of children with available post-operative PSG; younger children had better PSG outcomes. Our study shows that post-operative respiratory events are frequent in children with very severe OSA, particularly with an AHI > 40/h, younger children (<2 years of age), lower oxygen saturation (SpO2), and poor nutritional status, necessitating close monitoring.

Metabolic, behavioral health, and disordered eating comorbidities associated with obesity in pediatric patients: An Obesity Medical Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. This CPS will be followed by a companion CPS covering further comorbidities, including genetics and social consequences related to overweight and obesity. These CPSs are intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices greater than or equal to the 95th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. It provides clinical information regarding identifying and treating metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children over the 95th percentile of weight/height for age.

Conclusions

This OMA clinical practice statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children and provides an overview of current recommendations. These recommendations lay out a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea

OBJECTIVES/HYPOTHESIS

To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA).

METHODS

Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared.

RESULTS

There were 887 patients included in this study. 14.8% (n = 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O₂  < 90% (tb90) (95% CI = 1.07-1.14, OR = 1.10, p < 0.001), Black race (95% CI = 1.53-3.58, OR = 2.34, p < 0.001), primary neurologic co-morbidity (1.67-6.32, OR = 3.27, p < 0.001), Down syndrome (1.25-5.94, OR = 2.72, p = 0.01), and age (0.84-0.94, OR = 0.88, p < 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90.

CONCLUSIONS

Our results demonstrate that there are other potential risk factors outside of AHI and O₂ nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Office Blood Pressure Monitoring in Children with Obesity and Obstructive Sleep Apnea

OBJECTIVE

To investigate the relative contributions of obesity and obstructive sleep apnea (OSA) to unfavorable blood pressure in children.

STUDY DESIGN

Children aged 3-18 years with OSA-related symptoms were recruited. All children underwent office blood pressure (BP) monitoring and full-night polysomnography. Obesity was defined as a body mass index ≥95th percentile. OSA severity was divided into primary snoring (apnea-hypopnea index [AHI] <1), mild OSA (5> AHI ≥1), and moderate to severe OSA (AHI ≥5). Age- and sex-adjusted logistic regression analysis was performed to determine the associations among OSA, obesity, and elevated BP.

RESULTS

This cross-sectional study enrolled 1689 children (66% boys), with a mean age of 7.9 years. Compared with children with primary snoring, children with moderate to severe OSA had significantly higher systolic BP (108.1 mmHg vs 105.6 mmHg), diastolic BP (75.0 mmHg vs 70.4 mmHg), systolic BP percentile (75.0 vs 70.4), and diastolic BP percentile (74.0 vs 69.2). The rate of unfavorable BP (ie, elevated BP or hypertension level BP) also was significantly higher in children with more severe OSA. Children with obesity had higher BP and BP percentile. Logistic regression analysis revealed that children with obesity and moderate to severe OSA have a 3-fold greater risk of unfavorable BP compared with children without obesity and primary snoring.

CONCLUSIONS

We identified a 3-fold greater risk of unfavorable BP in children with obesity and moderate to severe OSA.

Age- and gender-related characteristics in pediatric obstructive sleep apnea

BACKGROUND

Age and gender disparities in polysomnographic findings in children are not well understood.

OBJECTIVE

This study determined age and gender-related characteristics in pediatric obstructive sleep apnea (OSA).

METHOD

Retrospectively, data were collected. We analyzed polysomnographic data in the following age groups: 3-6 years (n = 681), 6-9 years (n = 553), 9-12 years (n = 297), 12-15 years (n = 200), and 15-18 years (n = 111).

RESULTS

A total of 1842 children were included (mean age: 8.0 years; boys: 67%; obesity: 21%). The apnea-hypopnea index (AHI) gradually increased with age (3-6, 6-9, 9-12, 12-15, and 15-18 years groups: 6.2, 5.9, 6.5, 8.1, and 9.9 event/h, respectively; p trend = 0.002). In all age groups, boys had a higher AHI than girls (7.8 vs. 4.1 events/h, p < 0.001). Children with obesity had a higher AHI than those without (12.9 vs. 4.9 events/h, p < 0.001). The mean AHI in the boys increased with age (3-6 to 15-18 years groups: 7.0-13.6 events/h, respectively; p trend < 0.001), whereas the mean AHI in the girls was not significantly different between ages (p trend = 0.492). In moderation analyses, gender was a moderator in the association between obesity and AHI, and the association between age and AHI during 12-15 and 15-18 years of ages.

