Primary snoring in school children: prevalence and neurocognitive impairments

Changes in behavioral and cognitive abilities after rapid maxillary expansion in children affected by persistent snoring after long-term adenotonsillectomy: A noncontrolled study

INTRODUCTION

The objective of this study was to verify changes in behavioral abilities and cognitive functions after rapid maxillary expansion (RME) in children with refractory sleep-disordered breathing (SDB) in the long term after adenotonsillectomy.

METHODS

A prospective clinical trial study using RME therapy was conducted. Participant inclusion criteria were children who had adenotonsillectomy with maxillary transverse deficiency and persistent SDB (obstructive apnea-hypopnea index ≥1). The study included 24 children aged 5-12 years, and of these 24 children, 13 had primary snoring and 11 had obstructive sleep apnea. The patients underwent laryngeal nasofibroscopy and a complete polysomnography. In addition, patients completed the Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire. Behavioral and neurocognitive tests were also completed before and after RME.

RESULTS

The Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life scores showed a statistically significant decrease in both groups (P <0.001) after RME. The results showed that neurocognitive and behavioral parameters (Child Behavior Checklist scale) were similar in primary snoring and obstructive sleep apnea (OSA) groups before RME. In the OSA group, the mean scores of the "Somatic" and "Aggressiveness" domains decreased significantly (P <0.05). The cognitive functions did not register significant differences pre- and post-RME in any of the cognitive functions, except for visuospatial function in the OSA group.

CONCLUSIONS

The noncontrolled design was a major limitation of our study. The need for treatment for SDB should consider the association of symptoms and behavioral disturbances with the child's obstructive apnea-hypopnea index. RME might prove to be an alternative treatment for children with SDB refractory to adenotonsillectomy, improving quality of life and behavioral aspects. However, a larger sample size with a control group is needed to substantiate these claims.

Characteristics of ADHD Symptoms and EEG Theta/Beta Ratio in Children With Sleep Disordered Breathing

Objectives. This study aimed to explore parent-reported symptoms of attention deficit-hyperactivity disorder (ADHD) and sleep electroencephalogram (EEG) theta/beta ratio (TBR) characteristics in children with sleep disordered breathing (SDB). Methods. The parents of children (aged 6-11 years) with SDB (n = 103) and healthy controls (n = 28) completed the SNAP-IV questionnaire, and children underwent overnight polysomnography. Children with SDB were grouped according to obstructive apnea/hypopnea index: primary snoring, mild, and moderate-severe obstructive sleep apnea (OSA) groups. The TBR in non-rapid eye movement (NREM) periods in three sleep cycles was analyzed. Results. Children with SDB showed worse ADHD symptoms compared with the healthy control. There was no intergroup difference in TBR. The time-related decline in TBR observed in the control, primary snoring and mild OSA groups, which was not observed in the moderate-severe OSA group. Overnight transcutaneous oxygen saturation was negatively associated with the hyperactivity/impulsivity score of ADHD symptom. The global TBR during the NREM period in the first sleep cycle was positively correlated with inattention score. Conclusion. Children with SDB showed more ADHD inattention symptoms than the healthy control. Although we found no difference in TBR among groups, we found significant main effect for NREM period. There existed a relationship between hypoxia, TBR, and scores of ADHD symptoms. Hence, it was speculated that TBR can reflect the nocturnal electrophysiological manifestations in children with SDB, which may be related to daytime ADHD symptoms.

Childhood sleep: physical, cognitive, and behavioral consequences and implications

BACKGROUND

Sleep problems in children have been increasingly recognized as a major public health issue. Previous research has extensively studied and presented many risk factors and potential mechanisms for children's sleep problems. In this paper, we aimed to identify and summarize the consequences and implications of child sleep problems.

DATA SOURCES

A comprehensive search for relevant English language full-text, peer-reviewed publications was performed focusing on pediatric sleep studies from prenatal to childhood and adolescence in a variety of indexes in PubMed, SCOPUS, and Psych Info published in the past two decades. Both relevant data-based articles and systematic reviews are included.

RESULTS

Many adverse consequences are associated with child sleep deficiency and other sleep problems, including physical outcomes (e.g., obesity), neurocognitive outcomes (e.g., memory and attention, intelligence, academic performance), and emotional and behavioral outcomes (e.g., internalizing/externalizing behaviors, behavioral disorders). Current prevention and intervention approaches to address childhood sleep problems include nutrition, exercise, cognitive-behavioral therapy for insomnia, aromatherapy, acupressure, and mindfulness. These interventions may be particularly important in the context of coronavirus disease 2019. Specific research and policy strategies can target the risk factors of child sleep as well as the efficacy and accessibility of treatments.

CONCLUSIONS

Given the increasing prevalence of child sleep problems, which have been shown to affect children's physical and neurobehavioral wellbeing, understanding the multi-aspect consequences and intervention programs for childhood sleep is important to inform future research direction as well as a public health practice for sleep screening and intervention, thus improving sleep-related child development and health.

Sleep disordered breathing and neurobehavioral deficits in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Sleep disordered breathing (SDB) is broadly recognized to be associated with neurobehavioral deficits, which have significant impacts on developing-aged children and adolescents. Therefore, our study aimed to quantify the proportion of neurobehavioral impairments attributed to SDB in general children and adolescents by population attributable fraction (PAF).

METHODS

The study was registered at PROSPERO (ID: CRD42023388143). We collected two types of literature on the prevalence of SDB and the risk of SDB-related neurobehavioral deficits from ten electronic databases and registers, respectively. The pooled effect sizes (Pe, Pc, RR) by random-effects meta-analysis were separately substituted into Levin's formula and Miettinen's formula to calculate PAFs.

RESULTS

Three prevalence literature and 2 risk literature, all with moderate/high quality, were included in the quantitative analysis individually. The prevalence of SDB was 11% (95%CI 2%-20%) in children and adolescents (Pe), while the SDB prevalence was 25% (95%CI 7%-42%) in neurobehavioral patients (Pc). SDB diagnosis at baseline was probably associated with about threefold subsequent incidence of neurobehavioral deficits (pooled RR 3.24, 95%CI 1.25-8.41), after multi-adjustment for key confounders. Up to 19.8% or 17.3% of neurobehavioral consequences may be attributed to SDB from Levin's formula and Miettinen's formula, respectively.

CONCLUSIONS

A certain number of neurobehavioral consequences may be attributable to SDB. It is essential for clinicians to identify and treat SDB timely, as well as screen for SDB in patients with neurobehavioral impairments. More longitudinal studies of SDB and neurobehavioral deficits are needed in the future to further certify the association between them.

The Comparison of the Sleep Structure and Sleep Spindle Activity in Children With Primary Snoring and Sleep-Disordered Breathing

Obstructive sleep apnea syndrome (OSAS) in children is associated with changes in the structure of sleep. The possible effects of snoring on spindle activity have not been established. We analyzed the polysomnography recordings and sleep spindle activity in children with primary snoring and/or OSAS compared with healthy children. Fifty-one children were included; 8 had primary snoring, 16 had OSAS and snoring, 11 had OSAS without snoring, and 16 were healthy controls. The density (P = .034) and duration (P = .019) of sleep spindles were decreased in children with OSAS compared with controls. The sleep spindle activity did not show significant changes between children with primary snoring and healthy controls, or between OSAS with/without snoring. We conclude that it is not snoring per se but OSAS that affects sleep spindle activity. Obstructive sleep apnea syndrome with/without snoring deserves greater attention because it has different phenotypes of the disease with different pathophysiologies.

