The identification of children with cleft palate and sleep disordered breathing using a referral system

Impact of Syndromes on Sleep-Disordered Breathing in Children After Cleft Palate Repair

OBJECTIVE

Prior research suggests that children with cleft palate (CP) are at increased risk of obstructive sleep-disordered breathing (SDB). However, few studies differentiate the effects of CP repair on SDB based on syndrome status. The goal of this study was to evaluate differences in SDB after palatoplasty among children with nonsyndromic CP, syndromic CP, and isolated Robin sequence (RS).

DESIGN

Retrospective chart review.

SETTING

Tertiary academic children's hospital.

PATIENTS/PARTICIPANTS

A total of 145 children who underwent primary CP repair from 2014 to 2021.

MAIN OUTCOME MEASURE

Post-palatoplasty SDB is defined as parent-reported symptoms and/or evidence of obstructive sleep apnea (OSA).

RESULTS

Median age at palatoplasty was 11.1 [IQR 10.2-13.6] months. Most patients (61.4%) had nonsyndromic CP, 26.9% had a syndrome, and 11.7% had RS. Children with syndromic CP and RS had more post-palatoplasty SDB symptoms (56.4% vs 58.8% vs 30.3%, P = .006) and higher rates of OSA (25.6% vs 29.4% vs 5.6%, P = .001) compared to children with nonsyndromic CP after palatoplasty. Children with syndromic CP and RS had nearly 3 to 4 higher odds of post-palatoplasty SDB than children with nonsyndromic CP (adjusted odds ratio [aOR] 2.88, 95% CI 1.29-6.47, P = .010; aOR 3.73, 95% CI 1.19-11.70, P = .024).

CONCLUSION

This study showed that children with CP experience higher rates of SDB after palatoplasty than the general pediatric population. Within the cohort, children with syndromic CP and isolated RS were more likely to have obstructive sleep disorders than nonsyndromic children after palatoplasty. Clinicians should counsel caregivers accordingly and closely monitor these groups for SDB after palate repair.

Effect of Sleep Position on Sleep-Disordered Breathing in Young Children With Unrepaired Incomplete Cleft Palates

Children with cleft lip/palate are usually faced with upper airway problems after surgical repair. The severity of upper airway obstruction is more likely associated with the age and preoperative diagnosis of obstructive sleep apnea (OSA). This study aimed to investigate the severity of OSA in toddlers before palatoplasty from the perspective of polysomnography. In this retrospective cohort study, 97 children with unrepaired cleft palate and habitual prone sleeping were identified with a mean age of 1.6 years (SD 0.6) and divided into 2 age groups (1.5 year or younger and older than 1.5 year). Detailed information was collected including demographics, sleep parameters, and respiratory disturbances. Polysomnography results showed these children were at high risks of OSA with averagely moderate severity at night during their early childhood [apnea-hypopnea index 7.2±3.2 events/hour; obstructive apnea index (OAI) 6.5±2.8 events/hour]. Positional OAI was greatly lower in prone than that in laterals or in supine. Far more sleep time was spent in prone than in supine (42.9%±42.2% versus 8.5%±15.7%), which were consistent with parental reporting of prone sleeping habits. There were no significant differences found between the 2 age groups in respiratory disturbances such as apnea-hypopnea index, OAI, mean oxygen saturation, and nadir oxygen saturation ( P =0.097-0.988). Thus, prone sleeping with a history of snoring might be indicators for early screening for OSA in the cleft population. Adequate attention should be paid to their upper airway and, if available, overnight polysomnography should be performed to ascertain their potential respiratory problems before repair surgery.

