Prevalence of obstructive sleep apnea among obese toddlers and preschool children

Obstructive sleep apnea is associated with impaired insulin clearance and hepatic insulin sensitivity in paediatric obesity

AIMS

Obstructive sleep apnea (OSA) affects up to 40% of children and adolescents with obesity and is linked to hyperinsulinism. However, the mechanisms underpinning this association remain unclear. The study aims to assess the three key determinants of hyperinsulinemia: insulin clearance, secretion, and sensitivity in paediatric patients with OSA.

METHODS

We enrolled 70 Children with obesity and suspected OSA who performed a nocturnal polygraphy to confirm OSA diagnosis and a 3-hour OGTT to assess glucose homeostasis. Mild OSA was defined for 1 < AHI ≤ 5, moderate-severe OSA as AHI >5. Insulin secretion rate (ISR) was estimated using C-peptide deconvolution. Basal and total insulin clearance during OGTT were calculated. Whole-body insulin sensitivity was evaluated with the Matsuda Index (WBISI), while hepatic insulin resistance index (HIRI) was calculated based on the AUCs of plasma glucose and insulin during the initial 30 minutes of OGTT.

RESULTS

A total of 36 children had mild OSA and 34 had moderate-severe OSA. The latter group showed reduced insulin clearance during OGTT (p = 0.008) and higher HIRI (p = 0.03). Basal insulin clearance (p = 0.07), ISR (p = 0.34), beta-cell glucose sensitivity (p = 0.53), and WBISI (p = 0.56) were similar between the two groups. OSA severity negatively correlated with fasting insulin clearance (r = -0.29, p = 0.01) and OGTT insulin clearance (r = -0.32, p = 0.007) and positively correlated with HIRI (r = 0.29, p = 0.02).

CONCLUSION

Moderate-severe OSA in children with obesity is associated with impaired insulin clearance and hepatic insulin sensitivity. These factors may contribute to hyperinsulinism in paediatric OSA.

A Comprehensive Review of Pediatric Obstructive Sleep Apnea: From Assessment to Intervention

Pediatric obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by upper airway obstruction during sleep, leading to oxygen desaturation and sleep disruptions. This comprehensive review examines the epidemiology, pathophysiology, clinical manifestations, diagnostic approaches, consequences, management strategies, challenges, and future directions of pediatric OSA. Prevalence rates vary globally, with notable associations found between OSA and obesity. The review explores the anatomical and neuromuscular factors contributing to airway obstruction, emphasizing the importance of timely identification and intervention to mitigate long-term health implications. Diagnostic tools such as polysomnography (PSG) are essential, although challenges in accessibility exist. Pediatric OSA is linked to various health issues, including cardiovascular complications, metabolic disturbances, and neurocognitive impairments. Treatment options range from surgical interventions like adenotonsillectomy to non-pharmacological therapies and pharmacotherapy. Challenges in diagnosis and treatment warrant research into innovative diagnostic approaches and refining clinical prediction rules. Addressing these areas will enhance clinical management and outcomes for children with OSA.

Differential sleep subtypes in children with OSA of different ages

OBJECTIVE

The aim of this study was to evaluate the variations in sleep architecture and types of sleep disturbances in preschool and school-age children diagnosed with obstructive sleep apnea (OSA).

METHODS

Children who underwent polysomnography (PSG) were enrolled and divided into two groups based on age: a preschool group and a school-age group. We analyzed differences in sleep architecture and types of sleep disturbances between these groups.

RESULTS

Total sleep time was significantly higher in the preschool group compared to the school-age group (P < 0.05). The percentage of Stage N1 sleep (N1%) was also higher in the preschool group (p < 0.05). Conversely, the percentage of Stage N2 sleep (N2%) was lower in the preschool group (p < 0.05). Additionally, the average and minimum heart rates were higher in the preschool group, while the minimum oxygen saturation, including during non-rapid eye movement (NREM) and REM stages, was lower compared to the school-age group (P < 0.05). The prevalence of positional OSA (P-OSA) was lower, and the prevalence of REM OSA (R-OSA) was higher in the preschool group (P < 0.05).

CONCLUSION

The prevalence of P-OSA was lower, and R-OSA was higher in preschool children compared to school-age children. Furthermore, the types of sleep disturbances in preschool children with OSA showed significant differences from those in school-age children with OSA.

Validation of the Arabic version of the Obstructive Sleep Apnea-18 quality of life questionnaire for evaluating children with sleep apnea-hypopnea syndrome

BACKGROUND

Pediatric obstructive sleep apnea (OSA) poses a significant health concern, affecting the well-being and quality of life of affected children. This study focuses on the translation, adaptation, and validation of the OSA-18 questionnaire for Arabic-speaking pediatric patients, aiming to contribute to the understanding of OSA and its implications on the quality of life in this population.

