Infant-feeding methods and childhood sleep-disordered breathing

Impact of Breastfeeding Duration on Adenoid Hypertrophy, Snoring and Acute Otitis Media: A Case-Control Study in Preschool Children

BACKGROUND

The aim of this study was to analyze the relationship between breastfeeding duration and adenoid size, snoring and acute otitis media (AOM).

METHODS

We analyzed the medical history of children admitted to the ENT outpatient clinic in 2022 and 2023, reported symptoms, ear, nose and throat (ENT) examination, and flexible nasopharyngoscopy examination of 145 children aged 3-5 years.

RESULTS

Breastfeeding duration of 3 and 6 months or more had a significant effect on the reduction of snoring (p = 0.021; p = 0.039). However, it had no effect on the adenoid size, mucus coverage and sleeping with an open mouth. Snoring was correlated with open mouth sleeping (p < 0.001), adenoid size with a 75% A/C ratio or more (p < 0.001), and adenoid mucus coverage in the Mucus of Adenoid Scale by Nasopharyngoscopy Assessment-MASNA scale (p = 0.009). Children who were breastfed for less than 3 months had more than a four-fold greater risk of snoring. There was a statistically significant correlation between AOM and gender (p = 0.033), breastfeeding duration in groups fed 1, 3 or 6 months or more (p = 0.018; p = 0.004; p = 0.004) and those fed with mother's breast milk 3 or 6 months or more (p = 0.009; p = 0.010). Moreover, a correlation was found between adenoid size and mucus coverage, tympanogram, and open-mouth sleeping (p < 0.001). Independent factors of snoring in 3- to 5-year-old children were breastfeeding duration of less than 3 months (p = 0.032), adenoid size with an A/C ratio of 75% or more (p = 0.023) and open mouth sleeping (p = 0.001).

CONCLUSIONS

Children breastfed for 3 and 6 months or more exhibited reduced rates of snoring. There was no effect of breastfeeding duration on adenoid size in children aged 3 to 5 years, suggesting that the link between breastfeeding duration and snoring is primarily associated with craniofacial development and muscle tone stimulation. A breastfeeding duration of 1 month or more plays a key role in reducing the rate of AOM. The mother's milk plays a protective role against AOM. The presence of mucus might be responsible for snoring in preschool children. A medical history of breastfeeding should be taken into consideration when snoring children are suspected of adenoid hypertrophy.

Pediatric sleep-disordered breathing in Shanghai: characteristics, independent risk factors and its association with malocclusion

OBJECTIVES

This study aimed to determine the prevalence and independent risk factors of SDB, and explore its association with malocclusion among 6-11-year-old children in Shanghai, China.

METHODS

A cluster sampling procedure was adopted in this cross-sectional study. Pediatric Sleep Questionnaire (PSQ) was applied to evaluate the presence of SDB. Questionnaires including PSQ, medical history, family history, and daily habits/environment were completed by parents under instruction, and oral examinations were implemented by well-trained orthodontists. Multivariable logistic regression was applied to identify independent risk factors for SDB. Chi-square tests and Spearman's Rank Correlation were used to estimate the relationship between SDB and malocclusion.

RESULTS

A total of 3433 subjects (1788 males and 1645 females) were included in the study. The SDB prevalence was about 17.7%. Allergic rhinitis (OR 1.39, 95% CI 1.09-1.79), adenotonsillar hypertrophy (OR 2.39, 95% CI 1.82-3.19), paternal snoring (OR 1.97, 95% CI 1.53-2.53), and maternal snoring (OR 1.35, 95% CI 1.05-1.73) were independent risk factors for SDB. The SDB prevalence was higher in children with retrusive mandibles than in proper or excessive ones. No significant difference was observed in the correlation between SDB and lateral facial profile, mandible plane angle, constricted dental arch form, the severity of anterior overjet and overbite, degree of crowding and spacing, and the presence of crossbite and open bite.

CONCLUSIONS

The prevalence of SDB in primary students in the Chinese urban population was high and highly associated with mandible retrusion. The independent risk factors included Allergic rhinitis, adenotonsillar hypertrophy, paternal snoring, and maternal snoring. More efforts should be made to enhance public education about SDB and related dental-maxillofacial abnormalities.

