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Abstract

Sleep-disordered breathing in children includes disorders of breathing that affect airway patency e.g. obstructive sleep apnoea (OSA), and also conditions that affect respiratory drive (central sleep disorders) or cause hypoventilation, either as a direct central effect or due to peripheral muscle weakness. OSA is an increasingly-recognised clinical entity affecting up to 5.7% young children. OSA, if left untreated, may be associated with adverse effects on growth and development including adverse cognitive and behavioural outcomes. Evidence also exists to suggest that untreated OSA may impact on later cardiovascular risk. Close attention should be paid to assessing and investigating this relatively common condition. This review deals with the presentation, investigation, management, and sequelae of OSA, as well as providing an overview of the presentation, investigation, management of central apnoea in children.

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... It has been hypothesized that some term infants may still have residual instability of respiratory control resulting in "overshooting" (high loop gain) of ventilation increase as a response to triggers such as hypoxia and arousal. This leads to excessive paCO2 decrease, below apnea threshold, causing apnea while waiting for paCO2 to increase 11 . Infants also have limited lung reserves, making desaturation events quicker and more frequent during an apneic episode. ...
... Infants also have limited lung reserves, making desaturation events quicker and more frequent during an apneic episode. This hypoxia continues the cycle of central apnea 1,11 . ...
... Apnea, bradycardia and oxygen desaturation events in term infants are known to cause significant effects on length of hospital stay, hospital cost and quality of life for the family 12 . Treatment for central apnea in children include pharmacological therapies, supplemental oxygenation and non-invasive or invasive ventilation 4,11 . Supplemental oxygen has been shown to abolish periodic breathing (PB) and reduce central apnea numbers and has the potential of breaking the cycle of central apnea in children by preventing the reactive desaturation 3,11 . ...
Article
Study objectives: To describe the outcomes of central sleep apnea (CSA) requiring home supplemental oxygen therapy in otherwise healthy term infants. Methods: All children <1 year of age undergoing polysomnography (PSG) between 2015-2020 at the Queensland Children's Hospital were retrospectively studied. Children with gestational age <37 weeks, underlying syndrome, cleft palate, those with obstructive apnea-hypopnea index (OAHI) >50% of total apnea-hypopnea index (AHI) or with underlying cardiac or pulmonary parenchymal pathology were excluded. PSG parameters were extracted for periods both on and off supplemental oxygenation. Results: Fifty-two [mean (SD) age at PSG 32.6 (34.7) days; 21F] term infants were included. There was a statistically significant improvement in AHI on supplemental oxygen [Mean (SD) in room air 50.2 (36.3) vs 11.6 (9), p< 0.001 on supplemental oxygen], in both rapid eye movement (REM) and non-rapid eye movement (NREM) sleep, as well as in mean oxygen saturations (96.6% in room air to 98.9% on oxygen; p<0.001). There was no statistically significant change in transcutaneous carbon dioxide levels or sleep duration. Oxygenation was prescribed for a median (interquartile range=IQR) age of 197 (127) days. Conclusions: CSA in term infants who are otherwise healthy generally has a good prognosis, with oxygen therapy prescribed for around six months. Oxygen therapy was associated with improved saturations and decrease in AHI when assessed with PSG.
... Sleep disordered breathing, which includes obstructive sleep apnoea (OSA), has an estimated prevalence of 1e5% [1] and restless legs syndrome/periodic limb movement disorder has an estimated prevalence of 2% [2]. OSA has been associated with impairments of memory, learning, behaviour, growth, quality of life and cardiovascular health [3]. Restless sleep disorders have been shown to result in sleep disruption, impaired cognitive function, reduced mood, and poorer quality of life [4]. ...
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Aim To audit the feasibility and patient experience of home polysomnography (sleep study) for the investigation of a sleep disorder in children. Methods The signal quality and outcomes of a Level 2 (home) polysomnography in young people undergoing investigation between September 2020 and January 2021 in a single centre was reviewed. A successful home polysomnogram was defined as a study with ≥6 h of sleep and all channels (EEG, thoraco-abdominal bands, calculated airflow, and pulse oximetry) present for at least 90% of the study time. Feedback from the guardian and young person was collected following the study using a questionnaire. Results Fifty-five patients, aged 4 months to 18 years, were included. A successful polysomnogram, on the first attempt, was achieved for 48/55 (87%) subjects. There were no differences in success when accounting for neurodevelopmental conditions, OSA severity or age. The majority (76%) of guardians felt that their child slept the same or better than normal and only 12% found having the study conducted at home difficult. Following the study, only 8% would have preferred a hospital sleep study in retrospect. Conclusions Home polysomnography produced a technically adequate study for the majority of subjects. Most families also found the experience of having a home sleep study to be positive. These data support the use of home sleep studies as an alternative to an in-patient sleep study, in appropriate circumstances, for young people undergoing investigation of a sleep disorder.
