Neurocognitive deficits in morbidly obese children with obstructive sleep apnea

Evaluation of Cognitive and Social Behavior After Adenotonsillectomy in Children

To evaluate improvement in cognitive and social behavior of children after adenotonsillectomy. This prospective, observational study was done on 50 patients between November 2016 to September 2019 with clinical features suggestive of adenoid and palatine tonsillar hypertrophy (grade 3, 4) at department of otorhinolaryngology in our institute. We used 10 questions of Glasgow Children's Benefit Inventory (GCBI), to evaluate the cognitive and social behavior of children after adenotonsillectomy. After surgery, we evaluated cognitive functions (distractibility, learning, concentration and irritability) and social behavior (Progress and development, liveliness, family harmony, fun with friends, happiness and leisure) of children. p value of comparison at 1 month and 6 months postoperative was significant (< 0.05) for all questions of GCBI. Adenotonsillectomy definitely have positive impact on cognitive and social behavior of children. So early surgical intervention in form of adenotonsillectomy is recommended in children having clinical symptoms of adenotonsillar hypertrophy and sleep disordered breathing.

The Boredom Prone Personality: A Multitrait-Multimethod Approach

The present investigation reports the convergent and discriminant validity coefficients for two versions of Farmer and Sundberg's (Journal of Personality Assessment, 50(1), 4-17, 1986) boredom proneness scale. Boredom proneness, a trait that refers to an enduring tendency to disengage from the environment, has been neglected by the field of psychology despite its theoretical relevance to performance and psychological well-being. This report sought: (a) to validate a shortened 8-item version of the original Boredom Proneness Scale published by Struk et al. (Assessment, 24(3), 346-359, 2017) and (b) to extensively examine the boredom proneness construct that the long and short versions of this scale assess. We employed a multitrait-multimethod approach that assessed a large number of theorized effects simultaneously. We replicated dozens of theorized and/or previously observed boredom proneness correlates (convergent validity) as well as many theorized null effects (discriminant validity). The overall pattern of significant and null effect sizes provided compelling evidence that the original boredom proneness scale as well as the 8 items that constitute the shorter version are valid measures of one's susceptibility to boredom. We propose that boredom proneness might be an underappreciated yet important theoretical moderator of Person X Situation effects.

Does sleep-disordered breathing add to impairments in academic performance and brain structure usually observed in children with overweight/obesity?

Approximately 4-11% of children suffer from sleep-disordered breathing (SDB), and children with obesity are at increased risk. Both obesity and SDB have been separately associated with poorer brain health, yet whether SDB severity affects brain health in children with obesity remains unanswered. This study aimed to examine associations of SDB severity with academic performance and brain structure (i.e., total brain and gray and white matter volumes and gray matter volume in the hippocampus) in children with overweight/obesity. One hundred nine children aged 8-12 years with overweight/obesity were included. SDB severity and its subscales (i.e., snoring, daytime sleepiness, and inattention/hyperactivity) were evaluated via the Pediatric Sleep Questionnaire (PSQ), and academic performance was evaluated with the Woodcock-Muñoz standardized test and school grades. Brain structure was assessed by magnetic resonance imaging. SDB severity was not associated with academic performance measured by the standardized test (all |β|> 0.160, P > 0.076), yet it was associated with the school grade point average (β = -0.226, P = 0.007) and natural and social science grades (β = -0.269, P = 0.024). Intention/hyperactivity seemed to drive these associations. No associations were found between SDB severity and the remaining school grades (all β < -0.188, P > 0.065) or brain volumes (all P > 0.05).

CONCLUSION

Our study shows that SDB severity was associated with lower school grades, yet it was not associated with the standardized measurement of academic performance or with brain volumes in children with overweight/obesity. SDB severity may add to academic problems in children beyond the effects contributed by overweight/obesity status alone.

WHAT IS KNOWN

• Sleep-disordered breathing (SDB) may affect brain structure and academic performance in children. • Children with overweight/obesity are at higher risk for the development of SDB, yet the comorbid obesity-SDB relationship with brain health has not been investigated thus far.

WHAT IS NEW

• To our knowledge, this is the first study examining the associations of comorbid obesity-SDB severity with brain volumes and academic performance in children. • SDB symptoms may adversely affect academic performance at school in children with overweight/obesity, beyond the effects of weight status alone.

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.

Exploring the Diagnostic Accuracy of the KidFit Screening Tool for Identifying Children with Health and Motor Performance-Related Fitness Impairments: A Feasibility Study

Child obesity is associated with poor health and reduced motor skills. This study aimed to assess the diagnostic accuracy of the KidFit Screening Tool for identifying children with overweight/obesity, reduced motor skills and reduced cardiorespiratory fitness. Fifty-seven children (mean age: 12.57 ± 1.82 years; male/female: 34/23) were analysed. The Speed and Agility Motor Screen (SAMS) and the Modified Shuttle Test-Paeds (MSTP) made up the KidFit Screening Tool. Motor Proficiency (BOT2) (Total and Gross) was also measured. BMI, peak-oxygen-uptake (VO2peak) were measured with a representative sub-sample (n = 25). Strong relationships existed between the independent variables included in the KidFit Screening Tool and; BMI (R² = 0.779, p < 0.001); Gross Motor Proficiency (R² = 0.612, p < 0.001) and VO2peak (mL/kg/min) (R² = 0.754, p < 0.001). The KidFit Screening Tool has a correct classification rate of 0.84 for overweight/obesity, 0.77 for motor proficiency and 0.88 for cardiorespiratory fitness. The sensitivity and specificity of the KidFit Screening Tool for identifying children with overweight/obesity was 100% (SE = 0.00) and 78.95%, respectively (SE = 0.09), motor skills in the lowest quartile was 90% (SE = 0.095) and 74.47% (SE = 0.064), respectively, and poor cardiorespiratory fitness was 100% (SE = 0.00) and 82.35% (SE = 0.093), respectively. The KidFit Screening Tool has a strong relationship with health- and performance-related fitness, is accurate for identifying children with health- and performance-related fitness impairments and may assist in informing referral decisions for detailed clinical investigations.