Early-Life Exposure to PM2.5 and Sleep Disturbances in Preschoolers from 551 Cities of China

Rationale: Air pollution has been linked with sleep disturbance in adults, but the association in children remains unclear. Objectives: To examine the associations of prenatal and postnatal exposure to fine particulate matter (particulate matter ⩽2.5 μm in aerodynamic diameter; PM_2.5) with sleep quality and sleep disturbances among children in 551 Chinese cities. Methods: A total of 1,15,023 children aged 3-7 years from the Chinese National Cohort of Motor Development were included. Sleep quality was measured using the Children's Sleep Habits Questionnaire (CSHQ). PM_2.5 exposure was estimated using a satellite-based model. Generalized additive mixed models with Gaussian and binomial distributions were used to examine the associations of PM_2.5 exposure with CSHQ scores and risk of sleep disturbance, respectively, adjusting for demographic characteristics and temporal trends. Measurements and Main Results: Early-life PM_2.5 exposure was associated with higher total CSHQ score, and the association was stronger for exposure at age 0-3 years (change of CSHQ score per interquartile range increase of PM_2.5 = 0.46; 95% confidence interval [CI], 0.29-0.63) than during pregnancy (0.22; 95% CI, 0.12-0.32). The associations were more evident in sleep-disordered breathing and daytime sleepiness. Postnatal PM_2.5 exposure was associated with increased risk of sleep disturbance (adjusted odds ratio for per-interquartile range increase of PM_2.5 exposure at age 0-3 years, 1.10; 95% CI, 1.04-1.15), but no associations were found for prenatal exposure. Children who were exclusively breastfed for <6 months and had neonatal ICU admission may be more vulnerable to sleep disturbance related to PM_2.5 exposure. Conclusions: PM_2.5 exposure can impair sleep quality in preschool children.

Siblings' Risk of Adenoid Hypertrophy: A Cohort Study in Children

BACKGROUND

The aim of this study was to compare adenoid size in preschool-age siblings using flexible nasopharyngoscopy examination (FNE) when they reach the same age. The occurrence of adenoid symptoms in these patients was also analyzed. This study was conducted to analyze the adenoid size in siblings when they reach the same age and substantiate a correlation between adenoid hypertrophy (AH) and adenoid symptoms.

METHODS

We analyzed and reported on the symptoms, ENT examination results, and FNE of 49 pairs of siblings who were examined at the same age.

RESULTS

There was a strong association in adenoid size between siblings when they are at a similar age (r = 0.673, p < 0.001). Second-born children whose older sibling had IIIo AH (A/C ratio > 65%) had a risk of IIIo AH 26 times greater than patients whose older sibling did not have IIIo AH (OR = 26.30, 95% CI = 2.82-245.54). Over 90% of snoring children whose siblings had confirmed IIIo AH would develop IIIo AH by the time they reach the same age. Second-born children in whom snoring occurs and whose older siblings have a IIIo AH have about a 46 times higher risk of IIIo AH compared to patients who did not meet these two conditions (p < 0.001, OR = 46.67, 95% CI = 8.37-260.30).

CONCLUSIONS

A significant familial correlation between adenoid size in siblings when they reach the same age was shown. If the older sibling has a confirmed overgrown adenoid (IIIo AH) and their younger sibling presents adenoid symptoms, particularly snoring, it is highly probable that they will also have an overgrown adenoid.

Immunomodulatory Properties of Human Breast Milk: MicroRNA Contents and Potential Epigenetic Effects

Infants who are exclusively breastfed in the first six months of age receive adequate nutrients, achieving optimal immune protection and growth. In addition to the known nutritional components of human breast milk (HBM), i.e., water, carbohydrates, fats and proteins, it is also a rich source of microRNAs, which impact epigenetic mechanisms. This comprehensive work presents an up-to-date overview of the immunomodulatory constituents of HBM, highlighting its content of circulating microRNAs. The epigenetic effects of HBM are discussed, especially those regulated by miRNAs. HBM contains more than 1400 microRNAs. The majority of these microRNAs originate from the lactating gland and are based on the remodeling of cells in the gland during breastfeeding. These miRNAs can affect epigenetic patterns by several mechanisms, including DNA methylation, histone modifications and RNA regulation, which could ultimately result in alterations in gene expressions. Therefore, the unique microRNA profile of HBM, including exosomal microRNAs, is implicated in the regulation of the genes responsible for a variety of immunological and physiological functions, such as FTO, INS, IGF1, NRF2, GLUT1 and FOXP3 genes. Hence, studying the HBM miRNA composition is important for improving the nutritional approaches for pregnancy and infant's early life and preventing diseases that could occur in the future. Interestingly, the composition of miRNAs in HBM is affected by multiple factors, including diet, environmental and genetic factors.

Associations among High Risk for Sleep-disordered Breathing, Related Risk Factors, and Attention Deficit/Hyperactivity Symptoms in Elementary School Children

Objective

: Habitual snoring is a common problem in children. We evaluated the association between a high risk for sleep-disordered breathing and attention deficit/hyperactivity symptoms.

Methods

Parents of 13,560 children aged 6 to 12 years responded to questionnaires including items on habitual snoring and the Korean attention deficit/hyperactivity disorder rating scale. The snoring score comprised the number of "yes" responses to habitual-snoring items, and a high risk for sleep-disordered breathing was defined as a snoring score ≥ 2.