Pediatric obstructive sleep apnea-Dental professionals can play a crucial role

The significant contribution of dental professionals to the management of selected adult obstructive sleep apnea (OSA) cases is understood. Among children, it has also been suggested that dental professionals may also help screen and manage this morbidity in selected cases. It has also been noted that our understanding of pediatric OSA lags significantly behind adult OSA. During the screening process for potential pediatric OSA cases, dental professionals may be quite helpful as specific craniofacial abnormalities have been previously associated with pediatric OSA, including Class II malocclusion, vertical facial growth and maxillary transversal deficiency. As dental professionals assess children more frequently than physicians, they can help screen sleep-disordered breathing signs and symptoms using validated questionnaires. In more advanced cases, orthodontists may be leading contributors to the management of selected cases where a craniofacial involvement is suspected. Rapid maxillary expansion and mandibular or maxillary anterior repositioning devices have been proposed as managing alternatives. So far, there is no substantial evidence if these approaches can be adopted to treat OSA fully or if the reported OSA signs and symptoms improvements observed in a selected group of patients are stable long-term. Nevertheless, dentists and orthodontists' integration into a transdisciplinary team should be encouraged to play a significant role. This review discusses dentists or orthodontists' potential contribution to screen and manage selective pediatric OSA patients as part of a transdisciplinary team.

Obstructive sleep apnea in children with non-syndromic cleft palate: a systematic review

STUDY OBJECTIVES

To characterize obstructive sleep apnea (OSA) in children with non-syndromic cleft palate based on polysomnographic parameters relative to primary palatoplasty.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Scopus, CINAHL, and Cochrane. Studies were only considered for inclusion if they examined exclusively non-syndromic cleft palate patients and reported polysomnogram data.

RESULTS

Seven studies met inclusion criteria, providing information on a total of 151 patients with a weighted mean age of 5.2 ± 5.0 years old (range 0.1- 12 years). Five studies presented data from either the pre- or post-operative period. Two studies investigated both pre- and post-palatoplasty polysomnogram data, and neither observed a significant change in apnea hypopnea index (AHI) values following surgery (mean pre-operative AHI of 2.7, mean improvement of 0.6 events/hour). The entire cohort had a pre-palatoplasty weighted mean AHI of 11.4 (range 1.5 -16.1) and post-palatoplasty AHI of 1.5 (range 0.2 - 5.2). Interpretation of polysomnographic data was limited by heterogeneity; however, the AHI values of children with non-syndromic cleft palate largely demonstrated mild to moderate OSA following palatoplasty.

CONCLUSIONS

The full effect of cleft palate repair on OSA in children with non-syndromic cleft palate remains understudied. While published data are heterogenous, few studies support the worsening of obstructive AHI after palatoplasty in children with non-syndromic cleft palate. Further studies with standardized polysomnographic parameters are needed to provide guidance for management of this population.

Does Sleep Position Influence Sleep-Disordered Breathing in Infants With Cleft Palate: A Feasibility Study?

OBJECTIVE

Cleft palate (CP) can affect breathing, leading to sleep-disordered breathing (SDB). Sleep position can affect SDB, but the optimum sleep position for infants with CP is unknown. We aimed to determine the design of a pragmatic study to investigate the effect of the 2 routinely advised sleep positions in infants with CP on oxygen saturations.

DESIGN

A multicentered observational cohort.

SETTING

Four UK-based cleft centers, 2 advising supine- and 2 side-lying sleep positions for infants with CP.

PARTICIPANTS

Infants with isolated CP born July 1, 2015, and December 31, 2016. Of 48 eligible infants, 30 consented (17 side-lying; 13 supine).

INTERVENTIONS

Oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2) home monitoring at age 1 and 3 months. Qualitative interviews of parents.

OUTCOME MEASURES

Willingness to participate, recruitment, retention, and acceptability/success (>90 minutes recording) of SpO2 and ETCO2 monitoring.

RESULTS

SpO2 recordings were obtained during 50 sleep sessions on 24 babies (13 side-lying) at 1 month (34 sessions >90 minutes) and 50 sessions on 19 babies (10 side-lying) at 3 months (27 sessions >90 minutes). The ETCO2 monitoring was only achieved in 12 sessions at 1 month and 6 at 3 months; only 1 was >90 minutes long. The ETCO2 monitoring was reported by the majority as unacceptable. Parents consistently reported the topic of sleep position in CP to be of importance.

