Age-stratified sex differences in polysomnographic findings and pharyngeal morphology among children with obstructive sleep apnea

Obstructive Sleep Apnea in Overweight and Obese Children: Factors Influencing Quality of Life

Introduction

There is a paucity of data regarding biological sex influence and the impact of obstructive sleep apnea (OSA) on the quality of life (QoL) of obese children with OSA. Thus, we aimed to assess the influence of biological sex on polysomnography (PSG) and evaluate the impact of OSA on obese children's QoL.

Methods

Records of overweight or obese pediatric patients referred for sleep studies at the Jordan University Hospital between 2018 and 2022 were retrospectively reviewed. Children underwent PSG and anthropometric measurements. OSA diagnosis and severity were determined per the Apnea-Hypopnea Index (AHI). QoL was determined by the OSA-18 tool.

Results

Across a sample of 136 children, biological sex did not influence PSG indices, but there were significant differences across the sleep disorder (p = 0.023) and daily functioning (p = 0.007) QoL domains. Age affected the non-REM sleep percentages and NADIR of O2 saturation (all p < 0.01). There were significant differences across the emotional distress and daytime function domains across age groups (all p < 0.05). Body mass index (BMI) did not significantly influence AHI strata, but was associated with worse daytime function (p < 0.05). Additionally, OSA severity was associated with poorer sleep disorder and concerns about caregivers' scores (all p < 0.05). On multivariate analysis, gender predicted OSA-18 total score, but not age, BMI, or AHI.

Conclusion

It appears that biological sex has no clinical impact on OSA among obese children. However, it appears that age significantly influences both OSA and its associated QoL.

Craniofacial Development Characteristics in Children with Obstructive Sleep Apnea for Establishment and External Validation of the Prediction Model

Purpose

Aimed to analyze the developmental characteristics of craniofacial structures and soft tissues in children with obstructive sleep apnea (OSA) and to establish and evaluate prediction model.

Methods

It's a retrospective study comprising 747 children aged 2-12 years (337 patients and 410 controls) visited the Department of Otolaryngology-Head and Neck Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University (July 2017 to March 2024). Lateral head radiographs were obtained to compare the cephalometric measurements. The clinical prediction model was constructed using LASSO regression analysis. We analyzed 300 children from the Xi'an Children's Hospital for external validation.

Results

Children with OSA had a higher body mass, a higher tonsil grade, larger AN ratio (ratio of the adenoids to the skeletal upper airway width), larger radius of the tonsils, a smaller angle between the skull base and maxilla (SNA) and smaller angle between the skull base and mandible (SNB), a larger distance from the hyoid to the mandibular plane (H-MP) and smaller distance between the third cervical vertebra and hyoid (H-C), a larger thickness of the soft palate (SPT) and smaller inclination angle of the soft palate than those of the controls (all p < 0.05). A prediction model was constructed for 2-12 years group (AUC of 0.812 [95% CI: 0.781-0.842]). Age-specific prediction models were developed for preschool children (AUC of 0.769 [95% CI: 0.725-0.814]), for school-aged children (AUC of 0.854 [95% CI: 0.812-0.895]).

Conclusion

Our study findings support the important role of craniofacial structures such as the hyoid, maxilla, mandible, and soft palate in pediatric OSA. Age-stratified predictive models for pediatric OSA indicated varying parameters across different age groups which underscore the necessity for stratifying by age in future research. The prediction model designed will greatly assist health care practitioners with rapidly identifying.

Obstructive Sleep Apnea in Pediatrics and Adolescent Women: A Systematic Review of Sex-Based Differences Between Girls and Boys

BACKGROUND/OBJECTIVES

Obstructive sleep apnea (OSA) is marked by repetitive occurrences of upper airway (UA) obstruction during sleep. Morbidities impacting the metabolic, cardiovascular (CV) and neurological systems are correlated with OSA. Only a few studies have described the existence of different characteristics depending on sex and, to date, the girl phenotype in OSA pediatrics is not well known. The objective of this systematic review is to identify the specific phenotype of OSA in pediatric and adolescent females compared to males.

METHODS

A systematic review was performed. The terms "pediatric sleep apnea" and "sex differences" were used to look for publications using PubMed, the Cochrane Library and Web of Science.

