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D'Elia C, Gozal D, Bruni O, Goudouris E, Meira E Cruz M. Allergic rhinitis and sleep disorders in children - coexistence and reciprocal interactions. J Pediatr (Rio J) 2022; 98:444-454. [PMID: 34979134 PMCID: PMC9510807 DOI: 10.1016/j.jped.2021.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To review, critically analyze and synthesize knowledge from the international literature regarding the association between allergic rhinitis (AR) and sleep disorders, the impact of AR treatment on children's sleep, and lay the foundation for future research on this topic. SOURCE OF DATA A literature search using PubMed database including original and review articles, systematic reviews and meta-analyses using keywords related to AR, sleep disorders and sleep-disordered breathing. SYNTHESIS OF DATA Sleep is fundamental to health, and its assessment and control of conditions that trigger or aggravate disturbances are of the uttermost importance. Allergic rhinitis (AR) is common in children and may interfere with both their quality of life and quality of sleep. It has emerged as one of the most important risk factors for habitual snoring in children and appeared to increase the risk of Obstructive Sleep Apnea (OSA), with AR severity exhibiting a significant and independent association with pediatric OSA severity. However, in some studies, those associations between AR and OSA in children are not very consistent. CONCLUSIONS A substantial level of controversy exists regarding the interactions between AR and OSA in children. Notwithstanding, identifying and treating AR in clinical settings is probably an important step toward improving symptoms and preventing deterioration of sleep quality in children and may improve the severity of underlying OSA. Considering the high prevalence, morbidity, economic and social implications of both AR and sleep problems, it is crucial that healthcare providers improve their understanding of the relationships between those conditions among children.
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Affiliation(s)
- Cláudio D'Elia
- Hospital Lusíadas, Departamento de Pediatria, Lisbon, Portugal; Centro Europeu do Sono, Portugal.
| | - David Gozal
- The University of Missouri School of Medicine, Child Health Research Institute, Department of Child Health, Columbia, United States
| | - Oliviero Bruni
- La Sapienza University, Department of Social Development and Psychology, Rome, Italy
| | - Ekaterini Goudouris
- Universidade Federal do Rio de Janeiro, Instituto Martagão Gesteira de Puericultura e Pediatria (IPPMG), Faculdade de Medicina, Departamento de Pediatria, Rio de Janeiro, RJ, Brazil
| | - Miguel Meira E Cruz
- Centro Europeu do Sono, Portugal; Lisbon School of Medicine, Sleep Unit, Centro Cardiovascular da Universidade de Lisboa, Lisbon, Portugal
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Fueyo GO. Chronic Rhinitis Treatment: Effects on Obstructive Sleep Apnea. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00307-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kajiyama T, Komori M, Hiyama M, Kobayashi T, Hyodo M. Changes during medical treatments before adenotonsillectomy in children with obstructive sleep apnea. Auris Nasus Larynx 2021; 49:625-633. [PMID: 34840035 DOI: 10.1016/j.anl.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/28/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The severity of pediatric obstructive sleep apnea (OSA) can vary from mild to very severe (AHI ≥ 30 events/h) with the seasons. The efficacy of medical treatment has been investigated in cases of mild and moderate pediatric OSA, but not in severe cases thoroughly. METHODS Our prospective cohort study involved 205 children who visited our outpatient clinic between December 2014 and May 2020. We performed home sleep tests after the initial visit, and then polysomnography after optimizing the control of rhinitis, sinusitis, adenoid hypertrophy, and tonsillitis by using medical treatments. RESULTS The respective proportions of patients who improved to obstructive AHI (O-AHI) < 1/h or who proceeded to surgery were 43.4% and 62.3% in mild cases; 43.3% and 52.2% in moderate cases; 30.2% and 68.4% in severe cases; and 0.0% and 100% in very severe cases. Additionally, nadir SaO2 improved significantly between before and after medical treatment in both O-AHI < 1/h and O-AHI ≥ 1/h patients (respectively p < 0.0001, p = 0.0009). The lowest nadir SaO2 before medical treatment was 74% in patients in whom O-AHI was normalized after medical treatments. CONCLUSION Medical treatment instituted before a surgical decision is made can provide substantial benefits and avoid unnecessary surgery if there is time for such treatments. In contrast, it may be difficult to normalize the O-AHI in pediatric patients with very severe OSA or a nadir SaO2 of less than 74% by medical treatment.
