How OSA Evolves From Childhood to Young Adulthood: Natural History From a 10-Year Follow-up Study

Advances in Sleep-Disordered Breathing in Children

Pediatric sleep-disordered breathing disorders are a group of common conditions, from habitual snoring to obstructive sleep apnea (OSA) syndrome, affecting a significant proportion of children. The present article summarizes the current knowledge on diagnosis and treatment of pediatric OSA focusing on therapeutic and surgical advancements in the field in recent years. Advancements in OSA such as biomarkers, improving continuous pressure therapy adherence, novel pharmacotherapies, and advanced surgeries are discussed.

Ferritin is a potential marker of cardiometabolic risk in adolescents and young adults with sleep-disordered breathing

Objective

To explore markers that reflect sleep-disordered breathing (SDB) severity and investigate their associations with cardiometabolic risk factors in adolescents and young adults.

Methods

Participants were recruited from our SDB epidemiological cohort. They underwent overnight polysomnography and ambulatory blood pressure (BP) monitoring. Complete blood count, ferritin, high-sensitivity C-reactive protein (hs-CRP), fasting blood glucose, and lipid profile were measured. Multiple linear regression was used to examine the association between red cell indices (RCIs), ferritin, and obstructive apnea-hypopnea index (OAHI). Subgroup analyses on participants with SDB were performed for the association of RCIs and ferritin with lipid profile, hs-CRP, and BP.

Results

There were 88 participants with SDB and 155 healthy controls aged 16-25 years. Hemoglobin (Hb; p < .001), hematocrit (HCT; p < .001), and ferritin (p < .001) were elevated with increasing SDB severity and were independently associated with OAHI (β=1.06, p < .001; β=40.2, p < .001; β=4.89 × 10-3, p = .024, respectively). In participants with SDB, after adjusting for age, sex, and BMI, significant associations were found between ferritin with low-density lipoprotein (LDL; β=0.936 × 10-3, p = .008) and triglyceride (TG; β =1.08 × 10-3, p < .001), as well as between Hb (β=1.40, p = .007), HCT (β=51.5, p = .010) and mean arterial pressure (MAP). Ferritin (β=0.091, p = .002), Hb (β=0.975, p = .005), and HCT (β=38.8, p = .004) were associated with hs-CRP independent of age, sex, BMI, plasma LDL, and MAP. OAHI was not associated with LDL and TG in the multivariable models.

Conclusions

Serum ferritin, but not OAHI, was associated with LDL and TG in participants with SDB, suggesting it is a potential marker of cardiometabolic risk in patients with SDB.

Efficacy of adenotonsillectomy on pediatric obstructive sleep apnea and related outcomes: A narrative review of current evidence

This review summarizes the current evidence in systematic reviews, meta-analysis and randomized controlled trials regarding adenotonsillectomy outcomes in pediatric obstructive sleep apnea (OSA). Adenotonsillectomy is effective in treating OSA in children without co-morbidities, despite postoperative residual OSA remained in roughly half of these children. For children with comorbidities such as Down syndrome, Prader-Willi syndrome, sickle cell disease, or cerebral palsy, adenotonsillectomy is less effective and associated with more postoperative complications than that in children without comorbidities. For other OSA-related outcomes, evidence from meta-analyses and randomized controlled trials confirm adenotonsillectomy results in improvement of subjective OSA-related outcomes (e.g. symptoms, behaviors, and quality of life), but the results in objective OSA-related outcomes (e.g. cardiometabolic parameters or neurocognitive functions) are inconsistent. Future studies should focus on randomized controlled trials comparing objective OSA-related outcomes and the long-term effects of adenotonsillectomy in children with OSA.

A rat model of adenoid hypertrophy constructed by using ovalbumin and lipopolysaccharides to induce allergy, chronic inflammation, and chronic intermittent hypoxia

BACKGROUND

Adenoid hypertrophy (AH) is a common pediatric disease that significantly impacts the growth and quality of life of children. However, there is no replicable and valid model for AH.

METHODS

An AH rat model was developed via comprehensive allergic sensitization, chronic inflammation induction, and chronic intermittent hypoxia (CIH). The modeling process involved three steps: female Sprague-Dawley rats (aged 4-5 weeks) were used for modeling. Allergen sensitization was induced via intraperitoneal administration and intranasal provocation using ovalbumin (OVA); chronic nasal inflammation was induced through intranasal lipopolysaccharide (LPS) administration for sustained nasal irritation; CIH akin to obstructive sleep apnea/hypopnea syndrome was induced using an animal hypoxia chamber. Postmodel establishment, behaviors, and histological changes in nasopharynx-associated lymphoid tissue (NALT) and nasal mucosa were assessed. Arterial blood gas analysis and quantification of serum and tissue levels of (interleukin) IL-4 and IL-13, OVA-specific immunoglobulin E (sIgE), eosinophil cationic protein (ECP), tumor necrosis factor (TNF-α), IL-17, and transforming growth factor (TGF)-β were conducted for assessment. The treatment group received a combination of mometasone furoate and montelukast sodium for a week and then was evaluated.

RESULTS

Rats exhibited notable nasal symptoms and hypoxia after modeling. Histopathological analysis revealed NALT follicle hypertrophy and nasal mucosa inflammatory cell infiltration. Elevated IL-4, IL-13, IL-17, OVA-sIgE, ECP, and TNF-α levels and reduced TGF-β levels were observed in the serum and tissue of model-group rats. After a week of treatment, the treatment group exhibited symptom and inflammatory factor improvement.

CONCLUSION

The model effectively simulates AH symptoms and pathological changes. But it should be further validated for genetic, immunological, and hormonal backgrounds in the currently used and other strains and species.

Is there an OAHI or O2 nadir that predicts the need for preoperative echocardiogram prior to adenotonsillectomy for children with severe obstructive sleep apnea?

PURPOSE

To investigate threshold values for obstructive apnea-hypopnea index (OAHI) and nadir oxygen saturation (NspO2) in children with severe obstructive sleep apnea (OSA) to identify children most appropriate for preoperative echocardiography.

METHODS

A multi-institutional retrospective chart review was performed on children who underwent echocardiography and polysomnogram within a year. Children with severe OSA as defined by OAHI > 10 or NspO2 < 80% were included. Receiver operator curves and Youden's J index were used to assess the discriminatory ability and threshold values of OAHI and NspO2 for right heart strain (RHS) on echocardiography.

RESULTS

A total of 173 prepubertal (< 10 years) children and 71 postpubertal (≥ 10 years) children of age were included. RHS was seen in 9 (5%) prepubertal children and 4 (6%) postpubertal children. In prepubertal children, OAHI and NspO2 were poor predictors of RHS (area under the curve [AUC] 0.53 [95%CI 0.45-0.61], p = 0.748; AUC 0.56 [95%CI 0.48-0.64], p = 0.609). In postpubertal children, threshold values of 55 events/hour and 69% were strong predictors for RHS (AUC 0.88 [95%CI 0.78-0.95], p < 0.001; AUC 0.92 [95%CI 0.83-0.97], p < 0.001).

