New approaches to the diagnosis of sleep-disordered breathing in children

Risk Assessment of Sleep Disordered Breathing in Cleft Lip and/or Palate

OBJECTIVE

Children with cleft lip and/or palate (CL/P) are at increased risk for Sleep Disordered Breathing (SDB), particularly Obstructive Sleep Apnea (OSA). At our institution, routine screening for SDB is performed using the Chevrin Pediatric Sleep Questionnaire (PSQ). This analysis is a practice audit looking at the outcomes of screening children with CL/P.

DESIGN/SETTING/PATIENTS/PARTICIPANTS

A single-center, retrospective analysis was done of all non-syndromic patients with CL/P over the age of 36 months over a 4-year period. Children with known OSA were eliminated from analysis.

MAIN OUTCOME MEASURES

Univariate logistic regression was used to assess predictors for SDB (PSQ score > 8) amongst various patient, disease, and treatment characteristics. Outcomes of those screened were tracked.

RESULTS

Of the 239 patients in the study cohort, 43 (18%) had positive PSQs. These subjects were more likely to have class III dental occlusion with maxillary retrusion (OR = 2.65, 95% CI: 1.2-5.8, p = 0.02). There were no differences amongst age, type of cleft, Veau classification, BMI, or history of pharyngeal surgery. One third of the group did not complete recommended testing. Twenty-five subjects with positive sleep screening underwent subsequent polysomnography and 21 (84%) had OSA.

CONCLUSION

Routine screening reveals a significant proportion of patients with CL/P with symptoms suggestive of OSA. While several patients did not complete confirmatory testing, those who completed a PSG had a high rate of identification of OSA. After excluding children with known OSA, patients with SDB are also likely to have class III dental occlusion and maxillary retrusion.

Modification of McGill Oximetry Score in Improving the Diagnostic Capability of Paediatric OSA

OBJECTIVES

This study aimed to devise a modified oximetry scoring system and calculate its diagnostic accuracy in detecting paediatric obstructive sleep apnoea syndrome (OSAS).

STUDY DESIGN

This prospective diagnostic accuracy study was divided into two phases.

SETTING

The study was conducted at a quaternary teaching hospital.

METHODS

Polysomnograms performed from 1 April 2014 to 31 December 2021 were included. In Phase 1, the parameters of 95 oximetry trend graphs were evaluated, and a modified scoring system was constructed. In Phase 2, the modified scoring system was employed in 272 oximetry trend graphs, and its diagnostic accuracy was determined. A logistic regression model was used to assess the ability of each scoring system to predict paediatric OSAS.

RESULTS

A total of 367 patients were recruited. In Phase 1, a four-tier severity classification system was constructed. In Phase 2, its diagnostic accuracy was found to be 53.3% sensitive, 97% specific, with positive predictive value of 98.5% and negative predictive value of 34.6%. The lowest detectable apnoea-hypopnoea index (AHI) was 4.5. The inter-rater reliability calculated was 80%. Logistic regression was applied to assess associations of the modified McGill score (MMS) or McGill oximetry score (MOS) with OSAS. The area under the receiver operating characteristic curve was higher for the MMS than for MOS (0.78 [95% CI 0.73-0.84] vs. 0.59 [95% CI 0.51-0.66]).

CONCLUSION

This study demonstrated that our modified scoring system had increased sensitivity at detecting OSAS at a much lower AHI and showed a much greater ability to predict paediatric OSAS.

Breathing patterns during sleep and their relationship with FEV1 in pediatric patients with cystic fibrosis residing at high altitude

Introduction

Sleep-disordered breathing (SDB) and gas exchange disorders are common in patients with cystic fibrosis (CF). Currently, the impact of the disease on sleep patterns in patients living at high altitude and the relationship of these patterns to lung function are largely unknown. The aim of this study was to determine the frequency of SDB in children with CF aged 6-18 years and the relationship between SDB and lung function (FEV1).

Methods

This is an analytical cross-sectional study of children aged 6-18 years diagnosed with CF. Spirometry before and after bronchodilators and polysomnography with capnography were performed. Descriptive analysis of qualitative and continuous variables was performed. Spearman's correlation coefficient was used to determine the correlation between polysomnogram and lung function (FEV1).

Results

Twenty-four patients with CF were included. The mean age was 10.5 ± 3.1 years and 62.5% were male. Nine children had bronchiectasis on chest CT. The median absolute baseline FEV1 was 1,880 (1,355-2,325) ml and 98% (83%-110%) of predicted value. No significant difference in FEV1% was observed between subjects with obstructive sleep apnea (OSA) and those without OSA (P = 0.56). The prevalence of OSA was 66.7% in children younger than 13 years and 40% in children older than 13 years. The Spearman correlation coefficient between FEV1 and percentage of total sleep time with saturation less than 90% (T90) was rho -0.52 (p-value = 0.018), and between FEV1 and percentage of total sleep time with saturation less than 85% (T85) was statistically significant with rho -0.45 (p-value = 0.041). A positive correlation was observed between FEV1 and SpO2 during sleep with rho 0.53 and a statistically significant p-value (0.014).

Conclusions

A high prevalence of sleep apnea was found in children with CF living at high altitude, with a negative correlation between FEV1 and T90 and T85 oxygenation indices, and a positive correlation between FEV1 and SpO2 during sleep.

Evaluation of the Garmin Vivofit 4 for assessing sleep in youth experiencing sleep disturbances

Objective

Wearable monitors are increasingly used to assess sleep. However, validity is unknown for certain monitors and populations. We tested the Garmin Vivofit 4 in a pediatric clinical sample.