Results

The odds ratio (OR) of a high risk for sleep-disordered breathing was significantly higher in boys (OR = 1.47; p < 0.001), overweight children (OR = 2.20; p < 0.001), and children with current secondhand-smoking exposure (OR = 1.38; p < 0.001). The Korean attention deficit/hyperactivity disorder rating scale score increased significantly with the snoring score (0 vs. 1, B = 1.56, p < 0.001; 0 vs. 2, B = 2.44, p < 0.001; 0 vs. 3, B = 2.48, p < 0.001; 0 vs. 4, B = 3.95; p < 0.001).

Conclusion

Our study confirms several risk factors of sleep-disordered breathing, namely male sex, overweight, and exposure to tobacco smoking, and found a positive association between habitual snoring and attention deficit/hyperactivity symptoms.

Risk factors of obstructive sleep apnea syndrome in children

Background

The known risk factors of childhood OSAS include tonsillar and adenoidhypertrophy, obesity, craniofacial anomalies, neuromuscular disorders and African-American (AA) ancestry. Whether other factors such as allergic rhinitis (AR), premature, environmental tobacco smoking (ETS) are associated with OSAS are inconsistent in different studies. Our study enrolled children of a broad age range and included potential risk factors of OSAS derived from previous studies and our own experience. Our objective is to identify risk factors of OSAS in children in a clinical setting.

Methods

Children between 2 and 15 years of age exhibiting snoring symptoms who visited the sleep center for polysomnography (PSG) were enrolled. All children completed a questionnaire, physical examination and PSG. The questionnaire included demographic data and information related to potential risk factors for sleep disorders. A physical examination included measurements of height, weight, neck circumference, waist and hip ratio, visual evaluation of the tonsils and the degree of adenoid obstruction. Children with obstructive apnea-hypopnea index (OAHI) ≥ 1 were defined as OSAS.

Results

A total of 1578 children were enrolled and1009 children exhibited OSAS. Univariate analyses showed that snoring occurring for ≥ 3 months, male gender, preterm birth, breastfeeding, obesity, neck circumference ≥ 30 cm, waist/hip ratio ≥ 0.95, tonsillar hypertrophy, and adenoid hypertrophy were associated with OSAS. The proportion of low educational level was higher in parents who breastfed their babies than those who didn’t. Multivariate analysis showed that snoring for ≥ 3 months, male gender, obesity, breastfeeding, tonsillar hypertrophy, and adenoid hypertrophy were associated with OSAS. Confounders such as socioeconomic status, parental occupation, and health-related behaviors should be explored further to investigate the relationship between breastfeeding and OSAS.

Conclusion

The independent risk factors for OSAS in children included snoring ≥ 3 months, male gender, obesity, breastfeeding, tonsillar and adenoid hypertrophy.

The study was registered on Clinical Trials government (NCT02447614). The name of the trial is “Follow-up Studies of Primary Snoring (PS) and Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) in Chinese Children” and the URL is https://clinicaltrials.gov/.

Oral dysfunction as a cause of malocclusion

This narrative review surveys current research demonstrating how oral dysfunction can escalate into malocclusion, acquired craniofacial disorder and contribute to generational dysfunction, disorder and disease.

INTRODUCTION

Baseline orthodontic consultations are generally recommended beginning age seven. However, the dysmorphic changes that result in malocclusion are often evident years earlier. Similarly, following orthodontic treatment, patients require permanent retention when the bite is not stable, and without such retention, the malocclusion can return.

SETTING AND POPULATION

Narrative review article including research on infants, children and adults.

MATERIALS AND METHODS

This review is a brief survey of the symptomology of orofacial myofunctional disorder and outlines 10 areas of oral function that impact occlusal and facial development: breastfeeding, airway obstruction, soft tissue restriction, mouth breathing, oral resting posture, oral habits, swallowing, chewing, the impact of orofacial myofunctional disorder (OMD) over time and maternal oral dysfunction on the developing foetus.

CONCLUSION

Malocclusions and their acquired craniofacial dysmorphology are the result of chronic oral dysfunction and OMD. In order to achieve long-term stability of the face, it is critical to understand the underlying pathologies contributing to malocclusion, open bite and hard palate collapse.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Breastfeeding and risk of habitual snoring in children: A meta-analysis

Research regarding the effects of breastfeeding on habitual snoring in children has yielded conflicting results. Therefore, a meta-analysis was carried out to evaluate the effect of breastfeeding on the risk of habitual snoring in children. Relevant studies published in English or Chinese were identified by a search of PubMed, Embase, Web of Science, Chinese National Knowledge Infrastructure, China Biology Medical literature, and Wanfang databases up to October 2018. Random effects model was used to pool the findings, and results were expressed as odds ratios (OR) with 95% CIs. Eleven studies with 71,622 participants were included in the present meta-analysis. The pooled OR of habitual snoring for more versus less breastfeeding (duration) was 0.74 (95% CI [0.62, 0.90]), and the result remained significant in cohort studies (OR, 0.74; 95%CI [0.66, 0.84]). We found no evidence of publication bias. This meta-analysis of observational studies indicates that breastfeeding for a long time is associated with reduced risk of habitual snoring in children. The finding needs to be investigated in well-designed prospective studies.

