Natural history of snoring and obstructive sleep apnea in Thai school-age children

Worldwide prevalence and associated risk factors of obstructive sleep apnea: a meta-analysis and meta-regression

PURPOSE

This study aimed to identify the prevalence of obstructive sleep apnea (OSA) and associated risk factors globally.

METHODS

Six databases and registrations and three grey databases were explored for observational field research. Independently and impartially paired reviewers selected research, gathered data, and evaluated the methodological quality. Heterogeneity was investigated using subgroup analysis and meta-regression following the moderating variable in a meta-analysis of proportions with a random-effects model. The critical appraisal instrument developed by the Joanna Briggs Institute was used to evaluate the listed studies' methodology. The certainty of the evidence was evaluated using the GRADE tool.

RESULTS

A total of 8236 articles were collected during the database search, resulting in 99 articles included for qualitative synthesis, and 98 articles were included for the meta-analysis. The estimated combined prevalence of OSA was 54% [CI 95% = 46-62%; I2 = 100%]. Mean age, percentage of moderate-severe cases, and the sample's body mass index (BMI) did not affect the heterogeneity that was already present when meta-regressed (p > 0.05). Ninety-one studies were deemed to have a low risk of bias, while eight were deemed to have a moderate risk. For OSA prevalence outcomes, the GRADE criteria were considered very low.

CONCLUSION

Approximately half of the people worldwide have OSA. High BMI, increasing age, and male gender are described as risk factors in the literature, but these covariates do not affect pre-existing heterogeneity.

Arabic translation and validation of a pediatric sleep questionnaire to assess the prevalence of sleep-disordered breathing among Saudi pre-school children

OBJECTIVES

(1) To translate to Arabic a validated pediatric sleep questionnaire, (2) To assess the validity and reliability of the translated questionnaire, and (3) To assess the prevalence of sleep-disordered breathing (SDB) among a group of pre-school children in Jeddah, Saudi Arabia.

METHODS

Using forward and back-translation, a set of 6 hierarchically arranged questions that comprise the Gozal sleep questionnaire was translated into Arabic. Validity was assessed using face validity and content validity for consistency and clarity, using both item-level and scale-level content validity indices (I-CVI, S-CVI). Consent forms were sent to 1783 mothers recruited from 8 different pre-schools in Jeddah between October 2017 and April 2018, and 209 signed and returned the consent forms. Out of this sample, 34 mothers were contacted to assess internal consistency using Cronbach's alpha, and test-retest reliability using Interclass correlation coefficient (ICC). Finally, all 209 mothers were contacted to answer the questionnaire to obtain the prevalence of SDB.

RESULTS

Using face validity and content validity, the translated questionnaire proved to be valid with perfect I-CVI and S-CVI. Internal consistency (Cronbach's Alpha 0.64-0.89) and test-retest reliability (ICC=0.87, p<0.001) showed the translated questionnaire to have good to favorable reliability. Depending on the severity of SDB, the prevalence of SDB was 7.7%, 5.7%, and 3.8% for mild, moderate and severe cut-off values respectively.

CONCLUSION

A validated pediatric sleep questionnaire to assess SDB was translated into Arabic and the translation proved to be valid and reliable. The prevalence of SDB was found to be very comparable to other areas in the world.

Prevalence and Risk Factors for Rapid Eye Movement-Related Obstructive Sleep Apnea in Children

OBJECTIVES

Different pathophysiological mechanisms and the distribution of respiratory events among rapid eye movement (REM) and non-rapid eye movement (NREM) sleep modulate the effect of obstructive sleep apnea (OSA). We aimed to study the prevalence and risk factors for REM-related OSA in children.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

We recruited 366 children with OSA confirmed by polysomnography (PSG) over a 5-year period. REM-related OSA is defined by an obstructive apnea-hypopnea index (OAHI) in the REM sleep ≥2× than during NREM sleep.

RESULTS

The prevalence of REM-related OSA in children was 50.3%. Children with REM-related OSA were more likely to be female (P = 0.042), and had lower prevalence of adenotonsillar hypertrophy (P = 0.043) compared with children with other OSA subtypes. Children with REM-related OSA slept longer in the supine position (P = 0.003), had shorter duration of NREM1 sleep (P = 0.018), lower nadir SpO₂ (P = 0.005), and a higher oxygen desaturation index 3% (ODI3%) (P = 0.014), and lower arousal index (P = 0.034) compared with other OSA subtypes. Female gender and supine sleep was the independent risk factors for REM-related OSA.

CONCLUSION

The prevalence of REM-related OSA was 50.3%. OAHI_REM should be considered as an important parameter in future clinical research studies done in children with OSA.

Sleep-Related Breathing Problem Trajectories Across Early Childhood and Academic Achievement-Related Performance at Age Eight

Background: Childhood sleep disordered breathing (SDB) has been linked to poorer academic performance; however, research has not investigated the extent improvement in SDB may alter outcomes across key academic skills. This study aimed to investigate if children's early SDB status could predict later academic outcomes, and if an improvement in SDB status across the early childhood years would coincide with better, later performance in key academic skills related to reading, numeracy, and listening comprehension.

