A systematic review and meta-analysis of cohort studies of echocardiographic findings in OSA children after adenotonsilectomy

Prevalence of pulmonary hypertension in children with obstructive sleep apnea living at high altitude

Introduction

The prevalence of obstructive sleep apnea (OSA) is 1-4 %. Some reports describe its association with pulmonary hypertension (PH), but its prevalence is unknown. No studies at high altitude have determined the relationship between OSA and PH. The aim of this study was to establish the prevalence of PH in children diagnosed with OSA living in a high-altitude city at 2640 m above sea level.

Methods

Children between 2 and 16 years of age referred to the Sleep Laboratory of the Fundación Neumológica Colombiana in Bogotá with a positive polysomnogram for OSA were included, and a two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate PH. Statistical analysis was performed using median, interquartile range, chi-squared test, and Kruskall-Wallis test.

Results

Of the 55 patients (n: 55), 63.6 % were male, with a median age of 6 years, 14 children (25.5 %) were overweight; 12 children (21.8 %) had mild OSA, 12 (21.8 %) had moderate OSA and 31 (56.4 %) severe OSA. In patients with severe OSA, the minimum saturation during events was 78 % with a desaturation index (DI) of 33.8/hour (p < 0.01). T90 and T85 increased proportionally with OSA severity (p < 0.05). Of the 55 patients with OSA, none had PH according to echocardiography; 4 patients (7.2 %) had pulmonary artery systolic pressure (PASP) at the upper limit of normal (ULN), and it was not related to a higher body mass index (BMI).

Conclusions

We found no association between OSA and PH in children with OSA at high altitude.

Efficacy of adenotonsillectomy on pediatric obstructive sleep apnea and related outcomes: A narrative review of current evidence

This review summarizes the current evidence in systematic reviews, meta-analysis and randomized controlled trials regarding adenotonsillectomy outcomes in pediatric obstructive sleep apnea (OSA). Adenotonsillectomy is effective in treating OSA in children without co-morbidities, despite postoperative residual OSA remained in roughly half of these children. For children with comorbidities such as Down syndrome, Prader-Willi syndrome, sickle cell disease, or cerebral palsy, adenotonsillectomy is less effective and associated with more postoperative complications than that in children without comorbidities. For other OSA-related outcomes, evidence from meta-analyses and randomized controlled trials confirm adenotonsillectomy results in improvement of subjective OSA-related outcomes (e.g. symptoms, behaviors, and quality of life), but the results in objective OSA-related outcomes (e.g. cardiometabolic parameters or neurocognitive functions) are inconsistent. Future studies should focus on randomized controlled trials comparing objective OSA-related outcomes and the long-term effects of adenotonsillectomy in children with OSA.

Relationship between ODI and sleep structure of obstructive sleep apnea and cardiac remodeling

PURPOSE

The purpose of the study was to evaluate the quantitative relationship between Oxygen Desaturation Index (ODI) and sleep structure of obstructive sleep apnea (OSA) and cardiac remodeling.

METHODS

In this study, patients were enrolled from January 2015 to October 2022, and were divided into 3 groups according to AHI: patients with AHI < 15, patients with 15 ≤ AHI < 30, and 260 patients with AHI ≥ 30. Stratified linear regression was used to analyze independent risk factors for cardiac remodeling in OSA.

RESULTS

A total of 479 patients were enrolled. We found that compared with AHI < 15 group (n = 120), the group with AHI > 30 (n = 260) had increased left atrial anteroposterior diameter, left ventricular end-diastolic internal diameter, left ventricular posterior wall thickness, right ventricular anteroposterior diameter, and interventricular septal thickness (P < 0.05). The group with 15 ≤ AHI ≤ 30 (n = 99) had increased left atrial anteroposterior diameter (P < 0.05). Multivariate linear regression revealed that N2 sleep was an independent risk factor for left ventricular posterior wall thickness, with positive correlation (p < 0.05). N3 sleep was an independent risk factor for transverse right atrial diameter and right ventricular anteroposterior diameter, with negative correlation (P < 0.05). ODI was an independent risk factor for interventricular septal thickness, with positive correlation (P < 0.05). The arousal index was an independent risk factor for increased left atrial anteroposterior diameter, with positive correlation (P < 0.05).

