Consequences of snoring and sleep disordered breathing in children

Characteristics of sleep in children with heavy prenatal alcohol exposure

BACKGROUND

Sleep plays an important role in neurodevelopment. However, the effects of prenatal alcohol exposure on sleep quality have been understudied, despite reports of sleep disturbance in infants prenatally exposed to alcohol and elevated levels of sleep problems reported by caregivers of children with fetal alcohol spectrum disorders. The current study characterizes sleep in children with prenatal alcohol exposure using both objective (actigraphy) and subjective (questionnaires, sleep diaries) methods.

METHODS

Participants aged 6-10 years, with and without prenatal alcohol exposure, were included in the study (alcohol-exposed [AE]: n = 35; control [CON]: n = 39). Objective sleep was measured via 24-h actigraphy for 2 weeks. Parents completed sleep diaries and sleep questionnaires (Children's Sleep Habits Questionnaire, Pediatric Sleep Questionnaire). Multivariate analysis of variance was used to characterize the sleep profile (objective, subjective) and examine group differences.

RESULTS

There were no group differences on actigraphy metrics averaged across 2 weeks. However, the AE group showed significantly greater intraindividual variability on most actigraphy measures, particularly total sleep time, percent sleep, wake after sleep onset, and number of wake bouts. Parents reported significantly more sleep problems in the AE group than in the CON group, primarily driven by night wakings, parasomnias (e.g., sleepwalking), snoring, and daytime sleepiness. These effects were more severe in children >8.5 years of age.

CONCLUSIONS

Despite similar 2-week average sleep outcomes, children with prenatal alcohol exposure showed greater intraindividual sleep variability and parents reported more sleep problems related to sleep behavior and snoring. These difficulties with sleep may be related to other cognitive and behavioral outcomes. Importantly, sleep is a modifiable behavior, and interventions that focus on variability in sleep, particularly in sleep duration, can impact the quality of life in children with prenatal alcohol exposure and their families.

Effect of Chronic Rhinitis Treatment in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

The purpose of this study is to examine the effect of chronic rhinitis treatment on attention-deficit/hyperactivity disorder (ADHD) symptoms in children with ADHD.

METHODS

Children and adolescents with ADHD were screened for chronic rhinitis symptoms. Participants with positive chronic rhinitis screening underwent the skin prick test and received rhinitis treatment for 3 months. All participants were evaluated using the parent's and teacher's Vanderbilt ADHD rating scales, total nasal symptom score, and Quality of Life Questionnaire (OSA-18) for pediatric obstructive sleep apnea at pretreatment and posttreatment.

RESULTS

Overall, 140 children and adolescents with ADHD were enrolled and screened for chronic rhinitis. Fifty-four children and adolescents with positive screening results underwent the skin prick test and received rhinitis treatment. After 3 months of treatment, inattentive, hyperactive/impulsive, and total ADHD symptom scores were significantly decreased as reported by parents ( p = 0.031 to <0.001) and teachers ( p = 0.001 to <0.001) compared with those before treatment. A subgroup analysis also showed improvement in ADHD symptoms as reported by parents and teachers in the allergic and nonallergic rhinitis groups. Pearson's correlation coefficient analyses showed positive correlations between improvement in the ADHD symptom scores reported by parents and improvement in the quality of life related to sleep problems from the OSA-18 questionnaire (r = 0.377-0.387).

CONCLUSION

Treating chronic rhinitis can improve ADHD symptoms in children and adolescents with ADHD. Pediatricians should be aware of and treat chronic rhinitis to maximize ADHD symptom control.

Protective effects of choline against hypoxia-induced injuries of vessels and endothelial cells