Pediatric Obstructive Sleep Apnea in High-Risk Populations: Clinical Implications

Certain common medical conditions are associated with a higher risk of pediatric obstructive sleep apnea (OSA). A lower threshold for screening is therefore indicated for such patient cohorts. In this article, we briefly discuss the high prevalence of OSA in children born prematurely, and in those with Down syndrome, craniofacial disorders, and neuromuscular disorders. Primary care providers should have an increased index of suspicion for OSA in these children, considering the neurocognitive disability that occurs in these high-risk groups when OSA is left untreated. [Pediatr Ann. 2017;46(9):e336-e339.].

Association between Breast Feeding and Paediatric Sleep Disordered Breathing: a Systematic Review

BACKGROUND

Breast feeding has been suggested as a potential protective factor against childhood snoring and sleep disordered breathing (SDB). SDB can have major health consequences. The objective of this systematic review is to synthesise the available literature concerning any potential association between infant feeding methods and SDB in young children.

METHODS

Five electronic databases were searched. All searches were inclusive until August 5, 2016. Two authors independently reviewed potentially relevant articles for eligibility. Any prospective or retrospective study, case-control study, cohort study, clinical trial, and cross-sectional study that evaluated the association between infant feeding methods and SDB were included. Data on study design, aim of study, sample size, study population, assessment tool, infant feeding methods, and outcome measures were extracted.

RESULTS

Nine studies fulfilled the criteria to be finally included in this review, only cohorts and cross-sectional studies were identified. While seven of the selected studies reported a statistically significant association between breast feeding and reduced risk of SDB, the remaining two studies did not report any association. The main methodological limitation was high heterogeneity in the diagnostic criteria and assessment tools to identify SDB and limited data collection on infant feeding methods.

CONCLUSIONS

The current evidence may point to a protective association, however, as uncertainty is moderate, any suggestion that breast feeding may or may not decrease the risk of SDB is currently unwarranted. More research on the topic is required to resolve some of the contradictions between included studies.

Not living with both parents is associated with more health- and developmental problems in infants aged 7 to 11 months: a cross sectional study

BACKGROUND

In Western countries, many children are affected by the separation of their parents. Our main objective was to assess the possible impact of parental separation family structure on certain aspects of somatic health in low-age children.

METHODS

We conducted a cross-sectional study based on data collected in the framework of free preventive medicine consultations in the French Community of Belgium. The data was derived from assessments conducted, between 2006 and 2012, on children 7 to 11 months after birth during which information of 79701 infants was collected regarding the risk of sudden infant death, psychomotor development, and development in terms of height and weight. The main outcome measures were: episode of risk of sudden infant death, polysomnography, home monitoring, psychomotor development, and body mass index.

RESULTS

The parents of 6.6% of the infants were separated. We established multivariable models, based on the presence or absence of confounders. The adjusted ORs (95% CI) of symptoms perceived as frightening, notably at night, of a prescription for a polysomnography, of an abnormal polysomnography result, and of follow-up by home monitoring were thus respectively 1.3 (1.1-1.6), 1.1 (0.9-1.3), 1.8 (1.3-2.4), and 1.3 (1.1-1.6). The adjusted ORs (95% CI) for psychomotor delay and for a body mass index above the 97(th) percentile were respectively 1.3 (1.0-1.6) and 1.2 (1.1-1.3) in the event of separation.

CONCLUSIONS

This study confirms the possibility that not living with both parents is an independent risk factor for the somatic health and psychomotor development of infants. This observation should be verified because it would have a major impact on the actions of family doctors and other first-line healthcare providers, in particular with regard to information and targeted prevention.

Breastfeeding and snoring: a birth cohort study

OBJECTIVE

To investigate the relationship between breastfeeding and snoring in childhood.

METHODS

In a cohort of children with a family history of asthma who were recruited antenatally we prospectively recorded data on infant feeding practices throughout the first year of life. Snoring status and witnessed sleep apnea were measured at age 8 years by parent-completed questionnaire. Associations were estimated by logistic regression with, and without, adjustment for sets of confounders designed to exclude biasing effects.