Sustained auditory attention ability in children based on the breathing mode

ABSTRACT Purpose: to analyze the auditory behavior and the performance in the Sustained Auditory Attention Ability Test (SAAAT) of children with different breathing modes. Methods: a total of 30 individuals (19 males and 11 females), ranging from seven to 11 years old, participated in the research. They were distributed into nasal-breathers, mouth-breathers, and oronasal-breathers groups. The Scale of Auditory Behaviors (SAB) questionnaire was applied to those responsible for the children, so as to characterize their auditory behavior. In the SAAAT, the following error patterns were analyzed: inattention, decreased vigilance, impulsivity, and total errors. For the inferential analysis, the Mann-Whitney, chi-square, and Kruskal-Wallis statistical tests were used. Results: the individuals with mouth- and oronasal-breathing modes had more complaints in the SAB questionnaire when compared with nasal-breathers. Regarding the SAAAT, it was found that the age group of seven to eight years was the one that had the worst performance in the test. The groups with oral and oronasal breathing had more errors, with a statistically significant difference between the groups for inattention and total errors. Conclusion: it can be concluded that individuals with oral and oronasal breathing had more complaints in the auditory behavior and worse performance in the SAAAT, especially for inattention and total errors.

Post-concussion Symptom Factors and Neuropsychological Outcomes in Collegiate Athletes

OBJECTIVES

Research indicates that symptoms following a concussion are related to cognitive dysfunction; however, less is known about how different types of symptoms may be related to cognitive outcomes or how specific domains of cognition are affected. The present study explored the relationship between specific types of symptoms and these various cognitive outcomes following a concussion.

METHODS

One-hundred twenty-two student-athletes with sports-related concussion were tested with a battery that included a symptom report measure and various cognitive tests. Symptoms factors were: Physical, Sleep, Cognitive, Affective and Headache. Participants were grouped into "symptom" and "no symptom" groups for each factor. Cognitive outcomes included both overall performance as well as impairment scores in which individuals were grouped into impaired and not impaired based on a cutoff of 2 or more tests at the impaired level (<80 in standard scores). These cognitive outcomes were examined for all the tests combined and then specifically for the memory tests and attention/processing speed tests. A Bonferroni correction was used, and the results were considered significant at a level of p<.008.

RESULTS

Headache symptoms were significantly (p<.008) associated with overall cognitive impairment as well as memory and attention/processing speed impairment. Sleep symptoms were related to memory impairments.

CONCLUSIONS

The symptom specific relationships to cognitive outcomes demonstrated by our study can help guide treatment and accommodations for athletes following concussion. (JINS, 2018, 24, 684-692).

Correlation between sleep profile and behavior in individuals with specific learning disorder

PURPOSE

This study aimed to correlate sleep profile and behavior in individuals with Specific Learning Disorder (SLD).

METHODS

The Sleep General Habits Questionnaire, Sleep Diary, and Sleep Disturbance Scale for Children (SDSC) were used in analysis of sleep, whereas the Child Behavior Checklist (CBCL) inventory was used in analysis of behavior.

RESULTS

65.5% of the individuals with SLD presented symptoms of sleep disorders, most frequently wakefulness-sleep transition and sleep disturbance total score, which showed values higher than acceptable. In addition, individuals with SLD presented higher sleep latency than those with typical development. Concerning behavior, 72.4% of the individuals with SLD presented clinical condition of behavior problems. In the control group, none of the participants showed symptoms of sleep or behavior problems. In the SLD group, correlation was observed between behavioral problems and sleep disturbance.

CONCLUSION

Individuals with SLD showed high rates of sleep disturbance and behavioral problems. The worse the sleep disturbance, the worse the behavioral aspects in these individuals.

Neurocognitive and behavioral functioning in adolescents with sleep-disordered breathing: a population-based, dual-energy X-ray absorptiometry study

BACKGROUND/OBJECTIVES

Sleep-disordered breathing (SDB) has been associated with neurocognitive and behavioral problems in young children; however, this association is less studied in adolescents. Evidence suggests that obesity plays a key role in the development of SDB, although its relative association with neurobehavioral functioning remains unclear. We examined whether SDB and obesity are associated with neurocognitive and behavioral problems in adolescents.

SUBJECTS/METHODS

A total of 421 adolescents (17.0±2.2y, 53.9% male) from the Penn State Child Cohort, a general population sample, underwent a 9-h polysomnography, clinical history, physical examination, neurocognitive evaluation and Dual-energy X-ray Absorptiometry (DXA) scan, and completed the Child or Adult Behavior Checklist. Obstructive sleep apnea (OSA) was defined as an apnea-hypopnea index (AHI)⩾2, primary snoring (PS) as AHI<2+snoring and no-SDB as AHI<2 without snoring. Body weight measures included body mass index (BMI) percentile, waist circumference (WC) and DXA-measured total adipose tissue (TAT).

