Obstructive sleep apnea syndrome in children: Epidemiology, pathophysiology, diagnosis and sequelae

Sleep problems and associations with psychopathology and cognition in young people with 22q11.2 deletion syndrome (22q11.2DS)

BACKGROUND

Young people with 22q11.2 deletion syndrome (22q11.2DS) are at high risk for neurodevelopmental disorders. Sleep problems may play a role in this risk but their prevalence, nature and links to psychopathology and cognitive function remain undescribed in this population.

METHOD

Sleep problems, psychopathology, developmental coordination and cognitive function were assessed in 140 young people with 22q11.2DS (mean age = 10.1, s.d. = 2.46) and 65 unaffected sibling controls (mean age = 10.8, s.d.SD = 2.26). Primary carers completed questionnaires screening for the children's developmental coordination and autism spectrum disorder.

RESULTS

Sleep problems were identified in 60% of young people with 22q11.2DS compared to 23% of sibling controls (OR 5.00, p < 0.001). Two patterns best-described sleep problems in 22q11.2DS: restless sleep and insomnia. Restless sleep was linked to increased ADHD symptoms (OR 1.16, p < 0.001) and impaired executive function (OR 0.975, p = 0.013). Both patterns were associated with elevated symptoms of anxiety disorder (restless sleep: OR 1.10, p = 0.006 and insomnia: OR 1.07, p = 0.045) and developmental coordination disorder (OR 0.968, p = 0.0023, and OR 0.955, p = 0.009). The insomnia pattern was also linked to elevated conduct disorder symptoms (OR 1.53, p = 0.020).

CONCLUSIONS

Clinicians and carers should be aware that sleep problems are common in 22q11.2DS and index psychiatric risk, cognitive deficits and motor coordination problems. Future studies should explore the physiology of sleep and the links with the neurodevelopment in these young people.

Oral microbiome: possible harbinger for children's health

The human microbiome functions as an intricate and coordinated microbial network, residing throughout the mucosal surfaces of the skin, oral cavity, gastrointestinal tract, respiratory tract, and reproductive system. The oral microbiome encompasses a highly diverse microbiota, consisting of over 700 microorganisms, including bacteria, fungi, and viruses. As our understanding of the relationship between the oral microbiome and human health has evolved, we have identified a diverse array of oral and systemic diseases associated with this microbial community, including but not limited to caries, periodontal diseases, oral cancer, colorectal cancer, pancreatic cancer, and inflammatory bowel syndrome. The potential predictive relationship between the oral microbiota and these human diseases suggests that the oral cavity is an ideal site for disease diagnosis and development of rapid point-of-care tests. The oral cavity is easily accessible with a non-invasive collection of biological samples. We can envision a future where early life salivary diagnostic tools will be used to predict and prevent future disease via analyzing and shaping the infant’s oral microbiome. In this review, we present evidence for the establishment of the oral microbiome during early childhood, the capability of using childhood oral microbiome to predict future oral and systemic diseases, and the limitations of the current evidence.

Obstructive sleep apnea in developmental age. A narrative review

Sleep is a physiological function that undergoes, at different stages of life, to considerable variations in neurophysiological and behavioral functions. The developmental age is a period characterized by a continuous process of physical and neuropsychological changes and synaptic remodeling processes that are the neurophysiological basis of brain plasticity, typical of this developmental phase, occurring mainly during sleep. In the description of obstructive sleep apnea (OSA) in children, two main points should be highlighted: its variability in different age groups, and its specificity compared with OSA in adults. The definition and criteria used for the diagnosis of OSA in adults are not applicable to OSA in developmental age. Although the adenotonsillar hypertrophy is the most common risk factor for pediatric OSA, obesity is becoming an increasingly prevalent risk factor, mostly in early childhood (6-9 years) and adolescence. OSA has been shown to affect cognitive function in children and adults. However, OSA impact on cognitive function in children is more severe since acting on the plastic brain structures can change the neuro-psychic development, learning skills, and social interactions. There is a clear difference in the definition of pathology between developmental age and adulthood according to the instrumental parameters: an AHI ≥ 5, which represents, in the pediatric age, the cut-off for a therapeutic pathway necessary to avoid a long-term effect on the child, instead, it represents in adulthood, the lower limit value for the definition of disease. This is a narrative review concerning obstructive sleep apnea in developmental age.Conclusions: OSA is a common disorder in children and those at risk must be identified, studied, and treated promptly because untreated OSA can be responsible for cardiovascular, metabolic, and neurocognitive morbidities and may induce, sometimes, non-reversible deficits given his insistence on a period of physical and neuro-psychic development.What is Known:•This is a review concerning Obstructive Sleep Apnea in developmental age•Clinical manifestation, diagnostic and therapeutic criteria of sleep apnea in developmental ageWhat is New:•This is a "narrative" review•This narrative review describes sleep apnea comparing and analyzing the different ages of life.

Asthma is associated with increased probability of needing CPAP in children with severe obstructive sleep apnea

OBJECTIVE

Initiation of continuous positive airway pressure (CPAP) in children with severe obstructive sleep apnea syndrome (OSAS) is challenging and the distinct features of the subset of children requiring CPAP are poorly defined. Asthma often coexists with OSAS in children. The goal of this study was to explore the influence of asthma in the need for CPAP therapy in children with severe OSAS.

HYPOTHESIS

Asthmatic children with severe OSAS have higher probability of needing CPAP than children with severe OSAS without asthma.

METHODS

Cross-sectional study of clinical presentation, individual risk factors, and initial overnight polysomnogram (PSG) parameters in children with severe OSAS. Severe OSAS was defined as an obstructive apnea hypopnea index ≥10/h. The association between asthma and CPAP initiation was studied individually and adjusted by pertinent covariates.

RESULTS

Four hundred eligible children (mean age 7 years, ±SD 5.3) with severe OSAS were enrolled and 133 individuals (33%) were identified to have asthma. The proportion of children needing CPAP was significantly higher in asthmatics with severe OSAS (29%) compared to those with OSAS alone (14%) (P < 0.01). Multivariate analysis demonstrated that the association between asthma and the need of CPAP in pediatric severe OSAS was independent of demographics, OSAS severity, obesity, and history of adenotonsillectomy (P < 0.01).

CONCLUSION

Asthmatic children with severe OSAS have higher probability of needing CPAP independent of relevant covariables. This study further substantiates the link between OSAS and asthma in children and suggests the diagnosis of asthma may influence the need of CPAP therapy for severe OSAS.

