1
|
Worldwide prevalence and associated risk factors of obstructive sleep apnea: a meta-analysis and meta-regression. Sleep Breath 2023; 27:2083-2109. [PMID: 36971971 DOI: 10.1007/s11325-023-02810-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE This study aimed to identify the prevalence of obstructive sleep apnea (OSA) and associated risk factors globally. METHODS Six databases and registrations and three grey databases were explored for observational field research. Independently and impartially paired reviewers selected research, gathered data, and evaluated the methodological quality. Heterogeneity was investigated using subgroup analysis and meta-regression following the moderating variable in a meta-analysis of proportions with a random-effects model. The critical appraisal instrument developed by the Joanna Briggs Institute was used to evaluate the listed studies' methodology. The certainty of the evidence was evaluated using the GRADE tool. RESULTS A total of 8236 articles were collected during the database search, resulting in 99 articles included for qualitative synthesis, and 98 articles were included for the meta-analysis. The estimated combined prevalence of OSA was 54% [CI 95% = 46-62%; I2 = 100%]. Mean age, percentage of moderate-severe cases, and the sample's body mass index (BMI) did not affect the heterogeneity that was already present when meta-regressed (p > 0.05). Ninety-one studies were deemed to have a low risk of bias, while eight were deemed to have a moderate risk. For OSA prevalence outcomes, the GRADE criteria were considered very low. CONCLUSION Approximately half of the people worldwide have OSA. High BMI, increasing age, and male gender are described as risk factors in the literature, but these covariates do not affect pre-existing heterogeneity.
Collapse
|
2
|
Use of pulse oximetry as an investigative test for paediatric respiratory sleep disorders. Arch Dis Child Educ Pract Ed 2023; 108:429-438. [PMID: 37280089 DOI: 10.1136/archdischild-2022-324846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 06/08/2023]
Abstract
The article covers the following elements: practical and technological considerations for optimising data collection and output; reference ranges for oximetry parameters across the ages; things to consider when interpreting a pulse oximetry study (eg, sleep/wake times); the ability of pulse oximetry to predict obstructive sleep apnoea; using oximetry as a screening tool for sleep disordered breathing in children with Down syndrome; things to consider when setting up a home oximetry service; and a case of an infant being weaned from oxygen using pulse oximetry studies.
Collapse
|
3
|
Allergic rhinitis and sleep disorders in children - coexistence and reciprocal interactions. J Pediatr (Rio J) 2022; 98:444-454. [PMID: 34979134 PMCID: PMC9510807 DOI: 10.1016/j.jped.2021.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To review, critically analyze and synthesize knowledge from the international literature regarding the association between allergic rhinitis (AR) and sleep disorders, the impact of AR treatment on children's sleep, and lay the foundation for future research on this topic. SOURCE OF DATA A literature search using PubMed database including original and review articles, systematic reviews and meta-analyses using keywords related to AR, sleep disorders and sleep-disordered breathing. SYNTHESIS OF DATA Sleep is fundamental to health, and its assessment and control of conditions that trigger or aggravate disturbances are of the uttermost importance. Allergic rhinitis (AR) is common in children and may interfere with both their quality of life and quality of sleep. It has emerged as one of the most important risk factors for habitual snoring in children and appeared to increase the risk of Obstructive Sleep Apnea (OSA), with AR severity exhibiting a significant and independent association with pediatric OSA severity. However, in some studies, those associations between AR and OSA in children are not very consistent. CONCLUSIONS A substantial level of controversy exists regarding the interactions between AR and OSA in children. Notwithstanding, identifying and treating AR in clinical settings is probably an important step toward improving symptoms and preventing deterioration of sleep quality in children and may improve the severity of underlying OSA. Considering the high prevalence, morbidity, economic and social implications of both AR and sleep problems, it is crucial that healthcare providers improve their understanding of the relationships between those conditions among children.
Collapse
|
4
|
Observational study to define reference ranges for the 3% oxygen desaturation index during sleep in healthy children under 12 years using oximetry motion-resistant technology. Arch Dis Child 2021; 106:583-586. [PMID: 33082136 DOI: 10.1136/archdischild-2020-320066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/26/2020] [Accepted: 09/22/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To define reference ranges for the 3% oxygen desaturation index (DI3) in healthy children under 12 years old during sleep. DESIGN Observational. SETTING Home. SUBJECTS Healthy children aged 6 months to 12 years of age. INTERVENTION Nocturnal pulse oximetry at home. Parents documented sleep times. Visi-Download software (Stowood Scientific) analysed data with artefact and wake periods removed. MAIN OUTCOME MEASURES The following oximetry parameters used in the assessment of sleep-disordered breathing conditions were measured: 3% (DI3) and 4% (DI4) oxygen desaturation indices-the number of times per hour where the oxygen saturation falls by at least 3% or 4% from baseline, mean saturations (SAT50), minimum saturations (SATmin), delta index 12 s (DI12s), and percentage time with saturations below 92% and 90%. RESULTS Seventy-nine children underwent nocturnal home pulse oximetry, from which there were 66 studies suitable for analysis. The median values for DI3 and DI4 were 2.58 (95% CI 1.96 to 3.10) and 0.92 (95% CI 0.73 to 1.15), respectively. The 95th and 97.5th centiles for DI3 were 6.43 and 7.06, respectively, which inform our cut-off value for normality. The mean values for SAT50 and SATmin were 97.57% (95% CI 97.38% to 97.76%) and 91.09% (95% CI 90.32% to 91.86%), respectively. CONCLUSION In children aged 6 months to 12 years, we define normality of the 3% oxygen desaturation index as <7 using standalone, motion-resistant pulse oximeters with short averaging times.