Methods

Participants (n = 25) wore the monitor on their nondominant wrist during an overnight polysomnogram. Garmin and polysomnography were compared using 95% equivalence testing, mean absolute error, and Bland-Altman analysis.

Results

On average (mean ± SD), the Garmin predicted later sleep onset (by 0.84 ± 1.60 hours) and earlier sleep offset (by 0.34 ± 0.70 hours) than polysomnography. The resulting difference for total sleep time was -0.55 ± 1.21 hours. Sleep onset latency was higher for Garmin than polysomnography (77.4 ± 100.9 and 22.8 ± 20.0 minutes, respectively), while wake after sleep onset was lower (5.2 ± 9.3 and 43.2 ± 37.9 minutes, respectively). Garmin sleep efficiency averaged 3.3% ± 13.8% lower than polysomnography. Minutes in light sleep and deep sleep (the latter including rapid eye movement) were within ±3.3% of polysomnography (both SDs = 14.9%). No Garmin means were significantly equivalent with polysomnography (adjusted p > 0.99). Mean absolute errors were 0.47 to 0.95 hours for time-based variables (sleep onset, offset, and latency, plus total sleep time and wake after sleep onset), and 8.9% to 21.2% for percentage-based variables (sleep efficiency and sleep staging). Bland-Altman analysis showed systematic bias for wake after sleep onset, but not other variables.

Conclusions

The Vivofit 4 showed consistently poor individual-level validity, while group-level validity was better for some variables (total sleep time and sleep efficiency) than others.

Diagnosis of Paediatric Obstructive Sleep-Disordered Breathing beyond Polysomnography

Obstructive sleep-disordered breathing (SDB) has significant impacts on health, and therefore, a timely and accurate diagnosis is crucial for effective management and intervention. This narrative review provides an overview of the current approaches utilised in the diagnosis of SDB in children. Diagnostic methods for SDB in children involve a combination of clinical assessment, medical history evaluation, questionnaires, and objective measurements. Polysomnography (PSG) is the diagnostic gold standard. It records activity of brain and tibial and submental muscles, heart rhythm, eye movements, oximetry, oronasal airflow, abdominal and chest movements, body position. Despite its accuracy, it is a time-consuming and expensive tool. Respiratory polygraphy instead monitors cardiorespiratory function without simultaneously assessing sleep and wakefulness; it is more affordable than PSG, but few paediatric studies compare these techniques and there is optional recommendation in children. Nocturnal oximetry is a simple and accessible exam that has high predictive value only for children at high risk. The daytime nap PSG, despite the advantage of shorter duration and lower costs, is not accurate for predicting SDB. Few paediatric data support the use of home testing during sleep. Finally, laboratory biomarkers and radiological findings are potentially useful hallmarks of SDB, but further investigations are needed to standardise their use in clinical practice.

Severe Pediatric Sleep Apnea: Drug-Induced Sleep Endoscopy Based Surgery

Although adenotonsillectomy is the recommended treatment of obstructive sleep apnea (OSA) in children, some patients with preoperative severe OSA (Apnea-hypopnea index/AHI > 10) remain symptomatic after surgery and may need further workup. This study aims to: (1) analyse preoperative factors and its relation with surgical failure/persistent OSA (AHI > 5 after adenotonsillectomy) in severe pediatric OSA; (2) determine the levels of airway collapse during DISE (drug induced sleep endoscopy) in cases of surgical failure; (3) evaluate the efficacy of targeted surgery based on DISE findings. This retrospective study was conducted between August and September 2020. Across 9 years (from 2011 to 2020), all children diagnosed with severe OSA in our Hospital underwent adenotonsillectomy and repeated type 1 polysomnography (PSG) 3 months after surgery. Cases of surgical failure underwent DISE for planning eventual directed surgery. Chi-square test was used to assess the relationship between persistent OSA and preoperative patients' characteristics. 80 cases of severe pediatric OSA were diagnosed (68.8% males; mean age: 4.3 years-standard deviation: 2.49; mean AHI: 16.3-standard deviation 7.14) in the aforementioned period. We found a significant association between surgical failure (11.3% of cases; mean AHI: 6.9-SD 0.91) and obesity (p = 0.002; confidence level of 95%). Neither preoperative AHI nor other PSG parameters were associated with surgical failure. In cases of surgical failure, epiglottis collapse was present in every DISEs and adenoid tissue was present in 66% of children. All cases of surgical failure had directed surgery and surgical cure (AHI ≤ 5) was obtained in 100% of cases. This study suggests that obesity is the strongest predictor of surgical failure in children with severe OSA who undergo adenotonsillectomy. Epiglottis collapse and presence of adenoid tissue are the most common findings in postoperative DISEs of children with persistent OSA after primary surgery. DISE based surgery seems a safe and effective tool to manage persistent OSA after adenotonsillectomy.