Obstructive Sleep Apnoea in Children and Adolescents with Ehlers-Danlos Syndrome

BACKGROUND

In Ehlers-Danlos syndrome (EDS), a group of monogenic disorders affecting connective tissues, obstructive sleep apnoea (OSA) is highly prevalent in adults. The prevalence of OSA in children with EDS is unknown.

OBJECTIVES

This prospective cross-sectional study aimed at determining the prevalence of OSA in paediatric EDS patients.

METHODS

Children with EDS (n = 24) were recruited from the Children's Hospital Zurich and matched to healthy controls. Participants completed home respiratory polygraphy and questionnaires (Sleep-Related Breathing Disorder Scale [SRBD], Epworth Sleepiness Scale [ESS], and Child Health Questionnaire [CHQ]). The American Academy of Sleep Medicine criteria were applied for OSA diagnosis (obstructive apnoea-hypopnoea index [oAHI] ≥1/h). Conditional logistic regression was used to compare the prevalence of OSA and to adjust for possible confounding.

RESULTS

OSA was found in 42% of paediatric EDS patients and in 13% of matched controls (OR = 4.5, 95% CI = 0.97-20.83, p = 0.054). The median oAHI was higher in EDS patients than in controls (0.77/h, IQR = 0.19-1.76, vs. 0.24/h, IQR = 0.0-0.60, p < 0.001 adjusted for age, sex, and BMI z-score). EDS patients had lower scores in most CHQ scales and higher SRBD and ESS scores than controls (0.26, IQR = 0.1-0.35, vs. 0.07, IQR = 0-0.19, p = 0.004); 7 ± 4 vs. 5 ± 4, p = 0.033, respectively).

CONCLUSION

OSA is a previously underestimated EDS-related complication increasing disease burden.

IL-17A expression in the adenoid tissue from children with sleep disordered breathing and its association with pneumococcal carriage

Tonsil and adenoid-tissue hypertrophy (AH) is the most common cause of pediatric sleep-disordered breathing (SDB), with AH possibly initiated by repeated exposure to infectious agents or allergens. Here, we evaluated IL-17A activity in adenoid tissue from children with SDB and its association with AH and pneumococcal carriage. Thirty-five children (aged 3-12 years) with SDB and receiving adenoidectomy and tonsillectomy were enrolled. During surgery, nasopharyngeal carriage was determined by bacterial culture and multiplex PCR via nasopharyngeal swab, and adenoid samples were collected. IL-17A and associated cytokine expression was evaluated by real-time PCR and western blotting. The mRNA analysis showed that IL-17A level, IL-17A:IL-10 ratio, and RAR-related orphan receptor-γt:forkhead box P3 ratio were significantly higher in adenoid tissues with AH, as were IL-17A level and IL-17A:IL-10 ratio in adenoid tissues with pneumococcal carriage. Additionally, pneumococcal carriage was more common in nasopharyngeal adenoids from patients without AH than those with AH. IL-17A was upregulated in adenoid tissues from patients with AH and with pneumococcal carriage. These results suggested that pneumococcal carriage initiates an IL-17A-mediated immune response in nasopharyngeal adenoids, which might be associated with AH in patients with SDB.

Oral health status of children with mouth breathing due to adenotonsillar hypertrophy

OBJECTIVES

Mouth breathing is an important health problem, commonly encountered in children. In children, adeno-tonsillar hypertrophy is the main reason causing partial or complete upper airway obstruction and reduction in airflow. This study aimed to determine the oral health status of children aged 3-15 years, with mouth breathing who were due to have surgery for adeno-tonsillar hypertrophy and referred to the Department of Otorhinolaryngology at Children's Hospital of a University in Ankara, Turkey between January-July 2015.

METHODS

The approval of the Non-Interventional Clinical Researches Ethics Board of Hacettepe University and written informed consents from the parents were obtained. The parents completed a questionnaire before the surgery. The children were examined using dental mirror and explorer under dental unit lighting. Oral health status was evaluated with DMFT/S, dmft/s, ICDAS II, dental plaque and gingival indices. The chi-square test, Kruskal Wallis and Mann Whitney U tests were used to statistically analyse the results, with statistical significance p<0.05.

RESULTS

Of the 170 children who had adenotonsillar hypertrophy with mouth breathing, 150 the parents agreed to participate the study. 77 of the children (51.3%) were male; the mean age was 5.9 ± 2.6. Mean dmft was 3.8 ± 3.6, dmfs 9.7 ± 1.1, DMFT 0.4 ± 1.0 and DMFS 0.6 ± 1.5 respectively. Among the children, 101 (67.3%) had cavitated dental caries, and according to ICDAS II, none had healthy teeth, 15 (10.0%) had initial, 42 (28.0%) had moderate and 93 (62.0%) had advanced caries. Of the children, 89.3% had gingivitis and the proportion of gingivitis in posterior region was found to be significantly higher than anterior region (p < 0,001).

CONCLUSIONS

The oral health status of mouth breathing in children with adeno-tonsillar hypertrophy was poor. To reduce the risk of dental caries and periodontal disease among these children, regular dental follow-up and preventive programmes for oral health are needed.

Orexin-A aggravates the impairment of hippocampal neurons caused by intermittent hypoxemia by the OXR-PLCβ1-ERK1/2 pathway

Obstructive sleep apnea is a highly prevalent but under-recognized disorder that causes neurocognitive deficits such as spatial memory and learning deficits. These deficits are frequently accompanied by an increase in orexin-A, which has been shown to be involved in learning and memory as well as in neuronal apoptosis in brain areas involved in cognition, such as the hippocampus. The aim of this work was to study the possible harmful effects of orexin-A on intermittent hypoxemia-induced hippocampal neuronal damage and to investigate the potential underlying molecular mechanisms and signaling pathways in vitro. We established a hypoxia model in cultured rat hippocampal neurons and evaluated the effects of orexin-A by testing the apoptosis rate of the hippocampal neurons. Further studies using the extracellular signal-regulated kinase 1/2 inhibitor U0126, siRNA-PLCβ1, and siRNA-PLCβ4 were carried out to evaluate the mechanisms by which orexin-A contributes toward impairment of hippocampal neurons. The results showed that orexin-A increases intermittent hypoxemia-induced hippocampal neurons damage by overphosphorylating extracellular signal-regulated kinase 1/2 through the OXR-PLCβ1 pathway.

