Understanding sociodemographic factors related to health outcomes in pediatric obstructive sleep apnea

Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature

CONTEXT

Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices.

OBJECTIVE

We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes.

DATA SOURCES

A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023).

STUDY SELECTION

Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric.

DATA EXTRACTION

Extraction domains included study, patient, and procedure characteristics.

RESULTS

Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent.

LIMITATIONS

All studies were retrospective and quality varied from good to fair.

CONCLUSIONS

While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care.

TYPE OF STUDY

Systematic Review.

LEVEL OF EVIDENCE

Level III.

Racial Disparity in Tympanostomy Tube Placement in Inpatient Pediatric Admissions

This study aims to evaluate if race and ethnicity affect rates of tympanostomy tube (TT) placement during inpatient pediatric admissions in children with otologic conditions. A review of the 2016 Kids' Inpatient Database was conducted based on the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for common otologic conditions. Among 85 827 weighted pediatric inpatient discharges with ICD-10-CM codes for common otologic conditions, 213 underwent TT placement. Odds ratios (ORs) for children of Hispanic ethnicity and Asian or Pacific Islander race undergoing TT placement when compared to other ethnicities and races were 0.60 (P = .011) and 0.21 (P = .040), respectively. Multiple logistic regression showed Hispanic ethnicity was associated with lower rates of TT placement when compared to non-Hispanic white children (OR = 0.62; 95% confidence interval = 0.40-0.96). Future studies should assess why these differences exist and if these differences are associated with racial/ethnic bias or attributed to patient/family preference.

Reasons and predictors for early termination of pediatric polysomnography: one children's hospital's experience

STUDY OBJECTIVES

We sought to identify reasons for early polysomnography termination in pediatric patients.

METHODS

We retrospectively reviewed all studies conducted at the Pediatric Sleep Center at UT Southwestern Medical Center from January 1, 2017, through December 31, 2019, that were terminated before study completion. We investigated reasons for early termination and gathered characteristics such as age, sex, presence of neurocognitive impairment, payor status, seasonal variability, and testing site location.

RESULTS

There were 137 patients who terminated their studies before completion, comprising 1.05% of all patients who arrived for their scheduled polysomnographies during that time frame. The 3 main categories of reasons were equipment intolerance (47%), acute illness (33%), and parental refusal (20%). Parental refusal reasons included the patient's becoming combative, a lack of specialized equipment, patient's inability to fall asleep, forgetting the patient's nighttime medications, and the parent's inability to stay the night. Males represented a greater proportion of those who terminated due to intolerance of equipment (75%). Patients who terminated early due to equipment intolerance consisted of more neurologically impaired patients compared with those who terminated due to acute illness (56% vs 24%). Termination due to acute illness occurred more during the wintertime (44%) than in the summer (7%). In those who terminated due to parental refusal, there was a greater proportion of children under 6 years of age (75%).

CONCLUSIONS

Determining factors that are associated with early polysomnography termination is an important step to help identify at-risk groups and implement strategies to improve study completion.

CITATION

Luong S, Culp M, McCreary M, Wani A, Caraballo M. Reasons and predictors for early termination of pediatric polysomnography: one children's hospital's experience. J Clin Sleep Med. 2023;19(10):1711-1716.

Assessment of neighborhood-level disadvantage and pediatric obstructive sleep apnea severity

Objectives

To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children.

Methods

A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy.

Results

Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38).

Conclusions

The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study.

Level of Evidence

Level 4.

Factors affecting polysomnography compliance and delays to surgical treatment of obstructive sleep apnea

OBJECTIVE

To evaluate adherence to polysomnography in pediatric patients and determine if demographics, socioeconomic status, polysomnography indication, or prior otolaryngology intervention are associated with polysomnography adherence and time to definitive surgery.

STUDY DESIGN

Retrospective review study.

SETTING

Tertiary-care children's hospital.