Craniofacial Sleep Medicine: The Important Role of Dental Providers in Detecting and Treating Sleep Disordered Breathing in Children

Obstructive sleep apnea (OSA) is a clinical disorder within the spectrum of sleep-related breathing disorders (SRDB) which is used to describe abnormal breathing during sleep resulting in gas exchange abnormalities and/or sleep disruption. OSA is a highly prevalent disorder with associated sequelae across multiple physical domains, overlapping with other chronic diseases, affecting development in children as well as increased health care utilization. More precise and personalized approaches are required to treat the complex constellation of symptoms with its associated comorbidities since not all children are cured by surgery (removal of the adenoids and tonsils). Given that dentists manage the teeth throughout the lifespan and have an important understanding of the anatomy and physiology involved with the airway from a dental perspective, it seems reasonable that better understanding and management from their field will give the opportunity to provide better integrated and optimized outcomes for children affected by OSA. With the emergence of therapies such as mandibular advancement devices and maxillary expansion, etc., dentists can be involved in providing care for OSA along with sleep medicine doctors. Furthermore, the evolving role of myofunctional therapy may also be indicated as adjunctive therapy in the management of children with OSA. The objective of this article is to discuss the important role of dentists and the collaborative approach between dentists, allied dental professionals such as myofunctional therapists, and sleep medicine specialists for identifying and managing children with OSA. Prevention and anticipatory guidance will also be addressed.

Obstructive Sleep Apnea in Neonates

Neonates have distinctive anatomic and physiologic features that predispose them to obstructive sleep apnea (OSA). The overall prevalence of neonatal OSA is unknown, although an increase in prevalence has been reported in neonates with craniofacial malformations, neurological disorders, and airway malformations. If remained unrecognized and untreated, neonatal OSA can lead to impaired growth and development, cardiovascular morbidity, and can even be life threatening. Polysomnography and direct visualization of the airway are essential diagnostic modalities in neonatal OSA. Treatment of neonatal OSA is based on the severity of OSA and associated co-morbidities. This may include medical and surgical interventions individualized for the affected neonate. Based on this, it is expected that infants with OSA have more significant healthcare utilization.

[Diagnosis and correction of the obstructive sleep apnea syndrome in children with tonsillar ring pathological conditions]

OBJECTIVE

To summarize the results of a study of the clinical and polygrapic features of sleep in children with pathologic conditions of the tonsillar ring and obstructive sleep apnea. Tonsillar hypertrophy is the most common cause of obstructive sleep apnea in children. Using the data of overnight polysomnographic study and/or nocturnal pulse oximetry, groups of patients were distinguished depending on the presence and severity of their sleep breathing disorders. The effectiveness of adenotomy, adenotonsillotomy and/or adenotonsillectomy in children is demonstrated, depending on the severity of obstructive sleep apnea syndrome. Evaluation of breathing in sleeping children by polygraphic methods is necessary for early detection of obstructive sleep apnea syndrome and monitoring the effectiveness of surgical treatment.

Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children

STUDY OBJECTIVES

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA.

METHODS

Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance.

RESULTS

Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home.

CONCLUSIONS

T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA.

CITATION

Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

Validation of a Spanish version of the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire in children living in a high-altitude city

OBJECTIVES

We aimed to validate a Spanish version of the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire (SRBD-PSQ) in children living in a high-altitude Colombian city.

METHODS

In a prospective cohort validation study, patients aged between 2 and 17 years who attended the Ear, Nose, and Throat pediatric department of our institution for symptoms related to sleep-related breathing disorders had a baseline visit at enrollment, a second visit the day scheduled for the surgical intervention, and a follow-up visit at least 3 months after the surgical intervention. In these three visits, we gathered the necessary data for assessing the criterion validity, construct validity, test-retest reliability, internal consistency, and sensitivity to change of the Spanish version of the SRBD-PSQ.

RESULTS

In total, 121 patients were included in the analyses. The exploratory factor analysis (generalized least squares method, varimax rotation) yielded a four-factor structure, explaining 65.93% of the cumulative variance. The intraclass correlation coefficient (ICC) of the measurements was 0.887 (95% CI: 0.809-0.934), and the Lin concordance correlation coefficient was 0.882 (95% CI, 0.821-0.943). SRBD-PSQ scores at baseline were significantly higher than those obtained after adenotonsillectomy surgery (median [IQR] 11.0 [9.0- 14.0] vs. 4.00 [1.50-7.0]; p < 0.0001). Cronbach's α was 0.7055 for the questionnaire as a whole.

CONCLUSIONS

The Spanish version of the SRBD-PSQ has acceptable construct validity, excellent test-retest reliability and sensitivity to change, and adequate internal consistency-reliability when used in pediatric patients living at high altitude with symptoms related to sleep-related breathing disorders.

Snoring toddlers with and without obstructive sleep apnoea differed with regard to snoring time, adenoid size and mouth breathing

AIM

The difficulty of assessing the likelihood of obstructive sleep apnoea (OSA) in children who snore without full-night polysomnography is widely recognised. Our aim was to identify features that were characteristic of two-year-old children with OSA and evaluate whether this information could be used to assess the likelihood of OSA.

METHODS

The study was carried out as part of the Child-Sleep Project, a longitudinal birth cohort study of children born at Tampere University Hospital, Finland. This part of the study focused on the children in the cohort who snored and was carried out between 2013 and 2015. The primary outcomes were measured using parental questionnaires, polysomnography and clinical examinations.

RESULTS

In total, 52 children participated at a mean age of 27 months (range 23-34). Of these, 32 (44% male) snorers and 20 (70% male) controls. The most significant findings were that children who had OSA demonstrated longer snoring time (P = .003), a greater tendency for mouth breathing (P = .007) and bigger adenoid size (P = .008) than snorers without OSA.

CONCLUSION

Snoring time, adenoid tissue size and mouth breathing were important features that identified the likelihood of OSA in snoring toddlers.

