Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old. An epidemiologic study of lower limit of prevalence

Polysomnogram outcomes in patients with laryngomalacia and obstructive sleep apnoea treated surgically versus non-surgically

OBJECTIVE

To compare supraglottoplasty versus non-surgical treatment in children with laryngomalacia and mild, moderate and severe obstructive sleep apnoea.

METHODS

Patients were classified based on their obstructive apnoea hypopnoea index on initial polysomnogram, which was compared to their post-treatment polysomnogram.

RESULTS

Eighteen patients underwent supraglottoplasty, and 12 patients had non-surgical treatment. The average obstructive apnoea hypopnoea index after supraglottoplasty fell by 12.68 events per hour (p = 0.0039) in the supraglottoplasty group and 3.3 events per hour (p = 0.3) in the non-surgical treatment group. Comparison of the change in obstructive apnoea hypopnoea index in the surgical versus non-surgical groups did not meet statistical significance (p = 0.09).

CONCLUSION

All patients with laryngomalacia and obstructive sleep apnoea had a statistically significant improvement in obstructive apnoea hypopnoea index after supraglottoplasty irrespective of obstructive sleep apnoea severity, whereas patients who received non-surgical treatment had more variable and unpredictable results. Direct comparison of the change between the two groups did not find supraglottoplasty to be superior to non-surgical treatment. Larger prospective studies are recommended.

Classification and Epidemiology of Sleep Disorders in Children and Adolescents

Sleep disturbances are common in children and adolescents but still remain unrecognized and undertreated. Several classification systems of sleep disorders are available, which include recent attempts to develop more specific nosologic categories that reflect developmental aspects of sleep. The prevalence of sleep disorders has been studied across various samples of healthy, typically developing children and those with special medical, psychiatric, and neurodevelopmental needs. Sleep disorders are highly prevalent in children and adolescents with psychiatric disorders, making it important for mental health professionals to be aware of sleep problems and to address them in the context of psychiatric comorbidities.

Prevalence of obstructive sleep apnea (OSA) among preschool aged children in the general population: A systematic review

Untreated pediatric obstructive sleep apnea (OSA) is associated with significant morbidities affecting behavior, neurocognitive development, endocrine and metabolic health. This systematic review evaluated prevalence of OSA reported in population-based studies among preschoolers as early intervention may have positive effects on health and quality of life. Thirty studies were included. High degrees of heterogeneity in methods and definitions were observed between the studies. Seven studies confirmed OSA by implementing objective methods after screening for habitual snoring with only two studies utilizing polysomnography, the reference standard, testing 1.2% of the combined cohorts (n = 82/4575) to confirm disease. Diagnosis of OSA was based on utilizing retired thresholds of the apnea-hypopnea-index (AHI), AHI4%≥5/hour of sleep (hrSleep), reporting prevalence of 1.8% and 6.4%, respectively. The remaining five studies implemented relatively insensitive objective recording methods to confirm disease in a limited number of children (n = 449/2486; 18.0%), estimating prevalence in the range of 0.7%-13.0%. The remaining literature is based on implementing questionnaires only to evaluate OSA. Studies published before 2014 reported 3.3%-9.4% prevalence, while more recent studies published 2016-2023 report higher prevalence, 12.8%-20.4%, when excluding outliers. This trend suggests that prevalence of OSA may possibly have been increasing in preschoolers over the past decade.

Otorhinologic Disorders in 22q11.2 Deletion Syndrome

OBJECTIVE

Investigate incidence and natural history of otologic and sinonasal disease associated with 22q11.2 deletion syndrome.

STUDY DESIGN

Case series.

SETTING

Tertiary care children's hospital.

METHODS

Charts from consecutive children born 2000 to 2018 with a diagnosis of 22q11.2 deletion, DiGeorge, or velocardiofacial syndrome based on the International Classification of Diseases (ICD)-9 and ICD-10 codes were reviewed. Otologic and rhinologic diagnoses and surgeries and immune and microbiologic laboratory findings were collected from the medical record.

RESULTS

After the exclusion of patients with no 22q11.2 deletion (n = 101), otologic care at an outside hospital (n = 59), and loss to follow-up prior to 3 years of age (n = 22), 128 were included. Males comprised 80 (62.5%) patients, 115 (89.8%) were white, and the median age at genetic confirmation of 22q11.2 deletion was 119 days (range 0 days to 14.6 years). Recurrent acute otitis media (RAOM), chronic otitis media with effusion, chronic rhinosinusitis, and recurrent acute sinusitis were diagnosed in 54 (42.2%), 37 (28.9%), 10 (7.8%), and 8 (6.3%), respectively. Tympanostomy tubes were placed in 49 (38.3%). Adenoidectomy and sinus surgery were performed in 38 (29.7%) and 4 (3.1%), respectively. Neither immunoglobulin nor cluster of differentiation deficiency increased the odds of RAOM diagnosis, tympanostomy tube placement, or chronic/recurrent sinusitis. Methicillin-resistant Staphylococcus aureus was the most common organism in sinus cultures (4/13, 30.8%). Streptococcus pneumonia dominated otorrhea cultures (11/21, 52.4%).

CONCLUSION

Approximately half of children with 22q11.2 deletion may experience otologic disease that often requires surgical management. Future studies will utilize a larger cohort to examine the role of immunodeficiency in otologic and rhinologic disease in this population.

Sleep in 22q11.2 Deletion Syndrome: Current Findings, Challenges, and Future Directions

PURPOSE OF REVIEW

To summarize current literature available on sleep in 22q11.2 Deletion Syndrome (22q11.2DS; Velocardiofacial or DiGeorge Syndrome), a neurogenetic disorder caused by a hemizygous deletion in a genomic region critical for neurodevelopment. Due to the greatly increased risk of developmental psychiatric disorders (e.g., autism and schizophrenia) in 22q11.2DS, this review focuses on clinical correlates of sleep disturbances and potential neurobiological underpinnings of these relationships.

RECENT FINDINGS

Sleep disturbances are widely prevalent in 22q11.2DS and are associated with worse behavioral, psychiatric, and physical health outcomes. There are reports of sleep architecture and sleep neurophysiology differences, but the literature is limited by logistical challenges posed by objective sleep measures, resulting in small study samples to date. Sleep disturbances in 22q11.2DS are prevalent and have a substantial impact on well-being. Further investigation of sleep in 22q11.2DS utilizing multimodal sleep assessments has the potential to provide new insight into neurobiological mechanisms and a potential trans-diagnostic treatment target in 22q11.2DS.

Home continuous positive airway pressure therapy in infants: a single-center experience

STUDY OBJECTIVES

There are limited data on indications and outcomes of home continuous positive airway pressure (CPAP) therapy in the first year of life. We aimed to analyze the clinical, demographic, and polysomnographic characteristics of a cohort of children initiated on home CPAP for treatment of sleep-disordered breathing and as respiratory support in the first year of life.

METHODS

Children started on CPAP in the first year of life at the Queensland Children's Hospital were retrospectively evaluated for clinical and demographic parameters, underlying diagnoses, respiratory support, airway surgical intervention, and polysomnography results at baseline and on CPAP.