Collapse
|
5
|
Obstructive Sleep Apnoea Contributes to Executive Function Impairment in Young Children with Down Syndrome. Behav Sleep Med 2020; 18:611-621. [PMID: 31311334 DOI: 10.1080/15402002.2019.1641501] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE/BACKGROUND Children with Down syndrome (DS) commonly experience difficulties with executive function (EF). They are also vulnerable to obstructive sleep apnoea (OSA). OSA is associated with EF deficits in typically developing children. A recent study reported an association between OSA and cognitive deficits in 38 school-aged children with DS. We experimentally investigated EF behaviours in young children with DS, and their association with OSA. PARTICIPANTS AND METHODS Children with DS were recruited to take part in a larger study of OSA (N = 202). Parents of 80 children (50 male) aged 36 to 71 months (M = 56.90, SD = 10.19 months) completed the Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P). Of these 80 children, 69 were also successfully studied overnight with domiciliary cardiorespiratory polygraphy to diagnose OSA. RESULTS Obstructive apnoea/hypopnoea index was in the normal range (0-1.49/h) for 28 children but indicated OSA (≥1.5/h) in 41 children. Consistent with previous research, we found a large effect for children experiencing particular weaknesses in working memory, planning and organising, whilst emotional control was a relative strength. OSA was associated with poorer working memory (β = .23, R2 = .05, p = .025), emotional control (β = .20, R2 = .04, p = .047) and shifting (β = .24, R2 = .06, p = .023). CONCLUSIONS Findings suggest that known EF difficulties in DS are already evident at this young age. Children with DS already have limited cognitive reserve and can ill afford additional EF deficit associated with OSA. OSA is amenable to treatment and should be actively treated in these children to promote optimal cognitive development.
Collapse
|
6
|
Diagnostic meta-analysis of the Pediatric Sleep Questionnaire, OSA-18, and pulse oximetry in detecting pediatric obstructive sleep apnea syndrome. Sleep Med Rev 2020; 54:101355. [PMID: 32750654 DOI: 10.1016/j.smrv.2020.101355] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/12/2020] [Accepted: 05/06/2020] [Indexed: 11/27/2022]
Abstract
The aim of this meta-analysis was to compare the pooled sensitivity and specificity of the Pediatric Sleep Questionnaire (PSQ), Obstructive Sleep Apnea Questionnaire (OSA-18), and pulse oximetry (PO) according to OSAS severity. Three electronic databases were searched for studies evaluating sensitivity and specificity of the three tools against the apnea-hypopnea index measured using overnight in-laboratory or in-home polysomnography in children and adolescents from inception until January 11, 2020. A random-effects bivariate model was used to estimate the summary sensitivity and specificity of the tools. We identified 39 studies involving 6131 clinical and community children (aged 2.9-16.7 y). The PSQ exhibited the highest sensitivity (74%) for detecting symptoms of mild pediatric OSAS. The PSQ and PO had comparable sensitivity in screening moderate and severe pediatric OSAS (0.82 and 0.89 vs 0.83 and 0.83, respectively). PO yielded superior specificity in detecting mild, moderate, and severe pediatric OSAS (86%, 75%, and 83%, respectively) than did the PSQ and OSA-18 (all p < 0.05). Age, percentage of girls, index test criteria, methodology quality, and sample size significantly moderated sensitivity and specificity. For early detection of pediatric OSAS, the combined use of PSQ and PO is recommended when polysomnography is not available. PROSPERO REGISTRATION NUMBER: CRD42018090571.
