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

Association between habitual snoring and vigilant attention in elementary school children

OBJECTIVES

Vigilant attention (VA) is a fundamental neurocognitive function. However, the association between habitual snoring (HS) and VA in community-based children remains unclear. Therefore, this study aimed to elucidate the association.

METHODS

The study included 2014 children from grades 1-6 across six elementary schools. Snoring frequency was evaluated using a questionnaire administered to parents. VA was assessed using a brief 3-min psychomotor vigilance test (PVT-B). Generalized linear models and multivariate logistic regression analysis were utilized to examine the association between snoring frequency and PVT-B performance. Impaired PVT-B performance was defined as the worst quartile of PVT-B metrics.

RESULTS

The PVT-B performance significantly improved with advancing school grade level (p trend < 0.0001). A significant negative correlation was observed between snoring frequency and PVT-B performance. Particularly, in grade 1, HS was associated with a higher risk of impaired PVT-B performance, including response speed (mean reciprocal reaction time) (adjusted odds ratio [aOR] 2.56, 95% confidence interval [CI]: 1.20-5.50), more slowest 10% RT (aOR 3.28, 95% CI: 1.51-6.88), and more lapse500 (number of lapse of reaction time ≥ 500 ms) (aOR 3.18, 95% CI: 1.45-6.80) compared to children without snoring.

CONCLUSIONS

Our findings show that VA rapidly improves throughout elementary school. Additionally, younger children with HS are at risk of VA deficits, emphasizing the importance of early intervention for HS.

Snoring, obstructive sleep apnea, and upper respiratory tract infection in elementary school children in Japan

PURPOSE

Both obstructive sleep apnea (OSA) and the common cold are disorders of the upper respiratory tract, and may be associated. However, studies on the association between OSA and upper respiratory tract infections (URTI) in children are scarce. The aim of this study was to investigate possible associations between snoring, the severity of OSA, and URTI in elementary school children.

METHODS

This was a cross-sectional study in a community cohort of elementary school children (first and second graders) in Japan. Information on sleep habits, history of URTI, and OSA risk was obtained from a parental questionnaire. Children underwent overnight tracheal sound recordings from which apnea-hypopnea index was estimated. Multivariable logistic analysis was employed to define the association between snoring, OSA, and URTI ≥ 3 episodes over six months.

RESULTS

Of the 922 potential enrollees, 653 children and their parents (71%) agreed to participate in the study. Multivariable-adjusted ORs for URTI were 1.73 (95%CI: 1.16 to 2.59) in children who snored 1 to 4 nights per week and 2.82 (95%CI: 1.26 to 6.28) in snoring ≥ 5 nights per week compared with never snoring (reference). Likewise, subjectively reported louder snoring, as well as objectively defined louder sound levels, were significantly associated with URTI. In addition, OR for URTI in children with an estimated apnea-hypopnea index ≥ 2.0 events/hour was 2.65 (95%CI: 1.32 to 5.31) compared to children with apnea-hypopnea index less than 1.0 events/hour (reference).

CONCLUSIONS

Snoring and severity of OSA as measured by nocturnal tracheal sound recordings were associated with increased susceptibility to URTI in elementary school children.

Persistent obstructive sleep apnoea in children: treatment options and management considerations

Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.

Genetic insights into the risk of snoring on stroke and ischemic stroke: A single-variable and multivariable Mendelian randomization

Background

Multiple risk factors of stroke have been identified in previous studies; however, the causal role of snoring in the onset of stroke is less investigated. To clarify the causal association of snoring on stroke and its subtypes, this study is performed.

Methods

The single nucleotide polymorphisms in relation to snoring were retrieved from the UK biobank cohort with 408,317 participants. The data for stroke and its subtypes of European ancestry (67,162 cases and 453,702 controls) were obtained from the MEGASTROKE consortium. In single-variable Mendelian randomization (SVMR) and multivariable MR (MVMR) analyses, inverse variance weighting was used as the primary estimate, complemented with sensitivity analyses more robust to pleiotropy.

Results

Genetically predicted snoring increased the risk of stroke (odds ratio [OR] = 2.69, 95% confidence interval [CI] = 1.19-6.08, P = 0.016) and ischemic stroke (IS) (OR = 2.82, 95% CI = 1.23-6.44, P = 0.013), but not large artery stroke (LAS) (OR = 3.02, 95% CI = 0.31-29.44, P = 0.339), cardioembolic stroke (CES) (OR = 1.51, 95% CI = 0.58-3.92, P = 0.395). We provide novel genetic evidence that snoring increases the risk of stroke and IS, but not LAS, CES, and SVS.

Conclusion

Our findings provide novel genetic evidence that snoring increases the risk of stroke and IS, but not LAS, CES, and SVS.

Correlations between objective and subjective outcomes after adenotonsillar surgery in children with OSA

Objectives

To investigate whether the OSA-18 questionnaire and a postoperative patient-reported outcome measure (PROM) question correlated with polysomnography (PSG) data.

Methods

A prospective study of otherwise healthy young children with moderate to severe obstructive sleep apnea (OSA) to investigate if the obstructive apnea-hypopnea index (OAHI) before and 6-12 months after adenotonsil surgery correlated with the OSA-18 total symptom score (TSS) and the sleep disturbance subscale (SDS), as well as a PROM question on symptom improvement with responses on a 4-grade Likert scale.

