Obstructive sleep apnea in children: a critical update

Management of Paediatric Obstructive Sleep Apnoea: From a Multidisciplinary to an Interdisciplinary Care Model

The objective of this study is to offer a comprehensive overview of paediatric obstructive sleep apnoea (OSA), a prevalent condition characterised by intermittent upper airway obstruction that impairs both ventilation and sleep. The design of the study was a literature review using an electronic search. The study extensively reviews the pathophysiology, epidemiology, sequelae and diagnostic approaches of paediatric OSA. It highlights the role of various healthcare professionals in the management of this disorder, with each specialist providing unique contributions to the diagnosis, treatment and ongoing management of OSA. The current state of sleep teams managing OSA is multidisciplinary, including sleep physicians, pulmonologists and otolaryngologists (ENT surgeons), each contributing distinct expertise. This review contrasts a multidisciplinary approach, which relies on separate expert contributions, with an interdisciplinary model that emphasises integrated, collaborative decision-making for comprehensive, patient-centred care. This review focuses on the interactions between dental and medical professionals, as other papers will provide more detailed insights into the roles of other specialists, such as myofunctional therapists, nutritionists and others. In conclusion, the evolution from a multidisciplinary to an interdisciplinary care model marks a significant development in clinical practice, enhancing cooperation and shared decision-making among healthcare professionals, thereby improving the quality of life for paediatric patients with OSA.

Risk factors of high inflammatory state in pediatric obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) may induce chronic systemic inflammation, which may serve as a potential mechanism contributing to multiple complications. The timely identification of high inflammatory status (HIS) in pediatric OSA is crucial for effective clinical diagnosis and management. This study aimed to evaluate influencing factors in hsCRP levels, and further investigated the risk factors associated with HIS in pediatric OSA patients.

METHODS

Children aged 3 to 15 years who presented with snoring symptoms and underwent polysomnography (PSG) at the sleep center were included in this study. All participants completed a comprehensive questionnaire, a physical examination, nasopharyngeal X-ray imaging and a blood test. The physical examination included measurements of height, weight, and visual evaluation of tonsillar hypertrophy.

RESULTS

A total of 1,171 children were enrolled, with 562 cases diagnosed with OSA. Utilizing threshold for hsCRP generated via ROC curve, 299 and 872 children exhibited HIS and Low Inflammatory Status, respectively. Compared to the control group, the hsCRP levels in the OSA group were significantly elevated. Pediatric OSA with HIS had higher BMI and a greater proportion of both overweight and obese. Logistic regression analysis demonstrated that HIS was independently positively correlated with BMI and mean time of obstructive apnea, and negatively associated with minimum SpO2.

CONCLUSIONS

HsCRP in pediatric OSA patients were notably elevated, whilst identifying BMI, mean time of obstructive apnea, and minimum SpO2 as independent factors leading to HIS. HsCRP may function as an effective blood index capable of identifying individuals exhibiting HIS linked to OSA.

Prevalence of symptoms suggestive of sleep apnea among children and its impact on academic performance

BACKGROUND

Obstructive sleep apnea (OSA) is a common condition in pediatrics that requires prompt recognition and management to minimize its negative impact on their health and development. Data on the prevalence of OSA among school-age minors in Jordan is scarce. This study aims to estimate the prevalence of OSA in children and adolescents and identify factors that make them more likely to have OSA and its impact on academic achievement.

METHODS

This school-based cross-sectional study was conducted from January to March 2023. A questionnaire including information on demographic variables, school performance, and a validated sleep-related breathing disorder (SRBD) scale for pediatrics was distributed to 1798 students in schools all over Amman. The prevalence of OSA (defined as SRBD score > 33%) was reported as a proportion along with its 95% confidence interval.

RESULTS

Out of the 2000 questionnaires distributed, 1798 were analyzed. Among these, 1079 (60%) were from children aged 5 to 10 years, and 719 (40%) were from adolescents aged 11 to 18 years. The prevalence of high risk for OSA (HR-OSA) was higher among adolescents than in children (25.6% vs. 20.8%). Adolescents with unemployed fathers were more likely to be HR-OSA (33.70 vs 17.57%, p < 0.001). In contrast, paternal employment did not affect the prevalence of HR-OSA in children. Sleep talking, bruxism, and sweating during sleep were more common among children with positive SRBD. Nocturnal enuresis (NE) was associated with positive SRBD in children and adolescents. HR-OSA was associated with poor academic performance in both study groups.

CONCLUSION

HR-OSA is highly prevalent in Jordanian children and adolescents. HR-OSA can occur alongside other sleep disorders, and it significantly impairs the academic performance of affected individuals. This study found an association between high risk for OSA and other sleeping disorders (sleep talking, sleep bruxism, and sweat during sleeping) and nocturnal enuresis which needs to be confirmed in larger studies.

SleepECG-Net: Explainable Deep Learning Approach With ECG for Pediatric Sleep Apnea Diagnosis

Obstructive sleep apnea (OSA) in children is a prevalent and serious respiratory condition linked to cardiovascular morbidity. Polysomnography, the standard diagnostic approach, faces challenges in accessibility and complexity, leading to underdiagnosis. To simplify OSA diagnosis, deep learning (DL) algorithms have been developed using cardiac signals, but they often lack interpretability. Our study introduces a novel interpretable DL approach (SleepECG-Net) for directly estimating OSA severity in at-risk children. A combination of convolutional and recurrent neural networks (CNN-RNN) was trained on overnight electrocardiogram (ECG) signals. Gradient-weighted Class Activation Mapping (Grad-CAM), an eXplainable Artificial Intelligence (XAI) algorithm, was applied to explain model decisions and extract ECG patterns relevant to pediatric OSA. Accordingly, ECG signals from the semi-public Childhood Adenotonsillectomy Trial (CHAT, n = 1610) and Cleveland Family Study (CFS,n = 64), and the private University of Chicago (UofC, n = 981) databases were used. OSA diagnostic performance reached 4-class Cohen's Kappa of 0.410, 0.335, and 0.249 in CHAT, UofC, and CFS, respectively. The proposal demonstrated improved performance with increased severity along with heightened cardiovascular risk. XAI findings highlighted the detection of established ECG features linked to OSA, such as bradycardia-tachycardia events and delayed ECG patterns during apnea/hypopnea occurrences, focusing on clusters of events. Furthermore, Grad-CAM heatmaps identified potential ECG patterns indicating cardiovascular risk, such as P, T, and U waves, QT intervals, and QRS complex variations. Hence, SleepECG-Net approach may improve pediatric OSA diagnosis by also offering cardiac risk factor information, thereby increasing clinician confidence in automated systems, and promoting their effective adoption in clinical practice.

Lingual Tonsillectomy as Part of a DISE-Directed Multilevel Upper Airway Surgery to Treat Complex Pediatric OSA: A Safe and Appropriate Procedure

OBJECTIVE

To study the efficiency of lingual tonsillectomy (LT) as part of multilevel surgery in children with complex obstructive sleep apnea (OSA). To evaluate the safety and the outcomes of LT.

STUDY DESIGN

Retrospective case series.

SETTING

Pediatric tertiary care academic center.

METHODS

We included all children operated for LT to treat complex OSA, from January 2018 to June 2022. All patients underwent a protocolized drug-induced sleep endoscopy (DISE) followed by a coblation LT, associated with the treatment of all other obstructive sites. Patient demographics, medical history, surgery, and outcomes were reviewed. The efficiency of LT was analyzed exclusively in patients with a preoperative and postoperative sleep study.

RESULTS

One hundred twenty-three patients were included. Median age was 8 years (interquartile range, IQR [3-12]). Sixty-five (53%) patients had Down syndrome, 22 (18%) had a craniofacial malformation, and 8 (7%) were obese. LT was associated with adenoidectomy (n = 78, 63%), partial tonsillectomy (n = 70, 57%), inferior turbinoplasty/turbinectomy (n = 59, 48%), epiglottoplasty (n = 92, 75%), and/or expansion pharyngoplasty (n = 2, 2%). Eighty-nine patients underwent a sleep study before and after surgery. The median apnea-hypopnea index (AHI) decreased from 18 events/h (IQR [9-36]) before surgery to 3 events/h (IQR [1-5]) after surgery (P < .001) (patients with a postoperative AHI <1.5 events/h, n = 31, 35%, and an AHI <5 events/h, n = 32, 36%). Seventeen out of 30 (57%) patients could be weaned from continuous positive airway pressure after surgery. Two patients had a postoperative hemorrhage and 2 patients required a transient postoperative reintubation.

CONCLUSION

In children with complex OSA, LT as part of a DISE-directed multilevel upper airway surgery, was a very efficient and safe procedure.