METHODS

Electronic medical record was queried to identify patients ordered for a sleep study between January and May 2019. Demographic information, time to sleep study, and time to surgery were collected and calculated.

RESULTS

304 patients were recommended to obtain polysomnography, with adherence rate of 65.4%. There was no significant difference in adherence or loss to follow-up rates based on patient sex, age, language, socioeconomic status, state of residence, single-parent status, or polysomnography indication. There was no difference between time to surgery for patients who did or did not obtain polysomnography (181 vs. 161 days, P = .51). Patients with prior otolaryngology intervention were more likely to obtain polysomnography and less likely to be lost to follow-up (P < .05). Median household income demonstrated a significant inverse relationship with time to polysomnography (P < .05) as well as time to surgery (P < .05). Medically complex patients tended to experience longer time to surgery compared with non-complex patients.

CONCLUSION

Families with lower socioeconomic status or medically complex children may require assistance to obtain polysomnography and pursue surgery for sleep-disordered breathing. Patients without prior otolaryngology intervention may be less likely to follow up and may need assistance with navigating the polysomnography process.

The Need for Social and Environmental Determinants of Health Research to Understand and Intervene on Racial/Ethnic Disparities in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a sleep-disordered breathing (SDB) disorder, affects at least 25 million adults in the United States and is associated with increased risk for hypertension, diabetes, and cardiovascular disease (CVD). Racial/ethnic minorities have a disproportionate burden of OSA along with the health sequelae associated with this condition. Despite supporting evidence of racial/ethnic disparities, few studies have investigated SDB including OSA among minoritized racial/ethnic groups. In this scoping review of the literature, the authors summarize current findings related to racial/ethnic disparities in OSA, identified social and environmental determinants of health, treatment inequities, and promising evidence-based interventions and conclude with future research directions.

Socioeconomic inequalities in pediatric obstructive sleep apnea

STUDY OBJECTIVES

To examine the association between multiple measures of socioeconomic status (SES) and objectively measured obstructive sleep apnea (OSA) in a Canadian pediatric population.

METHODS

This was a cross-sectional study of 188 children (4-17 years, mean age 9.3 ± 3.5 years) prospectively recruited from two hospital sleep clinics in Canada, using multivariable-adjusted linear and logistic regression of five measures of SES including parental education, income, social class, geographic location, and perceived SES based on the MacArthur Scale of Subjective Social Status, assessed in relation to four polysomnographic OSA variables including apnea-hypopnea index, apnea index, mean oxygen saturation level, and oxygen desaturation index.

RESULTS

Overall, low household-level SES appeared to be associated with both frequency (apnea index ≥ 1 events/h) and severity (apnea-hypopnea index ≥ 5 events/h) of OSA in children, with maternal education showing the most consistent and significant associations. Specifically, children with mothers reporting less than high school education had nearly three times the odds of having OSA after controlling factors including body mass index (odds ratio 2.96 [95% confidence interval, 1.05-8.37]), compared to university-educated participants. Consistent associations were also observed for geographic location with less frequency and severity of OSA among nonurban children. Perceived SES was minimally inversely associated with our outcomes.

CONCLUSIONS

This cross-sectional, multicenter study demonstrated that SES factors are linked to the occurrence and severity of OSA in children. Results indicated the need to incorporate the screening of SES in the diagnostic process of pediatric OSA to provide more targeted intervention and patient-centered care.

CITATION

Park JW, Hamoda MM, Almeida FR, et al. Socioeconomic inequalities in pediatric obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):637-645.

