Facial patterns and primary nocturnal enuresis in children

Association between Hepatic Steatosis and Obstructive Sleep Apnea in Children and Adolescents with Obesity

BACKGROUND

Owing to the increasing rate of pediatric obesity, its complications such as non-alcoholic fatty liver disease (NAFLD) and obstructive sleep apnea (OSA) have become prevalent already in childhood. We aimed to assess the relationship between these two diseases in a cohort of children with obesity.

METHODS

We enrolled 153 children with obesity (mean age 10.5 ± 2.66, mean BMI 30.9 ± 5.1) showing OSA. Subjects underwent a laboratory evaluation, a cardio-respiratory polysomnography (PSG), and a liver ultrasound.

RESULTS

All subjects had a clinical diagnosis of OSA based on the AHI > 1/h (mean AHI 8.0 ± 5.9; range 2.21-19.0). Of these, 69 showed hepatic steatosis (62.3% as mild, 20.3% as moderate, and 17.4% as severe degree). A strong association between ALT and apnea/hypopnea index (AHI) was observed (p = 0.0003). This association was not confirmed after adjusting for hepatic steatosis (p = 0.53). By subdividing our population according to the presence/absence of steatosis, this association was found only in the steatosis group (p = 0.009). As the severity of steatosis increased, the significance of its association with AHI compared to the absence of steatosis became progressively stronger (all p < 0.0001).

CONCLUSIONS

Hepatic steatosis seems to drive the association between OSA and ALT levels, suggesting a potential pathogenic role of OSA in NAFLD.

Parental Stress and Parental Ratings of Behavioral Problems of Enuretic Children

Background: Primary monosymptomatic nocturnal enuresis (PMNE) may have a stressful impact on the everyday life of children and parents, and it may represent a cumulative stress factor increasing feelings of “learned helplessness.”

Methods: The current study investigated parental stress in a group of parents (n = 330) of children affected by PMNE, compared to a group of parents (n = 330) of typical developing children (TDC). In addition, the study evaluated whether parents of PMNE children experience more emotional, social, and behavioral problems in their children, compared to parents of TDC. Finally, the study correlated frequency of enuresis with stress values and Child Behavior Checklist (CBCL) subscales and total stress with CBCL. Both groups were given The Parental Stress Inventory-Short Form (PSI-SF) and the Child Behavior Checklist (CBCL).

Results: Parents of PMNE children showed significantly higher stress level than parents of TDC. Nocturnal enuresis, as a demanding clinical condition difficult to control, represents a relevant stress factor. Mothers appeared as more vulnerable to stress than fathers. Parents of PMNE children reported higher behavioral and emotional problems, compared to reports of parents of TDC. PMNE children appeared to their parents as having lower competency in social activities, school performance, and social relationships than TDC. Moreover, they were rated as more withdrawn, anxious-depressed, more aggressive, inattentive, and with more somatic complaints than healthy children. It was always the mother who rated a significantly higher number of emotional, social, and behavioral problems compared to fathers. Correlational analysis showed that the higher the frequency of enuresis, the greater the parental stress level, the lower the social activities, school performance and relational competencies and the higher the emotional, social and behavioral problems in children, according to the parents' evaluations. The greater the parental stress level, the lower the competencies rated and the higher the behavioral problems detected by parents.

Conclusion: The physicians who deal with PMNE children have taken into account the stressful role and emotional dimensions of this clinical condition, both for children and mothers, in order to improve clinical management. Psychological support is needed for parents, and mothers especially, for a more functional stress management related to the PMNE.

Current perspectives on the correlation of nocturnal enuresis with obstructive sleep apnea in children

BACKGROUND

Obstructive sleep apnea (OSA) and nocturnal enuresis (NE) are common clinical problems in children. OSA and NE are thought to be interrelated, but the exact pathophysiological mechanisms are not yet clear. This review aims to explain the possible pathogenesis of NE in children with OSA.

DATE SOURCES

We have retrieved all relevant original articles from Database that have been published so far, including the prevalence studies of NE and OSA in children, sleep characteristic studies that use polysomnography (PSG) to focus on children with NE, and studies on the relationship between OSA and NE.

RESULTS

Clinical studies have revealed that the risk of NE in children with OSA was increased compared with that of their healthy peers. This increased risk may be associated with sleep disorders, bladder instability, detrusor overactivity, nocturnal polyuria, endocrine and metabolic disorders, and inflammation.

CONCLUSIONS

Cardiopulmonary and renal reflex-induced neuroendocrine disorder may play an important role in the mechanism of NE in children with OSA, but this remains to be confirmed by animal studies. Other causes such as oxidative stress and inflammatory responses need to be further researched.

Study of behavioural disorders in children with primary enuresis

BACKGROUND

Enuresis results in behavioural disorder in children. This study investigated the behavioural disorders in children possessing primary enuresis.

MATERIALS AND METHODS

In this cross-sectional study, 100 children with primary enuresis were referred to children's hospital Khorramabad; the census method was used in this study. Data were collected using a short screening instrument for enuresis psychological problems, the reliability and validity of which have been confirmed in previous studies. First, a questionnaire was used to assess academic failure, anxiety, behavioural disorders, sleep, and psychological disorders. Results obtained were compared in terms of gender and age. Statistical analyses using inferential and descriptive statistics including Chi-square and Fisher test were employed.

RESULTS

The average age of children was 8.46 years. Sixty-six per cent of participants were male and the rest of them were female. Ninety per cent of subjects were between the age range of 1-9 years, and 10% were over 10 years old. Forty-three per cent of children suffered from anxiety disorders and 34% had sleep disorders, 4% also suffered from academic failure. Among behavioural disorders, hyperactivity and restlessness were the most common disorders, and they were significantly higher in nine boys. Headache, obsessive, and sleep disorders were more common in children above 10. There was a significant correlation between eating disorders, headache, sleep disorders, and strange movements in males, while feelings of sadness were more common in females.