RESULTS

WC and TAT were significantly associated with impaired vigilance, processing speed, working memory, and control interference and greater internalizing and externalizing behaviors, while BMI percentile was marginally associated. SDB per se (PS, AHI or OSA) was not significantly associated with impaired neurocognitive outcomes or greater behavioral problems. However, TAT was significantly associated with impaired vigilance and greater internalizing and externalizing behaviors and, to a lesser extent, slower processing speed and greater control interference, only in adolescents with OSA.

CONCLUSIONS

Central obesity, an etiopathogenic mechanism of OSA, is more strongly associated with neurocognitive and behavioral problems in adolescents than SDB alone. Deficits in low-order (vigilance) and high-order (executive) functions and behavioral problems observed in adolescents with OSA are primarily associated with increased central adiposity, a finding not entirely captured with less precise measures of obesity. These data support that OSA and its associated neurocognitive and behavioral morbidity are related to underlying metabolic dysfunction as early as adolescence.

Cognitive and Behavioral Consequences of Sleep Disordered Breathing in Children

There is now a plethora of evidence that children with sleep disordered breathing (SDB) show deficits in neurocognitive performance, behavioral impairments, and school performance. The following review will focus on the neurobehavioral impacts of SDB, pediatric sleep investigation challenges, potential mechanisms of behavioral and cognitive deficits in children with SDB, and the impact of SDB treatment.

School and family-based interventions for promoting a healthy lifestyle among children and adolescents in Italy: a systematic review

AIMS

Cardiovascular diseases affect adult population but risk factors develop as a result of known or assumed behavior since childhood. In Italy, up to 22.2% of children are overweight, 10.6% are obese, and 2.5% have severe obesity.

METHODS

We performed a systematic review of the literature to identify studies and initiatives addressing health promotion among children in Italy. Given the high heterogeneity of interventions and outcomes assessed we opted to perform a qualitative synthesis of the results. We described also nonrandomized trial where the intervention of primary prevention was very innovative, explained in detail, and reached an improving outcome for participants.

RESULTS

We identified 11 projects since 1983, only five were randomized control trials. Three involved children and teachers of primary and secondary schools and were based on specific curricular lectures about health. One was based on a game developed for high schools with the purpose to promote healthy lifestyle and physical activity. The fifth project was based on an enhanced physical activity program.

CONCLUSION

Our results show that school and family should be considered as the privileged places for health promotion. In Italy, the development of scientific-validated lifestyle interventions for children is still an unmet need.

The effect of adenoid hypertrophy on maxillofacial development: an objective photographic analysis

Background

Deformity in the dental arc and facial skeleton by adenoid hypertrophy due to chronic mouth breathing is a well-known process. Most of the related studies have been based on cephalometric analyses. The aim of this study is to detect the presence of skeletal deformities on the soft tissue by analyzing distances and angles on photographs.

Methods

Ninety-seven children having between 25 and 100 % of adenoids, ages 4–12 years (48 boys, 49 girls), and 90 cases having 0–25 % adenoid tissue, ages 4–12 years (54 boys, 36 girls), were studied by clinical history, physical examination (including endoscopy), and standardized clinical photographs. The children and parents were asked if any of the following were present in the children: snoring, sleep apnea, daytime sleepiness, poor school performance, mouth breathing during sleep, smoking parents, and restlessness during sleep.

Results

The assessment of linear and angular measurements on the clinical photographs showed, in the group having thicker adenoids compared with controls, a statistically significant increase in the distance between nasion and tip and nasion and subnasale and in the angle between Frankfort horizontal plane-gnathion-angulus mandible; there was also a statistically significant decrease in the distance between endocanthion and exocanthion and the angles between tragion-angulus mandible and gnathion and between nasion-angulus mandible and gnathion.

Conclusions

The analyses showed a significant increase in the anterior face height and increase in the angle between Frankfort horizontal plane-gnathion-angulus mandible and a retropositioned and posterior-rotated mandible due to thicker adenoids.

Trial registration

2010/140 Date: 04 January 2010.

Cognitive Executive Dysfunction in Children with Mild Sleep-Disordered Breathing

In children, moderate or severe sleep-disordered breathing (SDB) may impair cognitive executive functions (EFs), including working memory, attention, and mental flexibility. The main objective of this study was to assess EFs in children with mild levels of SDB. Subjects for this descriptive study were 12 children (5 girls, 7 boys) aged 8.0 to 11.9 years (M = 9.0 ± 0.85) participating in an ongoing study of the effects of adenotonsillectomy on behavior. Each subject had a nocturnal polysomnogram (PSG) and multiple sleep latency test (MSLT). Mild SDB was considered present if the child’s apnea/hypopnea index (AHI) was ≥ 1 and < 10. Between MSLT nap attempts, each child completed standardized tests of EFs. The sample showed significant impairment of sustained attention and vigilance on a computerized continuous performance test. Children with low mental flexibility scores on the Children’s Category Test (CCT) spent more time in stage 1 sleep (12.2% v. 9.5%, P = 0.028 on PSG) and showed a marginally higher arousal index (9.7 v. 6.5, P = 0.06 on PSG) than children with average or above-average CCT scores. AHI accounted for significant proportion of the variance in CCT scores when 1 outlier was removed (N = 11, Rsq = 0.67, P = 0.002). Mild levels of SDB and associated sleep architecture disruptions may be associated with impairment of EFs in children.