CONCLUSION

In children with severe OSA, evidence of RHS is low. Postpubertal children with OAHI > 55 and NspO2 < 69% appear most appropriate for echocardiography. Clinicians should weigh the risks and benefits of preoperative echocardiography for each child with these threshold values in mind.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Associations of early life and childhood risk factors with obstructive sleep apnoea in middle-age

BACKGROUND AND OBJECTIVE

Early-life risk factors for obstructive sleep apnoea (OSA) are poorly described, yet this knowledge may be critical to inform preventive strategies. We conducted the first study to investigate the association between early-life risk factors and OSA in middle-aged adults.

METHODS

Data were from population-based Tasmanian Longitudinal Health Study cohort (n = 3550) followed from 1st to 6th decades of life. Potentially relevant childhood exposures were available from a parent-completed survey at age 7-years, along with previously characterized risk factor profiles. Information on the primary outcome, probable OSA (based on a STOP-Bang questionnaire cut-off ≥5), were collected when participants were 53 years old. Associations were examined using logistic regression adjusting for potential confounders. Analyses were repeated using the Berlin questionnaire.

RESULTS

Maternal asthma (OR = 1.5; 95% CI 1.1-2.0), maternal smoking (OR = 1.2; 1.05, 1.5), childhood pleurisy/pneumonia (OR = 1.3; 1.04, 1.7) and frequent bronchitis (OR = 1.2; 1.01, 1.5) were associated with probable OSA. The risk-factor profiles of 'parental smoking' and 'frequent asthma and bronchitis' were also associated with probable OSA (OR = 1.3; 1.01, 1.6 and OR = 1.3; 1.01-1.9, respectively). Similar associations were found for Berlin questionnaire-defined OSA.

CONCLUSIONS

We found novel temporal associations of maternal asthma, parental smoking and frequent lower respiratory tract infections before the age of 7 years with adult OSA. While determination of their pathophysiological and any causal pathways require further research, these may be useful to flag the risk of OSA within clinical practice and create awareness and vigilance among at-risk groups.

Untangling the relationship between childhood risk factors and obstructive sleep apnoea in adulthood

See related article

Longitudinal risk factors for obstructive sleep apnea: A systematic review

Despite substantial disease burden, existing evidence on the risk factors for obstructive sleep apnea (OSA) have been derived primarily from cross-sectional studies without determining temporality. Therefore, we aimed to systematically synthesize the literature on longitudinal risk factors for sleep study-assessed OSA and questionnaire-assessed probable OSA from cohort studies in the general adult population settings. We systematically searched Embase and Medline (on OVID) databases. Eleven studies met the inclusion criteria. Meta-analyses were not conducted due to methodological heterogeneity of exposure and outcome measurements. There was consistent evidence that weight gain was associated with incident (n = 2) and greater severity (n = 2) of OSA. One study each observed an association of higher baseline body-mass index, male sex, asthma, a specific genetic polymorphism in rs12415421, and insulin resistance/hyperglycemia, with incident OSA. Long-term exposure to ambient air pollution (NO2, n = 1) was associated with OSA, and menopausal transitions (n = 1) with higher apnea-hypopnea index. There were no eligible studies on long-term smoking or alcohol use. In conclusion, approximately 10% increase in weight, especially in males, might alert clinicians to consider potential or worsening OSA. Large, well-designed longitudinal studies are needed to consolidate knowledge on other associations with OSA development, especially on potentially modifiable risk factors.

Early life predictors of obstructive sleep apnoea in young adults: Insights from a longitudinal community cohort (Raine study)

OBJECTIVE

Early-life obstructive sleep apnoea (OSA) predictors are unavailable for young adults. This study identifies early-life factors predisposing young adults to OSA.

METHODS

This retrospective study included 923 young adults and their mothers from the Western Australian Pregnancy Raine Study Cohort. OSA at 22 years was determined from in-laboratory polysomnography. Logistic regression was used to identify maternal and neonatal factors associated with OSA in young adulthood.

RESULTS

OSA was observed in 20.8% (192) participants. Maternal predictors of OSA included gestational diabetes mellitus (odds ratio (OR) 9.54, 95% confidence interval (CI) 1.7, 58.5, P = 0.011), preterm delivery (OR 3.18, 95%CI 1.1,10.5, P = 0.043), preeclampsia (OR 2.95, 95%CI 1.1,8.0, P = 0.034), premature rupture of membranes (OR 2.46, 95%CI 1.2, 5.2, P = 0.015), age ≥35 years (OR 2.28, 95%CI 1.2,4.4, P = 0.011), overweight and obesity (pregnancy BMI≥25 kg/m2) (OR 2.00, 95%CI 1.2,3.2, P = 0.004), pregnancy-induced hypertension (OR 1.89, 95%CI 1.1,3.2, P = 0.019), and Chinese ethnicity (OR 2.36,95%CI 1.01,5.5, P = 0.047). Neonatal predictors included male child (OR 2.10, 95%CI 1.5,3.0, P < 0.0001), presence of meconium-stained liquor during delivery (OR 1.60, 95%CI 1.0,2.5, P = 0.044) and admission to special care nursery (OR 1.51 95%CI 1.0,2.2, P = 0.040). Higher birth lengths reduced OSA odds by 7% for each centimetre (OR 0.93, 95%CI 0.87, 0.99, P = 0.033).

CONCLUSIONS

A range of maternal and neonatal factors predict OSA in young adults, including those related to poor maternal metabolic health, high-risk pregnancy and stressful perinatal events. This information could assist in the early identification and management of at-risk individuals and indicates that better maternal health may reduce the likelihood of young adults developing OSA.

Adenoid hypertrophy in children: a narrative review of pathogenesis and clinical relevance

Adenoids (nasopharyngeal tonsils), being part of Waldeyer's ring, are masses of lymphoid tissues located at the junction of the roof and the posterior wall of the nasopharynx. Adenoids play an important role in the development of the immune system and serve as a defence against infections, being the first organs that come into contact with respiratory and digestive antigens. The causes of adenoid hypertrophy are not fully known. They are most likely associated with aberrant immune reactions, infections, environmental exposures and hormonal or genetic factors. The aim of this review is to summarise the current knowledge of adenoid hypertrophy in children and associated diseases. Adenoid hypertrophy has many clinical manifestations that are frequent in the paediatric population and is accompanied by various comorbidities.

Persistent obstructive sleep apnoea in children: treatment options and management considerations

Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.

Validity and reliability of the Japanese version of the severity hierarchy score for pediatric obstructive sleep apnea screening

OBJECTIVE

This study aimed to evaluate the validity and reliability of the Japanese version of the severity hierarchy score (J-SHS) in the screening of pediatric obstructive sleep apnea (OSA) among Japanese community children.

METHODS

A total of 922 children from elementary schools in Tokyo were recruited. Their parents completed the J-SHS questionnaire, and the children underwent an overnight Tracheal Sound (TS) recording. The reliability of the J-SHS was assessed by Cronbach's alpha coefficients and Spearman's correlation. Construct validity was determined by factor analysis. The discriminative ability to diagnose OSA was evaluated by constructing ROC curves.

RESULTS

Five hundred and seventeen children (51.8% male, mean age 7.1 ± 0.7 years) were included. Cronbach's alpha coefficient was 0.80. Factor analysis resulted in a two-factor structure, with factor loadings all above 0.4. A J-SHS score of >1.88 exhibited a 60% sensitivity, 93% specificity, and an area under the curve (AUC) of 0.78 for detecting an apnea-hypopnea index (AHI) of ≥5/h; a J-SHS score of >2.06 exhibited a 75% sensitivity, 84% specificity and AUC of 0.84 for detecting an AHI of ≥3/h among the children with a snoring frequency above two nights/wk.