CONCLUSIONS

Increased ODI is an independent risk factor for interventricular septal thickness, while decreased slow wave sleep is an independent risk factor for right heart remodeling in OSA.

Role of automated functional imaging and myocardial work in assessment of cardiac function in children with obstructive sleep apnea

BACKGROUND

Early identification of abnormal left ventricular function in children with obstructive sleep apnea (OSA) is difficult using conventional echocardiographic indices and commonly used clinical markers of myocardial damage. We sought to investigate the value of automatic function imaging and myocardial work parameters in predicting early cardiac impairment in children having OSA with preserved left heart function and thereby identifying an optimal index for assessment.

PATIENTS AND METHODS

Fifty-two children who presented with symptoms of nocturnal sleep snoring and open-mouth breathing and 34 healthy controls were enrolled in this study. Clinical characteristics and conventional echocardiographic data were collected, and image analysis was performed using two-dimensional speckle-tracking echocardiography to obtain left ventricular global longitudinal strain (GLS), post-systolic index, peak strain dispersion, global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency.

RESULTS

Children with OSA had significantly lower GLS, GWI, and GCW than those without (P < 0.05). Additionally, GWI (β = -32.87, 95% CI: -53.47 to -12.27), and GCW (β = -35.09, 95% CI: -55.35 to -14.84) were found to correlate with the disease severity in the multiple linear regression mode, with worsening values observed as the severity of the disease increased. ROC curve analysis revealed that GCW was the best predictor of myocardial dysfunction, with an AUC of 0.809 (P < 0.001), and the best cutoff point for diagnosing myocardial damage in children with OSA was 1965.5 mmHg%, with a sensitivity of 92.5% and a specificity of 58.7%.

CONCLUSIONS

GLS, GWI, and GCW were identified as predictors of myocardial dysfunction in children with OSA, with GCW being the best predictor.

Low incidence of pulmonary hypertension in children with suspected obstructive sleep apnea: A prospective observational study

OBJECTIVES

Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity.

METHODS

A prospective study of children aged 1-13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1-2 (mild-moderate) and MOS 3-4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) ≥20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded.

RESULTS

One hundred and seventy children median age 3.8 years (IQR 2.7-6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH.

CONCLUSION

PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.

Echocardiographic findings in children with obstructive sleep apnea: A systematic review

OBJECTIVE

To systematically review the incidence of cardiac abnormalities in pediatric patients with obstructive sleep apnea (OSA) in order to assess the utility of preoperative echocardiographic evaluation for patients undergoing surgery.

STUDY DESIGN

A systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Data sources were searched from January 1, 1980 to March 25, 2020. Studies that examined echocardiographic findings and polysomnographic data for patients between birth and 18 years of age with polysomnogram-confirmed OSA were included. Studies that included patients with preexisting cardiac, metabolic, or hematologic disorders that could affect hemodynamic parameters were excluded. Included studies were assessed for quality and risk of bias using the U.S. National Institute of Health's Quality Assessment Tools.

RESULTS

Thirteen studies met inclusion criteria. Five studies were categorized as high risk of bias, three were categorized as medium risk, and five were categorized as low risk. Study design varied considerably between studies, including heterogeneous classifications of OSA severity, discrepant reporting of echocardiographic parameters, and differing estimations of pulmonary hemodynamics. Significant disagreement regarding the effect of OSA on cardiac function was found between all included studies.

CONCLUSION

Data demonstrating significant associations between OSA and cardiac abnormalities in children is inconsistent. Echocardiographic abnormalities are inconsistently found and, when present, their clinical significance remains poorly understood. Assessing the utility of preoperative echocardiography in children with OSA requires further investigation with prospective studies utilizing standardized classifications of OSA severity, reporting of echocardiographic parameters, and estimations of pulmonary hemodynamics.