INCLUSION CRITERIA

(1) peer-reviewed journal articles written in English; (2) investigations conducted on individuals diagnosed with OSA; and (3) investigations providing information about sex differences.

EXCLUSION CRITERIA

(1) studies carried out with individuals aged 18 years and older; (2) studies involving a sample size of fewer than 10 patients; and (3) editorials, letters and case reports.

RESULTS

Fifteen studies were included and classified in sections related to sex-based differences.

CONCLUSIONS

Limited information related to sex-based OSA differences in the pediatric population exists. These differences are conditioned by hormonal status, and are minimal in the premenarcheal period. Moreover, adolescent women present a lower prevalence of obesity and craniofacial alterations, lower OSA severity related to higher UA area and earlier tonsil regression. Hyperactivity is more frequent in boys. Some studies pointed to a higher risk of high diastolic blood pressure in girls than in boys.

Advances in Sleep-Disordered Breathing in Children

Pediatric sleep-disordered breathing disorders are a group of common conditions, from habitual snoring to obstructive sleep apnea (OSA) syndrome, affecting a significant proportion of children. The present article summarizes the current knowledge on diagnosis and treatment of pediatric OSA focusing on therapeutic and surgical advancements in the field in recent years. Advancements in OSA such as biomarkers, improving continuous pressure therapy adherence, novel pharmacotherapies, and advanced surgeries are discussed.

[The relationship between birth weight and obstructive sleep apnea in children]

Objective:To study the relationship between children's birth weight and obstructive sleep apnea（OSA）. Methods:The sleep data and birth information of children who underwent polysomnography in the Department of Otorhinolaryngology-Head and Neck Surgery of Henan Children's Hospital from October 2020 to July 2022 were retrospectively analyzed. The data of OSA detection rate, OSA severity, sleep structure and respiratory parameters in different birth weight groups were analyzed. Results:A total of 2 778 children met the inclusion criteria, including 1 833 males and 945 females. According to birth weight, the selected children were divided into three groups: 122 small for gestational age（SGA） group, 2 313 appropriate for gestational age（AGA）, and 343 large for gestational age（LGA） group. There was no significant difference in age between different groups（P=0.061）. In each group, boys are significantly more numerous than girls（P=0.001）. The difference in current body mass index（BMI） between groups was statistically significant: the current BMI was higher in the LGA group（17.51±4.01, P<0.001）. The severity of OSA was different in different birth weight groups（P=0.037）. There was a strong positive correlation between the severity of OSA and birth weight（r=0.992）. Children in the SGA group had shorter rapid eye movement（REM） sleep period（19.00[15.18, 23.33], P=0.012）, higher obstructive apnea-hypopnea index（OAHI） values（1.75[0.60, 5.13], P=0.019）, and had lower central apnea hypopnea index（CAHI） values（0.10[0.00, 0.50], P=0.020）. There were no significant differences in sleep structure and respiratory parameters between the LGA group and the AGA group. Multiple regression analysis of the factors affecting the OAHI index showed that the OAHI index of boys was higher than that of girls（95%CI 1.311-2.096, P<0.001）, and age was negatively correlated with the OAHI index（r=-0.105, 95%CI 0.856-0.946, P<0.001）, current BMI and OAHI index were positively correlated（r=0.037, 95%CI 1.010-1.065, P=0.007）. LGA was positively correlated with OAHI index（r=0.346, 95%CI 1.039-1.921, P=0.027）, and the correlation between LGA and OAHI（r=0.346） was higher than that between SGA and OAHI（r=0.340）. Conclusion:There was no significant difference in the incidence of OSA in children with different birth weight groups, but the OSA severity of LGA group was higher. Gender, age, BMI index and large for gestational age were the influencing factors for the occurrence of OSA in children, which should be paid more attention to in clinical practice.

Identification of obstructive sleep apnea in children with obesity: A cluster analysis approach

BACKGROUND

Obstructive sleep apnea (OSA) is a heterogeneous disorder with a prevalence of 25%-60% in children with obesity. There is a lack of diagnostic tools to identify those at high risk for OSA.