CONCLUSIONS

This study has demonstrated that it is feasible to perform domiciliary oxygen saturation studies in a research setting and has suggested that there may be a difference in the effects of sleep position that requires further investigation. We propose a study with randomization is indicated, comparing side-lying with supine-lying sleep position, representing an important step toward better understanding of SDB in infants with CP.

Study protocol for randomised clinical trial comparing the effectiveness of side-lying sleep positioning to back-lying at reducing oxygen desaturation resulting from obstructive sleep apnoea in infants with cleft palate (SLUMBRS2)

INTRODUCTION

The craniofacial abnormalities found in infants with cleft palate (CP) decrease their airway patency and increase their risk of obstructive sleep apnoea (OSA). We hypothesise that optimising sleep position in infants with CP may improve airway patency and offer a 'low-cost, high-impact' intervention to prevent the negative impacts of OSA. Because cleft centres give inconsistent advice about sleep position: some recommend back-lying and others side-lying, we will compare these in a randomised controlled trial.

METHODS AND ANALYSIS

The aim is to determine the clinical effectiveness of side-lying as compared with back-lying sleep positioning in terms of reducing oxygen desaturation resulting from OSA in 244 infants aged 3-5 weeks of age, diagnosed with an isolated CP in/by UK cleft centres. Primary outcome is the 4% Oxygen Desaturation Index measured using pulse oximetry during sleep.

RESEARCH PLAN

1. Multicentre randomised controlled trial of side-lying compared with back-lying sleep positioning in reducing oxygen desaturation resulting from OSA in infants with CP at one month of age. 2. Internal pilot questionnaire-based study to support parents and clinicians regarding study participation, seeking to identify and address any barriers to recruitment. Monitoring data from the internal pilot will be used in the final analysis. 3. Co-development of new UK recommendations with Cleft Lip and Palate Association (CLAPA) regarding sleep position for infants with CP.

ETHICS AND DISSEMINATION

The study protocol has received the favourable opinion of the West Midlands-South Birmingham Research Ethics Committee. Study results will be published on affiliated webpages and in peer-reviewed publications and conference contributions.

TRIAL REGISTRATION NUMBER

NCT04478201.

Oral Habits in Children With Orofacial Clefts: A Comparative Study

BACKGROUND AND AIM

Children with cleft lip and palate present with a wide range of dental and occlusal anomalies as a result of the cleft defect. These patients also present with oral habits which may affect their quality of life. The aim of this study was to compare the prevalence of oral habits in these children, with children without orofacial clefts.

METHODOLOGY

This was a cross-sectional comparative study comparing children with repaired cleft lip and/or palate aged 3 to 12 years, with children without orofacial clefts. Ethical approval for the study was obtained from the institutional review boards of both centers. Data collection was via interviewer administered questionnaires given to the parents/guardians of the children in each group. Data analysis was carried out using SPSS version 23. The level of significance was set at P < .05.

RESULTS

A total of 107 respondents participated in the study, comprising 53 children with repaired cleft lip and/or palate 54 children without orofacial clefts. The mean age for the children with Cleft lip and/or palate/ was 6.81 (standard deviation [SD] 1.898) years, while that for the control group was 7.78 (SD 1.68) years. Two oral habits recorded a significantly higher prevalence (P < .05) in the children with repaired clefts as compared to controls and these were lip sucking and bruxism. No significant difference in prevalence was recorded for all the other oral habits surveyed.

CONCLUSION

A significantly higher prevalence (P < .05) was observed in lip sucking and bruxism among children with cleft lip and palate, as compared to the children without orofacial clefts.

Parental Experience of Sleep-Disordered Breathing in Infants With Cleft Palate: Comparing Parental and Clinical Priorities

OBJECTIVE

To identify outcomes relating to sleep-disordered breathing (SDB) that are relevant to parents, during the early weeks of caring for infants with cleft palate (CP), and compare these with clinical outcomes identified in a systematic search of research literature.