Identifying individual sleep apnea/hypoapnea epochs using smartphone-based pulse oximetry

Sleep apnea, characterized by frequent pauses in breathing during sleep, poses a serious threat to the healthy growth and development of children. Polysomnography (PSG), the gold standard for sleep apnea diagnosis, is resource intensive and confined to sleep laboratories, thus reducing its accessibility. Pulse oximetry alone, providing blood oxygen saturation (SpO2) and blood volume changes in tissue (PPG), has the potential to identify children with sleep apnea. Thus, we aim to develop a tool for at-home sleep apnea screening that provides a detailed and automated 30 sec epoch-by-epoch sleep apnea analysis. We propose to extract features characterizing pulse oximetry (SpO2 and pulse rate variability [PRV], a surrogate measure of heart rate variability) to create a multivariate logistic regression model that identifies epochs containing apnea/hypoapnea events. Overnight pulse oximetry was collected using a smartphone-based pulse oximeter, simultaneously with standard PSG from 160 children at the British Columbia Children's hospital. The sleep technician manually scored all apnea/hypoapnea events during the PSG study. Based on these scores we labeled each epoch as containing or not containing apnea/hypoapnea. We randomly divided the subjects into training data (40%), used to develop the model applying the LASSO method, and testing data (60%), used to validate the model. The developed model was assessed epoch-by-epoch for each subject. The test dataset had a median area under the receiver operating characteristic (ROC) curve of 81%; the model provided a median accuracy of 74% sensitivity of 75%, and specificity of 73% when using a risk threshold similar to the percentage of apnea/hypopnea epochs. Thus, providing a detailed epoch-by-epoch analysis with at-home pulse oximetry alone is feasible with accuracy, sensitivity and specificity values above 73% However, the performance might decrease when analyzing subjects with a low number of apnea/hypoapnea events.

Detecting obstructive sleep apnea in children by self-affine visualization of oximetry

Obstructive sleep apnea (OSA), characterized by cessations of breathing during sleep due to upper airway collapse, can affect the healthy growth and development of children. The gold standard for OSA diagnosis, polysomnography(PSG), is expensive and resource intensive, resulting in long waiting lists to perform a PSG. Previously, we investigated the time-frequency analysis of blood oxygen saturation (SpO₂) to screen for OSA. We used overnight pulse oximetry from 146 children, collected using a smartphone-based pulse oximeter (Phone Oximeter), simultaneously with standard PSG. Sleep technicians manually scored PSG and provided the average of apnea/hypoapnea events per hour (AHI). In this study, we proposed an alternative method for analyzing SpO₂, in which a set of contracting transformations form a self-affine set with a 2D attractor, previously developed for qualitative visualization of the photoplethysmogram and electroencephalogram. We applied this technique to the overnight SpO₂ signal from individual patients and extracted features based on the distribution of points (radius and angle) in the visualization. The cloud of points in children without OSA (NonOSA) was more confined than in children with OSA, which was reflected by more empty pixels (radius and angles). The maximum value, skewness and standard deviation of the distribution of points located at different radius and angles were significantly (Bonferroni corrected) higher in NonOSA compared to OSA children. To detect OSA defined at different levels (AHI≥5, AHI≥10 and AHI≥15), three multivariate logistic regression models were implemented using a stepwise feature selection and internally validated through bootstrapping. The models (AHI≥5, AHI≥10, AHI≥15), consisting of 3, 4 and 1 features respectively, provided a bootstrap-corrected AUC of 73%, 81%, 73%. Thus, applying this visualization to nocturnal SpO₂ could yield both visual and quantitative information that might be useful for screening children for OSA.

Quality and readability of websites for patient information on tonsillectomy and sleep apnea

OBJECTIVES

Tonsillectomy is a common treatment for obstructive sleep apnea (OSA). The Internet allows patients direct access to medical information. Since information on the Internet is largely unregulated, quality and readability are variable. This study evaluates the quality and readability of the most likely visited websites presenting information on sleep apnea and tonsillectomy.

METHODS

The three most popular search engines (Google, Bing, Yahoo) were queried with the phrase "sleep apnea AND tonsillectomy." The DISCERN instrument was used to assess quality of information. Readability was evaluated using the Flesch-Kincaid Reading Grade Level (FKGL) and Flesch Reading Ease Score (FRES).

RESULTS

Out of the maximum of 80, the average DISCERN quality score for the websites was 55.1 (SD- 12.3, Median- 60.5). The mean score for FRES was 42.3 (SD- 15.9, Median- 45.5), which falls in the range defined as difficult. No website was above the optimal score of 65. The mean score for the FKGL was US grade-level of 10.7 (SD- 1.6, Median- 11.6). Only 4(27%) websites were in the optimal range of 6-8. There was very weak correlation between FRES and DISCERN (r = 0.07) and FKGL and DISCERN (r = 0.21).

CONCLUSIONS

Tonsillectomy is one of the most common surgeries in the US. However, the internet information readily available to patients varies in quality. Additionally, much of the information is above the recommended grade level for comprehension by the public. By being aware of what information patients are reading online, physicians can better explain treatments and address misunderstandings. Physicians may consider using similar methods to test the readability for their own resources for patient education.

Tracheostomy for Severe Pediatric Obstructive Sleep Apnea: Indications and Outcomes

Objectives (1) To describe characteristics of pediatric patients undergoing tracheostomy for obstructive sleep apnea (OSA). (2) To highlight perioperative events and outcomes of the procedure. Study Design Case series with chart review. Setting Four tertiary care academic children's hospitals. Subjects and Methods Twenty-nine children aged <18 years from January 1, 2010, to December 31, 2015, who underwent tracheostomy for severe OSA, defined as an apnea-hypopnea index (AHI) >10, were included in the study. Data on patient characteristics, polysomnographic findings, comorbidities, and perioperative events and outcomes were collected and analyzed. Results Twenty-nine patients were included. Mean age at tracheostomy was 2.0 years (95% CI, -2.2 to 6.2). Mean body mass index z score was -1.2 (95% CI, -4.9 to -2.5). Mean preoperative AHI was 60.2 (95% CI, -15.7 to 136.1). Mean postoperative intensive care unit stay was 23.2 days (95% CI, 1.44-45.0). One procedure was complicated by bronchospasm. Thirteen patients had craniofacial abnormalities; 10 had a neurologic disorder resulting in hypotonia; and 5 had a diagnosis of laryngomalacia. Mean follow-up was 30.6 months (95% CI, -10.4 to 71.6). Six patients were decannulated, with a mean time to decannulation of 40.8 months (95% CI, 7.9-73.7). Five patients underwent capped sleep study prior to decannulation with a mean AHI of 6.6 (95% CI, -9.9 to 23.1) and a mean oxygen nadir of 90.0% (95% CI, 80%-100%). Conclusion OSA is an uncommon indication for tracheostomy in children. Patients who require the procedure usually have an associated syndromic diagnosis resulting in upper airway obstruction. The majority of children who undergo tracheostomy for OSA will remain dependent at 24 months.

Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing?

PURPOSE

Data in the literature suggest that myofunctional therapy (MT) may be able to play a role in the treatment of children with sleep-disordered breathing (SDB). Our study investigated the effectiveness of MT in reducing respiratory symptoms in children with SDB by modifying tongue tone.

METHODS

Polysomnographic recordings were performed at baseline to assess obstructive sleep apnea (OSA) severity in 54 children (mean age 7.1 ± 2.5 years, 29 male) with SDB. Patients were randomly assigned to either the MT or no-MT group. Myofunctional evaluation tests, an assessment of tongue strength, tongue peak pressure, and endurance using the Iowa Oral Performance Instrument (IOPI), and nocturnal pulse oximetry were performed before (T0) and after (T1) 2 months of treatment.

RESULTS

MT reduced oral breathing (83.3 vs 16.6%, p < 0.0002) and lip hypotonia (78 vs 33.3%, p < 0.003), restored normal tongue resting position (5.6 vs 33.4%, p < 0.04), and significantly increased mean tongue strength (31.9 ± 10.8 vs 38.8 ± 8.3, p = 0.000), tongue peak pressure (34.2 ± 10.2 vs 38.1 ± 7.0, p = 0.000), and endurance (28.1 ± 8.9 vs 33.1 ± 8.7, p = 0.01) in children with SDB. Moreover, mean oxygen saturation increased (96.4 ± 0.6 vs 97.4 ± 0.7, p = 0.000) and the oxygen desaturation index decreased (5.9 ± 2.3 vs 3.6 ± 1.8, p = 0.001) after MT.

CONCLUSIONS

Oropharyngeal exercises appear to effectively modify tongue tone, reduce SDB symptoms and oral breathing, and increase oxygen saturation, and may thus play a role in the treatment of SDB.

Obstructive sleep apnoea in children with obesity

AIMS

The aim of this study was to identify factors that predict risk of obstructive sleep apnoea (OSA) in obese children, which could aid in prioritising sleep studies.

METHODS

A retrospective chart review was undertaken of obese children seen in the KOALA weight management clinic and Sleep clinic. Data collected included demographics, clinical history, examination findings, biochemical markers, and polysomnogram results.

RESULTS

Two hundred seventy-two obese children were seen in the KOALA clinic out of which 54 (20%) were also seen in the Sleep clinic because of snoring. Thirty-two were referred by the KOALA clinic; the remaining 22 were referred by other medical practitioners prior to being seen in the KOALA clinic. Thirty-nine had polysomnograms. The time from referral to Sleep clinic ranged from 10 days to 1.5 years with 50% seen within 6 months; with similar time gap between the blood tests and time of polysomnograms. Thirty-six percent (14/39) were reported to have OSA. Six children were Aboriginal/Torres Strait Islander (ATSI) and all had OSA, which was statistically significant (P = 0.004). There was a statistically significant correlation between high-sensitivity C-reactive protein (hs-CRP) and obstructive event index (OEI) in rapid eye movement (REM) sleep. (r = 0.50, P = 0.04). Correlation between low-density lipoprotein (LDL) and OEI in REM was r = 0.36, P = 0.06, which approached significance.

CONCLUSIONS

Ethnicity was a significant factor with more obese ATSI children having OSA. The significant correlation between hs-CRP with OEI is consistent with findings of previous studies. Several factors (glycosylated haemoglobin, LDL) approached significance.

Sleep Symptoms and Polysomnographic Patterns of Obstructive Sleep Apnea in Obese Children

OBJECTIVE

This study was conducted to investigate the sleep symptoms and polysomnographic patterns of obstructive sleep apnea in overweight and obese children.

MATERIALS & METHODS

Overweight or obese children aging 6-18 yr old referred during 2010 to Endocrinology Clinic of Ghods Hospital in Ghazvin, central Iran were enrolled in the study. Polysomnography was done for the diagnosis of obstructive sleep apnea and the BEARS and Children's Sleep Habits questionnaires were used to survey sleep behaviors.

RESULTS

We enrolled 30 children (14 males, 16 females). Twenty-one cases had body mass index (BMI) >95% and 9 had 85%

CONCLUSION

Prevalence of obstructive sleep apnea is high among overweight and obese children. Physicians should be familiar with its manifestations and consider polysomnography as an invaluable diagnostic test. There was no relation between the degree of obesity and severity of obstructive sleep apnea.

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Key Words

• BEARS questionnaire
• Obesity
• Obstructive apnea
• Polysomnography
• Sleep apnea- hypopnea syndrome

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MESH Headings Collapse

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Affiliation(s)

Azita Tavasoli Pediatric Neurology Department, Ali-Asghar Children's Hospital, Iran University of Medical Sciences, Tehran, Iran
Shabnam Jalilolghadr Pediatrics and Sleep Disorder Department, Qods Hospital, Qazvin University of Medical Sciences, Qazvin, Iran
Shiva Lotfi General Physicians, Qazvin University of Medical Sciences, Qazvin, Iran

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Clinical symptoms and related factors of obstructive sleep apnea among overweight and obese taxi drivers

Background: Obstructive sleep apnea (OSA) is common condition in commercial drivers while overweight and obesity as the most important risk factors. This study aimed to know the clinical symptoms and risk factors of OSA in overweight and obese taxi drivers in Jakarta, Indonesia. Methods: A cross-sectional study was done in 103 taxi drivers in Jakarta from November 2011–September 2013, by systematic random sampling from 10 taxi stations. Inclusion criteria were taxi drivers with body mass index (BMI) which 23–29.9 and mild or moderate OSA. Portable polysomnography (PSG) test was used to diagnose OSA. Parametric and nonparametric test were used in bivariate analysis. Logistic regression multivariable was used to final evaluate risk factors of OSA.Results: There were 54 (52.4%) of 103 drivers with OSA and 49 (47.6%) without OSA. Clinical symptoms found significantly (p<0.05) were snoring, unrefreshing sleep, occasional sleep while driving, and headache or nausea on waking up in the morning. Risk factors for OSA were increased BMI (OR=0.60, 95% CI=0.45–0.79, p=0.001), snoring history in the family (OR=4.92, 95% CI=1.82–13.31, p=0.002) and sleep duration <7 hours within 24 hours (OR=5.14, 95% CI=1.37–19.23, p=0.015).Conclusion: Clinical symptoms of OSA were snoring, unrefreshing sleep, occasional sleep while driving and headache or nausea on waking up in the morning. Risk factors of OSA were increased BMI, snoring history in the family and sleep duration <7 hours within 24 hours.