Collapse
|
7
|
STOP-Bang questionnaire should be used in all adults with Down Syndrome to screen for moderate to severe obstructive sleep apnea. PLoS One 2020; 15:e0232596. [PMID: 32384092 PMCID: PMC7209101 DOI: 10.1371/journal.pone.0232596] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 04/18/2020] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVES To determine the prevalence of obstructive sleep apnea (OSA) in adults with Down syndrome (DS), to investigate factors related to OSA severity and to identify which sleep questionnaire is the most appropriate for the screening of OSA in this population. METHODS Cross-sectional study that consecutively included 60 adults with DS. All patients underwent type III polysomnography and clinical and laboratory data were collected; sleep assessment questionnaires were applied. Multiple linear regression models evaluated the associations between OSA severity (measured by the respiratory event index-REI) and clinical and laboratory data and sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, BERLIN and STOP-Bang questionnaires). RESULTS Results show that 60 (100%) adults with DS had OSA, with moderate-severe OSA identified in 49 (81.6%). At the multivariate linear regression, REI significantly correlated with hematocrit levels, BMI and STOP-Bang questionnaire (SBQ) results (P <0.001). The positive STOP-Bang ≥3 points) showed 100% of sensitivity (95%CI: 92.75-100%), 45.45% of specificity (95%CI: 16.75-76.62), positive predictive value of 89.09% (95%CI: 82.64-93.34%), negative predictive value of 100%, accuracy of 90% (95%CI: 79.49-96.24%) and OR of 24.29. CONCLUSIONS Adults with DS have a very high prevalence of OSA. Hematocrit levels, BMI and SBQ showed a strong correlation with OSA severity. The SBQ performed well in identifying moderate to severe OSA in this population. Considered together, these results point to the need to perform OSA screening in all adults with DS, and STOP-Bang may play a role in this screening.
Collapse
|
8
|
Parent report of children's sleep disordered breathing symptoms and limited academic progress in reading, writing, and math. Sleep Med 2019; 65:105-112. [PMID: 31739228 DOI: 10.1016/j.sleep.2019.07.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/13/2019] [Accepted: 07/13/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To estimate via questionnaire within a population sample of New Zealand (NZ) children aged 6-to-10 years, the prevalence of sleep disordered breathing (SDB) and those struggling academically, and to identify individual and shared risk factors (health and demographic) for parent-reported SDB symptoms and academic difficulties. METHODS In this cross-sectional study, parents/caregivers of children were recruited through schools and social media to complete an online questionnaire covering health and demographic factors, their children's SDB symptoms (Pediatric Sleep Questionnaire; PSQ) and parental ratings of academic performance based on teacher feedback relative to expected progress in the national curriculum (well below/below/at/above) in reading, writing, and math. RESULTS A total of 1205 children (53% male) aged (mean) eight years two months were included, comprising 79.4% NZ European/other and 15.0% Māori. The survey-weighted prevalence of SDB (based on the PSQ) was 17.5%. This was higher amongst those with academic difficulties rated 'below/well below' expected progress for reading, writing and math (estimated at 24.0%, 31.0% and 27.5% respectively), with increased odds (adjusted odds ratios) for poor progress of 1.9 (95% CI: 1.2, 3.0), 1.8 (95% CI: 1.2, 2.7) and 2.4 (95% CI: 1.6, 3.7) respectively. There were no shared risk factors common to both SDB and academic difficulties identified from multivariate analyses. CONCLUSIONS The findings suggest that children with parent-reported SDB symptoms may be at high risk for poor progress in reading, writing, and math. Future research could examine whether treatment of SDB reduces barriers to learning and offsets educational risk.
Collapse
|
9
|
Cardiorespiratory sleep studies at home: experience in research and clinical cohorts. Arch Dis Child 2019; 104:476-481. [PMID: 30455364 DOI: 10.1136/archdischild-2018-315676] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/17/2018] [Accepted: 10/24/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the success rates of home cardiorespiratory polygraphy in children under investigation for sleep-disordered breathing and parent perspectives on equipment use at home. DESIGN Prospective observational study. SETTING Sheffield, Evelina London and Southampton Children's Hospitals. PATIENTS Data are reported for 194 research participants with Down syndrome, aged 0.5-5.9 years across the three centres and 61 clinical patients aged 0.4-19.5 years from one centre, all of whom had home cardiorespiratory polygraphy including respiratory movements, nasal pressure flow, pulse oximetry, body position and motion. MAIN OUTCOME MEASURES Percentage of home cardiorespiratory studies successfully acquiring ≥4 hours of artefact-free data at the first attempt. Parental report of ease of use of equipment and preparedness to repeat home diagnostics in the future. RESULTS 143/194 (74%; 95% CI 67% to 79%) of research participants and 50/61 (82%; 95% CI 71% to 90%) of clinical patients had successful home cardiorespiratory polygraphy at the first attempt. Some children required multiple attempts to achieve a successful study. Overall, this equated to 1.3 studies per research participant and 1.2 studies per clinical child. The median artefact-free sleep time for successful research studies was 515 min (range 261-673) and for clinical studies 442 min (range 291-583). 84% of research and 87% of clinical parents expressed willingness to repeat home cardiorespiratory polygraphy in the future. 67% of research parents found the equipment 'easy or okay' to use, while 64% of clinical parents reported it as 'easy' or 'very easy'. CONCLUSIONS Home cardiorespiratory polygraphy offers an acceptable approach to the assessment of sleep-disordered breathing in children.