Comparing the Excessive Daytime Sleepiness of Obese and Non-obese Patients

BACKGROUND

Obesity, particularly morbid obesity, has various physical and mental complications. Excessive daytime somnolence (EDS) is a sleep disorder that reduces individuals' performance capability and the accuracy of their short-term memory and causes learning problems. This retrospective study aimed to document the presence of EDS in a sample of obese patients in comparison to patients with a normal weight.

OBJECTIVES

This article compares the excessive daytime sleepiness of obese and non-obese patients in the minimally invasive surgery research center in Tehran, Iran.

PATIENTS AND METHODS

In this case-control study, we compared excessive daytime sleepiness in 55 obese patients who were candidates for laparoscopic surgery, with a body mass index (BMI) of equal to or greater than 30 kg/ m2, with 55 controls with a normal BMI (19.5 - 24.9 kg/ m2). The process of selecting the control group in our case-control study is matching in group levels, so that the controls are similar to the case group with regard to certain key characteristics, such as age, sex, and race. The sleep assessment was based on the Epworth sleepiness scale (ESS) questionnaire. Analysis of variance (ANOVA) was used to compare the means of quantitative data, such as the ESS score of groups.

RESULTS

Sleepiness was not affected by gender in cases or controls. The sleepiness prevalence was 29 (52.7%) in the cases group and 17 (30.9%) in the control group (OR = 2.493 (95% CI 1.144 -5.435)). The mean ESS scores in cases and controls were 7.82 ± 3.86 and 10.54 ± 6.15, respectively (P = 0.007). Moreover, the prevalence of sleepiness and the mean ESS scores in class III of obesity differed significantly from the controls (16 (57.1%) vs. 17 (30.9%)) (OR = 2.980 (95% CI 1.162 - 7.645)) and (11.04 ± 5.93 vs. 7.82 ± 3.86) (P = 0.013), respectively.

CONCLUSIONS

Our findings suggest a strong relationship between EDS and obesity, particularly morbid obesity. Therefore, physicians must be familiar with EDS as a mixed clinical entity indicating careful assessment and specific treatment planning.

Effects of Nutritional Status on Academic Performance of Malaysian Primary School Children

Numerous factors are known to affect the academic performance of students. These include prenatal conditions, birth conditions, postnatal events, nutritional, socio-economic factors and environmental factors. This paper examines the nutritional status and its relationship with academic performance of 9-10 years old primary school children recruited randomly in Selangor, Malaysia. A standard self-administered questionnaire was utilized to obtain pertinent information and a face-to-face interview was also conducted with the parents. Results of the academic performances were extracted from the students' report cards. The intellectual performance was assessed using Raven's Coloured Progressive Matrices. Physical examination was also conducted on these students by doctors. Overall 1,405 students and 1,317 parents responded to the survey. Of these 83.6% were Malays, 11.6% Indians, and 4.2% Chinese. The majority of them (82.9%) were from urban areas. The female: male ratio was 51:49; mean age was 9.71 years. The mean height and weight were 32.3 kg and 135.2 cm respectively. Their mean BMI was 17.42 kg/cm 2, with 0.9% underweight, 76.3% normal BMI, 16.3% overweight, and 6.3% obese. Academic performance was significantly correlated with breast feeding, income and educational level of their parents, BMI, and whether they have been taking breakfast. There was a weak correlation between presence of anaemia and intellectual performance. Improving the socio-economic status of the parents will lend a helping hand in the academic performance of the students. Since breast feeding is associated with better academic and intellectual performance it must be emphasized, particularly to expectant mothers in the antenatal clinics. Asia Pac J Public Health 2005; 17(2): 81-87.

Sleep Disordered Breathing and Academic Performance: A Meta-analysis

BACKGROUND AND OBJECTIVE

Sleep-disordered breathing (SDB) in children is associated with daytime functioning decrements in cognitive performance and behavioral regulation. Studies addressing academic achievement are underrepresented. This study aimed to evaluate the strength of the relationships between SDB and achievement in core domains and general school performance.

METHODS

Data sources included PubMed, Web of Science, CINAHL, and PsycINFO. Studies of school-aged children investigating the relationships between SDB and academic achievement were selected for inclusion in a systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data extracted were converted into standardized mean differences; effect sizes (ES) and statistics were calculated by using random-effects models. Heterogeneity tests (I(2)) were conducted.

RESULTS

Of 488 studies, 16 met eligibility criteria. SDB was significantly associated with poorer academic performance for core academic domains related to language arts (ES -0.31; P < .001; I(2) = 74%), math (ES -0.33; P < .001; I(2) = 55%), and science (ES -0.29; P = .001; I(2) = 0%), and with unsatisfactory progress/learning problems (ES -0.23; P < .001; I(2) = 0%) but not general school performance.

CONCLUSIONS

Variable definitions of both academic performance and SDB likely contributed to the heterogeneity among published investigations. Clear links between SDB and poorer academic performance in school-age children are demonstrated. ES statistics were in the small to medium range, but nevertheless the findings serve to highlight to parents, teachers, and clinicians that SDB in children may contribute to academic difficulties some children face.