CONCLUSION

Social personality development in children with enuresis can be improved by informing parents of enuresis.

Noninvasive imaging of brain oxygen metabolism in children with primary nocturnal enuresis during natural sleep

A series of studies have revealed that nocturnal enuresis is closely related to hypoxia in children with primary nocturnal enuresis (PNE). However, brain oxygen metabolism of PNE children has not been investigated before. The purpose of this study was to investigate changes in whole-brain cerebral metabolic rate of oxygen (CMRO₂ ), cerebral blood flow (CBF), and oxygen extraction fraction (OEF) in children suffering from PNE. We used the newly developed T2-relaxation-under-spin-tagging (TRUST) magnetic resonance imaging technique. Neurological evaluation, structural imaging, phase-contrast, and the TRUST imaging method were applied in children with PNE (n = 37) and healthy age- and sex-matched control volunteers (n = 39) during natural sleep to assess whole-brain CMRO₂ , CBF, OEF, and arousal from sleep scores. Results showed that whole-brain CMRO₂ and OEF values of PNE children were higher in controls, while there was no significant difference in CBF. Consequently, OEF levels of PNE children were increased to maintain oxygen supply. The elevation of OEF was positively correlated with the difficulty of arousal. Our results provide the first evidence that high oxygen consumption and high OEF values could make PNE children more susceptible to hypoxia, which may induce cumulative arousal deficits and make them more prone to nocturnal enuresis. Hum Brain Mapp 38:2532-2539, 2017. © 2017 Wiley Periodicals, Inc.

The Prevalence of Major Types of Occlusal Anomalies among Saudi Middle School Students

INTRODUCTION

Malocclusion is the most common dental anomaly among children and adolescents. Accordingly, this study was conducted to investigate the prevalence of major types of occlusal anomalies in permanent dentition among Saudi Arabian middle school adolescent students seeking orthodontic treatment in Jeddah.

MATERIALS AND METHODS

The sample comprised 150 males and 150 females with mean age of 14.25 (±1.09) for both males and females. Data were registered using the Bjork method.

RESULTS

The results of the study showed that postnormal occlusion, prenormal occlusion, and bimaxillary protrusion represented 22, 14.7, and 8.3% of the studied sample respectively. Moderate and severe overjet accounted for 24.7 and 5.7% and for overbite 28 and 13% respectively. Midline deviation was detected in 25.3% of the sample. Mild, moderate, and severe maxillary and mandibular crowding represented 10, 27.3, and 10% and 13, 40, and 9.7% respectively.

CONCLUSION

The prevalence of occlusal anomalies was 90% and some occlusal anomalies were higher in females.

CLINICAL SIGNIFICANCE

The prevalence of occlusal anomalies in Saudi Arabian middle school students necessitates the demand for obtaining baseline data for planning orthodontic services.

Therapeutic outcomes of mandibular advancement devices as an initial treatment modality for obstructive sleep apnea

Although continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA), there is a need for alternative treatment options, such as sleep surgeries and mandibular advancement devices (MADs), to overcome the limitations of CPAP.This study aimed to analyze the therapeutic outcomes of OSA subjects who were treated with a MAD, and to estimate the clinical impact of MAD as a first-line treatment for OSA.Forty-seven patients diagnosed with OSA received an adjustable MAD as an initial treatment. Drug-induced sleep endoscopic findings and sleep parameters (both pre-MAD and post-MAD treatment), such as apnea index, oxygen saturation, and degree of daytime sleepiness, were assessed retrospectively.The MAD treatment resulted in a significant reduction in apnea-hypopnea index, and also a significant elevation in lowest oxygen saturation. Satisfactory results of MAD treatment as a first treatment modality were observed in 27 patients, and a successful outcome was reached in approximately 72% of patients. The OSA patients who had lower body mass index and upper airway narrowing at the level of palate and tongue base showed relatively higher rates of a satisfactory outcome even in cases of moderate or severe OSA.These results suggest that the use of a MAD may be an alternative treatment option in OSA patients with retropalatal and retroglossal area narrowing regardless of disease severity. Additionally, MADs can be recommended as an initial treatment modality, and the effectiveness of MADs in achieving success may not be inferior to CPAP.

The use of magnetic resonance imaging in the evaluation of upper airway structures in paediatric obstructive sleep apnoea syndrome: a systematic review and meta-analysis

OBJECTIVES

A systematic review was conducted to assess the effectiveness of MRI in evaluating upper airway structures in children affected by obstructive sleep apnoea syndrome (OSAS).

METHODS

A literature search was performed in the Cochrane Central Register of Controlled Trials, Web of Science, Scopus and PubMed databases from their inception to 31/03/2016, including available randomized controlled trials and controlled clinical trials published in English assessing the use of MRI integrated with traditional polysomnography (PSG) among children up to 15 years of age affected by OSAS. The primary outcome to be evaluated was the efficacy of MRI in analyzing the upper airway total volume among healthy children compared with children affected by OSAS. Secondary outcomes were to compare the efficacy of MRI in analyzing the upper airway cross-sectional area in the areas adjacent to the adenoids and tonsils, adenoid and tonsil volume, and soft-tissue and maxillofacial bone parameters in the same sample. Results were expressed using a random-effects model and mean differences (MD) with 95% confidence intervals (CI).

RESULTS

The search yielded 1005 titles in total; the selection process narrowed to 3 titles, which were all assessed as indicating an unclear level of risk of bias. The meta-analysis found evidence of MRI effectiveness in evaluating differences in the upper airway total volume between paediatric patients affected by OSAS and paediatric patients not affected by OSAS (MD -0.56 cm(3); 95% CI: -1.05 to -0.07).

CONCLUSIONS

Although MRI could be considered effective in evaluating upper airway structures in children affected by OSAS, based on the present evidence, PSG is still the golden standard and further studies are required to verify MRI reliability.

