Sleep disordered breathing in children - Diagnostic questionnaires, comparative analysis

Relationship of ankyloglossia and obstructive sleep apnea: systematic review and meta-analysis

PURPOSE

Recent studies have highlighted the potential role of a short lingual frenulum as a risk factor for pediatric obstructive sleep apnea syndrome. A shortened frenulum may contribute to abnormal orofacial development, leading to increased upper airway resistance and susceptibility to upper airway collapsibility during sleep. Recognizing early indicators, such as a short lingual frenulum, is crucial for prompt intervention. This systematic review aims to evaluate the association between a short lingual frenulum and the risk of obstructive sleep apnea syndrome in children.

METHODS

This systematic review adheres to PRISMA criteria for a quantitative analysis. A comprehensive search was conducted on five databases until January 2024 to identify relevant studies. The selected articles underwent rigorous analysis, considering study design, sample characteristics, lingual frenulum characterization, sleep assessment methods, and key findings.

RESULTS

A total of 239 references were initially identified. Finally, six studies were included in the qualitative synthesis, with four studies eligible for the quantitative synthesis. The Newcastle-Ottawa scale was employed to assess study quality. Meta-analysis, supported by a moderate evidence profile according to the GRADE scale, revealed statistically significant differences, with odds ratios of 3.051 (confidence interval: 1.939 to 4.801) for a short frenulum and 12.304 (confidence interval: 6.141 to 24.653) for a high-arched palate.

CONCLUSION

This systematic review and meta-analysis provide evidence supporting the association between ankyloglossia and obstructive sleep apnea in children. Nevertheless, it is crucial to consider additional factors such as tongue mobility and the presence of a high-arched palate in further evaluations.

People's knowledge, attitudes, practice, and healthcare education demand regarding OSA: a cross-sectional study among Chinese general populations

Background

Population knowledge and attitudes toward obstructive sleep apnea (OSA) syndrome are critical to public health initiatives to overcome the disease. Healthcare education is an appropriate approach to expediting the process to build active medical practice models in the public.

Objective

This study aimed to assess the level of knowledge, attitude, and practice (KAP) regarding OSA and healthcare education demand among the Chinese general population.

Methods

A cross-sectional survey was performed online via Wenjuanxing in China between 8 February and 8 March 2022, using a 34-item questionnaire designed and reviewed by multidisciplinary experts.

Results

This study enrolled 1507 respondents, aged 18 to 68, with a city-to-countryside ratio of approximately 2:1. Four-fifths of respondents reported that they had children (n = 1237), and mothers accounted for 57.7%. If they or their children had symptoms of OSA, nearly nine in 10 respondents would undertake positive medical practices, especially parents. A total of 89.4% of the respondents reported a desire to receive healthcare education through the new multimedia approach, and most were concerned about the etiology of OSA.

Conclusion

The current study indicated that even the higher educated and urban populations in China had insufficient knowledge about positive attitudes toward and practices regarding OSA, indicating an urgent demand for healthcare education. A special emphasis should be placed on appropriating population demand for healthcare education and promoting the benefits of active medical practice models in sleep medicine.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Sleep-disordered breathing in children seeking orthodontic care-an Australian perspective

BACKGROUND

The prevalence of sleep-disordered breathing in children is underestimated due to impediments in detection and diagnosis. Consequently, delayed management may affect the quality of life and the growth and development of a child. Due to their patient demographic, orthodontists are optimally positioned to identify those at risk of sleep-disordered breathing and make referrals for investigation and management. This study aims to determine the prevalence of children at risk of sleep-disordered breathing in an Australian orthodontic population.

METHODS

A 1-year retrospective study was conducted in an urban Western Australian private orthodontic practice with two branches in similar socioeconomic demographics. The responses of new patients to a modified paediatric sleep questionnaire and standard medical history form were recorded.

RESULTS

In 1209 patients (4-18 years), 7.3% were at risk of sleep-disordered breathing. An association between sex and the potential risk of sleep-disordered breathing was found with 11% of males at risk of sleep-disordered breathing compared to 7% of females (P = 0.012).

CONCLUSIONS

The relatively high prevalence of children at risk of sleep-disordered breathing presenting for orthodontic care presents an opportunity to identify at-risk individuals through routine use of the paediatric sleep questionnaire. This would facilitate early referral for diagnosis and management of sleep-disordered breathing.

Oral language skills in Brazilian children with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is associated with a negative impact on neurocognitive development in children. Receptive/expressive oral language is a complex process, with limited investigations on the repercussion of OSA. This study aimed to analyze receptive and expressive oral language skills in children with obstructive sleep apnea (OSA).