Ahmad WMA, Ahmed Asif J, Khoo SP, Husein A, Ab-Ghani Z, Kassim NK. Biomarkers for Temporomandibular Disorders: Current Status and Future Directions

Numerous studies have been conducted in the previous years with an objective to determine the ideal biomarker or set of biomarkers in temporomandibular disorders (TMDs). It was recorded that tumour necrosis factor (TNF), interleukin 8 (IL-8), IL-6, and IL-1 were the most common biomarkers of TMDs. As of recently, although the research on TMDs biomarkers still aims to find more diagnostic agents, no recent study employs the biomarker as a targeting point of pharmacotherapy to suppress the inflammatory responses. This article represents an explicit review on the biomarkers of TMDs that have been discovered so far and provides possible future directions towards further research on these biomarkers. The potential implementation of the interactions of TNF with its receptor 2 (TNFR2) in the inflammatory process has been interpreted, and thus, this review presents a new hypothesis towards suppression of the inflammatory response using TNFR2-agonist. Subsequently, this hypothesis could be explored as a potential pain elimination approach in patients with TMDs.

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.

Quantitative Analysis of Thoracoabdominal Asynchrony in Pediatric Polysomnography

STUDY OBJECTIVES

Objective measurements of thoracoabdominal asynchrony (TAA), such as average phase angle (θavg), can quantify airway obstruction. This study demonstrates and evaluates use of θavg for predicting obstructive sleep apnea (OSA) in pediatric polysomnography (PSG).

METHODS

This prospective observational study recruited otherwise healthy 3- to 8-year-old children presenting for PSG due to snoring, behavioral problems, difficulty sleeping, and/or enlarged tonsils. Respiratory inductance plethysmography (RIP) was directly monitored and data were collected during each PSG. θavg and average labored breathing index (LBIavg) were calculated for earliest acceptable 5-minute periods of stage N3 sleep and stage R sleep. Associations between θavg and obstructive apnea index (OAI) and obstructive apnea-hypopnea index (OAHI), as well as between LBIavg and OAI and OAHI, were examined.

RESULTS

Forty patients undergoing PSG were analyzed. Thirty percent of patients had OSA, 57.5% had enlarged tonsils, and 17.5% were obese. θavg during stage N3 sleep and stage R sleep had significant positive correlations with OAI (Spearman r = .35 [P = .03] and .40 [P = .01], respectively) and θavg during stage N3 sleep with OAHI (r = .35 [P = .03]). LBIavg showed lower correlations. Median θavg during stage R sleep (33.1) was significantly greater than during stage N3 sleep (13.7, P = .0005).

CONCLUSIONS

Association of θavg with OAI and OAHI shows that θavg reflects airway obstruction and has potential use as a quantitative indicator of OSA. RIP provides valuable information that is readily available in PSG. The significant difference between θavg in stage N3 sleep and stage R sleep confirms the clinical observation that there is more asynchrony during rapid eye movement sleep than non-rapid eye movement sleep.

Sleep clinical record: what differences in school and preschool children?

The sleep clinical record (SCR) may be a valid method for detecting children with obstructive sleep apnoea (OSA). This study aimed to evaluate whether there were differences in SCR depending on age and to identify the possible risk factors for OSA development.

We enrolled children with sleep disordered breathing between 2013 and 2015, and divided them according to age into preschool- and school-age groups. All patients underwent SCR and polysomnography.

OSA was detected in 81.1% and 83.6% of preschool- and school-age groups, respectively. Obesity, malocclusions, nasal septal deviation and inferior turbinate hypertrophy were significantly more prevalent in school-age children (p<0.05); however, only tonsillar hypertrophy had significant hazard ratio (2.3) for OSA development. Saddle nose, nasal hypotonia, oral breathing and tonsillar hypertrophy were significantly more prevalent for development of OSA in preschoolers (p<0.03). The SCR score was significantly higher among preschool children than in school-age children (8.4±2.22 versus 7.9±2.6; p=0.044). Further, SCR score >6.5 had a sensitivity of 74% in predicting OSA in preschool children with positive predictive value of 86% (p=0.0001).

Our study confirms the validity of the SCR as a screening tool for patient candidates for a PSG study for suspected OSA, in both school and preschool children.

The differences in sleep clinical record between school and preschool children suspected to have OSAhttp://ow.ly/X778Q

Biomarkers associated with obstructive sleep apnea and morbidities: a scoping review

OBJECTIVE

To map potential biomarkers of obstructive sleep apnea (OSA)-associated morbidities in both adults and children, to identify gaps in current evidence, and to determine the value of conducting a full systematic review.

METHODS

A scoping review was undertaken of studies in patients with OSA that evaluated the potential value of biological markers in identifying OSA-associated morbidities. Retained articles were only those studies whose main objective was to identify morbidity biomarkers in subjects with OSA, the latter being confirmed with a full overnight polysomnography (PSG) in a laboratory or at-home settings. The methodology of the selected studies was classified using an adaptation of the evidence quality criteria recommended by the American Academy of Pediatrics. Additionally the biomarkers were categorized according to their potential clinical applicability.

RESULTS

572 citations were identified of which 48 met inclusion criteria. Thirty-four studies were conducted in adults and 14 involved children. Most of the studies evaluated blood biomarkers, and presented 31 potential diagnostic biomarkers.

CONCLUSION

The majority of studies that performed explored blood-based biomarkers, with most not identifying definitive morbidity biomarkers. Of the potentially promising morbidity biomarkers, plasma IL-6 and high sensitivity C-reactive protein appear to exhibit a favorable profile, and may discriminate OSA patients with and without morbidities in both adults and children. MRP 8/14 was retained in children as well as cardiovascular morbidity-associated biomarker. Urinary neurotransmitters may also provide a good tool for screening OSA cognitive morbidity in children.

