Findings of routine nocturnal polysomnography in children with Down syndrome: a retrospective cohort study

Adenotonsillectomy outcomes in children with down syndrome and obstructive sleep apnea: a single center study

PURPOSE

This study aimed to evaluate polysomnographic (PSG) outcomes of tonsillectomy and adenoidectomy (T&A) in children with Down Syndrome (DS) and OSA, and the difference in PSG outcomes of T&A between children with DS and age- and gender-matched normally developing (non-DS) children.

METHODS

This was a single center retrospective study that included children with DS and OSA who underwent T&A and had pre-operative and post-operative PSG. The baseline and the differences of pre- and post-operative PSG variables were compared with those of an age- and gender-matched group of non-DS children.

RESULTS

Forty-eight children with DS were included in the study; the median age was 5 years (IQR 5.5), 58% were males, and the median BMI was 18.2 (IQR 3.3). There was statistically significant improvement noted between pre-operative and post-operative OAHI 17.9 ± 26.7 vs. 9.1 ± 13.6 (p = 0.022) and non-REM AHI 13.9 ± 19.7 vs. 6.9 ± 14.2 (p = 0.027). However, there were no significant changes in sleep architecture, oxygen desaturation nadir, or CO2 levels. 54.2% of the DS children continued to have moderate to severe OSA after T&A. Univariate logistic regression showed that for every 1% increase in oxygen desaturation nadir, the odds of having residual moderate or severe OSA decreased by 28% (p = 0.002) compared to the cured and mild OSA groups. There was no significant pre- and post-operative differences in PSG variables noted in 16 children with DS compared to age- and gender-matched non-DS children.

CONCLUSION

Despite the overall significant reduction of OAHI in children with DS and OSA who underwent T&A, there was a residual moderate to severe OSA in about half of the included children. Oxygen desaturation nadir was a predicting factor for persistent moderate to severe OSA. There were no significant pre- and post-operative PSG differences in between DS children compared to non-DS children.

Efficacy and safety of adenotonsillectomy in the management of obstructive sleep apnea syndrome in children with Down syndrome: A systematic review and meta-analysis

Obstructive sleep apnea (OSA) is commonly observed in children with Down syndrome (DS) and may affect their physical and psychological development. Currently, adenotonsillectomy is the first line treatment option for paediatric patients with OSA. However, surgical outcomes for such patients are not satisfactory. In this study, we analysed the efficacy and safety of adenotonsillectomy in the treatment of children with obstructive sleep apnea and Down syndrome. We systematically searched the PubMed, Web of Science, EMBASE, and the Cochrane databases and pooled data from nine relevant studies involving 384 participants. Subsequently, we analysed four outcomes in polysomnography, namely: net postoperative changes in the apnea-hypopnea index (AHI), the minimum oxygen saturation, sleep efficiency, and arousal index. Meta-analysis of the AHI showed a decrease of 7.18 events/h [95% CI (-9.69, -4.67) events/h; p < 0.00001] and an increase in the minimum oxygen saturation of 3.14% [95% CI (1.44, 4.84) %; p = 0.0003]. There was no significant increase in sleep efficiency [MD 1.69%, 95% CI (-0.59, 3.98) %; p = 0.15], but the arousal index significantly decreased by -3.21 events/hour [95% CI (-6.04, -0.38) events/h; p < 0.03]. In addition, the overall success rate was 16% (95% CI, 12%-21%) for postoperative AHI < 1 and 57% (95% CI, 51%-63%) for postoperative AHI <5. The postoperative complications recorded included airway obstruction and bleeding. This study demonstrated the efficacy of adenotonsillectomy as a treatment option for OSA. However, it is important to note that residual OSA and potential postoperative complications require further attention in future studies.

Tolerance of polysomnography in children with neurodevelopmental disorders compared to neurotypical peers

STUDY OBJECTIVES

Diagnostic polysomnography (PSG) is the gold standard test to evaluate sleep-disordered breathing in children. Little is known about how children with neurodevelopmental disorders (NDD) tolerate electrodes and sensors in PSG compared to neurotypical children.

METHODS

In this retrospective cohort study of children > 12 months of age who underwent diagnostic PSG at our center from 01/01/2021-30/06/2021, we used sleep technician and physician reports to determine how PSG was tolerated in children with NDD compared to neurotypical children. Subanalyses included tolerance of individual electrodes and sensors and subgroups of NDD (eg, Trisomy 21).