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Affiliation(s)
- Taihei Kajiyama
- Department of Otolaryngology, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Masahiro Komori
- Department of Otolaryngology, Kochi Medical School, Kochi University, Nankoku, Japan.
| | - Mariko Hiyama
- Department of Otolaryngology, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Taisuke Kobayashi
- Department of Otolaryngology, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Masamitsu Hyodo
- Department of Otolaryngology, Kochi Medical School, Kochi University, Nankoku, Japan
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4
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Gozal D, Ismail M, Brockmann PE. Alternatives to surgery in children with mild OSA. World J Otorhinolaryngol Head Neck Surg 2021; 7:228-235. [PMID: 34430830 PMCID: PMC8356096 DOI: 10.1016/j.wjorl.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/17/2021] [Accepted: 03/18/2021] [Indexed: 12/01/2022] Open
Abstract
Precision medicine requires coordinated and integrated evidence-based combinatorial approaches so that diagnosis and treatment can be tailored to the individual patient. In this context, the treatment approach to mild obstructive sleep apnea (OSA) is fraught with substantial debate as to what is mild OSA, and as to what constitutes appropriate treatment. As such, it is necessary to first establish a proposed consensus of what criteria need to be employed to reach the diagnosis of mild OSA, and then examine the circumstances under which treatment is indicated, and if so, whether and when anti-inflammatory therapy (AIT), rapid maxillary expansion (RME), and/or myofunctional therapy (MFT) may be indicated.
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Affiliation(s)
- David Gozal
- Department of Child Health and Child Health Research Institute, and MU Women and Children's Hospital, University of Missouri School of Medicine, Columbia, MO, USA
| | - Mahmoud Ismail
- Department of Neurology and Sleep Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Pablo E Brockmann
- Department of Pediatric Cardiology and Pulmonology, Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Pediatric Sleep Center, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Leung TN, Cheng JW, Chan AK. Paediatrics: how to manage obstructive sleep apnoea syndrome. Drugs Context 2021; 10:dic-2020-12-5. [PMID: 33828609 PMCID: PMC8007210 DOI: 10.7573/dic.2020-12-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Theresa Nh Leung
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong SAR, China
| | - James Wch Cheng
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong SAR, China
| | - Anthony Kc Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Fehrm J, Nerfeldt P, Browaldh N, Friberg D. Effectiveness of Adenotonsillectomy vs Watchful Waiting in Young Children With Mild to Moderate Obstructive Sleep Apnea: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 146:647-654. [PMID: 32463430 DOI: 10.1001/jamaoto.2020.0869] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Adenotonsillectomy (ATE) is one of the most common surgical procedures to treat children with obstructive sleep apnea (OSA), but to our knowledge there are no randomized clinical trials confirming the benefit of surgery compared with watchful waiting in children between 2 and 4 years of age. Objective To determine whether ATE is more effective than watchful waiting for treating otherwise healthy children with mild to moderate OSA. Design, Setting, and Participants This randomized clinical trial was conducted from December 2014 to December 2017 at the Otorhinolaryngology Department of the Karolinska University Hospital, Stockholm, Sweden. A total of 60 children, 2 to 4 years of age, with an obstructive apnea-hypopnea index (OAHI) score of 2 or greater and less than 10, were randomized to ATE (n = 29) or watchful waiting (n = 31). A total of 53 participants (88%; ATE, n = 25; watchful waiting, n = 28) completed the study. Data were analyzed from August 2018 to December 2018. Interventions Adenotonsillectomy. Main Outcomes and Measures The primary outcome was the difference between the groups in mean OAHI score change. Secondary outcomes were other polysomnography parameters, score on the Obstructive Sleep Apnea-18 (OSA-18) questionnaire, and subgroup analyses. Polysomnography and the OSA-18 questionnaire were completed at baseline and after 6 months. Results Of the 60 included children, 34 (57%) were boys and the mean (SD) age at first polysomnography was 38 (9) months. Both groups had a decrease in mean OAHI score, and the difference in mean OAHI score change between the groups was small (-1.0; 95% CI, -2.4 to 0.5), in favor of ATE. However, there were large differences between the groups in favor of ATE regarding the OSA-18 questionnaire (eg, total OSA-18 score: -17; 95% CI, -24 to -10). Also, a subgroup analysis of 24 children with moderate OSA (OAHI ≥5 and <10) showed a meaningful difference in mean OAHI score change between the groups in favor of ATE (-3.1; 95% CI, -5.7 to -0.5). Of 28 children, 10 (36%) in the watchful waiting group received ATE after the follow-up, and 7 of these had moderate OSA at baseline. Conclusions and Relevance This randomized clinical trial found only small differences between the groups regarding changes in OAHI, but further studies are needed. However, there were large improvements in quality of life after ATE. These results suggest that otherwise healthy children with mild OSA and mild effect on quality of life may benefit from watchful waiting, while children with moderate OSA should be considered for ATE. Trial Registration ClinicalTrials.gov Identifier: NCT02315911.