Biomarkers associated with obstructive sleep apnea: A scoping review

The overall validity of biomarkers in the diagnosis of obstructive sleep apnea (OSA) remains unclear. We conducted a scoping review to provide assessments of biomarkers characteristics in the context of obstructive sleep apnea (OSA) and to identify gaps in the literature. A scoping review of studies in humans without age restriction that evaluated the potential diagnostic value of biological markers (blood, exhaled breath condensate, salivary, and urinary) in the OSA diagnosis was undertaken. Retained articles were those focused on the identification of biomarkers in subjects with OSA, the latter being confirmed with a full overnight or home-based polysomnography (PSG). Search strategies for six different databases were developed. The methodology of selected studies was classified using an adaptation of the evidence quality criteria from the American Academy of Pediatrics. Additionally the biomarkers were classified according to their potential clinical application. We identified 572 relevant studies, of which 117 met the inclusion criteria. Eighty-two studies were conducted in adults, 34 studies involved children, and one study had a sample composed of both adults and children. Most of the studies evaluated blood biomarkers. Potential diagnostic biomarkers were found in nine pediatric studies and in 58 adults studies. Only nine studies reported sensitivity and specificity, which varied substantially from 43% to 100%, and from 45% to 100%, respectively. Studies in adults have focused on the investigation of IL-6, TNF-α and hsCRP. There was no specific biomarker that was tested by a majority of authors in pediatric studies, and combinatorial urine biomarker approaches have shown preliminary promising results. In adults IL-6 and IL-10 seem to have a favorable potential to become a good biomarker to identify OSA.

Cost-benefit Analysis of Polysomnography versus Clinical Assessment Score-15 (CAS-15) for Treatment of Pediatric Sleep-disordered Breathing

Objective

To determine the cost of medical care using the Clinical Assessment Score-15 (CAS-15) scale versus polysomnography (PSG) for children with sleep-disordered breathing in terms of benefit.

Study Design

Cost-benefit analysis.

Setting

Hospital-based pediatric otolaryngology practice.

Subjects and Methods

Ninety-three patients from our original CAS-15 study were included. Four clinical measures were used and payment data were obtained. Cost-benefit analysis was performed for 2 clinical pathways. In pathway 1, all children had PSG; those with positive studies were referred for adenotonsillectomy. In pathway 2, children with CAS-15 ≥ 32 were referred for adenotonsillectomy regardless of PSG. Paired t test compared intrasubject mean total cost (pathway 1 vs pathway 2). Further analyses computed a change score for the clinical measures (follow-up minus baseline); these were divided by estimated treatment cost, producing 4 cost-benefit ratios for each pathway. Paired t tests compared the mean of these ratios between the pathways.

Results

Of 65 PSG+ (15 CAS–), 54 underwent surgery; of 28 PSG– (17 CAS–), 7 underwent surgery. Model estimated costs demonstrate a mean cost benefit of $US1172 (SE = $214) for pathway 2 versus pathway 1 ( P < .001). CAS-15 is also cost-beneficial versus PSG in 3 of 4 clinical measures (Child Behavior Checklist total problem T score, P = .008, mean OSA-18 survey score, P < .001, apnea hypopnea index, P < .001).

Conclusions

We present evidence that a CAS-15–based treatment decision criterion is superior to PSG in terms of monetary cost and in benefit per unit cost for 3 of 4 clinical measures evaluated.

Contextualised urinary biomarker analysis facilitates diagnosis of paediatric obstructive sleep apnoea

BACKGROUND

Intrinsic variance of the urine proteome limits the discriminative power of proteomic analysis and complicates potential biomarker detection in the context of paediatric sleep disorders.

METHODS AND RESULTS

Using a rigorous workflow for proteomic analysis of urine, we demonstrate that gender and diurnal effects constitute two important sources of variability in healthy children. In the context of disease, complex pathophysiological perturbations magnify these proteomic differences and therefore require contextualised biomarker analysis. Indeed, by performing biomarker discovery in a gender- and diurnal-dependent manner, we identified ∼30-fold more candidate biomarkers of paediatric obstructive sleep apnoea (OSA), a highly prevalent condition in children characterised by repetitive episodes of intermittent hypoxia and hypercapnia, and sleep fragmentation in the context of recurrent upper airway obstructive events during sleep. Remarkably, biomarkers were highly specific for gender and sampling time as poor overlap (∼3%) was observed in the proteins identified in boys and girls across morning and bedtime samples.

CONCLUSIONS

As no clinical basis to explain gender-specific effects in OSA or healthy children is apparent, we propose that implementation of contextualised biomarker strategies will be applicable to a broad range of human diseases, and may be specifically applicable to paediatric OSA.

Overnight polysomnography versus respiratory polygraphy in the diagnosis of pediatric obstructive sleep apnea

BACKGROUND

Substantial discrepancies exist in the type of sleep studies performed to diagnose pediatric obstructive sleep apnea (OSA) in different countries. Respiratory polygraphic (RP) recordings are primarily performed in sleep laboratories in Europe, whereas polysomnography (PSG) constitutes the majority in the US and Australia. Home RP show consistent apnea-hypopnea index (AHI) underscoring, primarily because the total recording time is used as the denominator when calculating the AHI compared to total sleep time (TST). However, laboratory-based RP are less likely affected, since the presence of sleep technicians and video monitoring may enable more accurate TST estimates. We therefore examined differences in AHI in PSG and in-lab RP, and whether RP-based AHI may impact clinical decision making.