The utility of preoperative echocardiography in pediatric obstructive sleep apnea

PURPOSE

The purpose of this study was to determine the associations between cardiac function and postoperative adverse events in pediatric patients with obstructive sleep apnea (OSA).

METHODS

Patients between birth and 18 years of age diagnosed with OSA between January 1, 2015, and December 31, 2018, who underwent echocardiographic evaluation within 6 months of surgery at a tertiary care children's hospital were evaluated. Exclusion criteria included history of neuromuscular disorders, tracheostomy placement, or a predominance of central apneic events recorded during polysomnography (PSG). Patients were grouped by OSA severity. Chi-squared analysis and logistic regression were utilized to determine associations between demographic characteristics, OSA severity, preoperative echocardiographic abnormalities, and postoperative adverse events.

RESULTS

One hundred ten children met inclusion criteria for the study, including 22 with mild OSA, 22 with moderate OSA, and 66 with severe OSA. Race and the presence of congenital heart disease (CHD) were significantly associated with differences in OSA severity. Echocardiographic abnormalities were found in 45 patients, but exclusion of patients with CHD revealed no significant associations with differences in OSA severity. Postoperative adverse events were identified in 18 (16%) patients, and only O₂ saturation nadir was found to be a significant predictor of these complications.

CONCLUSION

Preoperative echocardiogram abnormalities are not commonly found in children with OSA and presence of abnormalities does not predict postoperative adverse events. O₂ saturation nadir measured on preoperative PSG is a significant predictor of postoperative adverse events and should be examined as a clinical indicator of OSA severity.

Prevalence of Pulmonary Hypertension in Pediatric Patients With Obstructive Sleep Apnea and a Cardiology Evaluation: A Retrospective Analysis

STUDY OBJECTIVES

Pulmonary hypertension (PH) has been reported as a serious complication of obstructive sleep apnea (OSA) in children; however, estimated prevalence rates vary widely (zero to 85%). The purpose of this study is to determine the prevalence of PH in children with OSA and identify factors that may predict an increased PH risk in children with OSA.

METHODS

A retrospective review of all pediatric beneficiaries (88,058) in the San Antonio Military Health System with a diagnosis of OSA and a clinical evaluation by a pediatric cardiologist. OSA severity and nadir oxygen saturation were recorded from overnight polysomnography. Reason for referral, comorbid disorders, echocardiogram results, and cardiac diagnoses were obtained from cardiology records.

RESULTS

OSA was identified in 2,020 pediatric patients (2.3%). A pediatric cardiology consultation was reported for 296 patients with OSA. After excluding 95 patients for incorrect OSA diagnoses, incomplete data, or OSA treatment before cardiology evaluation, 163 patients were included in the final analysis. A diagnosis of PH was found in 3 patients with OSA (1.8%). Two of these patients had obesity, and all three had comorbid cardiac disorders.

CONCLUSIONS

Prevalence of PH in pediatric patients with OSA is low and none of the patients with PH had severe OSA. Current guidelines recommend PH screening in patients with severe OSA, yet OSA severity may not accurately predict risk. Factors evaluated in this study did not demonstrate an increased PH risk; additional research is necessary to improve screening in pediatric patients with OSA.

CITATION

Burns AT, Hansen SL, Turner ZS, Aden JK, Black AB, Hsu DP. Prevalence of pulmonary hypertension in pediatric patients with obstructive sleep apnea and a cardiology evaluation: a retrospective analysis. J Clin Sleep Med. 2019;15(8):1081-1087.

