1
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Zhang W, Shen Y, Ou X, Wang H, Liu S. Sleep disordered breathing and neurobehavioral deficits in children and adolescents: a systematic review and meta-analysis. BMC Pediatr 2024; 24:70. [PMID: 38245707 PMCID: PMC10799548 DOI: 10.1186/s12887-023-04511-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 12/26/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Sleep disordered breathing (SDB) is broadly recognized to be associated with neurobehavioral deficits, which have significant impacts on developing-aged children and adolescents. Therefore, our study aimed to quantify the proportion of neurobehavioral impairments attributed to SDB in general children and adolescents by population attributable fraction (PAF). METHODS The study was registered at PROSPERO (ID: CRD42023388143). We collected two types of literature on the prevalence of SDB and the risk of SDB-related neurobehavioral deficits from ten electronic databases and registers, respectively. The pooled effect sizes (Pe, Pc, RR) by random-effects meta-analysis were separately substituted into Levin's formula and Miettinen's formula to calculate PAFs. RESULTS Three prevalence literature and 2 risk literature, all with moderate/high quality, were included in the quantitative analysis individually. The prevalence of SDB was 11% (95%CI 2%-20%) in children and adolescents (Pe), while the SDB prevalence was 25% (95%CI 7%-42%) in neurobehavioral patients (Pc). SDB diagnosis at baseline was probably associated with about threefold subsequent incidence of neurobehavioral deficits (pooled RR 3.24, 95%CI 1.25-8.41), after multi-adjustment for key confounders. Up to 19.8% or 17.3% of neurobehavioral consequences may be attributed to SDB from Levin's formula and Miettinen's formula, respectively. CONCLUSIONS A certain number of neurobehavioral consequences may be attributable to SDB. It is essential for clinicians to identify and treat SDB timely, as well as screen for SDB in patients with neurobehavioral impairments. More longitudinal studies of SDB and neurobehavioral deficits are needed in the future to further certify the association between them.
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Affiliation(s)
- Weiyu Zhang
- Department of Respiratory Medicine and Sleep Lab, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Yubin Shen
- Department of Respiratory Medicine and Sleep Lab, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Xiwen Ou
- Department of Respiratory Medicine and Sleep Lab, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Hongwei Wang
- Department of Respiratory Medicine and Sleep Lab, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Song Liu
- Department of Respiratory Medicine and Sleep Lab, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China.
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2
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Howarth TP, Karhu T, Kainulainen S, Chen X, Mahamid A, Töyräs J, Leppänen T. Oxygen resaturation rate is significantly associated with objectively assessed excessive daytime sleepiness in suspected obstructive sleep apnoea patients. Sleep Med 2023; 107:171-178. [PMID: 37187080 DOI: 10.1016/j.sleep.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/22/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Commonly utilised metrics such as the apnoea-hypopnoea index show limited correlation to excessive daytime sleepiness (EDS). Oxygen desaturation parameters show better predictive power, however oxygen resaturation parameters have not yet been investigated. Oxygen resaturation may represent increased cardiovascular fitness and thus we hypothesized that a higher resaturation rate would be protective against EDS. METHODS Oxygen saturation parameters were computed via ABOSA software for adult patients referred for polysomnography and multiple sleep latency test in Israel Loewenstein hospital 2001-2011. EDS was defined as a mean sleep latency (MSL) below 8 min. RESULTS 1629 patients (75% male, 53% obese, median age of 54 years) were included for analysis. The average desaturation event nadir was 90.4% and resaturation rate 0.59%/second. Median MSL was 9.6 min, and 606 patients met criteria for EDS. Patients who were younger, female, and with larger desaturations had significantly higher resaturation rates (p < 0.001). In multivariate models, adjusted for age, sex, body mass index, and average desaturation depth, resaturation rate showed a significant negative correlation with MSL (z-score standardised beta, -1 (95%CI -0.49, -1.52)), and significantly increased odds ratio (OR) of EDS (OR, 1.28 (95%CI 1.07, 1.53)). The beta associated with resaturation rate was larger, though non-significantly, than that of desaturation depth (difference 0.36 (95% CI -1.34, 0.62), p = 0.470). CONCLUSION Oxygen resaturation parameters show significant associations with objectively assessed EDS independent of desaturation parameters. Thus, resaturation and desaturation parameters may reflect differing underlying mechanistic pathways and both be considered novel and appropriate markers for assessing sleep-disordered breathing and associated outcomes.
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Affiliation(s)
- Timothy P Howarth
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Darwin Respiratory and Sleep Health, Darwin Private Hospital, Darwin, Australia; College of Health and Human Sciences, Charles Darwin University, Darwin, Australia.
| | - Tuomas Karhu
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Samu Kainulainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Xin Chen
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Alaa Mahamid
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Juha Töyräs
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia; Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Timo Leppänen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland; School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
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3
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Chuang HH, Wang CY, Chuang LP, Huang YS, Li HY, Fang TJ, Lin RH, Lee LA. The 3% Oxygen Desaturation Index is an Independent Risk Factor for Hypertension Among Children with Obstructive Sleep Apnea. Nat Sci Sleep 2022; 14:1149-1164. [PMID: 35733819 PMCID: PMC9208670 DOI: 10.2147/nss.s362557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) and obesity are both directional risk factors of hypertension. Chronic intermittent hypoxemia (IH) is a commonly observed pathophysiological mechanism involved in multiple comorbidities of OSA. However, their interactions are not well understood in children. This study aimed to investigate the associations of IH indexes (oxygen desaturation index 3% [ODI3], mean peripheral oxygen saturation [SpO2], least SpO2, and time with SpO2 < 85%), apnea-hypopnea index, and weight status with hypertension in a sample of pediatric OSA patients. METHODS The medical records of 365 pediatric OSA patients were retrospectively reviewed in this cross-sectional study. Demographics, anthropometrics, standard in-laboratory polysomnography, and nocturnal blood pressure were collected. Multivariate logistic regression with forward selection was used to identify independent predictors of hypertension. RESULTS Multivariate logistic regression analysis showed that ODI3 (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01-1.03) and body mass index z-score (OR = 1.34, 95% CI = 1.12-1.60) were independent continuous predictors of pediatric hypertension, whilst severe OSA (OR = 2.62, 95% CI = 1.60-4.29) and overweight/obesity (OR = 2.63, 95% CI = 1.59-4.34) were independent categorical predictors. Traditional risk factors including male sex (OR = 2.33, 95% CI = 1.02-5.33), late childhood/adolescence (OR = 1.98, 95% CI = 1.01-3.88), and overweight/obesity (OR = 2.97, 95% CI = 1.56-5.67) combined with sleep hypoxemia (least SpO2 ≤ 95%) (OR = 2.24, 95% CI = 1.16-4.04) predicted hypertension (R 2 = 0.21) in the severe IH subgroup (n = 205), while the no/mild IH subgroup (n = 160) had an entirely different predictor, severe OSA (OR = 3.81, 95% CI = 1.49-9.74) (R 2 = 0.07). CONCLUSION The close relationships among IH, overweight/obesity, and hypertension highlight the importance of reducing IH and body weight in children with OSA.