Collapse
|
10
|
Home oximetry to screen for obstructive sleep apnoea in Down syndrome. Arch Dis Child 2018; 103:962-967. [PMID: 29760010 DOI: 10.1136/archdischild-2017-314409] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/01/2018] [Accepted: 04/03/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Children with Down syndrome are at high risk of obstructive sleep apnoea (OSA) and screening is recommended. Diagnosis of OSA should be confirmed with multichannel sleep studies. We aimed to determine whether home pulse oximetry (HPO) discriminates children at high risk of OSA, who need further diagnostic multichannel sleep studies. DESIGN Cross-sectional prospective study in a training sample recruited through three UK centres. Validation sample used single-centre retrospective analysis of clinical data. PATIENTS Children with Down syndrome aged 0.5-6 years. INTERVENTION Diagnostic multichannel sleep study and HPO. MAIN OUTCOME MEASURES Sensitivity and specificity of HPO to predict moderate-to-severe OSA. RESULTS 161/202 children with Down syndrome met quality criteria for inclusion and 25 had OSA. In this training sample, the best HPO parameter predictors of OSA were the delta 12 s index >0.555 (sensitivity 92%, specificity 65%) and 3% oxyhaemoglobin (SpO2) desaturation index (3% ODI)>6.15 dips/hour (sensitivity 92%, specificity 63%). Combining variables (delta 12 s index, 3% ODI, mean and minimum SpO2) achieved sensitivity of 96% but reduced specificity to 52%. All predictors retained or improved sensitivity in a clinical validation sample of 50 children with variable loss of specificity, best overall was the delta 12 s index, a measure of baseline SpO2 variability (sensitivity 92%; specificity 63%). CONCLUSIONS HPO screening could halve the number of children with Down syndrome needing multichannel sleep studies and reduce the burden on children, families and health services alike. This approach offers a practical universal screening approach for OSA in Down syndrome that is accessible to the non-specialist paediatrician.
Collapse
|
11
|
A cohort study reporting normal oximetry values in healthy infants under 4 months of age using Masimo technology. Arch Dis Child 2018; 103:868-872. [PMID: 29574409 DOI: 10.1136/archdischild-2017-314361] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/06/2018] [Accepted: 02/25/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine sleeping saturation indices in healthy infants using a modern pulse oximeter with motion artefact extraction technology. DESIGN Prospective cohort. SETTING Home. SUBJECTS Healthy term infants. INTERVENTION Nocturnal pulse oximetry at home at 1 month of age (Recording 1) and repeated at age 3-4 months (Recording 2). Parents documented sleep times. Visi-Download software (Stowood Scientific) analysed data with artefact and wake periods removed. MAIN OUTCOME MEASURES Saturations (SAT50), desaturation index >4% (DI4) and >3% (DI3) from baseline/hour, delta index 12 s (DI12s), minimum saturations (SATmin), percentage time with saturations below 90% and 92%. RESULTS Forty-five babies were studied at 1 month and 38 babies at 3-4 months. Mean (CI) SAT50, DI4, DI3, DI12s and SATmin (CI) were 97.05 (96.59 to 97.52), 16.16 (13.72 to 18.59), 25.41 (22.00 to 28.82), 0.96 (0.88 to 1.04) and 80.4% (78.8% to 82.0%) at 1 month, respectively, and 97.65 (97.19 to 98.12), 8.12 (6.46 to 9.77), 13.92 (11.38 to 16.47), 0.72 (0.65 to 0.78) and 84.7% (83.3% to 86.1%) at 3-4 months. Median (CI) percentage times with saturations below 90% and 92% were 0.39 (0.26 to 0.55) and 0.82 (0.60 to 1.23), respectively, at 1 month and 0.11 (0.06 to 0.20) and 0.25 (0.17 to 0.44) at 3-4 months. For paired samples (n=32) DI4 (P=0.006), DI3 (P=0.03), DI12s (P=0.001), percentage time with saturations below 90% (P=0.001) and 92% (P=0.000) all fell significantly and SATmin (P=0.004) rose between the two recordings. CONCLUSION Desaturation indices are substantially higher in young infants than older children where a DI4 over 4 is considered abnormal. These decrease by 3-4 months of age but still remain elevated compared with older children.
Collapse
|
12
|
[Exercise capacity in children with mild sleep-disordered breathing]. Rev Mal Respir 2018; 35:708-715. [PMID: 30107963 DOI: 10.1016/j.rmr.2017.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/12/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION While the association between sleep-disordered breathing (SDB) and low physical activity has been reported in children, little information is available on the impact of SDB on exercise capacity. The aim of this study was to assess exercise capacity in children with SDB in order to estimate the relevance of exercise training intervention. METHODS Twelve young patients with suspected SDB matched with 11 presumably healthy subjects of same age range (aged 13±0.5yr) were investigated. Both groups underwent physical activity assessment, full night polysomnography, incremental and all-out exercise tests. RESULTS The respiratory disturbance index was higher in the patient group (4.6±4.7 vs 0.8±0.6; P=0.02). Children with SDB had lower VO2max (32.0±9.9 vs 42.3±5.7mL.kg-1.min-1, P=0.007) and lower peak power (8.6±3.4 vs 11.8±1.9W.kg-1, P=0.009). A significant correlation between VO2max and weekly physical activity only was found in the SDB group (P=0.005). CONCLUSION Mild SDB may be associated with impairment of both aerobic and anaerobic exercise capacity in children, related to poor physical activity. Exercise training could bring clinical benefit in this population.