METHODOLOGY

This study included 52 children (27 females, 51.92 %) with a mean age of 7 ± 2 years (age range of 4-11 years), which underwent type 3 polysomnography (PSG). The participants were divided into N-OSA (n = 16) and OSA (n = 36) groups based on the apnea-hypopnea index. The speech-language therapist evaluated hearing and oral language for phonology, expressive semantics, syntax, receptive semantics (Peabody Image Vocabulary Test), pragmatics, and understanding of verbal instructions (Token Test).

RESULTS

Oral language assessments showed a difference in the pragmatics subsystem (p = 0.047), with positive correlation between OSA severity and oral language functions such as pragmatics and syntax (desaturation index, p = 0.045).

CONCLUSION

Obstructive sleep apnea (OSA) had a negative impact on oral language skills, including the syntax and pragmatics subsystems.

Sleep disordered breathing and oral health-related quality of life in children with different skeletal malocclusions

OBJECTIVE

To evaluate the relationship among different skeletal malocclusion patterns, sleep-disordered breathing (SDB) and children's oral health-related quality of life (OHRQoL).

METHODS

Two hundred-five patients were divided into three groups, considering skeletal malocclusion. Parents completed the Pediatric Sleep Questionnaire (PSQ) on behalf of the patients, who completed the 14-question version of the Oral Health Impact Profile (OHIP-14).

RESULTS

SDB was observed in 10.7% of children. The overall prevalence of snoring, difficulty breathing during sleeping, mouth breathing, and dry mouth on awakening was 8.78%, 7.31%, 36.09%, and 37.07%, respectively. However, there was no significant difference in OHIP-14 parameters among the skeletal groups. A positive correlation was found between OHIP-14 and PSQ and was significant in Class I and III.

CONCLUSION

Although there was no significant difference, SDB risk and sleep quality were found as most to least problematic, in the following sequential order: Class II > Class III > Class I.

Rationalising requests for preoperative sleep studies and postoperative HDU beds: a quality improvement project in paediatric ENT patients undergoing elective surgery

Background

Sleep disordered breathing represents a spectrum of upper airway obstruction including snoring, increased respiratory effort and obstructive sleep apnoea. An increasing demand for paediatric preoperative sleep studies and postoperative high dependency unit (HDU) beds was having a significant impact on service delivery at this ear, nose and throat (ENT) unit.

Methods

Retrospective and prospective review of all paediatric sleep study requests over a 30-month period in a single tertiary ENT department. Data were collected on indication for and result of sleep study, patient outcome, operative details and HDU bed occupancy. During the study period, a ‘Sleep Study’ proforma was introduced which incorporated the ‘I’m Sleepy Score’ (ISS) and ENT-UK national guidelines.

Results

Retrospective review included 198 sleep studies, of which 62% (n=118) showed no evidence of obstructive sleep apnoea (OSA). There was little consistency in patients’ sleep study results and need for monitoring on HDU following adenotonsillectomy. Prospective review following intervention included 60 patients, of which 62% (n=37) showed evidence of OSA. The mean ISS in this cohort was 4.7. Only those with moderate-to-severe OSA or with relevant risk factors underwent overnight HDU observation. The number of sleep study requests fell by >50%; from 11 per month to 5 per month. The total HDU bed occupancy was reduced by 50% following intervention (from n=18 to n=9).

Conclusion

The use of the ISS and incorporation of ENTUK’s recommendations has reduced the number of negative sleep studies being requested and has rationalised the number of paediatric HDU bed requests being made. This has helped provide a prudent elective paediatric ENT service in this unit with corresponding cost benefits.

Sleep-Disordered Breathing and Cardiovascular Disease in Children and Adolescents: A Scientific Statement From the American Heart Association

Obstructive sleep apnea (OSA) is a known risk factor for cardiovascular disease in adults. It is associated with incident systemic hypertension, arrhythmia, stroke, coronary artery disease, and heart failure. OSA is common in children and adolescents, but there has been less focus on OSA as a primary risk factor for cardiovascular disease in children and adolescents. This scientific statement summarizes what is known regarding the impact of sleep‐disordered breathing and, in particular, OSA on the cardiovascular health of children and adolescents. This statement highlights what is known regarding the impact of OSA on the risk for hypertension, arrhythmia, abnormal ventricular morphology, impaired ventricular contractility, and elevated right heart pressure among children and adolescents. This scientific statement also summarizes current best practices for the diagnosis and evaluation of cardiovascular disease–related complications of OSA in children and adolescents with sleep apnea and highlights potential future research in the area of sleep‐disordered breathing and cardiovascular health during childhood and adolescence.