Genome-wide epigenetic profiling and transcriptome analysis in pediatric Obstructive Sleep Apnea: A focus on Black female children

Obstructive Sleep Apnea (OSA) is a common sleep-related breathing disorder characterized by airway obstruction during sleep. Diagnosing pediatric OSA is challenging, particularly in underrepresented populations, leading to disparities in treatment and long-term negative health outcomes. Our study aimed to identify alternative diagnostic tools by investigating genome-wide epigenetic changes and associated transcriptomic alterations in Black female, pediatric patients with OSA. Whole-genome bisulfite sequencing and RNA sequencing were performed on saliva samples from healthy controls and children with OSA. Analysis of differential methylation and gene expression patterns revealed dysregulated inflammation and metabolism pathways in children with OSA. Chromosomes 19 and 22 exhibited elevated methylation signatures in this patient population. Integration of methylation and gene expression data identified specific molecular markers, including NAP1L4, CCR1, and LIF. The study emphasizes the need to consider both genetic and environmental factors in pediatric OSA, and the identified markers may offer avenues for further research.

Pediatric Obstructive Sleep Apnea: Diagnostic Challenges and Management Strategies

Pediatric obstructive sleep apnea (OSA) is a prevalent yet often underdiagnosed condition affecting 1-5% of children globally, with higher prevalence in populations such as those with Down syndrome and obesity. Characterized by recurrent upper airway obstruction during sleep, OSA can lead to serious health consequences, including neurocognitive deficits, behavioral issues, and cardiovascular complications. The diagnosis is complicated by symptom overlap with conditions like Attention-Deficit/Hyperactivity Disorder (ADHD) while polysomnography (PSG) remains the gold standard for diagnosis, access to this test is limited in many regions. Treatment options include lifestyle modifications, surgical interventions like adenotonsillectomy, and non-invasive approaches such as upper airway stenting for patients who are non-compliant with continuous positive airway pressure (CPAP) therapy. Evidence indicates that adenotonsillectomy significantly reduces the apnea-hypopnea index (AHI) in children with adenotonsillar hypertrophy, although residual OSA is common, particularly in high-risk populations like those with Prader-Willi syndrome. Recent studies have explored pharmacological treatments, advanced diagnostic techniques, and machine learning applications to improve outcomes. This review emphasizes the importance of a multidisciplinary, individualized approach to the management of pediatric OSA, highlighting the need for further research into innovative therapeutic strategies and long-term outcomes for affected children.

Retrospective review of treatment outcomes and costs in children with sleep disordered breathing assessed with multi-channel studies

Current UK guidance on OSA management recommends only selective use of sleep studies - when there is diagnostic uncertainty, in children with comorbidities or to evaluate perioperative risk in those with suspected severe OSA. Routine use of sleep studies to confirm a diagnosis of obstructive sleep apnoea (OSA) in children before adenotonsillectomy is not currently recommended. We report the findings of a novel paediatric sleep service based on routine use of multi-channel sleep studies (MCSS) before adenotonsillectomy and present the results of a service evaluation assessing the impact of our practise on treatment outcomes and cost. We conducted a retrospective study of 264 children with sleep disordered breathing seen in our centre between July 2018-June 2019, using medical records and a sleep study database to determine treatment outcomes and costs. Using responses from a questionnaire completed by otolaryngologists for a separate prospective study, we compare our costs with estimates of those associated with a standard UK model of care i.e. with selective use of sleep studies. We estimate that our routine use of MCSS reduced the number of adenotonsillectomies by 44 % but at higher monetary costs than those estimated for the standard model of care. We note however, that reconfiguring our service to arrange a sleep study before the initial appointment, rather than after, would result in the service being cost neutral compared with the standard model. We also estimate that use of home multi-channel studies in our service would bring a significant cost saving (∼£50,000 - £80,000 per annum) compared to standard care.

Assessment of Changes in Behavior and Quality of Life after Monobloc Treatment in Children with Obstructive Sleep Apnea or Primary Snoring

Objective

The aim of this study was to examine the quality of life and behavioral disorders in children with obstructive sleep apnea (OSA) or primary snoring, as well as how these problems changed after monobloc treatment.

Methods

Fourteen children with primary snoring and 16 children with OSA who had skeletal class II malocclusion due to mandibular retrognathia were treated with monobloc appliances. To investigate the relationship between behavioral disorders and quality of life, parents were asked to complete four questionnaires: attention deficit and hyperactivity disorder (ADHD) scale, strength and difficulties questionnaire (SDQ), pediatric sleep questionnaire (PSQ), and Pittsburgh sleep quality scale (PSQS). Mann-Whitney U and Wilcoxon signed-rank tests were used to evaluate the data.

Results

According to the results of the PSQ and PSQS, an increase in sleep quality was observed after monobloc treatment. The decrease in the total ADHD score at the end of the treatment was found to be statistically significant in both the OSA (p<0.01) and snoring (p<0.01) groups. According to the SDQ scores, the increase in the social behavior score and the decrease in the peer bullying score in the snoring group were statistically significant (p<0.05).

Conclusion

The use of a monobloc appliance in pediatric patients exhibiting primary snoring and OSA resulted in a notable reduction in sleep-breathing disorder symptoms and a notable enhancement in their overall quality of life. Based on the analyses of the questionnaires, it was concluded that the increase in sleep quality improved the pediatric patients' quality of life after orthodontic treatment with orthodontic monobloc appliances.

Changes in the nasopharyngeal and oropharyngeal microbiota in pediatric obstructive sleep apnea before and after surgery: a prospective study

OBJECTIVE

To explore the changes and potential mechanisms of microbiome in different parts of the upper airway in the development of pediatric OSA and observe the impact of surgical intervention on oral microbiome for pediatric OSA.

METHODS

Before adeno-tonsillectomy, we collected throat swab samples from different parts of the oropharynx and nasopharynx of 30 OSA patients and 10 non-OSA patients and collected throat swab samples from the oropharynx of the above patients one month after the adeno-tonsillectomy. The 16 S rRNA V3-V4 region was sequenced to identify the microbial communities. The correlation analysis was conducted based on clinical characteristics.

RESULTS

There was a significant difference of alpha diversity in different parts of the upper airway of pediatric OSA, but this difference was not found in children with non-OSA. Beta diversity was significantly different between non-OSA and pediatric OSA. At the genus level, the composition of flora in different parts is different between non-OSA and pediatric OSA. The correlation analysis revealed that the relative abundance of Neisseria was significantly correlated with obstructive apnea hypopnea index. Furthermore, the functional prediction revealed that pathways related to cell proliferation and material metabolism were significantly different between non-OSA and pediatric OSA. Besides, the adeno-tonsillectomy has minimal impact on oral microbiota composition in short term.

CONCLUSION

The changes in upper airway microbiome are highly associated with pediatric OSA. The relative abundance of some bacteria was significantly different between OSA and non-OSA. These bacteria have the potential to become new diagnostic and early warning biomarkers.

Anthropometric measures and obstructive sleep apnea in children and adolescents: a systematic review of the literature and meta-analysis

BACKGROUND

Anthropometric measurements can be used to identify children at risk of developing obstructive sleep apnea (OSA). The study aimed to assess which anthropometric measurements (AMs) are most associated with an increased predisposition to develop OSA in healthy children and adolescents.

METHODS

We performed a systematic review (PROSPERO #CRD42022310572) that searched eight databases and gray literature.

RESULTS

In eight studies with low-to-high risk of bias, investigators reported the following AMs: body mass index (BMI), neck circumference, hip circumference, waist-to-hip ratio, neck-to-waist ratio, waist circumference, waist-to-height ratio, and facial AMs. The meta-analysis showed that the OSA group had an average of 1.00 cm greater for the neck circumference (p < 0.001; Cohen's d = 2.26 [0.72, 5.23]), 3.07 cm greater for the waist circumference (p = 0.030; Cohen's d = 0.28 [0.02, 0.53]), 3.96 cm greater for the hip circumference (p = 0.040; Cohen's d = 0.28 [0.02, 0.55]), 5.21° greater for the cervicomental angle (p = 0.020; Cohen's d = 0.31 [0.03, 0.59]), and 1.23° greater for maxillary-mandibular relationship angle (p < 0.001; Cohen's d = 0.47 [0.22, 0.72]) than the control group. The mandibular depth angle had a reduction of 1.86° (p = 0.001; Cohen's d = -0.36° [-0.65, -0.08]) in control than in patients with OSA. The BMI (p = 0.180), waist-to-hip ratio (p = 0.280), neck-to-waist ratio (p = 0.070), maxillary depth angle (p = 0.250), and upper/lower face height ratio (p = 0.070) showed no significant differences between groups.

