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Screening for obstructive sleep apnoea (OSA) in children—methodological considerations
Abstract
Despite the fact that approximately 1 to 4% of all children suffer from obstructive sleep apnoea (OSA), there are some uncertainties regarding the usefulness and procedures of screening for this condition. This narrative review sums up important and screening-related aspects of OSA and discuss screening procedures with regard to methodological aspects.
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Objectives
Drug‐induced sleep endoscopy (DISE) involves assessment of the upper airway using a flexible endoscope while patients are in a pharmacologically‐induced sleep‐like state. The aim of this article is to review the current literature regarding the role of DISE in children with obstructive sleep apnea (OSA). The indications, typical anesthetic protocol, comparison to other diagnostic modalities, scoring systems, and outcomes are discussed.
Methods
A comprehensive review of literature regarding pediatric DISE up through May 2017 was performed.
Results
DISE provides a thorough evaluation of sites of obstruction during sedation. It is typically indicated for children with persistent OSA after tonsillectomy, those with OSA without tonsillar hypertrophy, children with risk factors predisposing then to multiple sites of obstruction, or when sleep‐state dependent laryngomalacia is suspected. The dexmedotomidine and ketamine protocol, which replicates non‐REM sleep, appears to be safe and is often used for pediatric DISE, although propofol is the most commonly employed agent for DISE in adults. Six different scoring systems (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) have been used to report pediatric DISE findings, but none is universally accepted.
Conclusions
DISE is a safe and useful technique to assess levels of obstruction in children. There is currently no universally‐accepted anesthetic protocol or scoring system for pediatric DISE, but both will be necessary in order to provide a consistent method to report findings, enhance communication among providers and optimize surgical outcomes.
Level of Evidence
N/A.
Background: Tonsillectomy rates vary considerably among different states, regions, and times. This study was conducted to identify the prevalence of “chronic” tonsillitis, peritonsillar abscess, hypertrophy of the tonsils with and without adenoids in absolute and relative numbers in an 80 million people nation. Moreover, the number and rates of different surgical procedures to resolve either “chronic” tonsillitis, peritonsillar abscess, or upper airway obstruction due to (adeno)tonsillar hypertrophy over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy, abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was calculated and analyzed in relation to age and gender.
Material and methods: Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013.
Results: The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142,574 (in 2000) to 87,624 in 2013 (38.5%). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833,896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120,993 in 2006 to 84,332 procedures in 2013 (30.3%). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10,000 in 2010 to 58.68 per 10,000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10,000 to 10.90 per 10,000. In contrast, an increasing number of tonsillotomies was observed between 2007 (4,659 procedures) and 2013 (11,493). The cumulated number of procedures was 59,049. A constant number of 15,000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100,000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to the transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced in 5.98% of all patients after 245,721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06% vs. 7.02%). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only.
Conclusion: Chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continually, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (>10 years). The study reveals a dramatic change mandating further surveillance in insurance companies and authorities in the national health system of an 80 million people nation. (Tab. 1)
Tonsil surgery to address upper airway obstruction in children can be performed either as a tonsillectomy (TE) or as a tonsillotomy/intracapsular/partial tonsillectomy (TT). The advantage of TT is a decreased risk of postoperative morbidity. The disadvantage is the risk of tonsil regrowth with recurrence of symptoms and/or problems with future tonsil infections, which may demand a reoperation of the tonsils. The aim of this study is to compare the risk of reoperation of the tonsils following TE and TT in children with tonsil-related upper airway obstruction. This is a retrospective register-based cohort study of the Swedish National Patient Register. All children aged 1–12 years who underwent TE or TT from 2007 to 2012 for the main indication of upper airway obstruction were included in the study. The unique Personal Identity numbers were used to follow patients over time in the register and identify additional tonsil surgery. A total of 27,535 patients were included in the study, contributing 76,054 person-years of follow-up. A total of 684 patients (2.5 %) underwent a second tonsil surgery during follow-up. The incidences of reoperation were 1.94 per 1000 person-years in the TE group and 16.34 per 1000 person-years in the TT group. The risk for reoperation was seven times higher (HR 7.16) after TT compared to TE. Younger age was significantly associated with reoperation for both TE and TT and the difference in risk between TE and TT gradually decreased with time. The most common indication for reoperation after both TE and TT was “Upper airway obstruction”.
Tonsillotomy has gained popular acceptance as an alternative to the traditional tonsillectomy in the management of sleep-disordered breathing in children. Many studies have evaluated the outcomes of the two techniques, but uncertainty remains with regard to the efficacy and complications of tonsillotomy versus a traditional tonsillectomy. This study was designed to investigate the efficacy and complications of tonsillotomy versus tonsillectomy, in terms of the short- and long-term results.
We collected data from electronic databases including MEDLINE, EMBASE, and the Cochrane Library. The following inclusion criteria were applied: English language, children, and prospective studies that directly compared tonsillotomy and tonsillectomy in the management of sleep disordered breathing. Subgroup analysis was then performed.
In total, 10 eligible studies with 1029 participants were included. Tonsillotomy was shown to be advantageous over tonsillectomy in short-term measures, such as a lower hemorrhage rate, shorter operation time, and faster pain relief. In long-term follow-up, there was no significant difference in resolution of upper-airway obstructive symptoms, the quality of life, or postoperative immune function between the tonsillotomy and tonsillectomy groups. The risk ratio of SDB recurrence was 3.33 (95% confidence interval = 1.62 6.82, P = 0.001), favoring tonsillectomy at an average follow-up of 31 months.
Tonsillotomy may be advantageous over tonsillectomy in the short term measures and there are no significant difference of resolving obstructive symptoms, quality of life and postoperative immune function. For the long run, the dominance of tonsillotomy may be less than tonsillectomy with regard to the rate of sleep-disordered breathing recurrence.
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.).
To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with snoring - sleep disordered breathing (S-SDB).
Prospective agreement diagnostic study on retrospective data.
We conducted an inter-and intra-rater agreement study on video documentations of SNP performed on children (non-syndromic, complex, or operated upon) who presented with S-SDB. The videos featured various pharyngeal findings (normal, collapse, mixed or obstruction). Three ‘non-expert’ raters at various stages in their otolaryngological careers rated the videos independently, and on two separate occasions following an instructional session. We calculated both weighted and non-weighted linear kappa.