Short lingual frenulum and head-forward posture in children with the risk of obstructive sleep apnea

BACKGROUND

Recent studies have shown that a short lingual frenulum is a potential risk factor for obstructive sleep apnea syndrome (OSAS) in children. A short frenulum leads to abnormal orofacial development and may consequently contribute to sleep-disordered breathing by narrowing the upper airways and increasing the risk of upper-airway collapsibility. The aim of this study was to assess the impact of a short lingual frenulum on the risk of OSAS in children.

METHODS

Children from pre-, primary, secondary, and high school, aged 3-17 years, were included in the study. Parents/guardians were asked to fill in the Pediatric Sleep Questionnaire (PSQ), and then, children at risk of OSAS were enrolled in the study group. A control group was established randomly from patients with negative PSQ results. A physical examination, including measurements of head-forward posture (HFP) and length of the free tongue, inter-incisor distance and subjective high-arched palate evaluation was performed in children from both groups.

RESULTS

A total of 1,500 PSQ questionnaires were distributed, and less than half (713) were returned correctly filled in. In the second part of the study, 135 children were evaluated: 67 in the study group and 68 in the control group. The mean ages were 9.4 ± 3.0 and 9.5 ± 3.1 years, respectively. Children in the study group had significantly shorter lingual frenula, higher HFP measures, and had a higher prevalence of a high-arched palate. Based on statistical analysis, a short lingual frenulum (OR 5.02 [1.58-15.94]).

CONCLUSIONS

The study identified a relationship between a short lingual frenulum and the risk of OSAS in children. Detecting and addressing ankyloglossia in children is necessary before it leads to orofacial changes, malocclusion, and consequently, sleep apnea. Furthermore, OSAS was associated with higher HFP, but no relationship was found between the two parameters.

Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ*) into Brazilian Portuguese

INTRODUCTION

Obstructive sleep apnea is a frequent entity in childhood that can lead to important consequences for the health and children's quality of live. Polysomnography is the gold-standard exam to diagnose obstructive sleep apnea, but it is expensive, complex, and poorly affordable in Brazil. The pediatric sleep questionnaire has shown to be a valuable screening test for obstructive sleep apnea. It is a simple questionnaire with good sensitivity and specificity compared to polysomnography in the countries where it has been validated.

OBJECTIVE

Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ), into Brazilian Portuguese.

METHODS

The translation of the PSQ into Brazilian Portuguese was carried out in accordance with good practices. The validated and adapted questionnaire was applied to parents/caregivers of 60 children (40 of them with obstructive sleep apnea and 20 controls) aged 2-18 years. Retest was applied to 30 children with obstructive sleep apnea. The following tests were performed: internal consistency, test-retest, validation of questionnaire (the latter by ROC curve).

RESULTS

Brazilian PSQ has shown high internal consistency by Cronbach's alpha (0.86 for the total test, 0.83 for subscale "snoring", 0.64 for "sleepiness" and 0.65 for "behavior"). Test-retest presented a correlation of 0.89 for subscale "snoring", 0.93 for "sleepiness" and 0.86 for "behavior". Accuracy by ROC curve was 0.99. Nine was considered the optimal value to discriminate patients with obstructive sleep apnea from controls, with a sensitivity of 0.92 and specificity of 1.0.

CONCLUSION

The translation and cross-cultural adaptation of the PSQ into Brazilian Portuguese proved to be successful. In places with difficult access to polysomnography, PSQ can be a useful tool in screening and follow-up of children with obstructive sleep apnea.

Paediatrics: how to manage obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is defined as the intermittent reduction or cessation of airflow due to partial or complete obstruction of the upper airway during sleep. Paediatric OSAS has specific contributing factors, presenting symptoms and management strategies in various age groups. Untreated OSAS can lead to detrimental effects on neurocognitive development and cardiovascular and metabolic functions of a growing child. In the past decade, practice guidelines have been developed to guide the evaluation and management of OSAS. This article provides a narrative review on the current diagnostic and treatment options for paediatric OSAS. Alternative diagnostic tools other than the standard polysomnography are discussed. Adenotonsillectomy is considered the first-line therapy yet it is not suitable for treatment of all OSAS cases. Nocturnal non-invasive positive airway pressure ventilation is effective and could be the priority treatment for patients with complex comorbidities, residual OSAS post-adenotonsillectomy or obesity. However, intolerance and non-adherence are major challenges of positive airway pressure therapy especially in young children. There is increasing evidence for watchful waiting and other gentler alternative treatment options in mild OSAS. The role of anti-inflammatory drugs as the primary or adjunctive treatment is discussed. Other treatment options, including weight reduction, orthodontic procedures and myofunctional therapy, are indicated for selected patients. Nevertheless, the successful management of paediatric OSAS often requires a multidisciplinary team approach.