CONCLUSIONS

Compared to the control group, the OSA group exhibited a greater mean difference in neck circumference, the only anthropometric measurement with high certainty of evidence.

Pediatric obstructive sleep apnea diagnosis: leveraging machine learning with linear discriminant analysis

Objective

The objective of this study was to investigate the effectiveness of a machine learning algorithm in diagnosing OSA in children based on clinical features that can be obtained in nonnocturnal and nonmedical environments.

Patients and methods

This study was conducted at Beijing Children's Hospital from April 2018 to October 2019. The participants in this study were 2464 children aged 3-18 suspected of having OSA who underwent clinical data collection and polysomnography(PSG). Participants' data were randomly divided into a training set and a testing set at a ratio of 8:2. The elastic net algorithm was used for feature selection to simplify the model. Stratified 10-fold cross-validation was repeated five times to ensure the robustness of the results.

Results

Feature selection using Elastic Net resulted in 47 features for AHI ≥5 and 31 features for AHI ≥10 being retained. The machine learning model using these selected features achieved an average AUC of 0.73 for AHI ≥5 and 0.78 for AHI ≥10 when tested externally, outperforming models based on PSG questionnaire features. Linear Discriminant Analysis using the selected features identified OSA with a sensitivity of 44% and specificity of 90%, providing a feasible clinical alternative to PSG for stratifying OSA severity.

Conclusions

This study shows that a machine learning model based on children's clinical features effectively identifies OSA in children. Establishing a machine learning screening model based on the clinical features of the target population may be a feasible clinical alternative to nocturnal OSA sleep diagnosis.

Diffusion kurtosis imaging tractography reveals disrupted white matter structural networks in children with obstructive sleep apnea syndrome

To assess the disruptions of brain white matter (WM) structural network in children with obstructive sleep apnea (OSA) using diffusion kurtosis imaging (DKI). We use DKI tractography to construct individual whole-brain, region-level WM networks in 40 OSA and 28 healthy children. Then, we apply graph theory approaches to analyze whether OSA children would show altered global and regional network topological properties and whether these alterations would significantly correlate with the clinical characteristics of OSA. We found that both OSA and healthy children showed an efficient small-world organization and highly similar hub distributions in WM networks. However, characterized by kurtosis fractional anisotropy (KFA) weighted networks, OSA children exhibited decreased global and local efficiency, increased shortest path length compared with healthy children. For regional topology, OSA children exhibited significant decreased nodal betweenness centrality (BC) in the bilateral medial orbital superior frontal gyrus (ORBsupmed), right orbital part superior frontal gyrus (ORBsup), insula, postcentral gyrus, left middle temporal gyrus (MTG), and increased nodal BC in the superior parietal gyrus, pallidum. Intriguingly, the altered nodal BC of multiple regions (right ORBsupmed, ORBsup and left MTG) within default mode network showed significant correlations with sleep parameters for OSA patients. Our results suggest that children with OSA showed decreased global integration and local specialization in WM networks, typically characterized by DKI tractography and KFA metric. This study may advance our current understanding of the pathophysiological mechanisms of impaired cognition underlying OSA.

Persistent sleep-disordered breathing independently contributes to metabolic syndrome in prepubertal children

BACKGROUND

Obstructive sleep apnea (OSA) is a risk factor for metabolic syndrome (MetS) in adults, but its association in prepubertal children is still questionable due to the relatively limited cardiometabolic data available and the phenotypic heterogeneity.

OBJECTIVE

To identify the role of OSA as a potential mediator of MetS in prepubertal children.

METHODS

A total of 255 prepubertal children from the Childhood Adenotonsillectomy Trial were included, with standardized measurements taken before OSA treatment and 7 months later. MetS was defined if three or more of the following criteria were present: adiposity, high blood pressure, elevated glycemia, and dyslipidemia. A causal mediation analysis was conducted to assess the effect of OSA treatment on MetS.

RESULTS

OSA treatment significantly impacted MetS, with the apnea-hypopnea index emerging as mediator (p = .02). This mediation role was not detected for any of the individual risk factors that define MetS. We further found that the relationship between MetS and OSA is ascribable to respiratory disturbance caused by the apnea episodes, while systemic inflammation as measured by C-reactive protein, is mediated by desaturation events and fragmented sleep. In terms of evolution, patients with MetS were significantly more likely to recover after OSA treatment (odds ratio = 2.56, 95% confidence interval [CI] 1.20-5.46; risk ratio = 2.06, 95% CI 1.19-3.54) than the opposite, patients without MetS to develop it.

CONCLUSION

The findings point to a causal role of OSA in the development of metabolic dysfunction, suggesting that persistent OSA may increase the risk of MetS in prepubertal children. This mediation role implies a need for developing screening for MetS in children presenting OSA symptoms.

The high-risk pediatric patient for ambulatory surgery

PURPOSE OF REVIEW

The aim of this article is to briefly review the pediatric ambulatory surgery landscape, identify two of the most common comorbidities affecting this population, examine the influence of pediatric obesity and sleep disordered breathing (SDB)/obstructive sleep apnea (OSA) on perioperative care, and provide information that can be used when formulating site specific criteria for ambulatory surgical centers.

RECENT FINDINGS

Most pediatric surgeries performed are now ambulatory, a majority of which take place outside of academic centers. Children with comorbidities such as obesity and SDB/OSA are undergoing surgical or diagnostic procedures which were previously deemed unacceptable for ambulatory surgery. The increase in pediatric ambulatory surgery coupled with a recent shortage of pediatric anesthesiologists means many children will receive anesthesia care from general clinicians who care for children intermittently and may be unfamiliar with the perioperative risks these comorbidities can present.

SUMMARY

Our pediatric ambulatory surgical population is anticipated to demonstrate increasing rates of obesity and SDB/OSA. Bringing attention to potential perioperative complications associated with these comorbidities provides a stronger foundation upon which to formulate criteria for individual ambulatory centers. It allows for targeted anesthetic management, influences provider assignments and/or staffing ratios, and informs scheduling times. For anesthesiologists who do not practice pediatric anesthesia daily, knowing what to anticipate plays a significant role in the ability to eliminate surprises and care for these patients safely.

Is Obstructive Sleep Apnea-Associated Adenoid Hypertrophy Linked to Scoliotic Attitudes in Children?

Introduction Scoliosis, a multifaceted spinal deformity commonly affecting pediatric and adolescent populations, has spurred extensive scientific inquiry to understand its origins and impacts. Early-onset scoliosis (EOS), characterized by spinal curvature exceeding 10° before the age of 10, presents a unique challenge necessitating a comprehensive understanding of its etiological factors. Within this context, the potential role of hypoxia-induced by adenoid hypertrophy in contributing to the pathogenesis of EOS has emerged as an intriguing avenue of investigation. Materials and methods This retrospective study was conducted focusing on radiological and clinical data pertaining to children below 10 years of age who underwent isolated adenoidectomy for adenoid hypertrophy. Preoperative posteroanterior standing chest radiographs were utilized for scoliosis assessment, with Cobb angles serving as the primary measurement metric. To ensure accuracy and reliability, Cobb angle measurements were independently performed by two experienced observers. Statistical analyses encompassed the Mann-Whitney U test, Spearman correlation analysis, and intraclass correlation coefficient calculations to evaluate interobserver agreement. Results Among the cohort of 218 pediatric adenoidectomy patients, 177 individuals had radiographs suitable for EOS evaluation. The mean age of the participants was 5.72±2 years, with a nearly equal distribution of 52.5% male and 47.5% female patients. Strikingly, the study identified a 10.2% prevalence of coronal plane curvatures exceeding the critical threshold of 10°, indicative of EOS. The robust interobserver reliability was demonstrated by a commendable mean interclass correlation coefficient (ICC) value of 0.926, affirming consistent and accurate Cobb angle measurements between the observers. Conclusion In light of the heightened prevalence of EOS observed in children undergoing adenoidectomy, this study provides a compelling impetus for exploring the potential interrelationship between adenoid hypertrophy, hypoxia, and the emergence of early-onset scoliosis. The study underscores the importance of prospective research to elucidate the complex mechanisms connecting these factors, offering insights into potential risk factors and underlying pathogenic pathways associated with the development of early-onset scoliosis.