Which oropharyngeal factors are significant risk factors for obstructive sleep apnea? An age-matched study and dentist perspectives

OBJECTIVE

Obstructive sleep apnea (OSA) is a common sleep breathing disorder. Untreated OSA may lead to a number of cardiovascular complications. Dentists may play an important role in OSA detection by conducting careful oral examinations. This study focused on the correlation of oral anatomical features in Thai patients who presented with OSA.

METHODS

We conducted a prospective comparative study at a sleep/hypertension clinic and a dental clinic at Khon Kaen University in Thailand. Patients with OSA were enrolled in the study, along with age-matched patients with non-OSA (controls). Baseline characteristics, clinical data, and oropharyngeal data of all patients were compared between the two groups. Oropharyngeal measurements included tongue size, torus mandibularis, Mallampati classification, palatal space, and lateral pharyngeal wall area. Multivariate logistic regression analysis was used to identify the factors associated with OSA.

RESULTS

During the study period, there were 156 patients who met the study criteria; 78 were patients with OSA and the other 78 were healthy control subjects. In the OSA group, there were 43 males with a mean age of 53 (standard deviation 12.29) years and a mean BMI of 30.86 kg/mm(2). There were 37 males in the control group with a mean age of 50 (standard deviation 12.04) years and a mean BMI of 24.03 kg/mm(2). According to multivariate logistic analysis, three factors were perfectly associated with OSA, including torus mandibularis class 6, narrow lateral pharyngeal wall, and Mallampati class 4. There were two other significant factors associated with having OSA, namely, BMI and Mallampati classification. The adjusted odds ratios (95% confidence interval) of these two factors were 1.445 (1.017, 2.052) and 5.040 (1.655, 15.358), respectively.

CONCLUSION

Dentists may play an important role in the detection of OSA in patients with high BMI through careful oropharyngeal examination in routine dental treatment. A large torus mandibularis, Mallampati class 4, and a narrow lateral pharyngeal wall are important anatomical risk factors for OSA.

Preferences of color and lip position for facial attractiveness by laypersons and orthodontists

BACKGROUND

Previous studies have reported some evaluation methods about profiles, but so far, they have no consistent agreement on the esthetic profiles of color images. Thus, the aim of this study was to determine whether the judges have different preferences about the color of the photograph and lip position for esthetic profiles when comparing a Chinese boy and girl.

METHODS

The photographic records of a Chinese boy and girl with a good balanced profile were randomly selected. The images of the patients' profile were altered to produce silhouettes and black and white and color photographs (a total of six images). After evaluation by the judges, the best two photographs of the boy and girl were used to produce images of anterior-posterior lip positions with -6, -4, -2, 0, +2, +4, and +6 mm in relation to the esthetic plane, which was created by Ricketts. The judges were invited to enumerate the images in the order in which they considered the most attractive.

RESULTS

The chromophotograph was chosen as the best way to express the facial profile in both the boy and girl. The profiles with a deviation of -4 mm in the boy and a deviation of -2 mm in the girl from line E were considered as the most attractive, and the image with a deviation of +6 mm from the normal line E was considered the least attractive. There were statistically significant differences between the preferences of the profiles of the boy and girl; the same results were recorded in the variables educational background and clinic role of the judges.

CONCLUSION

The chromophotograph was considered as the best way to evaluate the esthetic profiles, and the judges preferred the boy with a concave profile than the concave profile of the girl.

Motivation of adult female patients seeking orthodontic treatment: an application of Q-methodology

BACKGROUND

Motivation is the impetus for patients to seek orthodontic treatment, affecting adherence, treatment outcomes, and satisfaction. The aim of this study was to assess the motivation of adult female patients seeking orthodontic treatment, and classify the patients according to their motivations.

METHODS

This study used Q-methodology as the main tool. Q-samples were collected and categorized (35 items). Forty-two adult female patients were interviewed before treatment as the P-sample, and their responses were categorized into the Q-methodology grid. Participants were asked to rank-order a set of 35 statements (Q-sample) from "agree most" to "disagree most" (Q-sorting). The finished Q-grids were analyzed using PQ method 2.35.

RESULTS

Four main factors were identified based on how adult female patients ranked statements: factor 1, patients who focus on their self-perception of their appearance; factor 2, patients who are concerned about the esthetics and function of their teeth; factor 3, patients who are easily influenced by others; factor 4, patients who want to improve their confidence and avoid negative thoughts caused by their teeth. The remaining patients who had other views did not match any of the above four groups.

CONCLUSION

The motivations of adult female patients seeking orthodontic treatment are complex. This study found that most adult female patients fell into one of four typical factor groups. Our findings may improve the adherence of adult female patients by developing a more ideal treatment program.

Medication adherence in the management of nocturia: challenges and solutions

OBJECTIVE

Nocturia affects millions of men and women. No prior reviews or meta-analyses have explored the issue of adherence in nocturia patients. The objective of our study was to examine the attributes and their interaction that might impact pharmacological adherence in nocturia care using a conceptual model of adherence.

MATERIALS AND METHODS

A literature search of the Medline, PubMed, Embase, PsycInfo, and CINAHL databases for studies published between January 1990 and June 2014 was conducted. We developed a conceptual model in order to facilitate our review.

RESULTS

Currently, multiple treatment options for nocturia exist, depending on the underlying cause. Adherence to nocturia treatment and outcomes are complex and intertwined, and nonadherence to nocturia treatment is common. In 15 studies meeting eligibility criteria, behavioral and pharmacologic interventions for nocturia were associated with reduced nocturia symptoms. Urinary symptoms that are associated with nocturia need individualized management depending on renal and hepatic function, medical comorbidities, and ongoing medication use in a patient. Another important factor related to adherence is the bother. Although nocturia is defined as nighttime-voiding frequency of one or more, not all persons may find this bothersome. The degree of bother is subjective, and may change from person to person. However, there is no information related to the association between bother and adherence to medication or behavioral treatments for nocturia. Medication dosing convenience, preference, and cost play important roles in adherence. We present a patient-centered conceptual model that brings together the various dimensions of medication adherence for nocturia.