Each independent observer rated sixty-one videos (2 weeks apart). Intra-observer agreement was 0.64 ± 0.08 (95% CI 0.48-0.81), 0.74 ± 0.07 (95% CI 0.60-0.88), 0.59 ± 0.08 (95% CI 0.43-0.74), for raters 1, two and three. Weighted kappa was 0.6 ± 0.1 (95% CI 0.41-0.79), 0.8 ± 0.06 (95% CI 0.7-0.92), 0.7 ± 0.07 (95% CI 0.57-0.83), respectively. Inter-rater agreements between raters one and two, two and three, three and four were 0.83 ± 0.06 (95% CI 0.71-0.95), 0.52 ± 0.08 (95% CI 0.36-0.70), and 0.53 ± 0.08 (95% CI 0.37-0.69), respectively. Weighted kappa was 0.83 ± 0.073 (95% CI 0.69-0.98), 0.68 ± 0.06 (95% CI 0.56-0.79), and 0.64 ± 0.07 (95% CI 0.49-0.78), respectively.
This is the first validation of pharyngeal findings on SNP in children. It is based on a four types’ classification. Overall reproducibility amongst the three raters and their agreement was moderate to good. Further work should be phase four trials investigating the impact on outcome.
Schlafstörungen und schlafassoziierte Störungen stellen im Kindesalter ein häufiges Problem dar. Die Zuweisung an ein pädiatrisches Schlaflabor wie auch die Diagnostik und Einleitung von Therapiemaßnahmen werden uneinheitlich gehandhabt. In diesem Konsensuspapier werden daher Empfehlungen formuliert, wann pädiatrische Patienten einem Kinderschlaflabor zugewiesen werden sollten und welche Voruntersuchungen notwendig sind. Des Weiteren wird erläutert, für wie viele Nächte der Patient untersucht und welche Parameter ermittelt werden sollten.
Die Polysomnographie (PSG), der diagnostische Goldstandard bei den schlafbezogenen Atmungsstörungen, den Hypersomnien und den schlafbezogenen Bewegungsstörungen, ist im Kindesalter in der Regel eine stationäre Leistung. Die Beobachtung der Kinder während der PSG muss durch geschultes Personal erfolgen. Die Durchführung und Auswertung der Diagnostik im Schlaflabor sollte durch einen pädiatrischen Schlafmediziner bzw. Somnologen überwacht werden.
Aufgrund des deutlichen Mehraufwands für eine PSG im Kindesalter wird eine adäquate Vergütung gefordert.
Tonsillotomy (TT) is now used more often than tonsillectomy (TE) for tonsil obstructive symptoms in Sweden. Both TE and TT give high patient satisfaction although TT results in fewer postoperative bleedings and shorter time when analgesics are needed. The objective of this study is to analyze the current prevalence of different tonsil surgery procedures, the rates of early and late bleeding and other complications. Data from the National Tonsil Surgery Register in Sweden were analyzed. Patients 1-15 years operated for symptoms due to tonsil hypertrophy were included. Surgical procedure, technique and bleedings during hospital stay were registered. Thirty days after surgery, unplanned contacts due to bleeding, infection or pain were reported as were symptom relief after 6 months. 24,083 patients were registered. Of the 10,826 children 1-15 years operated for obstructive symptoms, 64 % were TT or TT+A, and 34 % TE, TE+A. 69 % answered the 30-day questionnaire and 50 % the 6 months. Bleeding in hospital occurred in 1.38 %, late bleedings in 2.06 %: 3.7 % after TE+A, 0.8 % after TT+A. Differences in readmissions due to bleeding, number of days using analgesics, health care contacts due to pain and nosocomial infections were significant between TT and TE, but not differences with regard to symptom relief after 6 months.
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.
The critical pressure at which the pharynx collapses (Pcrit) is an objective measurement of upper airway collapsibility, an important pathogenetic factor in obstructive sleep apnoea. This study examined the inherent variability of passive Pcrit measurement during sleep and evaluated the effects of sleep stage and body posture on Pcrit. Repeated measurements of Pcrit were assessed in 23 individuals (15 male) with diagnosed obstructive sleep apnoea throughout a single overnight sleep study. Body posture and sleep stage were unrestricted. Applied upper airway pressure was repetitively reduced to obtain multiple measurements of Pcrit. In 20 subjects multiple measurements of Pcrit were obtained. The overall coefficient of repeatability for Pcrit measurement was 4.1 cm H₂O. Considering only the lateral posture, the coefficient was 4.8 cm H₂O. It was 3.3 cm H₂O in the supine posture. Pcrit decreased from the supine to lateral posture [supine mean 2.5 cm H₂O, 95% confidence interval (CI) 1.4-3.6; lateral mean 0.3 cm H₂O, 95% CI -0.8-1.4, P = 0.007] but did not vary with sleep stage (P = 0.91). This study has shown that the overall coefficient of repeatability was 4.1 cm H₂O, implying that the minimum detectable difference, with 95% probability, between two repeated Pcrit measurements in an individual is 4.1 cm H₂O. Such variability in overnight measures of Pcrit indicates that a single unqualified value of Pcrit cannot be used to characterize an individual's overall collapsibility during sleep. When within-subject variability is accounted for, change in body posture from supine to lateral significantly decreases passive pharyngeal collapsibility.
Background:
There has been marked expansion in the literature and practice of pediatric sleep medicine; however, no recent evidence-based practice parameters have been reported. These practice parameters are the first of 2 papers that assess indications for polysomnography in children. This paper addresses indications for polysomnography in children with suspected sleep related breathing disorders. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine.