A Case Report on Obstructive Sleep Apnea in a Pediatric Patient with Achondroplasia

A 22-month-old male diagnosed with achondroplasia was referred for difficulty in sleeping and was diagnosed to have severe obstructive sleep apnea (OSA) on polysomnography (PSG) (AHI 50.1). This patient had macrocephaly, midface hypoplasia, flat nasal bridge, relative macroglossia and enlarged palatine and adenoid tonsils. The patient underwent bilateral tonsillectomy with adenoidectomy without complication. Six months post-op, repeat polysomnography revealed a still severe (AHI 15.7) OSA with preferential recovery of REM and N3 sleep. Further outpatient follow-up and management is warranted. OSA despite being common in this subset of patients remains overlooked and not prioritized because of the multitude of coexisting concerns. Management of OSA in children with achondroplasia shows improved sleep structure and is helpful for further growth and development.

Medical Treatment of Obstructive Sleep Apnea in Children

Obstructive sleep apnea (OSA) is characterized by recurrent complete or partial obstruction of the upper airway. The prevalence is 1-4% in children aged between 2 and 8 years and rising due to the increase in obesity rates in children. Although persistent OSA following adenotonsillectomy is usually associated with obesity and underlying complex disorders, it can also affect otherwise healthy children. Medical treatment strategies are frequently required when adenotonsillectomy is not indicated in children with OSA or if OSA is persistent following adenotonsillectomy. Positive airway pressure treatment is a very effective modality for persistent OSA in childhood; however, adherence rates are low. The aim of this review article is to summarize medical treatment options for OSA in children.

Obstructive Sleep Apnea in Developmental Age: 22-Item Pediatric Sleep Questionnaire for an Observational Descriptive Investigation

The aim of this paper is to perform an observational descriptive study of the Obstructive Sleep Apnea Syndrome (OSAS) in a population of children by evaluating the prevalence and role of sex and age variables. The 22-item Pediatric Sleep Questionnaire (PSQ) was administered to parents of children aged 3 to 12 years. The questionnaire is a very simple tool since it allows for the indication of patients with possible OSAS diagnosis through a cut-off of 0.33. The anonymous diagnostic questionnaire, available in digital format, was administered to the population under study by a link or QR code. Only the questionnaires completed in all their parts were recorded and analyzed. Eight hundred and thirty-two questionnaires were collected. One hundred and fifty-four subjects obtained a PSQ score > 0.33 and the prevalence of OSAS was 18.51%. The Chi-square test showed a statistically significant association between the PSQ score > 0.33 and male sex. The higher prevalence of subjects with a value of PSQ > 0.33 (n = 277) are aged 3-4-5 years, followed by the 6-7-8 range in the group with PSQ score > 0.33, p < 0.05. The prevalence of OSAS was 18.51% in children aged 3 to 12 years. The variables male biological sex and the age group 3-8 year were statistically significant for subjects with OSAS diagnosis. This study underlines the use of the 22-item Pediatric Sleep Questionnaire as a first screening tool to identify children at risk of OSAS.

Adenoid lymphocyte heterogeneity in pediatric adenoid hypertrophy and obstructive sleep apnea

Introduction

Adenoid hypertrophy is the main cause of obstructive sleep apnea in children. Previous studies have suggested that pathogenic infections and local immune system disorders in the adenoids are associated with adenoid hypertrophy. The abnormalities in the number and function of various lymphocyte subsets in the adenoids may play a role in this association. However, changes in the proportion of lymphocyte subsets in hypertrophic adenoids remain unclear.

Methods

To identify patterns of lymphocyte subsets in hypertrophic adenoids, we used multicolor flow cytometry to analyze the lymphocyte subset composition in two groups of children: the mild to moderate hypertrophy group (n = 10) and the severe hypertrophy group (n = 5).

Results

A significant increase in naïve lymphocytes and a decrease in effector lymphocytes were found in severe hypertrophic adenoids.

Discussion

This finding suggests that abnormal lymphocyte differentiation or migration may contribute to the development of adenoid hypertrophy. Our study provides valuable insights and clues into the immunological mechanism underlying adenoid hypertrophy.

Effect of different head-high lateral extubation on adverse reactions in the peri-extubation period of pediatric OSAS surgery under general anesthesia

BACKGROUND

Children with OSAS are prone to various airway complications during tracheal extubation after tonsillectomy and adenoidectomy due to oropharyngeal secretions and oozing blood. However, few studies have examined the effect of position on airway complications after tracheal extubation in children with OSAS. The aim of this study was to investigate the appropriate position for extubation in children with OASA.

METHODS

A total of 459 children aged 3-14 years with OSAS who underwent tonsillectomy and adenoidectomy were recruited for this study. All children were treated with the same surgical approach and standard anesthesia methods of induction of anesthesia, tracheal intubation and maintenance of anesthesia. At the end of surgery, the children were delivered to the post anesthesia care unit and randomly divided into three groups: Group A: Head-high 0° in lateral position; Group B: Head-high 15° in lateral position; Group C: Head-high 30° in lateral position. The main outcomes of this study were the pulse oxygen saturation (SpO₂) and the Sedation-Agitation Scale (SAS) scores of the children after extubation, the outflow of oral-nasal secretions and the respiratory complications. Secondary outcomes were blood pressure, heart rate, end-respiratory carbon dioxide, respiratory rate, and post-operative awakening time of the children in three groups.

RESULTS

Data from a total of 423 children were statistically analyzed, 141 in Group A, 142 in Group B, and 140 in Group C. The main results showed a significant decrease in choking response after extubation in Group B (46.5%) and Group C (40.7%) compared to Group A (60.3%) (P < 0.05). The SAS score for postoperative agitation was higher in Group A (4.6 [Formula: see text] 0.9) than in Group B (4.4 [Formula: see text] 0.7) and Group C (4.3 [Formula: see text] 0.6) (P < 0.05). Also the SpO₂ after extubation was higher in Group B (97.2%) and Group C (97.1%) than in Group A (95.8%) (P < 0.05). In contrast, there was no difference in the occurrence of respiratory complication and postoperative agitation in children between Group B and Group C (all P > 0.05). In addition, there was no difference in the amount of oral-nasal secretions among the children in the three groups (all P > 0.05).

CONCLUSION

The head-high 15° lateral position and head-high 30° lateral position can reduce the incidence of airway complications and agitation and provide safe and comfortable extubation conditions for children during the peri-extubation period after tonsillectomy and adenoidectomy, which has certain clinical guidance value.

TRIAL REGISTRATION

Registration Number: NO.ChiCTR2200055835(20,01,2022) https://www.chictr.org.cn.

Characteristics of salivary microbiota in children with obstructive sleep apnea: A prospective study with polysomnography

Objectives

The present study aimed to investigate the characteristics of salivary microbiota of children with obstructive sleep apnea (OSA) and to assess longitudinal alterations in salivary microbiota before and after adenotonsillectomy.

Methods

A set of cross-sectional samples consisted of 36 OSA children (17 boys and 19 girls, 7.47 ± 2.24 years old) and 22 controls (9 boys and 13 girls, 7.55 ± 2.48 years old) were included in the study, among which eight OSA children (five boys and three girls, 8.8 ± 2.0 years old) who underwent treatment of adenotonsillectomy were followed up after 1 year. Saliva samples were collected, and microbial profiles were analyzed by bioinformatics analysis based on 16S rRNA sequencing.

Results

In cross-sectional samples, the OSA group had higher α-diversity as estimated by Chao1, Shannon, Simpson, Pielou_e, and observed species as compared with the control group (p &lt; 0.05). β-Diversity based on the Bray–Curtis dissimilarities (p = 0.004) and Jaccard distances (p = 0.001) revealed a significant separation between the OSA group and control group. Nested cross-validated random forest classifier identified the 10 most important genera (Lactobacillus, Escherichia, Bifidobacterium, Capnocytophaga, Bacteroidetes_[G-7], Parvimonas, Bacteroides, Klebsiella, Lautropia, and Prevotella) that could differentiate OSA children from controls with an area under the curve (AUC) of 0.94. Linear discriminant analysis effect size (LEfSe) analysis revealed a significantly higher abundance of genera such as Prevotella (p = 0.027), Actinomyces (p = 0.015), Bifidobacterium (p &lt; 0.001), Escherichia (p &lt; 0.001), and Lactobacillus (p &lt; 0.001) in the OSA group, among which Prevotella was further corroborated in longitudinal samples. Prevotella sp_HMT_396 was found to be significantly enriched in the OSA group (p = 0.02) with significantly higher levels as OSA severity increased (p = 0.014), and it had a lower abundance in the post-treatment group (p = 0.003) with a decline in each OSA child 1 year after adenotonsillectomy.

Conclusions

A significantly higher microbial diversity and a significant difference in microbial composition and abundance were identified in salivary microbiota of OSA children compared with controls. Meanwhile, some characteristic genera (Prevotella, Actinomyces, Lactobacillus, Escherichia, and Bifidobacterium) were found in OSA children, among which the relationship between Prevotella spp. and OSA is worth further studies.