Results

Of 201 children, 173 (86%) had complete data of OAHI and OSA-18 pre- and postoperatively. The mean age was 3.2 years (SD 1.0) and the mean OAHI was 15.9 (11.3). Significant correlations between changes in the OAHI and OSA-18 were found, both TSS (r = 0.29, p < .001) and SDS (r = 0.53, p < .001). A total of 136 (68%) patients responded to the PROM question, the majority of whose symptoms had disappeared (n = 102) or almost disappeared (n = 30). Four patients had unchanged symptoms, and none had worsening symptoms. A correlation was found between the PROM question and a change in the OAHI (r = 0.36, p < .001), as well as a change in the OSA-18 TSS (r = 0.24, p = .006) and the SDS (r = 0.34, p < .001). The specificity of the PROM question for prediction of a postoperative OAHI < 2 was 82%, and the sensitivity was 38%.

Conclusion

Changes in the OAHI significantly correlated with changes in the OSA-18, especially with the sleep disturbance scale, which could be an alternative for evaluation at follow-ups.

Level of Evidence

3.

Sleep-Related Breathing Disorders in Children—Red Flags in Pediatric Care

Objectives: In recent years, we have witnessed a growing interest in pediatric sleep-related breathing disorders (SRBD). Although a Pediatric Sleep Questionnaire (PSQ) exists and was found reliable in screening SRBD in children, many of the children remain underdiagnosed. The aim of the present study was to define anamnestic and clinical findings that can serve as red flags indicating the presence of SRBD in children. Methods: 227 children aged 4–12 years old were evaluated with regard to the following parameters: (i) anamnestic variables (e.g., general state of health, oral habits, bruxism, esophageal reflux, sleep continuity, snoring); (ii) clinical parameters (e.g., oral mucosa, palate, tonsils, tongue, floor of the mouth, angle classification, gingival health, caries risk) and (iii) presence of SRBD (through the PSQ). Results: Significant differences between children with and without SRBD were observed regarding continuous sleep, developmental delay, mouth breathing, and snoring. Taking medications for ADHD increased the odds of SRBD in children by over seven times, non-continuous sleep increased the odds of SRBD by six times, mouth breathing increased the odds by almost five times, and snoring increased the odds by over three times. Conclusions: Child caregivers from various fields (dentists, orthodontists, pediatric physicians, school nurses) should actively inquire about disturbed sleep, medications for ADHD, snoring, and mouth breathing among their young patients. Initial screening through a few simple questions may help raise red flags that can assist in the early detection of SRBD in children and lead to proper diagnosis and treatment.

Increased behavioral problems in children with sleep-disordered breathing

Background

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

Methods

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

Results

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

Conclusions

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

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

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

Cognition in pediatric SDB-Yes, no, maybe?

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

Clinical validation of a mandibular movement signal based system for the diagnosis of pediatric sleep apnea

BACKGROUND

Given the high prevalence and risk for outcomes associated with pediatric obstructive sleep apnea (OSA), there is a need for simplified diagnostic approaches. A prospective study in 140 children undergoing in-laboratory polysomnography (PSG) evaluates the accuracy of a recently developed system (Sunrise) to estimate respiratory efforts by monitoring sleep mandibular movements (MM) for the diagnosis of OSA (Sunrise™).

METHODS

Diagnosis and severity were defined by an obstructive apnea/hypopnea index (OAHI) ≥ 1 (mild), ≥ 5 (moderate), and ≥ 10 events/h (severe). Agreement between PSG and Sunrise™ was assessed by Bland-Altman method comparing respiratory disturbances hourly index (RDI) (obstructive apneas, hypopneas, and respiratory effort-related arousals) during PSG (PSG_RDI), and Sunrise RDI (Sr_RDI). Performance of Sr_RDI was determined via ROC curves evaluating the device sensitivity and specificity at PSG_OAHI ≥ 1, 5, and 15 events/h.

RESULTS

A median difference of 1.57 events/h, 95% confidence interval: -2.49 to 8.11 was found between Sr_RDI and PSG_RDI. Areas under the ROC curves of Sr_RDI were 0.75 (interquartile range [IQR]: 0.72-0.78), 0.90 (IQR: 0.86-0.92) and 0.95 (IQR: 0.90-0.99) for detecting children with PSG_OAHI ≥ 1, PSG_OAHI ≥ 5, or PSG_ OAHI ≥ 10, respectively.

CONCLUSION

MM automated analysis shows significant promise to diagnose moderate-to-severe pediatric OSA.

Safety and long-term efficacy of tonsillectomy versus subtotal tonsillectomy in children with sleep disordered breathing

OBJECTIVES

to compare safety and long-term symptoms after TE compared to Subtotal Tonsillectomy (STT).

METHODS

A retrospective review data of 412 patients, one to twelve years old that underwent either TE or STT, as treatment for sleep disorder breathing, at two different medical centers. Symptoms were assessed by a questionnaire 3-5 years post-surgery. Additionally, data regarding immediate post-operative symptoms and complications were also collected.

RESULTS

Long-term symptoms score was significantly lower in the TE group: 1.585 (±1.719) compared to 1.967 (±1.815) in the STT group (p = 0.033); 51.3% of patients in the ST group presented long-term SDB symptoms, compared to 40.6% in the TE group (p = 0.035); The main difference between the groups was snoring as 49% of the STT group suffered from snoring, versus 28.9% in the TE group (p < 0.001).