Health disparities in pediatric sleep-disordered breathing

Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Adenotonsillar Hypertrophy: The Relationship Between Obstruction Type and Attention in Children

We aimed to investigate the attention function, which is a parameter of cognitive functions, at different obstruction types (adenoid and tonsil hypertrophy, adenoid hypertrophy only, tonsillar hypertrophy only, and normal) of oral cavity and nasopharynx, and the relationship between obstruction level, type, and attention (N = 80). To evaluate attention function, Stroop test has been performed. Eighteen-item Quality of Life (OSA-18) and Brouillette Symptom Score questionnaires have been completed with each child's parents. Significant and positive relation has been found between Brouillette Symptom Score, OSA-18 score, and each 5 sections of Stroop test's points. It has been shown that children with adenotonsillar hypertrophy (ATH) are negatively affected in terms of obstructive symptoms and quality of life. At the situation of obstructive pathology, the Stroop test durations are affected negatively. Results are supporting that quality of life and attention parameter are affected negatively at children with ATH.

Management of children with co-occurring sleep disordered breathing and hearing loss

OBJECTIVES

To examine hearing loss incidence in a pediatric otolaryngology patients with sleep disordered breathing, and secondarily, identify possible disparities in management.

METHODS

A retrospective case-control study of pediatric patients with sleep-disordered breathing or obstructive sleep apnea from 2012 to 2019 was conducted at a private, not-for-profit, academic, tertiary care center. Study parameters were extracted from the electronic medical record and compared in study groups of patients with sleep-disordered breathing generated based on presence of hearing loss (cases) versus absence (controls). Study parameters were also compared in study groups based on timing of hearing loss onset.

RESULTS

14.8% of patients with sleep disordered breathing had hearing loss. Hearing loss was associated with an increased risk of undergoing adenotonsillectomy (OR 1.632 [1.294-2.058], p < 0.001, adjusted for age). In patients who underwent polysomnographic testing, 9.8% patients had pre-existing hearing loss and 12% patients developed hearing loss over the study period. Patients with pre-existing hearing loss and those who developed hearing loss had significantly more visits with otolaryngology compared to controls (p < 0.001). Hearing loss did not significantly delay adenotonsillectomy. More patients who developed hearing loss had adenotonsillectomies (OR 2.475 [1.672-3.663], p < 0.001, adjusted for age) versus controls. This difference was not identified in patients with pre-existing hearing loss.

CONCLUSION

Patients with evidence of hearing loss in addition to sleep disordered breathing had more adenotonsillectomies performed and more clinic visits. Further work must be done to understand the associations and implications of hearing loss in this population.

OSA 18 Questionnaire: Tool to Evaluate Quality of Life and Efficacy of Treatment Modalities in Pediatric Sleep Disordered Breathing Due to Adenotonsillar Hypertrophy

Aims to evaluate quality of life in paediatric SDB due to adenotonsillar hypertrophy and efficacy of treatment modalities (medical and surgical) by using OSA-18 questionnaire. Prospective study, conducted from April 2019 to June 2019, including 42 patients with clinical features suggestive of SDB due to adenotonsillar hypertrophy, in age group of 3-15 years. Nasopharyngoscopy was done to grade adenoid hypertrophy. OSA-18 QOL questionnaire was recorded in all patients and depending upon the severity of impact of QOL and grades of adenoid hypertrophy, patients were categorized into two groups. Group 1 received medical treatment and group 2 underwent adenotonsillectomy. Questionnaire was again recorded after 4 weeks. Pretreatment and post-treatment total mean and individual domain scores were compared. Paired t tests was used to evaluate results. Group 1 included 16 children with mild to moderate impact and received medical management. Pretreatment mean OSA-18 score of 70.31 was improved to 33.5. Group 2 enrolled 26 patients with severe impact, were subjected to adenotonsillectomy. Pretreatment and post-treatment mean score were 95.88 and 24.92 respectively. Both groups showed statistically significant improvement in all individual domains and total mean OSA-18 scores indicating improvement in QOL after treatment and efficacy of medical management for mild-moderate SDB and surgery for severe cases. OSA-18 questionnaire is self-administered and disease specific screening tool for early diagnosis and evaluation of QOL before and after treatment. It also helps to categorize patients for advocating appropriate treatment and to evaluate efficacy of treatment modalities.

Increased behavioral problems in children with sleep-disordered breathing

Background

Healthy sleep is essential for the cognitive, behavioral and emotional development of children. Therefore, this study aimed to assess the behavioral consequences of sleep disturbances by examining children with sleep-disordered breathing compared with control participants.

Methods

Seventy-eight children with SDB (average age: 6.7 years (SD = 1.83); 61 had OSA and 17 had primary snoring) and 156 control subjects (average age: 6.57 years (SD = 1.46) participated in the study. We matched the groups in age (t(232) = 0.578, p = 0.564) and gender (χ²(1) = 2.192, p = 0.139). In the SDB group, the average Apnea–Hypopnea Index was 3.44 event/h (SD = 4.00), the average desaturation level was 87.37% (SD = 6.91). Parent-report rating scales were used to measure the children’s daytime behavior including Attention Deficit Hyperactivity Disorder Rating Scale, Strengths and Difficulties Questionnaire, and Child Behavior Checklist.

Results

Our results showed that children with SDB exhibited a higher level of inattentiveness and hyperactive behavior. Furthermore, the SDB group demonstrated more internalizing (anxiety, depression, somatic complaints, social problems) (p < 0.001) and externalizing (aggressive and rule-breaking behavior) problems compared with children without SDB, irrespective of severity.

Conclusions

Based on our findings we supposed that snoring and mild OSA had a risk for developing behavioral and emotional dysfunctions as much as moderate-severe OSA. Therefore, clinical research and practice need to focus more on the accurate assessment and treatment of sleep disturbances in childhood, particularly primary snoring, and mild obstructive sleep apnea.

Neurocognitive Consequences in Children with Sleep Disordered Breathing: Who Is at Risk?

Sleep-disordered breathing (SDB) is a prevalent disease in children characterized by snoring and narrowing of the upper airway leading to gas exchange abnormalities during sleep as well as sleep fragmentation. SDB has been consistently associated with problematic behaviors and adverse neurocognitive consequences in children but causality and determinants of susceptibility remain incompletely defined. Since the 1990s several studies have enlightened these associations and consistently reported poorer academic performance, lower scores on neurocognitive tests, and behavioral abnormalities in children suffering from SDB. However, not all children with SDB develop such consequences, and severity of SDB based on standard diagnostic indices has often failed to discriminate among those children with or without neurocognitive risk. Accordingly, a search for discovery of markers and clinically useful tools that can detect those children at risk for developing cognitive and behavioral deficits has been ongoing. Here, we review the advances in this field and the search for possible detection approaches and unique phenotypes of children with SDB who are at greater risk of developing neurocognitive consequences.

Cognition in pediatric SDB-Yes, no, maybe?

Numerous studies in the past 10 years have reported on the neurocognitive sequalae of pediatric sleep disordered breathing (SDB). Variations in criteria used to define SDB in conjunction with the wide variety of neuropsychological measures selected to evaluate cognitive consequences of SDB have resulted in discrepancies within the literature. This review summarizes the extent literature regarding cognitive effects of pediatric SDB across domains of global intelligence, attention, executive function, memory, language, and visuospatial ability. This review also addresses the proposed etiology underlying neurocognitive consequences of pediatric SDB. The differences in findings across the literature are highlighted and discussed throughout.

Analysis of the Risk Factors Associated With Obstructive Sleep Apnea Syndrome in Chinese Children

Objective

The present study was developed to explore risk factors related to the incidence and severity of obstructive sleep apnea syndrome (OSAS) in children.