Methods: Eighty five case children with an SDB symptom score >25 (maximum 77) were matched to 85 control children (score <12) at recruitment (age 3). SDB severity (symptom history and clinical assessment) was evaluated at ages 3, 4, 6, and 8 years and performance on individually-administered academic skills assessed at age 8 (91% retention from age 3). Case children were categorized into “improved” or “not-improved” groups based on SDB trajectories over the 5 years. Contributions of SDB status and trajectory group to academic performance were determined using regression analysis adjusted for demographic variables.

Results: History of SDB from age 3 predicted significantly poorer performance on some key academic skills (oral reading and listening skills) at age 8. Children whose SDB improved (45%) performed better in oral reading fluency than those whose SDB did not improve, but difficulties with specific tasks involving oral language (listening retell) remained when compared to controls.

Conclusion: Findings support links between early SDB and worse academic outcomes and suggest key academic areas of concern around oral language. Findings highlight the need for child mental health professionals to be aware of children's sleep problems, particularly SDB (past and present), when assessing potential barriers to children's achievement, to assist with appropriate and timely referrals for evaluation of children's sleep difficulties and collaborative evaluation of response to intervention for sleep difficulties.

Supplemental Oxygen for Treatment of Infants With Obstructive Sleep Apnea

STUDY OBJECTIVES

Supplemental oxygen has been shown to decrease the frequency of obstructive respiratory events during sleep, but may result in alveolar hypoventilation. Limited information exists on the effect of supplemental oxygen on sleep and respiratory events in infants with obstructive sleep apnea (OSA).

METHODS

We conducted a retrospective study of infants with OSA who had sleep studies performed from 2007-2012. All infants underwent a room air diagnostic sleep study (RA-PSG), followed by a sleep study while breathing supplemental oxygen via nasal cannula (O₂-PSG) on a separate night. Infants with split-night studies or with inadequate sleep time were excluded.

RESULTS

Fifty-nine infants met criteria for entry into analysis. The mean age of infants at the time of RA-PSG was 13.0 ± 11.7 weeks and at O₂-PSG was 15.4 ± 13.0 weeks. The obstructive AHI decreased from 19.7 ± 13.0 during RA-PSG to 10.6 ± 11.7 during O₂-PSG (P < .001). The duration of longest obstructive apnea increased from 11.0 ± 4.2 seconds to 13.4 ± 7.4 seconds (P = .01). The lowest saturation associated with obstructive apneas increased from 80.7 ± 6.8% to 90.0 ± 6.7% (P < .001). Carbon dioxide data showed no difference in ventilation after supplemental oxygen administration. There was no significant change in the spontaneous arousal index, however, the percentage of respiratory events associated with arousal increased from 20.7 ± 11.1% to 35.7 ± 19.7% (P < .001).

CONCLUSIONS

Infants with OSA who received supplemental oxygen had a significant decrease in the frequency of obstructive respiratory events and improved oxygenation without adverse effect on alveolar ventilation. These data suggest that supplemental oxygen may be an effective treatment for infants with OSA who are not good candidates for continuous positive airway pressure or surgery.

CITATION

Brockbank J, Astudillo CL, Che D, Tanphaichitr A, Huang G, Tomko J, Simakajornboon N. Supplemental oxygen for treatment of infants with obstructive sleep apnea. J Clin Sleep Med. 2019;15(8):1115-1123.

Parent report of children's sleep disordered breathing symptoms and limited academic progress in reading, writing, and math

OBJECTIVES

To estimate via questionnaire within a population sample of New Zealand (NZ) children aged 6-to-10 years, the prevalence of sleep disordered breathing (SDB) and those struggling academically, and to identify individual and shared risk factors (health and demographic) for parent-reported SDB symptoms and academic difficulties.

METHODS

In this cross-sectional study, parents/caregivers of children were recruited through schools and social media to complete an online questionnaire covering health and demographic factors, their children's SDB symptoms (Pediatric Sleep Questionnaire; PSQ) and parental ratings of academic performance based on teacher feedback relative to expected progress in the national curriculum (well below/below/at/above) in reading, writing, and math.

RESULTS

A total of 1205 children (53% male) aged (mean) eight years two months were included, comprising 79.4% NZ European/other and 15.0% Māori. The survey-weighted prevalence of SDB (based on the PSQ) was 17.5%. This was higher amongst those with academic difficulties rated 'below/well below' expected progress for reading, writing and math (estimated at 24.0%, 31.0% and 27.5% respectively), with increased odds (adjusted odds ratios) for poor progress of 1.9 (95% CI: 1.2, 3.0), 1.8 (95% CI: 1.2, 2.7) and 2.4 (95% CI: 1.6, 3.7) respectively. There were no shared risk factors common to both SDB and academic difficulties identified from multivariate analyses.

CONCLUSIONS

The findings suggest that children with parent-reported SDB symptoms may be at high risk for poor progress in reading, writing, and math. Future research could examine whether treatment of SDB reduces barriers to learning and offsets educational risk.

Childhood obesity, weight loss and developmental trajectories predict the persistence and remission of childhood sleep-disordered breathing

BACKGROUND

Obesity has been recognized as a risk factor for childhood sleep-disordered breathing (SDB), yet it remains unclear how obesity and weight change predict the course of childhood SDB.