DESIGN

A qualitative study using telephone/face-to-face interviews with parents explored their understanding of breathing and respiratory effort in infants with CP.

SETTING

Care provided by 3 specialist cleft centers in the United Kingdom, with study conducted in parents' homes.

PARTICIPANTS

Criteria for participation were parents of infants with isolated CP aged 12 to 16 weeks. Thirty-one parents of infants with CP (over 12 weeks) were invited to participate in the interview. Interviews were completed with 27 parents; 4 parents could not be contacted after completing the sleep monitoring.

RESULTS

Parents' description of infants' sleep suggests that breathing is not considered as a separate priority from their principal concerns of feeding and sleeping. They observe indicators of infants' breathing, but these are not perceived as signs of SDB. Parents' decision to use lateral or supine sleep positioning reflects their response to advice from specialists, observation of their infants' comfort, ease of breathing, and personal experience. Outcomes, identified in published research of SDB, coincide with parents' concerns but are expressed in medical language and fit into distinct domains of "snoring," "sleep," "gas exchange," and "apnea."

CONCLUSIONS

Parents' description of sleeping and respiration in infants with CP reflect their everyday experience, offering insight into their understanding, priorities, and language used to describe respiration. Understanding parents' individual priorities and how these are expressed could be fundamental to selecting meaningful outcomes for future studies of airway interventions.

Surgical Closure of the Cleft Palate Has a Transient Obstructive Effect on the Upper Airway in Children

OBJECTIVE

To prospectively investigate the occurrence of respiratory symptoms related to obstructive sleep apnea (OSA) following primary palatoplasty in children with cleft palate (CP).

METHOD

Fifty-six nonsyndromic children presenting CP with a previously repaired cleft lip (CL) or without CL were assessed before and after palate repair. Twenty nonsyndromic children with isolated CL were analyzed as controls before and after lip repair. Respiratory symptoms were investigated preoperatively, and at early and late postoperative periods. Based on the parent reports of "difficulty of breathing (D), apnea events (A) and/or snoring (S) during sleep, a validated OSA index (1.42D + 1.41A + 0.71S - 3.83) was used to predict absence of OSA, possible OSA, and presence of OSA, at the 3 periods analyzed.

RESULTS

Screening for OSA showed that the CP group exhibited an increased mean index at the early postoperative assessment, suggesting "possible OSA," and a higher frequency of snoring at the early and late postoperative assessments, as compared to the CL group (P < .05). Sleep apnea events were not reported.

CONCLUSIONS

Surgical closure of the palate has an obstructive effect on the upper airway in the short term, causing OSA-related respiratory symptoms, mostly transient. However, the high prevalence of snoring still observed in the long term indicate that children with a palatal cleft who undergo surgical repair are at risk for OSA. The results support the conclusion that OSA is underappreciated in this population.

Respiratory Polysomnographic Findings in Patients Treated Primarily for Unilateral Cleft Lip and Palate

Cleft lip and palate (CLP) is the most common congenital craniofacial abnormality. Obstructive sleep apnea syndrome (OSAS) is a highly prevalent but underdiagnosed disease and is frequently associated with craniofacial anomalies. There are few studies describing the sleep breathing pattern of children with CLP. This study sought to characterize the respiratory profile of 23 children with unilateral cleft lip and palate, aged 7-12 years, who had undergone cleft lip and nasal repair at age 3-4 months and palatoplasty at 12-15 months, with a particular focus on evaluating the presence of OSAS in children with CLP. Polysomnography was performed and findings were analyzed descriptively. We found a mean and median for apnea/hypopnea index (AHI) of 1.11/h (SD = 0.78) and 0.9/h, respectively. The mean obstructive apnea index (OAI) was 0.27/h (SD = 0.38) and the median, 0.1/h. Nearly 30% of patients had an AHI above 1.4 events/h. There was no significant oxyhemoglobin desaturation in the study group. In this group, the prevalence of OSAS was higher than in noncleft populations when compared to the normality values adopted. This sample of patients with unilateral cleft lip and palate exhibited an increased prevalence of OSAS during the mixed dentition stage. Although the results showed that OSAS was mild, we advise closer observation of these patients. Polysomnography is recommended for the assessment of children with airway abnormalities, to individualize the extent of treatment.