CONCLUSIONS

TE showed an advantage over STT in resolving snoring in the long term.

The Impact of Preterm Birth on Sleep through Infancy, Childhood and Adolescence and Its Implications

There is emergent literature on the relationship between the development of sleep-wake cycles, sleep architecture, and sleep duration during the neonatal period on neurodevelopmental outcomes among children born preterm. There is also a growing literature on techniques to assess sleep staging in preterm neonates using either EEG methods or heart and respiration rate. Upon discharge from hospital, sleep in children born preterm has been assessed using parent report, actigraphy, and polysomnography. This review describes the ontogeny and measurement of sleep in the neonatal period, the current evidence on the impact of preterm birth on sleep both in the NICU and in childhood and adolescence, and the interaction between sleep, cognition, and social-emotional outcomes in this population.

Effects of a novel oral appliance on snoring in adults: A pilot study

AbstractBackground/purpose

Oral appliances (OAs) have been recommended as alternatives for adult patients with obstructive sleep apnea who are intolerant of continuous positive airway pressure therapy. The aim of this study was to explore the effect on snoring rates among adult patients through use of a novel OA termed the Lin OA (LOA, airflow-interference-type nasal congestion relieving and snore-ceasing oral appliance).

Materials and methods

The LOA consist of two parts: dental braces and a fixed tongue compressor. The compressor lengths range from 0.5 cm to 3.5 cm across versions. Patients used the LOA during sleep and the SnoreClock smartphone application recorded their snoring rates.

Results

A total of 4920 recordings (4239 recordings from 34 men, 681 recordings from 8 women) were used for the analysis. The recordings were sorted in accordance with the applied length of the LOA tongue compressor (0.5–3.5 cm, LOA-0.5, LOA-1 and LOA-3.5), and participants not using the LOA were denoted as the LOA-0 group. The women had higher snoring rates in the LOA-0, LOA-0.5 to LOA-2 groups, but lower snoring rates in the LOA-3 group than men by the univariate analysis. The snoring rates were significantly reduced by a mean of 5.04% with every 1 cm increase in tongue compressor length. Continuous LOA use resulted in snoring rate reductions of 0.02% per day by the random intercept model of the linear regression.

Conclusion

Use of this novel LOA may significantly reduce snoring rates by 5.04% with each 1 cm increase in tongue compressor length.

Alternatives to surgery in children with mild OSA

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.

Disturbed sleep in children born extremely preterm is associated with behavioural and emotional symptoms

AIM

To determine whether children born extremely preterm are at increased risk for sleep disturbances and to explore relationships between extremely preterm birth, sleep and attention-deficit/hyperactivity disorder (ADHD) symptoms and emotional symptoms.

METHOD

EPICure2 cohort study. Parents of 165 children born ≤26 weeks' gestation (53% male) and 121 children born at term (43% male) completed the Children's Sleep Habits Questionnaire, sleep disordered breathing subscale of the Pediatric Sleep Questionnaire, the emotional problems scale of the Strengths and Difficulties Questionnaire and the ADHD Rating Scale-5 at 11 years of age.

RESULTS

Extremely preterm children had greater habitual snoring (adjusted odds ratio 6.8; 95% confidence interval 2.3, 20.3), less frequently fell asleep within 20 minutes (Cohen's d 0.33), higher night wakings (d 0.44) and daytime sleepiness scores (d 0.40) than term-born children; there was no between-group difference in sleep duration scores. Among children without severe disability, night wakings scores partially mediated the relationship between preterm birth and inattention (additional 5% of variance explained), hyperactivity/impulsivity (13%) and emotional problems (9%). Snoring partially mediated the relationship between preterm birth, hyperactivity/impulsivity and inattention (additional 1-5% of variance).

CONCLUSION

Children born extremely preterm are at increased risk of disturbed sleep compared to term-born children. As night wakings partially mediated the relationship between preterm birth and ADHD symptoms and emotional problems, reducing sleep disturbance may improve sleep and reduce attention and emotional problems in this population.

Sleep-Related Breathing Problem Trajectories Across Early Childhood and Academic Achievement-Related Performance at Age Eight

Background: Childhood sleep disordered breathing (SDB) has been linked to poorer academic performance; however, research has not investigated the extent improvement in SDB may alter outcomes across key academic skills. This study aimed to investigate if children's early SDB status could predict later academic outcomes, and if an improvement in SDB status across the early childhood years would coincide with better, later performance in key academic skills related to reading, numeracy, and listening comprehension.

Methods: Eighty five case children with an SDB symptom score >25 (maximum 77) were matched to 85 control children (score <12) at recruitment (age 3). SDB severity (symptom history and clinical assessment) was evaluated at ages 3, 4, 6, and 8 years and performance on individually-administered academic skills assessed at age 8 (91% retention from age 3). Case children were categorized into “improved” or “not-improved” groups based on SDB trajectories over the 5 years. Contributions of SDB status and trajectory group to academic performance were determined using regression analysis adjusted for demographic variables.

Results: History of SDB from age 3 predicted significantly poorer performance on some key academic skills (oral reading and listening skills) at age 8. Children whose SDB improved (45%) performed better in oral reading fluency than those whose SDB did not improve, but difficulties with specific tasks involving oral language (listening retell) remained when compared to controls.