OBJECTIVE

The objective of the study is to investigate the role of body weight, upper airway abnormalities and developmental trajectories on the persistence and remission of childhood SDB in the transition to adolescence.

METHODS

The Penn State Child Cohort is a representative population sample of 700 children (5-12 years), of whom 421 were followed up as adolescents (12-23 years). Participants underwent a clinical history, physical examination and polysomnography at both time points.

RESULTS

Obesity and enlarged tonsils were cross-sectionally associated with childhood SDB. Longitudinally, baseline obesity predicted the persistence of childhood SDB (OR = 3.75, 95% CI = 2.00-7.05), while weight loss predicted its remission (OR = 1.67, 95% CI = 1.11-2.50). Children with enlarged tonsils who remitted from SDB had not experienced significant weight loss and only 4.4% had undergone adeno/tonsillectomy. Body fat distribution/composition at follow-up was similar in those who had remitted from childhood SDB as compared with those who had never experienced SDB, while those who persisted with childhood SDB showed significant android distribution and visceral adiposity at follow-up.

CONCLUSIONS

Our data support a causal role for obesity and weight loss in the chronicity and remission, respectively, of childhood SDB in the transition to adolescence and suggest that remission of SDB is related to developmental trajectories of the upper airway in a significant proportion of children. Thus, targeting childhood obesity and weight gain should be a priority in the prevention and treatment of SDB during this critical developmental period.

Prevalence of Sleep Disorders in Thai Children

OBJECTIVE

To evaluate the prevalence of sleep disorders in Thai children who underwent polysomnography at a single institution.

METHODS

A retrospective analysis of pediatric polysomnographic studies was performed from January 2011 through December 2014.

RESULTS

One hundred sixty-six studies were conducted; 142, 7, and 17 were diagnostic, split-night, and positive airway pressure (PAP) titration studies, respectively. In total, 136 diagnostic/split-night studies were performed to diagnose sleep disorders with presentation of snoring (92.6 %), heavy breathing (0.7 %), witnessed apnea (14.7 %), excessive daytime sleepiness (10.3 %), hyperactivity (2.2 %), restless sleep (11.0 %), enuresis/nocturia (5.9 %), abnormal behavior (4.4 %) and poor weight gain (0.7 %). Eleven diagnostic studies and one split-night study were performed to follow-up obstructive sleep apnea (OSA) after adenoidectomy and/or tonsillectomy. One diagnostic study was conducted to follow-up OSA after postmandibular distraction. OSA was the most common diagnosis with a prevalence of 92.7 %; 40.4 % of patients were diagnosed with severe OSA. The prevalence of sleep-related hypoventilation was 15.4 %. The second most common diagnosis was periodic limb movement disorder with a prevalence of 20.6 %. Seventeen PAP titration studies were performed. Four CPAP titration studies were conducted for OSA treatment. Twelve bi-level (BiPAP) titration studies were performed in eight children with hypoventilation. One BiPAP/average volume-assured pressure support titration was conducted in a patient with congenital central hypoventilation syndrome (CCHS).

CONCLUSIONS

The prevalence of sleep disorders in Thai children who underwent polysomnography at a tertiary-care hospital is very high. The factors that contribute are the limited availability and high costs of polysomnography in Thailand. This information will encourage pediatricians to look for sleep disorders in children.

Natural history of sleep disordered breathing in prepubertal children transitioning to adolescence

Because there is a lack of agreed upon diagnostic criteria, it is critical to understand the natural history of obstructive sleep apnoea (OSA) in children in order to establish treatment strategies based on objective data.The Penn State Child Cohort is a representative, general-population sample of 700 elementary school children at baseline, of whom 421 were reassessed 8 years later, during adolescence.The remission of childhood apnoea-hypopnoea index (AHI) ≥2 events per h in adolescence was 52.9%. Using the higher threshold of AHI ≥5 events per h, remission was 100.0%, with 50.0% partially remitting to AHI 2- <5 events per h and the other half remitting to AHI <2 events per h. The incidence of adolescent AHI ≥2 events per h in those with childhood AHI <2 events per h was 36.5%, while the incidence of AHI ≥5 events per h in those with childhood AHI <5 events per h was 10.6%. This longitudinal study confirms that prepubertal OSA tends to resolve naturally during the transition to adolescence, and that primary snoring and mild sleep disordered breathing (SDB) do not appear to be strongly associated with progression to more severe SDB.The key risk factors for SDB in adolescence are similar to those found in middle-aged adults (i.e. male sex, older age and obesity). Moreover, consistent with recent studies in adults, this study includes the novel cross-sectional finding that visceral fat is associated with SDB as early as adolescence.

Prognosis for Spontaneous Resolution of OSA in Children

BACKGROUND

Adenotonsillectomy (AT) is commonly performed for childhood OSA syndrome (OSAS), but little is known about prognosis without treatment.