Collapse
|
13
|
Gender dimorphism in pediatric OSA: Is it for real? Respir Physiol Neurobiol 2017; 245:83-88. [DOI: 10.1016/j.resp.2016.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 11/19/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
|
14
|
Sleep-disordered breathing and cognitive functioning in preschool children with and without Down syndrome. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2017; 61:778-791. [PMID: 28612424 DOI: 10.1111/jir.12387] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/28/2017] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Sleep affects children's cognitive development, preparedness for school and future academic outcomes. People with Down syndrome (DS) are particularly at risk for sleep-disordered breathing (SDB). To our knowledge, the association between SDB and cognition in preschoolers with DS is unknown. METHODS We assessed sleep by using cardiorespiratory polygraphy in 22 typically developing (TD) preschoolers and 22 with DS. Cognition was assessed by using the Mullen Scales of Early Learning and behaviour by using the Strengths and Difficulties Questionnaire (SDQ). The MacArthur Communicative Development Inventory (MCDI) measured language level. We predicted that sleep problems would be associated with lower cognitive and behavioural functioning. RESULTS In TD children, longer sleep duration was associated with higher scores on MCDI expressive language and fewer emotional symptoms such as fear and unhappiness on the SDQ, whilst SDB was associated with increased conduct problems and less prosocial behaviour on the SDQ. Conversely, for children with DS, SDB was associated with increased language understanding and use of actions and gestures on the MCDI. CONCLUSIONS The findings in the TD group support our hypotheses. We recommend that sleep problems are screened for and treated as even mild SDB may prompt poorer cognition and behaviour. For children with DS, we expect that multiple factors in this complex syndrome mask or mediate the association between sleep and cognitive development and tighter controls are necessary to uncover effects of sleep. We propose longitudinal studies as a necessary tool to assess the precise impact of sleep on cognitive development in accounting for individual differences in DS.
Collapse
|
15
|
Validation of the screening tool ApneaLink ® in comparison to polysomnography for the diagnosis of sleep-disordered breathing in children and adolescents. Sleep Med 2017; 37:13-18. [PMID: 28899523 DOI: 10.1016/j.sleep.2017.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/06/2017] [Accepted: 05/30/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE While out-of-center testing was introduced as an alternative for the diagnosis of obstructive sleep apnea in adults, polysomnography (PSG) is still considered mandatory in the diagnosis of sleep-disordered breathing (SDB) in children. The purpose of this study was to validate the outpatient screening device ApneaLink® in comparison to PSG in children and adolescents for the diagnosis of SDB. METHODS Sixty consecutive children and adolescents (10.4 ± 6.2, 0-22 years) with suspected SDB admitted to the sleep laboratory underwent simultaneous recording with full PSG and the screening device ApneaLink® based on flow measurement and oxygen saturation. RESULTS The mean apnea-hypopnea index (AHI) was 11.8 ± 19.7 in PSG and 10.3 ± 12.0 in ApneaLink®. When the AHI threshold was set to 5/h to diagnose SDB, the overall sensitivity for ApneaLink® was 79% and the specificity was 63%. After reducing the AHI threshold to 1/h, the sensitivity and specificity were 94% and 29%. In children older than 10 years, the performance of ApneaLink® improved (AHI 5/h: sensitivity 80%, specificity 64%; AHI 1/h: sensitivity 100%, specificity 50%). CONCLUSION These results show that the outpatient screening device ApneaLink® reliably identifies SDB in preselected children older than 10 years. In contrast, it may not be used for the exclusion of SDB.
Collapse
|
16
|
Das pädiatrische obstruktive Schlafapnoesyndrom. SOMNOLOGIE 2016. [DOI: 10.1007/s11818-016-0079-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
17
|
Prevalence and predictors of obstructive sleep apnoea in young children with Down syndrome. Sleep Med 2016; 27-28:99-106. [DOI: 10.1016/j.sleep.2016.10.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/06/2016] [Accepted: 10/08/2016] [Indexed: 11/20/2022]
|
18
|
Schlafbezogene Atmungsstörungen im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0176-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
19
|
The Importance of Sleep: Attentional Problems in School-Aged Children With Down Syndrome and Williams Syndrome. Behav Sleep Med 2016; 13:455-71. [PMID: 25127421 DOI: 10.1080/15402002.2014.940107] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In typically developing (TD) children, sleep problems have been associated with day-time attentional difficulties. Children with developmental disabilities often suffer with sleep and attention problems, yet their relationship is poorly understood. The present study investigated this association in school-aged children with Down syndrome (DS) and Williams syndrome (WS). Actigraphy and pulse oximetry assessed sleep and sleep-disordered breathing respectively, and attention was tested using a novel visual Continuous Performance Task (CPT).Attentional deficits were evident in both disorder groups. In the TD group, higher scores on the CPT were related to better sleep quality, higher oxyhemoglobin saturation (SpO2), and fewer desaturation events. Sleep quality, duration, and SpO2 variables were not related to CPT performance for children with DS and WS.