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Affiliation(s)
- Hai-Hua Chuang
- Department of Family Medicine, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan.,Department of Industrial Engineering and Management, National Taipei University of Technology, Taipei, Taiwan.,School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Chao-Yung Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan
| | - Li-Pang Chuang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Shu Huang
- Department of Child Psychiatry, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan
| | - Hsueh-Yu Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan
| | - Tuan-Jen Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan
| | - Rong-Ho Lin
- Department of Industrial Engineering and Management, National Taipei University of Technology, Taipei, Taiwan
| | - Li-Ang Lee
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou Main Branch, Chang Gung University, Taoyuan, Taiwan
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4
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Wu D, Au VH, Yang B, Horne SJ, Weedon J, Bernstein MJ, Goldstein NA. Impact of Adenotonsillectomy on Homework Performance in Children With Obstructive Sleep-Disordered Breathing. Ann Otol Rhinol Laryngol 2021; 131:1231-1240. [PMID: 34872386 DOI: 10.1177/00034894211062543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE As a first line treatment for pediatric obstructive sleep-disordered breathing (SDB), adenotonsillectomy (AT) has been shown to confer physiologic and neurocognitive benefits to a child. However, there is a scarcity of data on how homework performance is affected postoperatively. Our objective was to evaluate the impact of AT on homework performance in children with SDB. METHODS Children in grades 1 to 8 undergoing AT for SDB based on clinical criteria with or without preoperative polysomnography along with a control group of children undergoing surgery unrelated to the treatment of SDB were recruited. The primary outcome of interest was the differential change in homework performance between the study group and control at follow-up as measured by the validated Homework Performance Questionnaire (HPQ-P). Adjustments were made for demographics and Pediatric Sleep Questionnaire (PSQ) scores. RESULTS 116 AT and 47 control subjects were recruited, and follow-up data was obtained in 99 AT and 35 control subjects. There were no significant differences between the general (total) HPQ-P scores and subscale scores between the AT and control subjects at entry and there were no significant differences in the change scores (follow-up minus initial scores) between the groups. Regression modeling also demonstrated that there were no group (AT vs control) by time interactions that predicted differential improvements in the HPQ-P (P > .10 for each model) although initial PSQ score was a significant predictor of lower HPQ-P scores for all models. CONCLUSIONS Children with SDB experienced improvement in HPQ-P scores postoperatively, but the degree of change was not significant when compared to controls. Further studies incorporating additional educational metrics are encouraged to assess the true scholastic impact of AT in children with SDB.
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Affiliation(s)
- Derek Wu
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Vivienne H Au
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Billy Yang
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Sylvia J Horne
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jeremy Weedon
- Medical Research Library, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Michelle J Bernstein
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Nira A Goldstein
- Division of Pediatric Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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5
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Hypoxia, hypercarbia, and mortality reporting in studies of anaesthesia-related neonatal neurodevelopmental delay in rodent models. Eur J Anaesthesiol 2020; 37:70-84. [DOI: 10.1097/eja.0000000000001105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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6
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 265] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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7
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Hayes D, Wilson KC, Krivchenia K, Hawkins SMM, Balfour-Lynn IM, Gozal D, Panitch HB, Splaingard ML, Rhein LM, Kurland G, Abman SH, Hoffman TM, Carroll CL, Cataletto ME, Tumin D, Oren E, Martin RJ, Baker J, Porta GR, Kaley D, Gettys A, Deterding RR. Home Oxygen Therapy for Children. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2019; 199:e5-e23. [PMID: 30707039 PMCID: PMC6802853 DOI: 10.1164/rccm.201812-2276st] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Home oxygen therapy is often required in children with chronic respiratory conditions. This document provides an evidence-based clinical practice guideline on the implementation, monitoring, and discontinuation of home oxygen therapy for the pediatric population. Methods: A multidisciplinary panel identified pertinent questions regarding home oxygen therapy in children, conducted systematic reviews of the relevant literature, and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the quality of evidence and strength of clinical recommendations. Results: After considering the panel’s confidence in the estimated effects, the balance of desirable (benefits) and undesirable (harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were developed for or against home oxygen therapy specific to pediatric lung and pulmonary vascular diseases. Conclusions: Although home oxygen therapy is commonly required in the care of children, there is a striking lack of empirical evidence regarding implementation, monitoring, and discontinuation of supplemental oxygen therapy. The panel formulated and provided the rationale for clinical recommendations for home oxygen therapy based on scant empirical evidence, expert opinion, and clinical experience to aid clinicians in the management of these complex pediatric patients and identified important areas for future research.
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8
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary. Otolaryngol Head Neck Surg 2019; 160:187-205. [PMID: 30921525 DOI: 10.1177/0194599818807917] [Citation(s) in RCA: 166] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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9
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von Lukowicz M, Herzog N, Ruthardt S, Quante M, Iven G, Poets CF. Effect of a 1-week intense myofunctional training on obstructive sleep apnoea in children with Down syndrome. Arch Dis Child 2019; 104:275-279. [PMID: 30072363 DOI: 10.1136/archdischild-2018-315064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/05/2018] [Accepted: 07/22/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is common in children with Down syndrome (DS), yet difficult to treat. As muscular hypotonia of the upper airway may cause OSA and is also common in DS, we tested whether intense myofunctional therapy improves OSA in children with DS. PATIENTS AND METHODS Forty-two children underwent cardiorespiratory sleep studies immediately before and after a 1-week intensive training camp consisting of three daily 45 min sessions of myofunctional exercises according to Padovan. Primary outcome was the mixed-obstructive-apnoea/hypopnoea index (MOAHI), secondary outcomes the ≤3% oxygen desaturation index (DI3), the ≤90% desaturation index (DI90) and the lowest pulse oximeter saturation (SpO2nadir). RESULTS Eighteen recordings had ≥3 hours of artefact-free recording in both the pretreatment and post-treatment sleep study and were therefore included in the analysis. Mean age was 6.3 years (SD 2.5); 83% had OSA prior to intervention. Mean MOAHI was 6.4 (SD 8.6) before and 6.4 (SD 10.8) after the intervention (p>0.05); the DI3 and SpO2nadir also did not change. Only the DI90 decreased significantly from 2.7 (SD 4.5) to 2.1 (SD 3.7) (p<0.05). CONCLUSION The 1-week intense myofunctional training camp evaluated here in children with DS had only a marginal effect on OSA. Whether a longer follow-up period or duration of intervention would yield stronger effects remains to be determined.
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Affiliation(s)
- Magnus von Lukowicz
- Sleep Medicine, Department of Neonatology, University of Tuebingen, Tuebingen, Germany
| | - Nina Herzog
- Sleep Medicine, Department of Neonatology, University of Tuebingen, Tuebingen, Germany
| | | | - Mirja Quante
- Sleep Medicine, Department of Neonatology, University of Tuebingen, Tuebingen, Germany
| | | | - Christian F Poets
- Sleep Medicine, Department of Neonatology, University of Tuebingen, Tuebingen, Germany
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Chamseddin BH, Johnson RF, Mitchell RB. Obstructive Sleep Apnea in Children with Down Syndrome: Demographic, Clinical, and Polysomnographic Features. Otolaryngol Head Neck Surg 2018; 160:150-157. [DOI: 10.1177/0194599818797308] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objectives To evaluate demographic, clinical, and polysomnographic features of children with Down syndrome suspected of having obstructive sleep apnea. To identify factors that predict severe obstructive sleep apnea among children with Down syndrome. Study Design Case series with chart review. Setting Children’s Medical Center Dallas / University of Texas Southwestern Medical Center. Subject and Methods Demographic, clinical, and polysomnographic data were collected for children with Down syndrome aged 2 to 18 years. Simple and multivariable regression models were used to study predictors of severe obstructive sleep apnea (apnea-hypopnea index ≥10). P≤ .05 was considered significant. Results A total of 106 children with Down syndrome were included, with 89 (84%) <12 years old, 56 (53%) male, 72 (68%) Hispanic, 15 (14%) African American, and 14 (13%) Caucasian. Ninety percent of children had ≥1 medical comorbidities; 95 (90%) patients had obstructive sleep apnea; and 46 (44%) had severe obstructive sleep apnea. The mean SaO2 nadir was lower among obese than nonobese children (80% vs 85%, P = .02). Obese versus nonobese patients had a higher prevalence of severe obstructive sleep apnea (56% vs 35%, P = .03). Severe OSA was associated with heavier weight (odds ratio = 1.0, 95% CI: 1.0-1.1, P = .002) and age ≥12 years (odds ratio = 1.2, 95% CI: 0.2-2.5, P = .02). The multivariable model showed that severe obstructive sleep apnea was associated only with weight (odds ratio = 1.1, 95% CI: 1.0-1.1, P = .02). Conclusion Obese children with DS are at a high risk for severe OSA, with weight as the sole risk factor. The results of this study show the importance of monitoring the weight of children with DS and counseling parents of children with DS about weight loss.
