Obstructive sleep apnea in infants

Bronchopulmonary dysplasia as a determinant of respiratory outcomes in adult life

Respiratory disease is unfortunately common in preterm infants with the archetype being bronchopulmonary dysplasia (BPD). BPD affects approximately 50,000 preterm infants in the U.S. annually with substantial morbidity and mortality related to its pathology (alveolar, airway, and pulmonary vasculature maldevelopment). Predicting the likelihood and severity of chronic respiratory disease in these children as they age is difficult and compounded by the lack of consistent phenotyping. Barriers to understanding the actual scope of this problem include few longitudinal studies, information limited by small retrospective studies and the ever-changing landscape of therapies in the NICU that affect long-term respiratory outcomes. Thus, the true burden of adult respiratory disease caused by premature birth is currently unknown. Nevertheless, limited data suggest that a substantial percentage of children with a history of BPD have long-term respiratory symptoms and persistent airflow obstruction associated with altered lung function trajectories into adult life. Small airway disease with variable bronchodilator responsiveness, is the most common manifestation of lung dysfunction in adults with a history of BPD. The etiology of this is unclear however, developmental dysanapsis may underlie the airflow obstruction in some adults with a history of BPD. This type of flow limitation resembles that of aging adults with chronic obstructive lung disease with no history of smoking. It is also unclear whether lung function abnormalities in people with a history of BPD are static or if these individuals with BPD have a more accelerated decline in lung function as they age compared to controls. While some of the more significant mediators of lung function, such as tobacco smoke and respiratory infections have been identified, more work is necessary to identify the best means of preserving lung function for individuals born prematurely throughout their lifespan.

Epigenetic Alterations in Pediatric Sleep Apnea

Pediatric obstructive sleep apnea has significant negative effects on health and behavior in childhood including depression, failure to thrive, neurocognitive impairment, and behavioral issues. It is strongly associated with an increased risk for chronic adult disease such as obesity and diabetes, accelerated atherosclerosis, and endothelial dysfunction. Accumulating evidence suggests that adult-onset non-communicable diseases may originate from early life through a process by which an insult applied at a critical developmental window causes long-term effects on the structure or function of an organism. In recent years, there has been increased interest in the role of epigenetic mechanisms in the pathogenesis of adult disease susceptibility. Epigenetic mechanisms that influence adaptive variability include histone modifications, non-coding RNAs, and DNA methylation. This review will highlight what is currently known about the phenotypic associations of epigenetic modifications in pediatric obstructive sleep apnea and will emphasize the importance of epigenetic changes as both modulators of chronic disease and potential therapeutic targets.

A Convolutional Neural Network Architecture to Enhance Oximetry Ability to Diagnose Pediatric Obstructive Sleep Apnea

This study aims at assessing the usefulness of deep learning to enhance the diagnostic ability of oximetry in the context of automated detection of pediatric obstructive sleep apnea (OSA). A total of 3196 blood oxygen saturation (SpO2) signals from children were used for this purpose. A convolutional neural network (CNN) architecture was trained using 20-min SpO2 segments from the training set (859 subjects) to estimate the number of apneic events. CNN hyperparameters were tuned using Bayesian optimization in the validation set (1402 subjects). This model was applied to three test sets composed of 312, 392, and 231 subjects from three independent databases, in which the apnea-hypopnea index (AHI) estimated for each subject (AHICNN) was obtained by aggregating the output of the CNN for each 20-min SpO2 segment. AHICNN outperformed the 3% oxygen desaturation index (ODI3), a clinical approach, as well as the AHI estimated by a conventional feature-engineering approach based on multi-layer perceptron (AHIMLP). Specifically, AHICNN reached higher four-class Cohen's kappa in the three test databases than ODI3 (0.515 vs 0.417, 0.422 vs 0.372, and 0.423 vs 0.369) and AHIMLP (0.515 vs 0.377, 0.422 vs 0.381, and 0.423 vs 0.306). In addition, our proposal outperformed state-of-the-art studies, particularly for the AHI severity cutoffs of 5 e/h and 10 e/h. This suggests that the information automatically learned from the SpO2 signal by deep-learning techniques helps to enhance the diagnostic ability of oximetry in the context of pediatric OSA.

The maturation changes of sleep-related respiratory abnormalities in infants with laryngomalacia

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and central sleep apnea (CSA) are common in infants with laryngomalacia. The purpose of this study was to evaluate developmental changes in sleep-related breathing disorders over time in infants with laryngomalacia and understand the effect of supraglottoplasty (SGP) and nonsurgical treatment.

METHODS

This is a retrospective review of infants with laryngomalacia who had at least 2 diagnostic polysomnography studies performed from January 2000 and May 2015. We included infants who had either OSA or CSA. Comparison of sleep and respiratory parameters by age group (0-6, 6-12, and >12 months old) was performed in both SGP and non-SGP groups using a mixed-effect regression model. A log-normal mixed model was used to explore the changes in sleep and respiratory parameters with age. The time to resolution of CSA and OSA was analyzed using nonparametric survival analysis.

RESULTS

A total of 102 infants were included; 57 had only OSA and 45 had both CSA and OSA. There were significant decreases in apnea-hypopnea index, obstructive index, central apnea index, and arousal index with increasing age in both SGP and non-SGP groups. The mean age at resolution of CSA (central apnea index < 5) was 7.60 months old for SGP and 12.57 months old for non-SGP (P < .05). There were no significant differences in the mean age at resolution of OSA (obstructive index < 1; 35.18 [SGP] vs 41.55 months [non-SGP]; P = .60) between SGP and non-SGP groups. Infants with neurologic disease, congenital anomalies, or genetic syndromes required significantly more time to resolve OSA (28.12 [normal] vs 53.13 [neurological] vs 59.53 months [congenital anomalies and genetic]; P < .01).

CONCLUSIONS

Both OSA and CSA improve in infants with laryngomalacia with increasing age regardless of SGP. The mechanism underlying these changes may involve airway growth and maturation of respiratory control. Time to resolution of OSA is affected by the presence of neurologic diseases, congenital anomalies, and genetic syndromes. Further studies are needed to confirm these findings and to evaluate long-term outcomes in this population.

Screening Severe Obstructive Sleep Apnea in Children with Snoring

Efficient screening for severe obstructive sleep apnea (OSA) is important for children with snoring before time-consuming standard polysomnography. This retrospective cross-sectional study aimed to compare clinical variables, home snoring sound analysis, and home sleep pulse oximetry on their predictive performance in screening severe OSA among children who habitually snored. Study 1 included 9 (23%) girls and 30 (77%) boys (median age of 9 years). Using univariate logistic regression models, 3% oxygen desaturation index (ODI3) ≥ 6.0 events/h, adenoidal-nasopharyngeal ratio (ANR) ≥ 0.78, tonsil size = 4, and snoring sound energy of 801–1000 Hz ≥ 22.0 dB significantly predicted severe OSA in descending order of odds ratio. Multivariate analysis showed that ODI3 ≥ 6.0 events/h independently predicted severe pediatric OSA. Among several predictive models, the combination of ODI3, tonsil size, and ANR more optimally screened for severe OSA with a sensitivity of 91% and a specificity of 94%. In Study 2 (27 (27%) girls and 73 (73%) boys; median age, 7 years), this model was externally validated to predict severe OSA with an accuracy of 76%. Our results suggested that home sleep pulse oximetry, combined with ANR, can screen for severe OSA more optimally than ANR and tonsil size among children with snoring.