A social media intervention for the families of young Black men with obstructive sleep apnoea

OBJECTIVE

To address positive airway pressure (PAP) adherence in adolescents diagnosed with obstructive sleep apnoea (OSA) by pilot testing a novel, online, facilitated, peer-support and health education programme for families.

DESIGN SETTING AND METHODS

Families participated in separate Facebook peer-groups (adolescent [n=6] and parent [n=6]) for four weeks, followed by face-to-face interviews. Participants received OSA and PAP educational videos and posts, engaged with questions and polls, and viewed de-identified postings of peer PAP use data.

RESULTS

Adolescent participants were young Black males aged 13-17 years (n=6) with obesity (n=5), severe sleep apnoea (100%) and 4-15 months of prior PAP use. Parent participants were mothers (n=4) and fathers (n=2). Four of six young males increased their mean PAP use during the intervention period. Overall, parents were more engaged with the Facebook group page than adolescents, but interviews revealed the online group/peer-support and education provided was highly regarded and appreciated by families. Parents were particularly appreciative of being involved in care and diagnosis in this way.

CONCLUSION

Results of this pilot trial provide important data regarding intervention design, content, and delivery approaches to be considered in the development of future interventions aiming to engage families and improve adolescent PAP adherence.

Comparison of superior airway dimensions and cephalometric anatomic landmarks between 8–12-year-old children with obstructive sleep apnea and healthy children using CBCT images

Background. The etiology of obstructive sleep apnea (OSA) syndrome in children significantly differs from adults. In previous studies, only some of the indices have been investigated using CBCT. This study compares all the measurable indices of airway dimensions and anatomical cephalometric landmarks between children with OSA and healthy ones using cone-beam computed tomography (CBCT).

Methods. Dimensions of the airway and cephalometric values were measured on CBCT scans of 50 children aged 8–12 (25 patients with OSA and 25 healthy subjects) and then compared between the two groups. The results of this study were analyzed with independent t test using SPSS 17 at a significance level of P<0.05.

Results. Area, length, volume, anteroposterior length, and size of the upper airway in subjects with OSA were lower than those in healthy children, while the average values of SNA, SNB, and ANB in the OSA group were higher than those in the healthy group (P=0.366, P=0.012, and P=0.114, respectively). Also, BaSN, PNS/AD1, and PNS/AD2 measurements in subjects with OSA were lower than healthy subjects (P=0.041, P=0.913, and P=0.015, respectively). In addition, the width and anteroposterior length of the upper airway, SNB, BaSN, PNS/AD1, and PNS/AD2 indices were significantly different between the healthy group and those with OSA (P<0.05).

Conclusion. Reduced upper airway dimensions, adenoid tissue enlargement, and cranial base flexion might play an important role in OSA development in children. However, most skeletal variables, such as the anteroposterior relationship of jaws and jaw rotation, were not significantly different between the two groups.

Breathing Abnormalities During Sleep and Wakefulness in Rett Syndrome: Clinical Relevance and Paradoxical Relationship With Circulating Pro-oxidant Markers

Background

Breathing abnormalities are common in Rett syndrome (RTT), a pervasive neurodevelopmental disorder almost exclusively affecting females. RTT is linked to mutations in the methyl-CpG-binding protein 2 (MeCP2) gene. Our aim was to assess the clinical relevance of apneas during sleep-wakefulness cycle in a population with RTT and the possible impact of apneas on circulating oxidative stress markers.

Methods

Female patients with a clinical diagnosis of typical RTT (n = 66), MECP2 gene mutation, and apneas were enrolled (mean age: 12.5 years). Baseline clinical severity, arterial blood gas analysis, and red blood cell count were assessed. Breathing was monitored during the wakefulness and sleep states (average recording time: 13 ± 0.5 h) with a portable polygraphic screening device. According to prevalence of breath holdings, the population was categorized into the wakefulness apnea (WA) and sleep apnea (SA) groups, and apnea-hypopnea index (AHI) was calculated. The impact of respiratory events on oxidative stress was assessed by plasma and intra-erythrocyte non-protein-bound iron (P-NPBI and IE-NPBI, respectively), and plasma F2-isoprostane (F2-IsoP) assays.

Results

Significant prevalence of obstructive apneas with values of AHI &gt; 15 was present in 69.7% of the population with RTT. The group with SA showed significantly increased AHI values &gt; 15 (p = 0.0032), total breath holding episodes (p = 0.007), and average SpO2 (p = 0.0001) as well as lower nadir SpO2 (p = 0.0004) compared with the patients with WAs. The subgroups of patients with WA and SA showed no significant differences in arterial blood gas analysis variables (p &gt; 0.089). Decreased mean cell hemoglobin (MCH) (p = 0.038) was observed in the group with WAs. P-NPBI levels were significantly higher in the group with WA than in that with SAs (p = 0.0001). Stepwise multiple linear regression models showed WA being related to nadir SpO2, average SpO2, and P-NPBI (adjusted R2 = 0.613, multiple correlation coefficient = 0.795 p &lt; 0.0001), and P-NPBI being related to average SpO2, blood PaCO2, red blood cell mean corpuscular volume (MCV), age, and topiramate treatment (adjusted R2 = 0.551, multiple correlation coefficient = 0.765, p &lt; 0.0001).

Conclusion

Our findings indicate that the impact of apneas in RTT is uneven according to the sleep-wakefulness cycle, and that plasma redox active iron represents a potential novel therapeutic target.

Expression and clinical significance of IL-33 and its receptor ST2 in children with obstructive sleep apnea syndrome

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is characterized by a majority population of respiratory sleep disorders, which consists of simple snoring as well as increased upper airway resistance syndrome. Adenoid hypertrophy has been suggested as the main cause of OSAS in children. The role of interleukin-33 (IL-33) and its receptor suppressor of tumorigenicity 2 (ST2) in a variety of pediatric allergic diseases has been confirmed. We hypothesized that IL-33/ST2 path way might play a pivotal role in the pathogenesis of adenoid hypertrophy-associated OSAS in children.

METHODS

A total of 40 children undergoing adenoidectomy due to OSAS in the Otolaryngology of Tianjin Children's Hospital were selected as the study participants. The quantity of IL-33 and ST2 positive cells in adenoids was detected by immunohistochemical (IHC) streptavidin-peroxidase conjugate (SP) method.

RESULTS

The IL-33 positive cells were mainly distributed in the submucosa epithelium and vascular endothelium, and expressed in the nucleus and cytoplasm. Meanwhile, ST2 positive cells were primarily observed in the mucosa and expressed in the nucleus and cytoplasm, with a little expression of intercellular substance. There was a positive correlation between the proportion of adenoids in the posterior nostril diameter and the number of IL-33 positive cells. The expression of IL-33 in adenoids was positively correlated with the level of ST2 (r=0.809, P=0.000). The expression of IL-33 in adenoids was positively correlated with the level of eosinophil granulocyte (r=0.859, P=0.000). Moreover, the expression of ST2 in adenoids was positively correlated with the level of eosinophil granulocyte (r=0.814, P=0.000). The number of IL-33 positive cells was significantly higher in the moderate hypoxemia group than that in the mild hypoxemia group (P<0.05). There was no significant difference in the number of ST2 positive cells between the moderate hypoxemia group and mild hypoxemia group (P>0.05).

CONCLUSIONS

Both IL-33 and its receptor ST2 were expressed in adenoids of OSAS children. The severity of airway obstruction caused by adenoid hypertrophy was positively correlated with the expression of IL-33.

Much Ado about Sleep: Current Concepts on Mechanisms and Predisposition to Pediatric Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a form of sleep-disordered breathing characterized by upper airway collapse during sleep resulting in recurring arousals and desaturations. However, many aspects of this syndrome in children remain unclear. Understanding underlying pathogenic mechanisms of OSA is critical for the development of therapeutic strategies. In this article, we review current concepts surrounding the mechanism, pathogenesis, and predisposing factors of pediatric OSA. Specifically, we discuss the biomechanical properties of the upper airway that contribute to its primary role in OSA pathogenesis and examine the anatomical and neuromuscular factors that predispose to upper airway narrowing and collapsibility.