Methods

The present study enrolled pediatric patients who admitted to our department for snoring and/or open-mouth breathing. All children completed a questionnaire and underwent physical examination and polysomnography (PSG). The cases were separated into OSAS and primary snoring (PS) groups. Factors associated with these two groups were analyzed, with risk factors significantly associated with OSAS then being identified through logistic regression analyses. OSAS was further subdivided into mild, moderate, and severe subgroups, with correlations between risk factors and OSAS severity then being analyzed.

Results

In total, 1,550 children were included in the present study, of which 852 and 698 were enrolled in the OSAS and PS groups. In univariate analyses, obesity, family passive smoking, a family history of snoring, allergic rhinitis, asthma, adenoid hypertrophy, and tonsil hypertrophy were all related to pediatric OSAS (P < 0.05). In a multivariate logistic regression analysis, adenoid hypertrophy (OR:1.835, 95% CI: 1.482-2.271) and tonsil hypertrophy (OR:1.283, 95% CI:1.014-1.622) were independently associated with the risk of pediatric OSAS (P < 0.05). Stratification analyses revealed that OSAS incidence increased in a stepwise manner with increases in adenoid and tonsil grading (P < 0.01). Correlation analyses revealed that adenoid hypertrophy and tonsilar hypertrophy were not significantly associated with OSAS severity (r = 0.253, 0.069, respectively, P < 0.05), and tonsil and adenoid size were no correlation with obstructive apnea-hypopnea index (OAHI) (r = 0.237,0.193, respectively, P < 0.001).

Conclusion

Obesity, family passive smoking, a family history of snoring, allergic rhinitis, asthma, tonsil hypertrophy, and adenoid hypertrophy may be potential risk factors for pediatric OSAS. Adenoid hypertrophy and tonsil hypertrophy were independently related to the risk of pediatric OSAS, with OSAS incidence increasing with the size of the adenoid and tonsil, while the severity of OSAS is not parallel related to the adenoid or tonsil size.

The Effect of Adenotonsillectomy on Children's Behavior and Cognitive Performance with Obstructive Sleep Apnea Syndrome: State of the Art

(1) Background: This systematic review was designed to analyze adenotonsillectomy’s role in treating behavioural disorders and sleep-related quality of life in pediatric OSAS. (2) Methods: Papers that report pre-operative and post-operative outcomes by using the Epworth sleepiness scale, OSA-18, NEPSY, Conners’ rating scale, BRIEF, PSQ-SRBD, PedsQL and CBCL. We performed a comprehensive review of English papers published during the last 20 years regarding behavioural disorders in OSAS patients and adenotonsillectomy. (3) Results: We included 11 studies reporting behavioral outcomes and sleep related quality of life after surgery. We investigated changes in behavior and cognitive outcomes after AT, and we found significant improvements of the scores post-AT in almost all studies. After comparing the AT group and control group, only one study had no difference that reached significance at one year post-AT. In another study, it did not show any significant improvement in terms of all behavioural and cognitive outcomes. The questionnaires on sleep-related quality of life after AT (PSQ-SRBD or ESS or OSA-18 or KOSA) may improve with positive changes in sleep parameters (AHI, ODI and SpO2). Furthermore, there is a significantly higher decrease in OSAS symptoms than the pre-AT baseline score. (4) Conclusion: Future studies should pay more attention to characterizing patient populations as well as rapid surgical treatments through existing criteria.

Prevalence and evolution of snoring and the associated factors in two-year-old children

OBJECTIVES

To evaluate the prevalence and persistence of snoring during the first two years of life in two Finnish birth cohorts and to assess the associated factors.

STUDY DESIGN

The study population comprised 947 children from the CHILD-SLEEP (CS) and 1393 children from the FinnBrain (FB) birth cohorts. Questionnaires were provided to both parents when the child was 24 months of age. The questionnaire consisted of parts concerning the child's sleep and environmental factors.

RESULTS

The combined prevalence of habitual snoring in the two birth cohorts at the age of 24 months was 2.3% (95% CI 1.5-3.1), which is markedly lower than reported previously. Children suffering from recurrent infections (CS odds ratio (OR) 3.9, 95% CI 1.2-12.5) or asthma (FB OR 4.3, 1.4-13.5) snored habitually more often. Both the mother's (CS OR 3.2, 1.2-9.0) and father's (CS OR 3.4, 1.4-8.0) snoring every night added to the risk of the child snoring. In the multivariate models, parental snoring (CS adjusted odds ratio (OR_a) 2.8, 1.1-6.8), the mother's lower level of education (CS OR_a 2.9, 1.2-7.5, FB OR_a 2.1, 1.0-4.5), and the mother's lower monthly income (FB OR_a 2.9, 1.3-6.3) associated with the child's habitual snoring.

CONCLUSIONS

The prevalence of habitual snoring in two Finnish birth cohorts is lower than reported previously. The independent risk factors for habitual snoring at the age of two years were the parents' snoring and the mother's low income and low education.

Cardiovascular risks of children with primary snoring: A 5-year follow-up study

BACKGROUND AND OBJECTIVE

This study aimed to investigate if childhood primary snoring (PS) was associated with adverse cardiovascular outcomes at 5-year follow-up.

METHODS

This was a prospective matched cohort study. Subjects were recruited from a hospital-based cohort established from years 2006 to 2012 and they were aged 6-18 years at baseline. Each subject with PS was gender, age and BMI z-score matched with a control who had normal sleep study (obstructive apnoea-hypopnoea index [OAHI] < 1/h) and without habitual snoring (<3 nights/week) at baseline. All subjects underwent measurements of flow-mediated dilation (FMD) and carotid intima-media thickness (cIMT) and sleep study at baseline and follow-up visits. Twenty-four hour ambulatory blood pressure (ABP) was also recorded at follow-up.

RESULTS

Fifty-five case-control pairs were recruited and the length of follow-up was 5.1 ± 1.3 years. At follow-up visit, subjects with PS at baseline had significantly lower FMD (-0.34% [-0.59 to -0.10]), greater cIMT (+0.01 mm [+0.001 to +0.013]), higher wake systolic blood pressure (SBP) (+2.6 mm Hg [+0.02 to +5.1]), sleep SBP (+3.0 mm Hg [+0.3 to +5.6]), sleep diastolic blood pressure (+2.2 mm Hg [+0.04 to +4.4]) and sleep mean arterial pressure (+2.2 mm Hg [+0.1 to +4.2]) compared to matched controls in the fully adjusted model for variables including change in OAHI and parental history of cardiovascular diseases.

CONCLUSION

Childhood PS is associated with poorer endothelial function, greater cIMT and higher ABP at 5-year follow-up irrespective of change in obstructive sleep apnoea severity.

Association Between Habitual Snoring and Cognitive Performance Among a Large Sample of Preadolescent Children

Importance

Previous studies have identified an association between habitual snoring and lower cognitive performance in children. However, whether and to what extent this association is confounded by pertinent demographic, anthropometric, and socioeconomic characteristics is unknown.

Objective

To assess the extent to which potential confounding factors modify the association between parent-reported habitual snoring and cognitive outcomes among a large and diverse sample of typically developing preadolescent children.

Design, Setting, and Participants

This cross-sectional analysis used a baseline data set (version 2.0.1) from children enrolled in the ongoing Adolescent Brain Cognitive Development study between September 1, 2016, and October 15, 2018. Children aged 9 to 10 years without serious psychiatric or neurological comorbidities were recruited at 21 research sites in the US. Study recruitment was designed to approximate the racial and socioeconomic diversity of the US population. Data were analyzed from February 1 to March 31, 2020.

Exposures

Parent-reported habitual snoring in children that occurs 3 or more nights per week.