... Sleep-disordered breathing refers to a group of disorders characterized by abnormalities of respiration or ventilation during sleep [15]. It includes disorders that affect airway patency, e.g., obstructive sleep apnea (OSA) as a result of upper airway obstruction with increased respiratory effort, and also conditions that affect respiratory drive (central sleep apnea) in which there is absence of respiratory effort [16]. SDB can affect the central nervous system (CNS), the cardiovascular system, metabolic systems, and somatic growth, ultimately leading to reduced quality of life and increased disease burden [17]. ...
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Background Sanjad Sakati syndrome (SSS) is a rare autosomal recessive genetic disorder caused by mutation in TBCE (tubulin folding cofactor E) gene. Reported cases were almost exclusively of Middle-Eastern and Arabian children of consanguineous parents. We report the clinical manifestations, outcome, and an observed new association of sleep-disordered breathing (SDB) among children with Sanjad Sakati syndrome.Methods Clinical and routine laboratory data of SSS cases attending Sultan Qaboos University Hospital, Oman, were collected from the electronic patient records or through direct clinic interviews. In-lab polysomnography (PSG) and echocardiography were carried out for all the cases. SDB diagnosis was based on the guidelines of the American Academy of Sleep Medicine.ResultsOf 12 patients with SSS, 5 males (42%), all of them (100%) had obstructive sleep apnea (OSA) and 4 of them (33%) had additional significant central apnea and sleep-related hypoventilation. Eight patients (67%) had severe SDB with mean apnea–hypopnea index (AHI) of 26.5 events/h. Age at time of diagnosis with SDB ranged from 2 to 17 years with mean of 8.9 \(\pm 4.7\mathrm{ years}.\) Two patients had severe pulmonary hypertension as a complication of severe SDB and died from type 2 respiratory failure.Conclusions Sleep-disordered breathing is prevalent among children with SSS, especially OSA. This is the first study to report SDB in a large cohort of patients with this extremely rare syndrome. The study results encourage the importance of screening affected patients with SSS for sleep-disordered breathing early before developing severe morbidities such as pulmonary hypertension that further compromise their quality of life.
... 80 Current evidence suggests that the early recognition (preferably before the age of 5 years) and treatment of BRSD can improve the neurodevelopmental stages in children. 81 In fact, the longer the duration of nonrecognition of BRSD, the worse are the cognitive outcomes. 82 Emotional behaviors are under direct control of amygdala, locus coeruleus, and prefrontal cortex. ...
Chapter
Breathing-related sleep disorders (BRSD) encompass obstructive sleep apnea (OSA), central sleep apnea, and hypoventilation disorders. Risk factors for BRSD include obesity, metabolic dysfunction, smoking, use of respiratory depressant medications (like opiates and benzodiazepines) and alcohol consumption, all of which are highly prevalent among patients with psychiatric disorders. BRSDs are associated with substantial morbidity, disturbed quality of life, and worse prognosis of comorbid psychiatric disorders. Therefore, it is essential for psychiatric care providers to have the clinical skills to recognize BRSDs. Recent studies suggest that the prevalence rates of OSA in psychiatric patients are higher than the general population. Moreover, BRSD’s share common symptoms and risk-factors with psychiatric disorders. A comprehensive clinical approach including a thorough sleep history and examination along with the use of validated screening questionnaires like the STOP-BANG questionnaire, particularly for at-risk patients, is effective in identifying BRSD.
... More specifically, in a general population of children with 6 to 8 years, 10% were affected by SRBD [6]. Further, the prevalence of OSA is about 1% to 6% whilst the prevalence of habitual snoring range from 1% to 27%, in pediatric population [7][8][9][10]. ...
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The aim of this study was to examine the associations of sedentary behaviour, physical activity, cardiorespiratory fitness (CRF), and body composition parameters with risk of sleep-related breathing disorders (SRBD) in children with overweight/obesity. One-hundred and nine children (10.0 ± 1.1 years old, 45 girls) with overweight (n = 27) and obesity (n = 82) were included. Television viewing time was self-reported by using the Spanish adaptation of the “Youth Activity Profile” (YAP) questionnaire. Sedentary time and physical activity were measured with accelerometry. CRF was assessed with the 20-m shuttle-run test and body composition parameters with Dual-energy X-ray absorptiometry. SRBD were evaluated by using the Spanish version of the Pediatric Sleep Questionnaire. Television viewing time was positively associated with risk of SRBD (r = 0.222, p = 0.021). CRF was negatively correlated with risk of SRBD (r = −0.210, p = 0.030). Body composition parameters were positively associated with risk of SRBD (all p < 0.05), except fat mass index. Stepwise regression analyses showed that body mass index (BMI) explained the largest proportion of the variance in SRBD (r2 = 0.063, p = 0.01) and television viewing time was the only one added after BMI (r2 change = 0.048, p = 0.022). This study supports the notion that higher body weight status negatively influences risk of SRBD and adds that unhealthy behaviours could contribute to worsen SRBD, related to an increased risk of cardiovascular diseases. All the significant association observed in this manuscript were of small magnitude, indicating than other factors in addition to the one hereby studied contribute to explain the variance in SRBD.