CONCLUSION

The J-SHS exhibits good performance as a screening tool providing a quick and straightforward approach for identifying Japanese children at risk for OSA.

Special manifestations and treatment of rare cases of snoring with special facial features and hearing loss in children

This current case report describes two rare cases of children with both hearing loss and snoring. Case 1, a 17-month-old male patient, and case 2, an 11-year-old male patient, both presented with nasal obstruction, snoring and hearing loss. Physical examinations showed obvious enlargement of the head circumference and special facial features. The two children underwent otolaryngology examinations, endoscopy, hearing tests, laboratory examinations for bone metabolism markers, cranial computed tomography, X-rays and genome-wide exon sequencing. The first case was diagnosed with craniometaphyseal dysplasia, which was relieved after giving a low-calcium diet. The second case was diagnosed with osteopathia striata with cranial sclerosis by gene sequencing. Snoring improved after medication and the speech and quality of life improved with a hearing aid. Paediatric otolaryngological physicians need to have a deeper understanding of congenital diseases involving the bones. Only by genetic testing to determine the pathogenesis can those children be given the correct treatment, which is of great importance for improving their prognosis.

Evaluation of Upper Airway Stimulation for Adolescents With Down Syndrome and Obstructive Sleep Apnea

Importance

Patients with Down syndrome have a high incidence of persistent obstructive sleep apnea (OSA) and limited treatment options. Upper airway hypoglossal stimulation has been shown to be effective for adults with OSA but has not yet been evaluated for pediatric populations.

Objective

To evaluate the safety and effectiveness of upper airway stimulation for adolescent patients with Down syndrome and severe OSA.

Design, Setting, and Participants

This prospective single-group multicenter cohort study with 1-year follow-up was conducted between April 1, 2015, and July 31, 2021, among a referred sample of 42 consecutive adolescent patients with Down syndrome and persistent severe OSA after adenotonsillectomy.

Intervention

Upper airway stimulation.

Main Outcomes and Measures

The prespecified primary outcomes were safety and the change in apnea-hypopnea index (AHI) from baseline to 12 months postoperatively. Polysomnographic and quality of life outcomes were assessed at 1, 2, 6, and 12 months postoperatively.

Results

Among the 42 patients (28 male patients [66.7%]; mean [SD] age, 15.1 [3.0] years), there was a mean (SD) decrease in AHI of 12.9 (13.2) events/h (95% CI, -17.0 to -8.7 events/h). With the use of a therapy response definition of a 50% decrease in AHI, the 12-month response rate was 65.9% (27 of 41), and 73.2% of patients (30 of 41) had a 12-month AHI of less than 10 events/h. The most common complication was temporary tongue or oral discomfort, which occurred in 5 patients (11.9%). The reoperation rate was 4.8% (n = 2). The mean (SD) improvement in the OSA-18 total score was 34.8 (20.3) (95% CI, -42.1 to -27.5), and the mean (SD) improvement in the Epworth Sleepiness Scale score was 5.1 (6.9) (95% CI, -7.4 to -2.8). The mean (SD) duration of nightly therapy was 9.0 (1.8) hours, with 40 patients (95.2%) using the device at least 4 hours a night.

Conclusions and Relevance

Upper airway stimulation was able to be safely performed for 42 adolescents who had Down syndrome and persistent severe OSA after adenotonsillectomy with positive airway pressure intolerance. There was an acceptable adverse event profile with high rates of therapy response and quality of life improvement.

Trial Registration

ClinicalTrials.gov Identifier: NCT02344108.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Efficacy of orthodontic treatment versus adenotonsillectomy in children with moderate obstructive sleep apnoea and mandibular retrognathia: study design and protocol for a non-inferiority randomised controlled trial

INTRODUCTION

Orthodontic treatment and adenotonsillectomy (AT) are both conventional treatments for paediatric obstructive sleep apnoea (OSA). Each approach has distinct treatment advantages; however, there is currently a lack of solid evidence to support their efficacy comparison. We hypothesise that the objective effect of orthodontic treatment is not inferior to AT in children with moderate OSA and mandibular retrognathia, but orthodontic treatment has the advantage of promoting dentofacial growth.

METHODS AND ANALYSIS

This is a randomised, open-label, parallel-group, active controlled trial that will study the efficacy of orthodontic treatment versus AT in children with moderate OSA accompanied by tonsillar adenoid hypertrophy and mandibular retrognathia. A total of 98 patients will be enrolled and randomised in a 2:1 ratio to either orthodontic treatment or AT group. Participants will be recruited at Shanghai Stomatological Hospital, Shanghai Children's Hospital of Shanghai Jiaotong University and Children's Hospital of Fudan University, which are all located in Shanghai, China. The primary endpoint is the per cent change in the obstructive apnoea-hypopnoea index from baseline (month 0) to the primary endpoint (month 7), and the mean reduction in A point, nasion and B point angle on cephalometric measurements by lateral X-ray films. Important secondary efficacy endpoints include sleep duration with oxygen saturation below 90% according to polysomnography and subjective symptoms (assessed by the OSA-20 questionnaire), etc. Safety endpoints will also be evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of Shanghai Stomatological Hospital (approval no. (2021)002), Shanghai Children's Hospital of Shanghai Jiaotong University (approval no. 2021R046-F01) and Children's Hospital of Fudan University (approval no. (2021)136). Before enrolment, a qualified clinical research assistant will obtain written informed consent from both the participants and their guardians after full explanation of this study. The results will be presented at national or international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000037288.

Sleep Complaints Among School Children

Sleep complaints are common among children. These include both night-time and daytime symptoms, such as trouble falling asleep, problems in maintaining sleep, snoring, and unusual events during sleep and daytime functioning impairment. However, sleep complaints in children are often overlooked and undertreated in clinical practice. Untreated sleep problems may further impact on children's development and will persist into adulthood in some cases. This review summarizes the common sleep complaints and disorders in school children, and provides an overview of the epidemiology, clinical features, consequences, and treatment of the sleep problems.

The 3% Oxygen Desaturation Index is an Independent Risk Factor for Hypertension Among Children with Obstructive Sleep Apnea

BACKGROUND

Obstructive sleep apnea (OSA) and obesity are both directional risk factors of hypertension. Chronic intermittent hypoxemia (IH) is a commonly observed pathophysiological mechanism involved in multiple comorbidities of OSA. However, their interactions are not well understood in children. This study aimed to investigate the associations of IH indexes (oxygen desaturation index 3% [ODI3], mean peripheral oxygen saturation [SpO₂], least SpO₂, and time with SpO₂ < 85%), apnea-hypopnea index, and weight status with hypertension in a sample of pediatric OSA patients.

METHODS

The medical records of 365 pediatric OSA patients were retrospectively reviewed in this cross-sectional study. Demographics, anthropometrics, standard in-laboratory polysomnography, and nocturnal blood pressure were collected. Multivariate logistic regression with forward selection was used to identify independent predictors of hypertension.