Collapse
|
20
|
Rationale, design and methods for the 22 year follow-up of the Western Australian Pregnancy Cohort (Raine) Study. BMC Public Health 2015; 15:663. [PMID: 26169918 PMCID: PMC4501054 DOI: 10.1186/s12889-015-1944-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/16/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Young adulthood is a critical life period for health and health behaviours. Related measurements collected before and after birth, and during childhood and adolescence can provide a life-course analysis of important factors that contribute to health and behaviour in young adulthood. The Western Australian Pregnancy Cohort (Raine) Study has collected a large number of such measurements during the fetal, perinatal, infancy, childhood and adolescence periods and plans to relate them to common health issues and behaviours in young adults, including spinal pain, asthma, sleep disorders, physical activity and sedentary behaviour and, work absenteeism and presenteeism. The aim of this paper is to describe the rationale, design and methods of the 22 year follow-up of the Raine Study cohort. METHODS/DESIGN The Raine Study is a prospective cohort study. Participants still active in the cohort (n = 2,086) were contacted around the time of their 22nd birthday and invited to participate in the 22 year follow-up. Each was asked to complete a questionnaire, attend a research facility for physical assessment and an overnight sleep study, wear activity monitors for a week, and to maintain a sleep and activity diary over this week. The questionnaire was broad and included questions related to sociodemographics, medical history, quality of life, psychological factors, lifestyle factors, spinal pain, respiratory, sleep, activity and work factors. Physical assessments included anthropometry, blood pressure, back muscle endurance, tissue sensitivity, lung function, airway reactivity, allergic status, 3D facial photographs, cognitive function, and overnight polysomnography. DISCUSSION Describing the prevalence of these health issues and behaviours in young adulthood will enable better recognition of the issues and planning of health care resources. Providing a detailed description of the phenotype of these issues will provide valuable information to help educate health professionals of the needs of young adults. Understanding the life-course risk factors of health issues and behaviours in young adulthood will have important health planning implications, supporting the development of targeted interventions to improve current health status and reduce the onset and development of further ill-health across adulthood.
Collapse
|
21
|
Predicting poor school performance in children suspected for sleep-disordered breathing. Sleep Med 2015; 16:1077-83. [PMID: 26298782 DOI: 10.1016/j.sleep.2015.03.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/27/2015] [Accepted: 03/30/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Habitually snoring children are at a greater risk of poor school performance (PSP). We investigated the ability of conventional sleep-disordered breathing (SDB) measures for predicting PSP in habitually snoring children. METHODS The dataset of Hannover Study on Sleep Apnea in Childhood (HASSAC), a large community-based study in primary school children, was retrospectively analyzed. All habitual snorers were included. Based on their grades, children were grouped into good and poor school performers. SDB measures obtained by a parental questionnaire, a home pulse oximetry, and a home polysomnography were evaluated for their accuracy in predicting poor school performance by calculating receiver operating characteristic curves and area under this curve (AUC). The most predictive single factors were identified and entered into a prediction model. RESULTS Of 114 habitual snorers (mean age 9.6 years, 51 boys), 59 had PSP. All investigated SDB measures showed low accuracy (ie, AUC <0.8). The highest AUC observed was 0.686 for a questionnaire score, 0.565 for an oximetry factor, and 0.624 for a polysomnography factor. Of 20 single significant predictors for PSP, five were selected for inclusion into a prediction model. The model reached an unadjusted AUC of 0.826 and an adjusted AUC of 0.851. CONCLUSIONS Conventional SDB measures obtained with questionnaire, oximetry, or polysomnography may not be sufficiently predictive of PSP in children suspected for SDB. However, combining factors in a clinical prediction model may improve prediction. Results of such a model may be used to assess the risk of developing neurocognitive impairment and to decide whether a child suspected for SDB might benefit from treatment.