Combination of CO2 laser-assisted uvulopalatopharyngoplasty and nasal cavity expansion enhances treatment of obstructive sleep apnea-hypopnea syndrome

This study aimed to investigate the methods, effects, and application value of a combination of CO2 laser-assisted uvulopalatopharyngoplasty (UPPP) and selective nasal cavity expansion for the treatment of multiplanar narrowing-induced obstructive sleep apnea hypopnea syndrome (OSAHS). Ninety-three patients with OSAHS and multiplanar stenosis were treated with CO2 laser-assisted modified UPPP and selective surgical expansion of the nasal cavity, with 12 completing the operation in stages. Six months after the operation, 23 patients (24.7%) were effectively cured, 52 (55.9%) had excellent efficacy, and 18 (19.4%) were cured, and the total efficacy was 100%. One year after the surgery, the surgical outcomes of 65 patients were reviewed, and the surgeries were ineffective in four (6.2%), effective in 14 (21.5%), very effective in 36 (55.4%), and curative in 11 (16.9%), and the total efficacy was 93.8%. Another 93 cases were treated with the traditional UPPP method only. At the six-month postoperative review, 18 (19.4%) were effectively cured, 30 (32.3%) had excellent efficacy, and 10 (10.8%) were cured, while the surgery was ineffective in 35 (37.6%). The total efficacy was 62.4%. One year after the surgery, the surgical outcomes of 75 patients were reviewed, and the surgeries were ineffective in 29 (38.7%), effective in 14 (18.7%), very effective in 24 (32.0%), and curative in eight (10.7%), and the total efficacy was 61.3%. Compared to the traditional operative methods, the treatment with one operation involving CO2-laser-assisted UPPP and selective nasal cavity expansion was thoroughly effective on multiple stenosis sites, including nasal, nasopharyngeal, and oropharyngeal airways. However, potential complications must be carefully avoided.

Sleep and Headache

The interaction between sleep and headache or migraine is powerful and an elevated comorbidity between these 2 disorders has been reported in either adults or children. This comobidity is linked to common neurophysiological and neuroanatomical substrates that are genetically based strongly. The first reports on this relationship were related to the prevalence of parasomnias and sleep-disordered breathing in headache but recent research has expanded the comorbidity to several other sleep disorders, such as restless legs syndrome, periodic limb movements during sleep, and narcolepsy. The assessment of children with headache should always include an accurate anamnesis for the presence of sleep problems either in the child or in the relatives; no correct approach for treating children and adolescents is possible without an integrated method of evaluation and management.

Sleep disordered breathing risk in childhood cancer survivors: an exploratory study

BACKGROUND

Sleep disordered breathing (SDB) is emerging as a significant health condition for children. The purpose of this study is to evaluate SDB symptoms in childhood cancer survivors and identify associations with quality of life (QOL) and psychological symptoms.

PROCEDURE

A sample of 62 survivors aged 8-18 years were recruited during routine survivorship visits. All subjects and their parents completed questionnaires to evaluate sleep, QOL and psychological symptoms; scales included were: Pediatric Sleep Questionnaire, Sleep Disordered Breathing Subscale (PSQ-SDBS), Pediatric Quality of Life Inventory (PedsQL) and Depression Anxiety Stress Scale (DASS-21). Continuous data were used for all scales and a threshold score of >0.33 on the PSA-SDBS was used to identify risk of SDB. The relationships between measures of sleep and independent variables were examined using Pearson correlations and multiple linear regression models for significant associations.

RESULTS

Of the 62 subjects enrolled, underlying diagnoses included 29 leukemias, 30 solid tumors and 3 non-malignant diseases. Nineteen percent of subjects were identified as having SDB risk on the PSQ-SDBS. The lowest mean PedsQL subscale score for parent and child ratings were school QOL; Parent mean 73(±SD 19) and Child mean 71(±SD 20). The severity of SDB per the PSQ was significantly associated with reduced total and school QOL which remained significant after adjusting for stress.

CONCLUSIONS

Symptoms suggestive of SDB are common in childhood cancer survivors with negative implications for overall quality of life and school performance.

Sleep and breathing in premature infants at 6 months post-natal age

Background

Poor sleep contributes to the developmental problems seen in preterm infants. We evaluated sleep problems in preterm infants 6 months of post-gestational age using the subjective Brief Infant Sleep Questionnaire (BISQ) and objective sleep tests. We also compared the sleep of premature infants with that of full-term infants.

Methods

The study included 68 6-month-old full-term healthy infants and 191 premature infants born at <37 weeks gestation. All parents completed the BISQ-Chinese version and sleep diaries. At the same time, all premature infants were submitted to one night of polysomnography (PSG) in the sleep laboratory and also were set up with an actigraph kept for 7 days. Statistical analyses were performed using correlation coefficients and the t-test with SPSS version 18 to compare questionnaire responses with other subjective and objective measures of sleep.

Results

The sleep problems indicated in the subjective questionnaire for the premature infants, particularly: “the nocturnal sleep duration, number of night awakenings, daytime sleep duration, duration of time with mouth breathing, and loud-noisy breathing” had significant correlations with sleep diaries, actigraphy and PSG results. The BISQ showed that duration of infant’s sleeping on one side, nocturnal sleep duration, being held to fall asleep, number of nighttime awakenings, daytime sleep duration, subjective consideration of sleep problems, loud-noisy breathing, and duration spent crying during the night were significantly different between the premature infants and the term infants. PSG confirmed the presence of a very high percentage (80.6%) of premature infants with AHI > 1 event/hour as indicated by the questionnaire.