METHODS

Of all the children assessed for possible OSA who underwent PSG evaluation, 100 were identified and divided into 4 groups: (A) those with AHI < 1/h TST (n = 20), (B) 1 ≤ AHI < 5/h TST (n = 40), (C) 5 ≤ AHI < 10/h TST (n = 20), and (D) AHI ≥ 10/h TST (n = 20). Electroencephalography, electrooculography, and electromyography channels were deleted from the original unscored recordings to transform them into RP, and then rescored in random sequence. AHI-RP were compared to AHI-PSG, and therapeutic decisions based on AHI-RP and AHI-PSG were formulated and analyzed using clinical details derived from the patient's clinic letter.

RESULTS

Bland Altman analysis showed that in lab RP underestimated the AHI despite more accurate estimates of TST. This underestimation was due to missed hypopneas causing arousals without desaturation. Basing the therapeutic management decision on RP instead of PSG results changed the clinical management in 23% of all patients. The clinical management for patients in groups A and D was unaffected. However, 27.5% of patients in group B would have been given no treatment, as they would be diagnosed as having no OSA (AHI < 1/h TST) when they should have received a trial of anti-inflammatory therapy or been referred for ear, nose, and throat (ENT) review. Sixty percent of patients in group C would have received either a trial of medical treatment to treat mild OSA or no treatment, instead of referral to ENT services or commencement of continuous positive airway pressure.

CONCLUSION

Apnea-hypopnea index (AHI) is underestimated in respiratory polygraphy (RP), and the disparity in AHI-RP and AHI-polysomnography can significantly affect clinical management decisions, particularly in children with mild and moderate obstructive sleep apnea (1 < AHI < 10/h total sleep time).

Obstructive sleep apnea in children: a critical update

Obstructive sleep apnea (OSA) in children is a highly prevalent disorder caused by a conglomeration of complex pathophysiological processes, leading to recurrent upper airway dysfunction during sleep. The clinical relevance of OSA resides in its association with significant morbidities that affect the cardiovascular, neurocognitive, and metabolic systems. The American Academy of Pediatrics recently reiterated its recommendations that children with symptoms and signs suggestive of OSA should be investigated with polysomnography (PSG), and treated accordingly. However, treatment decisions should not only be guided by PSG results, but should also integrate the magnitude of symptoms and the presence or absence of risk factors and signs of OSA morbidity. The first-line therapy in children with adenotonsillar hypertrophy is adenotonsillectomy, although there is increasing evidence that medical therapy, in the form of intranasal steroids or montelukast, may be considered in mild OSA. In this review, we delineate the major concepts regarding the pathophysiology of OSA, its morbidity, diagnosis, and treatment.

Deep cervical lymph node hypertrophy: a new paradigm in the understanding of pediatric obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy.

STUDY DESIGN

Prospective case control study.

METHODS

A total of 70 screened patients (mean age 7.47 years) underwent polysomnography to confirm OSA, and then underwent MRI of the upper airway. Seventy-six matched controls (mean age 8.00 years) who already had an MRI underwent polysomnography. Volumetric analysis of lymphoid tissue volumes was carried out. Chi-square analysis and Student's t test were used to compare demographic data and lymph node volumes between cohorts. Fisher's Exact test and Chi-square analysis were used to compare sleep data.

RESULTS

Patients and controls demonstrated no significant difference in mean age (7.47 vs. 8.00 yrs), weight (44.87 vs. 38.71 kg), height (124.68 vs. 127.65 cm), or body-mass index (23.63 vs. 20.87 kg/m(2)). OSA patients demonstrated poorer sleep measures than controls (P < 0.05) in all polysomnography categories (sleep efficiency, apnea index, apnea-hypopnea index, baseline SpO2, SpO2 nadir, baseline ETCO2, peak ETCO2 , and arousal awakening index). Children with OSA had higher lymphoid tissue volumes than controls in the retropharyngeal region (3316 vs. 2403 mm(3), P < 0.001), upper jugular region (22202 vs. 16819 mm(3), P < 0.005), and adenotonsillar region (18994 vs. 12675 mm(3), P < 0.0001).

CONCLUSIONS

Children with OSA have larger volumes of deep cervical lymph nodes and adenotonsillar tissue than controls. This finding suggests a new paradigm in the understanding of pediatric OSA, and has ramifications for future research and clinical care.

Clinical and polysomnographic correlation in sleep-related breathing disorders in children

INTRODUCTION

Although polysomnography is the gold standard test for sleep-disordered breathing in children, there is controversy about its indication in all cases. Among the arguments both for and against is the lack of correlation between objective values and the symptoms.

OBJECTIVE

To evaluate the correlation between clinical data and apnea-hypopnoea index (AHI) in our work environment.

MATERIAL AND METHODS

We compared the preoperative clinical symptoms and AHI statistically in 170 children with sleep-disordered breathing who underwent polysomnography. We also analysed the correlation to postoperative level, with a subgroup of 80 children who underwent adenotonsillectomy with 1 year of polysomnography follow-up.

RESULTS

Before surgery, only the degree of tonsillar hypertrophy was statistically significant correlated with AHI. At post-operative follow-up, evidence of correlation between AHI and apnoea was observed: 38.1% of children improved in the group with persistence and 66.7% in the disease resolution group (P=.023). In addition, the correlations showed the level of improvement of snoring, as assessed by visual analogue scale. The mean was 5 points lower in the persistent group and 6.1 lower in the disease resolution group (P=.047).