Conclusion: Findings support links between early SDB and worse academic outcomes and suggest key academic areas of concern around oral language. Findings highlight the need for child mental health professionals to be aware of children's sleep problems, particularly SDB (past and present), when assessing potential barriers to children's achievement, to assist with appropriate and timely referrals for evaluation of children's sleep difficulties and collaborative evaluation of response to intervention for sleep difficulties.

Snoring and environmental exposure: results from the Swedish GA2LEN study

OBJECTIVE

Habitual snoring is associated with fatigue, headaches and low work performance. This cross-sectional study aimed to investigate if snoring is affected by environmental factors such as home dampness and exposure to air pollution.

SETTING

General population sample from four Swedish cities.

PARTICIPANTS

25 848 participants from the Swedish part of the epidemiological Global Asthma and Allergy and European network of excellence study carried out in 2008. The participants completed a postal questionnaire on snoring and, indoor and outdoor environmental exposure as well as potential confounders including smoking, weight, height and educational level.

RESULTS

Of the participants, 4211 (16.3%) were habitual snorers. Habitual snorers reported water damage (8.3% vs 7.0% p<0.0001), floor dampness (4.6% vs 3.8% % p<0.0001) and visible mould (5.2% vs 3.8% p<0.0001) in their homes more often than non-snorers. Habitual snorers stated being annoyed by air pollution more often than non-snorers with habitual snorers reporting being irritated with the air in their residential area to a higher extent (sometimes 16.2% vs 13.9%, and daily 4.6% vs 3.1%) as well as annoyance from traffic fumes (somewhat 19% vs 18.5% and very 5% vs 3.6%) (p<0.0001). These results remained significant after adjustment for age, body mass index, smoking history and educational level.

CONCLUSION

Snoring is more prevalent in subjects reporting home dampness and air pollution. These association should be confirmed in further research using objective measurements and a longitudinal approach.

Racial and Ethnic Disparities in Utilization of Tonsillectomy among Medicaid-Insured Children

OBJECTIVE

To examine racial differences in tonsillectomy with or without adenoidectomy (T&A) for sleep-disordered breathing (SDB) among Medicaid-insured children.

STUDY DESIGN

Retrospective analysis of the 2016 MarketScan Multistate Medicaid Database was performed for children ages 2 to <18 years with a diagnosis of SDB. Patients with medical complexity and infectious indications for surgery were excluded. Racial groups were categorized into non-Hispanic White, non-Hispanic Black, Hispanic, and other. Adjusted multivariate logistic regression was used to determine if race/ethnicity was a significant predictor of obtaining T&A, polysomnography, and time to intervention.

RESULTS

There were 83 613 patients with a diagnosis of SDB that met inclusion criteria, of which 49.2% were female with a mean age of 7.9 ± 3.8 years. The cohort consisted of White (49.2%), Black (30.0%), Hispanic (8.0%), and other (13.2%) groups. Overall, 15.4% underwent T&A. Black (82.2%) and Hispanic (82.3%) children had significantly higher rates of no intervention and White patients had the lowest rate of no intervention (76.9%; P < .0001) and the highest rate of T&A (18.7%; P < .0001). Mean time to surgery was shortest in White compared with Black children (P < .0001). Logistic regression adjusting for age and sex showed that Black children had 45% reduced odds of surgery (95% CI 0.53-0.58), Hispanic 38% (95% CI 0.58-0.68), and other 35% (95% CI 0.61-0.70) compared with White children with Medicaid insurance.

CONCLUSIONS

Racial and ethnic disparities exist in the utilization of T&A for children with SDB enrolled in Medicaid. Future studies that investigate possible sources for these differences and more equitable care are warranted.

Predictors of Behavioral Changes After Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial

Importance

Adenotonsillectomy (AT) is associated with improved behavior in children with obstructive sleep apnea (OSA). However, it is unknown whether polysomnographic parameters are superior to the parent-reported severity of sleep-disordered breathing (SDB) in predicting behavioral changes after AT.

Objective

To ascertain whether polysomnographic parameters vs parent-reported severity of SDB are better predictors of treatment-related behavioral changes in children with OSA.

Design, Setting, and Participants

This ad hoc secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) downloaded and analyzed data from January 1 to January 31, 2020. Children aged 5 to 9 years with a polysomnographic diagnosis of OSA were enrolled in the CHAT and subsequently randomized to undergo either early AT or watchful waiting with supportive care. All outcome measures were obtained at baseline and at follow-up (7 months after randomization).

Interventions

Early AT vs watchful waiting with supportive care.

Main Outcomes and Measures

Postrandomization changes between the baseline and follow-up periods were derived from (1) T scores in 4 validated behavioral assessments (Conners Global Index parent and teacher versions, Behavior Rating Inventory of Executive Function metacognition index, and Child Behavior Checklist of total, internalizing, and externalizing behavior subscales); (2) 8 aggregated polysomnographic parameters representing the severity of obstruction, hypoxemia, sleep quality, and structure; and (3) the parent-reported severity of SDB measured by the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (PSQ-SRBD) scale. The treatment-related changes in each of the behavioral outcomes attributable to changes in SDB severity (represented by the subjective PSQ-SRBD score and objective polysomnographic parameters) were measured and compared using mediation analysis.