Main Outcomes and Measures

Associations between habitual snoring and cognitive performance were assessed using the Sleep Disturbance Scale for Children and the National Institutes of Health Toolbox Cognition Battery, which includes 7 domain-specific and 3 composite (total cognitive function, fluid cognition, and crystallized cognition) standard scores that are uncorrected for covariates. Cognitive performance was examined before and after adjustment for covariates, which included age, sex, body mass index percentile, annual household income before taxes, and highest educational level of caregiver. The extent of confounding was assessed by the effect size, represented by Cohen d, before and after inclusion of covariates using linear mixed-effects models.

Results

A total of 11 873 children aged 9 to 10 years (6187 boys [52.1%]; 6174 White [52.0%]) with available data were included in the study. Of those, habitual snoring (≥3 nights per week) was reported in 810 children (6.8%), and nonhabitual snoring (1-2 nights per week) was reported in 4058 children (34.2%). In the unadjusted models, the total cognitive function composite score among children who habitually snored was significantly lower compared with children who never snored (Cohen d, 0.35; 95% CI, 0.28-0.42). Differences were also identified in the crystallized cognition (Cohen d, 0.34; 95% CI, 0.26-0.41) and fluid cognition (Cohen d, 0.28; 95% CI, 0.21-0.35) composite scores. The association between habitual snoring and cognitive performance was substantially attenuated after adjustment for covariates (Cohen d, 0.16 [95% CI, 0.09 to 0.24] for total cognitive function, 0.14 [95% CI, 0.07 to 0.21] for crystallized cognition, and 0.13 [95% CI, 0.06 to 0.21] for fluid cognition). Similar mitigation was also observed for all domain-specific scores.

Conclusions

In this cross-sectional study, when adjusted for baseline demographic, anthropometric, and socioeconomic characteristics, the association between parent-reported habitual snoring and cognitive performance was substantially attenuated among children aged 9 to 10 years.

Sleep-Wake Disorders in Childhood

PURPOSE OF REVIEW

The presentation of sleep issues in childhood differs from the presentation in adulthood and may be more subtle. Sleep issues may affect children differently than adults, and distinct treatment approaches are often used in children.

RECENT FINDINGS

Sodium oxybate was approved by the US Food and Drug Administration (FDA) in October 2018 for an expanded indication of treatment of sleepiness or cataplexy in patients with narcolepsy type 1 or narcolepsy type 2 aged 7 years or older, with side effect and safety profiles similar to those seen in adults. Restless sleep disorder is a recently proposed entity in which restless sleep, daytime sleepiness, and often iron deficiency are observed, but children do not meet the criteria for restless legs syndrome or periodic limb movement disorder.

SUMMARY

Children's sleep is discussed in this article, including normal sleep patterns and effects of insufficient sleep. Sleep disorders of childhood are reviewed, including insomnia, obstructive sleep apnea, restless legs syndrome, parasomnias, narcolepsy, and Kleine-Levin syndrome. Children with neurologic issues or neurodevelopmental disorders frequently have sleep disorders arising from an interaction of heterogeneous factors. Further attention to sleep may often be warranted through a polysomnogram or referral to a pediatric sleep specialist. Sleep disorders may cause indelible effects on children's cognitive functioning, general health, and well-being, and awareness of sleep disorders is imperative for neurologists who treat children.

Neurobehavioral Outcomes in School-Aged Children with Primary Snoring

OBJECTIVE

We assess behavioral and attentional problems and neurocognitive functioning in school-aged children with primary snoring (PS).

METHODS

Seventeen children with PS and 27 non-snoring peers aged 6-10 years took part in the study. All children underwent a polysomnography (PSG) at the Sleep Laboratory. Snoring was defined by parents and with PSG. Children with obstructive sleep apnea were excluded. The parents completed the Sleep Disturbance Scale for Children. Parents and teachers assessed behavioral and attentional problems with the Child Behavior Checklist and the Conners' Rating Scale-Revised. Neuropsychological assessment included the Wechsler Intelligence Scale for Children and the Developmental Neuropsychological Assessment (NEPSY test).

RESULTS

The PS group had significantly more parent-reported internalizing, total, and attentional problems than the control group. Teachers did not report behavioral problems in the PS group. The PS and control groups had equal IQ scores and similar core neurocognitive functions, except for one visuospatial subtest. The PS group had significantly more inspiratory flow limitation and increased diaphragmatic electromyography compared with the controls. Parents reported significantly more daytime sleepiness in the PS group. Daytime sleepiness and snoring time were consistently associated with more behavioral and attentional problems. Flow limitation and more oxygen saturation values under 90% were associated with attentional problems, higher oxygen desaturation index, and lower mean oxygen saturation percentage with reduced language functions.

CONCLUSIONS

Snoring with an increase in respiratory effort without apneas and hypopneas and parent-reported daytime sleepiness may be linked to daytime symptoms. School-aged children with PS are at risk for behavioral and attentional problems, but not cognitive impairments.

Comorbid monosymptomatic nocturnal enuresis and snoring exhibit an additive effect on impairments in health-related quality of life

INTRODUCTION/BACKGROUND

Health-related quality of life (HRQOL) is a relatively new concept in pediatrics, but it has shown to be extremely important in terms of clinical care, treatment planning, and compliance with medical and behavioral recommendations. Two groups of children who are at risk for impairments in HRQOL are those who have bed-wetting and those who snore or have sleep apnea.

OBJECTIVE

The present study sought to determine whether the combination of monosymptomatic nocturnal enuresis (MNE) and sleep-disordered breathing (SDB) results in diminished HRQOL in a pediatric sample.

STUDY DESIGN

A retrospective chart review was conducted in an outpatient pediatric urology clinic and in an outpatient pulmonology clinic. Parents of the patients completed the Pediatric Sleep Questionnaire (PSQ) to assess the presence of SDB and snoring, and HRQOL was assessed using the Obstructive Sleep Apnea Syndrome-18-item (OSAS-18) scale, both validated measures, as part of the child's clinical workup.

RESULTS

One hundred fifty-two (85 males and 67 females ) patients were included and were categorized into any of the following four groups: (1) MNE only, (2) SDB only, (3) MNE + SDB, or (4) healthy control. Patients in the SDB-only group had significantly more severe SDB than those in the other groups. As such, severity of SDB was controlled for in analyses. Results revealed that the four groups significantly differed on all subscales of the OSAS-18, which are Sleep Disturbance, Physical Symptoms, Emotional Symptoms, Daytime Functioning, and Caregiver Concerns. Post hoc analyses revealed the MNE + SDB group had more impairments on each subscale. Analysis of the total impairments revealed that children with only one condition (MNE or SDB) reported similar levels of impairments in HRQOL and patients with MNE + SBD reported significantly higher levels of impairments, as it appears that these comorbid conditions have an additive effect on HRQOL.

DISCUSSION

Children with comorbid MNE and SDB are at significantly higher risk for reporting impairments in their HRQOL than children who have only one of these conditions. While it is already known that children with MNE are at risk for emotional, behavioral, and social difficulties and children with SDB are at risk for neurobehavioral difficulties, it is possible that children with both conditions are at risk for a multitude of negative consequences.

CONCLUSION

These data emphasize the importance of urologist screening for SDB and pulmonologist screening for MNE as part of their routine clinical practice.

Reduced sleep spindle activity in children with primary snoring

BACKGROUND

Habitually snoring children are at risk of manifesting disease-related problems even if their sleep studies are overall within normal limits.

STUDY OBJECTIVES

To compare sleep spindle activity in children with primary snoring and healthy controls.