CONCLUSION

Male gender and obesity increase risk of OSA. Regarding age disparities, this study discovered a higher AHI in male adolescents than in young boys.

Prevalence and Risk Factors for Rapid Eye Movement-Related Obstructive Sleep Apnea in Children

OBJECTIVES

Different pathophysiological mechanisms and the distribution of respiratory events among rapid eye movement (REM) and non-rapid eye movement (NREM) sleep modulate the effect of obstructive sleep apnea (OSA). We aimed to study the prevalence and risk factors for REM-related OSA in children.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

We recruited 366 children with OSA confirmed by polysomnography (PSG) over a 5-year period. REM-related OSA is defined by an obstructive apnea-hypopnea index (OAHI) in the REM sleep ≥2× than during NREM sleep.

RESULTS

The prevalence of REM-related OSA in children was 50.3%. Children with REM-related OSA were more likely to be female (P = 0.042), and had lower prevalence of adenotonsillar hypertrophy (P = 0.043) compared with children with other OSA subtypes. Children with REM-related OSA slept longer in the supine position (P = 0.003), had shorter duration of NREM1 sleep (P = 0.018), lower nadir SpO2 (P = 0.005), and a higher oxygen desaturation index 3% (ODI3%) (P = 0.014), and lower arousal index (P = 0.034) compared with other OSA subtypes. Female gender and supine sleep was the independent risk factors for REM-related OSA.

CONCLUSION

The prevalence of REM-related OSA was 50.3%. OAHIREM should be considered as an important parameter in future clinical research studies done in children with OSA.

Changes in the nasal and pharyngeal airway volume with miniscrew-assisted rapid palatal expansion appliances

Objectives:

The purpose of this study was to assess the volumetric changes in the nasal and pharyngeal airway volume in patients with maxillary transverse deficiency treated with miniscrew-assisted rapid palatal expansion (MARPE) appliances.

Material and Methods:

The pre- and post-treatment cone-beam computed tomography scans of 20 subjects who underwent treatment with the MARPE appliance as part of their orthodontic treatment were included in the study. Pre- and post-expansion airway volume measurements of the nasal cavity, nasopharynx, and oropharynx were measured. Linear measurements of the skeletal structures surrounding the nasal cavity were taken to assess the pattern of airway expansion. Paired t-tests were used to evaluate nasal and pharyngeal airway volume changes with expansion. Pearson correlation test was utilized to assess the relationship between nasal and pharyngeal volume changes.

Results:

A total of 17 out of 20 samples had a successful split of the mid-palatal sutures. A significant increase in nasal airway volume (12.0%) was found post-expansion. In addition, a significant increase in linear measurements of the nasal cavity base width in the frontal plane (7.1%) and both the anterior and posterior widths in the transverse dimension (9.4% and 3.4%, respectively) were found. Significant positive correlations were found between airway volumes and increase in width of the maxillary expansion appliance.

Conclusion:

The effects of maxillary expansion with a MARPE appliance include an increase in nasal cavity volume, but not the nasopharyngeal and the oropharyngeal airway volume. The nasal cavity expands in a triangular pattern in both the frontal and transverse dimensions following orthopedic expansion with the MARPE appliance. Increase in airway volume is a result of the increase in width of the maxillary expansion appliance.

Sleep Disorders in Patients With Craniopharyngioma: A Physiopathological and Practical Update

Sleep disorders (SDs) represent an important issue in patients with craniopharyngioma (CP). Nearly 70% of these patients complain of sleep-wake cycle alterations and/or excessive diurnal somnolence due to sleep-related breathing disorders, such as obstructive sleep apnea (OSA) and/or central hypersomnia, including secondary narcolepsy. SDs may severely reduce quality of life, increase disease-related cardiorespiratory and cardiovascular morbidity, and finally play a major role in increased long-term mortality reported on patients with CP. A major risk factor for SDs is represented by the hypothalamic syndrome, which may develop because of direct hypothalamic damage by the tumor itself and/or complications of the treatments, neurosurgery and/or radiotherapy, and typically includes permanent neuroendocrine dysfunctions, morbid obesity, and secondary metabolic disorders. Despite increasing attention to SDs in the general population, and in particular to OSA as a risk factor for cardio-metabolic diseases and excessive daytime somnolence, sleep evaluation is still not routinely proposed to patients with CP. Hence, SDs are often underdiagnosed and undertreated. The aim of this paper is to update current knowledge of the pathogenesis and prevalence of SDs in patients with CP and propose practical algorithms for their evaluation and management in clinical practice. Particular attention is paid to screening and diagnostic tools for appropriate characterization of SDs, identification of risk factors, and potential role of hypothalamic sparing surgery in the prevention of morbid obesity and SDs. Available tools in sleep medicine, including lifestyle interventions, drugs, and respiratory devices, are discussed, as well as the importance of optimal hormone replacement and metabolic interventions. Current limits in the diagnosis and treatment of SDs in patients with CP and possible future avenues for research agenda are also considered.

Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children

STUDY OBJECTIVES

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA.

METHODS

Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance.

RESULTS

Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home.

CONCLUSIONS

T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA.

CITATION

Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

Clinical application of home sleep apnea testing in children: a prospective pilot study

STUDY OBJECTIVES

(1) To determine the sensitivity and specificity of the home sleep apnea test (HSAT) performed in typically developing children who were diagnosed with moderate to severe obstructive sleep apnea during overnight attended laboratory polysomnography (LPSG). (2) To determine the utility of a screening questionnaire to identify children at increased risk for obstructive sleep apnea.

METHODS

Participants completed 2 consecutive study nights, the first night with the HSAT followed by LPSG on the second night. The SHOOTS questionnaire, composed of 6 questions (snoring, hyperactivity, obesity, observed apnea, tonsillar hypertrophy, and sleepiness) concerning sleep-disordered breathing, was administered by the clinician before the first study night.

RESULTS

Thirty-eight participants completed both studies. The mean age was 13.8 ± 3.0 years. Twenty (53%) were male. Most participants were obese. The mean LPSG total sleep time was 7.34 ± 1.19 hours; the mean HSAT total recording time was 8.86 ± 1.73 hours (P < .001). The median obstructive apnea-hypopnea index for LPSG and HSAT was 6.6 and 0.8 events/h, respectively. For an obstructive apnea-hypopnea index ≥ 3.1 events/h by HSAT, the sensitivity was 71.43% (95% confidence interval, 41.9-91.6) and the specificity was 95.83% (95% confidence interval, 78.9-99.9) for identifying those with an LPSG obstructive apnea-hypopnea index of ≥ 10 events/h. For a SHOOTS score with ≥ 4 "yes" responses, the sensitivity and specificity were 85.7% (95% confidence interval, 57.2-98.2) and 54.2% (95% confidence interval, 32.8-74.4), respectively, for identifying those with an LPSG obstructive apnea-hypopnea index ≥ 10 events/h.

CONCLUSIONS

Using HSAT, we clinically applied cutoff values to identify moderate to severe obstructive sleep apnea in typically developing children. The SHOOTS questionnaire may aid in identifying children at risk for obstructive sleep apnea and who are candidates for HSAT.

CITATION

Revana A, Vecchio J, Guffey D, Minard CG, Glaze DG. Clinical application of home sleep apnea testing in children: a prospective pilot study. J Clin Sleep Med. 2022;18(2):533-540.

Tissue Doppler echocardiography in children with OSA before and after tonsillectomy and adenoidectomy: A systematic review and meta-analysis

BACKGROUND

When to order an echocardiogram in children with obstructive sleep apnea (OSA) is debated. Studies evaluating the utility of pre-operative standard echocardiography are inconsistent. Tissue Doppler imaging (TDI) is an additional technique that quantifies the velocity of myocardial motion to assess cardiac function. The utility of TDI in pediatric OSA remains unclear.

METHODS

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines using PubMed, Scopus, CINAHL, and Cochrane Library databases. Studies of echocardiographic findings using TDI in children with polysomnogram confirmed OSA before and after tonsillectomy and adenoidectomy (T&A) were included. 1,423 studies were screened, and 4 studies met inclusion criteria. Meta-analysis of echocardiographic findings was performed.

RESULTS

Data from 560 children were analyzed. Study groups included pre- and post-T&A children with OSA and non OSA controls. Pre-T&A S' wave at the tricuspid annulus (S' RV) was decreased with a mean difference of -1.04 [95% CI -1.57, -0.52, p < 0.001] and E'/A' ratio at the mitral annulus (E'/A' LV) was decreased with a mean difference of -0.74 [95% CI -0.85, -0.64, p < 0.001] when compared to controls. These variables were not statistically different when comparing post-T&A to controls.

CONCLUSIONS

TDI appears to successfully detect subclinical changes in cardiac function in children with OSA. However, echocardiography parameters of post-T&A and non OSA control children were similar. Further prospective studies stratified by OSA severity are needed with both TDI and standard echocardiography to define the utility of pre-operative cardiac imaging.