RESULTS

Twenty-nine infants (median age [interquartile range] at CPAP initiation, 182 days [126-265.5 days]) were included. The underlying etiology included Trisomy 21 (n = 6), craniofacial syndromes (n = 5), hypotonia (n = 8; 5 with noncraniofacial syndrome), airway malacia (n = 5), skeletal dysplasia (n = 2), nonsyndromic upper airway obstruction (n = 2), and chronic neonatal lung disease (n = 1). The median (interquartile range) obstructive apnea-hypopnea index was 14 events/h (6.2-31 events/h) at CPAP initiation, which improved on CPAP to 3.4 events/h (1.4-6.4 events/h). The median (interquartile range) transcutaneous CO2 max remained unchanged on CPAP (56.6 mm Hg [49-66.5 mm Hg] pre-CPAP vs 54.9 mm Hg [47-62 mm Hg] on CPAP). Fifteen children needed surgical airway intervention (11 pre-CPAP and 4 post-CPAP). CPAP therapy could be successfully stopped in 9 children, 2 children needed tracheostomy, and 1 child died during the follow-up period.

CONCLUSIONS

Home CPAP as respiratory support is an effective long-term therapy in infancy, and these patients can be weaned from CPAP therapy even if it was initiated early. Prospective studies with predefined criteria for CPAP initiation and cessation would help ascertain long-term outcomes in this poorly researched group.

CITATION

Joshi SS, Sivapalan D, Leclerc M-J, Kapur N. Home continuous positive airway pressure therapy in infants: a single-center experience. J Clin Sleep Med. 2023;19(3):473-477.

Sleep-related breathing disorders in young orthodontic patients

INTRODUCTION

This study aimed to find out the frequency of sleep-related breathing disorders (SRBD) in young orthodontic patients in Israel. SRBD is characterized by prolonged upper airway obstruction during sleep.

METHODS

The study group consisted of 309 children aged 6-17 years who attended the Orthodontic Clinic at Hadassah Medical Center. Parents were asked to complete a translated validated Pediatric Sleep Questionnaire.

RESULTS

Of the examined children, 10% were at high risk for SRBD. Boys were at higher risk for SRBD and were at high risk at a younger age than girls. Girls had a low risk of SRBD after adenotonsillectomy, whereas 50% of the boys that underwent adenotonsillectomy were at high risk for SRBD.

CONCLUSIONS

Our findings propose that 10% of the children aged 6-17 years, who were seeking orthodontic consultation at our medical center, were at high risk for SRBD. Boys were significantly at a higher risk for SRBD than girls and were at high risk at a younger age. It is important to screen young orthodontic patients for SRBD and to refer high-risk patients to their physicians for further evaluation and treatment.

Patients with Obstructive Sleep Apnea Symptoms Referral to Otolaryngologists in Iranian Residency Entrance Examination Volunteers: The Effect of Source of Education and Level of Knowledge

Obstructive sleep apnea (OSA) has various complications for individuals' health. This study aimed to evaluate the factors for referring obstructive sleep apnea patients to otolaryngologists in Iranian residency entrance examination volunteers. This cross-sectional study recruited volunteer participants from the Iranian Residency Entrance Examination on March 2, 2018. The Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA)/the Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) Questionnaires were distributed among residents attending exam preparation. Number of years working as a physician, number of adult and pediatric patients visited during the academic rank in residency examination, and the main specialty during general physician education in which they get familiar with obstructive sleep apnea were documented. The effect of the mentioned variables evaluated on patient referral preference specialty. Of the 95 volunteers, 57.9% were female; mean age was 29.6 ± 3.3 years. The overall knowledge score of the OSAKA questionnaire was 9.85 ± 3.9 and for the OSAKA-KIDS questionnaire was 9.2 ± 4.9. In patients under 18 years of age, the most frequent referrals were from otolaryngology specialists (51.2%). The only factor which had positive significant effect on adult patient referral preference was source of obstructive sleep apnea knowledge during general physician taring (p < 0.001). Given the low awareness about OSA in candidates for the residency entrance exam and the high importance of this treatable disease, the need for comprehensive training courses during residency is warranted and the adequacy of sleep apnea education through all involved specialty during general physician education should be improved.

Management of children with co-occurring sleep disordered breathing and hearing loss

OBJECTIVES

To examine hearing loss incidence in a pediatric otolaryngology patients with sleep disordered breathing, and secondarily, identify possible disparities in management.

METHODS

A retrospective case-control study of pediatric patients with sleep-disordered breathing or obstructive sleep apnea from 2012 to 2019 was conducted at a private, not-for-profit, academic, tertiary care center. Study parameters were extracted from the electronic medical record and compared in study groups of patients with sleep-disordered breathing generated based on presence of hearing loss (cases) versus absence (controls). Study parameters were also compared in study groups based on timing of hearing loss onset.

RESULTS

14.8% of patients with sleep disordered breathing had hearing loss. Hearing loss was associated with an increased risk of undergoing adenotonsillectomy (OR 1.632 [1.294-2.058], p < 0.001, adjusted for age). In patients who underwent polysomnographic testing, 9.8% patients had pre-existing hearing loss and 12% patients developed hearing loss over the study period. Patients with pre-existing hearing loss and those who developed hearing loss had significantly more visits with otolaryngology compared to controls (p < 0.001). Hearing loss did not significantly delay adenotonsillectomy. More patients who developed hearing loss had adenotonsillectomies (OR 2.475 [1.672-3.663], p < 0.001, adjusted for age) versus controls. This difference was not identified in patients with pre-existing hearing loss.

CONCLUSION

Patients with evidence of hearing loss in addition to sleep disordered breathing had more adenotonsillectomies performed and more clinic visits. Further work must be done to understand the associations and implications of hearing loss in this population.

Three-dimensional volumetric changes in the airway of growing unilateral complete cleft lip and palate patients after bone-anchored maxillary protraction

INTRODUCTION

This prospective controlled study evaluates volumetric, length, and average cross-sectional area (aCSA) airway changes in growing patients with unilateral complete cleft lip and palate after 1.5 years of bone-anchored maxillary protraction therapy.

METHODS

Thirty-five growing unilateral complete cleft lip and palate patients with maxillary deficiency were included (aged 11.3 ± 0.5 years). Cone-beam computed tomography scans were obtained before bone-anchored maxillary protraction (BAMP) therapy and after 1.5 years. A growing group without cleft (n = 18) patients served as a control group at 1.5 years posttreatment (aged 13.1 ± 1.2 years). Volumetric, length, and aCSA changes of the total airway, nasopharynx (NP), middle pharynx, and inferior pharynx airway were evaluated.

RESULTS

After 1.5 years of BAMP therapy, a significant increase was observed in the total airway volume and the NP (P <0.01). The middle and inferior pharynx showed an insignificant tendency of volumetric increase. Compared with the control group, a significantly larger airway volume could be observed in the total airway and NP (P <0.05). The aCSA of the NP increased significantly compared with pretreatment.

CONCLUSIONS

The total airway and NP volumes significantly increased in growing subjects with cleft lip and palate after 1.5 years of BAMP therapy to a level comparable to a control group without cleft. Volumetric increase in the NP in the BAMP group is mainly attributed to the increase in its cross-sectional area. BAMP can therefore be recommended as an effective therapy for patients with cleft lip and palate with positive effects on airway development.