The Link between Pediatric Obstructive Sleep Apnea (OSA) and Attention Deficit Hyperactivity Disorder (ADHD)

Obstructive sleep apnea (OSA) is a form of sleep-disordered breathing that affects up to 9.5% of the pediatric population. Untreated OSA is associated with several complications, including neurobehavioral sequelae, growth and developmental delay, cardiovascular dysfunction, and insulin resistance. Attention-deficit/hyperactivity disorder (ADHD) is among the neurobehavioral sequelae associated with OSA. This review aims to summarize the research on the relationship between OSA and ADHD and investigate the impacts of OSA treatment on ADHD symptoms. A literature search was conducted on electronic databases with the key terms: “attention deficit hyperactivity disorder” or “ADHD”, “obstructive sleep apnea” or “OSA”, “sleep disordered breathing”, and “pediatric” or “children”. Review of relevant studies showed adenotonsillectomy to be effective in the short-term treatment of ADHD symptoms. The success of other treatment options, including continuous positive airway pressure (CPAP), in treating ADHD symptoms in pediatric OSA patients has not been adequately evaluated. Further studies are needed to evaluate the long-term benefits of surgical intervention, patient factors that may influence treatment success, and the potential benefits of other OSA treatment methods for pediatric ADHD patients.

Prevalence of and risk factors for obstructive sleep apnea in children with sickle cell: a multicentric cross sectional study

The prevalence of obstructive sleep apnea syndrome (OSAS) is elevated in some high-risk populations. Children with sickle cell disease (SCD) are known to have many comorbidities, including OSAS. The objectives of this study were to assess the prevalence of and risk factors for OSAS among children with SCD in two major tertiary health care facilities in Jeddah, Saudi Arabia. This multicenter cross-sectional study took place in two major tertiary health care facilities-King Abdulaziz University Hospital and King Khalid National Guard Hospital, Jeddah, Saudi Arabia. Children with SCD who were admitted between January 2010 and December 2017 were enrolled. The Pediatric Sleep Questionnaire (PSQ) was used to screen for OSAS. Data were collected from 150 children with SCD aged between 2 and 18 years. Eighty-five percent of the children had sickle cell anemia (SCA) with HbSS, and the rest had sickle beta-thalassemia (HbS/ß-thalassemia). Based on the PSQ, 33 of the 150 (22%) children had OSAS (score ≥ 7). The average score on the PSQ was 3.8/22 (± 3.8). A history of adenotonsillar hypertrophy was found to be a significant risk factor in bivariate and multivariate analyses [aOR 5.5; 95% CI 1.84-16.35 (P < 0.001)]. The odds of having OSAS were ninefold higher in children who had periodic limb movements than in those who did not after adjustment [95% CI 1.75-48.03 (P < 0.001)]. OSAS is a highly prevalent disease among children with SCD. Many factors were associated with OSAS in the bivariate analysis, including nationality, education level, a history of adenotonsillar hypertrophy, and a history of periodic limb movements.

Epigenetic Alterations in Pediatric Sleep Apnea

Pediatric obstructive sleep apnea has significant negative effects on health and behavior in childhood including depression, failure to thrive, neurocognitive impairment, and behavioral issues. It is strongly associated with an increased risk for chronic adult disease such as obesity and diabetes, accelerated atherosclerosis, and endothelial dysfunction. Accumulating evidence suggests that adult-onset non-communicable diseases may originate from early life through a process by which an insult applied at a critical developmental window causes long-term effects on the structure or function of an organism. In recent years, there has been increased interest in the role of epigenetic mechanisms in the pathogenesis of adult disease susceptibility. Epigenetic mechanisms that influence adaptive variability include histone modifications, non-coding RNAs, and DNA methylation. This review will highlight what is currently known about the phenotypic associations of epigenetic modifications in pediatric obstructive sleep apnea and will emphasize the importance of epigenetic changes as both modulators of chronic disease and potential therapeutic targets.

[Comparative Study of Clinical Manifestations and Sleep Structure in Children with Obstructive Sleep Apnea-hypopnea Syndrome with Different BMI]

OBJECTIVE

To compare and analyze the clinical manifestations and sleep structure of children with obstructive sleep apnea-hypopneasyndrome (OSAHS) with different body mass index (BMI).

METHODS

452 children who were diagnosed with OSAHS between December 2016 and February 2021 by the Department of Respiratory Medicine, Children's Hospital of Soochow University were included in the study. All of them did polysomnography (PSG). They were divided, according to their BMI, into the normal BMI group, the overweight group, and the obesity group. Their clinical data and PSG results were collected.

RESULTS

287 boys (63.5%) and 165 girls (36.5%) were enrolled, with their age ranging between 3 and 15, and the median age being 5.5 (4.5, 7.0). Their BMI ranged between 12.09 kg/m 2 and 38.48 kg/m 2, with the median being 16.29 kg/m 2. 275 cases (60.8%) had normal BMI, 76 cases (16.8%) were overweight, and 101 cases (22.3%) were obese. There was no significant difference in the distribution of clinical manifestations and severity of OSAHS among the three groups. The duration and proportion of rapid eye movement (REM) stage sleep in the obese group was lower than that of the overweight and the normal BMI groups ( P<0.05). The lowest oxyhemoglobin saturation (LSaO 2) of children in the overweight group was lower than that of the normal BMI group ( P=0.050). The oxygen desaturation index (ODI) of the obese group was higher than that of the normal BMI and the overweight groups ( P<0.05).

CONCLUSION

Obesity worsens the degree of hypoxia in children with OSAHS and affects their sleep structure.

Acute lacunar infarct in an obese adolescent with obstructive sleep apnea

Obstructive sleep apnea is associated with an increased risk of acute ischemic cerebrovascular accidents in adults. However, this association has not been well established in the pediatric population. We report a case of acute right internal capsule lacunar infarct manifesting as left-sided hemiplegia in an adolescent with severe obesity. Severe untreated obstructive sleep apnea was identified during the hospital stay. Positive airway pressure therapy, weight loss, and tonsillectomy eventually normalized sleep-disordered breathing. The patient recovered completely without any residual neurological deficits with multidisciplinary care. Lacunar infarcts due to hypertension-related cerebral vasculopathy are a well-known cause of stroke in adults. Untreated obstructive sleep apnea may cause hypertension and potentially predispose even the pediatric population to develop lacunar infarcts. Polysomnography needs to be considered as a part of the diagnostic algorithm in pediatric patients with stroke.

CITATION

Chen B, Gorantla S, Shah V. Acute lacunar infarct in an obese adolescent with obstructive sleep apnea. J Clin Sleep Med. 2021;17(8):1743-1747.

Effect of sleep on upper airway dynamics in obese adolescents with obstructive sleep apnea syndrome

STUDY OBJECTIVES

The biomechanical basis of obstructive sleep apnea syndrome (OSAS) may influence upper airway dynamics. In this study, we investigate dynamic changes during respiration in wakefulness and sleep in obese adolescents with and without OSAS.

METHODS

Respiratory-gated dynamic magnetic resonance imaging (MRI) at the retropalatal and retroglossal regions was performed with simultaneous measurement of SpO2 and nasal-oral mask airflow and pressure. Airway cross-sectional area (CSA) was determined using AMIRA. Percent change in CSA was calculated from five continuous tidal breaths in states of wakefulness and sleep. Mixed effects models were used to evaluate interactions between group (OSAS/control), site (retropalatal/retroglossal), and stage (wake/sleep).

RESULTS

We studied 24 children with OSAS (mean age 15.49 ± 2.00 years, mean apnea-hypopnea index [AHI] 16.53 ± 8.72 events/h) and 19 controls (mean age 14.86 ± 1.75 years, mean AHI 2.12 ± 1.69 events/h). Groups were similar in age, sex, height, weight, and BMI Z-score. Participants with OSAS had a 48.17% greater increase in percent change of airway CSA during sleep than controls (p < 0.0001), while there was no difference between groups during wakefulness (p = 0.6589). Additionally, participants with OSAS had a 48.80% increase in percent change of airway CSA during sleep as compared with wakefulness (p < 0.0001), whereas no such relationship was observed in controls (p = 0.5513).

CONCLUSIONS

This study demonstrates significant effects of sleep on upper airway dynamics in obese children with OSAS. Dynamic MRI with physiological data can potentially provide further insight into the biomechanical basis of OSAS and assist in more effective management.

Long-Term Survival and Causes of Death in Children with Trisomy 21 After Congenital Heart Surgery

OBJECTIVE

To evaluate long-term transplant-free survival and causes of death in the trisomy 21 (T21) population after surgery for congenital heart disease (CHD) in comparison with patients who are euploidic.

STUDY DESIGN

This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, enriched with prospectively collected data from the National Death Index and the Organ Procurement and Transplantation Network for patients with sufficient direct identifiers. Kaplan-Meier survival plots were generated and multivariable Cox proportional hazards models were used to examine risk factors for mortality between patients with T21 and 1:1 matched patients with comparable CHD who are euploidic.