Methods:
A systematic review of the literature was performed, and the American Academy of Neurology grading system was used to assess the quality of evidence. RECOMMENDATIONS FOR PSG USE: 1. Polysomnography in children should be performed and interpreted in accordance with the recommendations of the AASM Manual for the Scoring of Sleep and Associated Events. (Standard) 2. Polysomnography is indicated when the clinical assessment suggests the diagnosis of obstructive sleep apnea syndrome (OSAS) in children. (Standard) 3. Children with mild OSAS preoperatively should have clinical evaluation following adenotonsillectomy to assess for residual symptoms. If there are residual symptoms of OSAS, polysomnography should be performed. (Standard) 4. Polysomnography is indicated following adenotonsillectomy to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway, and neurologic disorders (e.g., Down syndrome, Prader-Willi syndrome, and myelomeningocele). (Standard) 5. Polysomnography is indicated for positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome. (Standard) 6. Polysomnography is indicated when the clinical assessment suggests the diagnosis of congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorders or chest wall deformities. It is indicated in selected cases of primary sleep apnea of infancy. (Guideline) 7. Polysomnography is indicated when there is clinical evidence of a sleep related breathing disorder in infants who have experienced an apparent life-threatening event (ALTE). (Guideline) 8. Polysomnography is indicated in children being considered for adenotonsillectomy to treat obstructive sleep apnea syndrome. (Guideline) 9. Follow-up PSG in children on chronic PAP support is indicated to determine whether pressure requirements have changed as a result of the child's growth and development, if symptoms recur while on PAP, or if additional or alternate treatment is instituted. (Guideline) 10. Polysomnography is indicated after treatment of children for OSAS with rapid maxillary expansion to assess for the level of residual disease and to determine whether additional treatment is necessary. (Option) 11. Children with OSAS treated with an oral appliance should have clinical follow-up and polysomnography to assess response to treatment. (Option) 12. Polysomnography is indicated for noninvasive positive pressure ventilation (NIPPV) titration in children with other sleep related breathing disorders. (Option) 13. Children treated with mechanical ventilation may benefit from periodic evaluation with polysomnography to adjust ventilator settings. (Option) 14. Children treated with tracheostomy for sleep related breathing disorders benefit from polysomnography as part of the evaluation prior to decannulation. These children should be followed clinically after decannulation to assess for recurrence of symptoms of sleep related breathing disorders. (Option) 15. Polysomnography is indicated in the following respiratory disorders only if there is a clinical suspicion for an accompanying sleep related breathing disorder: chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality such as kyphoscoliosis. (Option) RECOMMENDATIONS AGAINST PSG USE: 16. Nap (abbreviated) polysomnography is not recommended for the evaluation of obstructive sleep apnea syndrome in children. (Option) 17. Children considered for treatment with supplemental oxygen do not routinely require polysomnography for management of oxygen therapy. (Option)
Conclusions:
Current evidence in the field of pediatric sleep medicine indicates that PSG has clinical utility in the diagnosis and management of sleep related breathing disorders. The accurate diagnosis of SRBD in the pediatric population is best accomplished by integration of polysomnographic findings with clinical evaluation.
The measurement of arousals during sleep is useful to quantify sleep fragmentation. The criteria for electroencephalography (EEG) arousals defined by the American Sleep Disorders Association (ASDA) have recently been criticized because of lack of interobserver agreement. The authors have adopted a scoring method that associates the increase in chin electromyography (EMG) with the occurrence of an α-rhythm in all sleep stages (Université Catholique de Louvain (UCL) definition of arousals). The aim of the present study was to compare the two scoring definitions in terms of agreement and repeatability and the time taken for scoring in patients with obstructive sleep apnoea syndrome (OSAS) of varying severity.
Two readers using both ASDA and UCL definitions scored twenty polysomnographies (PSGs) each on two occasions. The PSGs were chosen retrospectively to represent a wide range of arousal index (from 6–82) in OSAS patients.
There was no difference in the arousal indices between readers and between scoring methods. The mean±sd difference between the two definitions (the bias) was 1.1±3.76 (95% confidence interval: −0.66–2.86). There was a strong linear relationship between the arousal index scored with the two definitions (r=0.981, p<0.001). Mean±sd scoring duration was significantly shorter for UCL than for ASDA definitions (18.5±5.4 versus 25.3±6.6 min, p<0.001).
In conclusion, it has been found that in obstructive sleep apnoea syndrome patients, the American Sleep Disorders Association and Université Catholique de Louvain definitions were comparable in terms of agreement and repeatability.
To determine the prevalence of sleep-related breathing disturbances in a large cohort of school-aged and preschool-aged children of Southern Italy.
This cross-sectional prevalence study was designed in two phases: a screening phase aimed to identify symptomatic children from a cohort of 1,207 by a self-administered questionnaire, and an instrumental phase for the definition of sleep-related disorders.
One thousand two hundred seven children were screened by a self-administered questionnaire. There were 612 female children (51%) and 595 male children (mean age, 7.3 years; range, 3 to 11 years). According to answers, children were classified in three groups: nonsnorers, occasional snorers, and habitual snorers. All habitual snoring children underwent a polysomnographic home evaluation, and those with an oxygen desaturation index > 2 were considered for nocturnal polygraphic monitoring (NPM). Children with an apnea/hypopnea index > 3 received a diagnosis of obstructive sleep apnea syndrome (OSAS).
A total of 895 questionnaires (74.2%) were returned and scored; 710 children (79.3%) were identified as nonsnorers, 141 children (15.8%) were identified as occasional snorers, and 44 children (4.9%) were identified as habitual snorers. The percentage of male children who were habitual snorers was higher than the percentage of female children who were habitual snorers (6.1% vs 3.7%, respectively; p < 0.09). OSAS was diagnosed in nine children by NPM.
The lower limit of prevalence of OSAS in childhood is 1% (95% confidence interval [CI], 0.8 to 1.2). If we add the five children who underwent adenoidectomy and/or tonsillectomy because of worsening clinical condition and the two children who were shown to have evidence of OSAS on domiciliary oximetry, then the prevalence is 1.8% (higher limit of prevalence; 95% CI, 1.6 to 2.0).
The pathophysiological mechanisms of growth impairment frequently associated with the obstructive sleep apnea syndrome (OSAS) in children are poorly defined. The main objective of this study was to evaluate whether nighttime upper airway obstruction attributable to adenotonsillar hypertrophy and subsequent surgical treatment affect the circulating concentrations of insulin-like growth factor-I (IGF-I) and IGF-binding protein 3 (IGFBP-3) along with other growth parameters in children.