RESULTS

Habitual snoring was reported in 18.8% of the sample, and witnessed apnea in 2.7%. Any breastfeeding for longer than one month was associated with a reduced risk of habitual snoring at age 8 (adjusted OR 0.48, 95% CI 0.29 to 0.81) and duration of breastfeeding was inversely associated with the prevalence of habitual snoring (adjusted OR 0.79, 95% CI 0.62 to 1.00). Any breastfeeding for longer than 1 month was associated with a lower risk of witnessed sleep apnea (adjusted OR 0.17, 95% CI 0.04 to 0.71). The protective associations were not mediated by BMI, current asthma, atopy or rhinitis at age 8 years.

CONCLUSIONS

Breastfeeding for longer than one month decreases the risk of habitual snoring and witnessed apneas in this cohort of children with a family history of asthma. The underlying mechanism remains unclear but the finding would be consistent with a beneficial effect of the breast in the mouth on oropharyngeal development with consequent protection against upper airway dysfunction causing sleep-disordered breathing.

Prevalence of habitual snoring and its correlates in young children across the Asia Pacific

AIMS

To evaluate: (i) the prevalence of habitual snoring (HS) in a large sample of children aged from birth to 36 months in 14 countries across Asia Pacific; and (ii) the different correlates associated with HS in Caucasians, Chinese and non-Chinese, non-Caucasian Asians.

METHODS

This was a multi-centre, cross-sectional survey conducted across Asia Pacific. Parents/caregivers of 23,481 infants and toddlers completed an expanded version of the Brief Infant Sleep Questionnaire. We defined HS as snoring more than three nights per week.

RESULTS

Chinese and non-Caucasian non-Chinese (NCNC) children had a lower prevalence of HS across the age range from birth to 3 years than their Caucasian counterparts (6.2% and 5.1% vs. 11%, P < 0.01). Boys had a higher prevalence of HS compared to girls (χ(2) = 98.5, P < 0.0001). History of prematurity (OR = 1.37-1.56, CI (1.1-2.17), P < 0.01) and gender (OR = 1.53-1.54, CI (1.26-1.85), P < 0.0001) were found to be significant predictors for HS. Current breastfeeding (OR = 0.69, CI (0.54-0.88), P < 0.005) and greater parental age (OR = 0.86, CI (0.78-0.96), P < 0.01) were protective against HS among NCNC children. HS was less prevalent in younger Chinese subjects (OR = 0.88, CI (0.84-0.93), P < 0.0001). In Caucasians, parents' education (OR = 0.78, CI (0.67-0.91), P < 0.005) and their not sleeping in the same room as their child (OR = 0.62, CI (0.45-0.86), P < 0.005) were negatively associated with parental report of HS.

CONCLUSIONS

Prevalence of HS shows racial differences among countries across Asia Pacific. Future studies should assess craniofacial structure and body fat distribution as contributory factors for this differential prevalence.

Breastfeeding and infant sleep patterns: an Australian population study

OBJECTIVE

Our purpose was to determine if babies breastfed at 6 months of age were more likely to wake at night and less likely to sleep alone than formula-fed babies.

PATIENTS AND METHODS

Data were drawn from the first wave of The Longitudinal Study of Australian Children, an ongoing, nationally representative study of the growth and development of Australia's children. The 4507 participants met the criteria for this study. The measures examined infant sleep problems as the outcome and breastfeeding at 6 months of age as the exposure in addition to the demographic data, maternal mental health, infant birthweight and gestational age at delivery.

RESULTS

After adjustment for covariates, reports by mothers of infants that breastfed at 6 months of age suggested infants were 66% more likely to wake during the night and 72% more likely to report difficulty sleeping alone. However, breastfeeding had a strongly protective effect on wheezing, coughing, snoring and breathing problems, and it was not associated with restless sleep or problems getting to sleep for the infant.

CONCLUSIONS

Breastfeeding was found to be associated with increased night waking and this is consistent with other studies. There are biological reasons why this might be required to ensure breastfeeding continues to 6 months and beyond. The current low rates of sustained breastfeeding in many Western countries needs to be reconsidered in relation to parental and public health practices promoting prolonged nocturnal infant sleep patterns.

Pediatric sleep disorders and special educational need at 8 years: a population-based cohort study

OBJECTIVES

To examine associations between sleep-disordered breathing (SDB) and behavioral sleep problems (BSPs) through 5 years of age and special educational need (SEN) at 8 years.

METHODS

Parents in the Avon Longitudinal Study of Parents and Children reported on children's snoring, witnessed apnea, and mouth-breathing at 6, 18, 30, 42, and 57 months, from which SDB symptom trajectories, or clusters, were derived. BSPs were based on report of ≥ 5 of 7 sleep behaviors at each of the 18-, 30-, 42-, and 57-month questionnaires. Parent report of SEN (yes/no) at 8 years was available for 11049 children with SDB data and 11467 children with BSP data. Multivariable logistic regression models were used to predict SEN outcome by SDB cluster and by cumulative report of SEN.