METHODS

The Childhood Adenotonsillectomy Trial (CHAT) randomized 50% of eligible children with OSAS to a control arm (watchful waiting), with 7-month follow-up symptom inventories, physical examinations, and polysomnography. Polysomnographic and symptomatic resolution were defined respectively by an apnea/hypopnea index (AHI) <2 and obstructive apnea index (OAI) <1 and by an OSAS symptom score (Pediatric Sleep Questionnaire [PSQ]) < 0.33 with ≥ 25% improvement from baseline.

RESULTS

After 194 children aged 5 to 9 years underwent 7 months of watchful waiting, 82 (42%) no longer met polysomnographic criteria for OSAS. Baseline predictors of resolution included lower AHI, better oxygen saturation, smaller waist circumference or percentile, higher-positioned soft palate, smaller neck circumference, and non-black race (each P < .05). Among these, the independent predictors were lower AHI and waist circumference percentile < 90%. Among 167 children with baseline PSQ scores ≥ 0.33, only 25 (15%) experienced symptomatic resolution. Baseline predictors were low PSQ and PSQ snoring subscale scores; absence of habitual snoring, loud snoring, observed apneas, or a household smoker; higher quality of life; fewer attention-deficit/hyperactivity disorder symptoms; and female sex. Only lower PSQ and snoring scores were independent predictors.

CONCLUSIONS

Many candidates for AT no longer have OSAS on polysomnography after 7 months of watchful waiting, whereas meaningful improvement in symptoms is not common. In practice, a baseline low AHI and normal waist circumference, or low PSQ and snoring score, may help identify an opportunity to avoid AT.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00560859; URL: www.clinicaltrials.gov.

Long-Term Improvements in Sleep and Respiratory Parameters in Preschool Children Following Treatment of Sleep Disordered Breathing

STUDY OBJECTIVE

Sleep disordered breathing (SDB) in preschool-aged children is common, but long-term outcomes have not been investigated. We aimed to compare sleep and respiratory parameters in preschool children to examine the effects of treatment or non-treatment after 3 years.

METHODS

Children (3-5 years) diagnosed with SDB (n = 45) and non-snoring controls (n = 30) returned for repeat overnight polysomnography (39% of original cohort), 3 years following baseline polysomnography. Children with SDB were grouped according to whether they had received treatment or not. SDB resolution was defined as an obstructive apnea hypopnea index (OAHI) ≤ 1 event/h, no snoring detected on polysomnography and habitual snoring not indicated by parents on questionnaire.

RESULTS

Fifty-one percent (n = 23) of the children with SDB were treated. Overall, SDB resolved in 49% (n = 22), either spontaneously (n = 8) or with treatment (n = 14). SDB remained unresolved in 39% (n = 9) of those treated and 64% (n = 14) of the children who were untreated. Two of the non-snoring controls developed SDB at follow-up. The treated group had significantly lower OAHI (p < 0.01), respiratory disturbance index (p < 0.001), total arousal and respiratory arousal indices (p < 0.01 for both) at follow-up compared with baseline. There were no differences between studies for the untreated group.

CONCLUSIONS

Although treatment resulted in an improvement in indices related to SDB severity, 39% had SDB 3 years following diagnosis. These findings highlight that parents should be made aware of the possibility that SDB may persist or recur several years after treatment. This is relevant regardless of the severity of SDB at baseline and the treatment given.

Prospective cohort study on change in weight status and occurrence of habitual snoring in children

OBJECTIVE

To determine the association between the change in weight status and newly developed snoring in children.

DESIGN

This was a prospective cohort study.

SETTING

Structured interviews were conducted at participants' homes, and physical examinations were performed at The-pa Community Hospital in Southern Thailand.

PARTICIPANTS

Cohort subjects (n = 1076) were recruited from children born over a 1-year period between November 2000 and October 2001 in The-pa District of Songkhla Province, Southern Thailand. Data collection was performed when the child was 5 and 8.5 years old.

MAIN OUTCOME MEASURES

The child's snoring, weight, height and tonsillar size were examined. The change in weight status was categorised into four groups: not obese, became not obese, became obese and persistently obese.

RESULTS

Of 1076, 983 subjects (91.4%) completed both surveys. The overall prevalence of habitual snoring decreased from 13% at age 5 to 10.9% at age 8.5 years. Of the 855 children who reported not snoring in the first survey, 61 (7.1%) had become habitual snorers. After adjusting for tonsillar size, children who had become obese or were persistently obese had a significant association with becoming a new snorer with an odds ratio of 5.8 (Confidence interval, CI, 1.3-25.8) and 11.7 (CI, 2.5-54.9), respectively.

CONCLUSIONS

Children with newly developed obesity at 8.5 years old were strongly associated with new snoring occurrence, which is similar to the findings of long-term follow-up studies in adults. Our findings support the idea that the patterns of changes in weight status and snoring development in adults begin as early as the primary school years.

Sleep-disordered breathing, sleep duration, and childhood overweight: a longitudinal cohort study

OBJECTIVES

To examine independent associations between sleep-disordered breathing (SDB), sleep duration from birth through 6.75 years, and body mass index (BMI) through 15 years of age in a population-based cohort.