We initially studied 70 children (mean age: 5.8 years; range: 2.4-10.5 years) admitted to a university hospital because of clinical symptoms of OSAS. Their sleep was monitored with a 6-channel computerized polygraph. Data on anthropometry and circulating concentrations of IGF-I and IGFBP-3 were generated and compared with corresponding characteristics in control children (N = 35). Thirty children with an obstructive apnea-hypopnea index (OAHI) of 1 or more were categorized as children with OSAS (mean OAHI: 5.4 [95% confidence interval for mean (CI): 3.8-6.9]), whereas 40 children with an OAHI of <1 were considered as primary snorers (PS) (mean OAHI 0.13 [95% CI: 0.05-0.21]). Nineteen children with OAHI >2 underwent adenotonsillectomy attributable to OSAS and were reassessed 6 months later together with 34 nonoperated children with OAHI <2.
There were no initial differences in relative height and weight for height between the 3 groups of children. No differences were observed in peripheral IGF-I concentrations, but both OSAS and PS children had reduced peripheral IGFBP-3 levels. The operated children with initial OSAS experienced a highly significant reduction in their OAHI from 7.1 (95% CI: 5.1-9.1) to 0.37 (95% CI: 0.2-0.95). Weight-for-height, body mass index, body fat mass, and fat-free mass increased during the follow-up in the operated children with OSAS, whereas only fat-free mass and relative height increased in the PS children. Both the IGF-I and the IGFBP-3 concentrations increased significantly in the operated children, whereas no significant changes were seen in the PS children.
These observations indicate that growth hormone secretion is impaired in children with OSAS and PS. Respiratory improvement after adenotonsillectomy in children with OSAS results in weight gain and restored growth hormone secretion.
Obstructive sleep apnea (OSA) in children has emerged not only as a relatively prevalent condition but also as a disease that imposes a large array of morbidities, some of which may have long-term implications, well into adulthood. The major consequences of pediatric OSA involve neurobehavioral, cardiovascular, and endocrine and metabolic systems. The underlying pathophysiological mechanisms of OSA-induced end-organ injury are now being unraveled, and clearly involve oxidative and inflammatory pathways. However, the roles of individual susceptibility (as dictated by single-nucleotide polymorphisms), and of environmental and lifestyle conditions (such as diet, physical, and intellectual activity), may account for a substantial component of the variance in phenotype. Moreover, the clinical prototypic pediatric patient of the early 1990s has been insidiously replaced by a different phenotypic presentation that strikingly resembles that of adults afflicted by the disease. As such, analogous to diabetes, the terms type I and type II pediatric OSA have been proposed. The different manifestations of these two entities and their clinical course and approaches to management are reviewed.
Pediatric obstructive sleep apnea (OSA) has become widely recognized only in the last few decades as a likely cause of significant morbidity among children. Many of the clinical characteristics of pediatric OSA, and the determinants of its epidemiology, differ from those of adult OSA. We systematically reviewed studies on the epidemiology of conditions considered part of a pediatric sleep-disordered breathing (SDB) continuum, ranging from primary snoring to OSA. We highlight a number of methodologic challenges, including widely variable methodologies for collection of questionnaire data about symptomatology, definitions of habitual snoring, criteria for advancing to further diagnostic testing, and objective diagnostic criteria for SDB or OSA. In the face of these limitations, estimated population prevalences are as follows: parent-reported "always" snoring, 1.5 to 6%; parent-reported apneic events during sleep, 0.2 to 4%; SDB by varying constellations of parent-reported symptoms on questionnaire, 4 to 11%; OSA diagnosed by varying criteria on diagnostic studies, 1 to 4%. Overall prevalence of parent-reported snoring by any definition in meta-analysis was 7.45% (95% confidence interval, 5.75-9.61). A reasonable preponderance of evidence now suggests that SDB is more common among boys than girls, and among children who are heavier than others, with emerging data to suggest a higher prevalence among African Americans. Less convincing data exist to prove differences in prevalence based on age. We conclude by outlining specific future research needs in the epidemiology of pediatric SDB.
In their landmark publication, the authors were fundamentally preoccupied with the notion that:“The central idea of early disease detec-tion and treatment is essentially simple. However, the path to its successful achievement (on the one hand, bring-ing to treatment those with previously undetected disease, and, on the other, avoiding harm to those persons not in need of treatment) is far from simple though sometimes it may appear de-ceptively easy.”For this reason, Wilson and Jungner at-tempted to define screening criteria to guide the selection of conditions that would be suitable for screening, based, among other factors, on the capacity to detect the condition at an early stage and the availability of an acceptable treatment (Box 1). They considered these criteria “especially important when case-finding is carried out by a public health agency, where the pitfalls may be more numerous than when screening is performed by a personal physician”.Just as forty years ago, Wilson and Jungner wrote their treatise amidst a great deal of controversy surrounding the early detection of disease, there are now similar debates with respect to genetic screening. A growing number of diseases can now be detected in the pre-clinical stage, and even in the pre-pathological stage, using molecular and non-molecular diagnostic techniques.Large-scale screening for genetic conditions began around the time of the Wilson and Jungner publication. There was newborn screening for inborn errors of metabolism such as phenylketonuria, later followed by prenatal screening for Down syndrome and neural tube defects using ultrasound and biochemical mark-ers. Once individual disease genes started to be identified using novel molecular techniques, pilot screening programmes were established for several rare genetic conditions such as Tay Sachs disease and cystic fibrosis. With the advances in genetic technology, the rate at which new disease genes are being identified is out-pacing the ability of professionals and
Certain common medical conditions are associated with a higher risk of pediatric obstructive sleep apnea (OSA). A lower threshold for screening is therefore indicated for such patient cohorts. In this article, we briefly discuss the high prevalence of OSA in children born prematurely, and in those with Down syndrome, craniofacial disorders, and neuromuscular disorders. Primary care providers should have an increased index of suspicion for OSA in these children, considering the neurocognitive disability that occurs in these high-risk groups when OSA is left untreated.
Obstructive sleep apnoea (OSA) is one of the most common causes of sleep-disordered breathing (SDB) in children. It is associated with significant morbidity, potentially impacting on long-term neurocognitive and behavioural development, as well as cardiovascular outcomes and metabolic homeostasis. The low grade systemic inflammation and increased oxidative stress seen in this condition are believed to underpin the development of these OSA-related morbidities. The significant variance in degree of end organ morbidity in patients with the same severity of OSA highlights the importance of the interplay of genetic and environmental factors in determining the overall OSA phenotype. This review seeks to summarize the current understanding of the aetiology and mechanisms underlying OSA, its risk factors, diagnosis and treatment.