CONCLUSION

Few studies have explored adherence to medication and related factors in the care of nocturia. Our conceptual model can aid development of interventions to improve adherence to nocturia medications.

Sleep disordered breathing and airway disease in primary ciliary dyskinesia

BACKGROUND AND OBJECTIVE

Sleep-disordered breathing (SDB) may develop in primary ciliary dyskinesia (PCD), leading to these diseases worsening one another.

METHODS

Sixteen stable PCD patients (4.9-17.2 years) and 42 controls underwent overnight respiratory polysomnography (rPSG) and Sleep Disturbances Scale for Children (SDSC). In PCD we assessed nasal endoscopy, pulmonary function tests and chest high-resolution computed tomography (HRCT).

RESULTS

Compared with controls, PCD had higher obstructive apnoea (4.7 vs 0.2, P < 0.001), central apnoea (0.8 vs 0.2, P < 0.001), hypopnoea (1.8 vs 0.2, P < 0.001), apnoea-hypopnoea (7.8 vs 0.6, P < 0.001), oxygen desaturation indexes (ODI; 0.7 vs 0.2, P = 0.002), and mean oxygen desaturation (4% vs 1%, P < 0.001), while mean and nadir oxygen saturation (97.1% vs 98.1, P < 0.001) (93% vs 97.2%, P < 0.001) were lower, respectively. In PCD, SDSC was unrelated to rPSG (P > 0.05), with total score and subscores of disorders in initiating and maintaining sleep, and sleep-wake transition lower than controls. PCD patients had chronic rhinosinusitis (100%) and adenoidal hypertrophy (50%). Total HRCT score was 7 (range 0-14). ODI correlated with functional residual capacity (r = 0.8, P = 0.02), total HRCT (r = 0.6, P = 0.03) and peribronchial thickening scores (r = 0.7, P = 0.02). Oxygen saturation was associated with bronchiectasis severity score (r = -0.6, P = 0.02).

CONCLUSIONS

PCD's parents may underestimate SDB. As nocturnal desaturation is associated with lung function and structure abnormalities, SDB may significantly contribute to pulmonary morbidity.

Orthodontic treatment need for adolescents in the Campania region: the malocclusion impact on self-concept

BACKGROUND

Dental malocclusions can be considered not only as an oral health problem, because they are linked to quality of life perception. Many factors related to malocclusion have strong influences on the perception of facial esthetics (eg, anterior tooth alignment, tooth shape and position, lip thickness, symmetric gingival or tooth contour, lip profile, and overjet). Many reports have shown that the perception of facial esthetics can influence psychological development from early childhood to adulthood. The aim of this study is to investigate the effect of dental malocclusion on self-esteem in a sample of adolescents.

MATERIALS AND METHODS

The study population was composed of 516 orthodontically untreated subjects (256 males) mean ages 13.75±1.977 years recruited from schools in the Campania region of Italy between January 2011 and July 2011. To evaluate the self-esteem grade in our population, all subjects filled out the Multidimensional Self Concept Scale questionnaire and attended an orthodontic clinical evaluation to estimate dental occlusal aspects.

RESULTS

Pearson's analysis shows the relationship in our sample between some occlusal characteristics (crossbite and dental crowding) and aspects of self-concept evaluation (social, competence, academic, physical, and global score) of the Multidimensional Self Concept Scale questionnaire. Moreover, logistic regression analysis shows the potential role of dental crowding (odds ratio 5.359; 95% confidence interval 3.492-8.225) and crossbite (odds ratio 6.153; 95% confidence interval 3.545-10.678) as risk factors for development of global self-concept score abnormalities.

CONCLUSION

Our findings confirm the relationship between psychosocial well-being, self-esteem, and dental malocclusion among adolescents.

Respiration during sleep in children with therapy-resistant enuresis

AIM

Although there is a known association between enuresis and snoring or sleep apnoeas, respiration during sleep has not been thoroughly studied in enuretic children. This study was performed with the aim of filling this gap in our knowledge.

METHODS

Thirty-four children with therapy-resistant enuresis, but no history of heavy snoring or sleep apnoeas, underwent sleep registrations, including standard electroencephalography (EEG) and electrooculography (EOG) as well as registration of oxygen saturation, respiratory effort and nasal air flow. To assess nasal airway patency, rhinomanometry and acoustic rhinometry were performed before and after nasal decongestion.

RESULTS

The children were found to have a higher than expected apnoea hypopnoea index (AHI), due to a high frequency of hypopnoeas. They were also noted to have a tendency for respiratory arousals. Standard polysomnographic variables were normal.

CONCLUSION

We provide baseline data of nocturnal respiration in enuretic children. The children were found to have subclinical signs of disordered respiration. This may be one of the explanations for their high arousal thresholds.

Pediatric neurofibromatosis 1 and parental stress: a multicenter study

BACKGROUND

Neurofibromatosis 1 (NF1) is a complex and multifaceted neurocutaneous syndrome with many and varied comorbidities. The literature about the prevalence and degree of maternal stress and the impact of NF1 in the parent-child interaction is still scant. The aim of this study was to evaluate the prevalence of maternal stress in a large pediatric sample of individuals affected by NF1.

METHODS

Thirty-seven children (19 boys, 18 girls) of mean age 7.86±2.94 (range 5-11) years affected by typical NF1 and a control group comprising 405 typically developing children (207 boys, 198 girls; mean age 8.54±2.47 years) were included in this study. To assess parental stress, the mothers of all individuals (NF1 and comparisons) filled out the Parenting Stress Index-Short Form test.

RESULTS

The two study groups were comparable for age (P=0.116), gender (P=0.886), and body mass index adjusted for age (P=0.305). Mothers of children affected by NF1 reported higher mean Parenting Stress Index-Short Form scores on the Parental Distress domain (P<0.001), Difficult Child domain (P<0.001), and Total Stress domain than the mothers of typically developing children (controls) (P<0.001). No significant differences between the two groups were found for the Parent-Child Dysfunctional Interaction domain (P=0.566) or Defensive Responding domain scores (P=0.160).