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Affiliation(s)
| | - Romaine F. Johnson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Children’s Health, Children’s Medical Center Dallas, Dallas, Texas, USA
| | - Ron B. Mitchell
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Children’s Health, Children’s Medical Center Dallas, Dallas, Texas, USA
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11
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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]
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12
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Allareddy V, Martinez-Schlurmann N, Rampa S, Nalliah RP, Lidsky KB, Allareddy V, Rotta AT. Predictors of Complications of Tonsillectomy With or Without Adenoidectomy in Hospitalized Children and Adolescents in the United States, 2001-2010: A Population-Based Study. Clin Pediatr (Phila) 2016; 55:593-602. [PMID: 26603580 DOI: 10.1177/0009922815616885] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Outcomes of tonsillectomy (with or without adenoidectomy [w/woA]) in hospitalized children are unclear. We sought, to describe the characteristics of hospitalized children who underwent tonsillectomy (w/woA), to estimate the prevalence of complications and to evaluate the relative impact of different comorbid conditions (CMC) on the risk of occurrence of common complications following these procedures. All patients aged ≤21years who underwent a tonsillectomy (w/woA) were selected from the Nationwide Inpatient Sample (NIS 2001-2010). The associations between several patient/hospital-level factors and occurrence of complications were generated using multivariable logistic regression models. Over a decade, a total of 141 599 hospitalized patients underwent tonsillectomy (w116 319; woA 25 280). A total of 58.1% were males. Majority of the procedures were performed in teaching hospitals (TH, 73.7%), in large (bed-size) hospitals (LH, 57.8%), and in those who were electively admitted (EA, 67.3%). Frequently present CMC in patients included obstructive sleep apnea (OSA, 26.4%), chronic pulmonary disease (CPD, 14.6%), neurological disorders (ND, 6.7%), and obesity (4.8%). Majority of patients were discharged routinely (98%). Overall complication rate was 6.4% with common complications being postoperative pneumonia (2.3%), bacterial infections (1.4%), respiratory complications (1.3%), and hemorrhage (1.2%). All-cause mortality included a total of 60 patients. Patients in TH (odds ratio [OR] = 0.72, 95%CI = 0.62-0.85), LH (OR = 0.80, 95% CI = 0.69-0.93), and those who had the procedures during EA (OR = 0.64, 95% CI = 0.56-0.74) had significantly lower odds of complications compared with their counterparts. CMC such as anemia, CPD, coagulopathy, HT, ND, and fluid/electrolyte disorders were independent predictors of significantly higher complication risk (P < .05). In conclusion, hospitalized children who underwent tonsillectomy (w/woA) in large or teaching hospitals, or during elective admissions had lower risk of complications. Comorbidity is an important independent predictor of complications in this cohort.
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Affiliation(s)
| | | | | | | | - Karen B Lidsky
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Alexandre T Rotta
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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13
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O’Brien LM. Sleep-Related Breathing Disorder, Cognitive Functioning, and Behavioral-Psychiatric Syndromes in Children. Sleep Med Clin 2015; 10:169-79. [DOI: 10.1016/j.jsmc.2015.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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14
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Brockmann PE, Schlaud M, Poets CF, Urschitz MS. 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.
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Affiliation(s)
- Pablo E Brockmann
- Working Group on Pediatric Sleep Medicine, Department of Neonatology, University Children's Hospital, Tuebingen, Germany; Department of Pediatrics, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.
| | - Martin Schlaud
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Christian F Poets
- Working Group on Pediatric Sleep Medicine, Department of Neonatology, University Children's Hospital, Tuebingen, Germany
| | - Michael S Urschitz
- Working Group on Pediatric Sleep Medicine, Department of Neonatology, University Children's Hospital, Tuebingen, Germany; Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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15
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Biggs SN, Nixon GM, Horne RS. The conundrum of primary snoring in children: What are we missing in regards to cognitive and behavioural morbidity? Sleep Med Rev 2014; 18:463-75. [DOI: 10.1016/j.smrv.2014.06.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 06/20/2014] [Accepted: 06/20/2014] [Indexed: 12/11/2022]
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16
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Baldassari CM, Alam L, Vigilar M, Benke J, Martin C, Ishman S. Correlation between REM AHI and Quality-of-Life Scores in Children with Sleep-Disordered Breathing. Otolaryngol Head Neck Surg 2014; 151:687-91. [DOI: 10.1177/0194599814547504] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Prior research has demonstrated poor correlation between the obstructive apnea-hypopnea index (AHI) on full-night polysomnogram (PSG) and quality-of-life (QOL) scores. We aim to examine the association between rapid eye movement (REM) AHI and QOL scores in children with sleep-disordered breathing (SDB). Study Design Prospective trial. Setting Two tertiary children’s hospitals. Subjects and Methods Children between 3 and 16 years of age with suspected SDB who were undergoing PSG were eligible. Children with craniofacial anomalies were excluded. Subjects’ caregivers completed the Obstructive Sleep Apnea–18 (OSA-18), a validated QOL survey. Power analysis determined a group size of 34. Results One hundred twenty-seven patients were enrolled. The mean (SD) age was 6.3 (3.3) years. Most subjects (52%) were black and 26% were obese. The mean (SD) obstructive AHI of the subject population was 5.4 (11.9), while the mean (SD) REM AHI was 13.1 (23.7). The mean total OSA-18 score was 65.2, indicating a moderate impact of SDB on QOL. Neither the obstructive AHI ( P = .73) nor the REM AHI ( P = .49) correlated with total OSA-18 scores. However, lower nadir oxygen saturation was associated with significantly poorer QOL ( P = .02). The sleep disturbance OSA-18 subset score significantly correlated with both the obstructive AHI ( r2 = 0.22; P = .01) and the REM AHI ( r2 = 0.22; P = .01); the remaining 4 subset scores did not correlate with either factor. Conclusion Neither obstructive AHI nor REM AHI correlates with total OSA-18 QOL scores. With the exception of nadir oxygen saturation, PSG parameters do not reflect the burden of SDB on QOL in children.
