Obstructive sleep apnea in children with non-syndromic cleft palate: a systematic review

Management of Sleep-Disordered Breathing in Children With Craniofacial Abnormalities and Skeletal Dysplasia

INTRODUCTION

Anatomic malformations associated with craniofacial abnormalities (CFAs) and skeletal dysplasias (SDs) contribute to airway obstruction during sleep in children, which may be treated surgically, with positive airway pressure (PAP) therapy, or with dental appliances. This study examines the management of OSA in children with CFAs and/or SDs, including the prevalence of residual OSA postsurgery and PAP therapy compliance.

METHODS

This was a retrospective cohort study of children with CFAs and/or SD. Children were included if they underwent polysomnography (PSG) at the Queensland Children's Hospital between December 2014 and April 2022.

RESULTS

In this cohort of 150 children, 69% had a CFA, 25% had SD, and 5% had both a CFA and SD. The most common reason for referral to sleep clinic was snoring (61%). Half (n=75) received surgical intervention as first-line treatment (with adenotonsillectomy as the most common surgery), and of these children, 47 (77%) had no residual OSA, while 16 (23%) required further PAP therapy (as determined by PSG). PSG results were statistically similar between surgical and nonsurgical groups, but these data were skewed to more severe disease in the non-surgical group. PAP therapy adherence was 63% and was not age or sex dependent.

CONCLUSIONS

Surgical intervention was the most common first-line treatment offered to children with CFAs and/or SD. The rate of residual OSA following surgery was similar to previous reports, and CPAP was the most common form of PAP offered to children. Overall, PAP compliance in this cohort of children was also similar to previous reports.

Hospitalization Trends for Airway Infections and In-Hospital Complications in Cleft Lip and Palate

Importance

Cleft lip or palate is a prevalent birth defect, occurring in approximately 1 to 2 per 1000 newborns and often necessitating numerous hospitalizations. Specific rates of hospitalization and complication are underexplored.

Objective

To assess the rates of airway infection-associated hospitalization, overall hospital admissions, in-hospital complications, and mortality among children with a cleft lip or palate.

Design, Setting, and Participants

This nationwide, population-based cohort study used in-hospital claims data from the Federal Statistical Office in Switzerland between 2012 and 2021. Participants included newborns with complete birth records born in a Swiss hospital. Data were analyzed from March to November 2023.

Exposure

Prevalent diagnosis of a cleft lip or palate at birth.

Main Outcomes and Measures

Outcomes of interest were monthly hospitalization rates for airway infections and any cause during the first 2 years of life in newborns with cleft lip or palate. In-hospital outcomes and mortality outcomes were also assessed, stratified by age and modality of surgical intervention.

Results

Of 857 806 newborns included, 1197 (0.1%) had a cleft lip and/or palate, including 170 (14.2%) with a cleft lip only, 493 (41.2%) with a cleft palate only, and 534 (44.6%) with cleft lip and palate. Newborns with cleft lip or palate were more likely to be male (55.8% vs 51.4%), with lower birth weight (mean [SD] weight, 3135.6 [650.8] g vs 3284.7 [560.7] g) and height (mean [SD] height, 48.6 [3.8] cm vs 49.3 [3.2] cm). During the 2-year follow-up, children with a cleft lip or palate showed higher incidence rate ratios (IRRs) for hospitalizations due to airway infections (IRR, 2.33 [95% CI, 1.98-2.73]) and for any reason (IRR, 3.72 [95% CI, 3.49-3.97]) compared with controls. Additionally, children with cleft lip or palate had a substantial increase in odds of mortality (odds ratio [OR], 17.97 [95% CI, 11.84-27.29]) and various complications, including the need for intubation (OR, 2.37 [95% CI, 1.95-2.87]), extracorporeal membrane oxygenation (OR, 2.89 [95% CI, 1.81-4.63]), cardiopulmonary resuscitation (OR, 3.25 [95% CI, 2.21-4.78]), and respiratory support (OR, 1.94 [95% CI, 1.64-2.29]).

Conclusions and Relevance

In this nationwide cohort study, the presence of cleft lip or palate was associated with increased hospitalization rates for respiratory infections and other causes, as well as poorer in-hospital outcomes and greater resource use.

Polysomnogram Findings and Psychosocial and Academic Concerns in Children With Cleft Palate With or Without Cleft Lip

Children born with a cleft palate with or without a cleft lip (CP±L) are at risk for sleep-disordered breathing, particularly obstructive sleep apnea (OSA). While OSA and CP±L have both been associated with higher risk for psychosocial and academic concerns, their combined risk has been understudied. This paper aimed to describe polysomnography findings and psychosocial and academic concerns among children with isolated (iCP±L) and syndrome-associated (sCP±L) clefts who had undergone primary palatoplasty. Medical records were reviewed from 2004 to 2022 for demographics, medical history, polysomnography results, and family-reported psychosocial and academic variables. Of the 694 patients with CP±L who had a palatoplasty, 147 had a polysomnogram and 82 had at least one follow-up polysomnogram. Across time points, only 19% to 27% of participants had normal polysomnograms and the most frequent finding was mild OSA for 30% to 35% of patients. For children with iCP±L, more frequent oxygen desaturations were significantly associated with receiving special education services and family-reported academic concerns and OSA was associated with a history of receiving mental health services. Children with sCP±L had a significantly higher Obstructive Apnea-Hypopnea Index and a greater proportion of all-day special education classroom placements relative to youth with iCP±L. Study results suggest that cleft providers should monitor for OSA and sleep-disordered breathing symptoms, collaborate with pulmonologists for evaluation and treatment of sleep concerns, and address possible sleep-associated psychosocial and academic issues.

Reducing delayed detection of isolated cleft palate-related deformity: a call for routine intraoral examination of newborns

OBJECTIVE

To provide healthcare professional-friendly practical recommendations for early detection of cleft palate-related deformities in newborns and offer an overview of managing these high-prevalent congenital abnormalities.

SOURCE OF DATA

PubMed, SciELO, Lilacs, Cochrane, ScienceDirect, and Scopus databases were reviewed for cleft- and diagnosis-related studies.

SUMMARY OF THE FINDINGS

Unfortunately, the global prevalence of delayed detection of cleft palate-related deformities remains unacceptably high, with over a quarter of cleft palates missed at birth. This delayed identification causes physical and psychological distress for patients and families, including feeding challenges and weight faltering. To improve cleft management, it is essential to adopt routine detailed, in-depth intraoral examination immediately after birth. It is recommended not only to finger-assisted palpate the intraoral structures but also to visually inspect the oral cavity from gingiva to uvula using a wooden tongue depressor and light-assisted examination. With timely diagnosis and referral to specialized care, pediatricians, nurses, speech therapists, and plastic surgeons provide life-changing treatments, including health care maintenance, anticipatory guidance, feeding support, primary surgical reconstruction, and age- and condition-specific protocols.

CONCLUSIONS

Encouraging neonatologists and pediatricians, who are the first to examine newborns, to actively investigate the intraoral region for cleft palate-related deformities is instrumental in optimizing therapeutic approaches and prioritizing age-phases in treatment. Their crucial role in early detection and referral can lead to transformative outcomes, impacting not only the future of the newborns by facilitating functional integration into society but also yielding positive effects on families and the health system.