This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h(-1), those with an AHI of 1-5 episodes·h(-1) and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).
Background:
Obstructive sleep-disordered breathing (oSDB) is a condition that encompasses breathing problems when asleep, due to an obstruction of the upper airways, ranging in severity from simple snoring to obstructive sleep apnoea syndrome (OSAS). It affects both children and adults. In children, hypertrophy of the tonsils and adenoid tissue is thought to be the commonest cause of oSDB. As such, tonsillectomy - with or without adenoidectomy - is considered an appropriate first-line treatment for most cases of paediatric oSDB.
Objectives:
To assess the benefits and harms of tonsillectomy with or without adenoidectomy compared with non-surgical management of children with oSDB.
Search methods:
We searched the Cochrane Register of Studies Online, PubMed, EMBASE, CINAHL, Web of Science, Clinicaltrials.gov, ICTRP and additional sources for published and unpublished trials. The date of the search was 5 March 2015.
Selection criteria:
Randomised controlled trials comparing the effectiveness and safety of (adeno)tonsillectomy with non-surgical management in children with oSDB aged 2 to 16 years.
Data collection and analysis:
We used the standard methodological procedures expected by The Cochrane Collaboration.
Main results:
Three trials (562 children) met our inclusion criteria. Two were at moderate to high risk of bias and one at low risk of bias. We did not pool the results because of substantial clinical heterogeneity. They evaluated three different groups of children: those diagnosed with mild to moderate OSAS by polysomnography (PSG) (453 children aged five to nine years; low risk of bias; CHAT trial), those with a clinical diagnosis of oSDB but with negative PSG recordings (29 children aged two to 14 years; moderate to high risk of bias; Goldstein) and children with Down syndrome or mucopolysaccharidosis (MPS) diagnosed with mild to moderate OSAS by PSG (80 children aged six to 12 years; moderate to high risk of bias; Sudarsan). Moreover, the trials included two different comparisons: adenotonsillectomy versus no surgery (CHAT trial and Goldstein) or versus continuous positive airway pressure (CPAP) (Sudarsan). Disease-specific quality of life and/or symptom score (using a validated instrument): first primary outcomeIn the largest trial with lowest risk of bias (CHAT trial), at seven months, mean scores for those instruments measuring disease-specific quality of life and/or symptoms were lower (that is, better quality of life or fewer symptoms) in children receiving adenotonsillectomy than in those managed by watchful waiting:- OSA-18 questionnaire (scale 18 to 126): 31.8 versus 49.5 (mean difference (MD) -17.7, 95% confidence interval (CI) -21.2 to -14.2);- PSQ-SRBD questionnaire (scale 0 to 1): 0.2 versus 0.5 (MD -0.3, 95% CI -0.31 to -0.26);- Modified Epworth Sleepiness Scale (scale 0 to 24): 5.1 versus 7.1 (MD -2.0, 95% CI -2.9 to -1.1).No data on this primary outcome were reported in the Goldstein trial.In the Sudarsan trial, the mean OSA-18 score at 12 months did not significantly differ between the adenotonsillectomy and CPAP groups. The mean modified Epworth Sleepiness Scale scores did not differ at six months, but were lower in the surgery group at 12 months: 5.5 versus 7.9 (MD -2.4, 95% CI -3.1 to -1.7). Adverse events: second primary outcomeIn the CHAT trial, 15 children experienced a serious adverse event: 6/194 (3%) in the adenotonsillectomy group and 9/203 (4%) in the control group (RD -1%, 95% CI -5% to 2%).No major complications were reported in the Goldstein trial.In the Sudarsan trial, 2/37 (5%) developed a secondary haemorrhage after adenotonsillectomy, while 1/36 (3%) developed a rash on the nasal dorsum secondary to the CPAP mask (RD -3%, 95% CI -6% to 12%). Secondary outcomesIn the CHAT trial, at seven months, mean scores for generic caregiver-rated quality of life were higher in children receiving adenotonsillectomy than in those managed by watchful waiting. No data on this outcome were reported by Sudarsan and Goldstein.In the CHAT trial, at seven months, more children in the surgery group had normalisation of respiratory events during sleep as measured by PSG than those allocated to watchful waiting: 153/194 (79%) versus 93/203 (46%) (RD 33%, 95% CI 24% to 42%). In the Goldstein trial, at six months, PSG recordings were similar between groups and in the Sudarsan trial resolution of OSAS (Apnoea/Hypopnoea Index score below 1) did not significantly differ between the adenotonsillectomy and CPAP groups.In the CHAT trial, at seven months, neurocognitive performance and attention and executive function had not improved with surgery: scores were similar in both groups. In the CHAT trial, at seven months, mean scores for caregiver-reported ratings of behaviour were lower (that is, better behaviour) in children receiving adenotonsillectomy than in those managed by watchful waiting, however, teacher-reported ratings of behaviour did not significantly differ.No data on these outcomes were reported by Goldstein and Sudarsan.
Authors' conclusions:
In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time.For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG.We are unable to present data on the benefits of adenotonsillectomy in children with oSDB aged under five, despite this being a population in whom this procedure is often performed for this purpose.
OSA is associated with significant adverse outcomes with far-reaching health-care implications. OSA is much more common and severe in patients with Down syndrome (DS) than in the general population, yet there is a striking lack of literature in this area. In this review article, we have summarized the current state of knowledge and presented the available data on OSA in DS. The higher prevalence and severity of OSA in patients with DS may be related to unique upper airway anatomic features as well as increased risk for obesity, hypothyroidism, gastroesophageal reflux disease, and generalized hypotonia. Although many of the manifestations of OSA in patients with DS are similar to those seen in the general population, the relative morbidity is significantly higher. For individuals with DS who already face cognitive challenges, the added impact of OSA on cognitive function may hinder their ability to function independently and reach their full potential. Screening and evaluation for OSA should be done in children and adults with DS. Treatment of OSA in DS involves the use of CPAP, upper airway surgery, and dental appliances, along with weight-reduction strategies, nasal steroids, and oral leukotriene modifiers as adjunctive treatments. The treatment plan should be individualized for each patient with DS, taking into account age, comorbid conditions, and barriers to treatment adherence. Future research should aim to better characterize OSA, further evaluate neurocognitive outcomes, and evaluate the efficacy of treatments in patients with DS.