METHODS

Sleep spindle activity including analysis of fast and slow spindles (ie, >13 Hz and <13 Hz, respectively) was evaluated in polysomnographic (PSG) recordings of 20 randomly selected children with primary snoring (PS; normal PSG recordings except for objective presence of snoring; 12 boys, mean age 6.5 ± 2.1 years), and 20 age- and gender-matched PSG-confirmed non-snoring controls.

RESULTS

PS children showed significantly lower spindle indices in all non-rapid eye movement (NREM) sleep stages (p < 0.05). In contrast, fast spindles were found in 40% (n = 8) children with PS and in 25% (n = 5) controls. Sleep spindle activity was particularly higher in NREM sleep stage 2 in controls compared PS (76% versus 43% of all marked sleep spindles events in NREM sleep stage 2, p < 0.001).

CONCLUSIONS

Children with PS exhibit significantly reduced spindle activity when compared to matched controls. Reduced sleep spindle activity may be an indicator of sleep disruption and, therefore, could be involved in the development of disease-related consequences in snoring children.

Event-related potentials and behavior performance scores in children with sleep-disordered breathing

OBJECTIVE

To explore impaired cognition characteristics and abnormal behavior in children with Sleep-Disordered Breathing (SDB) via Event-Related Potentials (ERPs), continuous performance testing (CPT), and the Child Behavior Checklist (CBCL).

METHODS

A total of 108 children aged 6-8 years old were recruited, including fifty-four children (28 boys) with SDB and fifty-four normal children (28 boys). CBCL and Chinese version of the OSA-18 questionnaire were administered. Nineteen children with SDB (OSA-18 questionnaire value >60) and Nineteen normal children completed a CPT task. ERP was extracted using the BESA software.

RESULTS

No significant differences in the correct number, reaction time, or the number of commission error were noted between the CPT of the two groups (P > 0.05). The ERP Go-P3 amplitudes at F3, Fz and F4 of the SDB group were significantly higher than those of the control group (P < 0.05). The NoGo-N2 amplitudes at F3 and Fz of the SDB group were significantly lower than those of the control group (P < 0.05). The Fz and F4 Go-P3 and FZ NoGo-P3 latency of the SDB group were significantly longer than those of the control group (P < 0.05). However, among boys, the CBCL scores of the SDB group including the subscores, schizo, somatic complaints, compulsion, aggression, and hyperactivity, as well as the total score, were significantly higher than the control group (all P < 0.05).

CONCLUSION

Children with SDB demonstrate significant functional deficits in regard to conflict monitoring, attention, and inhibition. The frontal region is the primary area of dysfunction, especially in the left brain region, and inhibition function dysfunction may be a common pathogenesis of SDB and ADHD. Moreover, boys with SDB may exhibit more behavior problems when compared to girls.

Habitual Snoring at Age 3 Years: Links with Parent-Rated Remembering in Daily Life and Academic Achievement at Age 7 Years

OBJECTIVE

Habitual snoring in school-aged children is well known to link with poorer cognitive functioning and academic performance, but few studies have explored later developmental outcomes related to snoring initiated in early childhood. The aims of this study were to examine whether habitual snoring at age 3 years predicted perceived memory and academic functioning at age 7 years.

METHODS

Parents (n = 460) of children aged 7 years 2 ± 5 months completed a community follow-up survey about their perceptions of their child's sleep and health, memory in daily activities, and academic performance relevant to numeracy and literacy skills. The first survey was completed by 839 parents 4 years prior when children were aged 3 years (54.8% response rate at age 7 years). Parents rated their child's academic performance twice. First, they rated performance based on teachers' feedback relative to national standard ratings for numeracy and literacy, and second, based on their own observations.

RESULTS

Children reported to snore habitually at age 3 years received lower memory and academic composite score ratings at age 7 years. Age 3 years habitual snoring history predicted small but significant unique variation in age 7 years memory (p = 0.005), literacy (p < 0.001), and overall achievement ratings (p = 0.016) in regressions controlling for covariates, with evidence suggesting that memory may mediate links between snoring history and academic performance.

CONCLUSION

The findings suggest that habitual snoring in early childhood may adversely affect success in beginning schooling. More research is still needed to determine the best time for treatment so that longer-term consequences of sleep-disordered breathing may be prevented.

[Exercise capacity in children with mild sleep-disordered breathing]

INTRODUCTION

While the association between sleep-disordered breathing (SDB) and low physical activity has been reported in children, little information is available on the impact of SDB on exercise capacity. The aim of this study was to assess exercise capacity in children with SDB in order to estimate the relevance of exercise training intervention.

METHODS

Twelve young patients with suspected SDB matched with 11 presumably healthy subjects of same age range (aged 13±0.5yr) were investigated. Both groups underwent physical activity assessment, full night polysomnography, incremental and all-out exercise tests.

RESULTS

The respiratory disturbance index was higher in the patient group (4.6±4.7 vs 0.8±0.6; P=0.02). Children with SDB had lower VO₂max (32.0±9.9 vs 42.3±5.7mL.kg^-1.min^-1, P=0.007) and lower peak power (8.6±3.4 vs 11.8±1.9W.kg^-1, P=0.009). A significant correlation between VO₂max and weekly physical activity only was found in the SDB group (P=0.005).

CONCLUSION

Mild SDB may be associated with impairment of both aerobic and anaerobic exercise capacity in children, related to poor physical activity. Exercise training could bring clinical benefit in this population.

Sleep spindle activity in children with obstructive sleep apnea as a marker of neurocognitive performance: A pilot study

STUDY OBJECTIVES

To assess spindle activity as possible markers for neurocognitive consequences in children with mild obstructive sleep apnea.

METHODS

Children aged 6-11 years diagnosed with mild OSA (i.e., an apnea hypopnea index <5.0) were recruited and compared with age and gender-matched healthy controls. Polysomnographic recordings were analyzed for sleep microstructure and spindle activity. All children completed also an intelligence test battery (i.e., the Wechsler intelligence test for children, 4th version).

RESULTS

Nineteen children with OSA (13 boys, mean age 7.1 ± 1.4 y), and 14 controls (7 boys, mean age 8.1 ± 1.9 y) were included. Mean IQ was 110 ± 12 for the complete sample, in children with OSA 111 ± 13, and in controls 108 ± 12 (p = 0.602). Controls showed a higher spindle index in N2 stage than children with OSA: 143.0 ± 42.5 vs 89.5 ± 56.9, respectively (p = 0.003). Spindle index in NREM was strongly and significantly correlated with Verbal Comprehension Index (VCI), Working Memory Index (WMI), Processing Speed Index (PSI), and total IQ in children with OSA.

CONCLUSIONS

Children with mild OSA demonstrate a different pattern of sleep spindle activity that seems to be linked with neurocognitive performance, especially concerning memory. Sleep spindle activity seems to be involved with mechanisms related with neurocognitive consequences in children with OSA.

Comparison of two exhaled biomarkers in children with and without sleep disordered breathing

OBJECTIVE

Airway oxidative stress and inflammation are likely to be involved in sleep disordered breathing (SDB) in children. We aimed to measure concentrations of 8-isoprostane (8-IsoP) in the exhaled breath condensate (EBC) and exhaled nitric oxide (FE_NO) in patients with SBD and healthy children, in order to assess the relationship between these two biomarkers, disease severity, and overnight changes.

METHODS

Patients with SDB (n = 46) and healthy controls (n = 20) aged 4.5-15.1 years (M/F: 36/30) underwent exhaled measurements. Patients with SDB underwent standard polysomnography to define primary snoring (PS: AHI < 1) and obstructive sleep apnea (OSA). Upon awakening the following morning, FE_NO was measured and EBC was collected for the measurement of EBC 8-IsoP.