METHOD

Children with obesity, aged 8-19 years old, were enrolled into an ongoing multicenter, prospective cohort study related to OSA. We performed k-means cluster analysis to identify clinical variables which could help identify obesity related OSA.

RESULTS

In this study, 118 participants were included in the analysis; 40.7% were diagnosed with OSA, 46.6% were female and the mean (SD) body mass index (BMI) and age were 39.7 (9.6) Kg/m², and 14.4 (2.6) years, respectively. The mean (SD) obstructive apnea-hypopnea index (OAHI) was 11.0 (21.1) events/h. We identified two distinct clusters based on three clustering variables (age, BMI z-score, and neck-height ratio [NHR]). The prevalence of OSA in clusters 1 and 2, were 22.4% and 58.3% (p = 0.001), respectively. Children in cluster 2, in comparison to cluster 1, had higher BMI z-score (4.7 (1.1) versus 3.2 (0.7), p < 0.001), higher NHR (0.3 (0.02) versus 0.2 (0.01), p < 0.001) and were older (15.0 (2.2) versus 13.7 (2.9) years, p = 0.09), respectively. However, there were no significant differences in sex and OSA symptoms between the clusters. The results from hierarchical clustering were similar to k-means analysis suggesting that the resulting OSA clusters were stable to different analysis approaches.

INTERPRETATION

BMI, NHR, and age are easily obtained in a clinical setting and can be utilized to identify children at high risk for OSA.

Pediatric Ocular Health and Obstructive Sleep Apnea Syndrome: A Review

Obstructive sleep apnea (OSA) affects neurobehavioral, cognitive, and cardiovascular aspects, particularly in children, by obstructing the upper airways during sleep. While its impact in adult ocular health is recognized, there is ongoing debate about OSA's relevance in pediatrics. This review explores the relationship between OSA and ocular health in children, focusing on the effects and potential improvements through treatment. A systematic search found 287 articles through PubMeD/MEDLINE, Scopus, Web of Science, and ScienceDirect; 94.4% were excluded. After careful selection, six English articles were included, addressing the effects of OSA on children's eyes. Three studies examined choroidal alterations, three explored retinal and optic nerve changes, and two analyzed ocular changes following otorhinolaryngological intervention. The immediate correlation in children is inconclusive, but age may be a contributing factor. Pediatric OSA patients exhibit corneal anomalies and increased optic nerve thickness, possibly due to intermittent hypoxia. OSA influences retinal vascular density in children, with increased density after treatment and reduced choroidal thickness in cases of adenotonsillar hypertrophy. This review emphasized OSA's significant impact on children's ocular health, revealing alterations in the optic nerve, choroid, retina, and cornea. While the direct correlation with the optic nerve is not always evident, OSA raises intraocular pressure and induces structural changes. Treatment holds promise, highlighting the need for regular monitoring to promptly address childhood OSA.

Demographics of tonsillar hypertrophy among sickle cell disease patients in calabar

Background

Sickle cell disease (SCD) is the most common genetic disorder, with Africa bearing the highest burden. In this cohort study, sickle cell subjects are immunocompromised and predisposed to recurrent infections and tonsillar hypertrophy, especially in children. Subsequently, tonsillar hypertrophy leads to sleep-disordered breathing (SDB) with resulting hypoxemia, hypercapnia, and acidosis, raising the risk of HbS polymerization and, consequently, vaso-occlusive phenomena and other complications.

Aims

This study aimed to compare tonsillar hypertrophy between sickle cell patients and controls.

Materials and Methods

A cross-sectional descriptive study was conducted at, University of Calabar Teaching Hospital, Calabar from September 2019 to September 2021. The cohort of the study was an SCD patient confirmed using hemoglobin electrophoresis at the hematology laboratory of University of Calaabr teaching hospital and recruited via the adult and pediatric hematology unit of University of Calabar teaching hospital, and Calabar sickle cell club. The data were analyzed using Microsoft Excel and IBM Statistical Package and Service Solution (SPSS) version 22.