The current study aimed to lay a theoretical foundation for further development of choline as an anti-hypoxia damage drug. Wild-type, 3- to 5-month-old male Sprague-Dawley rats, weighing 180-220 g, were used in this study. The rats were randomly divided into a normoxic control group (n=16) and a chronic intermittent hypoxia (CIH) group (n=16). The effects of CIH on acetylcholine (ACh)-mediated endothelium-dependent vasodilatation in the rat cerebral basilar arterioles and mesenteric arterioles, as well as the protective effects of choline on the arterioles damaged by hypoxia were observed. Moreover, the effects of choline on endothelial cell proliferation during hypoxia were observed, and choline's functional mechanism further explored. The ACh-mediated vasodilatation of rat cerebral basilar and mesenteric arterioles significantly reduced during hypoxia (P<0.01). Choline significantly increased dilation in the rat cerebral basilar (P<0.01) and mesenteric arterioles (P<0.05) damaged by CIH compared with those in the control group. In addition, under hypoxic conditions, choline significantly promoted the proliferation of rat aortic endothelial cells (P<0.05) and significantly reduced lactate dehydrogenase activity in the cell culture supernatant in vitro (P<0.05). Furthermore, the effect of choline could be related to its ability to significantly increase the secretion of vascular endothelial growth factor (P<0.01) and activation of α7 non-neuronal nicotinic acetylcholine receptors under hypoxia (P<0.01). This study demonstrated that choline could have protective effects against hypoxic injuries.

Snoring in children

Chronic snoring (≥4 nights per week) is not benign. Otherwise healthy children with chronic snoring and evidence of adenotonsillar hypertrophy can be referred directly for adenotonsillectomy. Snoring children <30 months or with significant medical comorbidities should be referred for specialist sleep evaluation. Older children with intermittent snoring or without significant medical comorbidities can be managed with a combination of medical and surgical interventions listed herein.

Treatment of allergic rhinitis is associated with improved attention performance in children: the Allergic Rhinitis Cohort Study for Kids (ARCO-Kids)

Background

It has been well known that pediatric allergic rhinitis was associated with poor performance at school due to attention deficit. However, there were no cohort studies for the effect of treatment of allergic rhinitis on attention performance in pediatric population. Thus, the aim of this study was to investigate whether attention performance was improved after treatment in children with allergic rhinitis.

Methods

In this ARCO-Kids (Allergic Rhinitis Cohort Study for Kids), consecutive pediatric patients with rhinitis symptoms underwent a skin prick test and computerized comprehensive attention test. According to the skin prick test results, the children were diagnosed as allergic rhinitis or non- allergic rhinitis. All of the patients were regularly followed up and treated with oral medication or intranasal corticosteroid sprays. The comprehensive attention tests consisted of sustained and divided attention tasks. Each of the tasks was assessed by the attention score which was calculated by the number of omission and commission errors. The comprehension attention test was repeated after 1 year.

Results

A total of 797 children with allergic rhinitis and 239 children with non-allergic rhinitis were included. Initially, the attention scores of omission and commission errors on divided attention task were significantly lower in children with allergic rhinitis than in children with non-allergic rhinitis. After 1 year of treatment, children with allergic rhinitis showed improvement in attention: commission error of sustained (95.6±17.0 vs 97.0±16.6) and divided attention task (99.1±15.8 vs 91.8±23.5). Meanwhile, there was no significant difference of attention scores in children with non-allergic rhinitis.

Conclusions

Our study showed that management of allergic rhinitis might be associated with improvement of attention.

Sleep hygiene and problem behaviors in snoring and non-snoring school-age children

OBJECTIVES

The effects of sleep-disordered breathing, sleep restriction, dyssomnias, and parasomnias on daytime behavior in children have been previously assessed. However, the potential relationship(s) between sleep hygiene and children's daytime behavior remain to be explored. The primary goal of this study was to investigate the relationship between sleep hygiene and problematic behaviors in non-snoring and habitually snoring children.

METHODS

Parents of 100 5- to 8-year-old children who were reported to snore "frequently" to "almost always," and of 71 age-, gender-, and ethnicity-matched children who were reported to never snore participated in this study. As part of a larger, ongoing study, children underwent nocturnal polysomnography and parents were asked to complete the Children's Sleep Hygiene Scale (CSHS) and the Conners' Parent Rating Scales-Revised (CPRS-R:L).

RESULTS

In the snoring group, strong negative correlations (r=-.39, p<.001) between the CSHS overall sleep hygiene score and the CPRS-R:L DSM-IV total scores emerged. Additionally, several subscales of the CSHS and CPRS-R:L were significantly correlated (p-values from <.000 to .004) in snoring children. No significant correlations were observed between the CSHS and the CPRS-R:L in the non-snoring children.