Systematic Review: Sleep Disorders Based on Objective Data in Children and Adolescents Treated for a Brain Tumor

Background

Tumors of the central nervous system (CNS) are the most common solid childhood malignancy. Over the last decades, treatment developments have strongly contributed to the improved overall 5-year survival rate, which is now approaching 75%. However, children now face significant long-term morbidity with late-effects including sleep disorders that may have detrimental impact on everyday functioning and quality of life. The aims of this study were to (1) describe the symptoms that lead to polysomnographic evaluation; (2) describe the nature of sleep disorders diagnosed in survivors of childhood CNS tumor using polysomnography (PSG); and (3) explore the association between tumor location and diagnosed sleep disorder.

Methods

An extensive literature search following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines (PRISMA) was conducted. Inclusion criteria were children and adolescents diagnosed with a CNS tumor age <20 years having a PSG performed after end of tumor treatment. The primary outcome was sleep disorder confirmed by PSG.

Results

Of the 1,658 studies identified, 11 met the inclusion criteria. All the included articles were appraised for quality and included in the analysis. Analyses indicated that sleep disorders commonly occur among childhood CNS tumor survivors. Symptoms prior to referral for PSG were excessive daytime sleepiness (EDS), fatigue, irregular breathing during sleep and snoring. The most common sleep disorders diagnosed were sleep-related breathing disorders (i.e., obstructive sleep apnea) and central disorders of hypersomnolence (i.e., narcolepsy).

Conclusion

Our findings point to the potential benefit of systematically registering sleep disorder symptoms among CNS tumor patients together with tumor type and treatment information, so that at-risk patients can be identified early. Moreover, future rigorous and larger scale controlled observational studies that include possible modifiable confounders of sleep disorders such as fatigue and obesity are warranted.

Clinical Trial Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021243866, identifier [CRD42021243866].

Inflammatory Biomarkers for Children with Sleep Disorders: A Review

Introduction Obstructive sleep apnea (OSA) syndrome is a highly prevalent problem in children. Unfortunately sleep disorders in children remain largely unreported and underdiagnosed due to various reasons. Overnight in-laboratory polysomnography (PSG) is the gold standard diagnostic method for OSA; however, it has several drawbacks. Hence there is a need for simple alternative diagnostic methods, such as biomarkers. Children with OSA seem to have an inflammatory aspect to its pathophysiology; thus the rationale for evaluating inflammatory biomarkers.

Objective This narrative review aimed to evaluate the existing knowledge regarding inflammatory biomarkers for children with sleep disorders.

Materials and Methods An extensive search of all literature linked to the topic was performed in PubMed, Medline, EBSCOhost, Cochrane library database CENTRAL, and Google Scholar search engine. Keywords used in the search included combinations of the following: inflammation, sleep disorders, children, and biomarkers. Studies in the list of references of relevant literature were also included. A total of 155 articles published in the period from 1997 to 2021 were initially included in this review. Selected articles comprised original research, meta-analysis, and systematic reviews.

Results Studies have mainly centered their investigations on serum inflammatory biomarkers, namely interleukin-6, tumor necrosis factor-α, and C-reactive protein. Very few studies investigated salivary inflammatory biomarkers in children.

Conclusion Evidence suggests that children with sleep disorders have elevated levels of salivary as well as serum inflammatory biomarkers in comparison to normal healthy children. Also increased levels of these biomarkers correlate with disease severity. However, more studies are needed to determine the sensitivity and specificity of salivary inflammatory biomarkers for children with sleep disorders.

Can sleep questionnaires predict adenotonsillectomy outcome for children with sleep disordered breathing?

INTRODUCTION

Adenotonsillar hypertrophy is the main cause of childhood sleep disordered breathing (SDB) and adenotonsillectomy (TA) the most common treatment. Polysomnography (PSG) for diagnosing SDB is often difficult to obtain with Otolaryngologists usually relying on history and examination when recommending TA. Questionnaires assessing quality of life (QoL) may assist the Otolaryngologists decision making.

AIMS

To explore changes in QoL tools following TA for SDB in children aged 3 to 15 with the aim of identifying whether the Pediatric Sleep Questionnaire (PSQ) or Obstructive Sleep Apnoea -18 (OSA-18) is a better predictor of outcome following TA.

METHODS

QoL was assessed using OSA-18, PSQ and the Pediatric Quality of Life Inventory™ (PedsQL™). Four groups were recruited from three research databases, those with: SDB, recurrent tonsillitis (RT), SDB and RT, or no disease (controls). Children either received TA or underwent observation. QoL questionnaires were administered at recruitment and 3 months later. Test-retest reliability was assessed using Bland-Altman plots. Pre-intervention scores were plotted against changes in scores, with pre-established cut-offs and cut-offs indicated by control group variability.

RESULTS

There were 120 children, 25 had no intervention, and 19 were controls. All questionnaires showed test-retest reliability over time. Using the distribution of scores from the control group we estimated the 95th percentile to redefine the cut-off for OSA-18 (reduced from 60 to 46) and PSQ (unchanged from 0.33). Higher pre-operative scores predicted greater reduction following TA, with OSA-18 the most consistent predictor of QoL change. The PSQ classified 86.8% of children undergoing TA above the 0.33 cut-off; whereas OSA-18 classified 73.7% above the 46 cut-off. Of these, 71.2% and 87.5% showed improvement after TA, respectively. Using the 95% confidence interval for change in the control group to identify a 'meaningful' change in score, children with OSA-18 scores >46 had a 93% chance of a meaningful improvement, whereas PSQ scores >0.33 were associated with an 80% chance of a meaningful improvement.

CONCLUSIONS

OSA-18 is a better predictor of improved QoL than PSQ for TA in children with SDB. We propose a new cut off score (>46) for OSA-18. This may assist Otolaryngologists' decision making when assessing a child with SDB.

The role of the dentist in the diagnosis and management of pediatric obstructive sleep apnea

The objective of this article is to review the role of the dentist in the early diagnosis of pediatric obstructive sleep apnea (OSA) and to provide an in-depth review of the best evidence-based practices available to treat and/or to refer these patients for intervention.

Material and methods

A narrative review was performed using indexed data bases (PubMed, Medline, EMBASE, OVID, Scopus and Cochrane) up to year 2020, and approximately 1000 articles were reviewed. The articles included were those with the best information provided.

Results

Detailed review of the literature suggests that the role of the dentist has been redefined owing to their expertise in the orofacial region. Every patient consulting a dental practice is not merely a dental patient; he/she also requires a comprehensive medical review. The role of the dentist is pivotal in pediatric patients once diagnosed with OSA; as the patients grow, growth modification can be achieved, and future management will be easier. Initiating dental treatments during growth can benefit patients two-fold, saving them from malocclusion, and intervening in orofacial structural growth can help to avoid cumbersome treatments, such as CPAP and various surgeries. Proper diagnosis and management of systemic illnesses can prevent compromised quality of life, delays in treatment, morbidity and, in some cases, mortality.

Postoperative Changes in the Upper Airway Following Mandibular Distraction Osteogenesis in Pediatric Hemifacial Microsomia

BACKGROUND

Patients with hemifacial microsomia (HFM) may undergo unilateral mandibular distraction osteogenesis (MDO) before skeletal maturity in an effort to improve facial symmetry. Mandibular distraction osteogenesis's effect on airway volumes have been studied in the past, though to our knowledge, none have accounted for the effect of head and neck posture on airway morphology. This study aimed to tackle this shortcoming, using imaging to analyze the upper airway of patients with HFM before and after surgical intervention with MDO.