Results

Using Brodsky's grading, the prevalence of grade 3 and 4 hypertrophic tonsils in sickle cell subjects was 41.6% but 17.3% in control. The age range of 0-25 years was the most frequently affected with the peak at 0-5 years. The males among the sickle cell subjects were slightly more affected than the females (M: F =1.2:1), while the females were slightly more in the control (M: F =1:1.1).

Conclusions

Hypertrophic tonsils affect control and SCD, but the obstructive grades are commoner in genotypes SCD- Sickle cell disease Haemoglobin SS, SC and AA.

Obstructive sleep apnea screening in children with asthma

RATIONALE

Obstructive sleep apnea is highly prevalent in children with asthma, particularly in obese children. The sleep-related breathing disorder screening questionnaire has low screening accuracy for obstructive sleep apnea in children with asthma. Our goal was to identify the questions on the sleep-related breathing disorder survey associated with obstructive sleep apnea in children with asthma.

METHODS

Participants completed the survey, underwent polysomnography and their body mass index z-score was measured. Participants with survey scores above 0.33 were considered high risk for obstructive sleep apnea and those with an apnea-hypopnea index ≥ 2 events/h classified as having obstructive sleep apnea. Logistic regression was used to examine the association of each survey question and obstructive sleep apnea. Positive and negative predictive values were calculated to estimate screening accuracy.

RESULTS

The prevalence of obstructive sleep apnea was 40% in our sample (n = 136). Loud snoring, morning dry mouth, and being overweight were the survey questions associated with obstructive sleep apnea. The composite survey score obtained from all 22 questions had positive and negative predictive values of 51.0% and 65.5%, while the combined model of loud snoring, morning dry mouth, and being overweight had positive and negative predictive values of 60.3% and 77.6%. On the other hand, the body mass index z-score alone had positive and negative predictive values of 76.3% and 72.2%.

CONCLUSIONS

The body mass index z-score is useful for obstructive sleep apnea screening in children with asthma and should be applied routinely given its simplicity and concerns that obstructive sleep apnea may contribute to asthma morbidity.

Evaluating symptoms and polysomnographic findings among male and female children with obesity with and without obstructive sleep apnea

OBJECTIVE

Limited data regarding sex-based differences in the presentation and phenotype of obstructive sleep apnea (OSA) exists among children with obesity. The study objectives were to compare reported symptoms and polysomnogram (PSG) findings between children with obesity 1) with and without OSA and 2) males and females with OSA.

PATIENTS/METHODS

This cross-sectional study included children with obesity, aged 8-18 years, with a diagnostic PSG between 2015 and 2021, referred for evaluating sleep-related breathing. Patient demographics, anthropometrics, and PSG data were recorded. Symptoms were evaluated using Epworth Sleepiness Scale and Pediatric Sleep Questionnaire. Pubertal staging was collected using Tanner Stage questionnaire. PSG parameters, symptoms and pubertal stage were compared between sexes with and without OSA.

RESULTS

Of 148 children, 61 (41%) had OSA. Within the OSA group, 41/62 (69%) were male (p = 0.002). Males with OSA reported higher Pediatric Sleep Questionnaire scores compared to males without OSA (0.38 ± 0.2 vs 0.23 ± 0.1; p = 0.002). Males with OSA reported more trouble breathing (p = 0.04) and mouth breathing (p = 0.008) compared to females with OSA. Females with OSA showed longer sleep onset latency (45.8 ± 40.6 min vs 22.4 ± 26.7; p = 0.02) and higher supine obstructive-apnea hypopnea index (32.9 ± 31.1 vs 20.4 ± 18.4 events/hour; p = 0.02) compared to males with OSA. A significant interaction was found between male sex and waist-to-height ratio (β = 15.34, R² = 0.18, p = 0.05).

CONCLUSIONS

Sex differences in symptoms and phenotype of OSA exist among children with obesity. Such information is beneficial for early diagnosis and management to mitigate adverse outcomes and comorbidities.

Age- and gender-related characteristics in pediatric obstructive sleep apnea

BACKGROUND

Age and gender disparities in polysomnographic findings in children are not well understood.

OBJECTIVE

This study determined age and gender-related characteristics in pediatric obstructive sleep apnea (OSA).