METHODS

A study was conducted at Jordan University Hospital, involving 186 Arabic-speaking pediatric patients with suspected OSA. The OSA-18 questionnaire was translated and culturally adapted following the World Health Organization guidelines. Overnight polysomnography was conducted to assess OSA severity. Internal consistency, construct validity, convergent validity, and predictive/discriminant validity were analyzed.

RESULTS

The study sample (68.8% of males, median age: 10.87) showed a median Apnea-Hypopnea Index (AHI) of 7.0, OSA-18 score of 46.5, and Pediatric Sleep Questionnaire (PSQ) score of 7.0. Internal consistency of OSA-18 was acceptable, except for the "physical symptoms" domain. Exploratory and confirmatory factor analyses revealed five factors corresponding to different OSA-18 domains. Convergent validity was supported by significant correlations between OSA-18 and PSQ scores. However, no correlation was found between OSA-18 scores and AHI. OSA severity was associated with higher PSQ scores but not with AHI.

CONCLUSION

This study provides valuable insights into pediatric OSA in Arabic-speaking children. While the translation and validation of the OSA-18 questionnaire demonstrated acceptable reliability and convergent validity, the lack of correlation between OSA-18 scores and AHI raises questions about the survey's ability to capture the full impact of OSA objectively. Future research should focus on developing more reliable diagnostic tools, especially in resource-limited settings.

Pediatric obstructive sleep apnea-related risk factors: A cross-sectional study

OBJECTIVES

This study investigated obstructive sleep apnea (OSA)-related risk factors in children and adolescents.

MATERIALS AND METHODS

Records of 187 subjects from a private medical clinic were reviewed. Overnight polysomnography recordings and self/parent reports were gathered. Descriptive analysis of sociodemographic, anthropometric, sleep quality and sleep architecture variables and OSA diagnosis were performed. Associations between independent variables and OSA diagnosis were assessed through multivariable logistic regression with robust variance, with a significance level of 5%.  Results: 132 participants were diagnosed with OSA, and 55 were classified as "no OSA" (29.41%). Those overweight or obese were 4.97 times more likely to have OSA than those with normal weight (P =  0.005). Those who reported loud snoring were 2.78 times more likely to have OSA than those who reported mild or moderate snoring intensity. A one-unit increase in arousal index leads to 1.39 increase in the odds ratio (OR) of individuals diagnosed with OSA (P < 0.001), and each one-unit increase in sleep efficiency leads to 1.09 higher odds of not having OSA (P =  0.002).

CONCLUSIONS

Significantly increased OSA-related risk factors among overweight/obese children and adolescents and among those who had a parental/self-report of loud snoring were found.

An integrated bioinformatics analysis to identify the shared biomarkers in patients with obstructive sleep apnea syndrome and nonalcoholic fatty liver disease

Background

Obstructive sleep apnea (OSA) syndrome and nonalcoholic fatty liver disease (NAFLD) have been shown to have a close association in previous studies, but their pathogeneses are unclear. This study explores the molecular mechanisms associated with the pathogenesis of OSA and NAFLD and identifies key predictive genes.

Methods

Using the Gene Expression Omnibus (GEO) database, we obtained gene expression profiles GSE38792 for OSA and GSE89632 for NAFLD and related clinical characteristics. Mitochondrial unfolded protein response-related genes (UPRmtRGs) were acquired by collating and collecting UPRmtRGs from the GeneCards database and relevant literature from PubMed. The differentially expressed genes (DEGs) associated with OSA and NAFLD were identified using differential expression analysis. Gene Set Enrichment Analysis (GSEA) was conducted for signaling pathway enrichment analysis of related disease genes. Based on the STRING database, protein-protein interaction (PPI) analysis was performed on differentially co-expressed genes (Co-DEGs), and the Cytoscape software (version 3.9.1) was used to visualize the PPI network model. In addition, the GeneMANIA website was used to predict and construct the functional similar genes of the selected Co-DEGs. Key predictor genes were analyzed using the receiver operating characteristic (ROC) curve.

Results

The intersection of differentially expressed genes shared between OSA and NAFLD-related gene expression profiles with UPRmtRGs yielded four Co-DEGs: ASS1, HDAC2, SIRT3, and VEGFA. GSEA obtained the relevant enrichment signaling pathways for OSA and NAFLD. PPI network results showed that all four Co-DEGs interacted (except for ASS1 and HDAC2). Ultimately, key predictor genes were selected in the ROC curve, including HDAC2 (OSA: AUC = 0.812; NAFLD: AUC = 0.729), SIRT3 (OSA: AUC = 0.775; NAFLD: AUC = 0.750), and VEGFA (OSA: AUC = 0.812; NAFLD: AUC = 0.861) (they have a high degree of accuracy in predicting whether a subject will develop two diseases).