METHODS/DESCRIPTION

The authors retrospectively reviewed patients with a diagnosis of unilateral HFM whom underwent unilateral MDO with an oblique vector at age 4 to 14 years at a single institution from 2004 to 2019. Patients with pre- and post-MDO three-dimensional computed tomography scans of the upper airway within 12 months of distractor placement and removal, respectively, were included. Head and neck postures were determined by craniocervical, pitch, roll, and yaw angles. Pre- and post-operative pharyngeal airway volumes, pharyngeal surface area, minimum retropalatal cross-sectional areas (RP CSA) and retroglossal (RG) CSA and associated anteroposterior distances were measured using Mimics 22.0 (Materialise; Leuven, Belgium). Comparison was done using Kruskal-Wallis tests and linear mixed-effects models controlling for head and neck postures.

RESULTS

Ten patients met inclusion criteria. Mean age at pre-distractor placement computed tomography scan was 99 ± 35 months, and mean duration between pre- and post-surgery scans was 220 ± 90 days. Head and neck posture were found to be significant predictors of all airway dimensions. After controlling for significant factors with fixed effects linear modeling, surface area was found to be significantly smaller in patients after MDO by 189.48 mm2 (F[10.8] = -3.47, P = 0.0053), compared to their preoperative measurements. Surgery was not a significant predictor of changes in airway volume (F[11.6] = 0.52, P = 0.61), minimum RP CSA (F[12.2] =  -0.64, P = 0.53), minimum RG CSA (F[12.6] =  -1.64, P = 0.13), RP anteroposterior distance (F[14.0] = 0.30, P = 0.77), or RG anteroposterior distance (F[20.0] =  -0.04, P = 0.97).

CONCLUSIONS

Oblique vector MDO in patients with HFM is associated only with statistically significant changes in the surface area of the upper airway, and is not associated with statistically significant changes in dimensions like volume, CSA, or anteroposterior dimension. This is an important finding, as it may guide discussions surrounding risk/benefit ratio for MDO in childhood.

Association of sleep disturbances and craniofacial characteristics in children with class ii malocclusion: An evaluative study

Background

Behaviour problems, poor academic performance and failure to thrive are some of the potential sequelae of sleep problems in children. Hence, there is a need to evaluate the prevalence of sleep problems and significant associations in children with skeletal class II malocclusion with mandibular retrognathism.

Aims

This study aimed to determine associations if any between sleep practices and problems and craniofacial characteristics in children with skeletal class II malocclusion with mandibular deficiency.

Settings and Design

A cross-sectional study was conducted among a group of children with skeletal class II malocclusion with mandibular retrognathism.

Materials and Methods

Fifty children aged 8-14 years with skeletal class II with mandibular retrognathism and who required myofunctional therapy were selected. A validated sleep questionnaire assessed the sleep practices and problems. A detailed clinical examination including tonsils and evaluation for mouth breathing was performed. A lateral cephalogram recorded specific linear, angular variables as well as upper and lower pharyngeal airway space.

Statistical Analysis

Descriptive statistics, frequency, and percentages were calculated, and the Chi-square test was used.

Results

All children reported at least one sleep problem, with snoring reported by 76% of the children. Forty-two percent of the children showed a decreased upper airway, whereas 80% showed a decreased lower airway. Significant associations were seen between SN-MP and noisy breathing, upper airway, and snoring with a P value of 0.017. We also found significant associations between upper and lower airway and sleep positions with a P value of 0.021 and 0.005, respectively.

Conclusion

All the children exhibited at least one sleep problem. There was a strong association of certain sleep practices and sleep problems with cephalometric variables.

Perinatal Nutritional and Metabolic Pathways: Early Origins of Chronic Lung Diseases

Lung development is not completed at birth, but expands beyond infancy, rendering the lung highly susceptible to injury. Exposure to various influences during a critical window of organ growth can interfere with the finely-tuned process of development and induce pathological processes with aberrant alveolarization and long-term structural and functional sequelae. This concept of developmental origins of chronic disease has been coined as perinatal programming. Some adverse perinatal factors, including prematurity along with respiratory support, are well-recognized to induce bronchopulmonary dysplasia (BPD), a neonatal chronic lung disease that is characterized by arrest of alveolar and microvascular formation as well as lung matrix remodeling. While the pathogenesis of various experimental models focus on oxygen toxicity, mechanical ventilation and inflammation, the role of nutrition before and after birth remain poorly investigated. There is accumulating clinical and experimental evidence that intrauterine growth restriction (IUGR) as a consequence of limited nutritive supply due to placental insufficiency or maternal malnutrition is a major risk factor for BPD and impaired lung function later in life. In contrast, a surplus of nutrition with perinatal maternal obesity, accelerated postnatal weight gain and early childhood obesity is associated with wheezing and adverse clinical course of chronic lung diseases, such as asthma. While the link between perinatal nutrition and lung health has been described, the underlying mechanisms remain poorly understood. There are initial data showing that inflammatory and nutrient sensing processes are involved in programming of alveolarization, pulmonary angiogenesis, and composition of extracellular matrix. Here, we provide a comprehensive overview of the current knowledge regarding the impact of perinatal metabolism and nutrition on the lung and beyond the cardiopulmonary system as well as possible mechanisms determining the individual susceptibility to CLD early in life. We aim to emphasize the importance of unraveling the mechanisms of perinatal metabolic programming to develop novel preventive and therapeutic avenues.

Prevalence and evolution of snoring and the associated factors in two-year-old children

OBJECTIVES

To evaluate the prevalence and persistence of snoring during the first two years of life in two Finnish birth cohorts and to assess the associated factors.

STUDY DESIGN

The study population comprised 947 children from the CHILD-SLEEP (CS) and 1393 children from the FinnBrain (FB) birth cohorts. Questionnaires were provided to both parents when the child was 24 months of age. The questionnaire consisted of parts concerning the child's sleep and environmental factors.

RESULTS

The combined prevalence of habitual snoring in the two birth cohorts at the age of 24 months was 2.3% (95% CI 1.5-3.1), which is markedly lower than reported previously. Children suffering from recurrent infections (CS odds ratio (OR) 3.9, 95% CI 1.2-12.5) or asthma (FB OR 4.3, 1.4-13.5) snored habitually more often. Both the mother's (CS OR 3.2, 1.2-9.0) and father's (CS OR 3.4, 1.4-8.0) snoring every night added to the risk of the child snoring. In the multivariate models, parental snoring (CS adjusted odds ratio (OR_a) 2.8, 1.1-6.8), the mother's lower level of education (CS OR_a 2.9, 1.2-7.5, FB OR_a 2.1, 1.0-4.5), and the mother's lower monthly income (FB OR_a 2.9, 1.3-6.3) associated with the child's habitual snoring.

CONCLUSIONS

The prevalence of habitual snoring in two Finnish birth cohorts is lower than reported previously. The independent risk factors for habitual snoring at the age of two years were the parents' snoring and the mother's low income and low education.

