Midfacial and Dental Changes Associated with Nasal Positive Airway Pressure in Children with Obstructive Sleep Apnea and Craniofacial Conditions

Mandibular Lengthening by Distraction for Airway Obstruction in Treacher-Collins Syndrome: The 30-Year Results

Treacher-Collins syndrome is a rare facial clefting disorder, the management of which remains among the most challenging for craniofacial teams. Herein, we report the long-term outcome of early mandibular lengthening by distraction osteogenesis for established airway obstruction in Treacher-Collins syndrome. This case, which was the first literature report in this clinical scenario1, has subsequently been reviewed at skeletal maturity2 and can now be addressed more than 30 years later.

Management of Obstructive Sleep Apnea in the Infant: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the improvement in respiratory parameters of infants with obstructive sleep apnea (OSA) treated with medical or surgical intervention.

DATA SOURCES

A comprehensive review was completed using the PubMed, Web of Science, Embase, and Cochrane libraries including articles published from 1975 to 2024.

REVIEW METHODS

Interventions studied included adenotonsillectomy, mandibular distraction osteogenesis (MDO), tongue/lip adhesion, partial glossectomy, floor-of-mouth release, supraglottoplasty, oral appliances, tracheostomy, and positioning. Continuous positive airway pressure (CPAP) served as a control. Outcomes studied included pre- and postintervention obstructive apnea-hypopnea index. Studies included randomized controlled trials and case-control trials. A total of 2161 records were identified, and 59 studies were included in the analysis. Data was extracted following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and pooled using a random-effects model. The primary study outcome established prior to data collection was a change in the apnea-hypopnea index.

RESULTS

A meta-analysis of MDO performed in infants for OSA demonstrated an overall pooled mean difference (pre-apnea-hypopnea index minus post-apnea hypopnea index) of 30.1 (95% confidence interval: 22.9, 37.4; 10 studies, 373 patients). No other data was pooled for analysis due to study heterogeneity. All CPAP studies showed apnea resolution. Tailored therapies including supraglottoplasty and tongue-lip adhesion reduced but did not resolve apneic events.

CONCLUSION

Current investigations of the evaluation and treatment of infant OSA are limited by heterogeneity in reporting and study. Mandibular distraction and CPAP are promising.

Saving lives, one breath at a time: The key role of noninvasive ventilation interfaces

Home noninvasive ventilation (NIV) for children must consider the key role of the interface, in addition to selecting the ventilatory mode and settings. Acceptance and adherence to NIV often depend on the time spent selecting the right mask, as well as on regular and careful attention to preventing and addressing various issues that arise during NIV.

Interfaces for Home Noninvasive Ventilation

The choice of interface used to deliver noninvasive ventilation (NIV) is a critical element in successfully and safely establishing home NIV in people with sleep hypoventilation syndromes. Both patient-related and equipment-related factors need to be considered when selecting an interface. Recognizing specific issues that can occur with a particular style of mask is important when troubleshooting NIV problems and attempting to minimize side effects. Access to a range of mask styles and designs to use on a rotational basis is especially important for patients using NIV on a more continuous basis, those at risk of developing pressure areas, and children.

Maxillary Hypoplasia and Non-Invasive Ventilation: Literature Review and Proposed New Treatment Protocol

The impact of non-invasive ventilation (NIV) on pediatric maxillary growth is a subject of ongoing research considering its increased use in the pediatric population due to technological advancements and broader indications. This review examines the existing literature, encompassing original articles, case reports, and reviews, to evaluate the effects of NIV on maxillary development and explore potential treatment options. Although the majority of studies agree on the adverse effects of prolonged NIV on maxillary development, techniques for its correction remain understudied. Introducing a novel treatment protocol, we addressed the challenge of correcting severe midfacial hypoplasia in a child with congenital central hypoventilation syndrome (CCHS) undergoing NIV therapy, thus sidestepping the necessity for osteotomies. This proposed protocol holds promise in correcting the adverse impact of NIV on maxillary growth, emphasizing the need for further exploration into innovative treatment modalities.

The effect of continuous positive airway pressure on obstructive sleep apnea in children with syndromic craniosynostosis

BACKGROUND

Obstructive sleep apnea (OSA) is common in children with syndromic craniosynostosis (SC). However, objective data on the treatment of OSA in children with SC remain inadequate. This study aimed to explore the efficacy of continuous positive airway pressure (CPAP) in the management of OSA in children with SC.

METHODS

A retrospective study was performed in children with SC and OSA diagnosed by polysomnography (PSG), which was defined as an apnea hypopnea index (AHI) ≥ 1. Patients were included if they were treated with CPAP and had baseline PSG and follow-up sleep studies. Clinical and demographic data were collected from all enrolled subjects.

RESULTS

A total of 45 children with SC and OSA were identified, with an average age of 6.8 ± 4.7 years. Among them, 36 cases had moderate to severe OSA (22 with severe OSA) and received CPAP therapy followed by post-treatment sleep studies. Notably, there was a significant reduction in the AHI observed after CPAP treatment (3.0 [IQR: 1.7, 4.6] versus 38.6 [IQR: 18.2, 53.3] events/h; P < 0.001).

CONCLUSIONS

CPAP is effective and acceptable in treating severe OSA in children with SC.

The latest on positive airway pressure for pediatric obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is an important and evolving area in the pediatric population, with significant sequelae when not adequately managed. The use of positive airway pressure (PAP) therapy is expanding rapidly and is being prescribed to patients with persistent OSA post adenotonsillectomy as well as those children who are not surgical candidates including those with medical complexity.

AREAS DISCUSSED

This article provides a state-of-the-art review on the diagnosis of pediatric OSA and treatment with positive airway pressure (PAP). The initiation of PAP therapy, pediatric interface considerations, PAP mode selection, administration and potential complications of PAP therapy, factors influencing PAP adherence, the use of remote ventilation machine downloads, considerations surrounding follow-up of patients post PAP initiation and evaluation of weaning off PAP will be reviewed. The literature search was conducted via PubMed, Cochrane Library and Google Scholar databases through to March 2024.

EXPERT OPINION

Further research is required to address barriers to adherence. Further innovation of home monitoring devices for both the diagnosis and assessment of OSA is required, given the limited pediatric sleep medicine resources in several countries worldwide.