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Affiliation(s)
- Cristina Marie Baldassari
- Department of Otolaryngology–Head and Neck Surgery, Eastern Virginia Medical School, and Department of Pediatric Otolaryngology, Children’s Hospital of the King’s Daughters, Norfolk, Virginia, USA
| | - Lyla Alam
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Maria Vigilar
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Benke
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charley Martin
- Eastern Virginia Medical School, Graduate Program in Public Health, Norfolk, Virginia, USA
| | - Stacey Ishman
- Departments of Pediatric Otolaryngology–Head & Neck Surgery & Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, and Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
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17
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Pavone M, Cutrera R, Verrillo E, Salerno T, Soldini S, Brouillette RT. Night-to-night consistency of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatr Pulmonol 2013; 48:754-60. [PMID: 23533148 DOI: 10.1002/ppul.22685] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 08/28/2012] [Accepted: 08/29/2012] [Indexed: 01/18/2023]
Abstract
RATIONALE At-home nocturnal pulse oximetry has a high positive predictive value (PPV) for polysomnographically-diagnosed obstructive sleep apnea (OSA) but no studies have been published testing the night-to-night consistency of at-home nocturnal pulse oximetry for the evaluation of suspected OSA in children. We therefore determined the night-to-night consistency of nocturnal pulse oximetry as a diagnostic test for OSA in children. METHODS We prospectively studied 148 children (96 male) aged 4.9 ± 2.4 (1.2-11.8) years, referred for suspected OSA. To evaluate night-to-night consistency, we compared an oximetry analysis method, the McGill Oximetry Score (MOS), from two consecutive at-home nocturnal pulse oximetry recordings. RESULTS Pulse oximetry metrics were similar on the two nights. The MOS on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive, 143/148 (Spearman's correlation coefficient = 0.90). A more detailed analysis using four categories (MOS 1, 2, 3, and 4) of OSA severity showed very good night-to-night agreement, 133/148 (Spearman's correlation coefficient = 0.91). Variability was increased in children younger than 4 years of age compared to older children. CONCLUSIONS Night-to-night consistency of nocturnal pulse oximetry as a diagnostic test for OSA showed excellent agreement. Night-to-night consistency of pulse oximetry, as analyzed by the MOS, for diagnosis and severity evaluation further validates this abbreviated testing method for pediatric OSA. Polysomnography (PSG) is required to rule in or rule out OSA in children if a single night oximetry testing is inconclusive.
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Affiliation(s)
- Martino Pavone
- Respiratory Unit, Department of Pediatrics, Bambino Gesù Children's Hospital, Piazza S. Onofrio, 00165 Rome, Italy.
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18
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Korndewal MJ, Geurts van Kessel WMH, Jak LG, Uiterwaal CSPM, Rövekamp MH, van der Ent CK. Influence of obesity on nocturnal oxygen saturation in young children. Eur J Pediatr 2012; 171:1687-93. [PMID: 22875313 DOI: 10.1007/s00431-012-1806-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 07/14/2012] [Accepted: 07/20/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Obesity is increasing worldwide and it is accompanied by major health effects. In adults and school-aged children, obesity is associated with decreased respiratory function, which may lead to disturbed sleeping and subsequently difficulties in concentration and behavioural disorders. The evidence for the association between obesity and decreased respiratory function in younger children is scarce. To explore the association between body weight and nocturnal respiratory function in young children, 1 to 3 years old, nocturnal pulse oximetry was performed at home. Children with tonsillar hypertrophy were excluded. Percentage of time with oxygen saturation (SpO(2)) <95 % was measured and its association with body mass index (BMI) for age z scores was analysed. Pulse oximetric data of 51 children, including 18 children with a BMI for age above +2 standard deviations, were obtained for this study. Linear regression analysis, correction for gender and parental smoking, showed a positive association between the natural logarithm of SpO(2) <95 % and BMI for age z score [regression coefficient (β) 0.19, 95 % confidence interval 0.00-0.39]. CONCLUSION In young children, higher body weight is associated with a decrease in nocturnal oxygen saturation.
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Affiliation(s)
- Marjolein J Korndewal
- Department of Pediatrics, Gelre Hospitals, Postbus 9014, 7300 DS Apeldoorn, The Netherlands.
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19
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Mandrell BN, Wise M, Schoumacher RA, Pritchard M, West N, Ness KK, Crabtree VM, Merchant TE, Morris B. Excessive daytime sleepiness and sleep-disordered breathing disturbances in survivors of childhood central nervous system tumors. Pediatr Blood Cancer 2012; 58:746-51. [PMID: 22009579 PMCID: PMC3519925 DOI: 10.1002/pbc.23311] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 07/25/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Improvements in treatment and management for pediatric central nervous system (CNS) tumors have increased survival rates, allowing clinicians to focus on long-term sequelae, including sleep disorders. The objective of this study was to describe a series of CNS tumor survivors who had sleep evaluations that included polysomnography (PSG) with attention to sleep disorder in relation to the tumor site. PROCEDURE We report on 31 patients who had retrievable reports including an overnight PSG; 17 also underwent multiple sleep latency tests (MSLT) to characterize their sleepiness. RESULTS Mean age at tumor diagnosis was 7.4 years, mean age at sleep referral 14.3 years, and a mean time between tumor diagnosis and sleep referral of 6.9 years. The most common tumor location was the suprasellar region, the most common reason for sleep referral was excessive daytime sleepiness (EDS), and the most common sleep diagnosis was obstructive sleep apnea (n = 14) followed by central sleep apnea (n = 4), hypersomnia due to medical condition (n = 4), and narcolepsy (n = 3). Twenty-six of the 31 subjects were obese/overweight, and among those with the concurrent complaint of EDS, the mean sleep latency on MSLT was 3.16 minutes, consistent with excessive sleepiness. CONCLUSIONS Suprasellar region tumor survivors who are obese or overweight are more likely to have complaints of EDS and are at greater risk of sleep-disordered breathing. Sleep-related symptoms may not be recognized and referral initiated until years after CNS diagnosis. A periodic and thorough sleep history should be taken when caring for CNS tumor survivors.
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Affiliation(s)
- Belinda N Mandrell
- Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA.
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Kaditis A, Kheirandish-Gozal L, Gozal D. Algorithm for the diagnosis and treatment of pediatric OSA: A proposal of two pediatric sleep centers. Sleep Med 2012; 13:217-27. [DOI: 10.1016/j.sleep.2011.09.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 09/04/2011] [Accepted: 09/07/2011] [Indexed: 01/28/2023]
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Abstract
The introduction of pulse oximetry in clinical practice has allowed for simple, noninvasive, and reasonably accurate estimation of arterial oxygen saturation. Pulse oximetry is routinely used in the emergency department, the pediatric ward, and in pediatric intensive and perioperative care. However, clinically relevant principles and inherent limitations of the method are not always well understood by health care professionals caring for children. The calculation of the percentage of arterial oxyhemoglobin is based on the distinct characteristics of light absorption in the red and infrared spectra by oxygenated versus deoxygenated hemoglobin and takes advantage of the variation in light absorption caused by the pulsatility of arterial blood. Computation of oxygen saturation is achieved with the use of calibration algorithms. Safe use of pulse oximetry requires knowledge of its limitations, which include motion artifacts, poor perfusion at the site of measurement, irregular rhythms, ambient light or electromagnetic interference, skin pigmentation, nail polish, calibration assumptions, probe positioning, time lag in detecting hypoxic events, venous pulsation, intravenous dyes, and presence of abnormal hemoglobin molecules. In this review we describe the physiologic principles and limitations of pulse oximetry, discuss normal values, and highlight its importance in common pediatric diseases, in which the principle mechanism of hypoxemia is ventilation/perfusion mismatch (eg, asthma exacerbation, acute bronchiolitis, pneumonia) versus hypoventilation (eg, laryngotracheitis, vocal cord dysfunction, foreign-body aspiration in the larynx or trachea). Additional technologic advancements in pulse oximetry and its incorporation into evidence-based clinical algorithms will improve the efficiency of the method in daily pediatric practice.