Mental health and sleep habits/problems in children aged 3-4 years: a population study

Background

Sleep is essential for mental health at all ages, but few studies have investigated the importance of sleep for mental health in early childhood. Therefore, this study examined the association between mental health and sleep habits/problems in children aged 34 years.

Methods

Children aged 3 to 4 years who were living in the community (n=415; 211/204 boys/girls) were recruited for this study. Their mental health was assessed using the Strengths and Difficulties Questionnaire (SDQ), and their sleep habits/problems were evaluated using the Child and Adolescent Sleep Checklist.

Results

Based on the total difficulties score of the SDQ, the children were divided into two groups: a poor mental health group (n=76) and a control group (n=339). In terms of sleep habits, which included total sleep time, bedtime, wake time, and nap conditions, there were no differences between the two groups. Regarding sleep-related problems, however, anxiety before going to sleep (p=0.026), circadian rhythm abnormalities (p=0.014), and sleepiness during classes outside of naptimes (p=0.031) were significantly higher in the poor mental health group than in the control group. Multiple regression analysis showed that poor mental health status was significantly associated with sleepiness and snoring (p=0.017 and p=0.018, respectively).

Conclusions

The mental health status of 34-year-old children was associated with sleep-related problems, namely sleepiness and snoring. Healthcare providers should pay attention to childrens irregular sleep-wake patterns; moreover, interventions for appropriate sleep hygiene will reduce the psychological burden on both children and their families.

Skeletal Changes in Growing Cleft Patients with Class III Malocclusion Treated with Bone Anchored Maxillary Protraction-A 3.5-Year Follow-Up

This prospective controlled trial aimed to evaluate the skeletal effect of 3.5-years bone anchored maxillary protraction (BAMP) in growing cleft subjects with a Class III malocclusion. Subjects and Method: Nineteen cleft patients (11.4 ± 0.7-years) were included from whom cone beam computed tomography (CBCT) scans were taken before the start of BAMP (T0), 1.5-years after (T1) and 3.5 y after (T2). Seventeen age- and malocclusion-matched, untreated cleft subjects with cephalograms available at T0 and T2 served as the control group. Three dimensional skeletal changes were measured qualitatively and quantitatively on CBCT scans. Two dimensional measurements were made on cephalograms. Results: Significant positive effects have been observed on the zygomaticomaxillary complex. Specifically, the A-point showed a displacement of 2.7 mm ± 0.9 mm from T0 to T2 (p < 0.05). A displacement of 3.8 mm ± 1.2 mm was observed in the zygoma regions (p < 0.05). On the cephalograms significant differences at T2 were observed between the BAMP and the control subjects in Wits, gonial angle, and overjet (p < 0.05), all in favor of the treatment of Class III malocclusion. The changes taking place in the two consecutive periods (ΔT1-T0, ΔT2-T1) did not differ, indicating that not only were the positive results from the first 1.5-years maintained, but continuous orthopedic effects were also achieved in the following 2-years. Conclusions: In conclusion, findings from the present prospective study with a 3.5-years follow-up provide the first evidence to support BAMP as an effective and reliable treatment option for growing cleft subjects with mild to moderate Class III malocclusion up to 15-years old.

Adherence to Sleep Therapies in Children and Adolescents

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

Classification and Epidemiology of Sleep Disorders in Children and Adolescents

Sleep disturbances are common in children and adolescents but still remain unrecognized and undertreated. Several classification systems of sleep disorders are available, which include recent attempts to develop more specific nosologic categories that reflect developmental aspects of sleep. The prevalence of sleep disorders has been studied across various samples of healthy, typically developing children and those with special medical, psychiatric, and neurodevelopmental needs. Sleep disorders are highly prevalent in children and adolescents with psychiatric disorders, making it important for mental health professionals to be aware of sleep problems and to address them in the context of psychiatric comorbidities.

Supplemental Oxygen for Treatment of Infants With Obstructive Sleep Apnea

STUDY OBJECTIVES

Supplemental oxygen has been shown to decrease the frequency of obstructive respiratory events during sleep, but may result in alveolar hypoventilation. Limited information exists on the effect of supplemental oxygen on sleep and respiratory events in infants with obstructive sleep apnea (OSA).

METHODS

We conducted a retrospective study of infants with OSA who had sleep studies performed from 2007-2012. All infants underwent a room air diagnostic sleep study (RA-PSG), followed by a sleep study while breathing supplemental oxygen via nasal cannula (O₂-PSG) on a separate night. Infants with split-night studies or with inadequate sleep time were excluded.

RESULTS

Fifty-nine infants met criteria for entry into analysis. The mean age of infants at the time of RA-PSG was 13.0 ± 11.7 weeks and at O₂-PSG was 15.4 ± 13.0 weeks. The obstructive AHI decreased from 19.7 ± 13.0 during RA-PSG to 10.6 ± 11.7 during O₂-PSG (P < .001). The duration of longest obstructive apnea increased from 11.0 ± 4.2 seconds to 13.4 ± 7.4 seconds (P = .01). The lowest saturation associated with obstructive apneas increased from 80.7 ± 6.8% to 90.0 ± 6.7% (P < .001). Carbon dioxide data showed no difference in ventilation after supplemental oxygen administration. There was no significant change in the spontaneous arousal index, however, the percentage of respiratory events associated with arousal increased from 20.7 ± 11.1% to 35.7 ± 19.7% (P < .001).

CONCLUSIONS

Infants with OSA who received supplemental oxygen had a significant decrease in the frequency of obstructive respiratory events and improved oxygenation without adverse effect on alveolar ventilation. These data suggest that supplemental oxygen may be an effective treatment for infants with OSA who are not good candidates for continuous positive airway pressure or surgery.

CITATION

Brockbank J, Astudillo CL, Che D, Tanphaichitr A, Huang G, Tomko J, Simakajornboon N. Supplemental oxygen for treatment of infants with obstructive sleep apnea. J Clin Sleep Med. 2019;15(8):1115-1123.

A multidisciplinary weight loss intervention in obese adolescents with and without sleep-disordered breathing improves cardiometabolic health, whether SDB was normalized or not

OBJECTIVES

Pediatric obesity and sleep-disordered breathing (SDB) are strongly associated, and both promote metabolic impairments. However, the effects of a lifestyle intervention on the overall metabolic syndrome (MetS) are unknown. The objectives were i) to evaluate the effects of a lifestyle intervention on cardiometabolic risk (CMR), assessed with a dichotomous (MetS) and a continuous (MetScore_FM) instrument, in obese adolescents with and without SDB and ii) to compare the post-intervention cardiometabolic responses between adolescents with persistent (apnea-hypopnea index; AHI≥2) or normalized-SDB (AHI<2).

METHODS

Seventy-six adolescents with obesity recruited from two specialized institutions underwent a 9-12month diet and exercise intervention. Sleep and SDB (AHI≥2) were studied by polysomnography. Anthropometric parameters, fat mass (FM), glucose, insulin, lipid and leptin profiles, blood pressure (BP), MetScore_FM and MetS were assessed pre- and post-intervention. We performed comparisons between Non-SDB and SDB groups and between Normalized-SDB and Persistent-SDB subgroups.