METHOD

Retrospectively, data were collected. We analyzed polysomnographic data in the following age groups: 3-6 years (n = 681), 6-9 years (n = 553), 9-12 years (n = 297), 12-15 years (n = 200), and 15-18 years (n = 111).

RESULTS

A total of 1842 children were included (mean age: 8.0 years; boys: 67%; obesity: 21%). The apnea-hypopnea index (AHI) gradually increased with age (3-6, 6-9, 9-12, 12-15, and 15-18 years groups: 6.2, 5.9, 6.5, 8.1, and 9.9 event/h, respectively; p trend = 0.002). In all age groups, boys had a higher AHI than girls (7.8 vs. 4.1 events/h, p < 0.001). Children with obesity had a higher AHI than those without (12.9 vs. 4.9 events/h, p < 0.001). The mean AHI in the boys increased with age (3-6 to 15-18 years groups: 7.0-13.6 events/h, respectively; p trend < 0.001), whereas the mean AHI in the girls was not significantly different between ages (p trend = 0.492). In moderation analyses, gender was a moderator in the association between obesity and AHI, and the association between age and AHI during 12-15 and 15-18 years of ages.

CONCLUSION

Male gender and obesity increase risk of OSA. Regarding age disparities, this study discovered a higher AHI in male adolescents than in young boys.

Sex differences in the relationship of sleep-disordered breathing and asthma control among children with severe asthma

OBJECTIVE

Children with severe asthma are underrepresented in studies of the relationship of sleep-disordered breathing (SDB) and asthma and little is known about sex differences of these relationships. We sought to determine the relationship of SDB with asthma control and lung function among boys and girls within a pediatric severe asthma cohort.

METHODS

Patients attending clinic visits at the Boston Children's Hospital Pediatric Severe Asthma Program completed the Pediatric Sleep Questionnaire (PSQ), Asthma Control Test (ACT) and Spirometry. The prevalence of SDB was defined as a PSQ score >0.33. We analyzed the association between PSQ score and both ACT score and spirometry values in mixed effect models, testing interactions for age and sex.

RESULTS

Among 37 subjects, mean age was 11.8 years (4.4) and 23 (62.2%) were male, the prevalence of SDB was 43.2% (16/37). Including all 80 observations, there was a moderate negative correlation between PSQ and ACT scores (r=-0.46, p < 0.001). Multivariable linear regression models revealed a significant sex interaction with PSQ on asthma control (p = 0.003), such that for each 0.10 point increase in PSQ there was a 1.88 point decrease in ACT score for females but only 0.21 point decrease in ACT score for males. A positive PSQ screen was associated with a 9.44 point (CI 5.54, 13.34, p < 0.001) lower ACT score for females and a 3.22 point (CI 0.56, 5.88, p = 0.02) lower score for males.

CONCLUSIONS

SDB is common among children with severe asthma. Among children with severe asthma, SDB in girls portends to significantly worse asthma control than boys.

Supplemental data for this article is available online at https://doi.org/10.1080/02770903.2021.1897838.

Sleep Complaints Among School Children

Sleep complaints are common among children. These include both night-time and daytime symptoms, such as trouble falling asleep, problems in maintaining sleep, snoring, and unusual events during sleep and daytime functioning impairment. However, sleep complaints in children are often overlooked and undertreated in clinical practice. Untreated sleep problems may further impact on children's development and will persist into adulthood in some cases. This review summarizes the common sleep complaints and disorders in school children, and provides an overview of the epidemiology, clinical features, consequences, and treatment of the sleep problems.

Sleep disordered breathing from preschool to early adult age and its neurocognitive complications: A preliminary report

Objective

The onset and development of sleep disordered breathing (SDB) remains unclear in an age - dependent manner. Despite treatment, persistent symptoms such as snoring and excessive daytime sleepiness, as well as cognitive impairment may be present. The aim of the research was to determine the prevalence of residual symptoms of SDB in adolescence and early adulthood, the predisposing factors and its neurocognitive complications.

Methods

In the present pilot study-cohort, a questionnaire was utilized to 154 people (average age: 17.9 ± 3), who as children (mean age: 5.3 ± 1.4) had AHI ≥2.5 episodes/h. They were divided into two groups based on AHI = 5 episodes/h. Depending on the results, they were invited to undergo a repeated polysomnography (PSG) and complete the Montreal Cognitive Assessment (MoCA) test. Statistical analysis was made with IBM SPSS software.