Results

A total of 453 children were assessed at baseline, of whom 234 were girls (52%) and the mean (SD) age was 6.6 (1.4) years. The postrandomization changes in 7 of 8 behavioral outcome measures between the baseline and follow-up periods were partially mediated by the changes in PSQ-SRBD scores (range of nonzero causally mediated effects, 2.4-3.5), without contribution from any of the polysomnographic parameters.

Conclusions and Relevance

This secondary analysis of a national randomized clinical trial found that most treatment-related behavioral changes in children with OSA were mediated by the changes in parent-reported SDB severity alone. These findings suggest that polysomnographic parameters provide clinicians with limited means to predict the improvement in neurobehavioral morbidity in OSA.

Trial Registration

ClinicalTrials.gov Identifier: NCT00560859.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions

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

Associations between frontal lobe structure, parent-reported obstructive sleep disordered breathing and childhood behavior in the ABCD dataset

Parents frequently report behavioral problems among children who snore. Our understanding of the relationship between symptoms of obstructive sleep disordered breathing (oSDB) and childhood behavioral problems associated with brain structural alterations is limited. Here, we examine the associations between oSDB symptoms, behavioral measures such as inattention, and brain morphometry in the Adolescent Brain Cognitive Development (ABCD) study comprising 10,140 preadolescents. We observe that parent-reported symptoms of oSDB are associated with composite and domain-specific problem behaviors measured by parent responses to the Child Behavior Checklist. Alterations of brain structure demonstrating the strongest negative associations with oSDB symptoms are within the frontal lobe. The relationships between oSDB symptoms and behavioral measures are mediated by significantly smaller volumes of multiple frontal lobe regions. These results provide population-level evidence for an association between regional structural alterations in cortical gray matter and problem behaviors reported in children with oSDB.

Increased Platelet Aggregation in Children and Adolescents with Sleep-disordered Breathing

Rationale: Sleep-disordered breathing (SDB) is associated with increased vascular resistance in children and adults. Persistent increased vascular resistance damages vascular endothelial cells-a marker of which is increased platelet activation.Objectives: This study compared whole-blood impedance platelet aggregation in children with clinically diagnosed SDB warranting adenotonsillectomy and healthy control subjects.Methods: Thirty children who had SDB warranting intervention clinically diagnosed by experienced pediatric otolaryngologists were recruited from adenotonsillectomy waitlists, and 20 healthy children from the community underwent overnight polysomnography to determine SDB severity (obstructive apnea-hypopnea index). Snoring frequency was collected from parents. In the morning, a fasting blood sample was taken, and whole-blood platelet aggregation was measured.Measurements and Main Results: Children with SDB exhibited increased platelet aggregation to TRAP (thrombin receptor-activating peptide) (children with SDB = 114.8 aggregation units [AU] vs. control subjects = 98.0 AU; P < 0.05) and COL antibody (96.7 vs. 82.2 AU; P < 0.05) and an increased trend in ADP antibody (82.3 vs. 69.2 AU; P < 0.07) but not aspirin dialuminate (82.1 vs. 79.5 AU; P > 0.05). No significant association was observed between either the obstructive apnea-hypopnea index and any aggregation parameter, but parental report of snoring was positively associated with TRAP aggregation (Kendall's τ-c = 0.23; P < 0.05).Conclusions: The finding of increased platelet aggregation is consistent with endothelial damage. This suggests that the profile of cardiovascular changes noted in adults with SDB may also occur in children with SDB.

Associations among High Risk for Sleep-disordered Breathing, Related Risk Factors, and Attention Deficit/Hyperactivity Symptoms in Elementary School Children

Objective

: Habitual snoring is a common problem in children. We evaluated the association between a high risk for sleep-disordered breathing and attention deficit/hyperactivity symptoms.

Methods

Parents of 13,560 children aged 6 to 12 years responded to questionnaires including items on habitual snoring and the Korean attention deficit/hyperactivity disorder rating scale. The snoring score comprised the number of "yes" responses to habitual-snoring items, and a high risk for sleep-disordered breathing was defined as a snoring score ≥ 2.

Results

The odds ratio (OR) of a high risk for sleep-disordered breathing was significantly higher in boys (OR = 1.47; p < 0.001), overweight children (OR = 2.20; p < 0.001), and children with current secondhand-smoking exposure (OR = 1.38; p < 0.001). The Korean attention deficit/hyperactivity disorder rating scale score increased significantly with the snoring score (0 vs. 1, B = 1.56, p < 0.001; 0 vs. 2, B = 2.44, p < 0.001; 0 vs. 3, B = 2.48, p < 0.001; 0 vs. 4, B = 3.95; p < 0.001).

Conclusion

Our study confirms several risk factors of sleep-disordered breathing, namely male sex, overweight, and exposure to tobacco smoking, and found a positive association between habitual snoring and attention deficit/hyperactivity symptoms.

Sleep characteristics and problems of 2-year-olds with Williams syndrome: relations with language and behavior

Background

Sleep problems have been shown to have a negative impact on language development and behavior for both typically developing children and children with a range of neurodevelopmental disorders. The relation of sleep characteristics and problems to language and behavior for children with Williams syndrome (WS) is unclear. The goal of this study was to address these relations for 2-year-olds with WS. Associations of nonverbal reasoning ability, nighttime sleep duration, and excessive daytime sleepiness with language ability and behavior problems were considered.