Obesity as a risk factor for poor neurocognitive outcomes in older adults with heart failure

Heart failure (HF) has reached epidemic proportions and is a significant contributor to poor outcomes. HF is an established risk factor for Alzheimer's disease, vascular dementia, and abnormalities on neuroimaging. Moreover, up to 80% of HF patients also exhibit milder impairments on cognitive tests assessing attention, executive function, memory, and language. The mechanisms of cognitive impairment in HF are not entirely clear and involve a combination of physiological processes that negatively impact the brain. Cerebral hypoperfusion and common comorbid conditions in HF are among the most commonly proposed contributors to poor neurocognitive outcomes in this population. Obesity is another likely risk factor for adverse brain changes and cognitive impairment in HF, as it is a known contributor to neurocognitive outcomes in healthy and patient samples. This paper reviews the literature on HF and cognitive function and introduces obesity as a significant risk factor for poor neurocognitive outcomes in this population.

Health promotion in obstructive sleep apnea syndrome

Introduction Obstructive sleep apnea syndrome (OSAS), which is commonly underdiagnosed, has a high occurrence in the world population. Health education concerning sleep disorders and OSAS should be implemented. Objectives The objective was to identify studies related to preventive actions on sleep disorders, with emphasis on OSAS. Data Synthesis A literature review was conducted using Lilacs, Medline, PubMed, and Scopus by combining the following keywords: "Health Promotion," "Sleep Disorders," "Primary Prevention," "Health Education," and "Obstructive Sleep Apnea Syndromes." Initially, 1,055 papers, from 1968 to 2013, were located, with the majority from the Scopus database. The inclusion criteria were applied, and four articles published between 2006 and 2012 were included in the present study. Conclusions The studies on preventive actions in sleep disorders, with emphasis on OSAS, involved the general population and professionals and students in the health field and led to increased knowledge on sleep disorders and more appropriate practices.

Neglect: failure to thrive and obesity

Medical providers need to monitor growth at every visit. Weight status is influenced by genetics, medical conditions, socioeconomic status, and family environment. Screening for food security and psychosocial risk factors is an integral tool to identify families at risk for nutritional deficits and child maltreatment. Nutritional rehabilitation is best accomplished in an outpatient, multidisciplinary setting. Medical neglect should be considered in failure to thrive and obesity when there is a serious risk of harm from identified medical complications, additional or worsening medical complications occurring despite a multidisciplinary approach, and/or non-adherence with the treatment plan.

Craniofacial contribution to residual obstructive sleep apnea after adenotonsillectomy in children: a preliminary study

STUDY OBJECTIVES

Pediatric obstructive sleep apnea (OSA) is frequently associated with adenotonsillar hypertrophy, and the fact that about 30% of affected children continue to show OSA after adenotonsillectomy (AT) suggests the presence of some other predisposing factor(s). We hypothesized that abnormal maxillofacial morphology may be a predisposing factor for residual OSA in pediatric patients.

METHODS

A total of 13 pediatric OSA patients (9 boys and 4 girls, age [median (interquartile range)] = 4.7 (4.0, 6.4) y, body mass index (BMI) z score = -0.3 (-0.8, 0.5)) who had undergone AT were recruited for this study. Maxillomandibular size was measured using an upright lateral cephalogram, and correlations between size and the apnea hypopnea index (AHI) values obtained before (pre AT AHI) and about 6 months after AT (post AT AHI) were analyzed.

RESULTS

AHI decreased from 12.3 (8.9, 26.5)/h to 3.0 (1.5, 4.6)/h after AT (p < 0.05). Residual OSA was seen in 11 of the 13 patients (84.6%) and their AHI after AT was 3.1 (2.7, 4.7)/h. The mandible was smaller than the Japanese standard value, and a significant negative correlation was seen between maxillomandibular size and post AT AHI (p < 0.05).

CONCLUSIONS

These findings suggest that the persistence of OSA after AT may be partly due to the smaller sizes of the mandible in pediatric patients. We propose that the maxillomandibular morphology should be carefully examined when a treatment plan is developed for OSA children.

Do respiratory cycle-related EEG changes or arousals from sleep predict neurobehavioral deficits and response to adenotonsillectomy in children?

STUDY OBJECTIVES

Pediatric obstructive sleep apnea (OSA) is associated with hyperactive behavior, cognitive deficits, psychiatric morbidity, and sleepiness, but objective polysomnographic measures of OSA presence or severity among children scheduled for adenotonsillectomy have not explained why. To assess whether sleep fragmentation might explain neurobehavioral outcomes, we prospectively assessed the predictive value of standard arousals and also respiratory cycle-related EEG changes (RCREC), thought to reflect inspiratory microarousals.

METHODS

Washtenaw County Adenotonsillectomy Cohort II participants included children (ages 3-12 years) scheduled for adenotonsillectomy, for any clinical indication. At enrollment and again 7.2 ± 0.9 (SD) months later, children had polysomnography, a multiple sleep latency test, parent-completed behavioral rating scales, cognitive testing, and psychiatric evaluation. The RCREC were computed as previously described for delta, theta, alpha, sigma, and beta EEG frequency bands.

RESULTS

Participants included 133 children, 109 with OSA (apnea-hypopnea index [AHI] ≥ 1.5, mean 8.3 ± 10.6) and 24 without OSA (AHI 0.9 ± 0.3). At baseline, the arousal index and RCREC showed no consistent, significant associations with neurobehavioral morbidities, among all subjects or the 109 with OSA. At follow-up, the arousal index, RCREC, and neurobehavioral measures all tended to improve, but neither baseline measure of sleep fragmentation effectively predicted outcomes (all p > 0.05, with only scattered exceptions, among all subjects or those with OSA).