Pulmonary arterial pressure and nasal obstruction in mouth-breathing children: Similarities between adenotonsillar hypertrophy and allergic rhinitis

BACKGROUND

Upper airway obstruction may cause pulmonary hypertension in childhood. In this study we aimed to identify a possible correlation of systolic pulmonary arterial pressure (SPAP), using Doppler echocardiography, with nasal patency (NP), as measured by rhinomanometry, in mouth-breathing (MB) children with allergic rhinitis (AR) and adenotonsillar hypertrophy (ATH).

METHODS

In this cross-sectional study we evaluated 183 patients, from 2 to 12 years of age, at an MB referral clinic in Brazil, from December 2013 to 2017. We allocated patients to 4 etiology groups: group 1, 60 MBs with ATH; group 2, 47 MBs with AR; group 3, 43 MBs with both ATH and AR; and group 4, 33 nasal breathing control subjects. The ratio of total nasal inspiratory flow (assessed by active anterior rhinomanometry) and expected inspiratory flow adjusted for height determined the percent NP (%NP).

RESULTS

The median %NP was higher in controls than in the MB groups (controls, 114% [79-147%]; ATH: 65% [5-116%]; AR: 57% [23-144%]; ATH and AR: 64% [3-120%]; p < 0.001). Median SPAP was higher in the MB groups than in controls (SPAP: ATH, 26.0 [20.0-35.0] mmHg; AR, 26.0 [22.0-32.0] mmHg; ATH and AR, 26.30 [20.0-34.0] mmHg; control, 22.0 [16.0-30.0] mmHg; p < 0.001). SPAP showed a negative association with %NP (Spearman's rho = -0.24; p < 0.001).

CONCLUSION

Reduced nasal airflow in MB children showed a correlation with higher levels of systolic pulmonary arterial pressure. The AR and ATH groups were similar in nasal obstruction severity and systolic pulmonary arterial pressure level distribution.

Sleep Clinical Record application in Brazilian children and its comparison with Italian children

Objective

To apply the Sleep Clinical Record (SCR) to a sample of Brazilian children with sleep complaints, to compare the results with Italian children, and to identify variables that influence phenotype.

Methods

Brazilian and Italian children, 4-11 years of age and matched for age, gender, obesity, and apnea-hypopnea index and who presented with complaints related to sleep, were selected. The instrument used was the SCR, and the procedure used was full-night cardiorespiratory monitoring.

Results

The sample consisted of 51 Brazilian children and 102 Italian children. Brazilian children presented with oral breathing (55%), tonsillar hypertrophy (69%), Friedman palate position (88%), malocclusion (84%), and OSAS score (Brouilette questionnaire) (55%). The SCR among obese Brazilian children was higher as compared to that in nonobese subjects (obese, 10.84 vs nonobese, 9.13; p = 0.03). In the comparison between Brazilian and Italian children, the total Brazilian SCR was higher than the Italian SCR score (Brazilian SCR, 10.21 ± 7.56; Italian SCR, 8.95 ± 2.55; p = 0.002). The Italian SCR score was influenced by obesity, whereas the Brazilian SCR was influenced by others symptoms (daytime sleepiness, enuresis, nocturnal choking, headache, limb movements).

Conclusion

Brazilian children with sleep-disordered breathing show a higher SCR score as compared to Italian children. Obesity and tonsillar hypertrophy, Friedman palate position alteration, and dental malocclusion further influenced the total SCR score among Brazilian children. This may be due to access difficulties in Brazil where children should have more assistance to obtain medical care.

The association of obstructive sleep apnea and left ventricular hypertrophy in obese and overweight children with history of elevated blood pressure