STUDY DESIGN

The Avon Longitudinal Study of Parents and Children collected parent questionnaire data on child sleep duration and SDB symptoms from birth through 6.75 years and child BMI from the Avon Longitudinal Study of Parents and Children research clinics (n = 1899). For SDB, logistic regression models-minimal, confounder, and confounder + sleep duration adjusted-examined associations with BMI at 7, 10, and 15 years of age. For short sleep duration (≤10th percentile), comparable SDB-adjusted models examined associations with BMI at 15 years of age.

RESULTS

Children with the worst SDB symptoms vs asymptomatic children, had increased odds of overweight at 7 (OR = 2.08, 95% CI = 1.04-4.17), 10 (OR = 1.79, 95% CI = 1.02-3.16), and 15 years of age (OR = 2.25, 95% CI = 1.27-3.97) in models adjusted for sleep duration. Similarly, short sleep duration at ≈5-6 years was associated with overweight at 15 years, independent of SDB. Children with short sleep duration at 4.75 years were more likely to be overweight at 15 years in minimally (OR = 2.21, 95% CI = 1.52-3.20), confounder (OR = 1.99, 95% CI = 1.34-2.96), and SDB-adjusted (OR = 2.04, 95% CI = 1.36-3.04) models.

CONCLUSIONS

Both SDB and short sleep duration significantly and independently increase children's odds of becoming overweight. Findings underscore the potential importance of early identification and remediation of SDB, along with insufficient sleep, as strategies for reducing childhood obesity.

Natural history of snoring and other sleep-disordered breathing (SDB) symptoms in 7-year-old New Zealand children: a follow-up from age 3

PURPOSE

We aimed to examine the natural history of snoring and associated symptoms in a community sample of New Zealand children at ages 3 and 7 years, and identify factors associated with habitual snoring at age 7 years.

METHODS

Parent/s of children (n = 839) who completed the community survey about their child's sleep and breathing at age 3 years were re-contacted via mail 4 years later when children were aged 7 years. Parents were asked to complete a follow-up questionnaire which included items relating to their child's sleep and health, and family demographic information. There was a 54.8% (n = 460) response rate.

RESULTS

At follow-up, habitual snoring was prevalent in 9.2% of the sample, similar to the 11.3% reported at age 3 years. However, habitual snoring status changed over time; 36.2% (n = 21/58) remained habitual snorers; 63.8% (n = 37/58) were no longer snoring habitually, while 5.3% (n = 21/397) had started habitual snoring since the initial survey. Overall, the reported severity of SDB-related symptoms decreased over time, regardless of initial habitual snoring status. Nonetheless, habitual snoring at follow-up was significantly associated with mouth breathing, sleeping with the neck extended, sweating profusely, night waking, and parent-reported child irritability.

CONCLUSIONS

Our findings highlight the dynamic nature of SDB, where habitual snoring and related symptoms can develop, remain present, or resolve at different times, over early-mid-childhood years. Given the dynamic nature of habitual snoring over the early childhood years, pediatricians should continue to screen for snoring and sleep apnea on an annual basis throughout childhood.

Remission and incidence of obstructive sleep apnea from middle childhood to late adolescence

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.

Follow-up of obstructive sleep apnea in children

Introduction

the evolution of snoring and OSAS in children is not well established since few studies of patients without surgical treatment have been published.

Objective

to evaluate the evolution of sleep disordered breathing in children who had not been submitted to upper airway surgery.

Method

twenty-six children with snoring who had not undergone upper airway surgery were evaluated prospectively. Patients were evaluated by full physical examination and nocturnal polysomnography, after which they were divided into 2 groups: apnea (16 children) and snoring (10 children). After 6 months following the initial evaluation, patients were submitted to a new nocturnal polysomnography, and all data were compared to those of the first examination.

Results

the groups did not show any differences regarding age, weight, height and airway physical examination. After 6 months of follow-up, the apnea index did not change, but the respiratory disturbance index increased in the snoring group and the number of hypopneas decreased in the group apnea.

Conclusion

there was an increase in the percentage of N1 sleep stage and the respiratory disturbance index in the patients with primary snore. The AHI did not show significant alteration in both groups, but the number of hypopneas decreased in patients with SAOS.

Public health implications of obstructive sleep apnea burden

OBJECTIVE

To assess the implications of obstructive sleep apnea (OSA) burden among Indian children.

METHODS

MonteCarlo simulations were performed in order to estimate the number of OSA related obesity cases among Indian children (1-14 y of age) and the number of cases of stroke, coronary heart disease (CHD) and type 2 diabetes, considered as main adverse outcomes of OSA related childhood obesity, according to untreated and treated [adenotonsillectomy (AT) alone and AT associated to continuous positive airway pressure (CPAP)] pediatric OSA. Data used to perform MonteCarlo simulations were derived from a review about current literature exploring OSA related obesity.

RESULTS

The analysis on the number of adverse outcomes according to treated and untreated obesity related to OSA showed that treatments reduce the number of obesity cases, resulting in a great reduction of the amount of stroke, CHD and type 2 diabetes cases. However, the cost for treating adverse outcome was higher in patients treated for obesity related to OSA compared to those not receiving any treatment.