Conclusion

In this study, four co-expression differential genes for OSA and NAFLD were obtained, and they can predict the occurrence of both diseases. Transcriptional mechanisms involved in OSA and NAFLD interactions may be better understood by exploring these key genes. Simultaneously, this study provides potential diagnostic and therapeutic markers for patients with OSA and NAFLD.

Utility of the psychomotor vigilance task in screening for obstructive sleep apnoea

PURPOSE

The study aimed to assess the performance of the PVT in patients with suspected OSA, evaluate its role in population screening for OSA.

METHODS

The NoSAS, STOP-Bang, ESS scores and PVT tests were performed after suspected OSA patients' admission, followed by PSG. Then we compared the PVT results, calculated the sensitivity, specificity and ROC curve of PVT, and analyzed the accuracy of STOP-Bang and NoSAS questionnaire combined with PVT in predicting OSA.

RESULTS

A total of 308 patients were divided into four groups based on AHI: primary snoring (2.74 ± 1.4 events/h, n = 37); mild OSA (9.96 ± 3.25 events/h, n = 65); moderate OSA (22.41 ± 4.48 events/h, n = 76); and, severe OSA (59.42 ± 18.37 events/h, n = 130). There were significant differences in PVT lapses (p < 0.001) and reaction time (RT, p = 0.03) among the four groups. The PVT lapses and RT were positively correlated with AHI (p < 0.001) and ODI (p < 0.001), and negatively correlated with LSpO2 (p < 0.001). When diagnosing OSA (AHI ≥ 5 events/h), the AUCs of PVT, ESS, STOP-Bang, and NoSAS were 0.679, 0.579, 0.727, and 0.653, respectively; the AUCs of STOP-Bang and NoSAS combined with PVT increased. After combined PVT, the diagnostic specificity of STOP-Bang and NoSAS at nodes with AHI ≥ 5, ≥ 15 and ≥ 30 events/h increased to varying degrees.

CONCLUSION

Patients with OSA exhibited impairment in the PVT, and the combination of the PVT and STOP-Bang or NoSAS scores can improve the diagnostic efficacy and specificity for OSA.

Comparing Sleep Patterns and Clinical Features between Preschool and School-Age Children with OSA

OBJECTIVE

This study aimed to evaluate sleep patterns and investigate differences in clinical features among young individuals with snoring and obstructive sleep apnea (OSA).

METHODS

Data from 213 children and adolescents who underwent polysomnography (PSG) for primary snoring or OSA were collected between July 2017 and December 2021. To analyze differences in sleep architecture, hypoxia levels, and other clinical features, the participants were divided into two age groups: a preschool group and a school-age group.

RESULTS

The school-age group had significantly higher apnea-hypopnea index, obstructive apnea index, oxygen desaturation index, and body mass index than the preschool group. Both the lowest and average oxygen saturation levels were lower in the school-age group. Adenoid hypertrophy was more prevalent in the preschool group. The rate of overweight or obesity was 35.6% in the preschool group and even 94.2% in the school-age group. There were higher percentages of N1 and N2 sleep stages, and lower percentages of N3 and REM sleep stages in the school-age group. The groups exhibiting moderate to severe OSA demonstrated significant alterations in the difference between sleeping and waking diastolic blood pressure.

CONCLUSION

There is a higher frequency of respiratory events among school-age children compared with their preschool peers. Moreover, alterations in sleep structure are more prominent in the school-age group. Adenoid hypertrophy may serve as the primary instigator of OSA in preschool children, whereas the predominant causes in school-age children may be obesity or excessive weight.

LEVEL OF EVIDENCE

Retrospective chart review, 3 Laryngoscope, 134:1472-1478, 2024.

Prevalence of obstructive sleep apnea (OSA) among preschool aged children in the general population: A systematic review

Untreated pediatric obstructive sleep apnea (OSA) is associated with significant morbidities affecting behavior, neurocognitive development, endocrine and metabolic health. This systematic review evaluated prevalence of OSA reported in population-based studies among preschoolers as early intervention may have positive effects on health and quality of life. Thirty studies were included. High degrees of heterogeneity in methods and definitions were observed between the studies. Seven studies confirmed OSA by implementing objective methods after screening for habitual snoring with only two studies utilizing polysomnography, the reference standard, testing 1.2% of the combined cohorts (n = 82/4575) to confirm disease. Diagnosis of OSA was based on utilizing retired thresholds of the apnea-hypopnea-index (AHI), AHI4%≥5/hour of sleep (hrSleep), reporting prevalence of 1.8% and 6.4%, respectively. The remaining five studies implemented relatively insensitive objective recording methods to confirm disease in a limited number of children (n = 449/2486; 18.0%), estimating prevalence in the range of 0.7%-13.0%. The remaining literature is based on implementing questionnaires only to evaluate OSA. Studies published before 2014 reported 3.3%-9.4% prevalence, while more recent studies published 2016-2023 report higher prevalence, 12.8%-20.4%, when excluding outliers. This trend suggests that prevalence of OSA may possibly have been increasing in preschoolers over the past decade.