RESULTS

A long-term survival analysis was completed for 3376 patients with T21 (75 155 person-years) who met inclusion criteria. The 30-year survival rate for patients with T21 ranged from 92.1% for ventricular septal defect to 65.3% for complex common atrioventricular canal. Of these, 2185 patients with T21 were successfully matched with a patient who was euploidic. After a median follow-up of 22.86 years (IQR, 19.45-27.14 years), 213 deaths occurred in the T21 group (9.7%) compared with 123 (5.6%) in the euploidic comparators. After adjustment for age, sex, era, CHD complexity, and initial palliation, the hazard ratio of CHD-related mortality was 1.34 times higher in patients with T21 (95% CI, 0.92-1.97; P = .127).

CONCLUSIONS

CHD-related mortality for patients with T21 after cardiac surgical intervention is comparable with euploidic comparators. Children with T21 require lifelong surveillance for co-occurring conditions associated with their chromosomal abnormality.

Validity and Cost-Effectiveness of Pediatric Home Respiratory Polygraphy for the Diagnosis of Obstructive Sleep Apnea in Children: Rationale, Study Design, and Methodology

Obstructive sleep apnea (OSA) in children is a prevalent, albeit largely undiagnosed disease associated with a large spectrum of morbidities. Overnight in-lab polysomnography remains the gold standard diagnostic approach, but is time-consuming, inconvenient, and expensive, and not readily available in many places. Simplified Home Respiratory Polygraphy (HRP) approaches have been proposed to reduce costs and facilitate the diagnostic process. However, evidence supporting the validity of HRP is still scarce, hampering its implementation in routine clinical use. The objectives were: Primary; to establish the diagnostic and therapeutic decision validity of a simplified HRP approach compared to PSG among children at risk of OSA. Secondary: (a) Analyze the cost-effectiveness of the HRP versus in-lab PSG in evaluation and treatment of pediatric OSA; (b) Evaluate the impact of therapeutic interventions based on HRP versus PSG findings six months after treatment using sleep and health parameters and quality of life instruments; (c) Discovery and validity of the urine biomarkers to establish the diagnosis of OSA and changes after treatment.

Cognitive parameters in children with mild obstructive sleep disordered breathing

PURPOSE

Sleep disordered breathing (SDB) in children is commonly described as a continuum from primary snoring (PS) to obstructive sleep apnea (OSA), based on apnea indices from polysomnography (PSG). This study evaluated the difference in neurocognitive and behavioral parameters, prior to treatment, in symptomatic pre-school children with PSG-diagnosed OSA and PS.

METHODS

All children had positive Pediatric Sleep Questionnaire (PSQ) results and were deemed suitable for adenotonsillectomy by an ENT surgeon. Neurocognitive and behavioral data were analyzed in pre-school children at recruitment for the POSTA study (The Pre-School OSA Tonsillectomy Adenoidectomy Study). Data were compared between PS and OSA groups, with Obstructive Apnea-Hypopnea Index, OAHI < 1/h or 1-10/h, respectively.

RESULTS

Ninety-one children were enrolled, including 52 with OSA and 39 with PS. Distribution of IQ (using Brief Intellectual Ability, BIA) was slightly skewed towards higher values compared with the reference population. No significant differences were found in neurocognitive or behavioral parameters for children with OSA versus those with PS.

DISCUSSION

Neurocognitive and behavioral parameters were similar in pre-school children symptomatic for OSA, regardless of whether or not PSG diagnosed PS or OSA. Despite having identical symptoms, children with PS on PSG are often treated conservatively, whereas those with OSA on PSG are considered for adenotonsillectomy. This study demonstrates that, regardless of whether or not PS or OSA is diagnosed on PSG, symptoms, neurocognition, and behavior are identical in these groups. We conclude that symptoms and behavioral disturbances should be considered in addition to OAHI when determining the need for treatment.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials registration number ACTRN12611000021976.

The Relationship between Sleep, Obesity, and Metabolic Health in Adolescents - a Review

In this literature review, we discuss the importance of adequate sleep and the various effects of suboptimal sleep on weight maintenance and metabolic health specifically for adolescents. Two major contributors to adolescents experiencing decreased sleep duration and quality, and thus increasing the risk for developing metabolic syndrome in adolescence as well as later in adulthood, are increased electronic screen time particularly at night and early school start times. The less time adolescents spend sleeping, the less quality sleep they obtain, and the greater the disruption of endocrine hormone function. As another consequence, adolescents are more prone to making poor food choices, from choosing relatively nutrient-poor foods to consuming excess calories without necessarily increasing their energy expenditure. These choices put adolescents at greater risk for becoming obese throughout their lifespan.

Prevalence of Sleep-Disordered Breathing in a Cohort of Adult Fontan Patients

Sleep-disordered breathing (SDB) is described in patients with acquired heart failure but its prevalence in adults with congenital heart disease is not well documented. It is likely that single-ventricle patients who have undergone Fontan palliation poorly tolerate the additional stress of SDB on their fragile cardiac physiology. This study sought to determine the prevalence of SDB in a population of adult Fontan patients. We performed a retrospective chart review of adult Fontan patients followed in our program (n = 55). All charts were evaluated for documentation of polysomnography (PSG). SDB was characterized as nocturnal hypoxemia without apnea or obstructive sleep apnea (OSA). Baseline demographics and clinical characteristics were documented, as were PSG findings including Apnea Hypopnea Index (AHI, events/hour) and desaturation events of > 5% from baseline saturation. Twenty-two of our 55 patients (40%) had undergone PSG (45% male, mean age 29 years). Of these patients, 17 had a PSG positive for SDB (77%). Nine patients (41%) had nocturnal hypoxemia without apnea, while 8 patients (36%) had a PSG positive for OSA. Lower baseline oxygen saturations, but not BMI or age, were statistically significantly correlated with higher AHI. SDB was present in the majority of our Fontan cohort who had undergone PSG, occurring at a higher prevalence than what is described in the general population, suggesting that screening should be considered for all Fontan patients. However, further study is needed to confirm this prevalence in a larger population, and if therapy has an impact on clinical outcomes.

Does obstructive sleep apnoea contribute to obesity, hypertension and kidney dysfunction in children? A systematic review protocol

INTRODUCTION

Childhood obstructive sleep apnoea (OSA) is a highly prevalent disorder that may directly contribute to the development of obesity, hypertension and renal injury. Although those associations seem to be clearer in adults, studies in children have revealed conflicting results and updated synthesis of the evidence is lacking. The aim of this systematic review is to summarise the available evidence on the effect of OSA on obesity, systemic blood pressure and kidney function, to help to elucidate whether respiratory interventions to correct OSA would have the potential to improve those outcomes.

METHODS AND ANALYSIS

A systematic literature review search was created by a medical librarian and peer-reviewed by a second librarian prior to running. Ovid Medline, Ovid Embase, CINAHL via EbscoHOST, Wiley Cochrane Library and ProQuest Dissertations and Theses Global were searched on 25 February 2020. Titles and abstracts will be screened by two independent reviewers for inclusion, followed by full-text screening of relevant articles. Studies in children will be included if they report data on OSA and weight, systemic blood pressure or kidney parameters. The extracted data will be combined for analysis and the information subcategorised in groups based on outcome. Risk of bias will be determined using tools specific to study methodology and certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.

ETHICS AND DISSEMINATION

This study will provide essential information for healthcare professionals to better understand the relationship between childhood OSA and changes in body mass index, systemic blood pressure and kidney function indicators. Our findings will be disseminated through conferences and publications. The results of this review may guide the initiation of new strategies and the development of future research studies. This research did not involve human subjects and therefore did not undergo research ethical review.

PROSPERO REGISTRATION NUMBER

CRD42020171186.

Observational Study of Pulse Transit Time in Children With Sleep Disordered Breathing

Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study. Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and "abnormal other." Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study. Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62-0.90) and specificity 0.79 (C.I. 0.49-0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67-0.92) and specificity 0.37 (95% C.I. 0.17-0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31-0.46) and specificity 0.98 (C.I. 0.97-1.00). Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.

Mean platelet volume levels in children with sleep-disordered breathing: a meta-analysis

BACKGROUND

Pediatric sleep-disordered breathing (SDB) correlated with respiratory conditions of snoring and hypopnea. Mean platelet volume (MPV) was an inflammatory marker, related to increased inflammatory condition of pediatric patients. Increase of MPV level may cause failure to thrive or increased upper airway infection rate. The aim of this study was to perform systematic review and meta-analysis to investigate the difference on MPV values for pediatric SDB, and compare the change on MPV after surgery in patients with pediatric SDB.

METHODS

A systemic review of the studies from PubMed, EMBASE, and Cochrane Library databases was conducted in March 2020, supported by reviewing of published articles for studies comparing MPV in pediatric SDB. Meta-analysis was used to compare the change of MPV in pediatric SDB, and sub-group analysis was also used to compare the MPV decrease after surgeries of adenoidectomy or adenotonsillectomy.