Conclusion

Premature infants have more sleep problems than full-term infants, including the known risk of abnormal breathing during sleep, which has been well demonstrated already with the BISQ-Chinese (CBISQ).

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-014-0303-6) contains supplementary material, which is available to authorized users.

Evaluation of a new pediatric positive airway pressure mask

STUDY OBJECTIVES

The choice and variety of pediatric masks for continuous positive airway pressure (CPAP) is limited in the US. Therefore, clinicians often prescribe modified adult masks. Until recently a mask for children aged < 7 years was not available. This study evaluated apnea-hypopnea index (AHI) equivalence and acceptability of a new pediatric CPAP mask for children aged 2-7 years (Pixi; ResMed Ltd, Sydney, Australia).

METHODS

Patients aged 2-7 years were enrolled and underwent in-lab baseline polysomnography (PSG) using their previous mask, then used their previous mask and the VPAP III ST-A flow generator for ≥ 10 nights at home. Thereafter, patients switched to the Pixi mask for ≥ 2 nights before returning for a PSG during PAP therapy via the Pixi mask. Patients then used the Pixi mask at home for ≥ 21 nights. Patients and their parents/guardians returned to the clinic for follow-up and provided feedback on the Pixi mask versus their previous mask.

RESULTS

AHI with the Pixi mask was 1.1 ± 1.5/h vs 2.6 ± 5.4/h with the previous mask (p = 0.3538). Parents rated the Pixi mask positively for: restfulness of the child's sleep, trouble in getting the child to sleep, and trouble in having the child stay asleep. The Pixi mask was also rated highly for leaving fewer or no marks on the upper lip and under the child's ears, and being easy to remove.

CONCLUSIONS

The Pixi mask is suitable for children aged 2-7 years and provides an alternative to other masks available for PAP therapy in this age group.

Detection of sleep apnea by case-finding and home monitoring with Somnolter®: a pilot study

BACKGROUND

Obstructive sleep apnea and hypopnea syndrome (OSAHS) is a disorder that causes clinical symptoms (e.g. snoring, excessive daytime sleepiness and impaired concentration) that may increase the risk of traffic accidents, cardiovascular disease, type 2 diabetes and reduce the quality of life. A recently developed device (Somnolter®) detects apneas and hypopneas in a home setting, allowing to detect OSAHS in a more comfortable environment compared to the gold standard polysomnography. The aim of our study was to investigate whether the Somnolter® is useful in family practice to identify patients with OSAHS.

METHODS

Questionnaires were offered to patients in five general practitioner (GP) practices.Based on the questionnaire and body mass index, patients with an increased risk of OSAHS were contacted to collaborate in the study. In this convenience sample, 18 patients were successfully tested with the Somnolter® measuring SaO2, mandibular movements, body position, heart rate, nasal air flow and thoracic and abdominal breathing movements. The Somnolter® automatically analyses the data and different parameters to detect OSAHS. Afterwards, the data were manually revised by the researchers.

RESULTS

Out of 365 subjects, 31 met the inclusion criteria and 18 were successfully tested at home. Sixteen out of 18 patients had an Apnea Hypopnea Index (AHI) ≥ 5, ten of them had mild OSAHS, 3 were categorized as moderate OSAHS and finally 3 matched the criteria of severe OSAHS.

CONCLUSION

The proposed case-finding strategy still needs optimization, but is considered helpful in selecting patients at high risk of OSAHS. OSAHS was detected in 14 out of 18 patients tested with the Somnolter®. In the future the Somnolter® might be a feasible alternative to diagnose OSAHS.

Prevalence and associated factors of pulmonary hypertension in Kenyan children with adenoid or adenotonsillar hypertrophy

OBJECTIVES

Adenotonsillar hypertrophy is a common condition in childhood, whose serious complications of pulmonary hypertension and cor pulmonale are devastating but local prevalence is unknown. This study determined the prevalence and associated factors of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy at Kenyatta National Hospital, Kenya.

METHODS

This was a cross sectional hospital based survey conducted among children below 12 years of age with clinical and radiological adenoid hypertrophy attending the ear, nose and throat (ENT) outpatient clinic and general pediatric wards. Doppler echocardiography was used to determine pulmonary hypertension defined as a mean pulmonary arterial pressure (mPAP) of ≥ 25 mm Hg using the Chemla equation. Children with mPAP of ≥ 25 mm Hg were compared to those with lower pressures and clinical and radiological factors associated with pulmonary hypertension determined using multivariate logistic regression analysis.

RESULTS

Of the 123 eligible children in the study, 27 had pulmonary hypertension giving a prevalence of 21.9% (95% CI 14.64%-29.27%). Independent factors associated with pulmonary hypertension included nasal obstruction (OR=3.0 [95% CI 1.08-8.44] p=0.035) and hyperactivity on history (OR=0.2 [95% CI 0.07-0.59] p=0.003) and adenoid-nasopharyngeal ratio (ANR) >0.825 on lateral neck radiography (OR=5.0 [95% CI 1.01-24.37] p=0.048).

CONCLUSION

One in five children with adenoid or adenotonsillar hypertrophy had pulmonary hypertension with a 3-fold and 5-fold increased odds in those with nasal obstruction on history and ANR >0.825 on lateral neck radiography respectively and an 80% reduced odds in reportedly hyperactive children.

Oropharyngeal exercises to reduce symptoms of OSA after AT

PURPOSE

This study evaluated the efficacy of oropharyngeal exercises in children with symptoms of obstructive sleep apnea syndrome (OSA) after adenotonsillectomy.

METHODS

Polysomnographic recordings were performed before adenotonsillectomy and 6 months after surgery. Patients with residual OSA (apnea-Hypopnea Index, AHI > 1 and persistence of respiratory symptoms) after adenotonsillectomy were randomized either to a group treated with oropharyngeal exercises (group 1) or to a control group (group 2). A morphofunctional evaluation with Glatzel and Rosenthal tests was performed before and after 2 months of exercises. All the subjects were re-evaluated after exercise through polysomnography and clinical evaluation. The improvement in OSA was defined by ΔAHI: (AHI at T1 - AHI at T2)/AHI at T1 × 100.