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Affiliation(s)
- Sotirios Fouzas
- Respiratory Unit, Department of Pediatrics, University Hospital of Patras, Rio, 265 04 Patras, Greece.
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22
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Abou-Khadra MK. Sleep of children living in institutional care facilities. Sleep Breath 2011; 16:887-94. [PMID: 21915643 DOI: 10.1007/s11325-011-0592-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 08/22/2011] [Accepted: 09/05/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe sleep patterns and problems among institutionalized children. METHODS In this cross-sectional study, the caregivers of 118 children, aged 4-12 years from six institutional care facilities completed the Children's Sleep Habits Questionnaire (CSHQ). RESULTS The mean (±SD) of night bedtime was 21:05 ± 2:52, mean morning wake-up time was 06:58 ± 0:31, mean total sleep duration was 10 ± 1.1 h, and mean night-sleep duration was 9.5 ± 0.9 h. The percentage of children who took a daytime nap was 34.7% (n = 41) and the mean duration of nap was 0.5 ± 0.7 h. The most frequently reported sleep problems were bedtime resistance, daytime sleepiness and night awakening. Children with bedtime at or after 9 PM, night-sleep duration less than 10 h and daytime napping had more disturbed sleep. CONCLUSIONS Sleep problems are common among this sample of institutionalized children.
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Affiliation(s)
- Maha K Abou-Khadra
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
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23
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Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144:S1-30. [PMID: 21493257 DOI: 10.1177/0194599810389949] [Citation(s) in RCA: 664] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy. PURPOSE The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care. RESULTS The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A β-hemolytic streptococcus.
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Affiliation(s)
- Reginald F Baugh
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA.
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Gozal D, Kheirandish-Gozal L. New approaches to the diagnosis of sleep-disordered breathing in children. Sleep Med 2010; 11:708-13. [DOI: 10.1016/j.sleep.2009.12.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 12/21/2009] [Accepted: 12/22/2009] [Indexed: 11/26/2022]
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Kohler MJ, Lushington K, Kennedy JD. Neurocognitive performance and behavior before and after treatment for sleep-disordered breathing in children. Nat Sci Sleep 2010; 2:159-85. [PMID: 23616708 PMCID: PMC3630946 DOI: 10.2147/nss.s6934] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Neurocognitive and behavioral problems are increasingly reported in children with sleep-disordered breathing (SDB). The impact of treatment for SDB on neurocognition and behavior is, therefore, an issue of increasing importance. To date, there has been little consideration given to the quality of studies when reviewing associated neurocognitive and behavioral problems in children with SDB, and furthermore, there has been little systematic review of treatment outcomes. The aim of this review was to provide an up-to-date and critical review of the current literature. Findings indicate a specific pattern of neurocognitive problems in children with SDB; however, the pattern of behavioral problems is less clear. Very few studies were found to provide a rigorous investigation of posttreatment neurocognitive and behavior outcomes. Despite this, relatively consistent improvements in global intelligence, attention, and visual spatial ability are shown; however, persistent deficits in other domains are also evident. For behavior, problems of hyperactivity, aggression or conduct problems, and somatic complaints improve following treatment. In contrast, symptoms of anxiety and social problems less consistently improve. These findings should aid in the development of more targeted investigations and well-designed studies exploring both the causative mechanisms and the treatment response for neurocognitive and behavior problems in children with SDB.
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Affiliation(s)
- Mark J Kohler
- Children's Research Centre, University of Adelaide, North Adelaide, Australia
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Ayhan H, Iyigun E, Tastan S, Orhan ME, Ozturk E. Comparison of two different oxygen delivery methods in the early postoperative period: randomized trial. J Adv Nurs 2009; 65:1237-47. [DOI: 10.1111/j.1365-2648.2009.04984.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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ABOU-KHADRA MK. Sleep patterns and sleep problems among Egyptian school children living in urban, suburban, and rural areas. Sleep Biol Rhythms 2009. [DOI: 10.1111/j.1479-8425.2009.00392.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Costa DJ, Mitchell R. Adenotonsillectomy for obstructive sleep apnea in obese children: A meta-analysis. Otolaryngol Head Neck Surg 2009; 140:455-60. [DOI: 10.1016/j.otohns.2008.12.038] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 12/09/2008] [Accepted: 12/16/2008] [Indexed: 01/17/2023]
Abstract
Objective: The purpose of this study was to determine the effectiveness of adenotonsillectomy (T&A) for treating obstructive sleep apnea (OSA) in obese children. Data Sources: PubMed and Ovid databases. Review Methods: A meta-analysis of studies that reported sleep parameters in obese children with OSA before and after T&A. Data were analyzed using the random effects model. Statistical significance was P ≤ 0.05. Results: Data from four studies that included 110 children were analyzed. The mean sample size was 27.5 (range, 18–33). The mean body mass index z score was 2.81. The mean pre- and postoperative apnea-hypopnea index (AHI) was 29.4 (range, 22.2–34.3) and 10.3 (range, 6.0–12.2), respectively. The weighted mean difference between pre- and postoperative AHI was a significant reduction of 18.3 events per hour (95% confidence interval [CI], 11.2–25.5). The mean pre- and postoperative oxygen saturation nadir was 78.4 percent (range, 73.9%-81.1%) and 85.7 percent (range, 83.6%-89.9%), respectively. The weighted mean difference was a significant increase of the oxygen saturation nadir of 6.3 percent (95% CI, 3.9–8.7). Forty-nine percent of children had a postoperative AHI <5, 25 percent of children had a postoperative AHI <2, and 12 percent of children had a postoperative AHI <1. Conclusions: T&A improves but does not resolve OSA in the majority of obese children. The efficacy and role of additional therapeutic options require more study. The high incidence of obesity in children makes this a public health priority.
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Affiliation(s)
- Dary J. Costa
- Department of Otolaryngology, St Louis University School of Medicine, St. Louis, MO
| | - Ron Mitchell
- Department of Otolaryngology, St Louis University School of Medicine, St. Louis, MO
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Kargoshaie A, Akhlaghi M, Najafi M. Oxygen saturation improvement after adenotonsillectomy in children. Pak J Biol Sci 2009; 12:276-280. [PMID: 19579958 DOI: 10.3923/pjbs.2009.276.280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The goal of this study was to establish whether adenotonsillectomy is effective on the severity of oxygen desaturation or improve oxygen saturation in children with sleep breathing disorders. Thirty-two children, aged 4-7 years, with clinical indication for adenotonsillectomy were enrolled in a non-controlled clinical trial. Pre- and postoperative nocturnal oxygen saturation monitoring was done and oxygen desaturation index as well as desaturation events were analyzed using Wilcoxon and paired Student's t-tests. Snoring was the most prevalent (87.5%) complaint before operation. The study revealed a significant improvement in the postoperative oxygen desaturation index (1.60 +/- 3.22) compared with the preoperative oxygen desaturation index (3.98 +/- 4.93) (p < 0.01). Oxygen desaturation events at the level of oxygen saturation 85-89% was significantly improved after operation (p < 0.01). No significant differences were seen in the desaturation events at the levels of oxygen saturation lower than 85%. Nocturnal oxygen saturation improves mildly after adenotonsillectomy in children with sleep breathing disorders.