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Affiliation(s)
- Johan Fehrm
- Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Pia Nerfeldt
- Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Nanna Browaldh
- Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Danielle Friberg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Division of Otorhinolaryngology, Department of Surgical Science, Uppsala University, Uppsala, Sweden
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Bhattacharjee R. Question 5: Which children with OSA should be considered for medical therapy? Paediatr Respir Rev 2021; 37:64-67. [PMID: 33342726 DOI: 10.1016/j.prrv.2020.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Rakesh Bhattacharjee
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
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Ji T, Lu T, Qiu Y, Li X, Liu Y, Tai J, Guo Y, Zhang J, Wang S, Zhao J, Ni X, Xu Z. The efficacy and safety of montelukast in children with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med 2020; 78:193-201. [PMID: 33465554 DOI: 10.1016/j.sleep.2020.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The efficacy and safety of montelukast in children with obstructive sleep apnea (OSA) remain controversial. Therefore, the aims of this systemic review and meta-analysis are to verify this issue and further provide reference for clinical practice. METHODS Seven databases were searched for randomized controlled trials (RCTs) up to September 30, 2019. The literature screening and data extraction were performed by two independent researchers. Adverse reactions from trials were also recorded. Meta-analysis was performed and analyzed heterogeneity. Methodological and evidence quality were followed by to evaluate according to Cochrane handbook. RESULTS A total of 4 RCTs including 305 children with mild to moderate OSA were involved. Compared with placebo, we found that oral montelukast (OM) significantly improved polysomnography (PSG) monitoring parameters, typical and relevant symptoms including snoring and mouth breathing, and adenoid morphology in children with OSA. When compared with routine drugs, not only PSG monitoring parameters and adenoid morphology, but also sleep-disordered breathing (SDB)-related questionnaire scores were improved in patients with OSA treated by combination of OM and routine drugs. In addition, compared with single nasal spray of mometasone furoate, the present study also showed that OM combined with nasal spray of mometasone furoate significantly improved PSG monitoring parameters, symptoms of snoring and mouth breathing and reduced tonsil morphology in pediatric OSA. In terms of treatment safety, one study reported adverse reactions of OM such as headache, nausea and vomiting, while no adverse events were reported after OM treatment in another study. CONCLUSION As a classic leukotriene receptor antagonist, montelukast can be used to treat children with mild to moderate OSA in the short term and improve clinical characteristics. The promotion and application of OM in clinic is considered to be a noninvasive option to avoid surgical treatment.
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Affiliation(s)
- Tingting Ji
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Tingting Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, PR China
| | - Yue Qiu
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Xiaodan Li
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Yali Liu
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Jun Tai
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China; Children's Hospital Capital Institute of Pediatrics, Beijing, PR China
| | - Yongli Guo
- Beijing Key Laboratory for Pediatric Diseases of Otolaryngology, Head and Neck Surgery, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Jie Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Shengcai Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Jing Zhao
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Xin Ni
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China; Beijing Key Laboratory for Pediatric Diseases of Otolaryngology, Head and Neck Surgery, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China.
| | - Zhifei Xu
- Department of Respiratory Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China.
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Tipold A, Vazifedan T, Baldassari CM. Efficacy of Adenoidectomy for the Treatment of Mild Sleep Apnea in Children. Otolaryngol Head Neck Surg 2020; 164:657-661. [PMID: 32838641 DOI: 10.1177/0194599820950719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES (1) To assess outcomes in children undergoing adenoidectomy for the treatment of mild obstructive sleep apnea (OSA). (2) To identify clinical factors that predict which children will have persistent obstruction following adenoidectomy. STUDY DESIGN Case series with chart review over a 10-year period. SETTING Tertiary children's hospital. SUBJECTS AND METHODS Children between 2 and 17 years old undergoing adenoidectomy for treatment of mild OSA (obstructive apnea-hypopnea index [AHI] between 1 and 5 on polysomnogram) were included. The need for additional medical or surgical intervention following adenoidectomy was recorded. When available, postoperative polysomnogram data were reviewed. RESULTS In total, 134 children with a mean age of 5.4 years were included. Fifty-three percent (n = 71) were female and 57% (n = 76) were black. The mean (SD) baseline AHI was 2.2 (1.09). Caregivers reported a moderate impact of sleep disturbance on quality of life with a mean (SD) preoperative total OSA-18 score of 64.1 (19.28). Postadenoidectomy outcomes were reported for 105 patients (78%) with a mean follow-up time of 6 months. Sixty-nine percent (n = 72) of children had resolution of obstructive symptoms. While 31% (n = 33) of children required additional intervention following adenoidectomy, only 6.8% (n = 9) underwent a subsequent tonsillectomy. Demographic factors such as age and baseline AHI did not predict which children required additional treatment following adenoidectomy. CONCLUSION Adenoidectomy may be an effective treatment for mild OSA. A randomized trial comparing outcomes for adenoidectomy and adenotonsillectomy is needed to determine the ideal surgical treatment for nonsevere OSA in children.
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Affiliation(s)
- Austin Tipold
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Turaj Vazifedan
- Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
| | - Cristina M Baldassari
- Department of Pediatric Sleep Medicine, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Gozal D, Tan HL, Kheirandish-Gozal L. Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision. J Clin Med 2020; 9:jcm9030888. [PMID: 32213932 PMCID: PMC7141493 DOI: 10.3390/jcm9030888] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/06/2020] [Accepted: 03/18/2020] [Indexed: 12/18/2022] Open
Abstract
Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.
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Affiliation(s)
- David Gozal
- Department of Child Health and the Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA;
- Correspondence:
| | - Hui-Leng Tan
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK;
| | - Leila Kheirandish-Gozal
- Department of Child Health and the Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA;
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