Robin Sequence: Neonatal Mandibular Distraction

Pierre Robin sequence is defined by the clinical triad: mandibular hypoplasia, glossoptosis, and airway obstruction. Mandibular distraction osteogenesis (MDO) is a standard treatment of Robin sequence associated with severe airway obstruction and is the only intervention that directly corrects the underlying anatomic pathologic condition. Compared with tongue-lip adhesion, MDO has demonstrated more success in treating airway obstruction in infants with Pierre Robin sequence, including patients with syndromic diagnoses and concomitant anomalies. This article provides a current, comprehensive review of neonatal mandibular distraction and offers treatment guidelines based on a combined surgical experience of more than 400 patients.

Small sleepers, big data: leveraging big data to explore sleep-disordered breathing in infants and young children

STUDY OBJECTIVES

Infants represent an understudied minority in sleep-disordered breathing (SDB) research and yet the disease can have a significant impact on health over the formative years of neurocognitive development that follow. Herein we report data on SDB in this population using a big data approach.

METHODS

Data were abstracted using the Cerner Health Facts database. Demographics, sleep diagnoses, comorbid medication conditions, healthcare utilization, and economic outcomes are reported.

RESULTS

In a cohort of 68.7 million unique patients, over a 9-year period, there were 9,773 infants and young children with a diagnosis of SDB (obstructive sleep apnea [OSA], nonobstructive sleep apnea, and "other" sleep apnea) who met inclusion criteria, encompassing 17,574 encounters, and a total of 27,290 diagnoses across 62 U.S. health systems, 172 facilities, and 3 patient encounter types (inpatient, clinic, and outpatient). Thirty-nine percent were female. Thirty-nine percent were ≤1 year of age (6,429 infants), 50% were 1-2 years of age, and 11% were 2 years of age. The most common comorbid diagnoses were micrognathia, congenital airway abnormalities, gastroesophageal reflux, chronic tonsillitis/adenoiditis, and anomalies of the respiratory system. Payor mix was dominated by government-funded entities.

CONCLUSIONS

We have used a novel resource, large-scale aggregate, de-identified EHR data, to examine SDB. In this population, SDB is multifactorial, closely linked to comorbid medical conditions and may contribute to a significant burden of healthcare costs. Further research focusing on infants at highest risk for SDB can help target resources and facilitate personalized management.

The impact of obstructive sleep apnea on bronchiolitis severity in children with Down syndrome

OBJECTIVES

Acute bronchiolitis commonly causes respiratory failure in children ≤2 years, and is particularly severe in those with Down syndrome (DS). Obstructive sleep apnea (OSA), common in DS, is also associated with respiratory complications. However, it is unknown whether OSA is associated with worse outcomes in children with and without DS, hospitalized with bronchiolitis. We hypothesized that in children with bronchiolitis, OSA is associated with worse outcomes in those with DS, independent of DS-related comorbidities.

METHODS

Hospital discharge records of children with bronchiolitis aged ≤2 years were obtained for 1997-2012 from the Kid's Inpatient Database. The primary outcome was invasive mechanical ventilation (IMV), and secondary outcomes were non-invasive mechanical ventilation (NIMV), length of hospital stay, and inflation-adjusted cost of hospitalization (IACH). Multivariable regression was conducted to ascertain the associations between OSA and primary and secondary outcomes accounting for DS-associated comorbidities.

RESULTS

There were 928,961 hospitalizations for bronchiolitis. The DS group with bronchiolitis (n = 8697) was more likely to have OSA [241 (2.77%) vs 1293 (0.14%), p < 0.001] compared to the non-DS group (n = 920,264). Multivariable logistic regression showed that OSA was associated with IMV (adjusted odds ratio [OR], 3.32 [95% CI 2.54-4.35], p < 0.0001) in all children with bronchiolitis; and in those with DS, it was associated with IMV (adjusted OR, 2.34 [95% CI 1.38-3.97], p = 0.002), NIMV (adjusted OR, 8.21 [95% CI 4.48-15.04], p < 0.0001) and IACH (adjusted β, 0.18 [95% CI 0.02-0.34], p = 0.031).

CONCLUSIONS

OSA is independently associated with assisted ventilation in all children hospitalized with bronchiolitis, regardless of DS-associated comorbidities in those with DS. The severity of bronchiolitis in children with DS may be driven by the high prevalence of OSA.

Spontaneous and apnea arousals from sleep in preterm infants

BACKGROUND

The significance of arousal in apnea termination in preterm infants is not known.

METHODS

We investigated the appearance of arousals from sleep with polysomnography for 21 preterm infants at a median age of 36 gestational weeks.

RESULTS

The polysomnographic appearance of sleep was fragmented by frequent arousals. The number of spontaneous arousals unrelated to apneas was 18 per hour in sleep; higher in rapid eye movement (REM) sleep than in non-REM sleep (p < 0.001). Eighty-two percent of arousals were regarded as spontaneous, and 18% were related to apneas. In turn, arousal followed 5% of all apneas; 30% of mixed, 2% of central, and 20% of long apneas defined as apnea of prematurity. Apneas without an arousal led to lower oxygen saturation levels than those followed by an arousal (p < 0.001). Mixed apneas with an arousal had stronger breathing effort and a higher number of breaths compared with apneas without an arousal (p < 0.05).

CONCLUSIONS

In preterm infants, frequent spontaneous arousals or arousal-type phenomena make the polysomnographic appearance of sleep fragmented. However, even long apneas or hypoxia commonly fail to elicit arousals or any sign of sleep interruption. Our findings suggest that arousal appears not to be the main mechanism for apnea termination in preterm infants.

IMPACT

Polysomnographic appearance of sleep in preterm infants is fragmented by arousals. Contrary to older children and adults, arousal to apnea is uncommon in preterm infants. Even long mixed apneas with desaturation mostly fail to elicit an arousal response. In preterm infants, apnea termination appears not to depend on an arousal. Low arousability is suggested to be caused by a low ventilation response to hypoxia.

Paediatrics: how to manage obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is defined as the intermittent reduction or cessation of airflow due to partial or complete obstruction of the upper airway during sleep. Paediatric OSAS has specific contributing factors, presenting symptoms and management strategies in various age groups. Untreated OSAS can lead to detrimental effects on neurocognitive development and cardiovascular and metabolic functions of a growing child. In the past decade, practice guidelines have been developed to guide the evaluation and management of OSAS. This article provides a narrative review on the current diagnostic and treatment options for paediatric OSAS. Alternative diagnostic tools other than the standard polysomnography are discussed. Adenotonsillectomy is considered the first-line therapy yet it is not suitable for treatment of all OSAS cases. Nocturnal non-invasive positive airway pressure ventilation is effective and could be the priority treatment for patients with complex comorbidities, residual OSAS post-adenotonsillectomy or obesity. However, intolerance and non-adherence are major challenges of positive airway pressure therapy especially in young children. There is increasing evidence for watchful waiting and other gentler alternative treatment options in mild OSAS. The role of anti-inflammatory drugs as the primary or adjunctive treatment is discussed. Other treatment options, including weight reduction, orthodontic procedures and myofunctional therapy, are indicated for selected patients. Nevertheless, the successful management of paediatric OSAS often requires a multidisciplinary team approach.

Obstructive Sleep Apnea in Children Under 3 Years of Age

OBJECTIVE

To identify predictors of severe obstructive sleep apnea (OSA) in children under 3 years of age and to compare demographics, comorbidities, and polysomnographic characteristics of infants and toddlers with OSA.

STUDY DESIGN

Retrospective case series.

METHODS

We examined children under 3 years of age who had polysomnogram between August 2012 and March 2020. Demographics, clinical, and polysomnographic parameters were compared in children age 0-1 versus 1-3 years and 0-2 versus 2-3 years and severe versus mild-moderate OSA. Univariate analysis was used to compare age groups; multiple logistic regression for predictors of severe OSA. Significance was set at P < .05.