Mask interfaces and devices for home noninvasive ventilation in children

Home noninvasive ventilation (NIV), including continuous (CPAP) and bilevel (BPAP) positive airway pressure, is increasingly used in children worldwide. In this narrative review, we present a comprehensive summary of the equipment available for home NIV in pediatrics, excluding neonates. NIV may be challenging in young children, as the majority of the equipment has been developed for adults. Regarding the interfaces, only a few masks have been specifically developed for young children in recent years, while older children may benefit from a large variety of interfaces. Even though much progress has been made, skin injuries are still present, and need to be managed rapidly. Several studies addressed the management of the side effects, but recent studies are lacking regarding orofacial anomalies. No recent study reported the available interfaces for young children and the strategies for an optimal mask fit. Regarding the devices, an adapted NIV device to pediatrics that allows an adequate patient's breathing detection should guarantee optimal ventilatory efficiency and monitoring of NIV. A close follow-up and regular monitoring should be mandatory to rule out the potential issues, optimize NIV therapy and ascertain the efficacy of NIV. However, studies are lacking to guide the choice of devices in young children and the optimal management of home NIV in pediatrics. We summarized the characteristics of the different interfaces available for young children and the limitations of NIV devices. We finally addressed potential areas for future research on long-term home NIV in children.

Use of T-Scan III in analyzing occlusal changes in molar fixed denture placement

BACKGROUND

This study aims to analyze the longitudinal variation of occlusal force distribution prior to and after fixed restoration for molar full-crowns with T-SCAN III which provide reference for occlusal adjustment and long-term maintenance.

METHODS

We enrolled a total of 20 patients who received conventional restorative treatment for molars. The occlusion examination was conducted in 3 stages (before placement, immediately after placement, and 3 months after placement) using T-SCAN III (Tekscan South Boston, MA, USA, 10.0) to examine and measure the occlusal contact areas of the full dentition.

RESULTS

The results indicated that the occlusal force distribution in the molar region of the patients changed before and after the fixed restoration, but the percentages of occlusal force in the dental arch of the molar did not differ significantly before and after the restoration (P > 0.05). Three months after the fixed restoration, the percentage of occlusal force in the restored dental arches of lateral teeth increased significantly (P < 0.05).

CONCLUSION

The results of this study indicated that the occlusal forces of the patients changed with tooth movement and adaptation, which is mainly reflected in the increasing occlusal force. Quantitative occlusal force analysis using T-SCAN III occlusal analyzer can provide more objective and accurate data to effectively guide clinical occlusion adjustments.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea

STUDY OBJECTIVES

Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery.

METHODS

A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes.

RESULTS

A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005).

CONCLUSIONS

This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%).

CITATION

Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Predictors of NIV-related adverse events in children using long-term noninvasive ventilation

BACKGROUND AND OBJECTIVES

An increasing number of children with diverse medical conditions are using long-term noninvasive ventilation (NIV). This study examined the impact of demographic, clinical, and technology-related factors on long-term NIV adverse events in a large cohort of children using long-term NIV.

METHODS

This was a multicenter retrospective review of all children who initiated long-term NIV in the province of Alberta, Canada, from January 2005 to September 2014, and followed until December 2015. Inclusion criteria were children who had used NIV for 3 months or more and had at least one follow-up visit with the NIV programs.

RESULTS

We identified 507 children who initiated NIV at a median age of 7.5 (interquartile range: 8.6) years and 93% of them reported at least one NIV-related adverse event during the initial follow-up visit. Skin injury (20%) and unintentional air leaks (19%) were reported more frequently at the initial visit. Gastrointestinal symptoms, midface hypoplasia, increased drooling, aspiration and pneumothorax were rarely reported (<5%). Younger age and underlying conditions such as Down syndrome, achondroplasia, and Duchenne muscular dystrophy were early predictors of unintentional air leak. Younger age also predicted child sleep disruption in the short term and ongoing parental sleep disruption. Obesity was a risk factor for persistent nasal symptoms. Mask type was not a significant predictor for NIV-related short- or long-term complications.

CONCLUSIONS

This study demonstrates that NIV-related complications are frequent. Appropriate mask-fitting and headgear adaptation, and a proactive approach to early detection may help to reduce adverse events.

Mandibular Advancement Appliances in Pediatric Obstructive Sleep Apnea: An Umbrella Review

Introduction  Obstructive sleep apnea (OSA) is defined as intermittent partial or complete collapse of the upper airway during sleep. It is a common condition in childhood, with an incidence ranging from 1.2% to 5.7%, and it can harm several aspects of children's life, such as cognitive, metabolic and cardiovascular functions, among others. There are treatment options, such as adenotonsillectomy, myofunctional therapy, mandibular advancement appliances (MAAs), rapid maxillary expansion, and positive airway pressure devices, but there is still doubt about which method is more suitable for the treatment of OSA in children. Objective  To analyze the effectiveness of MAAs in the treatment of pediatric OSA. Materials and Methods  The search was conducted in August 2021 in different electronic databases, such as PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS, Ovid, SciELO, Web of Science, EMBASE BIREME, BBO BIREME, and the Cochrane Library. Results  Only three systematic reviews and two meta-analyses were included in the present study. All studies showed improvement in the score on the apnea-hypopnea index after using MAAs in the treatment of pediatric OSA. Conclusion  Although more randomized studies are needed, based on the present umbrella review, MAAs must be considered part of the multidisciplinary treatment for pediatric OSA.

Base of Tongue Surgery and Pediatric Obstructive Sleep Apnea

OBJECTIVE

Drug-induced sleep endoscopy-directed lingual tonsillectomy and midline posterior glossectomy have been employed for the treatment of obstructive sleep apnea in children. The purpose of this study is to evaluate outcomes in children undergoing lingual tonsillectomy, midline posterior glossectomy, or combined base of tongue reduction procedures for obstructive sleep apnea.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care academic medical center.

METHODS

A case series was performed with chart review of pediatric patients with obstructive sleep apnea who underwent base of tongue surgery as directed by drug-induced sleep endoscopy. Pre- and postoperative obstructive apnea-hypopnea index (oAHI) was compared. Age, sex, body mass index z score, and medical history were also evaluated.

RESULTS

A total of 168 children were included, with a mean ± SD age of 8.3 ± 3.6 years. Of these patients, 101 underwent lingual tonsillectomy alone; 25, midline posterior glossectomy alone; and 42, both. Their mean oAHI improvement was 3.52 ± 8.39, 2.55 ± 5.59, and 3.70 ± 6.07, respectively. Each surgical group experienced significant improvement in sleep apnea when pre- and postoperative oAHI was compared (P < .01). Overall surgical success, as defined by oAHI <1 (or <5 without clinical symptoms), was 75% (126 patients).

CONCLUSION

When guided by drug-induced sleep endoscopy, pediatric tongue base surgery can significantly improve oAHI and thus demonstrates promising success in treating pediatric obstructive sleep apnea.

Sleep Endoscopy and Cine Magnetic Resonance Imaging Evaluation of Children With Persistent Obstructive Sleep Apnea

OBJECTIVE

To compare findings of same-day cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) and examine how each technique uniquely contributes to the evaluation of persistent obstructive sleep apnea following adenotonsillectomy.

STUDY DESIGN

Retrospective cohort study.

SETTING

Quaternary care center.