Evolution of Obstructive Sleep Apnea in Infants with Cleft Palate and Micrognathia

STUDY OBJECTIVES

Children with craniofacial anomalies are a heterogeneous group at high risk for obstructive sleep apnea (OSA). However, the prevalence and structural predictors of OSA in this population are unknown. We hypothesized that infants with micrognathia would have more significant OSA than those with isolated cleft palate ± cleft lip (ICP), and those with ICP would have more significant OSA than controls. We postulated that OSA severity would correlate with reduced mandibular size, neurodevelopmental scores, and growth.

METHODS

Prospective cohort study. 15 infants with ICP, 19 with micrognathia, and 9 controls were recruited for polysomnograms, neurodevelopmental testing, cephalometrics (ICP and micrognathia groups) at baseline and a follow-up at 6 mo.

RESULTS

Baseline apnea-hypopnea index (AHI) [median (range)] of the micrognathia group [20.1 events/h (0.8, 54.7)] was greater than ICP [3.2 (0.3, 30.7)] or controls [3.1 (0.5, 23.3)] (p = 0.001). Polysomnographic findings were similar between ICP and controls. Controls had a greater AHI than previously reported in the literature. Cephalometric measures of both midface hypoplasia and micrognathia correlated with OSA severity. Neurodevelopment was similar among groups. OSA improved with growth in participants with ICP and postoperatively in infants with micrognathia.

CONCLUSIONS

Micrognathia, but not ICP, was associated with more significant OSA compared to controls. Both midface and mandibular hypoplasia contribute to OSA in these populations. OSA improved after surgical correction in most infants with micrognathia, and improved without intervention before palate repair in infants with ICP.

Comparison of Clinical Symptoms and Severity of Sleep Disordered Breathing in Children With and Without Cleft Lip and/or Palate

OBJECTIVE

To determine whether the clinical presentation or severity of sleep disordered breathing differs between children with or without a history of cleft lip and/or palate (CL/P) presenting for sleep assessment.

DESIGN

Retrospective chart review.

SETTING

Tertiary care pediatric hospital cleft clinic, sleep clinic.

PATIENTS

Children >6 months of age presenting to the cleft clinic with sleep concerns and children without CL/P presenting to the sleep clinic in the same 2-year period.

MAIN OUTCOMES MEASURES

Clinical symptoms and overnight polysomnography (PSG) results.

RESULTS

A total of 168 children (55 from cleft clinic, 113 from sleep clinic) were identified. Age at clinical review (6.6 ± 4.1 years versus 6.8 ± 4.0 years, P = ns), sex distribution (64.6% versus 58.4%, P = ns), and the presence of syndromes or significant medical conditions (12% versus 16%, P = ns) were similar between groups. Snoring was the reason for referral in 59% of children with CL/P and 69% of non-CL/P children (P = ns). The only presenting feature that differentiated between the groups was a lower incidence of tonsillar enlargement in children with CL/P (33% versus 79%, chi-square 30.4, P < 0.001). Sleep study results showed similar apnea-hypopnea indices (6.2 ± 6.9 versus 7.9 ± 7.1 events/hr, P = ns) with more central apnea in children with CL/P (1.5 ± 1.5 versus 1.0 ± 1.0 events/hr, P = 0.017).

CONCLUSIONS

Snoring and obstructive sleep apnea are common in CL/P with less tonsillar enlargement than non-CL/P children. Children with CL/P have similar OSA severity compared to non-cleft children but more central apnea which may indicate differences in the control of breathing.

Incidence of positive screening for obstructive sleep apnea in patients with isolated cleft lip and/or palate

OBJECTIVE

To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P).

METHODS

The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test.