CONCLUSION

NF1 is considered a multisystemic and complex disease, with many still unrecognized features in pediatric patients and in their families. In this light, our findings about the higher levels of maternal stress highlight the importance of considering the environmental aspects of NF1 management in developmental age.

Association of orthodontic treatment needs and oral health-related quality of life in Saudi children seeking orthodontic treatment

INTRODUCTION

The objective was to assess the effects of different orthodontic treatment needs on the oral health-related quality of life (OHRQoL) of Saudi children seeking orthodontic treatment as perceived by the children and their parents.

METHODS

A cross-sectional evaluation of orthodontic patients and their attending parents was conducted to assess the relationship between orthodontic treatment needs and the OHRQoL. The study sample comprised 120 young orthodontic patients (36 boys, 84 girls; age range, 12-15 years). Each participant was assessed for orthodontic treatment needs and OHRQoL using the Dental Health Component of the Index of Orthodontic Treatment Needs and the Michigan Oral Health-related Quality of Life Scales-Version C (child) and Version PG (parent/guardian), respectively.

RESULTS

Orthodontic treatment needs significantly affected mouth aching, chewing and biting, going to school, and playing. Higher income and borderline index of orthodontic treatment needs are significantly related to oral health impact on quality of life perceived by the child, while younger age and high school education are related to oral health impact on quality of life as perceived by the parent/guardians.

CONCLUSION

These findings emphasize the impact of malocclusion on OHRQoL in children.

Anxiety and depression levels in prepubertal obese children: a case-control study

INTRODUCTION

Childhood obesity has become a worldwide epidemic in Western and in developing countries and has been accompanied by many serious and severe comorbidities, such as diabetes, hypertension, sleep apnea syndrome, depression, dyslipidemia, impaired glucose homeostasis, steatohepatitis, and intracranial hypertension, as well as medical concerns unique to youth, such as accelerated pubertal and skeletal development and orthopedic disorders. To date, no specific studies about the psychological assessment in pediatric obesity are present. Therefore, the aim of this study was to evaluate the putative relationship between psychological troubles and obesity in a sample of school-aged children.

MATERIALS AND METHODS

The study population consists of 148 obese subjects (body mass index [BMI] >95th percentile) (69 males, mean age 8.9±1.23 years) consecutively referred from clinical pediatricians to the Child and Adolescent Neuropsychiatry department at the Second University of Naples. In all subjects, weight, height, and BMI z-score were evaluated. In order to assess the anxiety levels and the presence of depressive symptoms, the Children Depression Inventory (CDI) and the Italian Self-Administered Psychiatric Scales for Children and Adolescents (SAFA) were administered. The control group consisted of 273 healthy children (129 males and 144 females) (mean age 9.1±1.8 years), enrolled in schools within the Campania region of Italy.

RESULTS

No significant differences between the two study groups were found for age (8.9±1.23 years in the obese sample and 9.1±1.8 years in the control group) (P=0.228) or sex (ratio male/female: 69/79 in the obese group versus 129/144 in the control group) (P=0.983). Obviously, significant difference was found for the BMI z-score (2.46±0.31 in the obese group vs 0.73±0.51 in the control group) (P<0.001). The obese subjects showed significant higher level of depressive symptoms (CDI total score) (16.82±7.73 vs 8.2±2.9) (P<0.001) and anxiety (SAFA - Anxiety [SAFA-A]) scale score (58.71±11.84 vs 27.75±11.5) (P<0.001) compared with the control group. Moreover, the Pearson's correlation analysis showed a significantly positive relationship between the BMI z-score and both the CDI (r=0.677; P<0.001) and SAFA-A scores (r=0.591; P<0.001).

CONCLUSION

Our findings highlighted the importance of assessing the presence of internalizing problems, such as anxiety and depression, in the common management of childhood obesity.

The effect of breathing exercises on the nocturnal enuresis in the children with the sleep-disordered breathing

BACKGROUND

The nocturnal enuresis is one of the most common complaints of childhood. Upper airway obstruction and nocturnal snoring affect the nocturnal enuresis in children.

OBJECTIVES

The aim of this study was to investigate the effects of breathing exercises on the nocturnal enuresis in the children with the sleep-disordered breathing.

PATIENTS AND METHODS

This study was conducted in year of 2011 by a semi-experimental design with the control group among 40 children, aged 6 - 12 years, who had the nocturnal enuresis. Participants were examined based on the criteria of nocturnal enuresis, oral breathing, and nocturnal snoring. Subsequently, they were randomly assigned to the case and control groups. In the case group, the breathing exercises were performed for 45 minutes, and were pursued for four weeks in the morning following and prior to sleeping, and subsequently the arterial blood gases were measured and the frequency of enuresis and the respiratory rates (RR) were recorded.

RESULTS

After intervention the means of PaCO2 and RR in the control group were significantly higher than the case group (P < 0.0001). Likewise, O2sat, PaO2 in the case group were higher than the control group (P < 0.0001). The nocturnal enuresis decreased significantly in the case group, compared to the control group (P < 0.0001).

CONCLUSIONS

This study suggests that the breathing exercises may reduce the frequency of nocturnal enuresis in the patients with the oral breathing and nocturnal snore. The clinical implications of these findings should be verified in the future longitudinal studies.

Obstructive sleep apnea and endothelial progenitor cells

BACKGROUND

Obstructive sleep apnea (OSA) occurs in 4% of middle-aged men and 2% of middle-aged women in the general population, and the prevalence is even higher in specific patient groups. OSA is an independent risk factor for a variety of cardiovascular diseases. Endothelial injury could be the pivotal determinant in the development of cardiovascular pathology in OSA. Endothelial damage ultimately represents a dynamic balance between the magnitude of injury and the capacity for repair. Bone marrow-derived endothelial progenitor cells (EPCs) within adult peripheral blood present a possible means of vascular maintenance that could home to sites of injury and restore endothelial integrity and normal function.