CONCLUSION

Sleep fragmentation, as reflected by standard arousals or by RCREC, appears unlikely to explain neurobehavioral morbidity among children who undergo adenotonsillectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT00233194.

Periodic leg movements during sleep in children scheduled for adenotonsillectomy: frequency, persistence, and impact

OBJECTIVE

The aim of this study was to assess the frequency and potential clinical impact of periodic leg movements during sleep (PLMS), with or without arousals, as recorded incidentally from children before and after adenotonsillectomy (AT).

METHODS

Children scheduled for AT for any clinical indications who participated in the Washtenaw County Adenotonsillectomy Cohort II were studied at enrollment and again 6 months thereafter. Assessments included laboratory-based polysomnography, a Multiple Sleep Latency Test (MSLT), parent-completed behavioral rating scales, neuropsychological testing, and psychiatric evaluation.

RESULTS

Participants included 144 children (81 boys) aged 3-12 years. Children generally showed mild to moderate obstructive sleep apnea (median respiratory disturbance index 4.5 (Q1 = 2.0, Q3 = 9.5)) at baseline, and 15 subjects (10%) had at least five periodic leg movements per hour of sleep (PLMI ≥ 5). After surgery, 21 (15%) of n = 137 subjects who had follow-up studies showed PLMI ≥ 5 (p = 0.0067). Improvements were noted after surgery in the respiratory disturbance index; insomnia symptoms; sleepiness symptoms; mean sleep latencies; hyperactive behavior; memory, learning, attention, and executive functioning on NEPSY assessments; and frequency of attention-deficit/hyperactivity disorder (DSM-IV criteria). However, PLMI ≥ 5 failed to show associations with worse morbidity in these domains at baseline or follow-up. New appearance of PLMI ≥ 5 after surgery failed to predict worsening of these morbidities (all p > 0.05), with only one exception (NEPSY) where the magnitude of association was nonetheless negligible. Similar findings emerged for periodic leg movements with arousals (PLMAI ≥ 1).

CONCLUSION

PLMS, with and without arousals, become more common after AT in children. However, results in this setting did not suggest substantial clinical impact.

Neurobehavioural correlates in older children and adolescents with obesity and obstructive sleep apnoea

AIM

The relationship between obstructive sleep apnoea (OSA) and poorer neurobehavioural outcomes in school-age children is well established, but the relationship in obese children and adolescents, in whom OSA is more common, is not so well established. We aimed to investigate this relationship in 10-18-year-olds.

METHODS

Thirty-one participants with a mean body mass index (BMI) of 32.3 ± 4.9 enrolled. BMI-for-age cut-offs were used to define obesity. Participants underwent polysomnography and were classified into OSA (apnoea-hypopnoea index (AHI) > 2 per hour) and non-OSA (AHI ≤ 2) groups. Intelligence, memory and learning, academic achievement, behaviour and executive functioning were assessed using the Wechsler Abbreviated Scale of Intelligence, Wide Range Assessment of Memory and Learning 2, Wechsler Individual Achievement Test II (WIAT-II), Behavioural Assessment System for Children 2 and Behaviour Rating Inventory of Executive Function, respectively.

RESULTS

Forty-eight per cent (15/31) were classified as having OSA, and 52% (16/31) as non-OSA. The obese cohort performed below the average of normative data on several neurobehavioural measures. WIAT-II maths scores were significantly lower (P = 0.034) in the OSA group than in the non-OSA group (means 84.5 vs. 94.6, respectively), losing significance after adjustment for IQ, age and gender. Self-reported school problems were significantly worse in the OSA group before and after multivariate adjustment (P = 0.010, Cohen's d = 1.02). No other significant differences were found.

CONCLUSIONS

Results suggest that OSA may increase risk for some poorer educational and behavioural outcomes. The findings are reasonably consistent with and add to the evidence base of the few studies that have explored this relationship.

Pediatric polysomnography for sleep-disordered breathing prior to tonsillectomy: a guideline review

Snoring and other signs of sleep-disordered breathing (SDB) represent a common management challenge for the pediatrician, pulmonologist, anesthesiologist, and otolaryngologist. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery published a clinical practice guideline for the treatment of patients with SDB. This guideline provides indications for polysomnography use in patients with SDB. In this article, we discuss the management of SDB in pediatric patients, which relies on the accurate assessment of symptoms of SDB, identification of comorbidities known to increase the severity of SDB, and appropriate preoperative assessment of the patient.

Cesarean section and the risk of overweight in grade 6 children

We examined the relationship between cesarean section (C-section) and the risk of overweight and obesity in children in grade 6 (mean age, 11.92 years; standard deviation = 0.34). Data from phase I through phase III of the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development were used. Children with complete data from 1991 through 2004 were included in this study (n = 917). Multiple logistic regression analyses were used to adjust for potential confounding and to evaluate the association of C-section and childhood overweight and obesity. Compared to children delivered vaginally, children delivered by C-section had approximately twice the likelihood of being overweight (odds ratio (OR) = 1.86, 95 % confidence interval (CI) = 1.27-2.73) or obese (OR = 1.87, 95 % CI = 1.19-2.95). However, when examined according to sex, males delivered by C-section had an increased risk for being overweight (OR = 1.78, 95 % CI = 1.01-3.12) and obese (OR = 2.58, 95 % CI = 1.36-4.88), while females had an increased risk only for being overweight (OR = 1.99, 95 % CI = 1.17-3.39).