RESULTS

Of the 413 children, 267 (65%) were male and 131 (32%) obese. The population included Hispanic (41%), African American (28%), and Caucasian (25%) children. A total of 98.5% had OSA and 35% had severe OSA. Children under 1 year of age more commonly had gastroesophageal reflux disease (GERD) (38% vs. 23%; P = .014); tonsillar hypertrophy was more common in children over 2 years of age (56% vs. 34%, P = .001). Down syndrome (odds ratio (OR): 3.16, 95% confidence interval (CI) = 1.14-8.68, P = .026) and tonsillar hypertrophy (OR: 1.97, 95% CI = 1.28-3.02, P = .002) were predictors of severe OSA.

CONCLUSION

Children under 3 years of age with OSA are more likely to be male and have GERD. Down syndrome and tonsillar hypertrophy are predictors of severe OSA, and children with these conditions should be prioritized for polysomnography.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2603-E2608, 2021.

Polysomnography use in complex term and preterm infants to facilitate evaluation and management in the neonatal intensive care unit

STUDY OBJECTIVES

1. To determine the characteristics of term and preterm infants for which polysomnography (PSG) was used as a primary diagnostic tool in infants with recurrent desaturation episodes, suspected obstructive apnea or both, and the prevalence of abnormal studies. 2. To identify the interventions following PSGs. 3. To assess the added value of airway and swallow evaluations.

METHODS

Retrospective cohort study of infants evaluated by PSG in the Neonatal Intensive Care Unit (NICU) at NYP-Weill Cornell from January 2012 to April 2018.

RESULTS

PSGs were performed on 31 infants; 15 (48%) term and 16 (52%) preterm infants. Indications for PSG were persistent desaturations (n=24), suspected obstructive apnea (n=15), and stridor (n=2). Primary comorbid conditions were respiratory (n=11), craniofacial (n=9), airway anomalies (n=6) and neurologic (n=5). The apnea-hypopnea index (AHI) was abnormal in 30 (97%) infants. Of those, 23 (74%) were severe, seven (23%) were moderate, and normal in one (3%). Apneic events were predominantly obstructive in 23 infants and predominantly central in 6. AHI improved in all but one follow-up PSG. The PSG findings resulted in interventions in 24 (77%) infants, in addition to concomitant otolaryngology evaluations (abnormal in 20/25) and swallow studies (abnormal in 9/14). Clinical signs completely resolved in 22 (71%) infants.

CONCLUSIONS

This is one of the first reports on the diagnostic value of inpatient PSGs in the NICU in infants with recurrent desaturation episodes, suspected obstructive apnea or both. Our findings indicate that PSG is an important tool in evaluating and targeting therapies in complex term and preterm infants with a wide variety of comorbidities.

Effects of upper airway obstruction or hypoxia on gastroesophageal reflux in newborn lambs

BACKGROUND

Although it is commonly accepted that upper airway obstruction (UAO) increases gastroesophageal reflux (GER), the link is poorly understood and insufficiently documented. In addition, while hypoxia is often encountered in infants with UAO, its consequences on GER are virtually unknown. The two aims of the present study were to characterize the effects of (1) UAO and (2) hypoxia on GER.

METHODS

Seventeen lambs underwent polysomnographic and esophageal impedance/pH-metry monitoring during UAO vs. a control condition (6 h, ten lambs) or 10% hypoxia vs. normoxic condition (3 h, seven other lambs).

RESULTS

Moderate-to-severe UAO was maintained throughout monitoring (inspiratory tracheal pressure of -13 (-15, -12) cm H₂O vs. -1 (-1, -1) cm H₂O in control condition, p = 0.005). While the number of GERs increased with UAO (2 (1, 4) vs. 0 (0, 3) in the control condition, p = 0.03), the increase was less than anticipated and inconsistent among the lambs. Also, sustained 10% hypoxia did not alter the number of GERs (2 (1, 3) vs. 0 (0, 5) in the control condition, p = 0.9).

CONCLUSIONS

The presence of an UAO for 6 h mildly increased the number of GERs, whereas hypoxia for 3 h had no significant effect.

IMPACT

The effect of upper airway obstruction and hypoxia on gastroesophageal reflux is poorly documented in the neonatal period. A moderate-to-severe upper airway obstruction for 6 h results in a mild, inconsistent increase in the number of gastroesophageal refluxes. Overall, a hypoxia of 10% for 3 h had no significant impact on gastroesophageal reflux. The prescription of an antireflux medication in infants with upper airway obstruction must not be systematic but rely on objective signs of a pathologic gastroesophageal reflux.

Intermittent hypoxia inhibits mandibular cartilage growth with reduced TGF-β and SOX9 expressions in neonatal rats

Intermittent hypoxia (IH) has been associated with skeletal growth. However, the influence of IH on cartilage growth and metabolism is unknown. We compared the effects of IH on chondrocyte proliferation and maturation in the mandibular condyle fibrocartilage and tibial hyaline cartilage of 1-week-old male Sprague-Dawley rats. The rats were exposed to normoxic air (n = 9) or IH at 20 cycles/h (nadir, 4% O₂; peak, 21% O₂; 0% CO₂) (n = 9) for 8 h each day. IH impeded body weight gain, but not tibial elongation. IH also increased cancellous bone mineral and volumetric bone mineral densities in the mandibular condylar head. The mandibular condylar became thinner, but the tibial cartilage did not. IH reduced maturative and increased hypertrophic chondrocytic layers of the middle and posterior mandibular cartilage. PCR showed that IH shifted proliferation and maturation in mandibular condyle fibrocartilage toward hypertrophic differentiation and ossification by downregulating TGF-β and SOX9, and upregulating collagen X. These effects were absent in the tibial growth plate hyaline cartilage. Our results showed that neonatal rats exposed to IH displayed underdeveloped mandibular ramus/condyles, while suppression of chondrogenesis marker expression was detected in the growth-restricted condylar cartilage.

Surgical versus Non-Surgical Management of Obstructive Sleep-disordered Breathing in Children: A Meta-analysis

Background:

Obstructive sleep-disordered breathing (OSDB) is a term for several chronic conditions in which partial or complete cessation of breathing occurs many times throughout the night, resulting in fatigue or daytime sleepiness that interferes with a person’s functions and reduces the quality of life.

Objective:

Comparing the effectiveness of surgical versus non-surgical treatment of OSDB in children in clinical trials through a meta-analysis study.

Patients and Methods:

A number of available studies and abstracts concerning the surgical versus non-surgical treatment of OSDB in children were identified through a comprehensive search of electronic databases. Data were abstracted from every study in the form of a risk estimate and its 95% confidence interval.

Results:

The current study revealed that there was a statistically significant improvement in the surgically treated patients rather than non-surgically treated patients regarding the quality of life.

Conclusion:

The current meta-analysis reports a significant clinical improvement in the surgical (adenotonsillectomy) group as compared to the non-surgical group, in terms of disease specific quality of life, and healthcare utilization in spite of the availability of only one study.

The Hypoplasic Mandible: What Makes it Different From the Healthy Child?

OBJECTIVE

This study aimed to analyze the morphology of the hypoplasic mandible and its evolution during the growth period to better understand how it differs from the pediatric healthy mandible.

METHOD

Three-dimensional mandibular models of hypoplasic and healthy children aged from 39 gestational weeks to 7 years old were analyzed with a morphometric method including data clustering. Morphological distinctions between pathological and healthy mandibles were highlighted. Bilateral and unilateral mandibular hypoplasia were distinguished.

RESULTS

The study sample was composed of 31 hypoplasic children and as many sex- and age-matched healthy children. Morphological distinctions between pathological and healthy mandibles were highlighted only from the first year of life. In bilateral hypoplasia, the overall mandibular dimensions were reduced while there was only a ramus asymmetry in unilateral mandibular hypoplasia (mean ± SD of the difference between the Grp03c and Grp03b subgroups: 6.80 ± 6.37 - P value = 1.64e^-3 for the height of the left ramus versus 0.18 ± 4.18 - P value = .82 for the height of the right ramus). Supervised classification trees were built to identify the pathology and discriminate unilateral from bilateral mandibular hypoplasia (prediction rates = 81% and 84%, respectively).