Method

Ninety-six 2-year-olds with genetically confirmed classic-length WS deletions participated. Parents completed the Pediatric Sleep Questionnaire, which includes a Sleep-Related Breathing Disorder (SRBD) scale with a subscale measuring excessive daytime sleepiness, to assess sleep characteristics and problems. Parents also completed the Child Behavior Checklist (CBCL) and the MacArthur-Bates Communicative Development Inventory: Words and Sentences to assess behavior problems and expressive vocabulary, respectively. Children completed the Mullen Scales of Early Learning to measure nonverbal reasoning and language abilities.

Results

Parents indicated that children slept an average of 10.36 h per night (SD = 1.09, range 7.3–13.3), not differing significantly from the mean reported by Bell and Zimmerman (2010) for typically developing toddlers (p = .787). Sixteen percent of participants screened positive for SRBD and 30% for excessive daytime sleepiness. Children who screened positive for SRBD had significantly more behavior problems on all CBCL scales than children who screened negative. Children with excessive daytime sleepiness had significantly more attention/hyperactivity, stress, and externalizing problems than those who did not have daytime sleepiness. Individual differences in parent-reported nighttime sleep duration and directly measured nonverbal reasoning abilities accounted for unique variance in expressive language, receptive language, and internalizing problems. Individual differences in parent-reported daytime sleepiness accounted for unique variance in externalizing problems.

Conclusions

The relations of nighttime sleep duration, positive screens for SRBD, and excessive daytime sleepiness to language and behavior in toddlers with WS parallel prior findings for typically developing toddlers. These results highlight the importance of screening young children with WS for sleep problems. Studies investigating the efficacy of behavioral strategies for improving sleep in children with WS are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11689-020-09336-z.

Is cellular energy monitoring more responsive to hypoxia than pulse oximetry?

Purpose

Pulse oximetry is the current standard for detecting drops in arterial blood oxygen saturation (SpO₂) associated with obstructive sleep apnea and hypopnea events in polysomnographic (PSG) testing. However, cellular energy monitoring (CE monitoring), a measure related to cellular hypoxia in the skin, is likely to be more responsive to inadequate breathing during sleep because during hypoxic challenge, such as occurs during apneic events, regulatory mechanisms restrict blood flow to the skin to preferentially maintain SpO₂ for more vital organs. We carried out initial proof of concept testing to determine if CE monitoring has promise for being more responsive to hypoxic challenge occurring during sleep-disordered breathing (SDB) than pulse oximetry.

Methods

We assessed both CE monitoring and pulse oximetry in a series of conditions which affect oxygen supply: (1) breathing nitrogen or 100% oxygen, (2) physical exertion, and (3) studying a night of sleep in an individual known to be a loud snorer. We also present the results of a preliminary study comparing CE monitoring to pulse oximetry in eight individuals undergoing standard clinical overnight polysomnography for suspected SDB.

Results

CE monitoring is responsive to changes in cellular oxygen supply to the skin and detects hypoxia during SDB events that is not detected by pulse oximetry.

Conclusion

CE monitoring is a promising tool for identifying pathology at the mild end of the SDB spectrum.

Neurobehavioral Outcomes in School-Aged Children with Primary Snoring

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Severe obstructive sleep apnea in patients with chronic obstructive pulmonary disease is associated with an increased prevalence of mild cognitive impairment

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are associated with mild cognitive impairment (MCI). However, this association is unclear. This study aimed to assess the prevalence of MCI in patients with overlap syndrome, determine whether OSA increases the risk of MCI in patients with COPD, and investigate the potential mechanisms for this association.

METHODS

Participants with stable Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 COPD and complaints of snoring in 2016-2018 were enrolled in this cross-sectional observational study. All were free of asthma, acute left-sided congestive heart failure, unstable coronary heart disease, uncontrolled hypertension, diabetes, encephalitis, and epilepsy. They underwent pulmonary function tests and overnight polysomnography and completed the Montreal Cognitive Assessment (MoCA). MCI was defined by an MoCA score of <23, while OSA was defined by an apnea-hypopnea index (AHI) of ≥15 per hour. The association between MCI, demographics, and comorbidities was tested by logistic regression analysis with adjustment for confounders. Sleep-disordered breathing measures were investigated as potential mechanisms underlying this relationship.

RESULTS

MCI was significantly more common in patients with overlap syndrome than in those with COPD (40.6% [43/106] vs 24.6% [42/171]). After adjustment, severe OSA was an independent contributor to MCI (odds ratio, OR 2.27; 95% confidence interval, CI 1.12-4.62). Increased percent of night-time spent with oxygen saturation <90% (TSat₉₀) was associated with increased odds of MCI (odds ratio 4.75, 95% CI 2.73-11.13).

CONCLUSIONS

MCI is more prevalent in overlap syndrome than in COPD. OSA may contribute to MCI in COPD. The mechanism may involve TSat₉₀.

Association of sleep spindle activity and sleepiness in children with sleep-disordered breathing

STUDY OBJECTIVES

The association of snoring and sleep-disordered breathing (SDB) with daytime sleepiness is well documented; however, the exact mechanisms, and especially the role of sleep microstructure that may account for this association remain incompletely understood. In a cohort of children with SDB, we aimed to compare sleep spindle activity between children with daytime sleepiness versus those without daytime sleepiness.