RESULTS

Fifty participants completed the study. Pre-intervention, twenty youth had SDB (40%) with higher insulin concentrations and systolic BP than Non-SDB participants (p < 0.01), for a similar degree of obesity. Post-intervention, MetScore_FM (p < 0.001) and MetS prevalence (p < 0.05) were decreased in both groups. Eleven participants (55%) normalized SDB along with a decrease in insulin concentrations and BP (p < 0.05). Triglycerides, total cholesterol and LDL-cholesterol concentrations (p < 0.01) improved equally in the Normalized and Persistent-SDB subgroups.

CONCLUSION

SDB was associated with lower insulin sensitivity and higher BP but did not affect the lipid profile. A diet and exercise lifestyle intervention is effective in decreasing the CMR whether or not SDB was normalized in obese adolescents.

Respiratory Dysfunction and Sleep-Disordered Breathing in Children With Myasthenia Gravis

OBJECTIVES

The purpose of this study was to prospectively evaluate sleep patterns and the presence of sleep-disordered breathing in children with myasthenia gravis. We further aimed to examine the relationship between sleep and daytime respiratory function using spirometry tests including upright and supine forced vital capacity, sniff nasal inspiratory pressure, and maximal inspiratory pressure.

METHODS

Eleven children between 3 and 18 years old with confirmed myasthenia gravis were recruited from The Hospital for Sick Children Neuromuscular Clinic in this prospective observational study. After informed consent was obtained, patients underwent a comprehensive clinical assessment with collection of anthropometric data. Following this, all subjects performed pulmonary function tests, overnight polysomnography and completed the Epworth Sleepiness Scale questionnaire.

RESULTS

Two of eleven children who reported no symptoms of sleep disordered breathing were diagnosed with mild to moderate obstructive sleep apnea. Pulmonary function tests showed abnormal maximal inspiratory pressure in 6 of 11 patients, whereas seated forced vital capacity as well as seated to supine forced vital capacity ratios were normal in the entire group.

CONCLUSIONS

In our small group of pediatric myasthenia gravis subjects, there was an unexpected finding of obstructive sleep apnea in 2 of the 11 patients studied. Maximal inspiratory pressure appears to be a more sensitive method of detecting abnormalities compared to upright or seated forced vital capacity. A larger multicenter study is needed to validate our findings and to determine the impact of obstructive sleep apnea in the pediatric myasthenia gravis population as well as risk factors associated with sleep disordered breathing.

Are obstructive sleep apnea and sleep improved in response to multidisciplinary weight loss interventions in youth with obesity? A systematic review and meta-analysis

BACKGROUND

Pediatric obesity is closely associated with obstructive sleep apnea (OSA) and short sleep duration. While multidisciplinary weight loss interventions are recommended for pediatric obesity management, the evidence for their effects on OSA severity and overall sleep in youth have not been systematically examined.

OBJECTIVES

To conduct a systematic review and meta-analysis investigating the effects of multidisciplinary weight loss interventions on OSA severity and prevalence, and on overall sleep health in youth with obesity.

METHODS

A systematic search of interventional studies (participants age range: 10-19 yrs) was performed using PubMed, CENTRAL and Embase, from inception to May 2019. The quality of the evidence was assessed using the Cochrane risk of bias tool.

RESULTS

Ten studies were included by the end of the screening process. Ninety percent of the included studies reported a decrease in OSA prevalence post-intervention, and OSA was normalized for 46.2-79.7% of the youth. The meta-analysis comprising seven longitudinal studies revealed significant reductions in apnea-hypopnea index (effect size: -0.51, 95%CI -0.94 to -0.08, p = 0.019), and oxygen desaturation index (effect size: -0.28, 95%CI = -0.50 to -0.05, p = 0.016). Seventy-five percent of the studies reported improved sleep duration in youth with OSA.

CONCLUSIONS

Evidence suggests that multidisciplinary weight loss interventions result in improvements in OSA severity and sleep duration in youth with obesity. Future randomized controlled trials are warranted to better assess and understand the independent implications of weight loss, fat mass decrease and chronic exercise on OSA and sleep health in this population.

Adherence in children using positive airway pressure therapy: a big-data analysis

BACKGROUND

Positive airway pressure (PAP) has become a prominent treatment for children with sleep-disordered breathing. However, there are no large-scale studies to clarify whether PAP is well tolerated in children, and which factors are associated with better adherence to PAP therapy. In this study, we aimed to clarify adherence patterns of PAP therapy in a large paediatric population.

METHODS

We did a cross-sectional big-data analysis in children from Oct 1, 2014, to Aug 1, 2018, using existing data derived from PAP devices uploaded nightly in the AirView cloud database. The AirView database is a usage tracking system available to all patients who are assigned PAP therapy, which requires consent from the patient or parent or guardian. All patients older than 4 years and younger than 18 years who used continuous or automated PAP devices were evaluated. Only patients living in the USA and enrolled with a single insurance company were included. If patients were participating in an engagement programme, programme onset must have been within 7 days of therapy onset. Our primary outcome was the proportion of patients who used PAP continuously over 90 days. The primary outcome was assessed in all patients who met the age inclusion criterion and had reliable age data available. Data on missing PAP use were imputed as zero, but data on other metrics were not imputed and excluded from analysis.

FINDINGS

We used data recorded from Oct 1, 2014, to Aug 1, 2018. Of 40 140 children screened, 36 058 (89·8%) were US residents and 20 553 (90·1%) of them met the eligibility criteria and had accessible data (mean age 13·0 years [SD 3·7]). On the basis of 90 days of monitoring data, 12 699 (61·8%) patients continuously used PAP. Factors significantly associated with adherence included age group, residual apnoea-hypopnoea index, use and onset of patient engagement programmes, PAP pressure, and nightly median PAP mask leak, all over the 90-day study period.

INTERPRETATION

To our knowledge, our study represents the largest analysis of children using PAP therapy to date. The findings suggest that adherence to PAP therapy is lower than in previous reports from adults. However, numerous actionable factors were associated with improvements in adherence and should be used strategically in clinical decision making to improve PAP adherence in children.

FUNDING

ResMed.

Ravelo-García A, Morgado-Dias F. A Systematic Review of Detecting Sleep Apnea Using Deep Learning

Sleep apnea is a sleep related disorder that significantly affects the population. Polysomnography, the gold standard, is expensive, inaccessible, uncomfortable and an expert technician is needed to score. Numerous researchers have proposed and implemented automatic scoring processes to address these issues, based on fewer sensors and automatic classification algorithms. Deep learning is gaining higher interest due to database availability, newly developed techniques, the possibility of producing machine created features and higher computing power that allows the algorithms to achieve better performance than the shallow classifiers. Therefore, the sleep apnea research has currently gained significant interest in deep learning. The goal of this work is to analyze the published research in the last decade, providing an answer to the research questions such as how to implement the different deep networks, what kind of pre-processing or feature extraction is needed, and the advantages and disadvantages of different kinds of networks. The employed signals, sensors, databases and implementation challenges were also considered. A systematic search was conducted on five indexing services from 2008-2018. A total of 255 papers were found and 21 were selected by considering the inclusion and exclusion criteria, using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach.

Sleep-Disordered Breathing in Pediatric Patients With Rett Syndrome

STUDY OBJECTIVES

Although respiratory abnormalities occurring during wakefulness are well recognized in patients with Rett syndrome (RS), less has been reported regarding sleep-disordered breathing (SDB) in this population. This study aims to characterize the presenting complaints, types and severity of SDB, and treatment modalities of patients with RS and sleep concerns.