METHODS

Chart review was performed for consecutive patients who underwent same-day cine MRI and DISE between 2015 and 2020. Descriptive statistics are reported, and Cohen kappa coefficients were calculated to evaluate the agreement between cine MRI and DISE for obstruction at the adenoids, lingual tonsils, and tongue base.

RESULTS

There were 137 patients, the mean age was 10.4 years (95% CI, 3.2-16.7), and 62.8% were male. The most common sites of obstruction on DISE were the tongue base (86.9%), velum (78.7%), epiglottis (74.5%), inferior turbinate (68.6%), and lingual tonsil (61.3%). The most common sites of obstruction on cine MRI were the hypopharynx (56.3%), tongue base (44.8%), lingual tonsil (38.0%), and macroglossia (37.6%). There was moderate agreement for adenoid hypertrophy (κ = 0.53) and poor agreement for lingual tonsil hypertrophy (κ = 0.15) and tongue base obstruction (κ = 0.09). DISE identified more instances of multilevel obstruction when compared with cine MRI (94.9% vs 48.2%).

CONCLUSION

DISE offered a better examination of nasal and supraglottic obstruction and is sensitive to partial vs complete collapse, while cine MRI offered better soft tissue resolution for lymphoid tissue hypertrophy and provided a global view of primary and secondary airway obstruction. Cine MRI and DISE are complementary modalities in the evaluation of children with persistent obstructive sleep apnea.

Effectiveness of functional orthopedic appliances as an alternative treatment among children and adolescents with obstructive sleep apnea: Systematic review and meta-analysis

INTRODUCTION

The objective here was to review the efficacy of functional jaw orthopedic appliances for treating children/adolescents with obstructive sleep apnea (OSA), through correlating the apnea/hypopnea index (AHI) and oxygen saturation (SaO₂) in polysomnography (PSG), in addition to questionnaire scores from the obstructive sleep apnea-18 (OSA-18).

METHODS

The PRISMA 2020 guidelines¹ were followed. A search was conducted in October 2021, with updating to May 2022, in the MEDLINE/PubMed, BVS (LILACS/BBO), ISI, SciELO (Web of Science), COCHRANE, EMBASE, SCOPUS and WHO databases and the gray literature. Data selection and extraction were performed by two independent reviewers, with Cohen kappa testing. All articles included in the meta-analyses showed good quality and low risk of bias. Statistical analyses were performed in the "R" software, using means with standard deviations, and differences in the means were represented graphically in forest plots. Heterogeneity was tested using I², in random-effect models.

RESULTS

From before to after treatment, treated individuals showed improved AHI, SaO₂ and OSA-18 scores². Comparing treated individuals and controls, AHI decreased in treated individuals and increased in controls. For SaO₂, the increase in treated individuals was greater than in controls. For OSA-18, daytime/nighttime symptoms decreased in treated individuals and increased in controls.

CONCLUSION

Functional jaw orthopedic appliances are appropriate and effective for children/adolescents with OSA whose etiology is deficient maxillomandibular growth and development. Functional jaw orthopedics treats the form and function of the stomatognathic system, thereby enhancing quality of life.

PROSPERO REGISTRATION PROTOCOL

CRD42021253341.

Adherence to Continuous Positive Airway Pressure Therapy in Pediatric Patients with Obstructive Sleep Apnea: A Meta-Analysis

Introduction

Obstructive sleep apnea (OSA) is a public health problem that affects children. Although continuous positive airway pressure (CPAP) therapy is effective, the CPAP adherence rate in children is varied. This study aimed to evaluate the CPAP adherence rate and factors associated with CPAP adherence in children with OSA using a systematic review.

Methods

The inclusion criteria were observational studies conducted in children with OSA and assessed adherence of CPAP using objective evaluation. The literature search was performed in four databases. Meta-analysis using fixed-effect model was conducted to combine results among included studies.

Results

In all, 34 studies that evaluated adherence rate and predictors of CPAP adherence in children with OSA were included, representing 21,737 patients with an average adherence rate of 46.56%. There were 11 calculations of factors predictive of CPAP adherence: age, sex, ethnicity, body mass index, obesity, income, sleep efficiency, the apnea-hypopnea index (AHI), severity of OSA, residual AHI, and lowest oxygen saturation level. Three different factors were linked to children with adherence and non-adherence to CPAP: age, body mass index, and AHI.

Conclusion

The CPAP adherence rate in children with OSA was 46.56%. Young age, low body mass index, and high AHI were associated with acceptable CPAP adherence in children with OSA.

Three-dimensional orthodontic imaging in children across the age spectrum and correlations with obstructive sleep apnea

STUDY OBJECTIVES

To determine baseline facial convexity measurements in children with obstructive sleep apnea (OSA) across the age spectrum.

METHODS

Polysomnogram, stereophotogrammetry, and biometric data were collected from children aged 0-18 years who were being investigated for OSA. Analyses evaluated differences in facial convexity according to OSA severity and other sleep parameters, while adjusting for age, ethnicity, and sex.

RESULTS

Ninety-one children, aged 0.05-16.02 years, met the inclusion criteria for this study. Initial analysis showed that the logarithm of age had a significant effect on facial convexity (P = 8.3·10-7) with significant effects of sex (P = 1.3·10-2), while excluding OSA. Ordinal logistic regression taking into consideration age, sex, weight, height, and ethnicity with OSA severity categorized as obstructive apnea-hypopnea index negative, mild, moderate, or severe showed that facial convexity was associated with OSA severity (P = 2.2·10-3); an increasing obtuse angle of convexity increased the tendency to be classified as having severe OSA.

CONCLUSIONS

Using three-dimensional imaging, we found an added impact of infancy on changes of facial convexity with age. While modeling could describe facial convexity without any OSA-associated sleep parameters, differences in facial convexity were present among groups with different levels of OSA severity adjusted for growth (age, weight, and height), sex, and ethnicity. The method provides a safer and cheaper alternative to other medical imaging techniques in children and holds potential for future use in studies of craniofacial structure.

CITATION

Tyler G, Machaalani R, Waters KA. Three-dimensional orthodontic imaging in children across the age spectrum and correlations with obstructive sleep apnea. J Clin Sleep Med. 2023;19(2):275-282.

Residual OSA in Down syndrome: does body position matter?

STUDY OBJECTIVES

To examine children with Down syndrome with residual obstructive sleep apnea (OSA) to determine if they are more likely to have positional OSA.

METHODS

A retrospective chart review of children with Down syndrome who underwent adenotonsillectomy at a single tertiary children's hospital was conducted. Children with Down syndrome who had a postoperative polysomnogram with obstructive apnea-hypopnea index (OAHI) > 1 event/h, following adenotonsillectomy with at least 60 minutes of total sleep time were included. Patients were categorized as mixed sleep (presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Positional OSA was defined as an overall OAHI > 1 event/h and a supine OAHI to nonsupine OAHI ratio of ≥ 2. Group differences are tested via Kruskal-Wallis test for continuous variables and Fisher's exact tests for categorical.