Trends in overweight and obesity in children under 24 months of age in Mexico (2012-2020): analysis of four national health surveys

The prevalence of childhood obesity has increased rapidly in Mexico, with significant consequences for the population's health in the future. Little is known about the prevalence of obesity in children under two years of age, even though this life stage is fundamental to prevent this condition. This study aims to determine the magnitude, distribution, and trends of overweight and obesity in children under 24 months of age using the Mexican National Health and Nutrition Surveys (ENSANUT) conducted in the last 10 years. The data presented here are derived from four ENSANUTs, carried out in Mexico in 2012, 2016, 2018, and 2020. They include 6,719 infants under 24 months with complete anthropometric data (weight/height) by age, gender, Indigeneity, area of residence, and socioeconomic status. The risk of overweight levels and overweight + obesity rates were calculated according to World Health Organization guidelines. We identified that infants < 12 months currently have a higher prevalence of overweight + obesity (10.3%) and that those aged 12 to 23 months are generally at a higher risk of overweight (26.1%). The most relevant findings of this study, linking weight trends to sex, region, socioeconomic status, and indigeneity, show that overweight and obesity prevalences vary across the Mexican population, without presenting a specific behavior. There is a high prevalence of overweight and obesity among Mexican infants and a slight trend toward increased obesity in infants < 12 months. Weight monitoring and obesity prevention interventions focused on the first 1,000 days of life are essential.

The impact of obstructive sleep apnea on nonalcoholic fatty liver disease

Obstructive sleep apnea (OSA) is characterized by episodic sleep state-dependent collapse of the upper airway, with consequent hypoxia, hypercapnia, and arousal from sleep. OSA contributes to multisystem damage; in severe cases, sudden cardiac death might occur. In addition to causing respiratory, cardiovascular and endocrine metabolic diseases, OSA is also closely associated with nonalcoholic fatty liver disease (NAFLD). As the prevalence of OSA and NAFLD increases rapidly, they significantly exert adverse effects on the health of human beings. The authors retrieved relevant documents on OSA and NAFLD from PubMed and Medline. This narrative review elaborates on the current knowledge of OSA and NAFLD, demonstrates the impact of OSA on NAFLD, and clarifies the underlying mechanisms of OSA in the progression of NAFLD. Although there is a lack of sufficient high-quality clinical studies to prove the causal or concomitant relationship between OSA and NAFLD, existing evidence has confirmed the effect of OSA on NAFLD. Elucidating the underlying mechanisms through which OSA impacts NAFLD would hold considerable importance in terms of both prevention and the identification of potential therapeutic targets for NAFLD.

Risk of Obstructive Sleep Apnea in Saudi Male Boys with Duchenne Muscular Dystrophy (DMD)

Background

Duchenne muscular dystrophy (DMD) patients are at a high risk of developing sleep-related breathing disorders (SRBD) such as obstructive sleep apnea (OSA). This study aimed to determine the risk of developing OSA among DMD patients.

Methods

This cross-sectional study was conducted from February 2022 to July 2022 in a tertiary healthcare facility. As a screening tool for OSA, we used the Pediatric Sleep Questionnaire (PSQ).

Results

Subjects included 60 boys with DMD, mean age 10.15 ± 3.54 years. The mean BMI for all subjects was 18.9 ± 4.08 kg/m2. Of these, 22 (36.7%) children were at high risk of OSA. Children who were overweight, and on steroids tended to be at higher risk of developing OSA (P < 0.043) and (P < 0.029) respectively.

Conclusion

Our study shows a significant risk of OSA in DMD patients. Therefore, Sleep studies should be part of the standard of care for DMD patients.

Pediatric Sleep Respiratory Disorders: A Narrative Review of Epidemiology and Risk Factors

Sleep is a fundamental biological necessity, the lack of which has severe repercussions on the mental and physical well-being in individuals of all ages. The phrase "sleep-disordered breathing (SDB)" indicates a wide array of conditions characterized by snoring and/or respiratory distress due to increased upper airway resistance and pharyngeal collapsibility; these range from primary snoring to obstructive sleep apnea (OSA) and occur in all age groups. In the general pediatric population, the prevalence of OSA varies between 2% and 5%, but in some particular clinical conditions, it can be much higher. While adenotonsillar hypertrophy ("classic phenotype") is the main cause of OSA in preschool age (3-5 years), obesity ("adult phenotype") is the most common cause in adolescence. There is also a "congenital-structural" phenotype that is characterized by a high prevalence of OSA, appearing from the earliest ages of life, supported by morpho-structural abnormalities or craniofacial changes and associated with genetic syndromes such as Pierre Robin syndrome, Prader-Willi, achondroplasia, and Down syndrome. Neuromuscular disorders and lysosomal storage disorders are also frequently accompanied by a high prevalence of OSA in all life ages. Early recognition and proper treatment are crucial to avoid major neuro-cognitive, cardiovascular, and metabolic morbidities.