RESULTS

Multivariate logistic regression analysis showed that ODI3 (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01-1.03) and body mass index z-score (OR = 1.34, 95% CI = 1.12-1.60) were independent continuous predictors of pediatric hypertension, whilst severe OSA (OR = 2.62, 95% CI = 1.60-4.29) and overweight/obesity (OR = 2.63, 95% CI = 1.59-4.34) were independent categorical predictors. Traditional risk factors including male sex (OR = 2.33, 95% CI = 1.02-5.33), late childhood/adolescence (OR = 1.98, 95% CI = 1.01-3.88), and overweight/obesity (OR = 2.97, 95% CI = 1.56-5.67) combined with sleep hypoxemia (least SpO₂ ≤ 95%) (OR = 2.24, 95% CI = 1.16-4.04) predicted hypertension (R ² = 0.21) in the severe IH subgroup (n = 205), while the no/mild IH subgroup (n = 160) had an entirely different predictor, severe OSA (OR = 3.81, 95% CI = 1.49-9.74) (R ² = 0.07).

CONCLUSION

The close relationships among IH, overweight/obesity, and hypertension highlight the importance of reducing IH and body weight in children with OSA.

Association of Pediatric Obstructive Sleep Apnea With Elevated Blood Pressure and Orthostatic Hypertension in Adolescence

Importance

Although pediatric guidelines have delineated updated thresholds for elevated blood pressure (eBP) in youth and adult guidelines have recognized obstructive sleep apnea (OSA) as an established risk factor for eBP, the relative association of pediatric OSA with adolescent eBP remains unexplored.

Objective

To assess the association of pediatric OSA with eBP and its orthostatic reactivity in adolescence.

Design, Setting, and Participants

At baseline of this population-based cohort study (Penn State Child Cohort) in 2000-2005, a random sample of 700 children aged 5 to 12 years from the general population was studied. A total of 421 participants (60.1%) were followed up in 2010-2013 after 7.4 years as adolescents (ages, 12-23 years). Data analyses were conducted from July 6 to October 29, 2020.

Main Outcomes and Measures

Outcomes were the apnea-hypopnea index (AHI) score, ascertained via polysomnography conducted in a laboratory; eBP measured in the seated position identified using guideline-recommended pediatric criteria; orthostatic hyperreactivity identified with BP assessed in the supine and standing positions; and visceral adipose tissue assessed via dual-energy x-ray absorptiometry.

Results

Among the 421 participants (mean [SD] age at follow-up, 16.5 [2.3] years), 227 (53.9%) were male and 92 (21.9%) were racial/ethnic minorities. A persistent AHI of 2 or more since childhood was longitudinally associated with adolescent eBP (odds ratio [OR], 2.9; 95% CI 1.1-7.5), while a remitted AHI of 2 or more was not (OR, 0.9; 95% CI 0.3-2.6). Adolescent OSA was associated with eBP in a dose-response manner; however, the association of an AHI of 2 to less than 5 among adolescents was nonsignificant (OR, 1.5; 95% CI, 0.9-2.6) and that of an AHI of 5 or more was approximately 2-fold (OR, 2.3; 95% CI, 1.1-4.9) after adjusting for visceral adipose tissue. An AHI of 5 or more (OR, 3.1; 95% CI, 1.2-8.5), but not between 2 and less than 5 (OR, 1.3; 95% CI, 0.6-3.0), was associated with orthostatic hyperreactivity among adolescents even after adjusting for visceral adipose tissue. Childhood OSA was not associated with adolescent eBP in female participants, while the risk of OSA and eBP was greater in male participants.

Conclusions and Relevance

The results of this cohort study suggest that childhood OSA is associated with adolescent hypertension only if it persists during this developmental period. Visceral adiposity explains a large extent of, but not all, the risk of hypertension associated with adolescent OSA, which is greater in male individuals.

Clinical features of obstructive sleep apnea in children with obesity

OBJECTIVES

To study the clinical features of obstructive sleep apnea (OSA) in children with obesity.

METHODS

A retrospective analysis was performed on the medical data of 33 obese children aged 7-15 years, who were diagnosed with OSA and received polysomnography (PSG) in the Department of Respiratory Medicine in Shenzhen Children's Hospital. Fifty OSA children with normal body weight, matched for sex and age, were enrolled as the control group.

RESULTS

Among the 33 obese children with OSA, the three most common daytime symptoms were inattention in 30 children (91%), somnolence in 22 children (67%), and morning fatigue in 21 children (64%), and the three most common nocturnal symptoms were snoring in 27 children (82%), mouth breathing in 20 children (61%), and sweating in 16 children (49%). Compared with the reference values of normal children, both the OSA + obesity group and the control group had prolonged light sleep, shortened deep sleep, and a significantly shortened rapid eye movement (REM) period, while there was no significant difference in these indices between the two groups (P>0.05). The apnea-hypopnea index, obstructive apnea/hypopnea index, and oxygen desaturation index in both REM and non-REM periods in the OSA +obesity group were significantly higher than those in the control group (P<0.05), while the lowest blood oxygen saturation during sleep was significantly lower in the OSA + obesity group (P<0.05).

CONCLUSIONS

The children with obesity and OSA have the main daytime symptoms of inattention, somnolence, and morning fatigue and the main nocturnal symptoms of snoring, mouth breathing, and sweating. There is no significant difference in sleep structure between OSA children with obesity and those with normal body weight; however, respiratory events and blood oxygen saturation decline are more severe in OSA children with obesity. Citation.

Hypertension in Children with Obstructive Sleep Apnea Syndrome-Age, Weight Status, and Disease Severity

Older age, obesity, and obstructive sleep apnea syndrome (OSAS) are known to increase the risk of hypertension in adults. However, data for children are scarce. This study aimed to investigate the relationships between hypertension, age, weight status, and disease severity in 396 children with OSAS. The prevalence rates of hypertension, obesity, and severe OSAS (apnea-hypopnea index ≥10) were 27.0%, 28.0%, and 42.9%, respectively. Weight z-score and apnea-hypopnea index were independently correlated with systolic blood pressure z-score, and minimal blood oxygen saturation (SpO₂) was independently associated with diastolic blood pressure z-score. Overall, late childhood/adolescence (odds ratio (OR) = 1.72, 95% CI = 1.05–2.81), obesity (OR, 2.58, 95% CI = 1.58–4.22), and severe OSAS (OR = 2.38, 95% CI = 1.48–3.81) were independent predictors of pediatric hypertension. Furthermore, late childhood/adolescence (OR = 2.50, 95% CI = 1.10–5.71) and abnormal SpO₂ (mean SpO₂ < 95%; OR = 4.91, 95% CI = 1.81–13.27) independently predicted hypertension in obese children, and severe OSAS (OR = 2.28, 95% CI = 1.27–4.10) independently predicted hypertension in non-obese children. In conclusion, obesity, OSAS severity, and abnormal SpO₂ are potentially modifiable targets to improve hypertension while treating children with OSAS.

C-reactive protein in children with obstructive sleep apnea and effects of adenotonsillectomy

OBJECTIVE

C-reactive protein (CRP) is an important serum marker of inflammation associated with cardiovascular outcomes. This study aims to evaluate the association between CRP and childhood obstructive sleep apnea (OSA) and clarify the effects of adenotonsillectomy on serum CRP levels in children with OSA.

METHODS

Children with symptoms suggestive of OSA who underwent an overnight polysomnography were recruited from a tertiary medical center. Their serum CRP levels were measured. For children who underwent adenotonsillectomy for OSA treatment, polysomnography and serum high-sensitivity CRP (hs-CRP) level measurement were conducted after surgery.