Collapse
|
22
|
Diagnostic accuracy of the Spanish version of the Pediatric Sleep Questionnaire for screening of obstructive sleep apnea in habitually snoring children. Sleep Med 2015; 16:631-6. [DOI: 10.1016/j.sleep.2014.10.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/16/2014] [Accepted: 10/17/2014] [Indexed: 11/16/2022]
|
23
|
Effects of rapid maxillary expansion and mandibular advancement on upper airways in Marfan’s syndrome children: a home sleep study and cephalometric evaluation. Sleep Breath 2015; 19:1213-20. [DOI: 10.1007/s11325-015-1141-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/02/2014] [Accepted: 02/03/2015] [Indexed: 11/26/2022]
|
24
|
Former Preterm Infants, Caffeine Was Good for You, But Now Beware of Snoring! Am J Respir Crit Care Med 2014; 190:720-1. [DOI: 10.1164/rccm.201409-1588ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
25
|
Abstract
PURPOSE OF REVIEW An inconsistent link between sleep-disordered breathing (SDB) and allergic rhinitis has been reported in the literature for decades. This review attempts to highlight some of the recent epidemiological studies purporting and refuting this connection, discuss possible mechanisms for this relationship and discuss how treatment of allergic rhinitis can help ameliorate SDB. RECENT FINDINGS Recently, a large systematic review that included 18 studies and 27 000 individuals of the association between allergic rhinitis and SDB in children was published supporting a correlation between SDB and allergic rhinitis. SUMMARY Although the evidence generally supports a connection between SDB and allergic rhinitis, this connection is not definitive and the mechanism linking these two diseases remains poorly understood. In addition to epidemiological studies, several small studies have demonstrated an improvement in SDB upon treatment of allergic rhinitis; however, large studies using objective measures to quantify SDB and allergic rhinitis are needed.
Collapse
|
26
|
Feasibility of unattended home polysomnography in children with sleep-disordered breathing. Int J Pediatr Otorhinolaryngol 2013; 77:1960-4. [PMID: 24120158 DOI: 10.1016/j.ijporl.2013.09.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 09/13/2013] [Accepted: 09/16/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the technical feasibility of unattended polysomnography (HPSG) for diagnosis of obstructive sleep apnea (OSA) in children. METHODS A single-night HPSG was performed on children referred to the pediatric respiratory laboratory. Non-interpretable HPSGs were defined as: recordings with (i) loss of ≥2 of the following channels: nasal flow, or thoraco-abdominal belts, or (ii) HPSG with less than 4 h of artifact-free recording time or (iii) less than 4 h SpO2 signal. RESULTS Of n = 101 included HPSGs, n = 75 were ambulatory and n = 26 in hospitalized subjects. Median (minimum-maximum) age was 2.8 (0-15.4) years. Interpretable and technically acceptable recordings were obtained in 94 subjects (93%). Only 7 recordings (4 at home versus 3 in hospitalized subjects, p-value = 0.254) were classified as non-interpretable and had to be repeated. Artifact-free recording time was 461 (23-766)min. Complete artifact-free pulse oximetry signal was obtained in 14% of the included subjects. Neither age, gender, AHI, nor place of performance was significantly associated with the interpretability of recordings. DISCUSSION HPSG showed a high rate of interpretability and technical acceptance. The high technical feasibility obtained by HPSG may help to improve simple screening tests for OSA in children.
Collapse
|
27
|
Reference values for respiratory events in overnight polygraphy from infants aged 1 and 3months. Sleep Med 2013; 14:1323-7. [DOI: 10.1016/j.sleep.2013.07.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/06/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
|
28
|
Prevalence of obstructive sleep apnea syndrome in Japanese elementary school children aged 6–8 years. Sleep Breath 2013; 18:359-66. [DOI: 10.1007/s11325-013-0893-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/10/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022]
|
29
|
Evaluation of the Child with Sleep-Disordered Breathing Scheduled for Adenotonsillectomy. Sleep Med Clin 2013. [DOI: 10.1016/j.jsmc.2012.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
30
|
The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review. Int Forum Allergy Rhinol 2013; 3:504-9. [PMID: 23307785 DOI: 10.1002/alr.21123] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 10/11/2012] [Accepted: 10/16/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND The objective of this work was to systematically review existing literature on the association between allergic rhinitis (AR) and sleep-disordered breathing (SDB) in children. METHODS We performed a literature search encompassing the last 25 years in PubMed, EMBASE, and Cochrane CENTRAL. Inclusion criteria included English-language papers containing original human data, number of subjects ≥7, and age <18 years old. Data was systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level-of-evidence. Two investigators independently reviewed all articles. RESULTS The initial search yielded 433 abstracts, of which 18 articles were included. Twelve (67%) of the 18 articles showed a statistically significant association between AR and SDB. All articles were either case-series or case-control studies. Based on the Newcastle-Ottawa scale, the quality of the articles was determined to be fair to good. For characterizing AR, 7 (39%) studies included skin-prick testing and/or in vitro testing. For determining presence of SDB, 7 (39%) of the studies used polysomnographic data, of which 1 study incorporated data from a home polysomnogram. Habitual snoring was the most common form of SDB studied, in 10 (56%) of the articles. Obstructive sleep apnea was studied in 6 (33%) articles. CONCLUSION Although the majority of the studies included in this review showed a significant association between AR and SDB, all of the studies were evidence level 3b and 4, for an overall grade of B- evidence (Oxford Evidence-Based Medicine Center). Further higher-quality studies should be performed in the future to better evaluate the relationship between AR and SDB in children.