Pediatric obesity and anesthetic challenges of metabolic surgery

Obesity in the pediatric population is considered a growing problem. It is likely that there will be a significant impact related to obesity on the health of future generations. Obesity has increased the incidence of a spectrum of diseases ranging from microvascular complications over the retina and peripheral nerves to an increased incidence of cancer. We have conducted an electronic search in MEDLINE, PubMed, ISI Web of Science, and Scopus scientific databases targeting studies published between 2000 till 2019. Several modalities have shown a wide spectrum of the effectiveness of weight control among adolescents. Despite achieving short-term success among obese adolescents, maintaining such change is challenging. The emergence of metabolic or bariatric surgeries has opened the door for long-term control over weight gain with considerable remission of unfavorable metabolic mediated or modulated effects associated with obesity such as diabetes mellitus and hypertension. The most commonly practiced metabolic surgery among adolescents is sleeve gastrectomy which is associated with comparable weight and metabolic control and a lesser risk of complication. Anesthesia is considered a major challenge among the pediatric population, especially those with significant obesity. Preoperative evaluation is always warranted to exclude and manage different associated comorbidities. The anesthetic challenges associated with pediatric obesity begin with intubation. Maintenance and emergence from anesthesia along with postoperative antiemetics and analgesia can pose additional challenges. Managing the postoperative period is considered a cornerstone in the early detection and management of any postoperative complication. Especially those complications related to the metabolic and nutritional aspects of the bariatric surgery. Finally, despite being a valuable option in managing obesity, bariatric surgery in adolescents comes with significant anesthetic challenges that need to be consistently evaluated and managed.

Application value of joint STOP-Bang questionnaire and Epworth Sleepiness Scale in screening for obstructive sleep apnea

Objective

This paper evaluates the application value of the STOP-Bang questionnaire combined with the Epworth Sleepiness Scale (ESS) in screening for obstructive sleep apnea (OSA) in the population.

Method

Thousand-six hundred seventy-one patients with suspected OSA who visited the Sleep Medicine Center of the First Affiliated Hospital of Guangzhou Medical University from August 2017 to August 2020 were monitored by overnight polysomnography (PSG) after completing the ESS scale and STOP-Bang questionnaire. The sensitivity, specificity, positive predictive value, negative predictive value and receiver operating characteristic (ROC) curves of the two scales were calculated, and the accuracy in predicting OSA of the STOP-Bang questionnaire combined with ESS was analyzed.

Results

With Apnea Hypopnea Index (AHI) cutoffs of ≥5, ≥15 and ≥30 events/h, the areas under the ROC curve scored by STOP-Bang were 0.724, 0.703 and 0.712, and those of ESS were 0.632, 0.634 and 0.695; the diagnostic odds ratio (DOR) values of STOP-Bang for OSA, moderate to severe OSA, and severe OSA were 3.349, 2.651 and 3.189, and those of ESS were 2.665, 2.279 and 3.289. The STOP-Bang score of three was used as the cut-off point for OSA diagnosis with higher sensitivity and lower specificity, while ESS had higher specificity. STOP-Bang (≥3) combined with ESS significantly improved its specificity for predicting OSA.

Conclusion

The STOP-Bang questionnaire is a simple and effective new tool for screening patients for OSA, while a STOP-Bang score of ≥3 combined with ESS can further improve its specificity. Thus, we suggest further screening with ESS after a STOP-Bang score of ≥3 in suspected patients.

Prevalence of and risk factors for obstructive sleep apnea in children with sickle cell: a multicentric cross sectional study

The prevalence of obstructive sleep apnea syndrome (OSAS) is elevated in some high-risk populations. Children with sickle cell disease (SCD) are known to have many comorbidities, including OSAS. The objectives of this study were to assess the prevalence of and risk factors for OSAS among children with SCD in two major tertiary health care facilities in Jeddah, Saudi Arabia. This multicenter cross-sectional study took place in two major tertiary health care facilities-King Abdulaziz University Hospital and King Khalid National Guard Hospital, Jeddah, Saudi Arabia. Children with SCD who were admitted between January 2010 and December 2017 were enrolled. The Pediatric Sleep Questionnaire (PSQ) was used to screen for OSAS. Data were collected from 150 children with SCD aged between 2 and 18 years. Eighty-five percent of the children had sickle cell anemia (SCA) with HbSS, and the rest had sickle beta-thalassemia (HbS/ß-thalassemia). Based on the PSQ, 33 of the 150 (22%) children had OSAS (score ≥ 7). The average score on the PSQ was 3.8/22 (± 3.8). A history of adenotonsillar hypertrophy was found to be a significant risk factor in bivariate and multivariate analyses [aOR 5.5; 95% CI 1.84-16.35 (P < 0.001)]. The odds of having OSAS were ninefold higher in children who had periodic limb movements than in those who did not after adjustment [95% CI 1.75-48.03 (P < 0.001)]. OSAS is a highly prevalent disease among children with SCD. Many factors were associated with OSAS in the bivariate analysis, including nationality, education level, a history of adenotonsillar hypertrophy, and a history of periodic limb movements.