RESULTS

This study included 326 children (mean age: 7.2 ± 3.0 years; boys: 67%). Children with apnea-hypopnea index (AHI) > 5 events/h had significantly higher hs-CRP levels than children with AHI of 1-5 events/h and AHI < 1 event/h [median (interquartile range): 0.08 (0.03-0.25) vs 0.03 (0.02-0.14) vs 0.04 (0.01-0.10), P < 0.001]. Log-transformed hs-CRP levels were positively associated with log AHI values (r = 0.2, P < 0.001). In multiple linear regression analysis, hs-CRP levels were independently associated with AHI; 101 children with OSA (ie, AHI > 1) underwent adenotonsillectomy. In children with OSA in the study cohort, a significant reduction of hs-CRP levels did not occur after surgery [from 0.07 (0.02-0.22) to 0.08 (0.03-0.17), P = 0.716]. In children with OSA having abnormal hs-CRP levels (ie, CRP > 1 mg/dL), hs-CRP levels significantly decreased after surgery [from 1.87 (1.11-2.78) to 0.20 (0.07-1.04), P = 0.043].

CONCLUSION

Children with OSA had increased hs-CRP levels. Children with OSA and abnormal hs-CRP levels exhibited significantly reduced hs-CRP levels following adenotonsillectomy.

Muscle type of palatopharyngeal muscle in children with severe obstructive sleep apnea

STUDY OBJECTIVES

To investigate the fiber-type distribution in palatopharyngeal muscle via adenosine triphosphatase and quantitative real-time polymerase chain reaction in children with severe obstructive sleep apnea (OSA).

METHODS

Study participants were 12 children with severe OSA and 15 children with simple snoring as the control group. Both groups were diagnosed by polysomnography and treated with tonsillectomy. The samples of palatopharyngeus muscle were studied under adenosine triphosphatase staining and quantitative real-time polymerase chain reaction to classify the different fiber types.

RESULTS

There were no differences in baseline age, body mass index, tonsil size, or sleep stage constitution between the 2 groups. Dominance (>60%) of type I fiber was observed both in children with simple snoring (3/15, 20%) and in those with severe OSA (1/12, 8.3%) via adenosine triphosphatase staining. Predominance of type II fibers was seen in 3/15 (20%) in the control group and 6/12 (50%) in the severe OSA group, respectively. Type grouping was also seen in 8/15 (53.3%) in non-OSA and 6/12 (50%) in severe OSA groups, respectively. There was no difference in distribution of subtype fibers assessed by quantitative real-time polymerase chain reaction between the 2 groups; the mean percentages of type I fibers were 25.8% ± 19.5% and 20.9% ± 16.6%, respectively (P > .05), similar to type IIa fibers (35.2% ± 23.4% and 40.9% ± 28.8%) (P > .05). There was a decrease in the percentage of type I fibers between children younger and older than 12 years (P < 0.05), although this was not due to OSA (P > 0.05).

CONCLUSIONS

There were no specific changes via adenosine triphosphatase staining or a difference in distribution of subtype fibers via quantitative real-time polymerase chain reaction between children with severe pediatric OSA and those with simple snoring, whereas the percentage of type I fiber decreased dynamically due to age but not OSA.

CLINICAL TRIAL REGISTRATION

Registry: Chinese Clinical Trials Registry; Name: A study of the mechanism of the conversion of upper airway expasion muscle's fiver types of OSA patient which may be mediated by estrogen-related receptor alpha; URL: https://www.chictr.org.cn/showproj.aspx?proj=6144; Identifier: ChiCTR-CCC-13003415.

Effect of adenotonsillectomy on blood pressure in children with obstructive sleep apnea: a meta-analysis

BACKGROUND

While adenotonsillectomy (T&A) is widely recognized as the first-line therapy for pediatric obstructive sleep apnea (OSA), effects of T&A on blood pressure (BP) remain unclear. This meta-analysis evaluates the associations between T&A and BP in children with OSA.

METHODS

The study protocol was registered on PROSPERO (CRD42020154425). Two authors independently searched the PubMed, Medline, EMBASE, and Cochrane databases. The keywords used were "sleep apnea syndromes," "adenotonsillectomy," and "child." A random-effects model was applied to determine office systolic BP (SBP), diastolic BP (DBP), and ambulatory BP changes.

RESULT

Twelve studies with 1193 children were analyzed (mean age: 7.6 y; 54% boys). The apnea-hypopnea index significantly reduced of 9.4 events/h (95% CI, -12.0 to -6.8) after T&A. Office SBP (-0.24 mmHg; 95% CI, -1.64 to 1.16) and DBP (-1.65 mmHg; 95% CI, -3.47 to 0.17) did not decrease significantly after surgery. No significant decreases were observed in 24-h ambulatory BP after T&A. Subgroup analysis showed a significant postoperative decrease in office SBP (-6.23 mmHg; 95% CI, -7.78 to -4.67) and DBP (-7.93 mmHg; 95% CI, -10.37 to -5.48) among children with hypertension but a slight increase in office SBP (2.50 mmHg; 95% CI, 1.14 to 3.86) and DBP (1.98 mmHg; 95% CI, -0.02 to 3.98) in those without (P for heterogeneity < 0.001).

CONCLUSION

This meta-analysis suggests the office and ambulatory BP changes after T&A in children with OSA are trivial. Moreover, children with hypertension experience a significantly greater decrease in office BP than children without hypertension.

[Atypical depression as a risk factor for obstructive sleep apnea syndrome in young adults]

OBJECTIVES

In the literature, several studies have investigated the particular relationship between major depression and obstructive sleep apnoea syndrome (OSAS). However, most of these studies have focused primarily on middle-aged to elderly individuals (≥40 years) which means that this problem has been little studied in young adults (<30 years). Nevertheless, in young adults the prevalence of major depression (particularly its atypical subtype) is not negligible, which seems to justify carrying out additional investigations in order to allow a better understanding of the potential role played by major depression in the pathophysiology of OSAS in this particular subpopulation. The aim of this study was therefore to empirically investigate the prevalence of OSAS in young adults and to study the risk of OSAS associated with major depression in this particular subpopulation.

METHODS

Polysomnographic and demographic data from 264 young adults were collected from the Erasme Hospital Sleep Laboratory (Brussels, Belgium) database to enable our analyses. During their two-night stay (including a first night of habituation and a night of polysomnography) at the Sleep Laboratory, these individuals underwent a complete somatic assessment (including blood test, electrocardiogram, daytime electroencephalogram and urinalysis), a systematic psychiatric assessment by a unit psychiatrist and an assessment of their complaints related to sleep. These different steps made it possible to systematically diagnose all somatic pathologies, psychiatric disorders according to the diagnostic criteria of the DSM-IV-TR and sleep pathologies according to the diagnostic criteria of the AASM. This allowed the selection of young adults included in our study based on our inclusion and exclusion criteria. Polysomnographic recordings from our Sleep Laboratory were visually scored according to AASM criteria. An obstructive sleep apnoea-hypopnoea index ≥5/hour was used for the diagnosis of OSAS. At the statistical level, in order to allow our analyses, we subdivided our sample of young adults into two groups: a control group without OSAS (n=215) and a patient group with OSAS (n=49). After checking the normal distribution of our data, normally distributed data were analysed with t-tests whereas asymmetrically or dichotomously distributed data were analysed with Wilcoxon tests or Chi² tests. Univariate regression models were used to study the risk of OSAS associated with major depression (categorized: absent, typical, atypical) in young adults and potential confounding factors. In multivariate regression models, the risk of OSAS associated with major depression (categorized: absent, typical, atypical) in young adults was adjusted only for confounding factors significantly associated with OSAS during univariate analysis. These confounding factors were introduced in a hierarchical manner in the various multivariate regression models constructed.