Results

Out of the total, 35.7% claimed to still snore. AHI was negatively correlated to the severity of residual symptoms (Mann-Witney U test, p <0.005). According to repeated PSGs, 9/17 met the criteria for OSAS, while high BMI was associated with the severity of new AHI (chi squared test, p<0.005). Additionally, 7/16 scored below the MoCA baseline (<26/30). The characteristics of cognitive declines were mapped, with most prominent having been visuospatial, short - term memory and naming/language deficits.

Discussion

A significant percentage of children with sleep breathing disorder present with residual symptoms during their transition to early adulthood, as well as undiagnosed neurocognitive complications. Clinicians suspicion for the underlying neurocognitive complications is required, even in young adults, while guidelines on monitoring pediatric OSAS patients after treatment should be addressed.

Long-term Impact of Adenotonsillectomy on the Quality of Life of Children with Sleep-disordered breathing

Introduction  Adenotonsillectomy is the first-line treatment for obstructive sleep apnea secondary to adenotonsillar hypertrophy in children. The physical benefits of this surgery are well known as well as its impact on the quality of life (QoL), mainly according to short-term evaluations. However, the long-term effects of this surgery are still unclear.

Objective  To evaluate the long-term impact of adenotonsillectomy on the QoL of children with sleep-disordered breathing (SDB).

Method  This was a prospective non-controlled study. Children between 3 and 13 years of age with symptoms of SDB for whom adenotonsillectomy had been indicated were included. Children with comorbities were excluded. Quality of life was evaluated using the obstructive sleep apnea questionnaire (OSA-18), which was completed prior to, 10 days, 6 months, 12 months and, at least, 18 months after the procedure. For statistical analysis, p -values lower than 0.05 were defined as statistically significant.

Results  A total of 31 patients were enrolled in the study. The average age was 5.2 years, and 16 patients were male. The OSA-18 scores improved after the procedure in all domains, and this result was maintained until the last evaluation, done 22 ± 3 months after the procedure. Improvement in each domain was not superior to achieved in other domains. No correlation was found between tonsil or adenoid size and OSA-18 scores.

Conclusion  This is the largest prospective study that evaluated the long-term effects of the surgery on the QoL of children with SDB using the OSA-18. Our results show adenotonsillectomy has a positive impact in children's QoL.

Are there gender differences in the severity and consequences of sleep disordered in children?

OBJECTIVES

In adults there is a distinct gender difference in the prevalence and severity of sleep disordered breathing (SDB), however there have been limited studies examining the effects of gender in children with SDB. We aimed to compare the effects of gender on severity of SDB, blood pressure, sleep and respiratory characteristics, quality of life, behavior and executive function.

METHODS

We included 533 children aged 3-18 years, who underwent standard pediatric overnight polysomnography (PSG) between 2004 and 2016. Blood pressure was recorded prior to each study. Quality of life, behavior and executive function were assessed with parental questionnaires. Children were grouped by gender and SDB severity based on their obstructive apnea hypopnea index (OAHI) into non-snoring controls, Primary Snoring (PS) (OAHI≤1 event/h), Mild obstructive sleep apnea (OSA) (OAHI>1-≤5 events/h) and moderate/severe (MS) OSA (OAHI>5 events/h) and data compared with 2-way ANOVA.

RESULTS

A total of 298 boys and 235 girls were studied. There were no differences in age, BMI z-score, SDB severity sleep characteristics or blood pressure between genders. Diastolic blood pressure was elevated in females with MS OSA compared to males (P < 0.05). Quality of life, behavior and executive function scores were all elevated in the SDB groups compared to controls. Females with MS OSA exhibited more internalizing behavioral problems compared to males (59.2 ± 2.4 vs. 51.4 ± 2.3, P < 0.05).

CONCLUSIONS

In contrast to studies in adults, we identified no gender differences in the severity or consequences of SDB in children, other than females with moderate-severe OSA exhibiting more internalizing problems and higher diastolic blood pressure.