CONCLUSIONS

Parental reports of behavioral patterns in snoring children indicate that poorer sleep hygiene is more likely to be associated with behavior problems, including hyperactivity, impulsivity, and oppositional behavior. In contrast, no significant relationships between sleep hygiene and problem behaviors emerged among non-snoring children. These results indicate that children at risk for sleep disordered breathing are susceptible to daytime behavior impairments when concurrently coupled with poor sleep hygiene practices.

Sleep disturbances in children with attention-deficit/hyperactivity disorder

In this article, we advocate the need for better understanding and treatment of children exhibiting inattentive, hyperactive, impulsive behaviors, by in-depth questioning on sleepiness, sleep-disordered breathing or problematic behaviors at bedtime, during the night and upon awakening, as well as night-to-night sleep duration variability. The relationships between sleep and attention-deficit/hyperactivity disorder (ADHD) are complex and are routinely overlooked by practitioners. Motricity and somnolence, the most consistent complaints and objectively measured sleep problems in children with ADHD, may develop as a consequence of multidirectional and multifactorial pathways. Therefore, subjectively perceived or reported restless sleep should be evaluated with specific attention to restless legs syndrome or periodic limb movement disorder, and awakenings should be queried with regard to parasomnias, dyssomnias and sleep-disordered breathing. Sleep hygiene logs detailing sleep onset and offset quantitatively, as well as qualitatively, are required. More studies in children with ADHD are needed to reveal the 24-h phenotype, or its sleep comorbidities.

EEG spectral analysis of apnoeic events confirms visual scoring in childhood sleep disordered breathing

PURPOSE

This study compared electroencephalogram (EEG) spectral analysis with standard visual scoring to assess the validity of clinical classification of arousals at respiratory event termination in children with obstructive sleep apnoea (OSA).

METHODS

Twenty children (six M/14 F) aged 7-12 years, diagnosed with moderate to severe OSA participated in this study. Overnight polysomnography was performed, and sleep stages and arousals visually scored using clinical paediatric measures. The EEG was spectrally analysed in six 5-s epochs across respiratory events, namely two consecutive 5-s epochs pre-event onset and a 5s epoch post-event onset, 5-s before event termination, and two contiguous 5-s epochs post-event termination. EEG spectral power distribution was compared across respiratory events visually categorised as full cortical arousals, subcortical activations, or non-arousals using specialised software (Sleep Research System 5.0).

RESULTS

There was no difference in power spectra between events in REM and NREM sleep and these were combined. There was a statistically significant fall from pre-arousal baseline values in delta and theta spectral power at respiratory event terminations associated with cortical arousals only. No change in power was detected at respiratory event terminations associated with subcortical activations or non-arousals.

CONCLUSIONS

The lack of significant EEG spectral power changes at respiratory event terminations not associated with visually identified cortical arousals indicates undetected micro-arousals are not present. The results support the validity of clinical classifications of arousals at respiratory event termination.

Mouth breathing children have cephalometric patterns similar to those of adult patients with obstructive sleep apnea syndrome

OBJECTIVE

To determine whether mouth breathing children present the same cephalometric patterns as patients with obstructive sleep apnea syndrome (OSAS).

METHOD

Cephalometric variables were traced and measured on vertical lateral cephalometric radiographs. The cephalometric measurements of 52 mouth and 90 nose breathing children were compared with apneic patients. The children had not undergone adenoidectomy or tonsillectomy and had not had or were not receiving orthodontic or orthopedic treatment.

RESULTS

Mouth breathing children showed same cephalometric pattern observed in patients with OSAS: a tendency to have a retruded mandible (p=0.05), along with greater inclination of the mandibular and occlusal planes (p<0.01) and a tendency to have greater inclination of the upper incisors (p=0.08). The nasopharyngeal and posterior airway spaces were greatly reduced in mouth breathing children, as observed in patients with apnea (p<0.01).

CONCLUSION

Mouth breathing children present abnormal cephalometric parameters and their craniofacial morphology resembles that of patients with OSAS.