... 3 Among children, adenotonsillar hypertrophy (ATH) can cause narrowing of the airway, leading to symptoms such as snoring, cessation of breathing and sleep fragmentation. 4 This in turn reduces oxygen delivery to the terminal alveoli, thus affecting the gas exchange process and leading to tissue hypoxia. 5 The neuropsychological sequelae of childhood OSA may include compromised cognitive, emotional and social function. 6,7 An adenotonsillectomy (AT) is considered the first line of treatment for paediatric OSA. ...
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Objectives: This study aimed to evaluate cognitive and behavioural changes among 9–14-year-old Omani children with obstructive sleep apnoea (OSA) after an adenotonsillectomy (AT). Methods: This naturalistic observational study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2012 and December 2014. Omani children with adenotonsillar hypertrophy (ATH) underwent overnight polysomnography and those with confirmed OSA were scheduled for an AT. Cognitive and behavioural evaluations were performed using standardised instruments at baseline prior to the procedure and three months afterwards. Results: A total of 37 children were included in the study, of which 24 (65%) were male and 13 (35%) were female. The mean age of the males was 11.4 ± 1.9 years, while that of the females was 11.1 ± 1.5 years. Following the AT, there was a significant reduction of 56% in mean apnoea-hypopnoea index (AHI) score (2.36 ± 4.88 versus5.37 ± 7.17; P <0.01). There was also a significant positive reduction in OSA indices, including oxygen desaturation index (78%), number of desaturations (68%) and number of obstructive apnoea incidents (74%; P <0.01 each). Significant improvements were noted in neurocognitive function, including attention/concentration (42%), verbal fluency (92%), learning/recall (38%), executive function (52%) and general intellectual ability (33%; P <0.01 each). There was a significant decrease of 21% in both mean inattention and hyperactivity scores (P <0.01 each). Conclusion: These results demonstrate the effectiveness of an AT in improving cognitive function and attention deficit hyperactivity disorder-like symptoms among children with ATH-caused OSA. Such changes can be observed as early as three months after the procedure.
... 3 Among children, adenotonsillar hypertrophy (ATH) can cause narrowing of the airway, leading to symptoms such as snoring, cessation of breathing and sleep fragmentation. 4 This in turn reduces oxygen delivery to the terminal alveoli, thus affecting the gas exchange process and leading to tissue hypoxia. 5 The neuropsychological sequelae of childhood OSA may include compromised cognitive, emotional and social function. 6,7 An adenotonsillectomy (AT) is considered the first line of treatment for paediatric OSA. ...
Objectives: This study aimed to evaluate cognitive and behavioural changes among 9-14-year-old Omani children with obstructive sleep apnoea (OSA) after an adenotonsillectomy (AT). Methods: This naturalistic observational study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2012 and December 2014. Omani children with adenotonsillar hypertrophy (ATH) underwent overnight polysomnography and those with confirmed OSA were scheduled for an AT. Cognitive and behavioural evaluations were performed using standardised instruments at baseline prior to the procedure and three months afterwards. Results: A total of 37 children were included in the study, of which 24 (65%) were male and 13 (35%) were female. The mean age of the males was 11.4 ± 1.9 years, while that of the females was 11.1 ± 1.5 years. Following the AT, there was a significant reduction of 56% in mean apnoea-hypopnoea index (AHI) score (2.36 ± 4.88 versus 5.37 ± 7.17; P <0.01). There was also a significant positive reduction in OSA indices, including oxygen desaturation index (78%), number of desaturations (68%) and number of obstructive apnoea incidents (74%; P <0.01 each). Significant improvements were noted in neurocognitive function, including attention/concentration (42%), verbal fluency (92%), learning/recall (38%), executive function (52%) and general intellectual ability (33%; P <0.01 each). There was a significant decrease of 21% in both mean inattention and hyperactivity scores (P <0.01 each). Conclusion: These results demonstrate the effectiveness of an AT in improving cognitive function and attention deficit hyperactivity disorder-like symptoms among children with ATH-caused OSA. Such changes can be observed as early as three months after the procedure.
Article
Background: The prevalence of sleep disordered breathing in children is underestimated due to impediments in detection and diagnosis. Consequently, delayed management may affect the quality of life, and the growth and development of a child. Due to their patient demographic, Orthodontists are optimally positioned to identify those at risk of sleep disordered breathing and make referrals for investigation and management. This study aims to determine the prevalence of children at risk of sleep disordered breathing in an Australian orthodontic population. Methods: A 1 year retrospective study was conducted in an urban Western Australian private orthodontic practice with two branches in similar socioeconomic demographics. The responses of new patients to a modified paediatric sleep questionnaire and standard medical history form were recorded. Results: In 1209 patients (4-18 years), 7.3% were at risk of sleep disordered breathing. An association between sex and the potential risk of sleep disordered breathing was found with 11% of males at risk of sleep disordered breathing compared to 7% of females (p=0.012). Conclusions: The relatively high prevalence of children at risk of sleep disordered breathing presenting for orthodontic care presents an opportunity to identify at risk individuals through routine use of the paediatric sleep questionnaire. This would facilitate early referral for diagnosis and management of sleep disordered breathing. © 2022 Australian Dental Association.