CONCLUSIONS

The reduction in the number of adverse outcomes due to treatment of obesity related OSA implicates the urgent need for public health policies in providing screening for OSA among children population: an early detection and a consequently prompt reaction to pediatric OSA could improve the burden of OSA related obesity.

Natural history of snoring in Hong Kong adolescents

AIM

To determine the natural history of snoring in children when they reached adolescence and the underlying risk factors for persistence of habitual snoring.

METHODS

A follow-up telephone survey was conducted to determine the natural history of snoring in children who reached adolescence. The targeted interviewees of the follow-up survey were parents of 3047 children. Adolescents who were snoring ≥6 nights a week were defined as habitual snorers. Potential risk factors for persistent and incident habitual snoring were studied, including age, gender, allergic rhinitis, asthma, body mass index (BMI), sleep duration and daytime sleepiness.

RESULTS

Of the 3047 subjects, 2005 (65.8%) were successfully interviewed by phone. The prevalence of habitual snorers was 12.7%. Ninety-one adolescents were persistent habitual snorers. Allergic rhinitis, male gender and higher BMI at follow-up were identified as significant risk factors for persistent habitual snoring. A further 163 children were identified as incident habitual snorers. The risk factors for incident habitual snoring included male gender, asthma, higher BMI at follow-up and younger age at the first survey. In the current study, the mean sleep duration was 7.6 ± 1.0 h. Overall, 90% of the current cohort slept less than the lower limit of international recommendations for sleep duration.

CONCLUSIONS

Around 40.6% of habitually snoring children continued to snore habitually as adolescents in the current study, while 9.2% of the initial non-habitual snorers became habitual snorers. Male gender and higher BMI were significant risk factors for both persistent and incident habitual snoring.

A four year follow-up of sleep and respiratory measures in elementary school-aged children with sleep disordered breathing

OBJECTIVE

Little is known of the long-term prognosis of children treated for sleep disordered breathing (SDB) and even less of children with milder forms of SDB who remain untreated. We aimed to investigate the long-term sleep and respiratory outcomes of children with a range of SDB severities.

METHODS

41 children with SDB and 20 non snoring controls (mean age, 12.9±0.2 y), underwent repeat overnight polysomnography (PSG) 4.0±0.3years after initial diagnosis. SDB severity, presence of snoring, sleep and respiratory parameters, sleep fragmentation index (SFI), the Pediatric Daytime Sleepiness Scale (PDSS), Sleep Disturbance Scale for Children (SDSC), and obstructive sleep apnea 18-item quality of life questionnaire were re assessed. Children with SDB were grouped into resolved (no snoring and obstructive apnea-hypopnea index [OAHI] <1) and unresolved (snoring or an OAHI > or =1).

RESULTS

At follow-up OAHI was reduced in both SDB groups (p<0.05); however, 54% (n=22) of children still continued to snore, having either persistent or new OSA (n=4). In this unresolved group, sleep was significantly disrupted; % nonrapid eye movement stage 1 (NREM1) sleep and SFI were increased (p<0.05), and total sleep time (TST) and sleep efficiency were decreased compared to the resolved and control groups (p<0.05). Overall, 29% of children were treated, and of these, 67% had resolved SDB. SDB groups had higher PDSS, SDSC, and OSA-18 scores compared to controls at follow-up (p<0.01).

CONCLUSIONS

Our study demonstrated that although SDB improved in the long-term, more than 50% of children had residual SDB (mostly primary snoring) and sleep disturbance. As even mild forms of SDB are known to have adverse cardiovascular, learning, and behavioral outcomes, which have implications for the health of these children.

Relationship between adenoid size and severity of obstructive sleep apnea in preschool children

OBJECTIVE

To investigate the contributions of adenoid and tonsil sizes to obstructive sleep apnea syndrome (OSAS) in normal-weight children in two age categories: preschool and schoolchildren.

METHODS

Fifty-eight normal-weight (body mass index z-score<2) symptomatic children with OSAS (apnea-hypopnea index ≥ 2) were evaluated. The patients were divided into two age categories: preschool (age<6; n=33) and schoolchildren (age ≥ 6; n=25). Polysomnographic findings and adenoid and tonsil sizes were compared. The relative contributions of body mass index and adenoid and tonsil sizes were also investigated with a regression analysis.

RESULTS

Adenoid grade and apnea index correlated significantly in preschool children (r=0.45, p<0.01). On regression analysis, adenoid grade was a significant predictor of the apnea index in preschool children. The influence of adenoid hypertrophy decreased from preschool to schoolchildren. Tonsil size had little influence on the apnea index in either group.

CONCLUSION

Adenoid hypertrophy was a major contributor to OSAS in normal-weight preschool children. The upper airway morphology of younger children with OSAS differed from that of older children with OSAS.

Diagnosis and management of childhood obstructive sleep apnea syndrome

OBJECTIVE

This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).

METHODS

The literature from 1999 through 2011 was evaluated.

RESULTS AND CONCLUSIONS

A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

The prevalence and correlates of habitual snoring during pregnancy

PURPOSE

Mounting evidence implicate habitual snoring, a prominent symptom of sleep-disordered breathing, as an important risk factor for adverse pregnancy outcomes including preeclampsia and gestational diabetes. Little, however, is known about the determinants of habitual snoring among pregnant women. We sought to assess its prevalence and to identify maternal characteristics associated with habitual snoring during pregnancy.