RESULTS

A total of 132 children with a NDD and 139 neurotypical children underwent diagnostic PSG. The median age of all children was 8 years, 39% were female, and 50% had a sleep disorder identified on PSG, with no significant differences between NDD and neurotypical groups. The most poorly tolerated sensors for all children were the nasal prongs (poorly tolerated in 30% of all children), followed by thermistor (14%) and electroencephalography electrodes (6%). Children with NDD were > 3 times more likely (odds ratio 3.1, 95% confidence interval 1.8-5.3) to experience problems tolerating any study leads than neurotypical children. Subgroup analysis revealed children with Trisomy 21 had the greatest difficulty tolerating PSG set-up and leads.

CONCLUSIONS

This retrospective study demonstrates that children with neurodevelopmental disorders are less likely to tolerate PSG monitoring than neurotypical children and highlights the need to develop alternative measures for evaluation of sleep disorders in this population.

CITATION

Lanzlinger D, Kevat A, Collaro A, Poh SH, Pérez WP, Chawla J. Tolerance of polysomnography in children with neurodevelopmental disorders compared to neurotypical peers. J Clin Sleep Med. 2023;19(9):1625-1631.

Caregiver knowledge of obstructive sleep apnoea in Down syndrome

BACKGROUND

Down syndrome (DS) population has a very high prevalence of obstructive sleep apnoea (OSA), but this remains underdiagnosed. Hence, we aimed to evaluate caregiver's knowledge of OSA and related sociodemographic factors that could contribute to OSA screening patterns in this population.

METHODS

An online survey though the LuMind IDSC Foundation focused on OSA diagnosis, treatments and the number of sleep studies performed. Data were compared between subjects born before and after the American Academy of Pediatrics (AAP) recommendations for OSA screening.

RESULTS

Of the caregivers, 724 (parents 96.3%), responded to the survey. The median [interquartile (IQR)] age of the subjects with DS was 12 [20;7] years. The majority (84.3%) had sleep apnoea diagnosis, and half of them were initially referred for a sleep study due to disturbed sleep symptoms. Only 58.7% of the responders were aware of the AAP recommendations. This was linked to higher socioeconomic and/or educational level and to an earlier OSA diagnosis. The median (IQR) age of OSA diagnosis was lowered after the AAP guidelines publication compared with before its publication (3 [4;2] years vs. 10 [18;5] years, P < 0.000). Adenotonsillectomy (81.9%) and continuous positive airway pressure (61.5%) were the most commonly prescribed treatments. Few had discussed other new therapies such as hypoglossal nerve stimulation (16.0%). Only 16.0% of the subjects repeated the sleep study to monitor OSA with ageing, and 30.2% had to wait more than 4 years between studies.

CONCLUSIONS

This study reinforces the need to improve OSA knowledge of caregivers and clinicians of individuals with DS to promote an earlier diagnosis and optimal treatment of OSA in this population.

Predictors of sleep disordered breathing in children with Down syndrome: a systematic review and meta-analysis

Children with Down syndrome are at increased risk of sleep disordered breathing (SDB). SDB is associated with significant morbidity including neurocognitive impairment, cardiometabolic disease and systemic inflammation. The identification of clinical markers that may predict SDB is critical in facilitating early diagnosis and treatment, and ultimately, preventing morbidity. The objective of this systematic review was to identify predictors of SDB in patients with Down syndrome. A search was conducted using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and the Cumulative Index to Nursing and Allied Health Literature. A meta-analysis was performed according to the Meta-analyses of Observational Studies in Epidemiology checklist. Our review of the literature identified inconsistent associations between a variety of variables and SDB in children with Down syndrome, although the quality of evidence was poor. Meta-analysis of age and sex identified that children with OSA were older than those without OSA, and there was a similar risk of OSA in males and females, although risk favoured males. Currently, the American Academy of Pediatrics guidelines recommend that children with Down syndrome undergo polysomnography by the age of 4 years. Our review supports the recommendation for routine screening of children with Down syndrome. However, results from our meta-analysis suggest a need for longitudinal screening to diagnose children who may develop SDB as they get older.

This review identified several predictors of sleep disordered breathing (SDB) in children with Down syndrome. Meta-analysis identified older age as a predictor. This supports routine longitudinal screening of all children with Down syndrome for SDB.https://bit.ly/3KGnqFK

Otolaryngologic Disease in Down syndrome

As the most common human chromosomal abnormality, Trisomy 21 is a condition that many otolaryngologists and likely all pediatric otolaryngologists will encounter during their careers. There are several considerations regarding airway obstruction, otologic conditions, anesthetic implications, and endocrine disorders that will impact the treatment of these patients. Further, there is increasing literature supporting the use of early instrumental assessment of swallowing, drug-induced sleep endoscopy at the time of first surgical intervention for sleep apnea, consideration of concurrent upper and lower airway evaluation, and early otologic management including potential surgical hearing rehabilitation.