Article
According to the importance of management of obstructive sleep apnea syndrome by otolaryngologists, this study was designed to investigate knowledge, attitudes and practice of junior and senior residents of otolaryngology and evaluate the effect of current residency training program on choosing the first lines of treatment. A total of 110 residents of otolaryngology were selected. Our study tools were obstructive sleep apnea knowledge and attitudes (OSAKA and OSAKA-KIDS) questionnaires. The participants were classified as junior and senior. Senior residents had significantly higher total knowledge score for OSAKA based on independent t test (12.73 Vs. 10.52). No significant difference was observed for OSAKA-KIDS (11.31 Vs. 10.69). The most frequent choice for the first line was CPAP (63.8%) and weight loss (41.5%) among junior and senior residents, respectively. Although the knowledge of otolaryngology residents increased during their program, the choice of first line treatment in obstructive sleep apnea was different between junior and senior residents. We found a need for further multidisciplinary education for residents especially in the management of sleep apnea particularly toward CPAP usage and this syndrome in pediatrics.
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Background: Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. Methods: We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. Results: The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). Conclusions: As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).
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This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS). The literature from 1999 through 2011 was evaluated. A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.
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This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. Of 3166 articles from 1999-2010, 350 provided relevant data. Most articles were level II-IV. The resulting evidence report was used to formulate recommendations. The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.
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The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined. To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS. A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI). Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children. AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.
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Sleep has been identified as a state that optimizes the consolidation of newly acquired information in memory, depending on the specific conditions of learning and the timing of sleep. Consolidation during sleep promotes both quantitative and qualitative changes of memory representations. Through specific patterns of neuromodulatory activity and electric field potential oscillations, slow-wave sleep (SWS) and rapid eye movement (REM) sleep support system consolidation and synaptic consolidation, respectively. During SWS, slow oscillations, spindles and ripples - at minimum cholinergic activity - coordinate the re-activation and redistribution of hippocampus-dependent memories to neocortical sites, whereas during REM sleep, local increases in plasticity-related immediate-early gene activity - at high cholinergic and theta activity - might favour the subsequent synaptic consolidation of memories in the cortex.
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Sleep Disordered Breathing (SDB) is a common childhood disorder that encompasses a range of sleep-related upper airway obstruction. Children with SDB demonstrate significant neurocognitive deficits. Adenotonsillectomy is the first line of treatment for SDB and whilst this improves respiratory disturbance, it remains to be established whether neurocognitive gains also result. A total of 44 healthy snoring children aged 3-12 years awaiting adenotonsillectomy (SDB group), and 48 age and gender matched non-snoring controls from the general community, completed the study. All children underwent polysomnography and neurocognitive assessment at baseline and after a 6-month follow-up (after surgery in the snoring group). Our primary aim was to determine whether neurocognitive deficits in snoring children were significantly improved following adenotonsillectomy. Wide ranging neurocognitive deficits were found at baseline in SDB children compared to controls, most notably a 10 point IQ difference (P<.001) and similar deficits in language and executive function. Whilst adenotonsillectomy improved respiratory parameters and snoring frequency at 6 months post surgery, neurocognitive performance did not improve relative to controls. Adenotonsillectomy successfully treated the respiratory effects of SDB in children. However, neurocognitive deficits did not improve 6-months post-operatively.
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During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a ‘concise, accurate and helpful document’. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.
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To determine whether primary snoring (PS) could be distinguished from childhood obstructive sleep apnea syndrome (OSAS) by clinical history. Retrospective study of clinical history of 83 children with snoring and/or sleep disordered breathing who were referred for polysomnography. Tertiary referral center; pediatric pulmonary sleep apnea clinic. We evaluated the ability of a clinical obstructive sleep apnea (OSA) score and other questions about sleep, breathing, and daytime symptoms to distinguish PS from OSAS in children. Parents were asked about the child's snoring, difficulty breathing, observed apnea, cyanosis, struggling to breathe, shaking the child to "make him or her breathe," watching the child sleep, afraid of apnea, the frequency and loudness of snoring, and daytime symptoms such as excessive daytime sleepiness (EDS). Based on polysomnography results, 48 patients were classified as PS and 35 as OSAS. Peak endtidal CO2 (49 +/- 3.2 vs 55 +/- 8.2 [SD] mm Hg); lowest arterial oxygen saturation measured by pulse oximetry (95 +/- 1.9 vs 82 +/- 14%); and apnea/hypopnea index (0.27 +/- .3 vs 8.4 +/- 6 events/h) indicated that the diagnostic criteria for PS versus OSA were reasonable. There were no differences between PS and OSA patients with respect to age, sex, race, failure to thrive, obesity, history of EDS, snoring history, history of cyanosis during sleep, or daytime symptoms except for mouth breathing. There were no significant differences in sleep variables between PS patients and those with any severity of OSAS. The OSA score misclassified about one of four patients. Comparing PS and OSA patients, significant findings were daytime mouth breathing (61 vs 85%; p = 0.024); observed apnea (46 vs 74%; p = 0.013); shaking the child (31 vs. 60%; p = 0.01); struggling to breathe (58 vs 89%; p = 0.003); and afraid of apnea (71 vs 91%; p = 0.028). However, none of these were sufficiently discriminatory to predict OSAS. We conclude that PS in children cannot be reliably distinguished from OSAS by clinical history alone.