RESULTS

OSA patients yielded higher awakening levels of 8-IsoP in EBC than PS patients and control subjects. The 8-IsoP levels, though not FE_NO, correlated with AHI (r = 0.40, p = 0.003) and SaO2 (r = -0.50, p = 0.001). Cut-off levels of 8-IsoP predicted OSA with a high AUC value (0.84, p = 0.000). Sensitivity and specificity for 8-IsoP levels above the percentile 50 (33.3 pg/mL) were 76.5% and 78.1%, respectively. 8-IsoP levels did not change from the evening to morning session, whereas morning FE_NO levels rose significantly only in patients with mild OSA (p = 0.03).

CONCLUSION

Levels of 8-IsoP, though not FE_NO, distinguish children with OSA from those with PS or healthy, correlate with disease severity and closely predict OSA in the whole sample.

Impaired memory consolidation in children with obstructive sleep disordered breathing

Memory consolidation is stabilized and even enhanced by sleep (and particularly by 12-15 Hz sleep spindles in NREM stage 2 sleep) in healthy children but it is unclear what happens to these processes when sleep is disturbed by obstructive sleep disordered breathing. This cross-sectional study investigates differences in declarative memory consolidation among children with primary snoring (PS) and obstructive sleep apnea (OSA) compared to controls. We further investigate whether memory consolidation group differences are associated with NREM stage 2 (N2) sigma (12-15 Hz) or NREM slow oscillation (0.5-1 Hz) spectral power bands. In this study, we trained and tested participants on a spatial declarative memory task with cued recall. Retest occurred after a period of daytime wake (Wake) or a night of sleep (Sleep) with in-lab polysomnography. 36 participants ages 5-9 years completed the protocol: 14 with OSA as defined by respiratory disturbance index (RDI) > 1/hour, 12 with primary snoring (PS) and 10 controls. OSA participants had poorer overall memory consolidation than controls across Wake and Sleep conditions [OSA: mean = -18.7% (5.8), controls: mean = 1.9% (7.2), t = -2.20, P = 0.04]. In contrast, PS participants and controls had comparable memory consolidation across conditions (t = 0.41; P = 0.38). We did not detect a main effect for condition (Sleep, Wake) or group x condition interaction on memory consolidation. OSA participants had lower N2 sigma power than PS (P = 0.03) and controls (P = 0.004) and N2 sigma power inversely correlated with percentage of time snoring on the study night (r = -0.33, P<0.05). Across all participants, N2 sigma power modestly correlated with memory consolidation in both Sleep (r = 0.37, P = 0.03) and Wake conditions (r = 0.44, P = 0.009). Further observed variable path analysis showed that N2 sigma power mediated the relationship between group and mean memory consolidation across Sleep and Wake states [Bindirect = 6.76(3.5), z = 2.03, P = 0.04]. NREM slow oscillation power did not correlate with memory consolidation. All results retained significance after controlling for age and BMI. In sum, participants with mild OSA had impaired memory consolidation and results were mediated by N2 sigma power. These results suggest that N2 sigma power could serve as biomarker of risk for cognitive dysfunction in children with sleep disordered breathing.

Sleep Outcomes in Children With Single-Suture Craniosynostosis Compared With Unaffected Controls

OBJECTIVE

To compare risk for sleep-disordered breathing between children with and without single-suture craniosynostosis.

PARTICIPANTS

A total of 184 children with single-suture craniosynostosis and 184 controls.

MAIN OUTCOME MEASURES

Parent reported sleep-disordered breathing-related symptoms.

RESULTS

Current sleep problems were reported in 19% of patients with single-suture craniosynostosis and 14% of controls (adjusted odds ratio = 1.6; 95% CI, 0.9 to 2.8). Ever having sleep problems was reported in 25% and 23% of cases and controls, respectively (adjusted odds ratio = 1.2; 95% CI, 0.7 to 1.9). Overall, snoring was statistically associated with single-suture craniosynostosis (P = .01) and was more often reported as 2+ nights per week (versus never) in patients with single-suture craniosynostosis (13%) than in controls (4%) (adjusted odds ratio = 3.5; 95% CI, 1.5 to 8.2).

CONCLUSIONS

Though preliminary, increased presence of snoring during sleep in children with single-suture craniosynostosis compared with controls suggests that children with isolated single-suture craniosynostosis may be at increased risk for sleep-disordered breathing. Further study using standardized assessments of sleep-disordered breathing is needed.

Sleep Duration, Snoring Prevalence, Obesity, and Behavioral Problems in a Large Cohort of Primary School Students in Japan

Study Objectives

Poor or short sleep and the presence of snoring indicative of sleep-disordered breathing (SDB) have been associated with behavioral problems in school-aged children. We examined the relationship between SDB, sleep duration, obesity risk, and behavioral characteristics in Japanese elementary school students using a large-scale survey.

Methods

We conducted a cross-sectional study of children enrolled in all 46 public primary schools in Matsuyama city, Japan. The children's parents or guardians completed a questionnaire that covered sleep habits, presence of SDB risk, and behavioral characteristics.

Results

In total, 24 296 responses were received (90% response rate). After excluding incomplete responses, we analyzed complete datasets for 17 769 children. Mean sleep duration decreased with age, as did the prevalence of pediatric SDB. We found an increased risk for the presence of SDB and short sleep among overweight/obese children. With SDB or short sleep, we observed significantly increased odds of restless behaviors, fidgety behaviors, and poor concentration in school.

Conclusions

Shorter sleep duration was associated with increased risk of obesity, and in turn, obesity increased SDB risk. Both short sleep duration and SDB risk were significantly associated with behavioral problems in school.

Parent-Reported Behavioral and Psychiatric Problems Mediate the Relationship between Sleep-Disordered Breathing and Cognitive Deficits in School-Aged Children

BACKGROUND

Numerous studies over the past several decades have illustrated that children who suffer from sleep-disordered breathing (SDB) are at greater risk for cognitive, behavioral, and psychiatric problems. Although behavioral problems have been proposed as a potential mediator between SDB and cognitive functioning, these relationships have not been critically examined.

METHODS

This analysis is based on a community-based cohort of 1,115 children who underwent overnight polysomnography, and cognitive and behavioral phenotyping. Structural model of the relationships between SDB, behavior, and cognition, and two recently developed mediation approaches based on propensity score weighting and resampling were used to assess the mediational role of parent-reported behavior and psychiatric problems in the relationship between SDB and cognitive functioning. Multiple models utilizing two different SDB definitions further explored direct effects of SDB on cognition as well as indirect effects through behavioral pathology. All models were adjusted for age, sex, race, BMI z-score, and asthma status.

RESULTS

Indirect effects of SDB through behavior problems were significant in all mediation models, while direct effects of SDB on cognition were not. The findings were consistent across different mediation procedures and remained essentially unaltered when different criteria for SDB, behavior, and cognition were used.

CONCLUSION

Potential effects of SDB on cognitive functioning appear to occur through behavioral problems that are detectable in this pediatric population. Thus, early attentional or behavioral pathology may be implicated in the cognitive functioning deficits associated with SDB, and may present an early morbidity-related susceptibility biomarker.

Effect of Sleep-disordered Breathing Severity on Cognitive Performance Measures in a Large Community Cohort of Young School-aged Children

RATIONALE

Sleep-disordered breathing (SDB) in children is associated with cognitive challenges. However, potential associations between SDB severity and neurocognitive function, as well as the presence of an SDB cutoff, have not been fully explored.

OBJECTIVES

To determine whether SDB-associated adverse changes in neurocognitive functioning are severity dependent.