The association of obstructive sleep apnea with dyslipidemia in Korean children and adolescents: a single-center, cross-sectional study

STUDY OBJECTIVES

To evaluate whether obstructive sleep apnea (OSA) and its severity are related to dyslipidemia and alanine transaminase elevation as a marker of nonalcoholic fatty liver disease in children.

METHODS

The data collected from polysomnography, laboratory measurements (lipid profile and liver enzyme), and body mass index in children aged 0-18 years who visited the pediatric department between 2012 and 2018 were retrospectively analyzed.

RESULTS

There were a total of 273 participants in the study (ages 0-6 years, 7-12 years, and 13-18 years: 61.9%, 26.4%, and 11.7%, respectively). In the ages 7-12 and 13-18 years groups, obesity was strongly associated with OSA severity (Cramer's V = 0.498, P < .001). High-density lipoprotein cholesterol levels were significantly lower in the OSA group than in the non-OSA group, irrespective of the presence of obesity. In addition, high-density lipoprotein cholesterol levels were significantly different between the OSA severity groups after adjusting for body mass index (P = .000). In participants who were obese, moderate and severe OSA were associated with alanine transaminase elevation (P = .023 and P = .045, respectively).

CONCLUSIONS

This study suggests that OSA may be an independent risk factor for dyslipidemia and that OSA and obesity have a synergistic effect on alanine transaminase elevation. Early diagnosis and treatment of OSA from childhood, especially in obese children, will reduce metabolic complications.

CITATION

Kang EK, Jang MJ, Kim KD, Ahn YM. The association of obstructive sleep apnea with dyslipidemia in Korean children and adolescents: a single-center, cross-sectional study. J Clin Sleep Med. 2021;17(8):1599-1605.

Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist

Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.

Prevalence of Pulmonary Hypertension in Pediatric Patients With Obstructive Sleep Apnea and a Cardiology Evaluation: A Retrospective Analysis

STUDY OBJECTIVES

Pulmonary hypertension (PH) has been reported as a serious complication of obstructive sleep apnea (OSA) in children; however, estimated prevalence rates vary widely (zero to 85%). The purpose of this study is to determine the prevalence of PH in children with OSA and identify factors that may predict an increased PH risk in children with OSA.

METHODS

A retrospective review of all pediatric beneficiaries (88,058) in the San Antonio Military Health System with a diagnosis of OSA and a clinical evaluation by a pediatric cardiologist. OSA severity and nadir oxygen saturation were recorded from overnight polysomnography. Reason for referral, comorbid disorders, echocardiogram results, and cardiac diagnoses were obtained from cardiology records.

RESULTS

OSA was identified in 2,020 pediatric patients (2.3%). A pediatric cardiology consultation was reported for 296 patients with OSA. After excluding 95 patients for incorrect OSA diagnoses, incomplete data, or OSA treatment before cardiology evaluation, 163 patients were included in the final analysis. A diagnosis of PH was found in 3 patients with OSA (1.8%). Two of these patients had obesity, and all three had comorbid cardiac disorders.

CONCLUSIONS

Prevalence of PH in pediatric patients with OSA is low and none of the patients with PH had severe OSA. Current guidelines recommend PH screening in patients with severe OSA, yet OSA severity may not accurately predict risk. Factors evaluated in this study did not demonstrate an increased PH risk; additional research is necessary to improve screening in pediatric patients with OSA.

CITATION

Burns AT, Hansen SL, Turner ZS, Aden JK, Black AB, Hsu DP. Prevalence of pulmonary hypertension in pediatric patients with obstructive sleep apnea and a cardiology evaluation: a retrospective analysis. J Clin Sleep Med. 2019;15(8):1081-1087.

Identifying cohort differences in children undergoing partial intracapsular tonsillectomy vs traditional tonsillectomy for sleep disordered breathing

OBJECTIVE

Partial intracapsular tonsillectomy (PIT) is a well-established technique for reducing post-operative morbidity in pediatric patients with sleep disordered breathing (SDB). Although tonsillar re-growth rates are reported as low, risks of symptom recurrence or need for completion tonsillectomy are clear disadvantages when compared to traditional tonsillectomy (TT). We aim to identify cohort differences to better guide clinical decision making and identify patient-specific factors that may influence this decision. A secondary aim was to evaluate potential risk factors for tonsillar regrowth.