METHODS

Pregnant women (N = 1,303) receiving prenatal care provided information about habitual snoring before and during pregnancy in in-person interviews completed in early pregnancy. We calculated adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) from multivariable models designed to identify factors associated with snoring during pregnancy.

RESULTS

Approximately 7.3 % of pregnant women reported habitual snoring during early pregnancy. The odds of habitual snoring during pregnancy was strongly related with maternal reports of habitual snoring prior to the index pregnancy (aOR = 24.32; 95 % CI, 14.30-41.51). Advanced maternal age (≥35 years) (aOR = 2.02; 95 % CI, 1.11-3.68), history of pregestational diabetes (aOR = 3.61; 95 % CI, 1.07-12.2), history of mood and anxiety disorders (aOR = 1.81; 95 % CI, 1.02-3.20), and prepregnancy overweight (25-29.9 kg/m(2)) (aOR = 2.31; 95 % CI, 1.41-3.77) and obesity (≥30 kg/m(2)) (aOR = 2.81; 95 % CI, 1.44-5.48) status were statistically significant risk factors for habitual snoring during pregnancy. In addition, maternal smoking during pregnancy (aOR = 2.70; 95 % CI, 1.17-6.26) was associated with habitual snoring during pregnancy.

CONCLUSIONS

Identification of risk factors for habitual snoring during pregnancy has important implications for developing strategies aimed at reducing the prevalence of sleep-disordered breathing, promoting improved sleep hygiene and improved pregnancy outcomes among reproductive-age women.

Respiratory disturbances in rett syndrome: don't forget to evaluate upper airway obstruction

Rett syndrome is characterized by loss of motor and social functions, development of stereotypic hand movements, seizures, and breathing disturbances. This study evaluates the presence of overnight respiratory disturbances. Polysomnography in combination with a questionnaire (the Sleep Disturbance Scale for Children) was performed in 12 Dutch patients with Rett. Respiratory disturbances were present in all, clinically relevant in 10 (apnea hypopnea per hour 1.0-14.5). In 8 children, central apneas were present during the day often with obstructive apneas at night. In 6, obstructive sleep apnea syndrome was diagnosed, in 3 severe, with frequent oxygen desaturations. Significant respiratory complaints were present in 3 patients, all had obstructive sleep apnea syndrome. Of the 12 patients with Rett, 8 (67%) snored, and in 5 obstructive sleep apnea syndrome was present. In children, hypertrophied tonsils and adenoids are a common cause of obstructive sleep apnea syndrome, which may benefit from therapeutic intervention. We recommend performing polysomnography in patients with Rett syndrome and respiratory complaints.

Snoring, mouth-breathing, and apnea trajectories in a population-based cohort followed from infancy to 81 months: a cluster analysis

OBJECTIVE

The objective of this study was to characterize phenotypes of sleep disordered breathing (SDB) in early childhood that clinicians may find useful while monitoring symptom progression and associated SDB morbidity.

METHODS

We performed a cluster analysis of SDB's primary symptoms: snoring, mouth-breathing, and apnea. Parents in the Avon Longitudinal Study of Parents and Children (ALSPAC) reported SDB symptoms by questionnaire for their child at 6, 18, 30, 42, 57, 69, and 81 months of age. Participants were those from the original cohort exclusive of children with congental or other medical conditions predisposing growth aberrations or respiratory problems (i.e. cleft palate, heart surgery and associated conditions, genetic syndromes-primarily Down's, cancer or kidney conditions, celiac disease, congenital adrenal hyperplasia), missing SDB measures for ≥ 2 timepoints, or missing birth length plus 2 subsequent height measures.

RESULTS

Five clusters emerged from 10,441 children and were characterized according to patterns of mean severity of SDB symptoms over time. "Normals" (50%) were asymptomatic throughout. The "late snores and mouth-breathing" cluster (20%) remained asymptomatic until 4 years old. The "early snores" (10%) and "early apnea" (10%) clusters had peak symptoms at 6 and 18 months, respectively. In "all SDB after infancy" (10%), symptoms peaked from 30 to 42 months and remained elevated. Exploratory analyses found that "early snores" were significantly shorter than "normals." Associations with tonsillectomies and wheezing frequency supported external validation.

CONCLUSIONS

Cluster analysis has elucidated the dynamic multi-symptom expression of SDB. The utility of cluster analysis will be evaluated in future analyses to predict growth, cognition and behavior outcomes.

Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study

STUDY OBJECTIVES

To describe the prevalence, persistence, and characteristics associated with sleep disordered breathing (SDB) symptoms in a population-based cohort followed from 6 months to 6.75 years.

DESIGN

Avon Longitudinal Study of Parents and Children (ALSPAC).

SETTING

England, 1991-1999.

PARTICIPANTS

12,447 children in ALSPAC with parental report of apnea, snoring, or mouth-breathing frequency on any one of 7 questionnaires.