RESULTS

The prevalence of OSAS in our population of young adults was 18.6 %. During univariate analyses, atypical depression [OR 2.51 (95% CI 1.18-5.32), p-value=0.014], male gender [OR 4.53 (95% CI 2.20-9.34), P-value <0.001], presence of snoring [OR 2.51 (95% CI 1.33-4.75), P-value=0.005], presence of at least one cardio-metabolic alteration [OR 2.26 (95% CI 1.19-4.28), P-value=0.012], body mass index>30 kg/m² [OR 4.55 (95% CI 2.07-10.03), P-value <0.001] and ferritin ≥150 μg/L [OR 3.28 (95% CI 1.69-6.36), P-value<0.001] were associated with increased risk of OSAS in our population of young adults. After adjusting for these major confounding factors associated with OSAS (gender, body mass index, cardio-metabolic alterations, ferritin level, and snoring) in the four models studied, multivariate regression analyses confirmed that unlike typical depression, atypical depression [OR 3.09 (95% CI 1.26-7.54), P-value=0.019] was a risk factor for OSAS in young adults.

CONCLUSIONS

In our study, we demonstrated that the prevalence of OSAS was 18.6 % in young adults referred to the Erasme Hospital Sleep Laboratory. In addition, we have shown that unlike typical depression, atypical depression was associated with an increased risk of OSAS in young adults, which seems to justify more systematic research of this pathology in young adults suffering from atypical depression in order to allow the establishment of adapted therapeutic strategies and avoid the negative consequences associated with the co-occurrence of these two pathologies.

Cardiovascular risks of children with primary snoring: A 5-year follow-up study

BACKGROUND AND OBJECTIVE

This study aimed to investigate if childhood primary snoring (PS) was associated with adverse cardiovascular outcomes at 5-year follow-up.

METHODS

This was a prospective matched cohort study. Subjects were recruited from a hospital-based cohort established from years 2006 to 2012 and they were aged 6-18 years at baseline. Each subject with PS was gender, age and BMI z-score matched with a control who had normal sleep study (obstructive apnoea-hypopnoea index [OAHI] < 1/h) and without habitual snoring (<3 nights/week) at baseline. All subjects underwent measurements of flow-mediated dilation (FMD) and carotid intima-media thickness (cIMT) and sleep study at baseline and follow-up visits. Twenty-four hour ambulatory blood pressure (ABP) was also recorded at follow-up.

RESULTS

Fifty-five case-control pairs were recruited and the length of follow-up was 5.1 ± 1.3 years. At follow-up visit, subjects with PS at baseline had significantly lower FMD (-0.34% [-0.59 to -0.10]), greater cIMT (+0.01 mm [+0.001 to +0.013]), higher wake systolic blood pressure (SBP) (+2.6 mm Hg [+0.02 to +5.1]), sleep SBP (+3.0 mm Hg [+0.3 to +5.6]), sleep diastolic blood pressure (+2.2 mm Hg [+0.04 to +4.4]) and sleep mean arterial pressure (+2.2 mm Hg [+0.1 to +4.2]) compared to matched controls in the fully adjusted model for variables including change in OAHI and parental history of cardiovascular diseases.

CONCLUSION

Childhood PS is associated with poorer endothelial function, greater cIMT and higher ABP at 5-year follow-up irrespective of change in obstructive sleep apnoea severity.

Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

Sleep disordered breathing from preschool to early adult age and its neurocognitive complications: A preliminary report

Objective

The onset and development of sleep disordered breathing (SDB) remains unclear in an age - dependent manner. Despite treatment, persistent symptoms such as snoring and excessive daytime sleepiness, as well as cognitive impairment may be present. The aim of the research was to determine the prevalence of residual symptoms of SDB in adolescence and early adulthood, the predisposing factors and its neurocognitive complications.

Methods

In the present pilot study-cohort, a questionnaire was utilized to 154 people (average age: 17.9 ± 3), who as children (mean age: 5.3 ± 1.4) had AHI ≥2.5 episodes/h. They were divided into two groups based on AHI = 5 episodes/h. Depending on the results, they were invited to undergo a repeated polysomnography (PSG) and complete the Montreal Cognitive Assessment (MoCA) test. Statistical analysis was made with IBM SPSS software.

Results

Out of the total, 35.7% claimed to still snore. AHI was negatively correlated to the severity of residual symptoms (Mann-Witney U test, p <0.005). According to repeated PSGs, 9/17 met the criteria for OSAS, while high BMI was associated with the severity of new AHI (chi squared test, p<0.005). Additionally, 7/16 scored below the MoCA baseline (<26/30). The characteristics of cognitive declines were mapped, with most prominent having been visuospatial, short - term memory and naming/language deficits.

Discussion

A significant percentage of children with sleep breathing disorder present with residual symptoms during their transition to early adulthood, as well as undiagnosed neurocognitive complications. Clinicians suspicion for the underlying neurocognitive complications is required, even in young adults, while guidelines on monitoring pediatric OSAS patients after treatment should be addressed.

Comparing respiratory polygraphy with pulse transit time analysis versus overnight polysomnography in the diagnosis of obstructive sleep apnoea in children

OBJECTIVE

Obstructive sleep apnea syndrome in children is associated with significant morbidity. Polysomnography is the main diagnostic tool but is time consuming and requires skilled manpower to supervise the patient overnight and hence long referral to diagnosis time. However, there are limitations and underestimation of the apnoea hyponea index (AHI) with alternative home sleep apnoea testing (HSAT), such as type 3 respiratory polygraphy (RP). Prior studies have demonstrated pulse transit time (PTT) to be a reliable indicator of cortical arousals. In this study, the use of PTT together with RP will be studied to determine whether the derived AHI is comparable to that of PSG.

METHOD

Forty-five patients with suspected OSA met the inclusion criteria underwent PSG in the sleep laboratory for analysis. The raw data for either PSG or RP analysis were allocated separately to two different accredited sleep technicians. The primary outcome AHI derived from PTT with RP was compared to the AHI derived from PSG. Secondary outcomes compared were obstructive apnoea index (OAI), total hypopnoea index (THI) and arousal index (AI). Bland Altman analysis was used to compare the agreement of AHI derived from the 2 modalities and demonstrate whether RP is non inferior or equivalent to the gold standard for diagnosing OSAS.

RESULTS

The patients studied had a median age of 8.8 years (range 3-17 years). The patients were not limited to certain spectrum of severity OSA and had AHI results spread from mild to severe OSA (AHI 0.4/hr to 72.2/hr). The RP with PTT-derived AHI was strongly correlated to the PSG derived AHI as seen on the Spearman plot (r = 0.98). The Bland Altman plot showed no evidence of underestimation of the AHI due to missed arousal related hypopneas. The difference of AHI derived from RP and PSG results were clinically insignificant. The differences between the PSG and RP total hypopnoea index (THI) and arousal index (AI) were also statistically insignificant.