Obesity is a potent cardiovascular disease (CVD) risk factor and is associated with left ventricular hypertrophy (LVH). Obstructive sleep apnea (OSA) is common among individuals with obesity and is also associated with CVD risk. The authors sought to determine the association of OSA, a modifiable CVD risk factor, with LVH among overweight/obese youth with elevated blood pressure (EBP). This was a cross-sectional analysis of the baseline visit of 61 consecutive overweight/obese children with history of EBP who were evaluated in a pediatric obesity hypertension clinic. OSA was defined via sleep study or validated questionnaire. Children with and without OSA were compared using Fisher's exact tests, Student's t tests, and Wilcoxon rank sum test. Multivariable logistic regression evaluated the association between OSA and LVH. In this cohort, 71.7% of the children had LVH. Children with OSA were more likely to have LVH (85.7% vs 59.4%, P = 0.047). OSA was associated with 4.11 times greater odds of LVH (95% CI 1.15, 14.65; P = 0.030), remaining significant after adjustment for age, sex, race, and BMI z-score (after adjustment for hypertension, P = 0.051). A severe obstructive apnea-hypopnea index (AHI >10) was associated with 14 times greater odds of LVH (95% CI 1.14, 172.64, P = 0.039). OSA was significantly associated with LVH among overweight/obese youth with EBP, even after adjustment for age, sex, race, and BMI z-score. Those with the most severe OSA (AHI >10) had the greatest risk for LVH. Future studies exploring the impact of OSA treatment on CVD risk in children are needed.

Sleep-Disordered Breathing is Associated With Increased Mortality in Hospitalized Infants With Congenital Heart Disease

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) has adverse cardiovascular effects in children and adults. In adults with cardiac disease, SDB is highly prevalent and confers increased mortality risk. It is unknown if SDB confers a similar risk in infants with congenital heart disease (CHD). We evaluated clinical and economic outcomes associated with SDB among inpatient infants with CHD in the United States from 1997-2012.

METHODS

This retrospective, cross-sectional study used discharge data from the Kids' Inpatient Database. Inclusion criteria included diagnosed CHD and age younger than 1 year. Exclusion criteria included apnea of prematurity, cardiac surgery during admission, and invasive mechanical ventilation. Generalized linear models were used to assess outcomes of mortality, length of stay, and total charges after controlling for SDB, clinical characteristics, hospital characteristics, and economic factors.

RESULTS

Across 461,778 inpatient infant cases of CHD from 1997-2012, 4,839 involved SDB (14% obstructive, 4% central, 82% not specified). Multivariable analyses show that central sleep apnea was independently associated with increased risk of inpatient mortality (odds ratio 4.3), 92% longer inpatient stay, and 112% higher total charges when compared to infants with CHD without comorbid SDB (P < .05). Obstructive and unspecified SDB were associated with longer adjusted lengths of stay (56% and 18%, respectively) and higher charges (48% and 21%, respectively) relative to infants with CHD without comorbid SDB (P < .001).

CONCLUSIONS

SDB, particularly central sleep apnea, was independently associated with worse outcomes in hospitalized infants with CHD. Further research on whether treatment of SDB in infants with CHD can abrogate adverse patient outcomes is needed.

Sleep: important considerations for the prevention of cardiovascular disease

PURPOSE OF REVIEW

Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors.

RECENT FINDINGS

Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities.

SUMMARY

Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.

Paediatric obstructive sleep apnoea: is our operative management evidence-based?

BACKGROUND

Despite the plethora of publications on the subject of paediatric obstructive sleep apnoea, there seems to be wide variability in the literature and in practice, regarding recourse to surgery, the operation chosen, the benefits gained and post-operative management. This may reflect a lack of high-level evidence.

METHODS

A systematic review of four significant controversies in paediatric ENT was conducted from the available literature: tonsillectomy versus tonsillotomy, focusing on the evidence base for each; anaesthetic considerations in paediatric obstructive sleep apnoea surgery; the objective evidence for the benefits of surgical treatment for obstructive sleep apnoea; and the medical treatment options for residual obstructive sleep apnoea after surgical treatment.

RESULTS AND CONCLUSION

There are many gaps in the evidence base for the surgical correction of obstructive sleep apnoea. There is emerging evidence favouring subtotal tonsillectomy. There is continuing uncertainty around the prediction of the level of post-operative care that any individual child might require. The long-term benefit of surgical correction is a particularly fertile ground for further research.