CONCLUSION

C-section was associated with an increased risk of overweight and obesity in children in grade 6, but the relationship differed according to gender. Further longitudinal studies are warranted to examine the long-term effect of delivery mode on the risk of childhood overweight.

Neurophysiological Basis of Sleep's Function on Memory and Cognition

A wealth of recent studies support a function of sleep on memory and cognitive processing. At a physiological level, sleep supports memory in a number of ways including neural replay and enhanced plasticity in the context of reduced ongoing input. This paper presents behavioral evidence for sleep's role in selective remembering and forgetting of declarative memories, in generalization of these memories, and in motor skill consolidation. Recent physiological data reviewed suggests how these behavioral changes might be supported by sleep. Importantly, in reviewing these findings, an integrated view of how distinct sleep stages uniquely contribute to memory processing emerges. This model will be useful in developing future behavioral and physiological studies to test predictions that emerge.

Esophageal pressures, polysomnography, and neurobehavioral outcomes of adenotonsillectomy in children

BACKGROUND

Esophageal pressure monitoring during polysomnography in children offers a gold-standard, “preferred” assessment for work of breathing, but is not commonly used in part because prospective data on incremental clinical utility are scarce. We compared a standard pediatric apnea/hypopnea index to quantitative esophageal pressures as predictors of apnea-related neurobehavioral morbidity and treatment response.

METHODS

Eighty-one children aged 7.8 ± 2.8 (SD) years, including 44 boys, had traditional laboratory-based pediatric polysomnography, esophageal pressure monitoring, multiple sleep latency tests, psychiatric evaluations, parental behavior rating scales, and cognitive testing, all just before clinically indicated adenotonsillectomy, and again 7.2 ± 0.8 months later. Esophageal pressures were used, along with nasal pressure monitoring and oronasal thermocouples, not only to identify respiratory events but also more quantitatively to determine the most negative esophageal pressure recorded and the percentage of sleep time spent with pressures lower than -10 cm H(2)O.

RESULTS

Both sleep-disordered breathing and neurobehavioral measures improved after surgery. At baseline, one or both quantitative esophageal pressure measures predicted a disruptive behavior disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined attention-deficit/hyperactivity disorder, conduct disorder, or oppositional defiant disorder) and more sleepiness and their future improvement after adenotonsillectomy (each P < .05). The pediatric apnea/hypopnea index did not predict these morbidities or treatment outcomes (each P > .10). The addition of respiratory effort-related arousals to the apnea/hypopnea index did not improve its predictive value. Neither the preoperative apnea/hypopnea index nor esophageal pressures predicted baseline hyperactive behavior, cognitive performance, or their improvement after surgery.

CONCLUSIONS

Quantitative esophageal pressure monitoring may add predictive value for some, if not all, neurobehavioral outcomes of sleep-disordered breathing.

Airway considerations in craniofacial patients

Children with syndromic craniosynostosis have an increased risk of airway obstruction. Addressing this issue early in their clinical course helps ensure a safe result. Because of their abnormal airways and a higher risk of sleep-related breathing disorders, regular evaluation of the airway is recommended. An algorithm for evaluation, including sleep study, and management of such children is proposed. Patients with abnormal sleep studies should undergo endoscopy (nasendoscopy or flexible fiberoptic bronchoscopy) to determine the site of the obstruction and then adenotonsillectomy when appropriate. Continuous positive airway pressure, nasopharyngeal airways, or surgery, including osteotomy or even tracheostomy, may be necessary. Regular evaluation of the airway is critical, because the airway status may improve or worsen with growth of the child. Finally, ongoing communication with the craniofacial team allows planning of various procedures in the individual patient with optimal management of the airway.

Eat, play, love: adolescent and parent perceptions of the components of a multidisciplinary weight management program

BACKGROUND

Participants' perceptions may be associated with the high attrition rates reported by weight management programs.

OBJECTIVE

To explore participants' perceptions of a weight management program.

METHODS

Semistructured interviews were performed (spring 2010) with past participants of the Michigan Pediatric Outpatient Weight Evaluation and Reduction program. Transcripts were reviewed and themes identified.

RESULTS

Parents (38) and adolescents (25) were interviewed separately; similar themes emerged. Theme 1: Support/encouragement-Participants emphasized the importance of a supportive environment with a positive, compassionate approach from providers. Theme 2: Exercise-Fun, achievable activities were a valued means of making exercise enjoyable and building self-efficacy. Theme 3: Nutrition-Hands on demonstrations and tangible suggestions were preferred over activities such as self-monitoring. Theme 4: Behavioral factors-Participants valued the opportunity to hear their peers' experiences. However, individual/family sessions addressing their personal concerns were also viewed as important.

CONCLUSION

Beyond program content, participants valued a supportive environment emphasizing health over habitus.

Differential effects of sleep disordered breathing on polysomnographic characteristics in preschool and school aged children

OBJECTIVE

Childhood sleep disordered breathing (SDB) peaks in the preschool years. We aimed to compare the effects of SDB on polysomnographic characteristics between preschool and school aged children.