METHODS

Retrospective chart review of pediatric patients with RS referred to our academic tertiary care institution from January 2007 to July 2017.

RESULTS

Thirteen patients were identified, 11 female (84.6%); mean age at polysomnography (PSG) was 10.3 years (standard deviation 4.94). Eleven were white (84.6%), 2 were black (15.4%). The most common presenting symptoms were snoring (10/13, 77%) and witnessed apnea (7/13, 53.8%). On baseline PSG, all patients (100%) exhibited hyperapneas followed by a central apnea during wake. Nine (69.2%) had obstructive sleep apnea (OSA) (obstructive apnea-hypopnea index (oAHI) > 1); four had severe OSA (oAHI ≥ 10). One had central sleep apnea (central apnea index > 5) and severe OSA. No patients exhibited hypoventilation on baseline PSG. Mean AHI of all patients was 8.77 ± 8.82 (oAHI 6.51 ± 6.91) events/h. Mean oxyhemoglobin nadir was 88.52 ± 5.6%. Treatment modalities included observation: 5 (38%), acetazolamide: 2 (15%), nasal mometasone: 1 (7.7%), adenotonsillectomy: 3 (23.1%), and positive airway pressure: 2 (15%).

CONCLUSIONS

Regarding patients with RS referred to the sleep medicine clinic, snoring and witnessed apneas were the most common presenting complaints. In addition to breathing abnormalities during wake, OSA was very common in our cohort. Further studies are needed to examine the pathogenesis of OSA in RS and relationships between disease genotype and respiratory abnormality phenotype.

Parental reports showed that snoring in infants at three and eight months associated with snoring parents and smoking mothers

AIM

This prospective study examined the prevalence of snoring during infancy and the prenatal and postnatal risk factors for this condition.

METHODS

The study population comprised 1388 infants from the CHILD-SLEEP birth cohort, who were recruited in the Pirkanmaa Hospital District, Finland, between 2011 and 2013. Sleep and background factor questionnaires were filled out prenatally by parents and when the infant was three and eight months old.

RESULTS

The prevalence of habitual snoring was 3.2% at the age of three months and 3.0% at eight months, and snoring infants had more sleeping difficulties at those ages, with odds ratios (ORs) of 3.11 and 4.63, respectively. At three months, snoring infants slept for a shorter length of time (p = 0.001) and their sleep was more restless (p = 0.004). In ordinal logistic regression models, parental snoring (adjusted OR = 1.65 and 2.60) and maternal smoking (adjusted OR = 2.21 and 2.17) were significantly associated with infant snoring at three and eight months, while formula feeding and dummy use (adjusted OR = 1.48 and 1.56) were only associated with infant snoring at three months.

CONCLUSION

Parental snoring and maternal smoking increased the risk of snoring. Infants who snored also seemed to suffer more from other sleep difficulties.

Obstructive sleep apnea severity and dental arches dimensions in children with late primary dentition: An observational study

Objective: The aim of this study was to compare the dimensions of the upper and lower arches in children affected by OSAS with different levels of severity of obstruction.Methods: Twenty-seven Caucasian children (14 males, 13 females; mean age 6, range 5.2-6.1 years) with a diagnosis of OSAS determined by polysomnography were enrolled in this study. The dimensions of both dental arches were measured, and the data were compared among children affected by severe, moderate, and mild OSAS.Results: Statistically significant differences among the three groups revealed that children with severe OSAS had the highest values of upper intercanine and intermolar distances in the sample.Discussion: A severe OSAS grade (AHI > 10) is associated with statistically significantly higher upper intercanine and intermolar distances compared with mild and moderate grades. An early approach to OSAS in children with late primary dentition is auspicated in order to prevent an influence on dental arches growth.

Dysbiosis in Snoring Children: An Interlink to Comorbidities?

BACKGROUND AND OBJECTIVES

Early microbial colonization has a key impact on infant health through nutritional, immunological, and metabolic programming. The origin of child snoring is multifactorial and complex, and may thereby also generate long-term health problems. The link between child snoring and gut microbes remains unclear, although indirect evidence exists regarding this relationship. This study aimed to characterize the connection between gut microbiota and child snoring.

METHODS

In a prospective, observational CHILD-SLEEP birth cohort study, gut microbiota in a subcohort of 43 of these children at 2 years of life was profiled with 16S ribosomal RNA gene amplicon sequencing.

RESULTS

A higher abundance of the Proteobacteria phylum, the Enterobacteriaceae family, and Erysipelotrichaceae family, as well as a higher ratio of Firmicutes to Bacteroidetes were detected in snorers as compared to controls. Furthermore, snorers showed significantly lower microbial diversity and richness than non-snorers.

CONCLUSIONS

The snoring children manifest different gut microbiota as compared with healthy children. Considering that snoring and sleep disorders can be a source of long-term consequences, including cardiovascular, metabolic, immunological, neurocognitive and behavioral consequences, our results proposes early microbiota as a new treatment target.

Optimising the Apnoea Classification Performance of a Neural Network Classifier Processing ECG-Oximetry Signals

In this paper we investigate using principal components analysis to optimize the performance of a neural network system processing simultaneously acquired electrocardiogram (ECG) and oximetry signals. The algorithm identifies epochs of normal breathing, central apnoea (CA), and obstructive apnoea (OA) by processing a pooled feature set containing information capturing the desaturations from the oximeter sensor as well as time and spectral features from the ECG. Training and testing of the system was facilitated with a dataset of 125 scored polysomnogram recordings with accompanying respiratory event annotations. When classifying the three epoch types, our system achieved a specificity of 91%, a sensitivity to CA of 28% and sensitivity to OA of 63%. A sensitivity of 81% was achieved when the CA and OA epochs were combined into one class.

Obstructive Sleep Apnea and Sleep Architecture in Adolescents With Severe Obesity: Effects of a 9-Month Lifestyle Modification Program Based on Regular Exercise and a Balanced Diet

STUDY OBJECTIVES

Physical exercise and lifestyle modification are recognized as adjunct therapy for obstructive sleep apnea (OSA) in overweight adults. The objectives of this study were to investigate the effects of long-term physical exercise combined with a balanced diet on sleep architecture, sleep duration, and OSA in adolescents with severe obesity.

METHODS

This interventional study was conducted in a nursing institution. Participants were aged 14.6 ± 1.2 years with obesity (body mass index (BMI) = 40.2 ± 6.5 kg/m2). At admission and at 9 months, participants underwent ambulatory polysomnography and incremental maximal exercise testing to determine cardiorespiratory fitness.

RESULTS

Twenty-four subjects completed the study. Analyses were performed on the whole population and on a subgroup of subjects with OSA (OSA-subgroup). OSA, defined as obstructive apnea-hypopnea index (OAHI) ≥ 2 events/h, was diagnosed in 58.3% of the population. OAHI was only associated with fat mass in males (r = .75, P < .05). At 9 months postintervention, weight loss (-11.1 kg, P < .0001) and improved cardiorespiratory fitness (VO2peak: +4.9 mL/min/kg, P < .001) were found in the whole population. Sleep duration was increased (+34 minutes, P < .05) and sleep architecture was changed with an increase of rapid eye movement sleep (+2.5%, P < .05) and a decrease of stage N3 sleep (-3.1%, P < .001). Similar results were found in the OSA subgroup. However, OAHI remained unchanged (P = .18).