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Affiliation(s)
- A Kargoshaie
- Department of Otorhynolaryngology, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Tomás Vila M, Beseler Soto B, Benac Prefasi M, Cardona Ferrer C, Pascual Olmos M, Lozano Campos I. Trastornos del sueño en niños y adolescentes con incapacidad psíquica. An Pediatr (Barc) 2008; 69:335-41. [DOI: 10.1157/13126558] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
OBJECTIVE The goal of the study was to determine the relative importance of sleep, IQ, neuropsychological, and attention-deficit/hyperactivity disorder (ADHD) scores in predicting academic achievement. METHOD Objective overnight polysomnograph sleep scores, parent ratings of sleep problems, IQ, neuropsychological test scores, and parent ratings of ADHD were used to predict academic achievement in a general population sample of 412 elementary schoolchildren, 6 to 12 years of age with IQs of 71 to 147. RESULTS Using stepwise linear regression analysis, IQ was the best single predictor of reading and math achievement test scores. The most powerful combined predictors of achievement were IQ and some of the neuropsychological test scores. Subjective parent-reported sleep problems and objective polysomnograph scores (apnea-hypopnea index, mean oxygen saturation and lowest saturation percentage during sleep, snoring frequency and severity, sleep latency, minutes to rapid eye movement (REM) sleep, arousal index, number of awakenings, sleep efficiency, and percentage of stage 1, 2, 3, 4, and REM sleep) did not contribute significantly more to the prediction of achievement. Children with and without sleep problems did not differ from each other in achievement. IQ, neuropsychological test scores, and ADHD ratings were all significantly related to achievement, but correlations between achievement and objective and subjective sleep scores were all nonsignificant. CONCLUSIONS There may be individual children for whom sleep problems affect achievement, but for a large group of community children, sleep was not significantly related to academic functioning. In contrast, IQ and neuropsychological test scores were powerful predictors of achievement.
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Muzumdar H, Arens R. Diagnostic issues in pediatric obstructive sleep apnea. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2008; 5:263-73. [PMID: 18250220 PMCID: PMC2645257 DOI: 10.1513/pats.200707-113mg] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 10/27/2007] [Indexed: 01/01/2023]
Abstract
Obstructive sleep apnea syndrome (OSAS) in children includes a spectrum of respiratory disorders with significant morbidities. Diagnosis of OSAS is based on clinical suspicion, history, and physical findings, and confirmation is made by polysomnography. There has been significant progress in recent years in technologies available for diagnosis of OSAS since the consensus statement of the American Thoracic Society in 1996. The current review describes methodologies that are available today for assessment and diagnosis of OSAS in children and summarizes the most recent recommendations of the American Academy of Sleep Medicine Task Force regarding scoring sleep-related respiratory events in children.
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Affiliation(s)
- Hiren Muzumdar
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY 10467-2490, USA
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Thomas RJ, Tamisier R, Boucher J, Kotlar Y, Vigneault K, Weiss JW, Gilmartin G. Nocturnal hypoxia exposure with simulated altitude for 14 days does not significantly alter working memory or vigilance in humans. Sleep 2008; 30:1195-203. [PMID: 17910391 PMCID: PMC1978402 DOI: 10.1093/sleep/30.9.1195] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES To assess the effect of 2 weeks of nocturnal hypoxia exposure using simulated altitude on attention and working memory in healthy adult humans. DESIGN Prospective experimental physiological assessment. SETTING General Clinical Research Center. PARTICIPANTS Eleven healthy, nonsmoking, subjects (7 men, 4 women). The subjects had a mean age of 27 +/- 1.5 years and body mass index of 23 +/- 0.9 kg/m2. INTERVENTIONS Subjects were exposed to 9 hours of continuous hypoxia from 2200 to 0700 hours in an altitude tent. Acclimatization was accomplished by graded increases in "altitude" over 3 nights (7700, 10,000 and 13,000 feet), followed by 13,000 feet for 13 consecutive days (FIO2 0.13). MEASUREMENTS AND RESULTS Polysomnography that included airflow measurements with a nasal cannula were done at baseline and during 3 time points across the protocol (nights 3, 7, and 14). Attention (10-minute Psychomotor Vigilance Task) and working memory (10-minute verbal 2-back) were assessed at baseline and on day 4, 8, 9, and 15. Nocturnal hypoxia was documented using endpoints of minimum oxygen saturation, oxygen desaturation index, and percentage of total sleep time under 90% and 80%. Total sleep time was reduced, stage 1 sleep was increased, and both obstructive and nonobstructive respiratory events were induced by altitude exposure. There was no difference in subjective mood, attention, or working memory. CONCLUSIONS Two weeks of nocturnal continuous hypoxia in an altitude tent did not induce subjective sleepiness or impair objective vigilance and working memory. Caution is recommended in the extrapolation to humans the effects of hypoxia in animal models.
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Affiliation(s)
- Robert Joseph Thomas
- Beth Israel Deaconess Medical School & Harvard Medical School, Boston, MA 02215, USA.
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Farahani R, Kanaan A, Gavrialov O, Brunnert S, Douglas RM, Morcillo P, Haddad GG. Differential effects of chronic intermittent and chronic constant hypoxia on postnatal growth and development. Pediatr Pulmonol 2008; 43:20-8. [PMID: 18041750 DOI: 10.1002/ppul.20729] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Exposure to chronic constant or intermittent hypoxia (CCH or CIH) may have different effects on growth and development in early life. In this work, we exposed postnatal day 2 (P2) CD1 mice to CCH or CIH (11% O2) for 4 weeks and examined the effect of hypoxia on body and organ growth until P30. Regression analysis showed that weight increased in control, CCH and CIH cohorts with age with r2 values of 0.99, 0.97, and 0.94, respectively. Between days 2 and 30, slopes were 0.93+/-0.057, 0.76+/-0.108, and 0.63+/-0.061 (g/day, means+/-SEM) for control, CIH, and CCH, respectively and significantly different from each other (P<0.001). The slopes between P2 and P16 were 0.78+/-0.012, 0.46+/-0.002, and 0.47+/-0.019 for control, CCH and CIH, respectively. From P16 to 30, slopes were 1.12+/-0.033, 1.09+/-0.143, and 0.82+/-0.08 for control, CIH, and CCH, respectively with no significant difference from each other, suggesting a catch-up growth in the latter part of the hypoxic period. Slower weight gain resulted in a 12% and 23% lower body weight in CIH and CCH mice (P<0.001) by P30. Lung/body ratios were 0.010, 0.015, 0.015 for control, CIH, and CCH at P30, respectively. The decrease in liver, kidney, and brain weight were greater in CCH than CIH. Smaller liver weight was shown to be due to a reduction in cell size and cell number. Liver in CIH and CCH mice showed a 5% and 10% reduction in cell size (P<0.05) and a reduction of 28% in cell number (P<0.001) at P30. In contrast, CCH and CIH heart weight was 13% and 33% greater than control at P30 (P<0.05), respectively. This increase in the heart weight was due to an increase in the size of cardiomyocytes which showed an increase of 12% and 14% (P<0.001) for CIH and CCH, respectively as compared to control. Brain weight was 0.48 and 0.46 g for CIH and CCH, respectively (95% and 92% of normal). We concluded that (a) CIH and CCH follow different body and organ growth patterns; (b) mostly with CCH, the liver and kidneys are reduced in size in a proportionate way to body size but heart, lung, and brain are either spared or increased in size compared to body weight; and (c) the decrease in liver is secondary mostly to a decrease in cell number.