CONCLUSIONS

Based on a morphometric analysis, we demonstrated that mandibular hypoplasia significantly impacts the mandibular morphology only from the first year of life, with a distinction between bilateral and unilateral hypoplasia.

Obstructive sleep apnea in children aged 3 years and younger: Rate and risk factors

OBJECTIVE

Undiagnosed and untreated obstructive sleep apnea (OSA) can predispose children to neurobehavioural consequences. However, there is a lack of data identifying rate of, and risk factors for, OSA in very young healthy children. The objective of this study was to determine the rate of OSA and identify risk factors associated with the presence and severity of OSA in children aged 3 years and younger.

METHODS

This was a retrospective chart review of healthy children between 1 and 3 years old who had a baseline polysomnogram (PSG) between January 2012 and June 2017. Patient demographics, referral history, and PSG data were recorded.

RESULTS

One hundred and thirteen children were referred for a PSG, of which 66 (58%) were diagnosed with OSA and 47 (42%) did not have OSA. In the OSA group, 13 (20%) were mild and 53 (80%) were moderate-severe. Nasal congestion (P=0.001), adenoid hypertrophy (P=<0.001), and tonsillar hypertrophy (P=0.04) reported at the time of referral were more common in the OSA group compared to the no-OSA group. Binary logistic regression analysis showed that referral from an otolaryngologist (odds ratio=2.6, 95% confidence interval=1.1 to 6.0) were associated with moderate-severe OSA.

CONCLUSION

A high rate of OSA was found among children aged 3 years and younger. Children referred by an otolaryngologist are more likely to be diagnosed with moderate-severe OSA. Children aged 3 years and younger with symptoms of OSA should be considered high-risk for OSA and be prioritized for early PSG and management.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study

OBJECTIVE

Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO.

DESIGN

Retrospective cohort analysis.

SETTING

Three tertiary care institutions.

PATIENTS

Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019.

MAIN OUTCOME MEASURES

The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events.

RESULTS

Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002).

CONCLUSION

Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Association between active tobacco use during pregnancy and infant respiratory health: a systematic review and meta-analysis

OBJECTIVE

To evaluate what is known about active tobacco use during pregnancy and the association with infant respiratory health.

DESIGN

Systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, EMBASE, Cochrane, CINAHL, and Maternity and Infant Care were searched thoroughly until June 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included case-control and cohort studies estimating the association between active tobacco use during pregnancy and infant respiratory health (wheezing and apnoea) and lung function parameters in the first 12 months of life.

DATA EXTRACTION AND SYNTHESIS

Extraction and risk of bias assessment were conducted by two independent reviewers. The odds ratio, relative risk and mean differences were pooled with a 95% CI using the generic inverse variance method. Heterogeneity was assessed and expressed by percentage using I2.

RESULTS

We identified 4423 abstracts, and 21 publications met the eligibility criteria. Pooled OR showed an increase in wheezing episodes in infants born to mothers who were active tobacco users during pregnancy (OR 1.50, 95% CI 1.27 to 1.77, p<0.01). Mixed results were found on lung function parameters, and a meta-analysis including two studies with comparable methodology showed a trend towards reduced maximum flow rate at functional residual capacity of -34.59 mL/s (95% CI -72.81 to 3.63, p=0.08) in 1-month-old infants born to women who smoked during pregnancy. A higher risk of apnoea was described for infants born to mothers who used smokeless tobacco during pregnancy, while the results in infants born to women who actively smoked tobacco during pregnancy were non-conclusive.

CONCLUSION

Infants born to mothers who actively smoked during pregnancy are at higher odds of having wheeze and may have lower lung function. Smokeless tobacco use in pregnancy may increase the risk of apnoea in infancy.

PROSPERO REGISTRATION NUMBER

CRD42018083936.

Polysomnographic Outcomes After Observation for Mild Obstructive Sleep Apnea in Children Younger Than 3 Years

OBJECTIVE

Mild obstructive sleep apnea (OSA), particularly in young children, is often treated with observation. However, there is little evidence regarding the outcomes with this approach. Our aim was to assess the impact of observation on sleep for children aged <3 years with mild OSA.

STUDY DESIGN

Case-control study.

SETTING

Pediatric tertiary care center.

METHODS

We reviewed cases of children (<3 years old) diagnosed with mild OSA (obstructive apnea-hypopnea index, 1-5 events/h) who were treated with observation between 2012 and 2017 and had at least 2 polysomnograms performed 3 to 12 months apart. Demographic data and comorbid diagnoses were collected.

RESULTS

Twenty-six children met inclusion criteria; their median age was 7.2 months (95% CI, 1.2-22.8). Nine (35%) were female and 24 (92%) were White. Their median body mass index percentile was 39 (95% CI, 1-76). Comorbidities included cardiac disease (42.3%), laryngomalacia (42.3%), allergies (34.6%), reactive airway disease (23.1%), and prematurity (7.7%). The obstructive apnea-hypopnea index significantly decreased from 2.7 events/h (95% CI, 1-4.5) to 1.3 (95% CI, 0-4.5; P = .013). There was no significant improvement in median saturation nadir (baseline, 86%; P = .76) or median time with end-tidal carbon dioxide >50 mm Hg (baseline, 0 minutes; P = .34). OSA resolved in 8 patients (31%) and worsened in 1 (3.8%). Only race was a significant predictor of resolution per regression analysis; however, only 2 non-White children were included.

CONCLUSION

In our cohort, resolution of mild OSA occurred in 31% of patients treated with 3 to 12 months of observation. The presence of laryngomalacia, asthma, and allergies did not affect resolution. Larger studies are needed to better identify factors (including race) associated with persistent OSA and optimal timing of intervention for these children.

LEVEL OF EVIDENCE

4.

Diagnosis and management of childhood sleep-disordered breathing. Clinical approach

Sleep-disordered breathing (SDB) includes disorders of breathing that affect airway patency, which impair children's sleep and lead to negative consequences. Obstructive sleep apnea, hypoventilation and upper airway resistance syndrome are common causes of morbidity and mortality in childhood. These clinical practice guidelines, intended for use by pediatricians and primary care clinicians, provide a clear recommendation for the diagnosis and management of sleep-disordered breathing, focusing on the most serious disorder, obstructive sleep apnea syndrome (OSAS). These clinical guidelines formulate clear recommendations to identify patients with suspected OSAS. Further, the manuscript will highlight the potential consequences of SBD in children, and how to overcome such difficulties, what could be the therapeutic options, a 12 recommendations and what are the future direction for pediatric sleep medicine.

Positive Airway Pressure for the Treatment of OSA in Infants

BACKGROUND

Positive airway pressure (PAP) is a standard therapy for the treatment of OSA in children, but objective data on the effectiveness of PAP in infants are sparse. The aim of this study was to compare the effectiveness of PAP in infants younger than 6 months of age with that in school-aged children.

RESEARCH QUESTION

Compared with PAP in school-aged children, can PAP be titrated as successfully in infants, and is adherence to PAP similar in both age groups?

STUDY DESIGN AND METHODS

Single-center retrospective study. For consecutive infants younger than 6 months of age and school-aged children 5 to 10 years of age with OSA treated with PAP, baseline and titration polysomnography data, PAP adherence data, and parent-reported barriers to adherence were compared between groups.

RESULTS

Forty-one infants and 109 school-aged children were included. Median obstructive apnea hypopnea index (OAHI) in infants was 25.7/h (interquartile range [IQR], 17.8-35.9/h) and was greater than that in school-aged children (12.1/hr; IQR, 7.6-21.5/h; P < .0001). After PAP titration, OAHI was reduced by a median of 92.1% in infants, similar to the median 93.4% reduction in school-aged children (P = .67). PAP was used in infants on 94.7% of nights, which was more than the 83% in school-aged children (P = .003). No differences were found in barriers to adherence between infants and school-aged children, with behavioral barriers being most common in both groups.