Predictors of a Normal Sleep Study in Healthy Children with Sleep Disordered Breathing Symptoms

OBJECTIVE

To determine the prevalence and characteristics of children with normal elective polysomnography for obstructive sleep disordered breathing (oSDB) based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines.

STUDY DESIGN

In this retrospective cohort study, we identified patients ages 2 to 18 who underwent diagnostic polysomnography (PSG) ordered by our otolaryngology department for SDB between 2012 and 2018.

SETTING

All patients were seen by otolaryngologists at an urban tertiary safety net hospital.

SUBJECTS AND METHODS

There were a total of 456 patients studied (average age 5.66 ± 3.19; 263 (57.7%) males, 193 (42.3%) females. Demographic factors (age, gender, race, ethnicity, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate and multivariate analysis.

RESULTS

Two hundred four patients (44.7%) had no obstructive sleep apnea (OSA) based on AHI<2 on PSG. Children with a larger tonsil size had 3.18 times the odds of OSA compared to those with a medium tonsil size (95% CI 1.64, 6.19) when adjusting for symptoms, age category, and race (P = .0007). Children ages 4 to 6 years had 0.25 times the odds of OSA compared to those ages 2-3 years (95% CI 0.12, 1.54) when adjusting for symptoms, tonsil size, and race (P = .0011). White children had 0.28 times the odds of OSA compared to Black children (95% CI 0.14, 0.57) when adjusting for symptoms, tonsil size, and age category (P = .0004).

CONCLUSION

Among our patient population, 44.7% had normal sleep studies. Younger children (ages 2-3) were less likely to have normal polysomnography. This research demonstrates that obtaining sleep studies in otherwise healthy children with SDB can affect management decisions, and they should be discussed with families with a focus on patient centered decision making.

Prevalence of Sleep-Disordered Breathing in Children Referring for First Dental Examination. A Multicenter Cross-Sectional Study Using Pediatric Sleep Questionnaire

Background: Sleep-related breathing disorders (SRDB) are a group of pathological conditions characterized by a dysfunction of the upper airways. The value of SRDB's prevalence, in the pediatric population, ranges from 2 to 11% depending on the different methodologies used in measure and the difficulties in the diagnosis. The aim of this study was to assess the prevalence of SRDB using the Pediatric Sleep Questionnaire (PSQ). Methods: 668 patients were enrolled from the Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Italy and from the Unit of Integrated Pediatric Dentistry, University of Murcia, Spain. The questionnaires were administered to patients with no previous orthodontic and surgical treatment who attended on the first visit at the two units of pediatric dentistry. Data regarding general health status were extracted from the standard anamnestic module for first visit. Prevalence and logistic regression models were computed. Results: The ages ranged from 2 to 16 years old (average 7 years old). The prevalence of SRDB was 9.7% for the entire sample. The models showed a positive correlation between three variables (snoring, bad habits, and anxiety) and SRDB. Conclusions: The prevalence obtained demonstrates the relevance of sleep disorders in the pediatric population and highlights the central role of pediatric dentists in the earlier diagnosis of these disorders.

Survey of parental awareness of obstructive sleep apnea among children in Guangdong province, South China

OBJECTIVES

Childhood obstructive sleep apnea (OSA) is underdiagnosed. The aim of this study was to assess the awareness level of OSA among parents in the general population of Guangdong province of South China.

METHODS

This descriptive epidemiological study was conducted from July to November 2019 using an anonymous questionnaire that evaluated the knowledge of OSA-related symptoms and complications. Exclusion criteria included age under 18 years, refusal to fill out the questionnaire, and a linguistic barrier.

RESULTS

A total of 1123 respondents participated in the survey. Among them, 530 (47.2%) respondents were aware of childhood OSA. The most common source of information about childhood OSA was the internet (49.9%). On multivariate analysis, the respondents obtained higher scores if they were mothers (B: -0.105, 95% confidence interval [CI]: -0.153,-0.057), lived in an urban area (B: -0.077, 95% CI: -0.125,-0.28), and knew about childhood OSA previously (B: -0.55, 95% CI:-0.598,-0.502).

CONCLUSION

Parents demonstrated limited awareness of OSA complications. Innovative educational campaigns must be organized to inform medical practitioners and the general public about this disease and raise awareness about its complications. The effectiveness of the ongoing health education campaigns to increase awareness should be monitored by examining the temporal trends in public knowledge of childhood sleep apnea.