RESULTS

A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were 'fidgets with hands or feet' (73.6%), 'interrupts others' (69.4%) and 'mouth breather during the day' (69.4%). The most sensitive items were 'stops breathing during the night' and 'trouble breathing during sleep', with positive predictive values of 0.78 and 0.67, respectively. Sex, body mass index, ancestry and cleft type were not significantly associated with increased risk for positive screening.

CONCLUSION

One in seven children with isolated CL/P screened positively for OSA according to the PSQ. This finding highlights the potential importance of routine screening in this at-risk group.

Incidence of positive screening for obstructive sleep apnea in patients with isolated cleft lip and/or palate

Objective

To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P).

Methods

The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test.

Results

A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were ‘fidgets with hands or feet’ (73.6%), ‘interrupts others’ (69.4%) and ‘mouth breather during the day’ (69.4%). The most sensitive items were ‘stops breathing during the night’ and ‘trouble breathing during sleep’, with positive predictive values of 0.78 and 0.67, respectively. Sex, body mass index, ancestry and cleft type were not significantly associated with increased risk for positive screening.

Conclusion

One in seven children with isolated CL/P screened positively for OSA according to the PSQ. This finding highlights the potential importance of routine screening in this at-risk group.

Increase in Sagittal Depth of the Bony Nasopharynx following Maxillary Protraction in Patients with Unilateral Cleft Lip and Palate

Objective

To study the change in the sagittal depth of the bony nasopharynx in patients with unilateral cleft lip and palate (UCLP), following maxillary protraction using reverse headgear.

Methods

Nineteen patients (14 male, five female; aged 9.36 ± 2.89 years) with repaired complete UCLP underwent maxillary protraction with a Delaire type reverse headgear at a tertiary-care referral teaching hospital. Control data were taken from five patients (four male, one female; aged 8.25 ± 2.25 years) who did not receive any orthopedic/orthodontic treatment for a similar duration of time as the treated patients. Average treatment/observation period was 11.71 ± 3.39 months for the treated patients and 12.40 ± 2.60 months for the untreated subjects. Changes in the sagittal bony nasopharynx depth were measured by comparing pretreatment (T1) and posttreatment (T2) lateral cephalograms. Correlations between the changes in the bony nasopharynx depth and in other variables measured in the treated patients were analyzed. An exploratory analysis of differences in the changes from T1 to T2 between the treated patients and untreated subjects was also conducted.

Results

The favorable skeletal changes seen in SNA and ANB following maxillary protraction were accompanied by a significant increase in the sagittal depth of bony nasopharynx (1.74 ± 1.10 mm; P < .001). This change was significant when compared with the data from the untreated subjects ( P = .004). Correlations between the increase in bony nasopharynx depth and changes in other variables studied in the treated patients were weak and not statistically significant.

Conclusion

Sagittal depth of the bony nasopharynx in patients with repaired UCLP increased following maxillary protraction therapy using reverse headgear.

Utility of screening for obstructive sleep apnea syndrome in children with craniofacial disorders

BACKGROUND

Children with craniofacial disorders are at increased risk for obstructive sleep apnea syndrome. Methods for diagnosing obstructive sleep apnea syndrome in this population remain controversial. Sleep studies are the criterion standard but are impractical for all patients. The utility of obstructive sleep apnea syndrome questionnaires such as the Pediatric Sleep Questionnaire is unknown in children with craniofacial disorders. The authors hypothesized that the Pediatric Sleep Questionnaire would be a sensitive tool for detecting obstructive sleep apnea syndrome in children with craniofacial abnormalities.

METHODS

A retrospective review of consecutive children with diagnosed craniofacial disorders who both completed the Pediatric Sleep Questionnaire and underwent polysomnography was performed. Demographics, Pediatric Sleep Questionnaire score, and polysomnographic data were recorded. Statistical analysis included calculation of sensitivity, specificity, positive predictive value, and negative predictive value for the Pediatric Sleep Questionnaire.