CONCLUSIONS

A combination of supervised aerobic exercise and a balanced diet led to weight loss, improved aerobic capacity, and modified sleep architecture without changes in OSA.

COMMENTARY

A commentary on this article appears in this issue on page 907.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Title: Exercise and Venous Compression on Upper Airway Resistance in Obese Teenagers With OSA (OBESOMAC), URL: https://clinicaltrials.gov/ct2/show/NCT02588469, Identifier: NCT02588469.

The evaluation and management of respiratory disease in children with Down syndrome (DS)

Children with Down syndrome (DS) have wide range of respiratory problems. Although underlying abnormalities in the respiratory system are important causes of morbidity and mortality in children with DS, particularly in the young, abnormalities in other organ systems may also impact respiratory function. A comprehensive evaluation of the child with DS and respiratory disease may prevent short-term morbidity and mortality, and reduce the incidence of complications in the long term. This review provides an overview of the various causes of respiratory disease, and insight into some of the newer therapies available to treat obstructive sleep apnea, in this population.

A Wireless Monitoring System Using a Tunneling Sensor Array in a Smart Oral Appliance for Sleep Apnea Treatment

Sleep apnea is a serious sleep disorder, and the most common type is obstructive sleep apnea (OSA). Untreated OSA will cause lots of potential health problems. Oral appliance therapy is an effective and popular approach for OSA treatment, but making a perfect fit for each patient is time-consuming and decreases its efficiency considerably. This paper proposes a System-on-a-Chip (SoC) enabled sleep monitoring system in a smart oral appliance, which is capable of intelligently collecting the physiological data about tongue movement through the whole therapy. A tunneling sensor array with an ultra-high sensitivity is incorporated to accurately detect the subtle pressure from the tongue. When the device is placed on the wireless platform, the temporary stored data will be retrieved and wirelessly transmitted to personal computers and cloud storages. The battery will be recharged by harvesting external RF power from the platform. A compact prototype module, whose size is 4.5 × 2.5 × 0.9 cm³, is implemented and embedded inside the oral appliance to demonstrate the tongue movement detection in continuous time frames. The functions of this design are verified by the presented measurement results. This design aims to increase efficiency and make it a total solution for OSA treatment.

The weighty issue of obesity in paediatric respiratory medicine

Some have observed that developed world is fat and getting fatter. This is even extending into the developing world, and it is important to appreciate that the consequences of childhood obesity last into adulthood and are associated with premature death. From the paediatric respiratory perspective, the deposition of excess adipose tissue in the thoraco-abdominal region begins early in life and is believed to alter diaphragm mobility and chest wall expansion, reduce lung compliance, and result in a rapid shallow breathing pattern with an increased work of breathing and reduction in maximum ventilatory capacity. This results in respiratory symptoms of exertional dyspnoea related to deconditioning which may present as exercise limitation, leading to confusion with common lung diseases such as asthma. The manifestations of the increasingly prevalent problems of overweight and obesity in young people and their interaction with common conditions of asthma and obstructive sleep apnoea will be discussed.

Blood count values and ratios for predicting sleep apnea in obese children

OBJECTIVES

To detect whether the mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are contributing factors in the diagnosis and severity of sleep apnea in obese children.

INTRODUCTION

Obesity is a public health problem, and its prevalence increases daily. Although PSG is the gold standard test in the investigation of sleep apnea, the application of this test requires equipment, personnel, time, and cost. There is no simple laboratory test for diagnosing and determining the severity of sleep apnea. Recently, MPV, NLR, and PLR, known as the inflammatory markers in CBC test parameters, have been investigated in some studies. We aim to investigate whether these parameters could provide a method for diagnosing and determining the severity of OSAS in obese children.

METHODS

Clinical records of 180 patients were evaluated. All subjects had venous blood samples collected from the antecubital vein in the morning, after an overnight fasting, one day before PSG. Hemoglobin, RDW, MPV, PLT, platelet distribution width (PDW), and WBC count were measured. After anthropometric and laboratory analysis, 127 obese children were assessed for sleep study. Eighty-three patients who met the required polysomnographic criteria were divided into three groups as follows: group A [non-OSAS, apnea-plus-hypopnea index (AHI) < 1], groupB (1 ≤ AHI < 5), and groupC (AHI ≥ 5).

RESULTS

Total recording time, total sleep time, sleep efficiency, REM, and NREM sleep stage latency values were not statistically significant among groups. However, the number of awakenings, AHI, oxygen desaturation events, mean oxygen saturation, lowest oxygen saturation, average desaturation, and snoring time values had significant difference among the groups. There was no statistically significant difference among the groups in terms of WBC, Hemoglobin, platelets, PDW, neutrophil, and lymphocyte values. However, RDW values showed a statistically significant difference between groups A and C. Although there was no statistically significant difference of MPV values among groups, NLR and PLR values were statistically significant between groups A and C.

CONCLUSION

According to our study, NLR, PLR, and RDW were found to be significantly higher in children whose AHI was ≥5 than in children from the other groups. However, no correlation was found between MPV levels and OSAS in children.

Obstructive sleep apnoea in craniofacial microsomia: analysis of 755 patients

A retrospective cohort study was set up to analyse the prevalence and treatment of obstructive sleep apnoea (OSA) in relation to the severity of the deformity in patients with craniofacial microsomia (CFM). This study included a population of 755 patients with CFM from three craniofacial centres. Medical charts were reviewed for severity of the deformity, types of breathing difficulty, age at which breathing difficulty first presented, treatment for OSA, and treatment outcome. In total, 133 patients (17.6%) were diagnosed with OSA. Patients with Pruzansky IIB/III classification or bilateral craniofacial microsomia were significantly more often diagnosed with OSA than unilaterally affected patients of Pruzansky I/IIA classification. The initial treatment of OSA consisted of adenotonsillectomy, tracheotomy, or non-invasive positive pressure ventilation. Thirty-seven patients received more than one treatment (range 1-3). In this study, the prevalence of OSA in patients with CFM was higher than the prevalence in the healthy population described in the literature. Although several treatment modalities are available for the treatment of OSA in patients with CFM, treatment should be individualized and based on clinical symptoms, the severity of the deformity, and comorbidities.

Obstructive Sleep Apnoea: Children are not little Adults

During a child's development, several important developmental physiological sleep processes occur, and, occasionally, pathological disorders occur, which results in differences between obstructive sleep apnoea (OSA) in adults and children. There are major differences in sleep and respiratory physiology as well as OSA symptoms and treatment options between children and adults. Many practitioners do not realize these differences, which results in delays in the diagnosis and treatment of OSA in children. The treatment options for OSA in children are markedly different compared with adults, effective in most children. The use of positive airway pressure (PAP) therapy delivered through continuous or bi-level positive airway pressure modes is successful in children and even in infants; however, there are several challenges facing parents and practitioners to achieve good compliance. The early recognition and treatment of paediatric OSA are essential to prevent deleterious consequences. This article discusses the major differences between paediatric and adult OSA and demonstrates why children are not little adults.