METHODS

We summarized pathogenetic mechanisms of OSA and searched for available studies on numbers and functions of EPCs in patients with OSA to explore the potential links between the numbers and functions of EPCs and OSA. In particular, we tried to elucidate the molecular mechanisms of the effects of OSA on EPCs.

CONCLUSION

Intermittent hypoxia cycles and sleep fragmentation are major pathophysiologic characters of OSA. Intermittent hypoxia acts as a trigger of oxidative stress, systemic inflammation, and sympathetic activation. Sleep fragmentation is associated with a burst of sympathetic activation and systemic inflammation. In most studies, a reduction in circulating EPCs has emerged. The possible mechanisms underlying the decrease in the number or function of EPCs include prolonged inflammation response, oxidative stress, increased sympathetic activation, physiological adaptive responses of tissue to hypoxia, reduced EPC mobilization, EPC apoptosis, and functional impairment in untreated OSA. Continuous positive airway pressure (CPAP) therapy for OSA affects the mobilization, apoptosis, and function of EPCs through preventing intermittent hypoxia episodes, improving sleep quality, and reducing systemic inflammation, oxidative stress levels, and sympathetic overactivation. To improve CPAP adherence, the medical staff should pay attention to making the titration trial a comfortable first CPAP experience for the patients; for example, using the most appropriate ventilators or proper humidification. It is also important to give the patients education and support about CPAP use in the follow-up, especially in the early stage of the treatment.

Positional abnormalities during sleep in children affected by obstructive sleep apnea syndrome: the putative role of kinetic muscular chains

Sleep-related breathing disorders (SRBD) are disorders of breathing during sleep characterized by prolonged partial upper airway obstruction, intermittent complete or partial obstruction (obstructive apnea or hypopnea), or both prolonged and intermittent obstruction that disrupts normal ventilation during sleep, normal sleep patterns, or both. Children with OSAS may sleep in unusual positions, such as seated or with neck hyperextended, even if the neck position is not the only unusual posture or the special sleeping positions that is possible to detect in children with SRBD. We have hypothesized that the assumption of unusual posture during sleep, in particular legs retracting or crossing during sleep, could be a way to enlarge the diaphragmatic excursion and promoting the alveolar gas exchanges avoiding the stress of the antero-lumbar and prevertebral muscular chains in SRBD subjects. We have hypothesized that the assumption of unusual posture during sleep, in particular legs retracting or crossing during sleep, could be a way to enlarge the diaphragmatic excursion and promoting the alveolar gas exchanges avoiding the stress of the antero-lumbar and prevertebral muscular chains in SRBD subjects. We can postulate that the prevertebral and antero-lumbar muscular chains could be oversolicited during the apnoic events, and the assumption of abnormal posture could be interpreted as a way to relax or diminish the strain or muscular stress caused by the apneas. The consequence of this hypothesis could be summarized in the concept that a specific rehabilitation or muscular program to improve the tone of this kinetic chain, could be useful to limit the effect nocturnal or diurnal of this so impacting syndrome.

Primary nocturnal enuresis as a risk factor for sleep disorders: an observational questionnaire-based multicenter study

INTRODUCTION

Primary nocturnal enuresis (PNE) is a common problem in developmental age with an estimated overall prevalence ranging from 1.6% to 15%, and possible persistence during adolescence. There is a growing interest in the sleep habits of children affected by PNE, which is derived from the contradictory data present in clinical literature. The aim of the present study was to evaluate the presence of sleep disturbances in a population of children affected by PNE, and to identify whether PNE could be considered as a risk factor for sleep disturbances among children.

MATERIALS AND METHODS

A total of 190 PNE children (97 males, 93 females) aged 7-15 years, (mean 9.64 ± 1.35 years), and 766 typically developing children matched for age (P = 0.131) and gender (P = 0.963) were enrolled. To evaluate the presence of sleep habits and disturbances, all of the subjects' mothers filled out the Sleep Disturbances Scale for Children (SDSC), a questionnaire consisting of six subscales: Disorders in Initiating and Maintaining Sleep (DIMS), Sleep Breathing Disorders (SBD), Disorders of Arousal (DA), Sleep-Wake Transition Disorders (SWTD), Disorders of Excessive Somnolence (DOES), and Nocturnal Hyperhidrosis (SHY). The results were divided into "pathological" and "normal" scores using a cut-off value (pathological score = at least three episodes per week), according to the validation criteria of the test. Then, the Chi-square test was used to calculate the statistical difference and a univariate logistic regression analysis was applied to determine the role of PNE as a risk factor for the development of each category of sleep disorders and to calculate the odds ratio (OR).

RESULTS

PNE children show a higher prevalence of all sleep disturbances (41.03% DIMS; 85.12% SBD; 63.29% DA; 67.53% SWTD; 31.28% DOES; 37.92% SHY; 25.33% SDSC total score), and according to OR results (SDSC total score OR = 8.293, 95% confidence interval [CI] = 5.079-13.540; DIMS OR = 7.639, 95% CI = 5.192-11.238; SBD OR = 35.633, 95% CI = 22.717-55.893; DA OR = 13.734, 95% CI = 9.476-19.906; SWTD OR = 14.238, 95% CI = 9.829-20.625; DOES OR = 5.602, 95% CI = 3.721-8.432; SHY OR = 6.808, 95% CI = 4.608-10.059), PNE could be considered as a risk factor for the development of sleep disorders.

CONCLUSION

Among PNE children, sleep could be strongly altered, thus helping to affirm the hypothesis that PNE tends to alter sleep architecture, or it could itself be the consequence of an abnormal sleep structure. The findings also point to the existence of a potential increase in the risk of developing sleep disorders in the presence of PNE.