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To assess the prevalence of sleep-disordered breathing in a nonselected group of children with Down syndrome and to determine significant predisposing factors for this condition. Prospective study. Tertiary care university hospital in Madrid, Spain. The study population included 108 consecutive children with Down syndrome (mean [SD] age, 7.9 [4.5] years; range, 1-18 years) independently of whether or not suggestive clinical features of sleep-disordered breathing were present. In addition to history, physical examination, and lateral radiographs of the nasopharynx, all participants underwent an overnight cardiorespiratory polygraphy at the hospital using a portable ambulatory device (Apnoescreen II plus). An apnea-hypopnea index of at least 3 was required for defining the presence of sleep-disordered breathing. The prevalence of sleep-disordered breathing was 54.6%, with a significantly higher prevalence in boys (64.7%) than in girls (38.5%) (P < .05). The group with sleep-disordered breathing was significantly younger (6.4 [3.9] years) than those with normal polysomnographic recordings (9.6 [4.6] years) (P < .001). In the multivariate analysis, age (less than 8 years old) (odds ratio [OR], 3.36; 95% confidence interval [CI], 1.40, 8.06); male sex (OR, 3.32; 95% CI, 1.32, 8.12); and tonsillar hyperplasia (OR, 5.24; 95% CI, 1.52, 19.03) were significantly associated with sleep-disordered breathing. Body mass index, adenoid hyperplasia, previous tonsillectomy or adenoidectomy, congenital heart disease, malocclusion, and macroglossia did not affect the prevalence of sleep-disordered breathing. The prevalence of sleep-disordered breathing in children with Down syndrome is very high, particularly in boys. Tonsillar hyperplasia may play a role in the pathophysiology of sleep-disordered breathing in these patients. Adenoid hyperplasia, obesity, and congenital heart disease were not important risk factors for sleep-disordered breathing.
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To assess whether sleep-disordered breathing (SDB), ranging from primary snoring to obstructive sleep apnea (OSA), is associated with increased behavioral morbidity. A cross-sectional study was conducted of school-aged children in an urban, community-based cohort, stratified for term or preterm (<37 weeks' gestation) birth status. A total of 829 children, 8 to 11 years old (50% female, 46% black, 46% former preterm birth) were recruited from a cohort study. All children had unattended in-home overnight cardiorespiratory recordings of airflow, respiratory effort, oximetry, and heart rate for measurement of the apnea hypopnea index (number of obstructive apneas and hypopneas per hour). SDB was defined by either parent-reported habitual snoring or objectively measured OSA. Functional outcomes were assessed with 2 well-validated parent ratings of behavior problems: the Child Behavioral Checklist and the Conners Parent Rating Scale-Revised:Long. Forty (5%) children were classified as having OSA (median apnea hypopnea index: 7.1 per hour; interquartile range: 3.1-10.5), 122 (15%) had primary snoring without OSA, and the remaining 667 (80%) had neither snoring nor OSA. Children with SDB had significantly higher odds of elevated problem scores in the following domains: externalizing, hyperactive, emotional lability, oppositional, aggressive, internalizing, somatic complaints, and social problems. Children with relatively mild SDB, ranging from primary snoring to OSA, have a higher prevalence of problem behaviors, with the strongest, most consistent associations for externalizing, hyperactive-type behaviors.
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Most children with sleep-disordered breathing (SDB) have mild-to-moderate forms, for which neurobehavioral complications are believed to be the most important adverse outcomes. To improve understanding of this morbidity, its long-term response to adenotonsillectomy, and its relationship to polysomnographic measures, we studied a series of children before and after clinically indicated adenotonsillectomy or unrelated surgical care. We recorded sleep and assessed behavioral, cognitive, and psychiatric morbidity in 105 children 5.0 to 12.9 years old: 78 were scheduled for clinically indicated adenotonsillectomy, usually for suspected SDB, and 27 for unrelated surgical care. One year later, we repeated all assessments in 100 of these children. Subjects who had an adenotonsillectomy, in comparison to controls, were more hyperactive on well-validated parent rating scales, inattentive on cognitive testing, sleepy on the Multiple Sleep Latency Test, and likely to have attention-deficit/hyperactivity disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) as judged by a child psychiatrist. In contrast, 1 year later, the 2 groups showed no significant differences in the same measures. Subjects who had an adenotonsillectomy had improved substantially in all measures, and control subjects improved in none. However, polysomnographic assessment of baseline SDB and its subsequent amelioration did not clearly predict either baseline neurobehavioral morbidity or improvement in any area other than sleepiness. Children scheduled for adenotonsillectomy often have mild-to-moderate SDB and significant neurobehavioral morbidity, including hyperactivity, inattention, attention-deficit/hyperactivity disorder, and excessive daytime sleepiness, all of which tend to improve by 1 year after surgery. However, the lack of better correspondence between SDB measures and neurobehavioral outcomes suggests the need for better measures or improved understanding of underlying causal mechanisms.