INTERPRETATION

Objective data demonstrate that PAP is both highly effective at treating OSA and well-tolerated in infants. Like older patients, PAP should be considered along with other therapies for the treatment of OSA in even the youngest children.

Can overnight portable pulse oximetry be used to stratify obstructive sleep apnea risk in infants? A correlation analysis

INTRODUCTION

There is limited evidence on the accuracy of oximetry in the evaluation of infant obstructive sleep apnea (OSA). We aimed to determine the utility of overnight oximetry to stratify infants at risk for OSA, to determine urgency for definitive screening with an overnight in-laboratory polysomnogram (PSG).

METHODS

Retrospective single-institution cohort study of infants undergoing PSG and a separate overnight oximetry over an 8-year period. Correlations, using oximetry in both in-hospital (attended) or at-home (unattended) settings, for ODI4₁₀ (decrease in oxygen saturation ≥ 4% from baseline, duration ≥ 10 seconds) and ODI4₀ (duration > 0 second) with the obstructive apnea-hypopnea index (AHIo) were obtained. The area under the curve was calculated, and sensitivity and specificity values have been presented as receiver operating characteristic curves.

RESULTS

Thirty-eight infants were included. The mean (SD) age (months) was 5.7 (3.9) at diagnostic PSG and 5.5 (3.7) at the time of oximetry. The mean AHIo for the entire cohort was 6.7 (6.2). The mean (SD) ODI4₀ was 8.6 (9.0) and the mean (SD) ODI4₁₀ was 5.4 (5.1).The correlation between ODI and AHIo was statistically significant for the cohort (ODI4₀ vs. AHIo [r = .59, P < .001] and ODI4₁₀ vs AHIo [r = .55, P = .0003]). Using an ODI4₀ cutoff of 3, the sensitivity, specificity, negative predictive value and positive predictive value for diagnosing OSA was: 86%, 40%, 50%, and 80% respectively for an AHIo greater than 2, and 100%, 35%, 100%, and 58% respectively for an AHIo greater than or equal to 5.

CONCLUSION

There is a significant positive correlation between the ODI₄ obtained from oximetry and the AHIo obtained from PSG in infants at risk for OSA. An ODI4₀ greater than 3 may be useful to stratify infants at risk for moderate to severe OSA when used in attended (in-hospital) or unattended (in-home) settings.

Obstructive Sleep Apnea with Paradoxical Vocal Cord Movement in Children during Sleep Endoscopy: Case Series

Objective

To describe a series of pediatric cases of obstructive sleep apnea (OSA) with paradoxical vocal cord movement noted on drug-induced sleep endoscopy (DISE).

Materials and Methods

Case series and chart review of children who had undergone DISE for OSA that showed PVCM.

Results

Three cases where paradoxical vocal cord motion (PVCM) was noted during DISE are described. Two had an enlarged adenoid, and one had no other site of obstruction. Two were treated with adenoidectomy and antireflux medications. One received proton pump inhibitors alone. In all 3 cases, OSA symptoms resolved.

Conclusion

This case series of documented obstructive sleep apnea related to paradoxical vocal cord movement suggests that this entity occurs during sleep with airway obstruction. Further clarification of etiology of PVCM during OSA and its management is needed.

Laryngomalacia in Neonates Versus Older Infants: HCUP-KID Perspective

This study evaluated the hospital course for neonates and older infants with a diagnosis of laryngomalacia (LM). Data came from the 2016 Kids' Inpatient Database of the Healthcare Cost Utilization Project. A total of 6537 children aged <1 year with a diagnosis of LM (International Classification of Diseases, 10th Revision, code Q31.5) were identified: 2212 neonates and 4325 non-neonates. Neonates had a higher mortality rate, 1.31% versus 0.72% in older infants, had more diagnoses (median 9 vs 7) and procedures (mean 85.24 vs 21.83), longer length of stay (median 10 vs 4 days), and higher total charges (median US$65 722 vs US$25 582). A total of 23.3% of neonates born during the admission and diagnosed with LM had undergone laryngoscopy. Second airway lesions were present in 12.33% of neonates and 15.77% of older infants. It appears that neonates are being discharged with a diagnosis of LM without laryngoscopy. Neonatal intensive care unit and newborn nursery policies should require visualization of the larynx prior to diagnosis of LM.

Prevalence and natural history of obstructive sleep apnea in pediatric patients with laryngomalacia

OBJECTIVE

Laryngomalacia is the most common cause of infant stridor, and obstructive sleep apnea (OSA) is sometimes found concurrently in patients with laryngomalacia. OSA has been shown to improve after surgical treatment of laryngomalacia, but the majority of laryngomalacia patients have spontaneous resolution of symptoms. It is unknown whether their comorbid OSA also resolves. This study seeks to define the incidence of OSA in laryngomalacia and assess for resolution of OSA with polysomnography data.

METHODS

Retrospective cohort study at a tertiary care academic medical center. All pediatric patients with diagnoses of laryngomalacia or stridor were reviewed, and patients with laryngomalacia confirmed by Otolaryngologist exam were included. All patients with laryngomalacia were recommended to undergo polysomnography.

RESULTS

A total of 108 patients had laryngomalacia confirmed by an Otolaryngologist. Of those patients, 56 completed a polysomnogram, and 44 (79%) were diagnosed with OSA. Among the OSA patients, 34 had no surgery, 5 underwent supraglottoplasty, and 5 underwent adenoidectomy or adenotonsillectomy. Follow-up polysomnograms were performed for 9 non-surgical patients, 4 supraglottoplasty patients, and 4 adenoidectomy or adenotonsillectomy patients. Mean change in AHI was -2.81 without surgery, -8.18 after supraglottoplasty, and -2.94 after adenoidectomy or adenotonsillectomy.

CONCLUSION

OSA is often present in patients who have laryngomalacia, and the proportion in this population was higher than previous reports. The only significant predictor for obstructive sleep apnea was race, specifically Black/African American. Among patients with follow-up polysomnograms, the largest OSA improvement was in supraglottoplasty patients, but all patients improved.

Surgical Intervention for Laryngomalacia: Age-Related Differences in Postoperative Sequelae

OBJECTIVE

Identify risk factors and determine perioperative morbidity of children undergoing surgery for laryngomalacia (LM).

METHODS

A retrospective analysis of the multi-institutional American College of Surgeons National Surgical Quality Improvement Program-Pediatric Database (ACS-NSQIP-P) was performed to abstract patients aged <18 years with LM (ICD-10 code Q31.5) who underwent laryngeal surgery (CPT code 31541) from 2015 to 2017. Analyzed clinical variables include patient demographics, hospital setting, length of stay, medical comorbidities, postoperative complications, readmission, and reoperation.

RESULTS

A total of 491 patients were identified, 283 were male (57.6%) and 208 were female (42.4%). The mean age at time of surgery was 1.07 years (range .01-17 years). Younger patients were more likely to undergo surgery in the inpatient setting compared to their counterparts (P < .001). Infants were more likely to have prolonged duration of days from admission to surgery (P < .001), days from surgery to discharge (P < .001), and total length of stay (P<.0010). Finally, there was no significant difference between age groups with respect to 30-day general surgical complications (P = .189), with an overall low incidence of reintubation (1.2%), readmission (3.1%), and reoperation (1.6%).

CONCLUSION

This analysis supports laryngeal surgery as a safe surgical procedure for LM. However, younger children are more likely to undergo operative intervention in the inpatient setting, endure delays from hospital admission to surgical intervention, and experience a prolonged length of stay due to their overall medical complexity. Recognition of key factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in this unique pediatric patient subpopulation.