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Affiliation(s)
- Reza Farahani
- Department of Pediatrics, New York Medical College, Valhalla, New York, USA
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Urschitz MS, Eitner S, Wolff J, Guenther A, Urschitz-Duprat PM, Schlaud M, Poets CF. Risk factors for sleep-related hypoxia in primary school children. Pediatr Pulmonol 2007; 42:805-12. [PMID: 17659603 DOI: 10.1002/ppul.20658] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sleep-related hypoxia has adverse effects on cognition in children. Knowledge of factors contributing to sleep-related hypoxia is sparse. We aimed to identify demographic and clinical factors associated with mild (nadir arterial oxygen saturation 91-93%), moderate (nadir arterial oxygen saturation <or=90%), and recurrent (oxygen desaturation index > 3.9) sleep-related hypoxia in children. Parental questionnaires were distributed and overnight recordings of arterial oxygen saturation performed in a population-based cross-section of primary school children (n = 995). Associations were determined using unconditional logistic regression as well as unadjusted and adjusted odds ratios (OR), and their 95% confidence intervals (95% CI) calculated. Male sex, overweight (i.e., body mass index >or= 75th percentile), household smoking, symptoms of sleep-disordered breathing, a current respiratory tract infection, and histories of asthma and respiratory allergy were all significantly associated with sleep-related hypoxia. In multiple regression analysis, (i) overweight (OR, 95% CI: 2.7, 1.7-4.3) and a history of respiratory allergy (1.7, 1.1-2.7) were independent risk factors for mild sleep-related hypoxia, (ii) overweight (3.2, 1.7-5.8), a history of respiratory allergy (2.4, 1.4-4.4), and household smoking >10 cigarettes/day (1.8, 1.1-2.8) were independent risk factors for moderate sleep-related hypoxia, and (iii) overweight (2.3, 1.04-5.3), a history of respiratory allergy (2.5, 1.2-5.1), and a current respiratory tract infection (4.4, 2.0-9.8), were independent risk factors for recurrent sleep-related hypoxia. Our data suggest that overweight, passive smoking, respiratory allergies, and acute lung disease may independently contribute to sleep-related hypoxia in children.
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Affiliation(s)
- Michael S Urschitz
- Department of Neonatology, University Hospital Tuebingen, Tuebingen, Germany.
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Abstract
There is evidence that sleep enhances memory and learning. Childhood is a critical period for neurodevelopment, and minor but persistent disruption of sleep may have long-term implications for cognitive performance. Sleep is critical for health and is undervalued both in our 24 h society and in paediatric clinical practice. Paediatricians need to understand the neurodevelopmental consequences of poor quality sleep in children.
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Affiliation(s)
- Catherine M Hill
- Division of Clinical Neurosciences, School of Medicine, University of Southampton, UK.
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Davis CL, Tkacz J, Gregoski M, Boyle CA, Lovrekovic G. Aerobic exercise and snoring in overweight children: a randomized controlled trial. Obesity (Silver Spring) 2006; 14:1985-91. [PMID: 17135615 PMCID: PMC1976410 DOI: 10.1038/oby.2006.232] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether regular aerobic exercise improves symptoms of sleep-disordered breathing in overweight children, as has been shown in adults. RESEARCH METHODS AND PROCEDURES Healthy but overweight (BMI > or =85th percentile) 7- to 11-year-old children were recruited from public schools for a randomized controlled trial of exercise effects on diabetes risk. One hundred children (53% black, 41% male) were randomly assigned to a control group (n = 27), a low-dose exercise group (n = 36), or a high-dose exercise group (n = 37). Exercise groups underwent a 13 +/- 1.5 week after-school program that provided 20 or 40 minutes per day of aerobic exercise (average heart rate = 164 beats per minute). Group changes were compared on BMI z-score and four Pediatric Sleep Questionnaire scales: Snoring, Sleepiness, Behavior, and a summary scale, Sleep-Related Breathing Disorders. Analyses were adjusted for age. RESULTS Both the high-dose and low-dose exercise groups improved more than the control group on the Snoring scale. The high-dose exercise group improved more than the low-dose exercise and control groups on the summary scale. No group differences were found for changes on Sleepiness, Behavior, or BMI z-score. At baseline, 25% screened positive for sleep-disordered breathing; half improved to a negative screen after intervention. DISCUSSION Regular vigorous exercise can improve snoring, a symptom of sleep-disordered breathing, in overweight children. Aerobic exercise programs may be valuable for prevention and treatment of sleep-disordered breathing in overweight children.
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Affiliation(s)
- Catherine L Davis
- Georgia Prevention Institute, Medical College of Georgia, 1499 Walton Way, HS-1711, Augusta, GA 30912, USA.
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Hill CM, Hogan AM, Onugha N, Harrison D, Cooper S, McGrigor VJ, Datta A, Kirkham FJ. Increased cerebral blood flow velocity in children with mild sleep-disordered breathing: a possible association with abnormal neuropsychological function. Pediatrics 2006; 118:e1100-8. [PMID: 17015501 PMCID: PMC1995426 DOI: 10.1542/peds.2006-0092] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Sleep-disordered breathing describes a spectrum of upper airway obstruction in sleep from simple primary snoring, estimated to affect 10% of preschool children, to the syndrome of obstructive sleep apnea. Emerging evidence has challenged previous assumptions that primary snoring is benign. A recent report identified reduced attention and higher levels of social problems and anxiety/depressive symptoms in snoring children compared with controls. Uncertainty persists regarding clinical thresholds for medical or surgical intervention in sleep-disordered breathing, underlining the need to better understand the pathophysiology of this condition. Adults with sleep-disordered breathing have an increased risk of cerebrovascular disease independent of atherosclerotic risk factors. There has been little focus on cerebrovascular function in children with sleep-disordered breathing, although this would seem an important line of investigation, because studies have identified abnormalities of the systemic vasculature. Raised cerebral blood flow velocities on transcranial Doppler, compatible with raised blood flow and/or vascular narrowing, are associated with neuropsychological deficits in children with sickle cell disease, a condition in which sleep-disordered breathing is common. We hypothesized that there would be cerebral blood flow velocity differences in sleep-disordered breathing children without sickle cell disease that might contribute to the association with neuropsychological deficits. DESIGN Thirty-one snoring children aged 3 to 7 years were recruited from adenotonsillectomy waiting lists, and 17 control children were identified through a local Sunday school or as siblings of cases. Children with craniofacial abnormalities, neuromuscular disorders, moderate or severe learning disabilities, chronic respiratory/cardiac conditions, or allergic rhinitis were excluded. Severity of sleep-disordered breathing in snoring children was categorized by attended polysomnography. Weight, height, and head circumference were measured in all of the children. BMI and occipitofrontal circumference z scores were computed. Resting systolic and diastolic blood pressure were obtained. Both sleep-disordered breathing children and the age- and BMI-similar controls were assessed using the Behavior Rating Inventory of Executive Function (BRIEF), Neuropsychological Test Battery for Children (NEPSY) visual attention and visuomotor integration, and IQ assessment (Wechsler Preschool and Primary Scale of Intelligence Version III). Transcranial Doppler was performed using a TL2-64b 2-MHz pulsed Doppler device between 2 pm and 7 pm in all of the patients and the majority of controls while awake. Time-averaged mean of the maximal cerebral blood flow velocities was measured in the left and right middle cerebral artery and the higher used for analysis. RESULTS Twenty-one snoring children had an apnea/hypopnea index <5, consistent with mild sleep-disordered breathing below the conventional threshold for surgical intervention. Compared with 17 nonsnoring controls, these children had significantly raised middle cerebral artery blood flow velocities. There was no correlation between cerebral blood flow velocities and BMI or systolic or diastolic blood pressure indices. Exploratory analyses did not reveal any significant associations with apnea/hypopnea index, apnea index, hypopnea index, mean pulse oxygen saturation, lowest pulse oxygen saturation, accumulated