Collapse
|
31
|
Abstract
OBJECTIVE This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS). METHODS The literature from 1999 through 2011 was evaluated. RESULTS AND CONCLUSIONS A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.
Collapse
|
32
|
Sleep-disordered breathing is associated with asthma severity in children. J Pediatr 2012; 160:736-42. [PMID: 22133422 PMCID: PMC3975834 DOI: 10.1016/j.jpeds.2011.10.008] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 08/30/2011] [Accepted: 10/10/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the relationships among obesity, sleep-disordered breathing (SDB, defined as intermittent nocturnal hypoxia and habitual snoring), and asthma severity in children. We hypothesized that obesity and SDB are associated with severe asthma at a 1- year follow-up. STUDY DESIGN Children aged 4-18 years were recruited sequentially from a specialty asthma clinic and underwent physiological, anthropometric, and biochemical assessment at enrollment. Asthma severity was determined after 1 year of follow-up and guideline-based treatment, using a composite measure of level of controller medication, symptom burden, and health care utilization. Multivariate logistic regression was used to examine adjusted associations of SDB and obesity with asthma severity at 12-month follow-up. RESULTS Among 108 subjects (mean age, 9.1±3.4 years; 45.4% African-American; 67.6% male), obesity and SDB were common, affecting 42.6% and 29.6% of subjects, respectively. After adjusting for obesity, race, and sex, children with SDB had a 3.62-fold increased odds of having severe asthma at follow-up (95% CI, 1.26-10.40). Obesity was not associated with asthma severity. CONCLUSION SDB is a modifiable risk factor for severe asthma after 1 year of specialty asthma care. Further studies are needed to determine whether treating SDB improves asthma morbidity.
Collapse
|
33
|
Abstract
Adenotonsillectomy is the mainstay of treatment for pediatric obstructive sleep apnea syndrome (OSAS). However, there is evidence that the child with severe OSAS is at increased risk of respiratory compromise. The most difficult risk factor to assess is the severity of OSAS, and these difficulties are reviewed.
Collapse
|
34
|
Sleep and its importance in adolescence and in common adolescent somatic and psychiatric conditions. Int J Gen Med 2011; 4:425-42. [PMID: 21731894 PMCID: PMC3119585 DOI: 10.2147/ijgm.s11557] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Indexed: 02/05/2023] Open
Abstract
Restoring sleep is strongly associated with a better physical, cognitive, and psychological well-being. By contrast, poor or disordered sleep is related to impairment of cognitive and psychological functioning and worsened physical health. These associations are well documented not only in adults but also in children and adolescents. Importantly, adolescence is hallmarked by dramatic maturational changes in sleep and its neurobiological regulation, hormonal status, and many psychosocial and physical processes. Thus, the role of sleep in mental and physical health during adolescence and in adolescent patients is complex. However, it has so far received little attention. This review first presents contemporary views about the complex neurobiology of sleep and its functions with important implications for adolescence. Second, existing complex relationships between common adolescent somatic/organic, sleep-related, and psychiatric disorders and certain sleep alterations are discussed. It is concluded that poor or altered sleep in adolescent patients may trigger and maintain many psychiatric and physical disorders or combinations of these conditions, which presumably hinder recovery and may cross into later stages of life. Therefore, timely diagnosis and management of sleep problems appear critical for growth and development in adolescent patients.
Collapse
|
35
|
Seasonal variability of sleep-disordered breathing in children. Pediatr Pulmonol 2011; 46:581-6. [PMID: 21284096 DOI: 10.1002/ppul.21408] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 10/24/2010] [Accepted: 10/25/2010] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Snoring and sleep-disordered breathing (SDB) are frequent pediatric conditions. Although allergies and respiratory viruses have been pathophysiologically implicated in these conditions, their seasonal distribution has not been examined. METHODS The records of all children participating in a prospective, cross-sectional community-based research study that included a questionnaire on snoring frequency and loudness and an overnight sleep study were retrospectively assessed for seasonal patterns based on the day the children were evaluated. RESULTS A total of 1,051 children were included with a mean age of 7 years. There were no seasonal differences in the number of children evaluated or in their demographic characteristics. However, the odds of increased snoring frequency and loudness were significantly higher in spring and summer and lowest in fall (P < 0.001). However, the mean AHI was highest and the nadir SaO(2) was lowest in winter and spring compared to summer and fall (P < 0.001 and P < 0.03, respectively). CONCLUSION Snoring and the severity of SDB exhibit distinct and essentially non-overlapping patterns of seasonal variation, with peaks in spring-summer for snoring and peaks in winter-spring for SDB severity. These findings suggest that both seasonal viral and allergen burdens may contribute to SDB severity and may prompt differing clinical referral patterns throughout the year.
Collapse
|
36
|
Primary snoring in school children: prevalence and neurocognitive impairments. Sleep Breath 2011; 16:23-9. [DOI: 10.1007/s11325-011-0480-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 12/28/2010] [Accepted: 01/05/2011] [Indexed: 10/18/2022]
|