RESULTS

Group 1 was composed of 14 subjects (mean age, 6.01 ± 1.55) while group 2 was composed of 13 subjects (mean age, 5.76 ± 0.82). The AHI was 16.79 ± 9.34 before adenotonsillectomy and 4.72 ± 3.04 after surgery (p < 0.001). The ΔAHI was significantly higher in group 1 (58.01 %; range from 40.51 to 75.51 %) than in group 2 (6.96 %; range from -23.04 to 36.96 %). Morphofunctional evaluation demonstrated a reduction in oral breathing (p = 0.002), positive Glatzel test (p < 0.05), positive Rosenthal test (p < 0.05), and increased labial seal (p < 0.001), and lip tone (p < 0.05).

CONCLUSIONS

Oropharyngeal exercises may be considered as complementary therapy to adenotonsillectomy to effectively treat pediatric OSA.

Effects of adenotonsillectomy on neurocognitive function in pediatric obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) in children does not only present with symptoms of sleep disturbances but also with associated symptoms such as growth failure, enuresis, academic learning difficulties, and behavioral problems, including attention deficit/hyperactivity disorder- (ADHD-) like symptoms. We evaluated neurocognitive functions before and after adenotonsillectomy in a patient with OSAS. An 11-year-old boy suspected of having ADHD with nocturnal enuresis was referred for evaluation. He was found to have adenotonsillar hypertrophy. Presence of snoring was evident only after detailed medical interview. Polysomnography confirmed the diagnosis of OSAS, which was subsequently treated by adenotonsillectomy. The apnea/hypopnea index decreased from 21.9 at baseline to 1.8 after surgery, and the frequency of enuresis fell from almost nightly to 2-3 times per month. Neurocognitive and behavioral assessment after the treatment of OSAS showed significant improvement in cognitive functions, especially attention capacity and considerable amelioration of behavioral problems including ADHD-like symptoms. As the most common cause of pediatric OSAS is adenotonsillar hypertrophy, medical interview and oropharyngeal examination should always be performed in children suspected of having ADHD. The necessity of sleep evaluation for children with ADHD-like symptoms was also emphasized.

Long-term moderate dose exogenous erythropoietin treatment protects from intermittent hypoxia-induced spatial learning deficits and hippocampal oxidative stress in young rats

Exposure to intermittent hypoxia (IH) is associated with cognitive impairments and oxidative stress in brain regions involved in learning and memory. In earlier studies, erythropoietin (EPO) showed a neuroprotective effect in large doses. The aim of the present study was to explore the effect of smaller doses of EPO, such as those used in the treatment of anemia, on IH-induced cognitive deficits and hippocampal oxidative stress in young rats. The effect of concurrent EPO treatment (500 and 1,000 IU/kg/day ip) on spatial learning and memory deficits induced by long-term exposure to IH for 6 weeks was tested using the Morris water maze (MWM) test and the elevated plus maze (EPM) test. Moreover, the effect on hippocampal glutamate and oxidative stress were assessed. Exposure to IH induced a significant impairment of spatial learning and cognition of animals in both MWM and EPM performance parameters. Moreover, hippocampal glutamate and thiobarbituric acid reactive substances (TBARS) increased while antioxidant defenses (GSH and GSH-Px) decreased. EPO in the tested doses significantly reduced the IH-induced spatial learning deficits in both MWM and EPM tests and dose-dependently antagonized the effects of IH on hippocampal glutamate, TBARS, GSH levels, and GSH-Px activity. Treatment with EPO in moderate doses that used for anemia, concurrently with IH exposure can antagonize IH-induced spatial learning deficits and protect hippocampal neurons from IH-induced lipid peroxidation and oxidative stress-induced damage in young rats, possibly through multiple mechanisms involving a potential antioxidative effect.

Pediatric obstructive sleep apnea syndrome

Pediatric obstructive sleep apnea syndrome (OSAS) is a common health problem diagnosed and managed by various medical specialists, including family practice physicians, pediatricians, pulmonologists, and general and pediatric otolaryngologists. If left untreated, the sequelae can be severe. Over the last decade, significant advancements have been made in the evidence-based management of pediatric OSAS. This article focuses on the current understanding of this disease, its management, and related clinical practice guidelines.

New therapeutics in promoting and modulating mandibular growth in cases with mandibular hypoplasia

Children with mandibular growth deficiency may develop airway obstruction. The standard treatment of severe airway obstruction involves invasive procedures such as tracheostomy. Mandibular distraction osteogenesis has been proposed in neonates with mandibular deficiency as a treatment option to avoid tracheostomy procedure later in life. Both tracheostomy and distraction osteogenesis procedures suffer from substantial shortcomings including scarring, unpredictability, and surgical complications. Forward jaw positioning appliances have been also used to enhance mandible growth. However, the effectiveness of these appliances is limited and lacks predictability. Current and future approaches to enhance mandibular growth, both experimental and clinical trials, and their effectiveness are presented and discussed.

Effects of twin block appliance on obstructive sleep apnea in children: a preliminary study

BACKGROUND

Oral appliances are increasingly advocated as a treatment option for obstructive sleep apnea (OSA). However, it is not clear how the different designs influence treatment efficacy in children. The aim of this study was to investigate the effects of twin block (TB) appliance on children with OSA and mandibular retrognathia.

METHODS

A total of 46 children (31 males, 15 females, aged 9.7 ± 1.5 years, BMI: 18.1 ± 1.04 kg/m(2)) diagnosed with mandibular retrognathia and OSA by polysomnography (PSG) and with no obesity or adenotonsillar hypertrophy were recruited for the study. Patients in the treatment group were instructed to wear the twin block oral appliance full time for an average of 10.8 months. The efficacy of treatment was determined by monitoring the PSG and cephalometric changes before and after appliance removal. Data were analyzed using paired t test.

RESULTS

Results showed an improvement in patient's facial profile after treatment with the TB appliance. The average AHI index decreased from 14.08 ± 4.25 to 3.39 ± 1.86 (p < 0.01), and the lowest SaO2 increased from 77.78 ± 3.38 to 93.63 ± 2.66 (p < 0.01). Cephalometric measurements showed a significant increase in the superior posterior airway space, middle airway space, SNB angle and facial convexity which indicate an enhancement in mandibular growth, and reduction in the soft palate length.

CONCLUSIONS

This preliminary study suggests that twin block appliance may improve the patient's facial profile and OSA symptoms in a group of carefully selected children presented with both OSA and mandibular retrognathia symptoms.