The role of the nasopharyngeal airway for obstructive sleep apnea in syndromic craniosynostosis

Syndromic craniosynostosis is known to be associated with obstructive sleep apnea (OSA), which can often present in infancy. Although multifactorial, a predominant contributing factor is midface hypoplasia. Nasal continuous positive airway pressure has proven to be an effective treatment modality but may be poorly tolerated in certain cases. This study looks at the effectiveness of bypassing midface obstruction with a nasopharyngeal airway (NPA). Twenty-seven children with syndromic craniosynostosis with confirmed moderate to severe OSA were initially treated with an NPA. The mean age of NPA insertion was 12.3 months (range, 0.5-48 mo). Seventeen had severe OSA, and 10 had moderate OSA preinsertion. Post-NPA insertion, 26 of 27 children (96%) demonstrated an improvement in sleep severity scores, resulting in 3 with moderate OSA and 24 with mild OSA. There was a significant improvement in mean oxygen saturation, mean number of saturation dips greater than 4% per hour, percentage time spent less than 90% SpO2, and number of pulse rate rises per hour. There were no significant differences in mean pulse rate. The NPA was well tolerated by this patient group, with 24 of 26 children retaining it for at least 6 weeks. We believe that an NPA is therefore an effective first-line treatment modality in the management of OSA in children with syndromic craniosynostosis. It is well tolerated by the patient and may obviate the need for continuous positive airway pressure or tracheostomy.

Normative psychomotor vigilance task performance in children ages 6 to 11--the Tucson Children's Assessment of Sleep Apnea (TuCASA)

Although the psychomotor vigilance task (PVT) is commonly used in sleep and other research settings, normative data for PVT performance in children have not been published. This report presents normal PVT performance measures among children without a sleep disorder participating in the Tucson Children's Assessment of Sleep Apnea (TuCASA) study. TuCASA is a community-based, prospective study of sleep-disordered breathing in Caucasian and Hispanic children ages 6 to 11 years. A standard 10-min PVT trial was completed by 360 participants-48% female and 36% Hispanic; mean age 8.9 years. Detailed analyses were performed for 162 children with respiratory disturbance indices <1 and no parent-reported sleep problems. Mean and median reaction times (RT) decreased with increasing age (p trend < 0.001). Children ages 6 and 11 had median RTs of 544.24 and 325.70 ms, respectively. Standard deviations in RTs also decreased with increasing age (p trend = 0.001), as did lapses (p trend < 0.001), but no trend was apparent in total errors. There were statistically significant (p = 0.006) differences in the performance of boys and girls. Gender differences were greatest at age 6, where boys had shorter RTs, and decreased with age until performance was approximately equal by age 11. No ethnic differences were detected. Children's PVT performance improves with age and differs by gender. These differences should be considered when the PVT is utilized in pediatric populations.

Manganese superoxide dismutase protects mouse cortical neurons from chronic intermittent hypoxia-mediated oxidative damage

Obstructive sleep apnea (OSA) syndrome has been recognized as a highly prevalent public health problem and is associated with major neurobehavioral morbidity. Chronic intermittent hypoxia (CIH), a major pathological component of OSA, increases oxidative damage to the brain cortex and decreases neurocognitive function in rodent models resembling human OSA. We employed in vitro and in vivo approaches to identify the specific phases and subcellular compartments in which enhanced reactive oxygen species (ROS) are generated during CIH. In addition, we utilized the cell culture and animal models to analyze the consequences of enhanced production of ROS on cortical neuronal cell damage and neurocognitive dysfunction. In a primary cortical neuron culture system, we demonstrated that the transition phase from hypoxia to normoxia (NOX) during CIH generates more ROS than the transition phase from NOX to hypoxia or hypoxia alone, all of which generate more ROS than NOX. Using selective inhibitors of the major pathways underlying ROS generation in the cell membrane, cytosol, and mitochondria, we showed that the mitochondria are the predominant source of enhanced ROS generation during CIH in mouse cortical neuronal cells. Furthermore, in both cell culture and transgenic mice, we demonstrated that overexpression of MnSOD-decreased CIH-mediated cortical neuronal apoptosis, and reduced spatial learning deficits measured with the Morris water maze assay. Together, the data from the in vitro and in vivo experiments indicate that CIH-mediated mitochondrial oxidative stress may play a major role in the neuronal cell loss and neurocognitive dysfunction in OSA. Thus, therapeutic strategies aiming at reducing ROS generation from mitochondria may improve the neurobehavioral morbidity in OSA.