RESULTS

There were 165 children with Down syndrome who met inclusion criteria, of which 130 individuals had mixed sleep. Patients who predominately slept supine had a greater OAHI than mixed and nonsupine sleep (P = .002). Sixty (46%) of the mixed-sleep individuals had positional OSA, of which 29 (48%) had moderate/severe OSA. Sleeping off their backs converted 14 (48%) of these 29 children from moderate/severe OSA to mild OSA.

CONCLUSIONS

Sleep physicians and otolaryngologists should be cognizant that the OAHI may be an underestimate if it does not include supine sleep. Positional therapy is a potential treatment option for children with residual OSA following adenotonsillectomy and warrants further investigation.

CITATION

Lackey TG, Tholen K, Pickett K, Friedman N. Residual OSA in Down syndrome: does body position matter? J Clin Sleep Med. 2023;19(1):171-177.

Patient-Centered Therapy for Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA) is one of the most common sleep problems defined by cessation or decreased airflow despite breathing efforts. It is known to be related to multiple adverse health consequences. Positive airway pressure (PAP) is considered an effective treatment that is widely used. Various modes of PAP and other emerging treatment options are now available. A multidisciplinary approach, understanding diverse phenotypes of OSA, and shared decision-making are necessary for successful OSA treatment. Patient-centered care is an essential modality to support patient care that can be utilized in patients with OSA to help improve outcomes, treatment adherence, and patient satisfaction.

Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement

This position statement provides guidance for age and weight considerations for using continuous positive airway pressure therapy in pediatric populations. The American Academy of Sleep Medicine commissioned a task force of experts in pediatric sleep medicine to review the medical literature and develop a position statement based on a thorough review of these studies and their clinical expertise. The American Academy of Sleep Medicine Board of Directors approved the final position statement. It is the position of the American Academy of Sleep Medicine that continuous positive airway pressure can be safe and effective for the treatment of obstructive sleep apnea for pediatric patients, even in children of younger ages and lower weights, when managed by a clinician with expertise in evaluating and treating pediatric obstructive sleep apnea. The clinician must make the ultimate judgment regarding any specific care in light of the individual circumstances presented by the patient, accessible treatment options, patient/parental preference, and resources.

CITATION

Amos L, Afolabi-Brown O, Gault D, et al. Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(8):2041-2043.

Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review

INTRODUCTION

Obstructive sleep apnea syndrome is a common condition in childhood and if left untreated can result in many health problems. An accurate diagnosis of the etiology is crucial for obstructive sleep apnea treatment success. Functional orthodontic appliances that stimulate mandibular growth by forward mandibular positioning are an alternative therapeutic option in growing patients.

OBJECTIVE

To perform a literature review about the effects of functional orthodontic appliances used to correct the mandibular deficiency in obstructive sleep apnea treatment.

METHODS

The literature search was conducted in June 2020 using Cochrane Library; PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS Ovid; SciELO Web of Science; EMBASE Bireme and BBO Bireme electronic databases. The search included papers published in English, until June 2020, whose methodology referred to the types and effects of functional orthopedic appliances on obstructive sleep apnea treatment in children.

RESULTS

The search strategy identified thirteen articles; only four articles were randomized clinical studies. All studies using the oral appliances or functional orthopedic appliances for obstructive sleep apnea in children resulted in improvements in the apnea-hypopnea index score. The cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace, improving the respiratory function in the short term.

CONCLUSION

Functional appliances may be an alternative treatment for obstructive sleep apnea, but it cannot be concluded that they are effective in treating pediatric obstructive sleep apnea. There are significant deficiencies in the existing evidence, mainly due to absence of control groups, small sample sizes, lack of randomization and no long-term results.

ERS Statement on pediatric long term noninvasive respiratory support

Long term noninvasive respiratory support, comprising continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV), in children is expanding worldwide, with increasing complexities of children being considered for this type of ventilator support and expanding indications such as palliative care. There have been improvements in equipment and interfaces. Despite growing experience, there are still gaps in a significant number of areas: there is a lack of validated criteria for CPAP/NIV initiation, optimal follow-up and monitoring; weaning and long term benefits have not been evaluated. Therapeutic education of the caregivers and the patient is of paramount importance, as well as continuous support and assistance, in order to achieve optimal adherence. The preservation or improvement of the quality of life of the patient and caregivers should be a concern for all children treated with long term CPAP/NIV. As NIV is a highly specialised treatment, patients are usually managed by an experienced pediatric multidisciplinary team. This Statement written by experts in the field of pediatric long term CPAP/NIV aims to emphasize on the most recent scientific input and should open up to new perspectives and research areas.

Comparison of airway pressures and expired gas washout for nasal high flow versus CPAP in child airway replicas

Background

For children and adults, the standard treatment for obstructive sleep apnea is the delivery of continuous positive airway pressure (CPAP). Though effective, CPAP masks can be uncomfortable to patients, contributing to adherence concerns. Recently, nasal high flow (NHF) therapy has been investigated as an alternative, especially in CPAP-intolerant children. The present study aimed to compare and contrast the positive airway pressures and expired gas washout generated by NHF versus CPAP in child nasal airway replicas.

Methods

NHF therapy was investigated at a flow rate of 20 L/min and compared to CPAP at 5 cmH₂O and 10 cmH₂O for 10 nasal airway replicas, built from computed tomography scans of children aged 4–8 years. NHF was delivered with three different high flow nasal cannula models provided by the same manufacturer, and CPAP was delivered with a sealed nasal mask. Tidal breathing through each replica was imposed using a lung simulator, and airway pressure at the trachea was recorded over time. For expired gas washout measurements, carbon dioxide was injected at the lung simulator, and end-tidal carbon dioxide (EtCO₂) was measured at the trachea. Changes in EtCO₂ compared to baseline values (no intervention) were assessed.

Results

NHF therapy generated an average positive end-expiratory pressure (PEEP) of 5.17 ± 2.09 cmH₂O (mean ± SD, n = 10), similar to PEEP of 4.95 ± 0.03 cmH₂O generated by nominally 5 cmH₂O CPAP. Variation in tracheal pressure was higher between airway replicas for NHF compared to CPAP. EtCO₂ decreased from baseline during administration of NHF, whereas it increased during CPAP. No statistical difference in tracheal pressure nor EtCO₂ was found between the three high flow nasal cannulas.

Conclusion

In child airway replicas, NHF at 20 L/min generated average PEEP similar to CPAP at 5 cm H₂O. Variation in tracheal pressure was higher between airway replicas for NHF than for CPAP. The delivery of NHF yielded expired gas washout, whereas CPAP impeded expired gas washout due to the increased dead space of the sealed mask.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01880-z.