RESULTS

Controlling for 16 putative confounders, previous history of SDB and BSPs was significantly associated with an SEN. BSPs were associated with a 7% increased odds of SEN (95% confidence interval [CI] 1.01-1.15), for each ∼1-year interval at which a BSP was reported. SDB, overall, was associated with a near 40% increased odds of SEN (95% CI 1.18-1.62). Children in the worst symptom cluster were 60% more likely to have an SEN (95% CI 1.23-2.08).

CONCLUSIONS

In this population-based longitudinal study, history of either SDB or BSPs in the first 5 years of life was associated with increased likelihood of SEN at 8 years of age. Findings highlight the need for pediatric sleep disorder screening by early interventionists, early childhood educators, and health professionals.

Persistent snoring in preschool children: predictors and behavioral and developmental correlates

OBJECTIVE

To clarify whether persistent snoring in 2- to 3-year-olds is associated with behavioral and cognitive development, and to identify predictors of transient and persistent snoring.

METHODS

Two hundred forty-nine mother/child pairs participated in a prospective birth cohort study. Based upon parental report of loud snoring ≥ 2 times weekly at 2 and 3 years of age, children were designated as nonsnorers, transient snorers (snored at 2 or 3 years of age, but not both), or persistent snorers (snored at both ages). We compared groups by using validated measures of behavioral and cognitive functioning. Potential predictors of snoring included child race and gender, socioeconomic status (parent education and income), birth weight, prenatal tobacco exposure (maternal serum cotinine), childhood tobacco exposure (serum cotinine), history and duration of breast milk feeding, and body mass relative to norms.

RESULTS

In multivariable analyses, persistent snorers had significantly higher reported overall behavior problems, particularly hyperactivity, depression, and inattention. Nonsnorers had significantly stronger cognitive development than transient and persistent snorers in unadjusted analyses, but not after demographic adjustment. The strongest predictors of the presence and persistence of snoring were lower socioeconomic status and the absence or shorter duration of breast milk feeding. Secondary analyses suggested that race may modify the association of childhood tobacco smoke exposure and snoring.

CONCLUSIONS

Persistent, loud snoring was associated with higher rates of problem behaviors. These results support routine screening and tracking of snoring, especially in children from low socioeconomic backgrounds; referral for follow-up care of persistent snoring in young children; and encouragement and facilitation of infant breastfeeding.

Effect of current breastfeeding on sleep patterns in infants from Asia-Pacific region

AIM

  The aim of this study was to assess the relationship between breastfeeding and sleep patterns in infants from Asia-Pacific region.

METHODS

  Parents of 10 321 infants (0-11 months) from Australia, China, Hong Kong, India, Indonesia, Korea, Japan, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand and Vietnam completed an expanded version of the Brief Infant Sleep Questionnaire.

RESULTS

  Overall, 4714 (45.72%) were currently being breastfed; 61.3% of those between 0 and 5 months and 36.6% of those between 6 and 11 months. Currently breastfed infants, when compared with not currently breastfed infants, had a significant increase in the number and duration of night-time wakings and less consolidated sleep. Interestingly, currently breastfed infants less than 6 months also showed longer duration of daytime sleep and obtained more sleep overall. Of note, of those who were currently breastfed, those infants who were nursed back to sleep during night, woke up more often at night (2.41 vs. 1.67 times) and had shorter continuous night-time sleep period (5.58 vs. 6.88 h; P < 0.001). There was no significant difference between breastfeeding and non-breastfeeding infants in the number of night wakings, when the nursing to sleep variable was controlled for in the analysis of variance.

CONCLUSION

  Breastfeeding is associated with reduced sleep consolidation in infants. This relationship, however, may be moderated by parenting practices of nursing to sleep and back to sleep during the night. Thus, parents of infants with night waking problems should be encouraged to limit the association between nursing and falling to sleep, to improve sleep while maintaining breastfeeding.

Sex, hormones, and stress: how they impact development and function of the carotid bodies and related reflexes

Progesterone and corticosterone are key modulators of the respiratory control system. While progesterone is widely recognized as an important respiratory stimulant in adult and newborn animals, much remains to be described regarding the underlying mechanisms. We review the potential implication of nuclear and membrane progesterone receptors in adults and in newborns. This raises intriguing questions regarding the contribution of progesterone as a protective factor against some respiratory control disorders during early life. We then discuss our current understanding of the central integration of stressful stimuli and the responses they elicit. The fact that this system interacts with the respiratory control system, either because both share some common neural pathways in the brainstem and hypothalamus, or because corticosterone directly modulates the function of the respiratory control network, is a fascinating field of research that has emerged over the past few years. Finally, we review the short- and long-term consequences of disruption of stress circuitry during postnatal development on these systems.