PARTICIPANTS AND METHODS

One hundred and fifty-two preschool (3-5 y) and 105 school-aged (7-12 y) children, referred for assessment of SDB, plus controls (39, 3-5 y and 34, 7-12 y) with no history of snoring underwent overnight polysomnography. Subjects were grouped by their obstructive apnea hypopnea index (AHI) into those with primary snoring, mild obstructive sleep apnea (OSA), and moderate/severe OSA. The effects of SDB severity on sleep architecture and respiratory characteristics were compared between the age cohorts using quantile regression.

RESULTS

There was an average reduction in median sleep efficiency of 3.5% (p=0.004) and an average increase in median WASO of 2% (p=0.08) between the age cohorts across the severity groups, with sleep efficiency falling and WASO increasing with increasing SDB severity in the school-aged, but not the preschool, cohort. There was an average difference in median central AHI of 0.6 events/h (p<0.001) between the age cohorts across the severity groups, with the 3-5 y old cohort but not the 7-12 y old cohort having more central apneas with increasing SDB severity.

CONCLUSIONS

We have demonstrated clinically important, age-related differences in sleep architecture in children with SDB. Preschool children with SDB maintain sleep efficiency and awaken fewer times throughout the night than do school aged children with a comparable severity of SDB, but experience more central apneas. This may have implications for the outcomes and treatment of SDB in children of different ages.

Relationships among obstructive sleep apnea, anthropometric measures, and neurocognitive functioning in adolescents with severe obesity

OBJECTIVE

To explore associations between measures of obstructive sleep apnea (OSA) and sleep quality, anthropometrics, and neurocognitive functioning in severely obese adolescents.

STUDY DESIGN

This was a cross-sectional pilot study performed at an academic medical center in 37 severely obese (body mass index [BMI] >97th percentile) adolescents. Study evaluations included polysomnography, BMI, waist circumference, and standardized neurocognitive tests to assess memory, executive functioning, psychomotor efficiency, academic achievement, and an approximation of full-scale IQ. Outcome data were evaluated categorically, based on clinical criteria for the diagnosis of OSA, and continuously to quantify associations between sleep parameters, anthropometrics, and neurocognitive test results.

RESULTS

Sleep fragmentation and poorer sleep quality were associated with reduced psychomotor efficiency, poorer memory recall, and lower scores on standardized academic tests. Having evidence of OSA was associated with lower math scores, but not with other neurocognitive measures. BMI and waist circumference were negatively associated with oxygen saturation.

CONCLUSION

Our pilot study findings suggest that sleep fragmentation and poorer sleep quality have implications for neurocognitive functioning in obese adolescents. The epidemic of childhood obesity has dire implications, not only for increasing cardiometabolic pathology, but also for possibly promoting less readily apparent neurologic alterations associated with poor sleep quality.

[Childhood obesity and sleep-related breathing disorders]

INTRODUCTION

The increasing prevalence of childhood obesity leads to an increase risk of sleep-disordered breathing and may exacerbate their comorbidities.

PURPOSE

To assess the rate of obesity in children with sleep-disordered breathing and to study the possible clinical and epidemiological differences between children with and without overweight in a private hospital in the Mediterranean area.

MATERIALS AND METHODS

We prospectively studied 340 children between 2 and 10 years. There were 170 children with sleep-disordered breathing (study group) and 170 healthy children (control group). In the problem group, the apnea-hypopnea index was around 7.61 ± 6.3.

RESULTS

The comparison of the percentage of cases with a BMI percentile ≥85 (overweight) between problem and control groups (44: 25.9% vs 34: 20%) or with a BMI ≥95 (obesity) (30: 17.6% vs 20: 11.8%) showed no statistically-significant differences. In addition, the comparison of clinical and epidemiological variables in the problem group, cases with (44/170: 25.9%) and without (126/170: 74.1%) overweight, did not show significant differences in any of the parameters analysed.

CONCLUSION

In the population studied, it does not appear that the group of children with sleep breathing disorders presents higher rates of obesity, nor does obesity influence its presentation clinically. These results had probably been influenced by the characteristics of the studied population and therefore should not be an obstacle for being attentive to the possible association of respiratory disease to obesity and its negative consequences.

[Epidemiology. Risk factors and genetic influence]

Epidemiological studies of sleep-disordered breathing in broad population samples are scarce. Nevertheless, currently available data indicate that habitual snoring is present in 7.45 % (95 % CI: 5.75-9.61) of the child population. Approximately 10 % of habitual snorers develop sleep apnea. However, in children with associated comorbidity (obesity, asthma…) or clinical symptoms of sleep-disordered breathing, the association between snoring and sleep apnea is significantly increased. The prevalence of sleep apnea according to parents' or guardians' observation of apnea episodes is 0.2-4 %. When the diagnosis is based on questionnaires administered directly to parents, the prevalence increases to 4-11 %. If diagnosis is made by objective means, the prevalence ranges from 1-4 %. Obesity is currently a major risk factor. In obese children, the prevalence of sleep apnea oscillates between 4.69 % and 6.6 % and consequently screening of sleep-disordered breathing in obese patients with or without suggestive symptoms should be routine. Genetic factors strongly influence sleep-disordered breathing and seem to account for 35-40 % of the variance in this disorder, although their precise role has yet to be clarified. Genetic study opens up an important gateway in the future medical approach to sleep-disordered breathing.

Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children

OBJECTIVE

This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders.

PURPOSE

There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology--Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

RESULTS

The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.