Parental concern as an indicator of the severity of Obstructive Sleep Apnea in children

INTRODUCTION

An accepted screening question for Obstructive Sleep Apnea (OSA) in children is "Does your child snore". However, this has no correlation to severity. The purpose of this study is to evaluate a simple 2-item questionnaire that reflects the degree of parental concern to predict the severity of Obstructive Sleep Apnea (OSA) in children as measured by Polysomnography (PSG).

METHODS

Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire that we devised and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child's breathing. Both questionnaires were compared to PSG results.

RESULTS

Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Correlations were found between the need for surgery score and the apnea-hypopnea index (r = 0.22, P = .029), as well as the mean SpO2 levels (r = -0.24, P = .02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P = .003). The need for surgery score was the only predictor for moderate-severe OSA (P = .039).

CONCLUSION

Querying parents on their perception of their child's need for surgery is a practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG.

Evaluation of the relationship between malocclusions and sleep-disordered breathing in children

OBJECTIVE

To determine the relationship between dental/skeletal malocclusions and sleep-disordered breathing (SDB) in the early diagnosis and treatment of sleep disorders in children.

METHODS

Patients were evaluated by pedodontists to identify dental, skeletal, and functional malocclusion (n = 240; <15 years). In order to determine the sleep and daytime behavior of the patients, pediatric sleep questionnaires (PSQ) were applied. Per results of the PSQ, patients with a mean of ≥ 0.33 were defined as the high-risk group.

RESULTS

A total of 25.8% children were in the high-risk group, with the most convex profile, high-angle growth direction, and mandibular retrognathy. The prevalence of habitual snoring, mouth breathing, and dry mouth was 48.4%, 64.5%, and 87.2% among all high-risk children, respectively.

CONCLUSION

Convex profile, high-angle growth direction, and retrognathic mandible were determined as risk factors for SDB. The prevalence of dry mouth, mouth breathing, and snoring was higher in the high-risk group.

Impact of AAO-HNS Guideline on Obtaining Polysomnography Prior to Tonsillectomy for Pediatric Sleep-Disordered Breathing

OBJECTIVE

To assess the impact of the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline on practice patterns in obtaining preadenotonsillectomy (AT) polysomnography (PSG) for pediatric sleep-disordered breathing (SDB).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary children's hospital.

SUBJECT AND METHODS

The study population included all patients referred to our pediatric otolaryngology clinic for consideration of AT for SDB during two 12-month time periods: before (2010-2011) and after (2015-2016) publication of the 2011 AAO-HNS guideline. Demographic, insurance, comorbidity, and Pediatric Sleep Questionnaire (PSQ) variables were assessed for association with pre-AT PSG using bivariate and multivariate logistic regression analysis.

RESULTS

A greater percentage of patients underwent pre-AT PSG in 2015-2016 vs 2010-2011 (30% vs 22%, P = .001). On multivariate analysis, presence of neuromuscular disorder was the only predictor associated with pre-AT PSG in 2010 to 2011 (odds ratio [OR], 3.00; 95% CI, 1.10, 8.06; P = .03). Presence of neuromuscular disorder (OR, 2.54; 95% CI, 1.51, 4.29; P < .0001), craniofacial anomaly (OR, 2.32; 95% CI, 1.20, 4.50; P = .013), or Down syndrome (OR, 3.45; 95% CI, 1.54, 7.72; P = .003) was associated with pre-AT PSG in 2015 to 2016. Positive PSQ screen was significantly associated with decreased odds of pre-AT PSG in both time periods.

CONCLUSION

After publication of the 2011 AAO-HNS guideline, there was a significant but modest increase in pre-AT PSG utilization in children with SDB and high-risk comorbidities at our institution, consistent with AAO-HNS guideline recommendations. However, overall guideline adherence remains low and may reflect limitations in PSG testing capacity.

Pediatric ambulatory anesthesia: an update

PURPOSE OF REVIEW

Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature.

RECENT FINDINGS

The criteria for undertaking pediatric adenotonsillectomy on an ambulatory basis, fasting after clear fluids, postoperative nausea and vomiting (PONV), perioperative pain management and discharge criteria comprise the themes addressed in this review.

SUMMARY

Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with dexamethasone. Pain management requires test doses of opioids intraoperatively in children with OSAS and nocturnal desaturation to identify those with reduced opioid dosing thresholds, an uncommon practice as yet. Furthermore, postdischarge nonsteroidal anti-inflammatory agents as well as other pain management strategies should replace oral opioids to prevent respiratory arrests in those who are ultra-rapid CYP2D6 metabolizers. Finally, discharge criteria are evolving and physiological-based criteria should replace time-based, reducing the risk of readmission.

Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of the Art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management.