RESULTS

Eighty-three children aged 2 to 18 years were included in the study. Of these, 44 (53.0 percent) screened positive on the Pediatric Sleep Questionnaire and 23 (27.7 percent) had polysomnographic evidence of obstructive sleep apnea syndrome, but the sensitivity of the Pediatric Sleep Questionnaire for detecting obstructive sleep apnea syndrome in this sample was only 0.57 and the specificity was 0.48. Positive predictive value and negative predictive value were 0.30 and 0.74, respectively. The correlation between the apnea hypopnea index and Pediatric Sleep Questionnaire score was 0.152 (p = 0.17).

CONCLUSIONS

A substantial portion of craniofacial patients referred for polysomnography was found to have obstructive sleep apnea syndrome. However, the Pediatric Sleep Questionnaire is not a good screening tool for obstructive sleep apnea syndrome in children with craniofacial conditions. More research is needed to determine which patients with craniofacial disorders should be evaluated for obstructive sleep apnea syndrome by polysomnography or other means.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Impact of sleep and breathing in infancy on outcomes at three years of age for children with cleft lip and/or palate

STUDY OBJECTIVES

To evaluate the relationship between sleep disordered breathing (SDB) in early infancy and outcomes at 3 years of age in children with cleft lip and/or palate (CL/P).

DESIGN

Observational follow-up study.

SETTING

Multidisciplinary CL/P clinic, tertiary centre.

PARTICIPANTS

Children with CL/P who participated in a study of sleep and breathing in infancy.

MEASUREMENTS AND RESULTS

The families of 52 children were approached for this follow-up study. The children underwent neurocognitive (Bayley Scales of Infant and Toddler Development, Third Edition; BSID-III), quality of life (Infant/Toddler Quality of Life Questionnaire; ITQOL), and growth assessments at 3 years. The families of 33 children (66%) completed follow-up at 36.7 ± 1.4 months. The apnea-hypopnea index (AHI) in infancy was 23.9 ± 18.0 events/h. Mean group BSID-III scores fell within the standardized normal range (10 ± 3) for all domains; however, language scores were lower than control children. Quality of life scores and growth parameter z-scores were similar to published control data. PSG variables in infancy showed significant relationships with outcomes at 3 years of age; lower percentage of AS/REM sleep was associated with lower cognition score; more obstructive events were associated with lower global behavior ITQOL score; and higher number of respiratory events in infancy was associated with lower weight z-score.

CONCLUSION

Neurocognition, quality of life, and growth measures from children with CL/P fall within a normal range; however, scores in the language domain are lower than controls. Sleep and respiratory elements of SDB in infancy appear to modify these outcomes at 3 years of age.

Sleep problems and early developmental delay: implications for early intervention programs

Sleep disorders negatively impact behavior, cognition, and growth--the same areas targeted by early intervention. Conversely, developmental delays and disabilities may themselves precipitate sleep disorders. Young children with developmental delays experience sleep disorders at a higher rate than do typically developing children; the most common types are difficulties initiating or maintaining sleep and sleep disordered breathing. To date, attention has been focused on sleep problems in children with specific conditions (e.g., autism, genetic syndromes, prematurity, and seizure disorder). The authors review evidence of sleep problems' broader impact across the range of children screened for early intervention. Eligibility evaluations for early intervention address the five developmental domains: adaptive, motor, cognitive, communication, and socioemotional. Disordered sleep may be symptomatic of socioemotional and adaptive problems. Assessing sleep problems within the evaluation may help establish eligibility for early intervention services and would maximize developmental potential by ensuring timely identification, referral, and treatment.