METHODS

Retrospective chart review of pediatric patients who underwent TT or PIT for SDB between 2015 and 2019 at a tertiary care academic medical center. Records were reviewed for age, gender, race, body mass index, comorbidities, diagnosis, apnea-hypopnea index, pre-operative Brodsky tonsil size, length of stay, post-operative hemorrhage, tonsillar regrowth, symptom recurrence, and need for completion tonsillectomy.

RESULTS

315 patients were included: 174 underwent TT and 141 underwent PIT. Patients undergoing TT were more likely to have a sleep study showing OSA (OR 3.01, p < 0.0001), asthma (OR 4.28, p = 0.000124), and other comorbidities (OR 4.06, p = 0.0258). The overall complication rate was 4.44% (14/315). Tonsillar regrowth was exclusive to the PIT group, occurring in 7/141 patients (4.96%). Age ≤4 years was significantly associated with increased risk of tonsillar regrowth (≤4 years: 7.69%, >4 years: 0%; p = 0.049). Race and pre-operative tonsil size were not associated with regrowth.

CONCLUSIONS

Our study supports the low incidence of tonsillar regrowth in PIT and suggests an association with younger age. Moreover, we found that patients undergoing TT are more likely to be older, have OSA, asthma, and other comorbidities.

Pediatric Obstructive Sleep Apnea and Neurocognition

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.

Referral indications and prevalence of sleep abnormalities in children with early onset scoliosis

This study describes the utility of overnight sleep studies in children with early onset scoliosis (EOS). Children with EOS have diminished respiratory reserve which is associated with abnormal breathing and sleep quality in children. Currently, there are no criteria for referral of these children to evaluate breathing during sleep or data on the use of sleep treatments as part of their supportive care. A review of the 159 patients with EOS who were followed at a single institution from 2003 to 2016 identified 68 who underwent overnight polysomnograms (PSGs). Sixty-five of 68 (96%) had elevated apnea-hypopnea index (AHI) and a majority (56%) were prescribed nighttime respiratory support. A majority of young children (< 5 years) with PSG were referred for a history of snoring, apnea, or restless sleep; all 30 had abnormal PSGs. Twenty-seven (90%) had nighttime hypoxemia (nadir oxygen saturation values < 92%). Eighteen (60%) were referred to otolaryngology, of whom 11 (37%) subsequently underwent tonsil and/or adenoid removal. In older children (≥ 5 years), those referred for PSGs had more severe restrictive chest wall disease [lower forced vital capacity (FVC) values] than those who were not sent for PSG. Correlation between FVC and apnea-hypopnea index, however, was not significant. Pre-operative coronal curve magnitude did not strongly correlate with nadir SaO₂ or AHI in either age group. These results suggest that sleep studies are underutilized in the management of children with EOS. Inadequate and poor-quality sleep adversely affects growth, behavior, and cognitive function in children. This study suggests that screening for sleep abnormalities should be incorporated into assessment and treatment of more patients with EOS.

Beyond the growth delay in children with sleep-related breathing disorders: a systematic review

INTRODUCTION

The availability of high-quality studies on the association between sleep-disordered breathing in children and delayed growth associated with the hormonal profile recorded before surgery and at follow-up is limited.

EVIDENCE ACQUISITION

Medline PubMed, Scopus and WebOfScience databases were searched for relevant publications published between January 2008 to January 2020 and a total of 261 potentially eligible studies were identified.

EVIDENCE SYNTHESIS

Following review 19 papers were eligible for inclusion: seven reported a significant postsurgical increase in growth regardless of initial weight status, type of surgery, type of study design, and length of follow-up period. The only high-quality study was a randomized controlled trial that found an increased risk of obstructive sleep apnea syndrome relapse in overweight children. Twelve studies reported the significant increase in growth parameters showing that IGF-1, IGFBP-3, and ghrelin may boost growth after surgery.

CONCLUSIONS

The current systematic review demonstrates a scarcity of high-quality studies on growth delay in children with sleep-disordered breathing. Significant catch-up growth after surgery in the short term and changes in IGF-1, IGFBP-3, ghrelin, and leptin levels has been reported in most published studies.

The cardiovascular risk in paediatrics: the paradigm of the obstructive sleep apnoea syndrome

BACKGROUND

Obstructive sleep apnoea syndrome (OSAS) describes a spectrum of abnormal breathing patterns during sleep characterised by snoring, increased upper airway resistance and pharyngeal collapsibility, with alteration of normal oxygenation and ventilation. Intermittent desaturations during sleep have multi-organ implications. Adults with OSAS have an increased risk of developing a dysfunctional endothelium that is characterised by greater adherence of inflammatory mediators to endothelial cells and hypercoagulability. There is increasing evidence to show that risk factors for comorbid cardiovascular disease (CVD) can develop during childhood and adolescence and are likely to continue over time. Risk factors for CVD include both modifiable factors and factors that cannot be changed.