Acupressure therapy for insomnia in adolescents: a polysomnographic study

BACKGROUND

The purpose of this study was to assess the efficacy of acupressure therapy in a sample of adolescents with insomnia using a standard polysomnographic evaluation.

METHODS

For this study, 25 adolescents affected by psychophysiological insomnia (mean age 15.04 ± 1.18 years, 12 boys) were enrolled. A device known as the Sea-Band(®) was used by the patients in order to improve their symptoms related to difficulty in falling asleep. All subjects enrolled underwent two sets of consecutive overnight polysomnographic studies in the Sleep Laboratory of the Clinic of Child and Adolescent Neuropsychiatry, comprising two studies at baseline (before treatment) and another two studies at the end of 6 months of treatment.

RESULTS

At the end of 6 months of treatment, there was a significant increase in all macrostructural parameters of sleep duration, and a reduction in sleep onset latency, wake after sleep onset, and stage 2 sleep. Moreover, the study group showed a significant increase in percent sleep efficiency (P < 0.001) and in slow wave sleep representation.

CONCLUSION

Acupressure is a noninvasive, safe, and effective method for the management of insomnia in adolescents, with good compliance and no adverse effects.

Attachment styles in children affected by migraine without aura

BACKGROUND

In recent years, great attention has been given to the presence of psychological problems and psychiatric comorbidity that are also present in children affected by primary headaches. The relationship between pain and attachment has been identified, and it may be that pain perception may change in relation with specific attachment styles. The aim of the present study was to assess the prevalent attachment style and verify its putative relationship and correlation with the main characteristics of migraine attacks, in school-aged children affected by migraine without aura (MoA).

MATERIALS AND METHODS

The study population consisted of 219 children (103 males, 116 females) aged between 6 and 11 years (mean 8.96 ± 2.14 years), consecutively referred for MoA compared with 381 healthy controls (174 males, 207 females; mean age 9.01 ± 1.75 years) randomly selected from schools. All the children were classified according to the attachment typologies of the Italian modified version of the Separation Anxiety Test; monthly headache frequency and mean headache duration were assessed from daily headache diaries kept by all the children. Headache intensity was assessed on a visual analog scale. The chi-square test and t-test, where appropriate, were applied, and the Spearman rank correlation test was applied to explore the relationship between the types of attachment style and clinical aspects of MoA.

RESULTS

The MoA group showed a significantly higher prevalence of type A (avoidant) attachment (P<0.001) and a significantly lower prevalence of type B (secure) attachment (P<0.001) compared with the control group. Moreover, the Spearman rank correlation analysis showed a significant relationship between MoA characteristics and the attachment style of MoA children.

CONCLUSION

The main findings of the present study were the higher prevalence among MoA children of the avoidant attachment style (type A) and the significantly lower prevalence of the secure style attachment (type B) compared with the normal controls, suggesting that the study of psychiatric comorbidity in pediatric headache may be enriched by this new aspect of analysis.

Effectiveness and safety of Nintendo Wii Fit Plus™ training in children with migraine without aura: a preliminary study

BACKGROUND

Migraine without aura (MoA) is a painful syndrome, particularly in childhood; it is often accompanied by severe impairments, including emotional dysfunction, absenteeism from school, and poor academic performance, as well as issues relating to poor cognitive function, sleep habits, and motor coordination.

MATERIALS AND METHODS

The study population consisted of 71 patients affected by MoA (32 females, 39 males) (mean age: 9.13±1.94 years); the control group consisted of 93 normally developing children (44 females, 49 males) (mean age: 8.97±2.03 years) recruited in the Campania school region. The entire population underwent a clinical evaluation to assess total intelligence quotient level, visual-motor integration (VMI) skills, and motor coordination performance, the later using the Movement Assessment Battery for Children (M-ABC). Children underwent training using the Wii-balance board and Nintendo Wii Fit Plus™ software (Nintendo Co, Ltd, Kyoto, Japan); training lasted for 12 weeks and consisted of three 30-minute sessions per week at their home.

RESULTS

The two starting populations (MoA and controls) were not significantly different for age (P=0.899) and sex (P=0.611). M-ABC and VMI performances at baseline (T0) were significantly different in dexterity, balance, and total score for M-ABC (P<0.001) and visual (P=0.003) and motor (P<0.001) tasks for VMI. After 3 months of Wii training (T1), MoA children showed a significant improvement in M-ABC global performance (P<0.001), M-ABC dexterity (P<0.001), M-ABC balance (P<0.001), and VMI motor task (P<0.001).

CONCLUSION

Our study reported the positive effects of the Nintendo Wii Fit Plus™ system as a rehabilitative device for the visuomotor and balance skills impairments among children affected by MoA, even if further research and longer follow-up are needed.

Occlusal traits in developmental dyslexia: a preliminary study

AIM

The objective of the study reported here was to assess the orthodontic features in children affected by developmental dyslexia (DD).

PATIENTS AND METHODS

A total of 28 children affected by DD (22 boys, six girls; mean age: 9.78 ± 1.69 years) were compared with 51 healthy children (38 boys, 13 girls; mean age 9.41 ± 1.48; range 7-10 years). Reading and writing skills were evaluated along with orthodontic features.

RESULTS

The DD and control groups were not significantly different in terms of total intelligence quotient (P = 0.441) and writing skills (P = 0.805 and P = 0.240, respectively), whereas significant differences were observed between the DD group and control group in both word reading (2.018 ± 1.714 vs 0.917 ± 0.563; P = 0.000) and non-word reading (2.537 ± 1.543 vs 0.862 ± 0.244; P = 0.000). Moreover, for many orthodontic features, there was no significant difference between the two groups; only in prevalence of diastemas (57.14%, P = 0.006), midline diastemas (46.42%, P = 0.007), overbite > 4 mm (71.42%, P = 0.006) and overjet > 4 mm (53.57%, P = 0.001), was there a statistically significant difference. According to univariate logistic regression analysis, the presence of diastemas (odds ratio [OR] 4.33; 95% confidence interval [CI] 1.61-11.65), midline diastemas (OR 4.68; 95% CI 1.61-13.43), an overbite >4 mm (OR 1.75; 95% CI 0.64-4.71), or an overjet >4 mm (OR 2.76; 95% CI 1.06-7.20) seems to play a role in the relationship between occlusal abnormalities and DD in children.