time at pulse oxygen saturation <90%, or respiratory arousals when examined in separate bivariate correlations or in aggregate when entered simultaneously. Similarly, there was no significant association between cerebral blood flow velocities and parental estimation of child's exposure to sleep-disordered breathing. However, it is important to note that whereas the sleep-disordered breathing group did not exhibit significant hypoxia at the time of study, it was unclear to what extent this may have been a feature of their sleep-disordered breathing in the past. IQ measures were in the average range and comparable between groups. Measures of processing speed and visual attention were significantly lower in sleep-disordered breathing children compared with controls, although within the average range. There were similar group differences in parental-reported executive function behavior. Although there were no direct correlations, adjusting for cerebral blood flow velocities eliminated significant group differences between processing speed and visual attention and decreased the significance of differences in Behavior Rating Inventory of Executive Function scores, suggesting that cerebral hemodynamic factors contribute to the relationship between mild sleep-disordered breathing and these outcome measures. CONCLUSIONS Cerebral blood flow velocities measured by noninvasive transcranial Doppler provide evidence for increased cerebral blood flow and/or vascular narrowing in childhood sleep-disordered breathing; the relationship with neuropsychological deficits requires further exploration. A number of physiologic changes might alter cerebral blood flow and/or vessel diameter and, therefore, affect cerebral blood flow velocities. We were able to explore potential confounding influences of obesity and hypertension, neither of which explained our findings. Second, although cerebral blood flow velocities increase with increasing partial pressure of carbon dioxide and hypoxia, it is unlikely that the observed differences could be accounted for by arterial blood gas tensions, because all of the children in the study were healthy, with no cardiorespiratory disease, other than sleep-disordered breathing in the snoring group. Although arterial partial pressure of oxygen and partial pressure of carbon dioxide were not monitored during cerebral blood flow velocity measurement, assessment was undertaken during the afternoon/early evening when the child was awake, and all of the sleep-disordered breathing children had normal resting oxyhemoglobin saturation at the outset of their subsequent sleep studies that day. Finally, there is an inverse linear relationship between cerebral blood flow and hematocrit in adults, and it is known that iron-deficient erythropoiesis is associated with chronic infection, such as recurrent tonsillitis, a clinical feature of many of the snoring children in the study. Preoperative full blood counts were not performed routinely in these children, and, therefore, it was not possible to exclude anemia as a cause of increased cerebral blood flow velocity in the sleep-disordered breathing group. However, hemoglobin levels were obtained in 4 children, 2 of whom had borderline low levels (10.9 and 10.2 g/dL). Although there was no apparent relationship with cerebral blood flow velocity in these children (cerebral blood flow velocity values of 131 and 130 cm/second compared with 130 and 137 cm/second in the 2 children with normal hemoglobin levels), this requires verification. It is of particular interest that our data suggest a relationship among snoring, increased cerebral blood flow velocities and indices of cognition (processing speed and visual attention) and perhaps behavioral (Behavior Rating Inventory of Executive Function) function. This finding is preliminary: a causal relationship is not established, and the physiologic mechanisms underlying such a relationship are not clear. Prospective studies that quantify cumulative exposure to the physiologic consequences of sleep-disordered breathing, such as hypoxia, would be informative.
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Affiliation(s)
- Catherine M Hill
- Division of Clinical Neurosciences, University of Southampton, United Kingdom.
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Raman L, Georgieff MK, Rao R. The role of chronic hypoxia in the development of neurocognitive abnormalities in preterm infants with bronchopulmonary dysplasia. Dev Sci 2006; 9:359-67. [PMID: 16764609 DOI: 10.1111/j.1467-7687.2006.00500.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bronchopulmonary dysplasia is the most common pulmonary morbidity in preterm infants and is associated with chronic hypoxia. Animal studies have demonstrated structural, neurochemical and functional alterations due to chronic hypoxia in the developing brain. Long-term impairments in visual-motor, gross and fine motor, articulation, reading, mathematics, spatial memory and attention skills are prevalent in survivors of bronchopulmonary dysplasia, and impairments appear to correlate with the severity of hypoxia. However, due to the simultaneous occurrence of multiple neurodevelopmental risk factors, a primary or potentiating role for chronic hypoxia in these impairments has yet to be conclusively established.
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Affiliation(s)
- Lakshmi Raman
- Department of Pediatrics, Hennepin County Medical Center, Minneapolis, MN, USA
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Abstract
The objective of this study was to quantify behavioral and attention capacity changes in children aged 4-11 y before and 3 mo after adenotonsillectomy (A/T). Overnight cardiorespiratory recordings were performed in 61 "behaviorally normal" children 1 wk before A/T. Tests of sustained attention using visual and auditory continuous performance tests (CPT) were completed by children 1 wk before and 3 mo after A/T. Behavioral Assessment Scales for Children (BASC) and a sleep questionnaire were completed by the parent/s at these same times. Results from overnight cardiorespiratory recordings showed that the children had mild sleep-related breathing disorders (SRBD) preoperatively with a mean apnea/hypopnea index of 3.0/h and a movement awakening index of 2.5/h. The majority had parent-perceived sleep and breathing difficulties that significantly improved post-A/T. BASC T scores for externalizing and internalizing behaviors improved post-A/T, e.g., behavioral symptom index mean pre-A/T was 56.2 (95% confidence interval, 52.8-59.6) compared with 50.9 (48.5-53.5) post-A/T. Some measures indicative of impulsivity and attentiveness obtained from the visual CPT before surgery, improved post-A/T, but no change was observed in any auditory CPT measures. Our data confirm improvements in subjective measures of sleep problems in children treated for SRBD and strengthen the notion of treating the disorder, not only related to the obvious clinical condition but also to the underlying sleep problems and adverse effects on daytime behavior and attention.
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Affiliation(s)
- Barbara C Galland
- Department of Women's & Children's Health, University of Otago, Dunedin, New Zealand.
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Blunden SL, Beebe DW. The contribution of intermittent hypoxia, sleep debt and sleep disruption to daytime performance deficits in children: consideration of respiratory and non-respiratory sleep disorders. Sleep Med Rev 2006; 10:109-18. [PMID: 16488632 DOI: 10.1016/j.smrv.2005.11.003] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In children, the most abundant available information regarding the effects of paediatric sleep disturbance on daytime function has been obtained by studying children with sleep disordered breathing (SDB). The purported underlying pathophysiological mechanisms responsible for these deficits include hypoxia secondary to obstructive apneas/hypopneas and/or disrupted sleep architecture from frequent arousals during sleep. This review will present evidence that, while hypoxia is likely to play a role for many children with SDB, sleep disruption is an important and often overlooked factor that can contribute to daytime deficits in children with SDB. Indeed, sleep deprivation and disruption appear to have a potent impact on the daytime functioning of the much larger number of children with non-respiratory sleep disorders. It is concluded that sleep deprivation, sleep disruption, and intermittent hypoxia independently may be sufficient to cause daytime effects in vulnerable children, and the combination of two or more of these factors can result in particularly impaired daytime functioning. These conclusions have significant implications for research and clinical practice.
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Affiliation(s)
- Sarah L Blunden
- Centre for Sleep Research, University of South Australia, Level 7, Playford Building, Frome Road, Adelaide, SA 5011, Australia.
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