Positive Airway Pressure Therapy for Pediatric Obstructive Sleep Apnea

Pediatric obstructive sleep apnea syndrome (OSAS) is a disorder of breathing during sleep, characterized by intermittent or prolonged upper airway obstruction that can disrupt normal ventilation and/or sleep patterns. It can affect an estimated 2–4% of children worldwide. Untreated OSAS can have far reaching consequences on a child’s health, including low mood and concentration as well as metabolic derangements and pulmonary vascular disease. Most children are treated with surgical intervention (e.g., first-line therapy, adenotonsillectomy); however, for those for whom surgery is not indicated or desired, or for those with postoperative residual OSAS, positive airway pressure (PAP) therapy is often employed. PAP therapy can be used to relieve upper airway obstruction as well as aid in ventilation. PAP therapy is effective in treatment of OSAS in children and adults, although with pediatric patients, additional considerations and limitations exist. Active management and care for various considerations important to pediatric patients with OSAS can allow PAP to be an effective and safe therapy in this population.

Debates in pediatric obstructive sleep apnea treatment

Pediatric obstructive sleep apnea (OSA) is among the most common sleep-disordered breathing (SDB) diseases in children. Its high prevalence and multiple systemic complications lead to increasing numbers of children and families affected by OSA. Timely diagnosis and effective intervention in children with this condition is extremely important in improving their prognosis. The major approaches in the treatment of OSA in children are to eliminate the causes of upper airway obstruction and prevent and treat complications. Considering the specific individual differences in children's growth and development, as well as the diversity of etiologies in children's OSA, pediatric treatment strategies need to be precise, multidisciplinary, and individualized. First-line clinical treatment consists of surgical (adenotonsillectomy) and non-surgical therapies [including anti-inflammatory medications and non-invasive ventilation (NIV)]. However, a considerable controversy exists concerning the indications, treatment standards, and the evaluation of the efficacy of the aforementioned treatment methods. In this review, reviews and assessment of literature studies and multidisciplinary clinical experience were performed to analyze the application of each treatment and discuss controversial issues and future research directions. We suggest that the above interventions should be tailored to each child's needs, comorbidities, and the availability and expertise of the practitioner. The ideal case is when a multidisciplinary team of doctors together with the patients and their parents, or guardians, have a thorough discussion regarding the benefits and risks of all available treatment options and all agree on an effective treatment plan.

Persistent OSA in obese children: does body position matter?

STUDY OBJECTIVES

The objective of this study was to determine if positional therapy is a viable treatment alternative for obese children with persistent obstructive sleep apnea (OSA).

METHODS

A retrospective review was performed of children who underwent an adenotonsillectomy for OSA from 2014 to 2017. Children were included if they had a body mass index ≥ 95th percentile and underwent a postoperative polysomnogram. Subjects fell into one of three categories: mixed sleep (the presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Cure was defined as an OSA/apnea-hypopnea index of < 1 events/h. Paired t tests were used to assess the differences, and a linear model adjusting for obesity class, age at procedure, and sex was performed to assess the differences between nonsupine and supine sleep.

RESULTS

There were 154 children who met the inclusion criteria. Using a paired t test, supine sleep position had a significantly higher average OSA/apnea-hypopnea index (7.9 events) compared with nonsupine (OSA/apnea-hypopnea index of 4.1); P value was < .01 for the 60 children with mixed sleep. Forty-three children had predominantly nonsupine sleep and 33 predominantly supine sleep, and a McNemar's test comparing these children showed that those sleeping in the nonsupine position were significantly more likely to be cured than those in the supine position (P < .001).

CONCLUSIONS

Sleep physicians and otolaryngologists should be cognizant of positional treatment when consulting with families and note that the postoperative polysomnography may be inaccurate if it does not include supine sleep. Positional therapy as a potential treatment option for obese children with persistent OSA after adenotonsillectomy warrants further investigation.

Clinical predictors of nonadherence to positive airway pressure therapy in children: a retrospective cohort study

STUDY OBJECTIVES

Despite the importance of treating sleep-disordered breathing, positive airway pressure adherence rates in children are low. Identifying readily available predictors of nonadherence would enable the development of targeted interventions and supports, but literature is limited. Our objective was to identify baseline clinical predictors of 6-month positive airway pressure therapy nonadherence in children with SDB through a retrospective cohort study.

METHODS

This study evaluated children (ages 8-17 years) prescribed positive airway pressure therapy for sleep-disordered breathing between 2011 and 2017 at a single pediatric tertiary hospital. The primary outcome was nonadherence at 6 months, measured using both machine downloads and self-report. Candidate baseline predictors included demographics, comorbidities, and sleep-disordered breathing characteristics. Relative risks (RR) and 95% confidence intervals (CI) were estimated using a modified Poisson regression. Missing data were imputed prior to analysis.

RESULTS

The study included 104 children. The independent predictors most strongly associated with greater nonadherence were older age (RR = 1.08 for a 1-year increase; 95% CI, 1.00-1.16) and higher oxygen saturation nadir (RR = 1.03 for a 1% increase; 95% CI, 1.00-1.05), whereas those most strongly associated with lower nonadherence were higher arousal index (RR = 0.97 for a 1 event/h increase; 95% CI, 0.95-1.00), developmental delay (RR = 0.58; 95% CI, 0.30-1.13), and asthma (RR = 0.72; 95% CI, 0.44-1.17).

CONCLUSIONS

Overall, children who are older, have less-severe sleep-disordered breathing, or less-disrupted sleep at baseline are more likely to be nonadherent to positive airway pressure therapy and may benefit from additional supports to acclimatize to therapy. As clinical predictors were only weakly associated with nonadherence, nonclinical characteristics may play a larger role in predicting adherence.

Le Fort II Distraction with Simultaneous Zygomatic Repositioning

Severe midface hypoplasia is often managed by Le Fort III distraction. Le Fort II distraction with zygomatic repositioning is a modification of the Le Fort III distraction operation aimed to correct abnormal facial ratios of patients with greater central than lateral midface deficiency. The operation starts with Le Fort III osteotomies and is followed by separation and fixation of bilateral zygomas. The central nasomaxillary Le Fort II segment is then distracted to achieve independent movements of the central and lateral midface. The Le Fort II zygomatic repositioning operation has become our procedure of choice for patients with Apert facial dysmorphology.

Material and Technology: Back to the Future for the Choice of Interface for Non-Invasive Ventilation - A Concise Review

Non-invasive ventilation (NIV) has dramatically changed the treatment of both acute and chronic respiratory failure in the last 2 decades. The success of NIV is correlated to the application of the "best ingredients" of a patient's "tailored recipe," including the appropriate choice of the selected candidate, the ventilator setting, the interface, the expertise of the team, and the education of the caregiver. The choice of the interface is crucial for the success of NIV. Type (oral, nasal, nasal pillows, oronasal, hybrid mask, helmet), size, design, material and headgears may affect the patient's comfort with respect to many aspects, such as air leaks, claustrophobia, skin erythema, eye irritation, skin breakdown, and facial deformity in children. Companies are paying great attention to mask development, in terms of shape, materials, comfort, and leak reduction. Although the continuous development of new products has increased the availability of interfaces and the chance to meet different requirements, in patients necessitating several daily hours of NIV, both in acute and in chronic home setting, the rotational use of different interfaces may remain an excellent strategy to decrease the risk of skin breakdown and to improve patient's tolerance. The aim of the present review was to give the readers a background on mask technology and materials in order to enhance their "knowledge" in making the right choice for the interface to apply during NIV in the different clinical scenarios.