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To further validate a questionnaire about symptoms of childhood obstructive sleep apnea (OSA) and to compare the questionnaire with polysomnography in their ability to predict outcomes of adenotonsillectomy. Retrospective analysis of data from a longitudinal study. University-based sleep disorders laboratory. The Washtenaw County Adenotonsillectomy Cohort, comprising 105 children aged 5.0 to 12.9 years at entry. Intervention Parents completed the 22-item Sleep-Related Breathing Disorder (SRBD) scale of the Pediatric Sleep Questionnaire, and children underwent polysomnography before and 1 year after clinically indicated adenotonsillectomy (n = 78, usually for suspected OSA) or unrelated surgical care (n = 27). Findings from commonly used hyperactivity ratings, attention tests, and sleepiness tests. At baseline, a high SRBD scale score (1 SD above the mean) predicted an approximately 3-fold increased risk of OSA on polysomnography (odds ratio, 2.80; 95% confidence interval, 1.68-4.68). One year later, OSA and symptoms had largely resolved, but a high SRBD score still predicted an approximately 2-fold increased risk of residual OSA on polysomnography (odds ratio, 1.89; 95% confidence interval, 1.13-3.18). Compared with several standard polysomnographic measures of OSA, the baseline SRBD scale better predicted initial hyperactivity ratings and 1-year improvement, similarly predicted sleepiness and its improvement, and similarly failed to predict attention deficit or its improvement. The SRBD scale predicts polysomnographic results to an extent useful for research but not reliable enough for most individual patients. However, the SRBD scale may predict OSA-related neurobehavioral morbidity and its response to adenotonsillectomy as well or better than does polysomnography.
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Study objectives To measure the accuracy and reliability of a portable home oximetry monitor with an automated analysis for the diagnosis of obstructive sleep apnea (OSA) in children. Design Prospective cohort study. Setting Alberta Lung Association Sleep Center, Alberta Children’s Hospital Sleep Clinic. Study subjects Consecutive, otherwise healthy children, aged 4 to 18 years, presenting to the Pediatric Sleep Service at the Alberta Children’s Hospital for assessment of possible OSA. Interventions All subjects underwent 2 nights of monitoring in the home with an oximetry-based portable monitor with an automatic internal scoring algorithm. A third night of monitoring was done simultaneously with computerized laboratory polysomnography according to American Thoracic Society guidelines. Measurements and results Both test-retest reliability of the portable monitor-based desaturation index (DI) between 2 nights at home and between laboratory and home were high using the Bland and Altman analysis (mean agreement, 0.32 and 0.64; limits of agreement, − 8.00 to 8.64 and − 0.75 to 6.50, respectively). The polysomnographic apnea-hypopnea index (AHI) agreed poorly with the portable monitor DI (mean difference, 1.27; limits of agreement, − 12.02 to 15.02). The sensitivity and specificity of the monitor for the identification of moderate sleep apnea (polysomnography AHI > 5/h) were 67% and 60%, respectively. Conclusion Portable monitoring based only on oximetry alone is not adequate for the identification of OSA in otherwise healthy children.
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Sleep disorders are very common in childhood and are often amenable to simple advice and parental education. Questions about sleep should be an integral part of every paediatric consultation. Children with underlying syndromes or complex medical conditions often have multiple sleep issues. Excessive sleepiness in children requires careful history-taking and consideration of specialised investigation. Obstructive sleep apnoea (OSA) is a common condition in childhood with important health implications. The high prevalence of OSA warrants rigorous attempts to identify children at higher risk and manage them appropriately. Adenotonsillectomy is a highly efficacious therapy for paediatric OSA. A current major issue is to improve ways of distinguishing mild from severe OSA before a child undergoes adenotonsillectomy, as those with more severe disease are at increased risk of postoperative complications and should undergo adenotonsillectomy in a tertiary centre. Children with obesity and other comorbid conditions are at increased risk of persisting OSA despite adenotonsillectomy. Topical (nasal) steroids and/or anti-inflammatory agents have a role in the non-surgical treatment of mild OSA. Continuous positive airway pressure and orthodontic interventions are treatment options for treatment of persisting OSA in children.