Endoscopic adenoidectomy in children with submucosal cleft palate

OBJECTIVE

To determine the safety and effectiveness of endoscopic partial adenoidectomy for the treatment of nasal obstruction in children with submucosal cleft palate.

METHODS

The medical files of children with symptoms of nasal obstruction and submucosal cleft palate who underwent partial transnasal endoscopic adenoidectomy from January 1993 to December 2003 were reviewed. Operative complications, relief of nasal obstruction, presence of postoperative velopharyngeal insufficiency were recorded.

RESULTS

There were no operative complications. All the children had relief of nasal obstruction. Velopharyngeal insufficiency was not observed during the postoperative follow-up.

CONCLUSIONS

Endoscopic partial adenoidectomy is a safe and effective procedure for the treatment of nasal obstruction in children with submucosal cleft palate.

Atopy as a risk factor for habitual snoring at age 1 year

STUDY OBJECTIVES

To determine the prevalence of habitual snoring (HS) in 1-year-old children, and to assess the relationship between HS and atopic status in these children.

DESIGN

Cross-sectional evaluation of a birth cohort selected from the population.

SETTING

Ohio and Kentucky River Valley communities.

PARTICIPANTS

Children participating in the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS) were recruited for this study.

MEASUREMENTS AND RESULTS

At age 1 year, the children were evaluated for atopic status and exposure to environmental tobacco smoke (ETS). Parents were asked to complete a questionnaire pertaining to their snoring frequency and that of their child. Children with HS (snoring three or more times per week) were compared to those who either did not snore or snored less than three times per week. Data were available on 681 of the 700 children participating in CCAAPS study. Of these 681 children (377 boys and 304 girls), 542 were white (80%), 118 were African American (17%), and 21 were biracial or Asian (3%). The mean age (+/- SD) of our cohort at the time of assessment for snoring was 13.7 +/- 2.6 months. Of the 681 children, 105 snored habitually (15%). There was a significant association between HS and the following: (1) positive atopic status (p = 0.005); (2) African-American race (p < 0.01); and (3) a history of snoring in the father (p < 0.01) or in the mother (p < 0.01). There was, however, no association between HS and ETS.

CONCLUSIONS

We found a 15% prevalence of HS in 1-year-old children born to atopic parents and a significant association with positive atopic status.

Symptoms of inattention and hyperactivity in children with habitual snoring: evidence from a community-based study in Istanbul

BACKGROUND

Neurobehavioural symptoms of inattention and hyperactivity are common in children with sleep-disordered breathing (SDB). Prevalence rates of habitual snoring and attention deficit hyperactivity disorder (ADHD) are very similar and both have a substantial negative effect on children's behavioural health.

OBJECTIVE

We examined the differences for subjective attentional and hyperactivity measures reported by parents and teachers among primary school children with habitual snoring and age- and sex-matched controls in a community-based case-control study in Istanbul. Methods In 2002, a survey was carried out to determine the prevalence of snoring in 2147 primary school children. After one year, in 2003, 151 children with habitual snoring and 302 controls from this survey were studied with parental SDB questionnaire, Conners' Parent (Conners-P) and Teacher Scales, and an inattention hyperactivity scale (IHS). Exclusion criteria included history of ADHD diagnosis, controls who started to snore and habitual snorers (HS) who no longer snored in this follow-up study.

RESULTS

Ninety-six HS and 190 control subjects (mean age: 9.4 +/- 1.3) were evaluated. HS had significantly more symptoms of hyperactivity (Conners-ADHD index) (P: 0.033), attentional (P: 0.019), and conduct and oppositional defiant in subscales (P: 0.001) of Conners-P and IHS-Parents. A pooled score of Conners-P ADHD Index > 60 and IHS-Parent score > 1.25 showed considerable difference in HS when compared with controls (5.1% vs. 1.4%) (P < 0.0001). Daytime hyperactivity and excessive daytime sleepiness reported by parents correlated with scores of Conners-P and IHS-P (P < 0.01). Teachers' observations showed significant correlations with learning disability and the level of academic performance in HS (P < 0.01). Other behavioural parameters related to SDB were not significantly correlated with teachers' ADHD ratings in HS.