CONCLUSION

Despite the limitations in the correlation between clinical data and polysomnography, especially in preoperative results, polysomnography remains the gold standard diagnostic tool. Efforts should be made to obtain objective parameters that provide higher levels of correlation.

The utility of a portable recording device for screening of obstructive sleep apnea in obese adolescents

STUDY OBJECTIVES

The ApneaLink Plus is a portable recording device that measures air flow, respiratory effort, heart rate, and pulse oximetry. In the current study, we asked whether this device could be used to screen for obstructive sleep apnea in the pediatric population.

METHODS

Sleep-laboratory polysomnography (PSG) was performed simultaneously with measurements using the portable device on obese pediatric patients referred for snoring. The obstructive apnea hypopnea index (OAHI) was calculated automatically by the device (autoscore) and manually by the investigators. Sensitivity, specificity, correlation, and receiver operating curves (ROC) were used to compare the portable device to PSG.

RESULTS

Twenty-five subjects (60% male, mean age 13.6 ± 3.0 years, OAHI on PSG 11.8 ± 27.1) were studied. We identified a significant correlation between the OAHI of the ApneaLink autoscore and PSG (Spearman Rho = 0.886 [p < 0.001]). Using the PSG results as standard, ROC curves comparing the ApneaLink OAHI with the PSG OAHI demonstrated high congruence. The autoscore agreement was very good at PSG OAHI > 1.5 (area under the receiver operating curve [AUC] 0.965, OAHI > 5 [AUC 0.937], and OAHI > 10 [AUC 1.00]). The agreement of the manual score and autoscore were essentially equivalent. The device's autoscore demonstrated high sensitivity at all cutoffs examined (100% at OAHI > 1.5, 85.7% at OAHI > 5, and 100% at OAHI > 10). The specificity increased with increasing cutoffs (46.2% at OAHI > 1.5, 83.3% at OAHI > 5, and 90.0% at OAHI > 10).

CONCLUSION

he ApneaLink Plus is a sensitive screening tool for evaluation of suspected OSAS in obese pediatric patients aged 9-18 years. The specificity improves with increasing OAHI cutoffs. The device detects OSAS when tested in a sleep laboratory on obese adolescents referred for symptoms of sleep related breathing disorder.

The Endothelium as a Target in Pediatric OSA

Pediatric sleep disordered breathing has emerged in the last few decades as a highly prevalent condition by virtue of its major morbidities encompassing the central nervous, cardiovascular, and metabolic systems. In this context, improved understanding of the pathophysiological mechanisms underlying the cellular and organ injury and repair mechanisms, and the variance of the phenotype at any level of disease severity is all the more critical if appropriate personalized therapies are to be developed in the future. In this paper, the current evidence and hypothetical framework pointing to the endothelium as a primary cellular target for many of the morbidities of pediatric sleep apnea is reviewed, and particular emphasis on the recruitment of the endothelial cell lineage will be explored. It is hoped that this perspective will foster both expansion and acceleration of discovery efforts aiming to ultimately prevent the potentially lifelong consequences of sleep apnea during childhood.

Sleep endoscopy as a diagnostic tool in pediatric obstructive sleep apnea

OBJECTIVES

Ten to twenty percent of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy (T&A). We hypothesize that sleep endoscopy, a flexible fiberoptic examination of the pharynx under anesthesia, is an effective tool for identifying sites of persistent obstruction.

METHODS

In this retrospective cohort study, we reviewed records of children who had symptoms consistent with OSA and a positive polysomnogram (PSG) who underwent sleep endoscopy followed by sleep endoscopy directed surgery. Data collection included age, BMI and co-morbidities. Apnea-hypopnea index (AHI) was compared to pre and post surgery for each child using a paired t-test.

RESULTS

Of the 80 children who underwent sleep endoscopy followed by directed surgery, 65% were male, mean age was 6 years (SD 3.75 years), average BMI was 19 (SD 0.43 years) and 28% had co-morbidities. For the 51% of patients who had persistent OSA after T&A, the mean AHI after sleep endoscopy directed surgery was significantly lower then before surgery (7.9 vs. 15.7, p<.01). For the 49% of patients who had never undergone surgery for OSA, or who were surgically naïve, and underwent sleep endoscopy directed surgery, the mean AHI was significantly lower then before surgery (8.0 vs. 13.8, p<.01).

CONCLUSIONS

Sleep endoscopy is a consistently reliable tool for identifying the sites of obstruction in both surgically naive children and those with persistent OSA after T&A.

Reliability of home-based physiological sleep measurements in snoring and non-snoring 3-year olds

PURPOSE

To study snoring and non-snoring 3-year olds in their own homes and to establish reference values and night-to-night variability of physiological measurements taken during sleep.

METHODS

One hundred and sixty-six children, aged 3.2-4.0 years, identified as at high (n = 83, M/F = 1.5:1) or low (n = 83, M/F = 1.4:1) risk for persistent snoring, as rated by a parent, wore a sleep screening system (Grey Flash) for up to five consecutive nights, to measure snoring, oxygen saturation, heart rate, movement, sleep efficiency, and sleep timing.