Objective:
To evaluate the diagnostic reliability of home respiratory polygraphy (HRP) in children with a clinical suspicion of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAS).
Methods:
A prospective blind evaluation was performed. Children between 2 to 14 years-old, with clinical suspicion of OSAS, who were referred to the Sleep Unit were included. An initial HRP followed by a ulterior date, same night, in-laboratory overnight respiratory polygraphy and polysomnography (PSG) in the Sleep Laboratory were performed. The AHI-HRP were compared to AHI-PSG, and therapeutic decisions based on AHI-HRP and AHI-PSG were analyzed using intraclass correlation coefficients (ICC), Bland-Altman plots and receiver operator curves (ROC).
Results:
27 boys and 23 girls, with a mean age of 5.3 ± 2.55 years were studied, and 66% were diagnosed with OSAS based on a PSG-defined obstructive RDI ≥3/hrTST. Based on the availability of concurrent HRP-PSG recordings, the optimal AHI-HRP corresponding to the PSG-defined OSAS criterion was established as ≥5.6/hr. The latter exhibited a sensitivity of 90.9% (95% CI: 79.6% -100%) and a specificity of 94.1% (95% CI: 80%-100%).
Conclusions:
Home respiratory polygraphic recordings emerge as a potentially useful and reliable approach for the diagnosis of OSAS in children, However, more research is required for the diagnosis of mild OSAS using HRP in children.
Study objective:
To study the incidence, remission, and prediction of obstructive sleep apnea (OSA) from middle childhood to late adolescence.
Design:
Longitudinal analysis.
Setting:
The Cleveland Children's Sleep and Health Study, an ethnically mixed, urban, community-based cohort, followed 8 y.
Participants:
There were 490 participants with overnight polysomnography data available at ages 8-11 and 16-19 y.
Measurements and results:
Baseline participant characteristics and health history were ascertained from parent report and US census data. OSA was defined as an obstructive apnea- hypopnea index ≥ 5 or an obstructive apnea index ≥ 1. OSA prevalence was approximately 4% at each examination, but OSA largely did not persist from middle childhood to late adolescence. Habitual snoring and obesity predicted OSA in cross-sectional analyses at each time point. Residence in a disadvantaged neighborhood, African-American race, and premature birth also predicted OSA in middle childhood, whereas male sex, high body mass index, and history of tonsillectomy or adenoidectomy were risk factors among adolescents. Obesity, but not habitual snoring, in middle childhood predicted adolescent OSA.
Conclusions:
Because OSA in middle childhood usually remitted by adolescence and most adolescent cases were incident cases, criteria other than concern alone over OSA persistence or incidence should be used when making treatment decisions for pediatric OSA. Moreover, OSA's distinct risk factors at each time point underscore the need for alternative risk-factor assessments across pediatric ages. The greater importance of middle childhood obesity compared to snoring in predicting adolescent OSA provides support for screening, preventing, and treating obesity in childhood.
Background
Snoring in children is a prevalent symptom and may be an indicator of obstructive sleep apnoea. Despite its importance, there is no national guideline on its appropriate management.
Objective
To provide recommendations for the management of snoring in children and adolescents treated in a primary care setting.
Methods
A total of 16 national paediatric sleep experts were included in a Delphi process and formulated recommendations in the form of a step-wise work-up procedure.
Results
The following 8 steps were developed: (1) Identification of true cases of habitual snoring. (2) Identification of high-risk patients who should undergo polysomnography in a sleep laboratory. (3) Identification of mild cases that may be treated with anti-inflammatory medication. (4) Identification of cases that should be referred to an otorhinolaryngologist for potential surgery. (5) Performance of polysomnography in cases that remain unclear despite steps 3 and 4 to rule out obstructive sleep apnoea. (6) Reconsideration of surgery in cases with moderate to severe obstructive sleep apnoea. (7) Identification of severe sleep apnoea cases requiring continuous positive airway pressure therapy. (8) Identification of cases suitable for orthodontic treatment, craniofacial surgery or speech therapy.
Conclusion
This guideline should help to improve the management of snoring children and adolescents in Germany.
Objective:
To investigate diagnostic test accuracy (DTA) of different tests for obstructive sleep apnea (OSA) compared to polysomnography (PSG) in children.
Methods:
We performed a systematic review according to DTA criteria published by the Cochrane Collaboration. Studies that compared any possible diagnostic test with PSG for diagnosing OSA were considered. Study quality assessment was conducted in each selected study and DTA measures recalculated by hand whenever possible. Excellent DTA was defined as positive likelihood ratio (PLR) > 10 and negative likelihood ratio (NLR) < 0.1.
Results:
We identified 1064 potentially relevant studies, of which 33 met inclusion criteria. Study quality was generally low; 5 studies fulfilled all quality criteria and 11 studies included >100 subjects. Included studies compared 40 different tests to PSG. Only 13 studies used the currently accepted definition for OSA (i.e., apnea hypopnea index ≥1). In these studies, PLR ranged from 1.017 to ∞, NLR from 0 to 1.089. Sleep lab-based polygraphy, urinary biomarkers, and rhinomanometry (one study each) showed excellent DTA.
Conclusion:
There is limited evidence concerning diagnostic alternatives to PSG for identifying OSA in children. However, polygraphy, urinary biomarkers, and rhinomanometry may be valid tests if their apparently high DTA is confirmed by subsequent studies.
Objective
To systematically review current studies on the effects of adenotonsillectomy (T&A) for obstructive sleep apnea (OSA) on cardiovascular parameters in children.Data SourcesPubMed database.Review MethodsA comprehensive PubMed MeSH search was done between 1970 and 2012.ResultsFourteen articles were included. The total number of children was 418. The mean sample size was 30 (range, 1-62), and the mean age of the sample population was 6 years (range, 2-10 years). Criteria used for the diagnosis of OSA ranged from full-night polysomnography (PSG) to clinical parameters. Three studies had results from preoperative and postoperative PSG. Cardiovascular parameters studied included blood pressure, heart rate, cardiac morphology, and cardiac function. All studies reported an improvement in cardiovascular parameters and OSA symptoms after surgery. Three studies reported improvement in blood pressure, 6 reported improvement in mean pulmonary artery pressures, 7 reported improvement in echocardiographic findings, and 1 reported a decrease in pulse rate and pulse rate variability after T&A for OSA.Conclusion
There is evidence that cardiovascular morbidities associated with OSA are potentially reversible. T&A may have a significant role in reversing the cardiovascular sequelae of OSA. However, there is a paucity of well-designed and powered studies to address this issue.