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Background: Obstructive sleep apnea (OSA) is characterized by partial or complete upper airway obstruction during sleep. Approximately 1% to 4% of children are affected by OSA, with adenotonsillar hypertrophy the most common underlying risk factor. Surgical removal of enlarged tonsils and adenoids is the most commonly used treatment for OSA. Given the perioperative risk of the intervention and an estimated recurrence rate of up to 20%, there has recently been an increased interest in non-surgical treatment modalities. As the enlarged adenoids and tonsils consist of hypertrophied lymphoid tissue, anti-inflammatory agents have been proposed as a useful non-invasive treatment option in children with OSA. Objectives: To assess the efficacy of anti-inflammatory drugs for the treatment of OSA in children. Search strategy: We identified trials using searches of the Cochrane Airways Group Specialized Register, MEDLINE (1950 to 2010), EMBASE (1988 to 2010), CINAHL (1982 to 2010), CENTRAL (1964 to 2010), Web of Science (1900 to 2010), LILACS (1982 to 2010) and International Pharmaceutical Abstracts (IPA) (1970 to 2010). Selection criteria: Randomized controlled trials (RCTs) comparing anti-inflammatory drugs against placebo, other anti-inflammatory drugs, or other treatment in children between one and 16 years with objectively diagnosed OSA (Apnea Hypopnea Index (AHI) ≥ 1/hour (h)). Data collection and analysis: Both authors independently performed data extraction and quality assessment. It was not possible to combine data from the included studies; we summarized data in a narrative fashion. Main results: We included three RCTs. The first study was a six-week parallel-group trial (25 participants, mean age 3.8 years, mean AHI 10.8/h) of intranasal fluticasone versus placebo showed a statistically significant effect of the drug on improving the AHI. The second study compared intranasal budesonide with placebo in a six-week cross-over trial (62 participants, mean age 8.2 years, mean AHI 3.7/h). The authors reported an advantage of the drug over placebo in reducing the AHI. However, the patients were not analyzed as randomized so the result must be interpreted with caution. No valid group comparisons were reported for the third trial (30 participants, oral montelukast versus placebo in a 12-week parallel-group trial), which has so far only been published as an abstract. Authors' conclusions: A single small study has found a short-term beneficial effect on the AHI in children with mild to moderate OSA. However, long-term safety and efficacy data are not available yet. Further RCTs are needed to evaluate anti-inflammatory drugs for OSA in children.
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Recurrent apnoea is common in preterm infants, particularly at very early gestational ages. These episodes of ineffective breathing can lead to hypoxaemia and bradycardia that may be severe enough to require the use of positive pressure ventilation. Methylxanthines (such as caffeine, theophylline or aminophylline) have been used to stimulate breathing and reduce apnoea and its consequences. To determine the effects of methylxanthine treatment on the incidence of apnoea and the use of intermittent positive pressure ventilation (IPPV) and other clinically important outcomes in preterm infants with recurrent apnoea. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2010), the Oxford Database of Perinatal Trials, MEDLINE (1966 to June 2010), EMBASE (1982 to June 2010), previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal hand searching mainly in the English language. All trials utilizing random or quasi-random patient allocation in which methylxanthine (theophylline, caffeine or aminophylline) as treatment for apnoea was compared with placebo or no treatment for apnoea in preterm infants were included. Methodological quality was assessed independently by the review authors. Data were extracted independently by the review authors. Analysis was done in accordance with the recommendations of the Cochrane Neonatal Review Group. Six trials reported on the effect of methylxanthine in the treatment of apnoea (three trials of theophylline and three trials of caffeine). Five trials that enrolled a total of 192 preterm infants with apnoea evaluated short term outcomes; in these studies, methylxanthine therapy led to a reduction in apnoea and use of IPPV in the first two to seven days. The post-hoc analysis of the large CAP Trial comparing caffeine to control in a subgroup of infants being treated for apnoea reported significantly reduced rates of PDA ligation; postmenstrual age at last oxygen treatment, last endotracheal tube use, last positive pressure ventilation; and reduced chronic lung disease at 36 weeks. Methylxanthine is effective in reducing the number of apnoeic attacks and the use of mechanical ventilation in the two to seven days after starting treatment. Caffeine is also associated with better longer term outcomes. In view of its lower toxicity, caffeine would be the preferred drug for the treatment of apnoea.
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To determine if adeno-tonsillectomy (T&A) in children with Down syndrome (DS) improves breathing, measured by apnea hypopnea index (AHI), rapid eye movement AHI (REM-AHI) and the lowest oxygen desaturation (SaO2), and sleep disruption, measured by arousal index (ArI) and time spent in stages 1-4 and rapid eye movement (REM) sleep and compare these results with a group of non-DS children with obstructive sleep apnea (OSA). Retrospective chart review at pediatric sleep center. Eleven DS and nine non-DS children underwent pre- and post-T&A polysomnography between 1997 and 2005. Pre- and post-T&A polysomnography parameters were compared using paired t-test and independent samples test. Mean age in DS group was 101 months and non-DS group was 80 months (64% males in DS and 88% in non-DS group). The average BMI was 29.8 and 27.6 for DS and non-DS group. The total AHI showed significant improvement after T&A but this was not as marked as the non-DS group. REM-AHI and lowest SaO2 did not show significant change in the DS children. The non-DS group showed significant improvement in all respiratory parameters. Both groups showed mild improvement in sleep parameters. With the modest overall improvement, 27% of the DS children required no further treatment. However, 73% required CPAP, BiPAP or oxygen for persistent OSA. This study supports the fact that T&A in DS children improves some parameters of OSA, however not as markedly as in non-DS children.