CONCLUSION

The study shows that RP with PTT can be considered a reliable diagnostic alternative compared with PSG. The role of PTT incorporated with RP was to minimize underestimation of AHI due to missed arousal associated hypopnea events. The results were apparent across mild to severe severity of OSA. There are advantages of RPs particularly in paediatrics. Overall this study offers promising preliminary insights that RP incorporated with PTT can be further explored as an acceptable home diagnostic tool for diagnosing OSA in children.

Natural History of REM-OSA in Children and Its Associations with Adverse Blood Pressure Outcomes: A Longitudinal Follow-Up Study

PURPOSE

Most respiratory events in childhood obstructive sleep apnea (OSA) take place during rapid-eye-movement (REM) sleep. This study aimed to describe the characteristics and natural history of childhood REM-OSA and to evaluate the associations between OSA subtypes and blood pressure (BP) outcomes.

PARTICIPANTS AND METHODS

This was a prospective 10-year follow-up study of a cohort established for a childhood OSA epidemiologic study. All subjects from the original cohort were invited to undergo a polysomnography (PSG) and 24-hour ambulatory blood pressure (ABP) monitoring. REM-OSA was defined with a ratio of obstructive apnea hypopnea index (OAHI) during REM sleep (OAHI_REM) to OAHI during non-REM sleep (OAHI_NREM) ≥ 2. Natural history was observed and linear mixed models were used to assess the associations between OSA subtypes and BP outcomes.

RESULTS

A total of 610 participants from baseline were included to study the epidemiology of REM-OSA in childhood. Among children with OSA, 65% had REM-OSA. At 10-year follow-up, 234 were included in the analysis. REM-OSA was more common at both baseline (58/92, 63%) and 10-year follow-up (34/58, 59%). For those with REM-OSA at baseline and persistent OSA at follow-up, the majority (72%) remained to have REM-OSA. Compared to those without OSA, subjects with REM-OSA had significantly higher nocturnal SBP (mean difference 2.19 mmHg, 95% confidence interval (CI): 0.12, 4.26; p = 0.039) and DBP (mean difference 1.58 mmHg, 95% confidence interval (CI): 0.11, 3.04; p = 0.035), and less nocturnal SBP dipping (mean difference -1.84%, 95% CI: -3.25, -0.43; p = 0.011), after adjusting for potential confounders. This significant association between REM-OSA and nocturnal SBP dipping was observed at baseline visit only.

CONCLUSION

REM-OSA was found to be a stable phenotype through childhood to young adulthood, and REM-OSA was associated with higher nocturnal BP and a lesser degree of nocturnal SBP dipping in children.

Redefining Success by Focusing on Failures After Pediatric Hypoglossal Stimulation in Down Syndrome

OBJECTIVES/HYPOTHESIS

Patients with Down syndrome have a high incidence of obstructive sleep apnea (OSA) and limited treatment options. Hypoglossal stimulation has shown efficacy but has not yet been approved for pediatric populations. Our objective is to characterize the therapy response of adolescent patients with down syndrome and severe OSA who underwent hypoglossal stimulation.

STUDY DESIGN

Prospective longitudinal trial.

METHODS

We are conducting a multicenter single-arm trial of hypoglossal stimulation for adolescent patients with Down syndrome and severe OSA. Interim analysis was performed to compare objective sleep and quality of life outcomes at 12 months postoperatively for the first 20 patients.

RESULTS

The mean age was 15.5 and baseline AHI 24.2. Of the 20 patients, two patients (10.0%) had an AHI under 1.5 at 12 months; nine patients of 20 (45.0%) under five; and 15 patients of 20 (75.0%) under 10. The mean decrease in AHI was 15.1 (P < .001). Patients with postoperative AHI over five had an average baseline OSA-18 survey score of 3.5 with an average improvement of 1.7 (P = .002); in addition, six of these patients had a relative decrease of apneas compared to hypopneas and seven had an improvement in percentage of time with oxygen saturation below 90%.

CONCLUSIONS

Patients with persistently elevated AHI 12 months after hypoglossal implantation experienced improvement in polysomnographic and quality of life outcomes. These results suggest the need for a closer look at physiologic markers for success beyond reporting AHI as the gold standard.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1663-1669, 2021.

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.

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.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

This comprehensive review of the 2019 restorative dental literature is offered to inform busy dentists regarding remarkable publications and noteworthy progress made in the profession. Developed by the Scientific Investigation Committee of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to 1 of 8 sections of the report: (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information likely to influence day-to-day dental treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source material when greater detail is desired. As the profession moves toward evidence-based clinical decision-making, an incredible volume of potentially valuable dental literature continues to increase. It is the intention of this review and its authors to provide assistance in negotiating the extensive dental literature published in 2019. It is our hope that readers find this work useful in the clinical management of dental patients.

The efficacy of different treatment approaches for pediatric OSAHS patients with mandibular retrognathia: study protocol for a multicenter randomized controlled trial

Background

Pediatric obstructive sleep apnea/hypopnea syndrome (OSAHS) is a multifactorial syndrome caused by many risk factors, such as craniofacial anomalies, adenotonsillar hypertrophy, obesity, and airway inflammation. Although new treatment patterns have recently been proposed, treatment methods for children remain particularly challenging and controversial. This randomized controlled trial was designed to investigate the efficacy of adenotonsillectomy and/or orthodontic treatment for children who have mild OSAHS with mandibular retrognathia.

Methods

A sample of 352 children with mild OSAHS and mandibular retrognathia, who are aged between 7 and 10 years, will be enrolled in the study. They will be randomized into four groups: the drug treatment group, the surgical treatment group, the orthodontic treatment group, or the surgery and postoperative orthodontic group. After randomization the children will receive treatments within 4 weeks. Outcome assessment will take place at the following points: (1) baseline, (2) 7 months after the treatment starting point, (3) 12 months after the treatment starting point, and (4) 24 months after the treatment starting point. The primary endpoint of the trial is the mean change in obstructive apnea/hypopnea index. Other endpoints will consist of the lowest oxygen saturation, apnea index, and hypopnea index assessed by polysomnography, subjective symptoms (assessed by the OSA-20 questionnaire), cephalometric measurements, and morphologic analysis of the upper airway.

Discussion

The results of this study will provide valuable evidence for the merits and long-term efficacy of different treatment approaches and contribute to facilitating the multidisciplinary treatment of pediatric OSAHS.

Trial registration

ClinicalTrials.gov: NCT03451318. Registered on 2 March 2018 (last update posted 19 April 2018).

[Tonsillectomy and tonsillotomy]

The number of operations for tonsillectomy have been significantly decreasing for many years in Germany. In children the number of adenotonsillectomies has decreased by two thirds within a decade. This phenomenon is mirrored by a significant increase in the number of annually performed tonsillotomies, a surgical procedure which is preferably performed for volume reduction in cases of tonsillar hypertrophy. The aim of this article is to elucidate the different interventional procedures, their typical indications and risks.

Childhood OSA is an independent determinant of blood pressure in adulthood: longitudinal follow-up study

BACKGROUND

Current literature supports cross-sectional association between childhood obstructive sleep apnoea (OSA) and elevated blood pressure (BP). However, long-term cardiovascular outcomes in children with OSA remain unexplored.

OBJECTIVE

To evaluate the associations of childhood OSA with BP parameters in a prospective 10 year follow-up study.