Characterization of sleep-disordered breathing in children with Duchenne muscular dystrophy by the American Academy of Sleep Medicine criteria vs disease-specific criteria: what are the differences?

STUDY OBJECTIVES

Individuals with Duchenne muscular dystrophy (DMD) frequently develop sleep-disordered breathing. Noninvasive ventilation is often prescribed for sleep-disordered breathing treatment based on the American Academy of Sleep Medicine (AASM) criteria. In 2018, DMD disease-specific criteria for sleep-disordered breathing were established. Our study aimed to examine the clinical interpretation differences using these different criteria.

METHODS

We performed a multicenter, retrospective chart review of children with DMD followed at The Hospital for Sick Children, Toronto, Canada, and Rady Children's Hospital, San Diego, California, who underwent polysomnography from August 1, 2012, to February 29, 2020. Baseline characteristics and polysomnography data were summarized using descriptive statistics. Agreement for the diagnosis of sleep-disordered breathing evaluated by kappa statistics and sensitivity/specificity analysis was assessed.

RESULTS

One hundred five male children with DMD (mean ± SD age: 12.1 ± 3.8 years; body mass index z score: 0.2 ± 2.3) were included. The proportions of children with DMD that met at least 1 AASM criterion and at least 1 DMD criterion were 45.7% and 67.6%, respectively. We found that 32.4% of children met neither AASM nor DMD criteria. Overall agreement between AASM and DMD criteria was moderate (k = 0.57). There was almost perfect agreement in sleep apnea diagnosis (k = 0.90); however, there was only slight agreement in hypoventilation diagnosis (k = 0.12) between AASM and DMD criteria.

CONCLUSIONS

There were more children with DMD diagnosed with nocturnal hypoventilation and prescribed noninvasive ventilation using DMD criteria compared with AASM criteria. Future studies should address whether the prescription of noninvasive ventilation for children with DMD based on both criteria is associated with different clinical outcomes.

CITATION

Hurvitz MS, Sunkonkit K, Massicotte C, Li R, Bhattacharjee R, Amin R. Characterization of sleep-disordered breathing in children with Duchenne muscular dystrophy by the American Academy of Sleep Medicine criteria vs disease-specific criteria: what are the differences? J Clin Sleep Med. 2022;18(2):609-615.

Age and gender-related differences in quality of life of Bangladeshi patients with Down Syndrome: A cross-sectional study

Currently available screening instruments for evaluation of individuals with intellectual disabilities do not capture all the complications associated with Down Syndrome (DS). Here, we examined age and gender-specific variability revolving around major challenges related to ophthalmologic and auditory health, social integration, daily life, and behavioral problems in 468 (age: 2–84 years) individuals with DS living in all eight divisions of Bangladesh. More than half of the children presented with significant difficulty in walking or other targeted movements compared with 37.9% of adolescents (p = 0.03). Nearly 70% of children exhibited communication difficulties, particularly revolving around the understanding of speech, comprehending or learning tasks or new materials, and in expressing thoughts in words or behaviors (p = 0.003–0.006). Uncontrolled urination was frequent and predominantly found among children (p = 0.04). No significant differences were present in females vs. males except for concern about physical appearance (females: 58.5% vs. males: 47.5%; p = 0.02). The severity of DS was associated with intellectual performance, communication difficulties, and self-sufficiency (i.e., uncontrolled micturition or bowel movements) but not with psychotic, ophthalmologic, auditory, or motor skills-related problems. Increased awareness of DS phenotypic profiles among professionals and caregivers can foster earlier detection and counselling and help formulate appropriate interventions to reduce long-term sequelae and enhance cognitive and behavioral developmental outcomes.

Management and outcome of extreme pediatric obstructive sleep apnea

OBJECTIVES

Classify post-adenotonsillectomy (AT) respiratory support, identify variables that predict these interventions, and evaluate outcomes in children with extreme obstructive sleep apnea (OSA).

METHODS

Retrospective chart analysis was performed on patients found to have apnea/hypopnea index (AHI) > 100 events/h. Patients with chronic diseases other than obesity were excluded.