Antagonism of progesterone receptor suppresses carotid body responses to hypoxia and nicotine in rat pups

We tested the hypothesis that antagonism of progesterone receptor (PR) in newborn rats alters carotid body and respiratory responses to hypoxia and nicotinic receptor agonists. Rats were treated with the PR antagonist mifepristone (daily oral gavage 40 μg/g/d) or vehicle between postnatal days 3 and 15. In 11-14-day-old rats, we used in vitro carotid body/carotid sinus nerve preparation and whole body plethysmography to assess the carotid body and ventilatory responses to hypoxia (65 mmHg in vitro, 10% O2 in vivo) and to nicotinic receptor agonists (as an excitatory modulator of carotid body activity-nicotine 100 μM for in vitro studies, and epibatidine 5 μg/kg, i.p., which mainly acts on peripheral nicotinic receptors, for in vivo studies). The carotid body responses to hypoxia and nicotine were drastically reduced by mifepristone. Compared with vehicle, mifepristone-treated rats had a reduced body weight. The ventilatory response to epibatidine was attenuated; however, the hypoxic ventilatory response was similar between vehicle and mifepristone-treated pups. Immunohistochemical staining revealed that mifepristone treatment did not change carotid body morphology. We conclude that PR activity is a critical factor ensuring proper carotid body function in newborn rats.

Snoring, mouth-breathing, and apnea trajectories in a population-based cohort followed from infancy to 81 months: a cluster analysis

OBJECTIVE

The objective of this study was to characterize phenotypes of sleep disordered breathing (SDB) in early childhood that clinicians may find useful while monitoring symptom progression and associated SDB morbidity.

METHODS

We performed a cluster analysis of SDB's primary symptoms: snoring, mouth-breathing, and apnea. Parents in the Avon Longitudinal Study of Parents and Children (ALSPAC) reported SDB symptoms by questionnaire for their child at 6, 18, 30, 42, 57, 69, and 81 months of age. Participants were those from the original cohort exclusive of children with congental or other medical conditions predisposing growth aberrations or respiratory problems (i.e. cleft palate, heart surgery and associated conditions, genetic syndromes-primarily Down's, cancer or kidney conditions, celiac disease, congenital adrenal hyperplasia), missing SDB measures for ≥ 2 timepoints, or missing birth length plus 2 subsequent height measures.

RESULTS

Five clusters emerged from 10,441 children and were characterized according to patterns of mean severity of SDB symptoms over time. "Normals" (50%) were asymptomatic throughout. The "late snores and mouth-breathing" cluster (20%) remained asymptomatic until 4 years old. The "early snores" (10%) and "early apnea" (10%) clusters had peak symptoms at 6 and 18 months, respectively. In "all SDB after infancy" (10%), symptoms peaked from 30 to 42 months and remained elevated. Exploratory analyses found that "early snores" were significantly shorter than "normals." Associations with tonsillectomies and wheezing frequency supported external validation.

CONCLUSIONS

Cluster analysis has elucidated the dynamic multi-symptom expression of SDB. The utility of cluster analysis will be evaluated in future analyses to predict growth, cognition and behavior outcomes.

Obstructive sleep apnea in the formerly preterm infant: an overlooked diagnosis

BACKGROUND

Obstructive sleep apnea syndrome (OSA) is a frequent disorder in children. The clinical characteristics of OSA in very young children under 2 years of age, and more particularly, in those born prematurely, and who have respiratory complications such as bronchopulmonary dysplasia (BPD), are not well defined. We therefore retrospectively reviewed our experience in a group of preterm infants with OSAS.

METHODS

The records of premature infants with BPD followed in the Pediatric Pulmonary Clinic at the University of Chicago who were diagnosed with OSA from 2004 to 2009 were reviewed and analyzed.

RESULTS

Twelve children, eight males, and four females with a mean gestational age of 27 weeks were found to have OSA. Mean age at diagnosis was 19 months. Inability to wean nighttime oxygen, the need to resume oxygen after intercurrent respiratory illness, and snoring were the most common presenting symptoms. The apnea-hypopnea index ranged from 1 to 120/h total sleep time (TST; mean: 29). SpO(2) nadir ranged from 50 to 91%. Despite adenotonsillectomy (AT), all children had persistent sleep disordered breathing.

CONCLUSION

In preterm infants, while snoring is a frequent symptom, poor weight gain, and inability to wean nighttime oxygen may indicate the need for further investigation for OSA. In the former preterm infant structural changes in the airway may play an important role along with adenotonsillar hypertrophy. A high level of clinical awareness is required to identify OSA in the formerly preterm infant.