Sleep and its importance in adolescence and in common adolescent somatic and psychiatric conditions

Restoring sleep is strongly associated with a better physical, cognitive, and psychological well-being. By contrast, poor or disordered sleep is related to impairment of cognitive and psychological functioning and worsened physical health. These associations are well documented not only in adults but also in children and adolescents. Importantly, adolescence is hallmarked by dramatic maturational changes in sleep and its neurobiological regulation, hormonal status, and many psychosocial and physical processes. Thus, the role of sleep in mental and physical health during adolescence and in adolescent patients is complex. However, it has so far received little attention. This review first presents contemporary views about the complex neurobiology of sleep and its functions with important implications for adolescence. Second, existing complex relationships between common adolescent somatic/organic, sleep-related, and psychiatric disorders and certain sleep alterations are discussed. It is concluded that poor or altered sleep in adolescent patients may trigger and maintain many psychiatric and physical disorders or combinations of these conditions, which presumably hinder recovery and may cross into later stages of life. Therefore, timely diagnosis and management of sleep problems appear critical for growth and development in adolescent patients.

Sleep problems in children and adolescents with common medical conditions

Untreated sleep disturbances and sleep disorders pose significant adverse daytime consequences and place children at considerable risk for poor health outcomes. Sleep disturbances occur at a greater frequency in children with acute and chronic medical conditions compared with otherwise healthy peers. Sleep disturbances in medically ill children can be associated with sleep disorders, comorbid with acute and chronic conditions, or secondary to underlying disease-related mechanisms, treatment regimens, or hospitalization. Clinical management should include a multidisciplinary approach with particular emphasis on routine, regular sleep assessments and prevention of daytime consequences, and promotion of healthy sleep habits and health outcomes.

Executive summary of respiratory indications for polysomnography in children: an evidence-based review

OBJECTIVE

This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children.

METHODS

A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep.

RESULTS

The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support.

CONCLUSIONS

Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.

Clinical practice: sleep problems during infancy

Sleep problems are very prevalent during infancy. The most common problems are those related to night wakings and sleep-disordered breathing (SDB). Most common night waking problems do not have identified physiologic etiology. Their causes appear to be behavioral or developmental by nature, and they usually respond well to behavioral interventions. SDB may result from a variety of anatomic and neurologic factors and is associated with a variety of medical and developmental disorders. Because of the high prevalence of sleep problems during infancy, their persistence, their potential adverse developmental effects, and the positive treatment outcomes, pediatricians should serve as the primary address for screening and referral to proper assessment and treatment.

Cleft lip and/or palate and breathing during sleep

Cleft of the lip and/or palate (CL/P) is a common defect which is associated with changes in facial structures and a smaller upper airway. As a result, infants and children with CL/P have an increased risk of sleep disordered breathing (SDB). This paper will review the anatomical and functional factors which place infants and children with CL/P at increased risk of SDB as well as review the literature which defines the magnitude of this risk. The information available on treatment of SDB in infants and children with CL/P will be presented. Finally, outstanding issues relevant to SDB in children with CL/P are discussed with direction for future research.

Screening for Obstructive Sleep Apnea in Preschool Children with Cleft Palate

Objective:

The objective of this study was to explore the prevalence, range of reported symptoms, and clinical risk factors of obstructive sleep apnea in preschool children with cleft lip and/or palate.

Design:

Questionnaires were distributed to parents/guardians of all children from birth to 5 years of age who were followed by the cleft clinic.

Results:

Questionnaire data and cleft classification were available for 248 children, with a mean age of 33.4 months. Obstructive sleep apnea was identified in 31.4% of the children. Only 29.5% of children with obstructive sleep apnea had undergone an investigation of these symptoms. The three most common symptoms reported in children with a questionnaire diagnosis of obstructive sleep apnea were (1) “heavy or loud breathing,” (2) “easily distracted,” and (3) “on the go” or “driven by a motor.” The only clinical risk factor associated with a questionnaire diagnosis of obstructive sleep apnea was the presence of a syndrome (χ2  =  3.5, p  =  .05). There were no significant differences in risk of obstructive sleep apnea by age, cleft classification, and surgical status.

Conclusion:

Preschool children with cleft lip and/or palate have a risk of obstructive sleep apnea that is as much as five times that of children without cleft. Obstructive sleep apnea appears to be underrecognized in this group of children. Further research is needed to investigate important risk factors for obstructive sleep apnea in children with cleft lip and/or palate.