RESULTS

There were seven studies included in the review. Six of them including 963 subjects showed that a significant increase of MPV was noted in pediatric SDB compared to those in pediatric non-SDB (P < 0.05). Total standardized mean difference (SMD) in MPV between pediatric SDB and non-SDB was 0.51 (95% CI =0.30-0.72, P < 0.05). A significant decrease of MPV was found in pediatric SDB patients who underwent surgery (total SMD = - 0.36; 95% CI = - 0.70- -0.02, P < 0.05). Decreases of MPV after adenoidectomy and adenotonsillectomy were observed, but only the effect of adenotonsillectomy had a statistical significance (total SMD = - 0.72; 95% CI = - 1.18 - -0.26, P < 0.05).

CONCLUSION

The MPV was significantly higher in patients with pediatric SDB, indicating the presence of increased platelet activity in pediatric SDB patients. The level of MPV could be reduced by the two surgeries, especially adenotonsillectomy.

Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common pediatric disorder characterized by recurrent events of partial or complete upper airway obstruction during sleep which result in abnormal ventilation and sleep pattern. OSAS in children is associated with neurobehavioral deficits and cardiovascular morbidity which highlights the need for prompt recognition, diagnosis, and treatment. The purpose of this state-of-the-art review is to provide an update on the evaluation and management of children with OSAS with emphasis on children with complex medical comorbidities and those with residual OSAS following first-line treatment. Proposed treatment strategies reflecting recommendations from a variety of professional societies are presented. All children should be screened for OSAS and those with typical symptoms (e.g., snoring, restless sleep, and daytime hyperactivity) or risk factors (e.g., neurologic, genetic, and craniofacial disorders) should undergo further evaluation including referral to a sleep specialist or pediatric otolaryngologist and overnight polysomnography, which provides a definitive diagnosis. A cardiology and/or endocrinology evaluation should be considered in high-risk children. For the majority of children, first-line treatment is tonsillectomy with or without adenoidectomy; however, some children exhibit multiple levels of airway obstruction and may require additional evaluation and management. Anti-inflammatory medications, weight loss, and oral appliances may be appropriate in select cases, particularly for mild OSAS. Following initial treatment, all children should be monitored for residual symptoms and polysomnography may be repeated to identify persistent disease, which can be managed with positive airway pressure ventilation and additional surgical approaches if required.

Sleep-disordered breathing and comorbidities: role of the upper airway and craniofacial skeleton

Obstructive sleep-disordered breathing (SDB), which includes primary snoring through to obstructive sleep apnea syndrome (OSAS), may cause compromise of respiratory gas exchange during sleep, related to transient upper airway narrowing disrupting ventilation, and causing oxyhemoglobin desaturation and poor sleep quality. SDB is common in chronic disorders and has significant implications for health. With prevalence rates globally increasing, this condition is causing a substantial burden on health care costs. Certain populations, including people with sickle cell disease (SCD), exhibit a greater prevalence of OSAS. A review of the literature provides the available normal polysomnography and oximetry data for reference and documents the structural upper airway differences between those with and without OSAS, as well as between ethnicities and disease states. There may be differences in craniofacial development due to atypical growth trajectories or extramedullary hematopoiesis in anemias such as SCD. Studies involving MRI of the upper airway illustrated that OSAS populations tend to have a greater amount of lymphoid tissue, smaller airways, and smaller lower facial skeletons from measurements of the mandible and linear mental spine to clivus. Understanding the potential relationship between these anatomical landmarks and OSAS could help to stratify treatments, guiding choice towards those which most effectively resolve the obstruction. OSAS is relatively common in SCD populations, with hypoxia as a key manifestation, and sequelae including increased risk of stroke. Combatting any structural defects with appropriate interventions could reduce hypoxic exposure and consequently reduce the risk of comorbidities in those with SDB, warranting early treatment interventions.

Prematurity as a Risk Factor of Sleep-Disordered Breathing in Children Younger Than Two Years: A Retrospective Case-Control Study

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) is a highly prevalent condition affecting 2% to 4% of children. However, the prevalence and characteristics of SDB in children younger than 2 years and the effect of prematurity as a risk factor remains unclear.

METHODS

Children younger than 24 months referred for PSG at two medical centers between the years 2014 to 2018 were included in this retrospective analysis. We excluded children with genetic syndromes. Polysomnography (PSG) was performed and scored according to American Academy of Sleep Medicine guidelines.

RESULTS

Ninety-eight children were included (age 14.1 ± 6.4 [2-23] months), with 31 born prematurely (PRETERM; 24 to 34 weeks gestational age). PRETERM had increased odds of SDB (age and sex adjusted), using a cutoff of AHI ≥ 5 events/h with an odds ratio of 4.3 (95% confidence interval 1.5-12.9). Gestational age was the only significant predictor for SDB in this cohort, every additional week of gestation reducing the odds of SDB by 12.5%. PRETERM SDB was also characterized by more severe nocturnal hypoxemia, increased frequency of central apnea, and altered sleep architecture.

CONCLUSIONS

Current findings underscore the importance of prematurity antecedents as a risk factor for SDB in young symptomatic children younger than 2 years referred for a PSG. Future studies focused on improved estimates of the prevalence of SDB among nonreferral young children appear warranted.

Current Practice Patterns in the Diagnosis and Management of Sleep-Disordered Breathing in Infants

STUDY OBJECTIVES

Currently, there are no universally accepted guidelines for diagnosis and management of sleep-disordered breathing (SDB) in infants. The purpose of this study was to survey pediatric sleep medicine providers regarding their current practice patterns for diagnosis and management of SDB in infants.

METHODS

An anonymous, web-based survey with 71 questions was distributed via the PEDSLEEP and Ped-Lung listserv, which serve as a hub of communication for pediatric sleep and pulmonary medicine providers worldwide.

RESULTS

Fifty-four providers from eight countries completed the survey. Ninety-six percent of providers reported performing sleep studies in infants with 53% performing more than 30 studies per year. There was no consensus on the definition of obstructive sleep apnea (OSA) in infants when using an obstructive apnea-hypopnea index (AHIo) cutoff: AHIo > 1 (30%), AHIo > 2 (35%), AHIo > 5 (24%), AHIo > 10 (2%) and other (9.3%). Thirty-six percent did not use pediatric criteria to define severity of OSA in infants. Opinions regarding management of five typical SDB cases were solicited and the results varied among respondents. Most of the providers (89%) thought that more research is needed to gather normative sleep data in infants and that their practice would benefit from evidence- based guidelines for diagnosis and management of SDB in infants (98%).

CONCLUSIONS

These results demonstrate substantial variability in practice patterns for diagnosis and management of SDB in infants. Further research and consensus guidelines are needed to ensure optimal care for infants with SDB.

Outcomes in children with down syndrome and mild obstructive sleep apnea treated non-surgically

OBJECTIVES

Nasal steroids, oral anti-leukotrienes and supplemental oxygen are effective in the treatment of mild obstructive sleep apnea (OSA) in otherwise healthy children. However, their efficacy is unknown in children with Down syndrome (DS). Here we examine the effect of single medication therapy versus observation versus oxygen on polysomnographic outcomes in these children.

METHODS

We reviewed children (<18 years) diagnosed with DS and mild OSA (obstructive apnea-hypopnea index [oAHI] ≥1 to <5 events/hour) treated non-surgically (with supplemental oxygen, one medication, or observation) between 2012 and 2017. Demographic data, comorbid diagnoses, and pre- and posttreatment polysomnograms were analyzed. We assessed pre- and posttreatment oAHI, oxyhemoglobin saturation nadir, percent total sleep time (%TST) in rapid eye movement (REM), and end-tidal carbon dioxide (ETCO₂ ) >50 mmHg.

RESULTS

Twenty-four children met inclusion criteria; 10 treated with medication, one with oxygen, and 13 with observation (baseline oAHI was 3.5, 3.3, and 2.9 events/hour, respectively). There was no significant change in oAHI, oxyhemoglobin saturation nadir, ETCO₂ , or percent TST in REM after treatment for any treatment group (P = .21-.94). There was no association between reported symptoms and AHI severity or change in AHI. OSA resolved in one patient treated with observation and two treated with medication, but worsened in two each in the medication and observation groups. Resolution of OSA occurred in 20% treated with medication, 7.7% with observation, and 0% with oxygen (P = .82).

CONCLUSION

In our cohort, resolution of mild OSA was low. This suggests that consideration should be given to multimodality treatments in children with DS and mild OSA. Prospective studies will help establish effectiveness in this cohort.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1828-1835, 2020.