Outcomes and safety of adenoidectomy in infants up to 12 months of age compared to older children

PURPOSE

To evaluate the safety and outcomes of adenoidectomy for the treatment of sleep disordered breathing (SDB) in infants up to 12 months of age as compared to children ages 13-72 months METHODS: A retrospective analysis was performed by reviewing the medical records of children who underwent adenoidectomy from 2005 to 2018. The data of older age groups were also collected for comparison. The patients were divided into three groups: up to 12 months (infants), 13-36 months (toddlers) and 37-72 months (preschool). The data were collected from electronic medical records and from a telephone survey based on a modified version of the OSA-18 questionnaire. Postoperative complications, and short and long-term outcomes were compared.

RESULTS

Twenty-one patients met the inclusion criteria for the main study group (infants). They were compared with forty-four toddlers and thirty-two preschoolers. Among the infants, four (19%) needed additional surgical intervention, none of the toddlers and four (12.5%) preschoolers. There were no differences in subjective outcomes between age groups (p = 0.365) in the first year after surgery. One year after surgery, outcomes remained similar in all age groups (p = 0.302) with regard to SDB, but subjective improvements in mouth breathing and nasal discharge were better among the older children (p = 0.011 and p = 0.012), respectively.

CONCLUSION

The outcomes of adenoidectomy for the treatment of SDB in infants up to 12 months of age is similar to children ages 13-72 months.

How might non nutritional sucking protect from sudden infant death syndrome

Epidemiology has identified an association between the use of pacifiers and protection from sudden infant death syndrome (SIDS). The use of pacifiers for SIDS prevention fails to gain adoption partly because there is no widely accepted physiologic mechanism to explain the epidemiologic association. Additionally, the scientific literature available on pacifier use focuses largely on the probable adverse effects. We hypothesize that pacifier use and all other forms of non-nutritional sucking (specifically digit sucking, also known as thumb sucking) is a life saving defense mechanism meant to splint open and stabilize the collapsible portion of the upper airway in infants.The main objective of this review article is to propose a mechanism to explain how pacifiers might help prevent SIDS. If the medical community accepts this mechanism, it can help promote pacifier use by the public and potentially reduce the incidence of SIDS.

Age and Upper Airway Obstruction: A Challenge to the Clinical Approach in Pediatric Patients

Upper airway abnormalities increase the risk of pediatric morbidity in infants. A multidisciplinary approach to obstructive sleep apnea syndrome (OSAS) poses challenges to clinical practice. The incidence and causes of OSA are poorly studied in children under 2 years of age. To fill this gap, we performed this retrospective observational study to determine the causes of obstructive sleep apnea (OSA) in children admitted to our hospital between January 2016 and February 2018, after a brief unexplained event (BRUE) or for OSA. We reviewed the medical charts of 82 patients (39 males; BRUE n = 48; OSAS n = 34) and divided them into two age groups: < 1 year old (1–12 months; n = 59) and >1 year old (>12–24 months; n = 23). Assessment included nap polysomnography, multichannel intraluminal impedance-pH, and nasopharyngoscopy. Sleep disordered breathing was comparable between the two groups. Omega-shaped epiglottis, laryngomalacia, and nasal septum deviation were more frequent in the younger group, and nasal congestion in older group. Tonsillar and adenoidal hypertrophy was more frequent in the older group, while laryngomalacia and gastroesophageal reflux was more frequent in the younger group. Tonsil and adenoid size were associated with grade of apnea-hypopnea index severity in the older group, and laryngomalacia and gastroesophageal reflux in the younger group. The main causes of respiratory sleep disorders differ in children before or after age 1 year. Our findings have potential clinical utility for assessing the pathophysiology of obstructive sleep disordered breathing in patients less than 2 years old.

Secondhand Smoke exposure and risk of Obstructive Sleep Apnea in Children

OBJECTIVES

Obstructive sleep apnea (OSA) has a prevalence of 4% in children. Few studies have explored the role of secondhand smoke (SHS) on OSA severity and have shown contradicting results. Most studies have focused on the effect of SHS on snoring. This study explored the association of SHS exposure and OSA severity in children aged 3-18 years.

METHODS

This is a retrospective single center IRB-approved study. Electronic Medical Records (EMR) were queried between 1/24/2015 and 1/24/2018 to obtain data on SHS exposure with standard questionnaires from perioperative database. SHS was analyzed as a binary variable and OSA was measured using obstructive apnea hypopnea index (OAHI) from polysomnography (PSG) as a continuous variable. Analyses were done on all children and in those with severe OSA (OAHI≥10/h) as a subgroup.

RESULTS

EMR query yielded 101,884 children of whom 3776 had PSG. Limiting baseline PSG in 3-18-year-old and reliable information on SHS yielded 167 analyzable children of whom 70 had severe OSA. Children exposed to SHS had significantly more public insurance than non-exposed (p < 0.0001). Among children with severe OSA, median OAHI was significantly higher in SHS exposed compared to non-exposed (29.0vs.19.5,p = 0.04), but not across all children. In multivariable analysis SHS exposure increased OAHI by 48% in severe OSA subgroup (95%CI: 8%-102%; p = 0.01) when adjusted for race, body mass index, and adjusted household income.

CONCLUSION

Children aged 3-18 years with severe OSA who were exposed to SHS were found to have 1.48 increase in odds of OAHI than those without SHS exposure. Results could be limited by retrospective nature of study and EMR tools.

Usefulness of Spectral Analysis of Respiratory Rate Variability to Help in Pediatric Sleep Apnea-Hypopnea Syndrome Diagnosis

The sleep apnea-hypopnea syndrome (SAHS) is a chronic respiratory disorder of high prevalence among children (up to 4%). Nocturnal polysomnography (PSG) is the gold standard method to diagnose SAHS, which is a complex, expensive, and time-consuming test. Consequently, alternative simplified methods are demanded. We propose the analysis of the respiratory rate variability (RRV) signal, directly obtained from the airflow (AF) signals. The aim of our study is to evaluate the usefulness of the spectral information obtained from RRV in the diagnosis of pediatric SAHS. A database composed of 946 AF and blood oxygen saturation (SpO2) recordings from children between 0 and 13 years old was used. Our database was divided into four severity groups according to the apnea-hipopnea index (AHI): no-SAHS (AHI <; 1 events/h), mild (1 events/h ≤ AHI <; 5 events/h), moderate (5 events/h ≤ AHI <; 10 events/h), and severe SAHS (AHI ≥ 10 events/h). RRV and 3% oxygen desaturation index (ODI3) were obtained from AF and SpO2 recordings, respectively. A spectral band of interest was determined (0.09-0.20 Hz.) and a total of 12 spectral features were extracted. Nine of these features showed statistically significant differences (p-value <; 0.05) among the four severity groups. The spectral features from RRV along with ODI3 were used as inputs to binary logistic regression (LR) classifiers. The diagnostic performance of LR models were evaluated for the AHI cut-off points of 1, 5, and 10 e/h, achieving 66.5%, 84.0%, and 88.5% accuracy, respectively. These results outperformed those obtained by single ODI3. The joint use of the spectral information from RRV and ODI3 achieved a high diagnostic capability in the most severely-affected children, thus showing their complementarity. These results suggest that the information contained in RRV spectrum together with ODI3 is useful to help identify moderate-to-severe SAHS.