Impact of lack of breast feeding during neonatal age on the development of clinical signs of pneumonia and hypoxemia in young infants with diarrhea

Background

Hypoxemia is a grave sequel of pneumonia, and an important predictor of a fatal outcome. Pneumonia in the neonatal period is often associated with lack of breast feeding. However, there is no published report on the impact of the cessation of breast feeding in the neonatal period on the development of pneumonia and hypoxemia. The purpose of our study was to assess the impact of non-breast feeding or stopping breast feeding during the neonatal period (henceforth to be referred to as non-breast fed) on clinical features of pneumonia and hypoxemia in 0–6-month-old infants with diarrhea admitted to an urban hospital in Bangladesh.

Methods

We prospectively enrolled all infants (n = 107) aged 0 to 6 months who were admitted to the Special Care Ward (SCW) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research Bangladesh (ICDDR,B) with diarrhea and pneumonia from September 2007 through December 2007.We compared the clinical features of pneumonia and hypoxemia of breast fed infants (n = 34) with those who were non-breast fed (n = 73).

Results

The median (inter-quartile range) duration of hypoxemia (hours) in non-breast-feds was longer than breast-fed infants [0.0 (0.0, 12.0) vs. 12.0 (0.0, 21.75); p = 0.021]. After adjusting for potential confounders such as inability to drink, fever, head nodding, cyanosis, grunting respiration, and lower chest wall in drawing, the non-breast-fed infants with pneumonia along with diarrhea had a higher probability of cough (OR 9.09; CI 1.34–61.71; p = 0.024), hypoxemia (OR 3.32; CI 1.23–8.93; p = 0.017), and severe undernutrition (OR 3.42; CI 1.29–9.12; p = 0.014).

Conclusions and Significance

Non-breast feeding or cessation of breast feeding during the neonatal period may substantially increase the incidence of severe malnutrition, incidence of cough, and both the incidence and duration of hypoxemia in young infants presenting with pneumonia and diarrhea. The findings emphasize the paramount importance of the continuation of breast feeding in the neonatal period and early infancy.

Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study

STUDY OBJECTIVES

To describe the prevalence, persistence, and characteristics associated with sleep disordered breathing (SDB) symptoms in a population-based cohort followed from 6 months to 6.75 years.

DESIGN

Avon Longitudinal Study of Parents and Children (ALSPAC).

SETTING

England, 1991-1999.

PARTICIPANTS

12,447 children in ALSPAC with parental report of apnea, snoring, or mouth-breathing frequency on any one of 7 questionnaires.

MEASUREMENTS

Symptom prevalence rates-assessed as "Always" and "Habitually"-are reported at 0.5, 1.5, 2.5, 3.5, 4.75, 5.75, and 6.75 years of age. The proportion of children in whom symptoms develop, persist or abate between observation points is reported. Exploratory multivariate analyses identified SDB risk factors at 1.5, 4.75, and 6.75 years.

RESULTS

The prevalence of apnea ("Always") is 1%-2% at all ages assessed. In contrast, snoring "Always" ranges from 3.6% to 7.7%, and snoring "Habitually" ranges from 9.6% to 21.2%, with a notable increase from 1.5- 2.5 years. At 6 years old, 25% are habitual mouth-breathers. The "Always" and "Habitual" incidence of each symptom between time points is 1%-5% and 5%-10%, respectively. In multivariate analyses of combined symptoms, socioeconomic factors have stronger, more persistent effects upon increased SDB risk than gestational age, gender, or race (aside from 1.5 years); adenoidectomy decreases risk by 40%-50%.

CONCLUSIONS

This is the first natural history study of the primary symptoms of SDB across a key 6-year period in the development of SDB symptoms. Snoring rates are higher and spike earlier than previously reported. Symptoms are dynamic, suggesting the need for early and continued vigilance in early childhood.

Pediatric obstructive sleep apnea: complications, management, and long-term outcomes

Obstructive sleep apnea (OSA) in children has emerged not only as a relatively prevalent condition but also as a disease that imposes a large array of morbidities, some of which may have long-term implications, well into adulthood. The major consequences of pediatric OSA involve neurobehavioral, cardiovascular, and endocrine and metabolic systems. The underlying pathophysiological mechanisms of OSA-induced end-organ injury are now being unraveled, and clearly involve oxidative and inflammatory pathways. However, the roles of individual susceptibility (as dictated by single-nucleotide polymorphisms), and of environmental and lifestyle conditions (such as diet, physical, and intellectual activity), may account for a substantial component of the variance in phenotype. Moreover, the clinical prototypic pediatric patient of the early 1990s has been insidiously replaced by a different phenotypic presentation that strikingly resembles that of adults afflicted by the disease. As such, analogous to diabetes, the terms type I and type II pediatric OSA have been proposed. The different manifestations of these two entities and their clinical course and approaches to management are reviewed.