RESULTS

Forty-one subjects were studied, average age of 11.4 ± 4.3 years, majority (73.1%) were Hispanic, with a mean total AHI (TAHI) of 128.1 ± 22.9/h. Twenty-eight (68.3%) patients underwent AT. Lower age (P < 0.001), lower BMI Z-score (P < 0.01), higher OAHI (P < 0.05) were associated with having surgery. Eleven out of 28 (39.3%) surgical patients required respiratory support (oxygen or positive airway pressure) postoperatively. Longer % total sleep time S_pO₂ <90% during PSG (P < 0.05) and lower S_pO₂ nadir (P < 0.05) were associated with requiring airway support. No patients experienced mortality, reintubation, or hospital readmission following AT, with majority (71.4%) discharged 1 day post-operatively. Eleven (57.9%) of the 19 patients who had a postoperative PSG had residual OSA, defined as AHI >5 events/h, but there was a significant improvement in TAHI (P < 0.01).

CONCLUSION

Our findings confirm the need for postoperative observation in a controlled setting for patients with extreme OSA undergoing AT. Although at higher risk of needing respiratory support, those patients undergoing AT for extreme OSA did not require re-intubation post-operatively or suffer serious harm. Barring contraindications to AT, surgery may still be a first-line therapy for some children with extreme OSA.

Sleep Disorders in Adults with Down Syndrome

Sleep disorders, despite being very frequent in adults with Down syndrome (DS), are often overlooked due to a lack of awareness by families and physicians and the absence of specific clinical sleep guidelines. Untreated sleep disorders have a negative impact on physical and mental health, behavior, and cognitive performance. Growing evidence suggests that sleep disruption may also accelerate the progression to symptomatic Alzheimer’s disease (AD) in this population. It is therefore imperative to have a better understanding of the sleep disorders associated with DS in order to treat them, and in doing so, improve cognition and quality of life, and prevent related comorbidities. This paper reviews the current knowledge of the main sleep disorders in adults with DS, including evaluation and management. It highlights the existing gaps in knowledge and discusses future directions to achieve earlier diagnosis and better treatment of sleep disorders most frequently found in this population.

Adherence to Sleep Therapies in Children and Adolescents

Improved recognition of obstructive sleep apnea (OSA) in children has led many to identify effective strategies to treat pediatric OSA. Positive airway pressure (PAP) therapy in children, which has been shown to resolve OSA, is highly contingent on adequate adherence. In pediatrics, adherence is complex, related largely to the influence of age. Consequently, reported adherence rates in children are often lower than adults. Notwithstanding, studies have identified significant risk factors, some modifiable, and several intervention strategies that may improve pediatric adherence. Close follow-up, including use of cloud-based monitoring, of children using PAP therapy may optimize adherence further.

Obstructive Sleep Apnea is Related with the Risk of Retinal Vein Occlusion

BACKGROUND

Retinal vein occlusion (RVO) was a vision-threatening retinal vascular disorder, however, the relationship between obstructive sleep apnea (OSA) and RVO risk remained unclear.

METHODS

A total of 45 RVO cases and 45 controls between April 2018 and April 2020 were included. All the participants underwent full-night polysomnography (PSG) and thus detected the severity of OSA. Besides, the relationship between the apnea-hypopnea index (AHI) and oxidative and inflammatory biomarkers, including 8-hydroxy-2 deoxyguanosine (8-OHdG), C-reactive protein (CRP), interleukin 1 beta (IL1β), interleukin 6 (IL6) and tumor necrosis factor alpha (TNFα) were detected. The incidences of macular edema (ME) and neovascular glaucoma (NVG) were detected in a three-months follow-up.

RESULTS

In this case-control study, it was found that OSA incidence was increased in the RVO cases comparing with the cataract controls. Advanced analyses about the RVO subtypes demonstrated that incidence of OSA was higher in the central RVO (CRVO) cases comparing with branch RVO (BRVO) cases. Plasma samples from OSA cases demonstrated relatively higher concentrations of oxidative stress parameters and inflammatory biomarkers, including 8-OHdG, CRP, IL1β, and IL6, in the RVO cases. Significant linear correlations between AHI and oxidative/inflammatory biomarkers were detected, and advanced analyses on the OSA subtypes demonstrated that these biomarkers were significantly higher in cases with later stages of OSA. In a three months follow-up, an impaired visual activity improvement rate and increased ME incidence in the OSA group among all the RVO cases were detected.

CONCLUSION

OSA was related with an increased incidence of RVO. Besides, OSA would lead to increased oxidative and inflammatory biomarkers concentrations in the RVO cases. OSA could be used as a harmful prognostic factor of visual activity improvement and ME incidences. These findings highlighted the role of OSA in the development of RVO.