METHODS

A total of 1,010 snoring and nonsnoring children ages 5-7 years were prospectively recruited from public schools and underwent polysomnography and neurocognitive assessments of intellectual, attention, memory, language, and executive function development. The children were subdivided into four severity groups on the basis of apnea-hypopnea index (AHI), followed by comparisons of cognitive function, with a particular focus on standardized subtests of intellectual, language, attention, memory, and executive function.

MEASUREMENT AND MAIN RESULTS

Differential Ability Scales Verbal (P < 0.001) and Nonverbal (P = 0.002) performance, as well as global conceptual ability (IQ) (P < 0.001) scores, differed significantly across the groups, with individuals with higher AHI showing worse performance. Additionally, specific NEPSY (a Developmental Neuropsychological Assessment) subscores focused on attention and executive skills differed across the groups, indicating differences in levels of engagement and problem solving. Children with higher AHI (>5 per hour of total sleep time) were significantly more impaired than all three lower AHI groups, indicating a dose-response impact of SDB.

CONCLUSIONS

This large community-based sample of children highlights the significant deleterious impact of SDB, particularly in children with moderate to severe obstructive sleep apnea, and also that even snoring alone affects neurocognitive function. By affecting developing capabilities, as illustrated by cognitive measures in a severity-graded manner, SDB could adversely impact children's capacity to attain academic and adaptive goals, ultimately hampering their ability to reach independence. Our findings support the need for increased awareness of SDB, with particular emphasis on children with more severe obstructive sleep apnea.

Frequency of snoring, rather than apnea-hypopnea index, predicts both cognitive and behavioral problems in young children

OBJECTIVE

Primary snoring (PS) and obstructive sleep apnea (OSA) not only affect the quality of sleep in a large number of young children, but have also been repeatedly associated with a variety of behavioral and cognitive problems. However, little is known about the potentially differing relationships of behavioral and cognitive pathology within the sleep disordered breathing (SDB) spectrum.

METHOD

This study examined data from an enriched for snoring community sample of 631 children aged between 4 and 10 years. Multivariate mixed models were used to assess the relationship between both snoring and the apnea-hypopnea index (AHI). Numerous cognitive and behavioral variables were used, while adjusting for several important demographic variables. These were followed by univariate analyses of individual measures and sensitivity analyses.

RESULTS

Results indicated that snoring status is a significant predictor of general behavioral (p = 0.008) and cognitive (p = 0.013) domains, even after adjusting for baseline covariates and AHI severity. More frequent snoring was associated with poorer outcomes independent of AHI. However, AHI did not emerge as a significant predictor of the overall cognitive functioning domain (p = 0.377). Additionally, although AHI was a significant predictor of the general behavioral functioning domain (p = 0.008), the significance pattern and nature of its relationship with individual behavioral measures were inconsistent in post-hoc analyses.

CONCLUSION

The findings of this study suggest that general behavioral and cognitive function may decline with greater snoring severity. Further, snoring should not simply be assumed to represent a lower severity level of SDB, but should be examined as a potential predictor of relevant outcomes.

Auditory behavior and auditory temporal resolution in children with sleep-disordered breathing

OBJECTIVE

Intermittent hypoxia caused by obstructive sleep apnea syndrome (OSAS) may lead to damage in brain areas associated to auditory processing. The aim of this study was to compare children with OSAS or primary snoring (PS) to children without sleep-disordered breathing with regard to their performance on the Gaps-in-Noise (GIN) test and the Scale of Auditory Behaviors (SAB) questionnaire.

METHODS

Thirty-seven children (6-12 years old) were submitted to sleep anamnesis and in-lab night-long polysomnography. Three groups were organized according to clinical criteria: OSAS group (13 children), PS group (13 children), and control group (11 children). They were submitted to the GIN test and parents answered SAB questionnaire. The Kruskal-Wallis statistical test was used to compare the groups; p < 0.05 was considered statistically significant.

RESULTS

The OSAS group performed significantly worse than PS (p = 0.011) and Control (p = 0.029) groups on gap detection percentage, while PS and Control groups showed no significant differences. The three groups showed similar gap detection thresholds. Regarding SAB questionnaire, PS group had significantly worse scores when compared to Control (p = 0.011), but not to OSAS (p = 0.101) groups. No statistical difference between OSAS and Control groups were found.

CONCLUSION

Children with OSAS showed worse performance on GIN test in comparison to children with PS and children without sleep-disordered breathing. PS negatively affected auditory behavior in children. These findings suggest that sleep-disordered breathing may lead to auditory behavior impairment.

When and why to treat the child who snores?

Obstructive sleep-disordered breathing (SDB) can result in cardiovascular and neurocognitive morbidity as well as adversely affect behavior, growth, quality of life, and nocturnal continence. This article summarizes the latest evidence regarding the morbidity related to obstructive SDB, commenting on the impact of severity of obstruction, that is, the difference in effects seen of moderate to severe obstructive sleep apnea syndrome (OSAS) compared to those of mild OSAS or primary snoring. The impact of therapy is discussed, focusing on which children are likely to benefit from treatment interventions; namely those with moderate or severe OSAS irrespective of the presence of morbidity, children with mild OSAS with associated morbidity or predictors of SDB persistence such as obesity, and children with complex conditions accompanied by upper airway obstruction like craniosynostosis and Prader-Willi syndrome. The co-existing conditions which may improve when treatment for obstructive SDB is offered are reviewed, while the clinical parameters associated with spontaneous improvement or resolution of obstructive SDB are discussed. The intention being to enable clinicians to make informed decisions on who should be treated, when and why. Pediatr Pulmonol. 2017;52:399-412. © 2016 Wiley Periodicals, Inc.

Adenotonsillectomy for childhood obstructive sleep apnoea reduces thoraco-abdominal asynchrony but spontaneous apnoea−hypopnoea index normalisation does not

The efficacy of adenotonsillectomy for treating obstructive sleep apnoea syndrome (OSAS) in children has been established, but its precise effects on inspiratory effort are not well documented.

In 353 children enrolled in the Childhood Adenotonsillectomy Trial, randomised to undergo either early adenotonsillectomy (n=182) or a strategy of watchful waiting with supportive care (WWSC) (n=171), thoraco-abdominal asynchrony (TAA) was analysed during quiet, non-apnoeic and non-hypopnoeic breathing during sleep at baseline and at 7 months using overnight polysomnography.

Children who underwent early adenotonsillectomy demonstrated a reduction in TAA post-surgery while the WWSC arm showed no change. On assessing TAA with regard to normalisation of clinical polysomnography findings at follow-up, TAA was reduced in children who had surgical resolution of OSAS (based on apnoea–hypopnoea index), but not in children who displayed spontaneous normalisation of apnoea–hypopnoea index. In the latter group, TAA was inversely correlated with quality of life.

We conclude that adenotonsillectomy reduces TAA during quiet sleep. Monitoring of instantaneous TAA may yield additional insight in the dynamic changes of inspiratory effort. In combination with traditional indices of obstruction, TAA may more accurately characterise the degree of sleep-disordered breathing in children.

Increased severity of sleep-disordered breathing is associated with insomnia and excessive somnolence in primary school children

OBJECTIVE

The aim of the study was to investigate the prevalence of difficulty with initiation or maintenance of sleep (DIMS) and excessive daytime sleepiness (EDS) in a general pediatric population, and to evaluate the relationship between these conditions and sleep-disordered breathing (SDB) symptom intensity.

METHODS

This population-based cross-sectional study from 27 primary schools in a medium-sized city in Poland was based on use of a questionnaire regarding demographic data, symptoms of SDB, DIMS, and EDS. Data were collected between September and December 2014. In all, 2940 caregivers were recruited and were asked to fill-out questionnaires and written consent.