RESULTS

The snoring group snored 25% of their total sleep time, while the non-snoring group snored just 7.6%. Reliability estimates were calculated, using intraclass correlations to establish the reliability of single recordings and the Spearman-Brown prophecy formula to estimate reliability over multiple recordings. Snoring (percent), turn index (number of turns per hour), and mean heart rate were adequately assessed in both groups with one recording night (all intraclass correlation coefficients (ICCs) ≥0.70). Furthermore, mean SpO(2) was measured with sufficient reliability with two recordings in non-snorers (ICC = 0.71), while five recording nights were necessary to reach reliability in snorers (ICC = 0.71). SpO(2) nadir did not reach adequate reliability in either group even after seven recording nights.

CONCLUSIONS

Our results showed that snoring can be measured reliably at home with just one recording night, whereas most other physiological sleep measures require two or more recordings.

The role of polysomnography in diagnosing and treating obstructive sleep apnea in pediatric patients

Obstructive sleep apnea in children is associated with serious neurocognitive and cardiovascular morbidity, systemic inflammation, and increased health care use, yet remains underdiagnosed. Although the prevalence of obstructive sleep apnea is 1-3% in the pediatric population, the prevalence of primary snoring (PS) is estimated to be 3-12%. The challenge for pediatricians is to differentiate PS from obstructive sleep apnea in a cost-effective, reliable, and accurate manner before recommending invasive or intrusive therapies, such as surgery or continuous positive airway pressure. The validity of polysomnography as the gold standard for diagnosing obstructive sleep apnea has been challenged, primarily related to concerns that abnormalities on polysomnography do not correlate well with adverse outcomes, that those abnormalities have statistical more than clinical significance, and that performing polysomnograms on all children who snore is a practical impossibility. The aim of this article is to review the clinical utility of diagnostic tests other than polysomnography to diagnose obstructive sleep apnea, to highlight the limitations and strengths of polysomnography, to underscore the threshold levels of abnormalities detected on polysomnography that correlate with morbidity, and to discuss what the practical implications are for treatment.

Obstructive sleep apnea syndrome in children

The clinical syndrome of obstructive sleep apnea (OSAS) in children is a distinct, yet somewhat overlapping disorder with the condition that occurs in adults, such that the clinical manifestations, polysomnographic findings, diagnostic criteria and treatment approaches need to be considered in an age-specific manner. Childhood OSAS has now become widely recognized as a frequent disorder and as a major public health problem. Pediatric OSAS, particularly when obesity is concurrently present, is associated with substantial end-organ morbidities and increased healthcare utilization. Although adenotonsillectomy (T&A) remains the first line of treatment, evidence in recent years suggests that the outcomes of this surgical procedure may not be as favorable as expected, such that post-T&A polysomnographic evaluation may be needed, especially in high-risk patient groups. In addition, incorporation of nonsurgical approaches for milder forms of the disorder and for residual OSAS after T&A is now being investigated.

Update on pediatric sleep-disordered breathing

Pediatric sleep-disordered breathing (SDB) includes an increasingly recognized, highly prevalent, yet still underdiagnosed spectrum of respiratory disorders, the most common and clinically significant of which is obstructive sleep apnea. SDB is linked with significant end-organ dysfunction across various systems, particularly with cardiovascular, neurocognitive, and metabolic consequences. This review summarizes recent advances in understanding of pediatric SDB and discusses the challenges inherent in diagnosing and treating children with SDB.

Seasonal variability of sleep-disordered breathing in children

INTRODUCTION

Snoring and sleep-disordered breathing (SDB) are frequent pediatric conditions. Although allergies and respiratory viruses have been pathophysiologically implicated in these conditions, their seasonal distribution has not been examined.

METHODS

The records of all children participating in a prospective, cross-sectional community-based research study that included a questionnaire on snoring frequency and loudness and an overnight sleep study were retrospectively assessed for seasonal patterns based on the day the children were evaluated.

RESULTS

A total of 1,051 children were included with a mean age of 7 years. There were no seasonal differences in the number of children evaluated or in their demographic characteristics. However, the odds of increased snoring frequency and loudness were significantly higher in spring and summer and lowest in fall (P < 0.001). However, the mean AHI was highest and the nadir SaO(2) was lowest in winter and spring compared to summer and fall (P < 0.001 and P < 0.03, respectively).

CONCLUSION

Snoring and the severity of SDB exhibit distinct and essentially non-overlapping patterns of seasonal variation, with peaks in spring-summer for snoring and peaks in winter-spring for SDB severity. These findings suggest that both seasonal viral and allergen burdens may contribute to SDB severity and may prompt differing clinical referral patterns throughout the year.

Treatment of obstructive sleep apnea in children

Obstructive sleep apnea (OSA) in children is a frequent disease for which optimal diagnostic methods are still being defined. Treatment of OSA in children should include providing space, improving craniofacial growth, resolving all symptoms, and preventing the development of the disease in the adult years. Adenotonsillectomy (T&A) has been the treatment of choice and thought to solve young patient's OSA problem, which is not the case for most adults. Recent reports showed success rates that vary from 27.2% to 82.9%. Children snoring regularly generally have a narrow maxilla compared to children who do not snore. The impairment of nasal breathing with increased nasal resistance has a well-documented negative impact on early childhood maxilla-mandibular development, making the upper airway smaller and might lead to adult OSA. Surgery in young children should be performed as early as possible to prevent the resulting morphologic changes and neurobehavioral, cardiovascular, endocrine, and metabolic complications. Close postoperative follow-up to monitor for residual disease is equally important. As the proportion of obese children has been increasing recently, parents should be informed about the weight gain after T&A. Multidisciplinary evaluation of the anatomic abnormalities in children with OSA leads to better overall treatment outcome.