MEASUREMENTS

Symptom prevalence rates-assessed as "Always" and "Habitually"-are reported at 0.5, 1.5, 2.5, 3.5, 4.75, 5.75, and 6.75 years of age. The proportion of children in whom symptoms develop, persist or abate between observation points is reported. Exploratory multivariate analyses identified SDB risk factors at 1.5, 4.75, and 6.75 years.

RESULTS

The prevalence of apnea ("Always") is 1%-2% at all ages assessed. In contrast, snoring "Always" ranges from 3.6% to 7.7%, and snoring "Habitually" ranges from 9.6% to 21.2%, with a notable increase from 1.5- 2.5 years. At 6 years old, 25% are habitual mouth-breathers. The "Always" and "Habitual" incidence of each symptom between time points is 1%-5% and 5%-10%, respectively. In multivariate analyses of combined symptoms, socioeconomic factors have stronger, more persistent effects upon increased SDB risk than gestational age, gender, or race (aside from 1.5 years); adenoidectomy decreases risk by 40%-50%.

CONCLUSIONS

This is the first natural history study of the primary symptoms of SDB across a key 6-year period in the development of SDB symptoms. Snoring rates are higher and spike earlier than previously reported. Symptoms are dynamic, suggesting the need for early and continued vigilance in early childhood.

Habitual snoring in school-aged children: environmental and biological predictors

Background

Habitual snoring, a prominent symptom of sleep-disordered breathing, is an important indicator for a number of health problems in children. Compared to adults, large epidemiological studies on childhood habitual snoring and associated predisposing factors are extremely scarce. The present study aimed to assess the prevalence and associated factors of habitual snoring among Chinese school-aged children.

Methods

A random sample of 20,152 children aged 5.08 to 11.99 years old participated in a cross-sectional survey, which was conducted in eight cities of China. Parent-administrated questionnaires were used to collect information on children's snoring frequency and the possible correlates.

Results

The prevalence of habitual snoring was 12.0% (14.5% for boys vs. 9.5% for girls) in our sampled children. Following factors were associated with an increased risk for habitual snoring: lower family income (adjusted odds ratio [OR] = 1.46), lower father's education (OR = 1.38 and 1.14 for middle school or under and high school of educational level, respectively), breastfeeding duration < 6 months (OR = 1.17), pregnancy maternal smoking (OR = 1.51), obesity (OR = 1.50), overweight (OR = 1.35), several respiratory problems associated with atopy and infection, such as chronic/allergic rhinitis (OR = 1.94), asthma (OR = 1.43), adenotonsillar hypertrophy (OR = 2.17), and chronic otitis media (OR = 1.31), and family history of habitual snoring (OR = 1.70).

Conclusion

The prevalence of habitual snoring in Chinese children was similar to that observed in other countries. The potential predisposing factors covered socioeconomic characteristics, environmental exposures, chronic health problems, and family susceptibility. Compared to socioeconomic status and family susceptibility, environmental exposures and chronic health problems had greater impact, indicating childhood habitual snoring could be partly prevented by health promotion and environmental intervention.

Incidence and remission of sleep-disordered breathing and related symptoms in 6- to 17-year old children--the Tucson Children's Assessment of Sleep Apnea Study

OBJECTIVE

To determine the incidence and remission of sleep-disordered breathing in adolescent children.

STUDY DESIGN

A total of 319 children completed 2 home polysomnograms approximately 5 years apart. Sleep-disordered breathing (SDB) was determined to be present if a child had a respiratory disturbance index>or=1 event per hour associated with >or=3% oxygen desaturation. Subjective symptoms such as witnessed apnea, excessive daytime sleepiness, difficulty initiating and maintaining sleep, and habitual loud snoring were considered present if they occurred frequently or almost always. Body mass index percentiles were calculated with childhood growth charts from the Centers for Disease Control and Prevention adjusted for sex and age.

RESULTS

The mean age at assessment was 8.5 years at baseline and 13.7 years at follow-up, respectively. Incident SDB was more common in boys (odds ratio [OR]=3.93, P=.008, confidence interval [CI]=1.41-10.90). Children with prevalent SDB were more likely to be boys (OR=2.48, P=.006) and had a greater increase in body mass index percentile change (OR 1.01, P=.034). Children with prevalent SDB also had 3.41 greater odds for development of obesity from baseline to follow-up in comparison with children with prevalent NoSDB.

CONCLUSIONS

Adolescent boys are more likely to have persistent and incident SDB than girls. Children with prevalent SDB are more likely to have development of obesity. These risks are similar to those observed in adults.

Obstructive sleep breathing disorders

Obstructive sleep apnea (OSA) is increasingly recognized in children. There is accumulating robust evidence to support early diagnosis and treatment of this condition. The purpose of this review is to provide an update on the epidemiology, clinical features, complications, and treatment of childhood OSA. The authors have also proposed an easy-to-follow flowchart on the management of children with snoring or sleep disturbance for clinical use by busy pediatricians.

Epidemiology of pediatric obstructive sleep apnea

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.

[Snoring in children]

Only snoring loud enough to be heard behind a closed door have to be investigated and treated. Snoring is severe when associated with sleep apneas. The 3 most frequent causes of snoring in children are enlarged adenoids, enlarged tonsils and blocked nose due to allergic rhinitis.