RESULTS

A total of 68% of the questionnaires (n = 1987) were returned and analyzed. Habitual snoring (HS) was reported in 104 (5.3%) children. DIMS and EDS were seen in 137 children (6.9%) and 117 children (5.9%), respectively. The prevalence of DIMS increased from 3.5% in children who never snored to 28.6% in children who snored very often or always. Similarly, the prevalence of EDS was 2.7% in children who did not snore and increased to 19% in children who snored very often or always. No correlation was seen between increasing DIMS (r = 0.006, p > 0.05) or EDS (r = -0.031, p > 0.05) scores and body mass index.

CONCLUSIONS

This study is the first to measure the symptoms of both DIMS and EDS in a general pediatric population and to assess the relationship between both DIMS and EDS and SDB in children. We found that children with more frequent snoring had a higher prevalence of DIMS as well as EDS; however, there was no correlation between body mass index and either DIMS or EDS symptom severity.

Sleep disordered breathing symptoms and daytime sleepiness are associated with emotional problems and poor school performance in children

This study examined the prevalence of sleep disordered breathing (SDB) symptoms and their associations with daytime sleepiness, emotional problems, and school performance in Chinese children. Participants included 3979 children (10.99±0.99 years old) from four elementary schools in Jintan City, Jiangsu Province, China. Children completed a self-administered questionnaire on sleep behavior and emotional problems, while parents completed the Child Sleep Habit Questionnaire (CSHQ). SDB symptoms included 3 items: loud snoring, stopped breathing, and snorting/gasping during sleep. Teachers rated the children's school performance. The prevalence rates of parent- and self-reported SDB symptoms were 17.2% and 10.1% for "sometimes" and 8.9% and 5.6% for "usually". SDB symptoms, more prevalent in boys than in girls, increased the risks for depression, loneliness, and poor school performance. Daytime sleepiness mediated the relationship between SDB symptoms and depression, loneliness, and poor school performance. This study suggests the importance of early screening and intervention of SDB and daytime sleepiness in child behavioral and cognitive development.

Sleep-disordered breathing in children with Down syndrome: Usefulness of home polysomnography

OBJECTIVE

To investigate the technical feasibility of unattended home polysomnography (HPSG) in children with Down syndrome.

METHODS

Data from children with Down syndrome under 10 years of age referred to a diagnostic sleep study was analyzed. A full sleep-lab based polysomnography (PSG) or a HPSG with a portable device was performed. Uninterpretable HPSGs were defined as: recordings with (i) loss of ≥2 of the following channels: nasal flow, or thoracoabdominal sensors, or (ii) HPSG with less than 4h of artifact-free recording time or (iii) less than 4h SpO2 (peripheral capillary oxygen saturation) signal.

RESULTS

A total of 44 children (68% males) were included in the study, with a mean age of 3.6 (0.1-10) years. PSG was performed in 8 cases and HPSG in 36 cases. Six HPSG recordings were classified as uninterpretable and had to be repeated. Age, gender and BMI were no significant predictors of uninterpretability of the HPSG. Obstructive sleep apnea (OSA) was present in 61% (n=27) of all subjects, and classified as mild, moderate, and severe in 43% (n=19), 11% (n=5), and 7% (n=3) of cases, respectively. Interpretable and technically acceptable HPSGs were obtained in 30 subjects (83%). Age, gender and BMI were no significant predictors for interpretability of the HPSG.

DISCUSSION

This study demonstrates that a portable polysomnographic home device may be helpful for diagnosing OSA in children with Down syndrome. Considering the potential consequences of untreated OSA, this screening test may be helpful for early diagnosis of OSA in children with Down syndrome.

Update on paediatric obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is one of the most common causes of sleep-disordered breathing (SDB) in children. It is associated with significant morbidity, potentially impacting on long-term neurocognitive and behavioural development, as well as cardiovascular outcomes and metabolic homeostasis. The low grade systemic inflammation and increased oxidative stress seen in this condition are believed to underpin the development of these OSA-related morbidities. The significant variance in degree of end organ morbidity in patients with the same severity of OSA highlights the importance of the interplay of genetic and environmental factors in determining the overall OSA phenotype. This review seeks to summarize the current understanding of the aetiology and mechanisms underlying OSA, its risk factors, diagnosis and treatment.

Sleep-Disordered Breathing in Adolescents and Younger Adults: A Representative Population-Based Survey in Chile

BACKGROUND

Prevalence and potential risk contributors of sleep-disordered breathing (SDB) in adolescents and younger adults remain unclear. We hypothesized that SDB prevalence in younger Hispanic adults is higher than the limited evidence indicates.

METHODS

This is a population-based study of Hispanic subjects surveyed as part of the Chilean National Health Survey database. For this study, only subjects aged 15 to 40 years were included. Sleep and demographic questionnaires were used to assess SDB prevalence and its risk factors. Anthropometric measurements were performed in each subject. Prevalence was calculated for each SDB-related symptom. A regression model was constructed to investigate demographic risk factors of SDB.

RESULTS

A total of 2,147 subjects were included. Mean age (± SD) was 27.2 ± 7.2 years, n = 899 (42%) were men. Habitual snoring was highly prevalent, with an average of 53.8% in men and 38.3% in women. Snoring, witnessed apneas, and daytime somnolence increased continuously with age, with an abnormal SDB questionnaire score detected in 2.5%. Reported sleep duration was 7.61 ± 1.67 hours during weekdays and 8.27 ± 2.11 hours during weekends. Snoring frequency was significantly higher in men than women at nearly all age groups, and an adjusted regression model (OR [95% CI]) identified male sex (2 [1.6-2.5]; P < .001) and BMI (1.08 [1.03-1.12]; P < .001) as independent risk factors for snoring.

CONCLUSION

The risk of SDB is highly prevalent in younger adults, even in females, and increases with age and BMI. The high prevalence and low awareness justify active screening and treatment of SDB in this population.

Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management

This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h(-1), those with an AHI of 1-5 episodes·h(-1) and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).

The history of primary snoring in children: the effect of adenotonsillectomy

Primary snoring (PS) is considered as the most benign form of sleep-disordered breathing (SDB), and treatment is usually not prescribed. Studies suggest that PS may not be as benign as had formerly been considered. We aimed to investigate the natural history of PS in children with adenotonsillar hypertrophy, and compare those who underwent adenotonsillectomy (AT) with those who did not.

MATERIAL AND METHODS

Children diagnosed with PS based on polysomnographic findings were included in the study. Information retrieved from their medical records, including medical history, physical examination, anthropometric measures, and polysomnography (PSG) results, was reviewed. A telephone interview was conducted 4-6 years following the PSG evaluation. The interview included the Pediatric Sleep Questionnaire Sleep-related Breathing Disorder (PSQ-SRBD) scale, demographics, anthropometric measures, and history of AT.

RESULTS

A total of 248 children (56% males) were studied (mean age: 5.4 ± 3.4 years). Telephone interviews were conducted 5.3 ± 1.1 years following PSG. Sixty-four children (26%) underwent AT/adenoidectomy (A) following PSG. Of the 184 children who did not undergo surgery, 62 (34%) had positive PSQ-SRBD scores five years after diagnosis. Children with PS who underwent AT had better PSQ-SRBD scores at five years post diagnosis than the nonoperated children.

CONCLUSIONS

A significant proportion of children with PS persist with SDB symptoms even five years following the diagnosis. In our cohort, a considerable percentage of children with a PSG diagnosis of PS underwent AT despite non-supportive sleep study results. Surgical intervention may have beneficial effects on some children with PS. Further studies using objective measures of sleep and incorporating the effect of SDB duration are required.