CONCLUSION

Increased rates of moderate hyperactivity as well as conduct and oppositional defiant symptoms in HS reported by the parents might reflect a negative impact on overall neurobehavioural health. The teachers' scores yielded no significant results among HS and controls. This may be caused by the limitation due to shared method variance. The negative effect of crowded classes on teachers' evaluations must be also taken into consideration. After exclusion of a diagnosis of ADHD in children presenting with hyperactivity and inattention, children with habitual snoring with prominent scores of behavioural measures should be considered as candidates for further assessment by a sleep specialist.

Modulation of hypoglossal motoneuron excitability by intracellular signal transduction cascades

Motoneuronal excitability is highly modulated by various inputs; however, comparatively little is known about postsynaptic signal transduction cascades that affect motoneuron excitability. In this review, we discuss the role of intracellular signaling cascades in the modulation of respiratory motoneuronal excitability. In particular, protein kinases and phosphatases dynamically and constitutively modulate respiratory-modulated inputs to XII motoneurons: (i) activation of protein kinase A (PKA) potentiates both excitatory and inhibitory drive currents; (ii) protein kinase G (PKG) depresses excitatory currents, and (iii) inhibition of protein phosphatases potentiates excitatory drive currents. We also describe a novel form of persistent plasticity (in vitro long-term facilitation; ivLTF) of motoneuronal output. ivLTF is induced by episodic activation of 5-HT(2) or alpha(1)-adrenoreceptors and is manifested as an increase in the amplitude of XII nerve output due to an increase in alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA)-mediated motoneuronal drive currents. Blockade of Group 1 metabotropic glutamate receptors or protein kinase C (PKC) prevents the induction of ivLTF.

Cognitive dysfunction in children with sleep-disordered breathing

Two daily school periods are mandatory in Brazil owing to a shortage of academic facilities, which can decrease cognitive performance, especially in children with sleep-disordered breathing. This study aimed to verify the influence of starting time to school on cognition, comparing children with sleep disorders and normal children. Cognition was assessed in 79 children with sleep-disordered breathing, 468 children with nonrespiratory sleep disorders, and 633 normal control children. We analyzed total sleep time, starting time to school (morning or afternoon), and grades. First grade morning students with sleep-disordered breathing had 8.04 higher odds for cognitive dysfunction than normal children. For children with sleep-disordered breathing, second and third grade morning students had higher odds for cognitive dysfunction than those who studied in the afternoon (3.69 and 4.07). Fourth grade morning students had 8.27 higher odds for cognitive dysfunction than first grade children. In conclusion, sleep-disordered breathing, grades, and starting time to school interact to affect cognition in Brazilian children.

Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy

OBJECTIVE

To compare the long-term effects (six years after surgery) of two techniques for pediatric tonsil surgery with respect to snoring, apneas, eating difficulties, infections and general health. The two methods were intracapsular partial tonsillectomy (tonsillotomy, "TT") using CO(2)-laser technique and traditional (total) blunt dissection tonsillectomy (TE).

STUDY DESIGN

A questionnaire distributed by mail to the parents of children, who, in 1998, were included in a prospective clinical randomized study in one tertiary care ENT clinic.

METHOD

A 10 question survey follow-up of 41 children, between 9 and 15 years of age, who originally, six years earlier had been randomized to either TT with CO(2)-laser (n=21) or TE (n=20). The main indication for the surgery was a history of sleep related breathing distress (SRBD). Before the present study, all of the children had participated in earlier follow-ups at six months and one year after surgery.

RESULTS

All the children in both groups answered the questionnaire. There were no significant differences between the answers from the two groups in any respects: the effect on snoring and apneas was equally stable for both groups. The number of children who remained free from snoring decreased from 40 after the first year to 25 after six years (11 TT, 14 TE). Snoring in the recurrent cases was not rated to be as frequent or as loud as before the surgery. Infections of the upper respiratory tract (URI) that had been treated with antibiotics occurred to the same extent in both groups. None had eating difficulties. The patients' satisfaction with the results of the surgery was high or very high in 18/21 TT and 20 TE cases, and the vast majority of the parents rated their children's present health status as improved compared with the preoperative condition.

CONCLUSION

Tonsillotomy with CO(2)-laser seems to be a reliable method for tonsil surgery with substantially less primary morbidity than conventional tonsillectomy and with the same positive long-term effects after six years.