Adult obstructive sleep apnoea (OSA) is associated with cognitive dysfunction. While many review articles have attempted to summarise the evidence for this association, it remains difficult to determine which domains of cognition are affected by OSA. This is because of marked differences in the nature of these reviews (e.g. many are unsystematic) and the many different tasks and domains assessed. This paper addresses this issue by comparing the results of only systematic reviews or meta-analyses assessing the effects of OSA on cognition, the relationship between OSA severity and cognition, and/or the effects of treatment on cognition in OSA. Electronic databases and hand searching were undertaken to select reviews that reported on these areas. We found 33 reviews; 5 reviews met predetermined, stringent selection criteria. The majority of reviews supported deficits in attention/vigilance, delayed long-term visual and verbal memory, visuo-spatial/constructional abilities and executive function in individuals with OSA. There is also general agreement that language ability and psychomotor function are unaffected by OSA. Data are equivocal for the effects of OSA on working memory, short term memory and global cognitive functioning. Attention/vigilance dysfunction appears to be associated with sleep fragmentation, and global cognitive function with hypoxemia. CPAP treatment of OSA appears to improve executive dysfunction, delayed long-term verbal and visual memory, attention/vigilance and global cognitive functioning. In order to improve our understanding of cognitive dysfunction in OSA, future research should pay particular attention to participant characteristics, measures of disease severity, and choice of neuropsychological tests. © 2012 The Authors. Respirology © 2012 Asian Pacific Society of Respirology.
This Clinical Report was revised. See https://doi.org/10.1542/peds.2022-057010
These guidelines are designed to assist the pediatrician in caring for the child in whom a diagnosis of Down syndrome has been confirmed by chromosome analysis. Although a pediatrician's initial contact with the child is usually during infancy, occasionally the pregnant woman who has been given a prenatal diagnosis of Down syndrome will be referred for review of the condition and the genetic counseling provided. Therefore, this report offers guidance for this situation as well.
Pediatric obstructive sleep apnea syndrome (OSAS), like adult OSAS, is characterized by intermittent upper airway collapse during sleep and is associated with anatomic and neuromuscular factors. However, the clinical manifestations, diagnostic criteria, and polysomnographic findings of OSAS in children are likely to be different from those in adults. The purpose of this study was to identify the characteristics that distinguish the clinical manifestations and polysomnographic findings of OSAS in children from those in adults.
The study population consisted of 34 children (mean age, 7.6 years; range, 4 to 16 years) with OSAS and 33 adults (mean age, 40.1 years; range, 18 to 58 years) with OSAS. We compared various clinical manifestations, such as body mass index, tonsil size, severity of symptoms and signs, and polysomnographic data, between these groups.
Obesity was more common among the adults, whereas tonsillar hypertrophy was more common among the children. There were significant differences between the groups in the severity of symptoms and signs, including witnessed apnea, daytime sleepiness, morning headache, memory reduction, and daytime fatigue. In the children with OSAS, slow-wave sleep was relatively well preserved, and respiratory events such as apnea and hypopnea occurred mainly during rapid eye movement sleep.
The clinical manifestations and polysomnographic findings in children with OSAS differ from those in adults with OSAS.
A history of poor weight gain can often be elicited in young children with chronic upper airway obstruction resulting from adenotonsillar hypertrophy. A series of 41 consecutive children under 3 years of age, who underwent inpatient adenotonsillectomy, were reviewed for changes in weight and height. Thirty-seven patients had adequate long-term follow-up. Of these, many had dramatic improvements in growth after adenotonsillectomy. Indications for surgery in this group were recurrent infection in three patients (7%), unilateral tonsillar mass in one patient (3%), and upper airway obstruction in 37 patients (90%). A clear history of sleep apnea was elicited in 59%. At the time of surgery, 19 of 41 patients (46%) were of the fifth percentile or lower for age-corrected weight. The inpatient hospital stay averaged 3.2 days. The postoperative complication rate was 27%, with postoperative stridor as the most common complication. After surgery, 28 children (75%) showed a change to a higher percentile for weight. Twenty-four (65%) had percentile changes of 15% or more. This change is significant according to results of the Wilcoxon signed-rank test (p less than 0.001). We conclude that a relationship exists between improved growth rate and adenotonsillectomy in our study group. The rapid improvement in growth appears to be most obvious in children with upper airway obstruction resulting from adenotonsillar hypertrophy. Upper airway obstruction (including andenotonsillar hypertrophy) should be suspected as a possible cause in the workup of children with suboptimum growth.
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.
This study examined risk factors for sleep-disordered breathing (SDB) in children and adolescents; specifically, quantifying risk associated with obesity, race, and upper and lower respiratory problems. Subjects were participants in a genetic-epidemiologic study of SDB and included 399 children and adolescents 2 to 18 yr of age, recruited as members of families with a member (a proband) with known sleep apnea (31 index families) or as members of neighborhood control families (30 families). SDB was assessed with home overnight multichannel monitoring and SDB was defined based on an apneahypopnea index >/= 10 (moderately affected) or < 5 (unaffected). SDB of moderate level was significantly associated with obesity (odds ratio, 4.59; 95% confidence interval [CI], 1.58 to 13.33) and African-American race (odds ratio, 3.49; 95% CI, 1.56 to 8.32) but not with sex or age. After adjusting for obesity, proband sampling, race and familial clustering, sinus problems and persistent wheeze each independently (of the other) predicted SDB. These data suggest the importance of upper and lower respiratory problems and obesity as risk factors for SDB in children and adolescents. Increased risk in African Americans appears to be independent of the effects of obesity or respiratory problems.