METHODS

Participants were recruited from a cohort established for our previous OSA epidemiological study. They were invited to undergo clinical examination, overnight polysomnography and 24-hour ambulatory BP monitoring. Multivariate linear regression was used to assess the associations of baseline childhood OSA with BP outcomes at follow-up. Multivariable log-binomial regression was used with inverse probability weighting to assess the adjusted associations of childhood OSA with hypertension and non-dipping of nocturnal BP in adulthood.

RESULTS

243 participants (59% male) attended the follow-up visit. The mean age was 9.8 (SD ±1.8) and 20.2 (SD ±1.9) years at baseline and follow-up respectively, with a mean follow-up duration of 10.4 (SD ±1.1) years. Childhood moderate-to-severe OSA was associated with higher nocturnal systolic blood pressure (SBP) (difference from normal controls: 6.5 mm Hg, 95% CI 2.9 to 10.1) and reduced nocturnal dipping of SBP (-4.1%, 95% CI -6.3% to 1.8%) at follow-up, adjusted for age, sex, Body Mass Index and height at baseline, regardless of the presence of OSA at follow-up. Childhood moderate-to-severe OSA was also associated with higher risk of hypertension (relative risk (RR) 2.5, 95% CI 1.2 to 5.3) and non-dipping of nocturnal SBP (RR 1.3, 95% CI 1.0 to 1.7) at follow-up.

CONCLUSION

Childhood OSA was found to be an independent risk factor for adverse BP outcomes in adulthood.

Obstructive sleep apnea in developmental age. A narrative review

Sleep is a physiological function that undergoes, at different stages of life, to considerable variations in neurophysiological and behavioral functions. The developmental age is a period characterized by a continuous process of physical and neuropsychological changes and synaptic remodeling processes that are the neurophysiological basis of brain plasticity, typical of this developmental phase, occurring mainly during sleep. In the description of obstructive sleep apnea (OSA) in children, two main points should be highlighted: its variability in different age groups, and its specificity compared with OSA in adults. The definition and criteria used for the diagnosis of OSA in adults are not applicable to OSA in developmental age. Although the adenotonsillar hypertrophy is the most common risk factor for pediatric OSA, obesity is becoming an increasingly prevalent risk factor, mostly in early childhood (6-9 years) and adolescence. OSA has been shown to affect cognitive function in children and adults. However, OSA impact on cognitive function in children is more severe since acting on the plastic brain structures can change the neuro-psychic development, learning skills, and social interactions. There is a clear difference in the definition of pathology between developmental age and adulthood according to the instrumental parameters: an AHI ≥ 5, which represents, in the pediatric age, the cut-off for a therapeutic pathway necessary to avoid a long-term effect on the child, instead, it represents in adulthood, the lower limit value for the definition of disease. This is a narrative review concerning obstructive sleep apnea in developmental age.Conclusions: OSA is a common disorder in children and those at risk must be identified, studied, and treated promptly because untreated OSA can be responsible for cardiovascular, metabolic, and neurocognitive morbidities and may induce, sometimes, non-reversible deficits given his insistence on a period of physical and neuro-psychic development.What is Known:•This is a review concerning Obstructive Sleep Apnea in developmental age•Clinical manifestation, diagnostic and therapeutic criteria of sleep apnea in developmental ageWhat is New:•This is a "narrative" review•This narrative review describes sleep apnea comparing and analyzing the different ages of life.

Adenotonsillectomy for the Treatment of Obstructive Sleep Apnea in Children with Prader-Willi Syndrome: A Meta-analysis

Objective

Adenotonsillectomy outcomes in obstructive sleep apnea (OSA) treatment among children with Prader-Willi syndrome (PWS) remain unclear. This study aimed to elucidate the effectiveness of adenotonsillectomy in OSA treatment among children with PWS.

Data Source

PubMed, MEDLINE, Embase, and Cochrane Review up to February 2019.

Review Methods

The registry number of the protocol published on PROSPERO was CRD42015027053. Two authors independently searched the relevant database. Polysomnography outcomes in these children were examined, including net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum and mean oxygen saturation, the overall success rate for a postoperative AHI <1, and the overall success rate for a postoperative AHI <5.

Results

Six studies with 41 patients were analyzed (mean age, 5.0 years; 55% boys; mean sample size, 6.8 patients). All children had PWS and received adenotonsillectomy for the treatment of OSA. The AHI was 13.1 events per hour (95% CI, 11.0-15.1) before surgery and 4.6 events per hour (95% CI, 4.1-5.1) after surgery. The mean change in the AHI was a significant reduction of 8.0 events per hour (95% CI, −10.8 to −5.1). The overall success rate was 21% (95% CI, 11%-38%) for a postoperative AHI <1 and 71% (95% CI, 54%-83%) for a postoperative AHI <5. Some patients developed velopharyngeal insufficiency postoperatively.

Conclusion

Adenotonsillectomy was associated with OSA improvement among children with PWS. However, residual OSA was frequently observed postoperatively in these patients.

Transition to Adult Care for Obstructive Sleep Apnea

Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include risk factors, such as obesity, male sex, and aging. More recently, there has been a precipitous increase in the prevalence of obstructive sleep apnea in youth. Drivers of this phenomenon include both increasing obesity and the survival of children with complex medical conditions into adulthood. Appropriate treatment and long-term management of obstructive sleep apnea is critical to ensure that these youth maintain well-being unfettered by secondary comorbidities. To this end, patient engagement and seamless transition of care from pediatric to adult health care systems is of paramount importance. To date, this is an unacknowledged and unmet need in most sleep programs. This article highlights the need for guideline-driven sleep disorder transition processes and illustrates the authors’ experience with the development of a program for sleep apnea.

Familial Aggregation and Heritability of Obstructive Sleep Apnea Using Children Probands

STUDY OBJECTIVES

Previous studies suggest the presence of familial aggregation of obstructive sleep apnea (OSA) in adults. However, similar data on childhood OSA are limited. This family study aimed to investigate the heritability and familial aggregation of childhood OSA and to examine whether significant differences existed between patients of normal weight and overweight.

METHODS

Children aged 6 to 18 years were recruited as probands either from attendants to sleep clinic (with habitual snoring) or the community (without habitual snoring). Parents and siblings of the probands were also invited to participate. All participants underwent nocturnal sleep study.

RESULTS

A total of 229 probands took part, of whom 33 had moderate to severe OSA, 70 had mild disease, and 126 had no OSA. A total of 412 relatives were also recruited. Although the overall heritability of obstructive apnea-hypopnea index (OAHI) was not significant (h² ± SE = 0.03 ± 0.09, P = .37), it was significant in overweight individuals on subgroup analysis (h² ± SE = 0.43 ± 0.24, P = .032). Significant interaction effect of overweight was demonstrated in both heritability and familial aggregation analyses. Bivariate genetic analysis found that the genetic correlation between OAHI and body mass index in overweight individuals (ρg ± SE = 0.63 ± 0.18) was significantly different from both 0 (P = .005) and 1 (P = .025).

CONCLUSIONS

The differential results of heritability and familial aggregation of OSA in normal weight and overweight subgroups substantiated the recommendation of separating childhood OSA into normal weight and overweight subtypes. In the overweight subgroup, there may be obesity-independent components involved in the genetic variance of OAHI, although a significant proportion of the genetic variance is shared with obesity.