CONCLUSION

Children with DD tend to present with altered dental features, particularly in the area of the incisors, suggesting that a persistently different tongue kinematic profile may thus affect both the developmental variability of the tongue and lip and the occlusion.

Executive dysfunction in children affected by obstructive sleep apnea syndrome: an observational study

INTRODUCTION

The role of sleep in cognitive processes can be considered clear and well established. Different reports have disclosed the association between sleep and cognition in adults and in children, as well as the impact of disturbed sleep on various aspects of neuropsychological functioning and behavior in children and adolescents. Behavioral and cognitive dysfunctions can also be considered as related to alterations in the executive functions (EF) system. In particular, the EF concept refers to self-regulatory cognitive processes that are associated with monitoring and controlling both thought and goal directed behaviors. The aim of the present study is to assess the impact of the obstructive sleep apnea syndrome (OSAS) on EF in a large sample of school aged children.

MATERIALS AND METHODS

The study population comprised 79 children (51 males and 28 females) aged 7-12 years (mean 9.14 ± 2.36 years) with OSAS and 92 healthy children (63 males and 29 females, mean age 9.08 ± 2.44 years). To identify the severity of OSAS, an overnight respiratory evaluation was performed. All subjects filled out the Italian version of the Modified Card Sorting Test to screen EFs. Moreover, to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale (PDSS).

RESULTS

No significant differences between the two study groups were found for age (P = 0.871), gender (P = 0.704), z-score of body mass index (P = 0.656), total intelligence quotient (P = 0.358), and PDSS scores (P = 0.232). The OSAS children showed a significantly higher rate of total errors (P < 0.001), perseverative errors (P < 0.001), nonperseverative errors (P < 0.001), percentage of total errors (P < 0.001), percentage of perseverative errors (P < 0.001), and percentage of nonperseverative errors (P < 0.001). On the other hand, OSAS children showed a significant reduction in the number of completed categories (P = 0.036), total correct sorts (P = 0.001), and categorizing efficiency (P < 0.001). The Pearson's correlation analysis revealed a significant positive relationship between all error parameters and apnea-hypopnea index, oxygen desaturation index, and percentage of mean desaturation of O2 with a specular negative relationship between the error parameters and the mean oxygen saturation values, such as a significant negative relationship between apnea-hypopnea index, oxygen desaturation index, percent of mean desaturation of O2, and the number of completed categories.

CONCLUSION

Our study identified differences in the executive functioning of children affected by OSAS and is the first to identify a correlation between alteration in respiratory nocturnal parameters and EF that has not yet been reported in developmental age. These findings can be considered as the strength and novelty of the present report in a large pediatric population.

[Craniofacial morphology and obstructive sleep apnoea-hypopnoea syndrome: a craniometric comparative analysis]

PURPOSE

The aim of this study was to define the relationship between paediatric obstructive sleep apnoea-hypopnea syndrome (OSAHS) and craniofacial morphovolumetric features through comparative craniometric analyses between affected children and controls based on conventional cephalometry.

MATERIALS AND METHODS

Cephalometric examinations of 40 children affected by OSAHS were retrospectively evaluated. Sixteen craniometric landmarks were identified, and 27 linear and angular indices related to craniofacial morphovolumetric features were measured. Subsequently, the same process of identifying landmarks and measuring indices was performed on the cephalometric examinations of 40 controls. For each index, we then calculated in both groups the mean, standard deviation, standard error and p value. By comparing the values obtained in the two series, we calculated the degree of significance of each difference between children with OSAHS and controls using the Student t test.

RESULTS

Differences of only 5/27 linear and angular indices considered were not statistically significant between groups, thus confirming susceptibility to the disorder in relation to certain splanchnocranic morphovolumetric features. The most significant differences involved mandibular plane inclination and distance between landmark sella and hyoid bone, a reliable index being the vertical position of the latter.

CONCLUSIONS

Despite the limitations associated with the 2D nature of conventional cephalometry, mainly related to projection and identification errors, and despite the upright position during examination, we consider the diagnostic value and information content of this technique high, thus reaffirming its role as a first-line imaging investigation in children with sleep-related breathing disorders.

Changes in CT cerebral blood flow and volume associated with rapid maxillary expansion in a rabbit model

OBJECTIVE

To evaluate hemodynamic changes of the brain under the high forces of a rapid maxillary expansion (RME) appliance in a rabbit model.

MATERIALS AND METHODS

Twenty-four male New Zealand white rabbits were selected (12 weeks old, mean weight 3.01 ± 0.22 kg). A modified acrylic resin bonded RME appliance was used for expansion. A series of perfusion computed tomography examinations was performed before expansion (T0), on the fifth day of expansion (T1), at the end of the expansion process (T2), and after 10 days of retention (T3). Cerebral blood flow, cerebral blood volume, and mean transit time maps were recorded and parametrics evaluated. Statistical analyses were performed with analysis of variance with post hoc tests.

RESULTS

Mean cerebral blood flow showed an increase from T0 to T2 and then a decrease from T2 to T3, but the change was not statistically significant. Mean cerebral blood volume and mean transit time increased significantly from T0 to T2, and all perfusion parameters increased from T0 to T3.

CONCLUSIONS

RME is a safe orthopedic method despite the high expansion force. Perfusion computed tomography is effective for evaluating the hemodynamic changes of the brain caused by some orthopedic therapies. The increase in both cerebral blood volume and cerebral blood flow may help to explain why RME could alleviate the symptoms of enuretic children.