The effect of tonsillectomy on obstructive sleep apnea: an overview of systematic reviews

OBJECTIVE

Tonsillectomy with adenoidectomy is a combination surgery that has been used to treat pediatric obstructive sleep apnea (OSA). For adults, tonsillectomy has also been reported as a primary treatment modality when the tissue is hypertrophied. The objective of this study is to provide an overview of published systematic reviews and meta-analyses of tonsillectomy with or without adenoidectomy as used in the treatment of OSA in children and adults.

DATA SOURCES

Nine databases, including PubMed/MEDLINE.

REVIEW METHODS

Databases were searched from their inception through July 9, 2017. The PRISMA statement was followed.

RESULTS

More than 20 recent systematic reviews and meta-analyses were identified regarding tonsillectomy as a treatment modality for OSA. There were four articles that addressed tonsillectomy's overall success, efficacy, and complications in otherwise healthy pediatric patients. Three studies evaluated tonsillectomy in obese children, and two specifically examined children with Down syndrome. Only one systematic review and meta-analysis discussed tonsillectomy as a treatment for OSA in the adult population.

CONCLUSION

Tonsillectomy as an isolated treatment modality is rarely performed in pediatric patients with OSA; however, tonsillectomy is commonly performed in combination with adenoidectomy and the combination has demonstrated efficacy as the primary treatment option for most children. In the limited adult data, tonsillectomy alone for OSA has a surprising success rate; yet, more research is required to determine long-term improvement and need for further treatment.

Longitudinal Cardiovascular Outcomes of Sleep Disordered Breathing in Children: A Meta-Analysis and Systematic Review

Objectives

The presence of sleep disordered breathing (SDB) is known to impact long-term cardiovascular morbidity in adults; however, the long-term effects in children are poorly understood. We aimed to systematically review and synthesize studies published to date on the long-term effects of SDB in children.

Study Design

Meta-analysis and systematic review using PubMed, CINAHL, Embase, and Scopus (all indexed years).

Methods

We searched for English-language articles containing original human data from prospective studies, with ≥7 participants, in children ≤18 years of age. Data regarding study design, demographics, clinical characteristics, outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by three investigators. Retrospective and cross-sectional studies were excluded.

Results

Of 1701 identified abstracts, 25 articles (combined n = 1418) were ultimately included. All studies reported longitudinal outcomes following treatment of SDB, 21 studies exclusively reporting outcomes after adenotonsillectomy. Therefore, studies were combined to objectively assess the effect of SDB treatment on cardiovascular outcomes. Although all cardiovascular parameters were within the normal range at baseline, at follow-up there was a significant decrease in mean pulmonary artery pressure, right ventricular end diastolic diameter, heart rate, mitral Em/Am ratio, and C-reactive protein. There was no significant change in interventricular septum thickness, left ventricular parameters (shortening fraction, systolic and end diastolic diameters, ejection fraction, posterior wall thickness, isovolumetric relaxation time), left atrial diameter, and aortic and pulmonary valve peak velocities.

Conclusions

Studies assessing the long-term cardiovascular effects of SDB in children are limited. The available literature indicates effects on autonomic function, right, and left heart function following treatment for SDB. However, well-designed, large-scale, prospective cohort studies (using standardized outcomes) are needed to better understand the relationship of cardiovascular morbidity in the context of pediatric SDB.

Sleep and the Cardiovascular System in Children

Subspecialty pediatric practice provides comprehensive medical care for a range of ages, from premature infants to children, and often includes adults with complex medical and surgical issues that warrant multidisciplinary care. Normal physiologic variations involving different body systems occur during sleep and these vary with age, stage of sleep, and underlying health conditions. This article is a concise review of the cardiovascular (CV) physiology and pathophysiology in children, sleep-disordered breathing (SDB) contributing to CV morbidity, congenital and acquired CV pathology resulting in SDB, and the relationship between SDB and CV morbidity in different clinical syndromes and systemic diseases in the expanded pediatric population.

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.

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).