Sleep disordered breathing in children is a common but largely underdiagnosed problem. It ranges in severity from primary snoring to obstructive sleep apnea syndrome (OSAS). Preliminary evidence suggests that children with severe OSAS show reduced neurocognitive performance, however, less is known about children who snore but do not have severe upper airway obstruction. Participants included 16 children referred to the Ear, Nose and Throat/Respiratory departments of a Children's Hospital for evaluation of snoring and 16 non-snoring controls aged 5-10 years. Overnight polysomnography (PSG) was carried out in 13 children who snored and 13 controls. The PSG confirmed the presence of primary snoring in seven and very mild OSAS (as evidenced by chest wall paradox) in eight children referred for snoring while controls showed a normal sleep pattern. To test for group differences in neurocognitive functioning and behavior, children underwent one day of testing during which measures of intelligence, memory, attention, social competency, and problematic behavior were collected. Compared to controls, children who snored showed significantly impaired attention and, although within the normal range, lower memory and intelligence scores. No significant group differences were observed for social competency and problematic behavior. These findings suggest that neurocognitive performance is reduced in children who snore but are otherwise healthy and who do not have severe OSAS. They further imply that the impact of mild sleep disordered breathing on daytime functioning may be more significant than previously realized with subsequent implications for successful academic and developmental progress.
In 1999, a survey was carried out in 1,008 Thai children aged 7 years, which found that 85 (8.5%) children were habitual snorers, and 7 (0.69%) children had mild obstructive sleep apnea syndrome (OSAS). Since the natural history of snoring and untreated mild OSAS is still largely unknown, this study was undertaken in 2002 in the same group of children to determine the natural history of snoring and OSAS. Questionnaires, consisting of questions about snoring, were sent to the parents of the 1,008 children. Polysomnography was performed in 1) the 7 children who had OSAS in the previous survey, and 2) other habitual snorers who had sleep-related symptoms in this survey. Seventy-five percent of the questionnaires were returned. The prevalence of habitual snoring had decreased slightly, from 8.5% in 1999 to 6.9% in 2002. Sixty-five percent of the children who had snored habitually in the previous survey no longer did so, whereas 4.5% of the children who previously never snored or snored sometimes had become habitual snorers. Of the 7 children who had OSAS previously, 5 had persistent snoring, and polysomnographic studies revealed more severe OSAS, with an apnea-hypopnea index (AHI) of 1.5-9.2 per hour of sleep. Five children were newly diagnosed with OSAS in this survey, with an AHI of 1.5-7.5. The overall prevalence of OSAS in this survey was 10/755 (1.3%). In conclusion, 65% of children who snored habitually no longer did so when they got older, while 9% of children had developed OSAS. We suggest that regular follow-up in children with habitual snoring may be needed, and additional research is required to determine the indications for polysomnography and neurobehavioral and cardiovascular assessment. We also showed that children with mild OSAS could develop more severe disease if left untreated, suggesting that deferment of treatment may have negative consequences.
To summarize published studies that evaluate whether adenotonsillectomy performed for sleep-disordered breathing in children is associated with improvements in behavior, cognitive function, and quality of life, whether those improvements show correlation with polysomnographic parameters, and suggest how future studies may provide additional clinically significant information.
A computerized search of the medical literature was performed for articles published between 1950 and March 2007 with the use of the OVID Medsearch database.
Analysis revealed 25 articles that satisfied the inclusion and exclusion criteria. All studies showed improvement in one or more of the specified outcome measures including general or disease specific quality of life, behavioral problems including hyperactivity and increased aggression or neurocognitive skills, such as memory, attention, or school performance. Limited correlation was often seen between improvements in outcome measures and polysomnographic variables.
Current studies strongly suggest adenotonsillectomy performed for sleep-disordered breathing in children is associated with improvements in quality of life, behavior, and cognitive function, but large, randomized, controlled studies are needed to provide definitive evidence of the benefits of this commonly performed surgical procedure in the general population.
Obstructive sleep apnea syndrome (OSAS) in children includes a spectrum of respiratory disorders with significant morbidities. Diagnosis of OSAS is based on clinical suspicion, history, and physical findings, and confirmation is made by polysomnography. There has been significant progress in recent years in technologies available for diagnosis of OSAS since the consensus statement of the American Thoracic Society in 1996. The current review describes methodologies that are available today for assessment and diagnosis of OSAS in children and summarizes the most recent recommendations of the American Academy of Sleep Medicine Task Force regarding scoring sleep-related respiratory events in children.
Data suggest that obstructive sleep apnea syndrome (OSA) results in sympathetic stimulation, brady/tachycardia and cardiac stress. Heart rate variability, but not baseline heart rate, is known to be elevated in pediatric OSA. Our patients with moderate to severe OSA (McGill Oximetry Scores of 3 or 4) have been re-evaluated with pulse oximetry after adenotonsillectomy (T&A). We hypothesized that pulse rate (PR) and pulse rate variability (PRV) would decrease after treatment of OSA with T&A.
This retrospective before-after study comprised pre- and post-operative oximetries and parental questionnaires of children 1-18 years old with moderate to severe OSA from September 2004 to August 2005, inclusive. We excluded patients with significant comorbidities.
In 25 subjects, age at surgery was 4.3 +/- 3.6 years (mean +/- SD). OSA symptoms decreased or resolved, saturation metrics improved, and parental concern about breathing during sleep decreased following T&A. PR decreased in 21 of 25 patients after T&A (mean PR from 99.7 +/- 11.2 to 90.1 +/- 10.7 bpm, P < 0.001; maximum PR from 150.6 +/- 14.5 to 137.4 +/- 15.6 bpm, P < 0.001). PRV, as measured by the standard deviation of the PR, decreased in 23 of 25 patients after T&A (from 10.3 +/- 2.1 to 8.2 +/- 1.6 bpm, [P < 0.001]). Pulse accelerations greater than 6, 7, 8 bpm also decreased post-operatively.
Nocturnal pulse oximetry complements clinical history to document improvement and/or resolution of moderate to severe OSA in children. Resolution of tachycardia and diminished PRV after T&A illustrate the stress that recurrent airway obstruction during sleep places on the cardiovascular system. Further work will be required to determine if PR and PRV as measured by pulse oximetry would be useful in the diagnosis and follow-up of OSA in children.
Reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children
- Alonso-Álvarez Ml Terán-Santos
- Ordax Carbajo
- E Cordero-Guevara
- J A Navazo-Egüia
- A I Kheirandish-Gozal
- L Gozal
- ML Alonso-Álvarez