Impact of inflammation on developing respiratory control networks: rhythm generation, chemoreception and plasticity

The respiratory control network in the central nervous system undergoes critical developmental events early in life to ensure adequate breathing at birth. There are at least three "critical windows" in development of respiratory control networks: 1) in utero, 2) newborn (postnatal day 0-4 in rodents), and 3) neonatal (P10-13 in rodents, 2-4 months in humans). During these critical windows, developmental processes required for normal maturation of the respiratory control network occur, thereby increasing vulnerability of the network to insults, such as inflammation. Early life inflammation (induced by LPS, chronic intermittent hypoxia, sustained hypoxia, or neonatal maternal separation) acutely impairs respiratory rhythm generation, chemoreception and increases neonatal risk of mortality. These early life impairments are also greater in young males, suggesting sex-specific impairments in respiratory control. Further, neonatal inflammation has a lasting impact on respiratory control by impairing adult respiratory plasticity. This review focuses on how inflammation alters respiratory rhythm generation, chemoreception and plasticity during each of the three critical windows. We also highlight the need for additional mechanistic studies and increased investigation into how glia (such as microglia and astrocytes) play a role in impaired respiratory control after inflammation. Understanding how inflammation during critical windows of development disrupt respiratory control networks is essential for developing better treatments for vulnerable neonates and preventing adult ventilatory control disorders.

Usefulness of recurrence plots from airflow recordings to aid in paediatric sleep apnoea diagnosis

BACKGROUND AND OBJECTIVE

In-laboratory overnight polysomnography (PSG) is the gold standard method to diagnose the Sleep Apnoea-Hypopnoea Syndrome (SAHS). PSG is a complex, expensive, labour-intensive and time-consuming test. Consequently, simplified diagnostic methods are desirable. We propose the analysis of the airflow (AF) signal by means of recurrence plots (RP) features. The main goal of our study was to evaluate the utility of the information from RPs of the AF signals to detect paediatric SAHS at different levels of severity. In addition, we also evaluated the complementarity with the 3% oxygen desaturation index (ODI₃).

METHODS

946 AF and blood oxygen saturation (SpO₂) recordings from children ages 0-13 years were used. The population under study was randomly split into training (60%) and test (40%) sets. RP was computed and 9 RP features were extracted from each AF recording. ODI₃ was also calculated from each SpO₂ recording. A feature selection stage was conducted in the training group by means of the fast correlation-based filter (FCBF) methodology to obtain a relevant and non-redundant optimum feature subset. A multi-layer perceptron neural network with Bayesian approach (BY-MLP), trained with these optimum features, was used to estimate the apnoea-hypopnoea index (AHI).

RESULTS

8 of the RP features showed statistically significant differences (p-value <0.01) among the SAHS severity groups. FCBF selected the maximum length of the diagonal lines from RP, as well as the ODI₃. Using these optimum features, the BY-MLP model achieved 83.2%, 78.5%, and 91.0% accuracy in the test group for the AHI thresholds 1, 5, and 10 events/h, respectively. Moreover, this model reached a negative likelihood ratio of 0.1 for 1 event/h and a positive likelihood ratio of 13.7 for 10 events/h.

CONCLUSIONS

RP analysis enables extraction of useful SAHS-related information from overnight AF paediatric recordings. Moreover, it provides complementary information to the widely-used clinical variable ODI₃. Thus, RP applied to AF signals can be used along with ODI₃ to help in paediatric SAHS diagnosis, particularly to either confirm the absence of SAHS or the presence of severe SAHS.

Respiratory Phenotypes for Preterm Infants, Children, and Adults: Bronchopulmonary Dysplasia and More

Ongoing advancements in neonatal care since the late 1980s have led to increased numbers of premature infants surviving well beyond the neonatal period. As a result of increased survival, many individuals born preterm manifest chronic respiratory symptoms throughout infancy, childhood, and adult life. The archetypical respiratory disease of prematurity, bronchopulmonary dysplasia, is the second most common chronic pediatric respiratory disease after asthma. However, there are several commonly held misconceptions. These misconceptions include that bronchopulmonary dysplasia is rare, that bronchopulmonary dysplasia resolves within the first few years of life, and that bronchopulmonary dysplasia does not impact respiratory health in adult life. This focused review describes a spectrum of respiratory conditions that individuals born prematurely may experience throughout their lifespan. Specifically, this review provides quantitative estimates of the number of individuals with alveolar, airway, and vascular phenotypes associated with bronchopulmonary dysplasia, as well as non-bronchopulmonary dysplasia respiratory phenotypes such as airway malacia, obstructive sleep apnea, and control of breathing issues. Furthermore, this review illustrates what is known about the potential for progression and/or lack of resolution of these respiratory phenotypes in childhood and adult life. Recognizing the spectrum of respiratory phenotypes associated with individuals born preterm and providing comprehensive and personalized care to these individuals may help to modulate adverse respiratory outcomes in later life.

Associations between age and sleep apnea risk among newborn infants

OBJECTIVE

Among older children, sleep-disordered breathing (SDB) is associated with measurable neurocognitive consequences. However, diagnostic SDB thresholds are lacking for infants < 12 months. We sought to evaluate the relationship between SDB indices, gestational age (GA), and postmenstrual age (PMA) for infants who underwent clinically-indicated polysomnograms at a tertiary care center.

METHODS

Every infant < 3-months chronological age whose first clinically-indicated polysomnogram was between 2/2012 and 2/2017 was included. Linear regression was used to evaluate associations between apnea-hypopnea index (AHI), obstructive-apnea index (OAI), and GA and PMA for infants with and without obvious clinical risk factors for SDB (eg, micrognathia and cleft palate).

RESULTS

For 53 infants without obvious SDB risk factors (GA 35.6 ± 4.5 weeks; PMA 41.2 ± 4.0 weeks), mean AHI was 27 ± 18 and OAI 2.9 ± 4.5. There was a weak inverse relationship between AHI and PMA (r ²  = 0.12, P = 0.01), but AHI was not predicted by GA (r ²  = 0.04, P = 0.13). Conversely, OAI was more strongly associated with GA (r ²  = 0.33, P < 0.0001) than PMA (r ²  = 0.08, P = 0.036). For 28 infants with congenital structural anomalies that predispose to SDB (GA 38.0 ± 3.1 weeks, PMA 43.1 ± 3.3 weeks, AHI 37.7 ± 30, OAI 8.2 ± 11.8), neither AHI nor OAI were related to PMA or GA.

CONCLUSIONS

Among infants who received clinically-indicated polysomnograms but did not have obvious structural risk for SDB, AHI declined with advancing PMA, but obstructive-apnea was best predicted by prematurity. In contrast, the SDB risk did not improve with increasing GA or PMA for infants with congenital structural risk factors; such infants may not outgrow their risk for SDB.

Sleep and body mass index in infancy and early childhood (6-36 mo): a longitudinal study

BACKGROUND

Relatively, few longitudinal studies have evaluated the association between sleep and body mass index (BMI) among younger children. In addition, few studies have evaluated the bidirectional longitudinal association between sleep duration and child BMI.

OBJECTIVE

The objective of the study is to determine in children aged 6 to 36 months (1) the cross-sectional association of sleep duration and sleep problems with child BMI z score, (2) whether sleep duration predicts changes in child BMI z score, and (3) and whether BMI z score can predict changes in child sleep duration.

METHODS

This study used longitudinal data from the BeeBOFT study (N = 2308). Child sleep duration and sleep problems (indicated by night awakenings and sleep-onset latency) were parent reported, and child BMI was measured using a standardized protocol by trained healthcare professionals at approximately 6, 14, and 36 months of age. Linear mixed models and linear regression models were applied to assess the cross-sectional and bidirectional longitudinal associations between sleep and BMI z scores.

RESULTS

Cross sectionally, shorter sleep duration was associated with higher BMI z scores at 14 (β = -0.034, P < 0.05) and 36 months (β = -0.045, P < 0.05). Sleep duration at 6 or 14 months did not predict BMI z score at either 14 or 36 months. Higher BMI z scores at 6 months predicted shorter sleep duration (hours) at 14 months (β = -0.129, P < 0.001). No association was found between sleep problems and child BMI z scores.