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To assess the impact of sleep-associated gas exchange abnormalities (SAGEA) on school academic performance in children. Prospective study. Urban public elementary schools. Two hundred ninety-seven first-grade children whose school performance was in the lowest 10th percentile of their class ranking. Children were screened for obstructive sleep apnea syndrome at home using a detailed parental questionnaire and a single night recording of pulse oximetry and transcutaneous partial pressure of carbon dioxide. If SAGEA was diagnosed, parents were encouraged to seek medical intervention for SAGEA. School grades of all participating children for the school year preceding and after the overnight study were obtained. SAGEA was identified in 54 children (18.1%). Of these, 24 underwent surgical tonsillectomy and adenoidectomy (TR), whereas in the remaining 30 children, parents elected not to seek any therapeutic intervention (NT). Overall mean grades during the second grade increased from 2.43 +/- 0.17 (SEM) to 2.87 +/- 0.19 in TR, although no significant changes occurred in NT (2.44 +/- 0.13 to 2.46 +/- 0.15). Similarly, no academic improvements occurred in children without SAGEA. SAGEA is frequently present in poorly performing first-grade students in whom it adversely affects learning performance. The data suggest that a subset of children with behavioral and learning disabilities could have SAGEA and may benefit from prospective medical evaluation and treatment.
Article
To determine the utility of pulse oximetry for diagnosis of obstructive sleep apnea (OSA) in children. We performed a cross-sectional study of 349 patients referred to a pediatric sleep laboratory for possible OSA. A mixed/obstructive apnea/hypopnea index (MOAHI) greater than or equal to 1 on nocturnal polysomnography (PSG) defined OSA. A sleep laboratory physician read nocturnal oximetry trend and event graphs, blinded to clinical and polysomnographic results. Likelihood ratios were used to determine the change in probability of having OSA before and after oximetry results were known. Of 349 patients, 210 (60%) had OSA as defined polysomnographically. Oximetry trend graphs were classified as positive for OSA in 93 and negative or inconclusive in 256 patients. Of the 93 oximetry results read as positive, PSG confirmed OSA in 90 patients. A positive oximetry trend graph had a likelihood ratio of 19.4, increasing the probability of having OSA from 60% to 97%. The median MOAHI of children with a positive oximetry result was 16.4 (7.5, 30.2). The 3 false-positive oximetry results were all in the subgroup of 92 children who had diagnoses other than adenotonsillar hypertrophy that might have affected breathing during sleep. A negative or inconclusive oximetry result had a likelihood ratio of.58, decreasing the probability of having OSA from 60% to 47%. Interobserver reliability for oximetry readings was very good to excellent (kappa =.80). In the setting of a child suspected of having OSA, a positive nocturnal oximetry trend graph has at least a 97% positive predictive value. Oximetry could: 1) be the definitive diagnostic test for straightforward OSA attributable to adenotonsillar hypertrophy in children older than 12 months of age, or 2) quickly and inexpensively identify children with a history suggesting sleep-disordered breathing who would require PSG to elucidate the type and severity. A negative oximetry result cannot be used to rule out OSA.
Article
To measure the accuracy and reliability of a portable home oximetry monitor with an automated analysis for the diagnosis of obstructive sleep apnea (OSA) in children. Prospective cohort study. Alberta Lung Association Sleep Center, Alberta Children's Hospital Sleep Clinic. Study subjects: Consecutive, otherwise healthy children, aged 4 to 18 years, presenting to the Pediatric Sleep Service at the Alberta Children's Hospital for assessment of possible OSA. All subjects underwent 2 nights of monitoring in the home with an oximetry-based portable monitor with an automatic internal scoring algorithm. A third night of monitoring was done simultaneously with computerized laboratory polysomnography according to American Thoracic Society guidelines. Both test-retest reliability of the portable monitor-based desaturation index (DI) between 2 nights at home and between laboratory and home were high using the Bland and Altman analysis (mean agreement, 0.32 and 0.64; limits of agreement, - 8.00 to 8.64 and - 0.75 to 6.50, respectively). The polysomnographic apnea-hypopnea index (AHI) agreed poorly with the portable monitor DI (mean difference, 1.27; limits of agreement, - 12.02 to 15.02). The sensitivity and specificity of the monitor for the identification of moderate sleep apnea (polysomnography AHI > 5/h) were 67% and 60%, respectively. Portable monitoring based only on oximetry alone is not adequate for the identification of OSA in otherwise healthy children.
The memory function of sleep
  • S Diekelmann
  • J Born
Diekelmann S, Born J. The memory function of sleep. Nat Rev Neurosci 2010; 11: 114e26.