Advanced interdisciplinary treatment protocol for pediatric obstructive sleep apnea including medical, surgical, and orthodontic care: a narrative review

OBJECTIVE

To suggest an updated interdisciplinary treatment protocol for pediatric obstructive sleep apnea (POSA) based on the integration of craniofacial growth modification into medical and surgical sleep practice.

METHODS

PubMed, Scopus, and Cochrane library were searched up to February 2020 using keywords. Among 184 articles, 80 studies were finally included. An integrated treatment protocol for POSA encompassing craniofacial skeletal management as well as medical and surgical care was attempted.

RESULTS

A differential diagnostic workflow for identifying the phenotype of POSA was suggested, and a phenotype-based treatment protocol for POSA was proposed. Despite the lack of high level of evidence, timely skeletal growth modification in three dimensions using craniofacial growth potential could be valuable treatment for upper airway development in POSA patients with craniofacial phenotypic cause.

CONCLUSION

A novel precision treatment protocol will advance clinicians to determine the primary option or to apply the combined strategy for POSA patients.

High flow nasal cannula treatment for obstructive sleep apnea in infants and young children

BACKGROUND

Continuous positive airway pressure (CPAP) is the nonsurgical treatment of choice for children with obstructive sleep apnea (OSA). However, CPAP limitations include difficulty with adherence and midface hypoplasia risk. We, therefore, sought to assess the effect of warm humidified air delivered via open nasal cannula (HFNC) on OSA in children in the sleep laboratory and at home.

METHODS

A retrospective review was performed among children recommended treatment of OSA with HFNC. Reasons for HFNC recommendation included poor surgical candidacy, residual OSA following surgery, and CPAP intolerance. Children underwent both diagnostic and HFNC titration sleep studies and were prescribed HFNC for home use. Standard sleep architecture, arousals, and apnea-hypopnea indices (AHI) were assessed with the evaluation of reported adherence and complications over 12 months of treatment.

RESULTS

Twenty-two children (average 12.8 months, 95% confidence interval [95% CI: 7.0, 18.6]) with OSA (obstructive AHI [OAHI] range: 4.8-89.2 events/h) underwent HFNC titration with significant reduction in OAHI (28.9 events/h [17.6, 40.2] vs 2.6 [1.1, 4.0]; P < .001) (mean [95% CI]). Nineteen patients received home HFNC treatment. By 12 months, four patients were lost to follow-up and OSA resolved in three patients (16%). Of 12 remaining patients, 7 (58%) continued therapy while 5 (42%) discontinued due to intolerance. The most common treatment complication was cannula dislodgement. Additional complications included skin irritation, dry mucus membranes, restlessness, oxygen desaturation, and increased central apneas.

CONCLUSION

HFNC offers a treatment alternative to CPAP in infants and young children with OSA and was well tolerated at home in our study.

Guidelines for diagnosis and management of congenital central hypoventilation syndrome

BACKGROUND

Congenital Central Hypoventilation Syndrome (CCHS) is a rare condition characterized by an alveolar hypoventilation due to a deficient autonomic central control of ventilation and a global autonomic dysfunction. Paired-like homeobox 2B (PHOX2B) mutations are found in most of the patients with CCHS. In recent years, the condition has evolved from a life-threatening neonatal onset disorder to include broader and milder clinical presentations, affecting children, adults and families. Genes other than PHOX2B have been found responsible for CCHS in rare cases and there are as yet other unknown genes that may account for the disease. At present, management relies on lifelong ventilatory support and close follow up of dysautonomic progression. BODY: This paper provides a state-of-the-art comprehensive description of CCHS and of the components of diagnostic evaluation and multi-disciplinary management, as well as considerations for future research.

CONCLUSION

Awareness and knowledge of the diagnosis and management of this rare disease should be brought to a large health community including adult physicians and health carers.

The impact of positive airway pressure on midface growth: a literature review

INTRODUCTION

The treatment of obstructive sleep apnea with positive airway pressure in children is restricted due to concerns that it could affect maxilla growth over time.

OBJECTIVE

To undertake a systematic review of the literature about the long-term impact of using a positive airway pressure mask on the midface in growing individuals.

METHODS

The literature search was conducted in September 2019 using the keywords ("long-term" OR "long term" OR "side effects" OR longitudinal) AND (children OR child OR preschool OR adolescents OR adolescent OR infant OR infants) AND (craniofacial OR "mid-face" OR midface OR midfacial OR facial OR maxillary) AND ("airway pressure" OR ventilation) in the databases PubMed, Web of Science and Lilacs. The search included papers published in English, until September 2019, on the effects of positive airway pressure on midfacial growth.

RESULTS

The search strategy identified five studies: two case reports, two cross-sectional studies and one retrospective cohort study. All studies evaluated the long-term effects of a using a nasal mask on the midface in children and adolescents; four showed midface hypoplasia and one no showed difference post- treatment compared to a control.

CONCLUSION

Most of the studies demonstrated that long-term use of nasal positive airway pressure in childhood/adolescence is associated with midface hypoplasia.

Positive Airway Pressure for the Treatment of OSA in Infants

BACKGROUND

Positive airway pressure (PAP) is a standard therapy for the treatment of OSA in children, but objective data on the effectiveness of PAP in infants are sparse. The aim of this study was to compare the effectiveness of PAP in infants younger than 6 months of age with that in school-aged children.

RESEARCH QUESTION

Compared with PAP in school-aged children, can PAP be titrated as successfully in infants, and is adherence to PAP similar in both age groups?

STUDY DESIGN AND METHODS

Single-center retrospective study. For consecutive infants younger than 6 months of age and school-aged children 5 to 10 years of age with OSA treated with PAP, baseline and titration polysomnography data, PAP adherence data, and parent-reported barriers to adherence were compared between groups.

RESULTS

Forty-one infants and 109 school-aged children were included. Median obstructive apnea hypopnea index (OAHI) in infants was 25.7/h (interquartile range [IQR], 17.8-35.9/h) and was greater than that in school-aged children (12.1/hr; IQR, 7.6-21.5/h; P < .0001). After PAP titration, OAHI was reduced by a median of 92.1% in infants, similar to the median 93.4% reduction in school-aged children (P = .67). PAP was used in infants on 94.7% of nights, which was more than the 83% in school-aged children (P = .003). No differences were found in barriers to adherence between infants and school-aged children, with behavioral barriers being most common in both groups.