CONCLUSIONS

Cross-sectional associations between shorter sleep duration and higher BMI z score emerged in early childhood (age 14 and 36 mo). Higher BMI z scores may precede shorter sleep duration but not vice versa.

Polysomnography Outcomes after Supraglottoplasty in Children with Obstructive Sleep Apnea

Objective

Laryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA.

Study Design

Retrospective case series.

Setting

Tertiary care medical center.

Subjects and Methods

Historical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery.

Results

Forty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery ( P = .003). Respiratory disturbance index was reduced from 27.3 events/h before supraglottoplasty to 7.8 events/h after surgery ( P = .003). The percentage of REM sleep decreased from 30.1% ± 2.4 to 24.8% ± 1.3 ( P = .04). Sleep efficiency was improved ( P = .05).

Conclusion

Overall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

Obstructive Sleep Apnea in Children With Beckwith-Wiedemann Syndrome

STUDY OBJECTIVES

Beckwith-Wiedemann syndrome (BWS) is a rare pediatric overgrowth disorder that includes a spectrum of clinical findings including macroglossia, especially in those with loss of methylation at the imprinting control region (IC2 LOM) on chromosome 11. Children with BWS can have very severe obstructive sleep apnea (OSA), but the prevalence of OSA in this population is poorly understood, as is the relationship between OSA and the BWS genotype/phenotype. We hypothesized that there would be a high prevalence of OSA in children with BWS, and that OSA would be more severe in children with IC2 LOM.

METHODS

Medical records from children evaluated from March 2015 through January 2018 were reviewed for results from polysomnography, genetic testing, and clinical assessment.

RESULTS

A total of 26 children with BWS not previously treated for OSA underwent polysomnography, genetic testing, and clinical assessment. Median (range) age was 5 months (3 days to 33 months). Most children, 20 (76.9%), had an obstructive apnea-hypopnea index (OAHI) > 2 events/h. Median (range) OAHI was 4.4 events/h (0 to 56.1 events/h). OAHI was significantly greater in participants younger than 6 months compared with those older than 6 months (P = .008). Those with IC2 LOM did not have a greater OAHI (P = .61) than those with other genetic causes of BWS, but OAHI had a strong positive correlation with BWS clinical score (Spearman rho = .54, P = .004).

CONCLUSIONS

There is a high prevalence of OSA in children with BWS with macroglossia. Younger children with BWS and those with more phenotypic features may be at greatest risk of OSA.

Wavelet analysis of oximetry recordings to assist in the automated detection of moderate-to-severe pediatric sleep apnea-hypopnea syndrome

BACKGROUND

The gold standard for pediatric sleep apnea hypopnea syndrome (SAHS) is overnight polysomnography, which has several limitations. Thus, simplified diagnosis techniques become necessary.

OBJECTIVE

The aim of this study is twofold: (i) to analyze the blood oxygen saturation (SpO2) signal from nocturnal oximetry by means of features from the wavelet transform in order to characterize pediatric SAHS; (ii) to evaluate the usefulness of the extracted features to assist in the detection of pediatric SAHS.

METHODS

981 SpO2 signals from children ranging 2-13 years of age were used. Discrete wavelet transform (DWT) was employed due to its suitability to deal with non-stationary signals as well as the ability to analyze the SAHS-related low frequency components of the SpO2 signal with high resolution. In addition, 3% oxygen desaturation index (ODI3), statistical moments and power spectral density (PSD) features were computed. Fast correlation-based filter was applied to select a feature subset. This subset fed three classifiers (logistic regression, support vector machines (SVM), and multilayer perceptron) trained to determine the presence of moderate-to-severe pediatric SAHS (apnea-hypopnea index cutoff ≥ 5 events per hour).

RESULTS

The wavelet entropy and features computed in the D9 detail level of the DWT reached significant differences associated with the presence of SAHS. All the proposed classifiers fed with a selected feature subset composed of ODI3, statistical moments, PSD, and DWT features outperformed every single feature. SVM reached the highest performance. It achieved 84.0% accuracy (71.9% sensitivity, 91.1% specificity), outperforming state-of-the-art studies in the detection of moderate-to-severe SAHS using the SpO2 signal alone.

CONCLUSION

Wavelet analysis could be a reliable tool to analyze the oximetry signal in order to assist in the automated detection of moderate-to-severe pediatric SAHS. Hence, pediatric subjects suffering from moderate-to-severe SAHS could benefit from an accurate simplified screening test only using the SpO2 signal.

Improving the Diagnostic Ability of Oximetry Recordings in Pediatric Sleep Apnea-Hypopnea Syndrome by Means of Multi-Class AdaBoost

Pediatric sleep apnea-hypopnea syndrome (SAHS) is a highly prevalent respiratory disorder that may impose many negative effects on the health and development of children. Due to the drawbacks of overnight polysomnography (PSG), the gold standard diagnosis technique, automated analysis of nocturnal oximetry has emerged as a simplified alternative. In order to improve diagnosis ability of oximetry, we propose to evaluate the usefulness of AdaBoost, a classification boosting algorithm, in the context of pediatric SAHS. A database composed of 981 SpO₂ recordings from pediatric subjects was used. For this purpose, a signal processing approach divided into two main stages was conducted: (i) feature extraction, where 3% oxygen desaturation index (ODI3), spectral, and nonlinear features were computed from the oximetry signal, and (ii) AdaBoost classification, where an AdaBoost.M2 model was trained with these features in order to determine the severity of pediatric SAHS according to the apnea-hypopnea index (AHI): AHI<1 events per hour (e/h), 1≤AHI<5 e/h, and AHI≥5 e/h. Our AdaBoost.M2 model achieved a Cohen's kappa of 0.474 in an independent test set in the 3-class classification task. In addition, high accuracies were obtained when using the AHI cutoffs for diagnosis of mild (AHI=1 e/h) and moderate-to-severe (AHI=5 e/h) SAHS: 80.9% and 82.9%, respectively. These results achieved slightly higher diagnostic accuracies than ODI3 as well as state-of-the-art studies. Therefore, AdaBoost could help to enhance the diagnostic ability of the oximetry signal to assess pediatric SAHS severity.

Detrended fluctuation analysis of the oximetry signal to assist in paediatric sleep apnoea-hypopnoea syndrome diagnosis

OBJECTIVE

To evaluate whether detrended fluctuation analysis (DFA) provides information that improves the diagnostic ability of the oximetry signal in the diagnosis of paediatric sleep apnoea-hypopnoea syndrome (SAHS).

APPROACH

A database composed of 981 blood oxygen saturation (SpO₂) recordings in children was used to extract DFA-derived features in order to quantify the scaling behaviour and the fluctuations of the SpO₂ signal. The 3% oxygen desaturation index (ODI3) was also computed for each subject. Fast correlation-based filter (FCBF) was then applied to select an optimum subset of relevant and non-redundant features. This subset fed a multi-layer perceptron (MLP) neural network to estimate the apnoea-hypopnoea index (AHI).

MAIN RESULTS

ODI3 and four features from the DFA reached significant differences associated with the severity of SAHS. An optimum subset composed of the slope in the first scaling region of the DFA profile and the ODI3 was selected using FCBF applied to the training set (60% of samples). The MLP model trained with this feature subset showed good agreement with the actual AHI, reaching an intra-class correlation coefficient of 0.891 in the test set (40% of samples). Furthermore, the estimated AHI showed high diagnostic ability, reaching an accuracy of 82.7%, 81.9%, and 91.1% using three common AHI cut-offs of 1, 5, and 10 events per hour (e h^-1), respectively. These results outperformed the overall performance of ODI3.

SIGNIFICANCE

DFA may serve as a reliable tool to improve the diagnostic performance of oximetry recordings in the evaluation of paediatric patients with symptoms suggestive of SAHS.