MATERIALS AND METHODS

Using the MEDLINE^® electronic database, we reviewed the scientific literature for published studies evaluating the association between sleep-disordered breathing and cardiovascular damage in children.

RESULTS

In this review, we show the role of blood markers in demonstrating the inflammation caused by intermitted oxygen desaturations during sleep in both healthy and obese children. Several instrumental techniques, in addition to serum biomarkers, can be used to assess vascular endothelial damage and its deterioration in the form of a pre-atherosclerotic condition. The confirmation of their role as markers of inflammation and vascular damage is supported by normalisation after resolution or improvement of the sleep-disordered breathing with surgery.

DISCUSSION

Great attention should be given to this condition in infants and children as it will significantly affect their present and future well-being as they grow into adulthood. Healthcare professionals, especially paediatricians, should be trained to recognise the signs and symptoms of the disease in order to send children forward for specialist care in centres dealing with sleep-disordered breathing.

Preschoolers with recurrent wheezing have a high prevalence of sleep disordered breathing

Objective: Sleep-disordered breathing (SDB) is highly prevalent in school children with poorly-controlled asthma. However, this association has not been assessed in preschoolers with recurrent wheeze, nor in those at risk for asthma. We hypothesized that preschoolers with asthma risk (positive asthma predictive index [API]) have a higher prevalence of SDB and higher inflammatory biomarkers (blood-hsCRP and urinary-LTE4) levels than those with negative API.Method: Children 2 to 5 years of age with recurrent wheezing were classified as positive or negative API. SDB was determined by the pediatric sleep questionnaire (PSQ) and its subscale (PSQSub6). Demographic characteristics, spirometry, blood hsCRP and urinary LTE4 were assessed.Results: We enrolled 101 preschoolers: 70 completed all measurements, 55.4% were males, mean age 4.07 ± 0.87 years, 45% overweight or obese, 70% had positive API, 87.5% had rhinitis. The prevalence of SDB measured by PSQ was 40.8% and by PSQSub6 was 29.6%. However, the proportion of SDB was similar between positive and negative API groups. The hsCRP (mean ± SD) was higher in the positive than in negative API (3.58 ± 0.58 and 1.32 ± 0.36 mg/L, p = 0.69, respectively); moreover, no differences in urinary LTE4 were found between groups. No correlation of PSQ (+) or PSQSub6 (+) with hsCRP and uLTE4 was found. However, preschoolers with positive API had significantly more post-bronchodilator percentage change in FEF25-75 than negative API (24.14 ± 28.1 vs. 4.13 ± 21.8, respectively, p = 0.01).Conclusions: In preschoolers with recurrent wheezing, we should be investigating for the coexistence of SDB, using early screening methods for detecting those conditions.

Cost-Effectiveness Analysis of Intracapsular Tonsillectomy and Total Tonsillectomy for Pediatric Obstructive Sleep Apnea

PURPOSE

We performed an economic evaluation using a decision-tree model to analyze the relative cost effectiveness from the United States Centers for Medicare and Medicaid Services (CMS) perspective of two different methods of tonsillectomy (traditional total tonsillectomy and partial intracapsular) for pediatric obstructive sleep apnea (OSA).

MATERIALS AND METHODS

Procedural costs were drawn from published literature and Medicare values. Effectiveness and probabilities were drawn from medical literature. Primary intervention was monopolar-technique total tonsillectomy or microdebrider-assisted partial intracapsular tonsillectomy. Secondary interventions included operative control of hemorrhage, treatment of severe dehydration, or revision tonsillectomy. The decision model starts with pediatric patients with OSA, choosing between total and partial tonsillectomy. Outcomes were measured by costs (US dollars), effectiveness [quality-adjusted life year (QALY)], and a willingness-to-pay threshold of US$100,000/QALY. Base case analysis, probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses were performed. Primary outcome was incremental cost-effectiveness ratio (ICER) for each of the two tonsillectomy techniques.

RESULTS

Base case analysis demonstrated that total tonsillectomy was more cost effective at US$12,453.40 per QALY gained. In PSA, 82.84% of the simulations show total tonsillectomy to be the more cost-effective strategy. Deterministic sensitivity analyses showed that when the rate of OSA recurrence is lower than 3.12%, partial tonsillectomy would be more cost effective. When the failure rate of partial tonsillectomy is below 1.0%, it is more cost effective even when total tonsillectomy is 100% successful.

CONCLUSION

Study results suggest that overall monopolar-technique total tonsillectomy is more cost effective. However, with varying adjustments for disutility caused by procedural complications, intracapsular tonsillectomy could become a more cost-effective technique for treating pediatric OSA.