Neighborhood environments and sleep among children and adolescents: A systematic review

Understanding salient environmental determinants of pediatric sleep is essential for informing interventions and public health initiatives. Emerging evidence suggests that the neighborhood environment can impact pediatric sleep, but this evidence has not yet been systematically reviewed. We conducted a systematic review of the scientific literature on associations between neighborhood environments and sleep in young children (0-5 y), school-aged children (6-12 y) and adolescents (13-18 y). We reviewed 85 articles published between 2003 and 2020. The most commonly examined neighborhood exposure was low socioeconomic status (40 studies), which was associated with sleep outcomes in 58% of studies (primarily shorter sleep duration, later sleep timing, or obstructive sleep apnea). Evidence was stronger for neighborhood safety/crime/violence (21 studies), with 86% of studies reporting associations with sleep outcomes (primarily self- or caregiver-reported sleep problems). Fewer studies examined associations of neighborhood physical environment exposures, including noise (15 studies), the built environment (seven studies), and air pollution (six studies). Limitations of the current body of evidence include 1) limited examination of neighborhood exposures other than socioeconomic status or safety, 2) use of primarily cross-sectional observational study designs, 3) lack of objective sleep outcome assessment, and 4) limits of current exposure assessment methods.

Demographic Characteristics of Children Diagnosed with Bacterial Tracheitis

OBJECTIVES

Examine the presentation and clinical course of patients with bacterial tracheitis (BT). Identify if socioeconomic differences exist among children who present with BT.

METHODS

This was a retrospective case series from a tertiary care pediatric medical center. The study group included patients less than 18 years old who were diagnosed with BT from January 2011 to March 2019. Patients with a tracheostomy and those who developed BT after prolonged hospitalization were excluded. Patient demographics were compared with the demographics of the counties surrounding the hospital.

RESULTS

33 patients with BT met inclusion criteria. The most common presenting symptoms were difficulty breathing, stridor, and sore throat (81.8% each), followed by cough (78.8%). Median length of stay was 3 days [interquartile range (IQR):2-4]. 19 patients (57.5%) were admitted to the intensive care unit. Intubation was required for 13 patients (39.4%), for a median length of 2 days [IQR:2-2]. Methicillin sensitive staphylococcus aureus was the most common bacterial etiology (33%). Mean presenting age was 8.58 years [95% confidence interval:7.3-9.9] and 14 patients were female (42.4%). 31 patients were white (93.9%), 1 was black (3%), and 1 was Hispanic (3%). BT patients were more likely to have private insurance compared to comparison (81.8% vs 63.4%, P < .001).

CONCLUSION

Children who presented with BT were more likely to be privately insured than a comparison population.

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.

The impact of social determinants of health on laryngotracheal stenosis development and outcomes

OBJECTIVES

The social determinants of health affect a wide range of health outcomes and risks. To date, there have been no studies evaluating the impact of social determinants of health on laryngotracheal stenosis (LTS). We sought to describe the social determinants in a cohort of LTS patients and explore their association with treatment outcome.

METHODS

Subjects diagnosed with LTS undergoing surgical procedures between 2013 and 2018 were identified. Matched controls were identified from intensive care unit (ICU) patients who underwent intubation for greater than 24 hours. Medical comorbidities, stenosis characteristics, and patient demographics were abstracted from the clinical record. Tracheostomy at last follow-up was recorded from the medical record and phone calls. Socioeconomic data was obtained from the American Community Survey.

RESULTS

One hundred twenty-two cases met inclusion criteria. Cases had significantly lower education compared to Tennessee (P = .009) but similar education rates as ICU controls. Cases had significantly higher body mass index (odds ratio [OR]: 1.04, P = .035), duration of intubation (OR: 1.21, P < .001), and tobacco use (OR: 1.21, P = .006) in adjusted analysis when compared to controls. Tracheostomy dependence within the case cohort was significantly associated with public insurance (OR: 1.33, P = .016) and chronic obstructive pulmonary disease (OR: 1.34, P = .018) in adjusted analysis.

CONCLUSION

Intubation practices, medical comorbidities and social determinants of health may influence the development of LTS and tracheostomy dependence after treatment. Identification of at-risk populations in ICUs may allow for prevention of tracheostomy dependence through the use of early tracheostomy and specialized follow-up.

LEVEL OF EVIDENCE

Level 3, retrospective review comparing cases and controls Laryngoscope, 130:1000-1006, 2020.