METHODS

Children with SDB who reported daytime sleepiness were recruited and compared with age- and sex-matched SDB controls. Polysomnographic recordings were analyzed evaluating sleep spindle activity. A statistical comparison was carried out in both groups to assess the association between sleepiness and sleep spindle activity.

RESULTS

Thirty-three children with SDB (mean age: 7.5 ± 1.7 years) were included, 10 with and 23 without daytime sleepiness. Spindle activity was lower in children with daytime sleepiness compared with those without; in stage N2, median (interquartile range) sleep spindle indexes were 77.5 (37.3) and 116.9 (71.2) (P = .015), respectively.

CONCLUSIONS

Spindles were significantly reduced in children with SDB and daytime sleepiness. The exact mechanisms of this association remain unknown and future research is needed in order to establish the exact role of sleep spindle activity on daytime symptoms in children with SDB.

Cognition After Early Tonsillectomy for Mild OSA

OBJECTIVES

It remains uncertain whether treatment with adenotonsillectomy for obstructive sleep apnea in children improves cognitive function. The Preschool Obstructive Sleep Apnea Tonsillectomy and Adenoidectomy study was a prospective randomized controlled study in which researchers evaluated outcomes 12 months after adenotonsillectomy compared with no surgery in preschool children symptomatic for obstructive sleep apnea.

METHODS

A total of 190 children (age 3-5 years) were randomly assigned to early adenotonsillectomy (within 2 months) or to routine wait lists (12-month wait, no adenotonsillectomy [NoAT]). Baseline and 12-month assessments included cognitive and behavioral testing, medical assessment, polysomnography, and audiology. The primary outcome was global IQ at 12-month follow-up, measured by the Woodcock Johnson III Brief Intellectual Ability (BIA). Questionnaires included the Pediatric Sleep Questionnaire, Parent Rating Scale of the Behavioral Assessment System for Children-II, and Behavior Rating Inventory of Executive Function, Preschool Version.

RESULTS

A total of 141 children (75.8%) attended baseline and 12-month assessments, and BIA was obtained at baseline and 12-month follow-up for 61 and 60 participants in the adenotonsillectomy versus NoAT groups, respectively. No cognitive gain was found after adenotonsillectomy compared with NoAT, adjusted for baseline; BIA scores at 12-month follow-up were as follows: adenotonsillectomy, 465.46 (17.9) versus NoAT, 463.12 (16.6) (mean [SD]). Improvements were seen for polysomnogram arousals and apnea indices and for parent reports of symptoms (Pediatric Sleep Questionnaire), behavior (Behavior Assessment System for Children behavioral symptoms, P = .04), overall health, and daytime napping.

CONCLUSIONS

Structured testing showed no treatment-attributable improvement in cognitive functioning of preschool children 12 months after adenotonsillectomy compared with NoAT. Improvements were seen after adenotonsillectomy in sleep and behavior by using polysomnogram monitoring and parental questionnaires.

Snoring and stertor are associated with more sleep disturbance than apneas and hypopneas in pediatric SDB

PURPOSE

Polysomnography is not recommended for children at home and does not adequately capture partial upper airway obstruction (snoring and stertor), the dominant pathology in pediatric sleep-disordered breathing. New methods are required for assessment. Aims were to assess sleep disruption linked to partial upper airway obstruction and to evaluate unattended Sonomat use in a large group of children at home.

METHODS

Children with suspected obstructive sleep apnea (OSA) had a single home-based Sonomat recording (n = 231). Quantification of breath sound recordings allowed identification of snoring, stertor, and apneas/hypopneas. Movement signals were used to measure quiescent (sleep) time and sleep disruption.

RESULTS

Successful recordings occurred in 213 (92%) and 113 (53%) had no OSA whereas only 11 (5%) had no partial obstruction. Snore/stertor occurred more frequently (15.3 [5.4, 30.1] events/h) and for a longer total duration (69.9 min [15.7, 140.9]) than obstructive/mixed apneas and hypopneas (0.8 [0.0, 4.7] events/h, 1.2 min [0.0, 8.5]); both p < 0.0001. Many non-OSA children had more partial obstruction than those with OSA. Most intervals between snore and stertor runs were < 60 s (79% and 61% respectively), indicating that they occur in clusters. Of 14,145 respiratory-induced movement arousals, 70% were preceded by runs of snore/stertor with the remainder associated with apneas/hypopneas.

CONCLUSIONS

Runs of snoring and stertor occur much more frequently than obstructive apneas/hypopneas and are associated with a greater degree of sleep disruption. Children with and without OSA are frequently indistinguishable regarding the amount, frequency, and the degree of sleep disturbance caused by snoring and stertor.

Reduced sleep spindle activity in children with primary snoring

BACKGROUND

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence and clinical impact of snoring in older community-dwelling adults

AIM

The prevalence and clinical impact of snoring in the independent older adult population is unknown. To address this, we carried out this cross-sectional epidemiological study of community-dwelling independent older adults.

METHODS

The study data were collected by the Japan Gerontological Evaluation Study 2013, a postal survey distributed to a large cohort of independent community-dwelling older adults (aged ≥65 years) in 2013, across 30 municipalities of 14 prefectures. We used data for 24 837 participants (13 135 women, mean age 73.5 years, and 11 702 men, mean age 73.3 years). The association of snoring with airway symptoms and history of hypertension, diabetes and heart disease were investigated using Poisson regression models.