Multiple system morbidities associated with children with snore symptom

OBJECTIVE

To exam the relationship between snoring and morbidities of multiple systems in children.

STUDY DESIGN

Children with snoring were enrolled and divided into primary snorer (PS) group and obstructive sleep apnea hypopnea syndrome (OSAHS) group based on polysomnography. The healthy children served as the control group. The growth parameters, maxillofacial malformations, blood chemistry, electrocardiogram, and echocardiogram were recorded and intelligence testing was performed in the enrolled children who were ≥6 years old.

RESULTS

The weight and height were similar in the control group (n = 60) and the PS group (n = 63), but lower in the OSAHS group (n = 89; P < 0.001). Occurrence of adenoidal face and dental malocclusion in the OSAHS and the PS group was significantly higher than that in the control group (P < 0.001). Compared with the control group, the OSAHS group had a lower serum high-density lipoprotein cholesterol level, higher low-density lipoprotein cholesterol level; and a possible higher pulmonary artery pressure based on the echocardiogram (P < 0.001). All the above parameters in the PS group were similar to those in the control group. Full-scale IQ and performance IQ of the OSAHS group was lower (P < 0.001), attention deficits were significantly higher in the OSAHS group (P < 0.001), but were similar in the PS group when compared to the control group.

CONCLUSIONS

OSAHS in children is associated with delayed growth, maxillofacial malformations, impaired cognitive functions, abnormalities in lipid metabolism, and changes in pulmonary artery pressures. PS children also have higher incidence of maxillofacial malformations but have a normal growth and normal cognitive functions.

Lower health related quality of life and psychosocial difficulties in children with monosymptomatic nocturnal enuresis--is snoring a marker of severity?

PURPOSE

Sleep disordered breathing in children is linked to numerous negative psychosocial consequences, including lower health related quality of life, increased behavioral problems and impaired neuropsychological functioning. We examined whether snoring, which is the least severe form of sleep disordered breathing, or health related quality of life could account for the increased rate of psychosocial difficulty in children with monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

Patients diagnosed with monosymptomatic nocturnal enuresis seen at an outpatient pediatric urology clinic completed measures of health related quality of life (Obstructive Sleep Apnea Syndrome-18-Item Questionnaire), sleep disordered breathing (Pediatric Sleep Questionnaire) and psychosocial difficulty (Pediatric Symptom Checklist). Patients were categorized into 2 groups (snoring vs no snoring) based on the Pediatric Symptom Checklist snoring subscale score.

RESULTS

Included in the study were 62 males and 45 females with a mean ± SD age of 9.09 ± 2.58 years and a mean body mass index of 21.00 ± 6.93 kg/m(2) (range 13 to 49). The sample was evenly split between 56 snorers (52.3%) and 51 nonsnorers (47.7%). Compared to children with monosymptomatic nocturnal enuresis who did not snore, MANCOVA results revealed that patients with monosymptomatic nocturnal enuresis who snored had significantly more externalizing problems and total psychosocial problems, in addition to significantly more impairment in all areas of health related quality of life.

CONCLUSIONS

Snoring in children with monosymptomatic nocturnal enuresis puts them at increased risk for behavioral and psychosocial problems, in addition to impaired health related quality of life. These findings support the need for future studies of the neurological links between sleep disordered breathing and monosymptomatic nocturnal enuresis.

Quality of life and sleep in obese adolescents

Obesity and sleep disorders in adolescence are strongly associated, and they impact both on the health and on quality of life (QL) in this age group.

OBJECTIVE

To comparatively assess QL and sleep in obese and eutrophic adolescents, who are older than ten years of age.

METHODS

Cross-sectional study including obese adolescents. This analysis was carried out between August 2009 and August 2010. The Control (eutrophic) Group comprised schoolchildren recruited from State schools in the city of Americana, in São Paulo State, Brazil. Instruments applied included a standardized questionnaire, the Sleep Behavior Questionnaire (SBQ), and the Pediatric QL Inventory (PedsQL TM 4.0).

RESULTS

The obese adolescents had poorer QL on physical (p<0.001), emotional (p=0.03), and social (p=0.002) functioning domains. A difference in mean psychosocial functioning was found between the groups (p=0.009) with obese subjects having a mean score of 69.5 (±16.0) and in eutrophic individuals of 76.2 (±16.7). A greater number of sleep problems was evident in the Obese Group (p=0.03).

CONCLUSIONS

The obese adolescents had an impaired QL and a higher frequency of sleep problems compared to the eutrophic subjects.

Apnea and oxygen desaturations in children treated with opioids after adenotonsillectomy for obstructive sleep apnea syndrome: a prospective pilot study

BACKGROUND

Recent case reports have alerted the medical community of fatality in children receiving codeine after tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome.

OBJECTIVE

The objective of this study was to compare the rates of oxygen desaturation before and after adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS), and to examine the relationship between cytochrome P450 2D6 (CYP2D6) genotype and respiratory events.

STUDY DESIGN

This was a prospective observational study.

METHODS

Twenty-six children with OSAS (mean age 78 months, range 1.8-17 years) who underwent adenotonsillectomy were studied. CYP2D6 genotype was characterized in 21 of these children. The primary endpoints of the study were the change in the rate of desaturation and in the nadir oxygen saturation values before and in the first 24 hours after surgery as measured by pulse oximetry.

RESULTS

Twenty-two children received codeine and four were managed with hydrocodone. There was no post-operative improvement in the mean rate of desaturation (1.84 ± 1.45/hour pre-operative vs 2.97 ± 3.3/hour post-operative; p = 0.119; 95% CI -2.56, 0.313), or the post-operative nadir of oxygen saturation (85.2 ± 5.8% pre-operative vs 84.0 ± 6.8% post-operative; p = 0.632; 95% CI -3.00, 4.84) on the night after surgery. Prior to surgery, six children had an oxygen saturation nadir <80%, while post-surgery, the number increased to eight children. Ten children improved their parameters after surgery. CYP2D6 genotype by itself did not predict the changes in desaturation or nadir.

CONCLUSION

Post-operative use of opioids following OSAS may not be safe for all children. It is conceivable that if the child is among the significant proportion that experiences increased oxygen desaturations, the CNS depressing effects of codeine or hydrocodone and their respectively potent morphine or hydromorphone metabolites can further compromise respiratory drive. Larger studies are needed to investigate the potential contribution of CYP2D6 genotype.