INTERPRETATION

Objective data demonstrate that PAP is both highly effective at treating OSA and well-tolerated in infants. Like older patients, PAP should be considered along with other therapies for the treatment of OSA in even the youngest children.

Alternative Approaches to Adenotonsillectomy and Continuous Positive Airway Pressure (CPAP) for the Management of Pediatric Obstructive Sleep Apnea (OSA): A Review

Continuous positive airway pressure (CPAP) is considered first-line treatment in the management of pediatric patients without a surgically correctible cause of obstruction who have confirmed moderate-to-severe obstructive sleep apnea (OSA). The evidence supports its reduction on patient morbidity and positive influence on neurobehavioral outcome. Unfortunately, in clinical practice, many patients either refuse CPAP or cannot tolerate it. An update on alternative approaches to CPAP for the management of OSA is discussed in this review, supported by the findings of systematic reviews and recent clinical studies. Alternative approaches to CPAP and adenotonsillectomy for the management of OSA include weight management, positional therapy, pharmacotherapy, high-flow nasal cannula, and the use of orthodontic procedures, such as rapid maxillary expansion and mandibular advancement devices. Surgical procedures for the management of OSA include tongue-base reduction surgery, uvulopalatopharyngoplasty, lingual tonsillectomy, supraglottoplasty, tracheostomy, and hypoglossal nerve stimulation. It is expected that this review will provide an update on the evidence available regarding alternative treatment approaches to CPAP for clinicians who manage patients with pediatric OSA in daily clinical practice.

Children with Down syndrome and mild OSA: treatment with medication versus observation

STUDY OBJECTIVES

Children with Down syndrome (DS) have a high prevalence of obstructive sleep apnea (OSA). Anti-inflammatory medications have been shown to be an effective treatment for mild OSA in otherwise healthy children. However, the efficacy in children with DS and mild OSA has not been investigated. Our aim was to examine the polysomnographic changes of children with DS and mild OSA treated with medication.

METHODS

A retrospective chart review was performed in children with DS (< 18 years) and mild OSA (obstructive apnea-hypopnea index ≤ 5 events/h) diagnosed by polysomnography (PSG) between 2006 and 2018. Patients were included if they were treated with medications (intranasal corticosteroids and/or montelukast) or by observation with a duration of at least 3 months and had baseline and follow-up PSGs. Demographic data, comorbid diagnoses, and PSG data were collected and analyzed.

RESULTS

Forty-five children met inclusion criteria. In the medication group, 29 children were identified. The median age was 7.4 years (interquartile range [IQR] 4.9-9.3). In the observation group, 16 children were identified. The median age was 4.0 years (IQR 3.2-5.3). The median time from baseline to follow-up PSG was 14.0 months (IQR 10.0-22.9) for the medication group and 10.5 months (IQR 6.5-33.5) for the observation group. There were no significant changes in the median obstructive apnea-hypopnea index from the baseline to follow-up PSG in either the medication group (2.8 [IQR 2.2-3.6) versus 3.5 [IQR 1.4-4.8) events/h; P = .25) or the observation group (2.3 [IQR 1.3-3.1] versus 2.9 [IQR 1.9-6.8] events/h; P = .12). Similarly, there were no significant differences in apnea-hypopnea index, oxygen nadir or end-tidal carbon dioxide between the groups (P = .07-1).

CONCLUSIONS

In our cohort, medication therapy did not significantly improve polysomnographic measures in children with DS and mild OSA. Several factors such as hypotonia and relative macroglossia may explain the ineffectiveness of medical therapy for OSA in this population. Further prospective studies are necessary to confirm these results and to evaluate if a subgroup of DS children may benefit from medical therapy.

Positive airway pressure adherence in pediatric obstructive sleep apnea: A systematic scoping review

Positive airway pressure (PAP) therapy is a commonly prescribed treatment for pediatric obstructive sleep apnea (OSA). Negative health consequences associated with untreated OSA make understanding the utilization of PAP therapy imperative. The aim of this review was to describe PAP use in children and adolescents with OSA, explore factors that influence use, and describe published scientific or clinical approaches to improve use. Among 20 studies, average PAP adherence was 56.9% (range, 24-87%). PAP use averaged 4.0 h (SD = 3.1) to 5.2 h (SD = 3.4) per night. Cautious consideration of summary estimates of PAP use is necessary as studies were heterogeneous and adherence definitions widely varied across studies. Age, sex, and developmental delay were the only factors associated with PAP use in more than one study. The majority of approaches to improve use were program evaluations rather than scientifically tested interventions. This review identified critical gaps in the existing literature and sets forth a research agenda for the future.

Factors related to positive airway pressure therapy adherence in children with obesity and sleep-disordered breathing

STUDY OBJECTIVES

Positive airway pressure (PAP) is used to treat children with concurrent obesity and sleep-disordered breathing (SDB), but achieving adherence remains challenging. We aimed to identify factors associated with PAP adherence in a prospective cohort of children with obesity prescribed PAP for newly diagnosed SDB.

METHODS

A questionnaire to assess factors related to PAP adherence was administered to participants and their parent ≥12 months after enrollment. Adherence (PAP use ≥4 hours/night on >50% of nights) was measured with PAP machine downloads, diaries, and physician assessments. Questionnaire responses were compared between adherent/nonadherent participants and between children/parents. Age, total and obstructive apnea-hypopnea index (OAHI), lowest oxygen saturation, and highest carbon dioxide were compared between adherent/nonadherent children with univariate differences of medians, with 95% confidence intervals.

RESULTS

Fourteen children (median age: 14.3 years; 93% male; all with obstructive sleep apnea) were included. Eleven (79%) were adherent to PAP. SDB symptom improvement was reported in 9 of 14 children (64%); 8 of 14 children (57%) had positive experiences with PAP. Most children assumed an active role in PAP initiation and felt supported by the clinical team. Responses between adherent/nonadherent groups and between children/parents were similar. Oxygen saturation nadir (median difference between nonadherent and adherent groups: 8.9%; 95% confidence interval: 1.7, 16.1), but not age, apnea-hypopnea index, OAHI, or maximum carbon dioxide, was associated with PAP adherence.

CONCLUSIONS

Children with obesity-related SDB with lower nocturnal oxygen saturation nadir were more likely to adhere to PAP therapy. Ensuring adequate understanding of PAP therapy and medical team support are key factors in PAP success.

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.

Clinical side effects of continuous positive airway pressure in patients with obstructive sleep apnoea

CPAP is considered the gold standard treatment in OSA and is highly efficacious in controlling OSA symptoms. However, treatment effectiveness is limited because of many factors including low adherence due to side effects. This review highlights the range of side effects associated with CPAP therapy in patients with OSA. This information is important for the initiation of patients onto CPAP as well as their continued care while on treatment, given the increase in non-medically supervised CPAP care models in use globally.

Sleep Apnea Treatment Considerations in Patients with Comorbidities

A wide range of sleep, psychiatric, and medical comorbidities can present with obstructive sleep apnea (OSA), complicating treatment because of intolerance or low adherence to traditional modalities of therapy. Providers must have heightened awareness of how these comorbidities can affect their patients' OSA and work together as a team to optimize health and well-being in this complex population.

Predictors of adherence to positive airway pressure therapy in children: a systematic review and meta-analysis

BACKGROUND

While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children.

METHODS

Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed.

RESULTS

We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence.

CONCLUSION

In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.

Interfaces, Circuits and Humidifiers

Long-term non-invasive ventilation (LTNIV) has been increasingly used in children to manage chronic respiratory failure and airway obstruction. Interfaces are of paramount importance for non-invasive ventilation (NIV) effectiveness and patient compliance. However, historically, the choice of pediatric mask has been limited by the scarce availability of commercial interfaces. In recent years, an increasing number of different masks have been commercialized for children, allowing to increase the number of patients who could benefit from LTNIV. Factors such as the age of the child, disease, craniofacial conformation, type of ventilator and mode of ventilation, and children's and family's preferences should be taken into account when selecting the appropriate mask. Adverse events such as skin lesions, facial growth impairment, and leaks must be prevented and promptly corrected. Humidification is a controversial issue on NIV, but it may be useful in certain circumstances. Regular cleaning and disinfection of interfaces and equipment must be addressed. During follow-up, educational programs, close supervision, and continuous support to children and families are crucial to the success of LTNIV therapy.

[Quantitative analysis of occlusal changes in posterior partial fixed implant supported prostheses]

OBJECTIVE

To analyze changes in occlusal force distribution and occlusal contact in posterior partial fixed implant-supported prostheses over time, and to provide reference for the precise occlusion design, adjustment and maintenance of implant prostheses.

METHODS

According to certain inclusion and exclusion criteria, patients were recruited from partially edentulous patients who had received implant-supported single crown or fixed bridge in the posterior region. The patients were collected since the implant prostheses settling and scheduled for the routine examination of implant prostheses and the occlusal examinations of complete dentition after 2 weeks, 3, 6, and 12 months. Occlusal examinations were taken with the articulating papers and T-Scan III (Tekscan, South Boston, USA), which could check and measure the occlusal contact condition of complete dentition. The occlusion time and relative occlusal forces of implant prostheses, mesial adjacent teeth and control teeth were recorded at the same time.

RESULTS

Thirty-seven posterior partial fixed implant prostheses in 33 patients (17 women and 16 men, aged 24-70 years) were followed up for 3-12 months (average 8.3 months). At baseline, the relative occlusal forces of implant prostheses were significantly lower than those of the corresponding control teeth (P<0.001). However, after 3 months, the relative occlusal forces of implant prostheses had significantly increased (P<0.05), while control teeth decreased significantly (P<0.05), resulting in no statistical significance between them. The implant prostheses occlusion time ratio also increased significantly from 2 weeks to 3 months (P<0.05). There was no significant difference from the third month to the sixth month, or from the sixth month to the twelfth month (P>0.05).

CONCLUSION

Light contact and time-delayed occlusion of posterior implant prostheses changes significantly in the first three months after settling implant prostheses. These changes mainly include the advance of the time point of the implant prosthesis to start the occlusion contact, and the increase of the occlusal force of the implant prosthesis. The occlusion of posterior implant prostheses should be carefully monitored at end of the third month follow-up clinically.

Updates on management of pediatric obstructive sleep apnea

Obstructive sleep apnea (OSA) affects about 1%-5% of the pediatric population. The consequences of untreated OSA in children include neurocognitive deficits, behavioral problems, poor school performance as well as systemic and pulmonary hypertension. The treatment options for pediatric OSA are numerous with a variety of surgical and non-surgical interventions. As our understanding of the complexities of OSA grows, the options for management have continued to expand as well. The objectives of this review are to describe the commonly prescribed treatments for pediatric OSA including adenotonsillectomy as well as use of positive airway pressure. We also highlight other surgical and non-surgical interventions available. In addition, we provide updates on current research focusing on newer diagnostic and experimental treatment modalities.

Can CPAP Therapy in Pediatric OSA Ever Be Stopped?

STUDY OBJECTIVES

Continuous positive airway pressure (CPAP) has been increasingly used in children with obstructive sleep apnea (OSA), though it is unclear whether it can ever be ceased. We describe the clinical, demographic, and polysomnographic (PSG) characteristics of a cohort of children with OSA who were successfully weaned off CPAP.

METHODS

From a pediatric cohort on CPAP for OSA at the Queensland Children's Hospital between January 2016 and December 2017, a subgroup of children who were taken off CPAP were retrospectively studied.

RESULTS

CPAP therapy was stopped for 53 children over a 2-year period; 29 of these were excluded from analysis due to change to bilevel support (n = 2), transition to adult care (n = 12), or cessation due to poor adherence (n = 15). A total of 24 children [median (interquartile range, IQR) age 4.1 years (1.0-10.5); 18 males] were successfully weaned off CPAP therapy based on improvement in clinical and PSG parameters; and were included in the analysis. These children had a median (IQR) apnea-hypopnea index (AHI) of 9.8 (5.7-46.0) at CPAP initiation, which improved to 3.3 (0.4-2.2) at CPAP cessation after a median (IQR) duration of 1.0 (0.5-2.0) year. The reasons for CPAP cessation included improved symptoms and/or PSG parameters with time (n = 11); improvement after airway surgery (n = 7), and improvement of body mass index (n = 2). In four children, CPAP therapy was ceased after initial trial due to low physician perceived clinical benefit.

CONCLUSIONS

This is the first study describing the characteristics of children and likely reasons for successful CPAP cessation. Children on CPAP should be regularly screened for ongoing CPAP need.

Mask interfaces for home non-invasive ventilation in infants and children

The selection of the mask interface for non-invasive ventilation (NIV) is recognized to be an essential part for therapy success. While nasal masks are the first recommended option in children and adults, there are indications for other mask types such as intolerance or complications from nasal masks. Evidence comparing performance, adherence and complication risk among mask interfaces in pediatrics is, however, scarce and information is often extrapolated from adult studies. Given this gap in knowledge and the lack of guidelines on NIV initiation in children, mask selection often relies on the clinicians' knowledge and expertise. Careful mask selection, a well-fitting headgear and time investment for mask desensitization are some important recommendations for adequate mask adaptation in children. Frequent mask-related complications include nasal symptoms, unintentional leak, mask displacement, skin injury, and midface hypoplasia. Close monitoring and a pro-active approach may help to minimize complications and promote the optimal use of home NIV.