RESULTS

The prevalence ratio (95% confidence intervals) for wheezing according to snoring frequency in men was 1.87 (1.45-2.43) among those who snored on 1-6 nights a week, and 2.95 (2.15-4.05) among those who snored every night. Similar relationships were observed for women. Expectoration, another airway symptom, was also associated with snoring frequency. Furthermore, snoring frequency was associated with a higher prevalence of hypertension, diabetes and heart disease. Both diabetes and heart disease were associated with snoring frequency in women independent of body mass index, but the association was only observed in men with a normal or lower body mass index.

CONCLUSIONS

Snoring is a highly prevalent and pathogenic symptom in adults aged ≥65 years. Geriatr Gerontol Int 2019; 19: 1165-1171.

A Deep Learning Model for Snoring Detection and Vibration Notification Using a Smart Wearable Gadget

Snoring, a form of sleep-disordered breathing, interferes with sleep quality and quantity, both for the person who snores and often for the person who sleeps with the snorer. Poor sleep caused by snoring can create significant physical, mental, and economic problems. A simple and natural solution for snoring is to sleep on the side, instead of sleeping on the back. In this project, a deep learning model for snoring detection is developed and the model is transferred to an embedded system—referred to as the listener module—to automatically detect snoring. A novel wearable gadget is developed to apply a vibration notification on the upper arm until the snorer sleeps on the side. The gadget is rechargeable, and it is wirelessly connected to the listener module using low energy Bluetooth. A smartphone app—connected to the listener module using home Wi-Fi—is developed to log the snoring events with timestamps, and the data can be transferred to a physician for treating and monitoring diseases such as sleep apnea. The snoring detection deep learning model has an accuracy of 96%. A prototype system consisting of the listener module, the wearable gadget, and a smartphone app has been developed and tested successfully.

Correlations between obstructive sleep apnea and adenotonsillar hypertrophy in children of different weight status

The present study aimed to evaluate the relationship between OSA and adenotonsillar size in children of different weight status. A total of 451 patients aged 2–13 years with suspected OSA were retrospectively enrolled in the study. Correlations between the apnea-hypopnea index (AHI) and adenotonsillar size in different weight status were investigated. The adenoidal/nasopharyngeal (A/N) ratio of underweight children was significantly higher than that of normal-weight children (P = 0.027). Both adenoid and tonsil size were positively correlated with logAHI in children of normal weight (r = 0.210, P = 0.001; and r = 0.212, P = 0.001) but uncorrelated in the other groups. Gender (OR = 1.49, 95% CI: 1.01–2.20, P = 0.043), obese (OR = 1.93, 95% CI: 1.10–3.40, P = 0.012), A/N ratio (OR = 1.55, 95% CI: 1.28–1.88, P < 0.001) and tonsil size (OR = 1.36, 95% CI: 1.18–1.57, P < 0.001) were all associated with the severity of OSA. Adenotonsillar hypertrophy contributed to OSA in normal-weight children. In children of abnormal weight, instead of treatment for adenotonsillar hypertrophy, appropriate treatments for other factors are required.

Related biomarkers of neurocognitive impairment in children with obstructive sleep apnea

OBJECTIVES

Different experiment approaches have demonstrated that children with obstructive sleep apnea (OSA) exhibit neurocognitive and behavioral deficits. This review summarized the potential biomarkers of OSA-associated neurocognitive impairment in children.

METHODS

A scoping review of studies on children with OSA that evaluated the potential value of different markers in identifying neurocognitive impairment was undertaken. Additionally, the biomarkers were categorized according to the different research methods, including brain imaging studies, serological indicators and urine markers.

RESULTS

Majority of the studies that evaluated blood biomarkers, plasma insulin growth factor-1 (IGF-1) and Alzheimer's disease (AD)-related biomarkers appeared to exhibit a favorable profile, and could discriminate between OSA children with or without neurocognitive impairments. Brain imaging studies and urinary neurotransmitters could also be helpful for screening OSA cognitive morbidity in children.

CONCLUSION

Due to limited research methods available in children, the cognitive susceptibility of children with OSA has been rarely studied. The main reason for this may be the limited research methods in children. Numerous study populations of children and complex psychological tests are required, which involve major labor and costs.Multi-center prospective studies are needed to identify suitable biomarkers for the timely prediction and effective intervention to prevent neurocognitive impairment in children with OSA and to explore further opportunities in this arena.

Nocturnal enuresis and sleep disordered breathing in primary school children: Potential implications

INTRODUCTION

The association between nocturnal enuresis (NE) and sleep disordered breathing (SDB) has been repeatedly reported, but has primarily been focused on clinical cohorts. The purpose of this study, was to assess whether SDB-related symptoms such as snoring and unrefreshing sleep in the morning are associated with NE in a large-scale community school-based survey.

METHODS

A cross-sectional assessment using a standard questionnaire was conducted on nearly 20 000 primary school children (5-12 years old) in Matsuyama, Japan. Associations between NE and the frequencies of snoring and unrefreshing sleep were evaluated using multivariate logistic and regression analyses.

RESULTS

Multivariate adjusted odds ratios (95% confidence intervals) for enuresis were 1.21 (1.04 to 1.40) and 1.36 (1.07 to 1.73) in boys who snored 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Those for enuresis were 1.67 (1.41 to 1.99) and 1.96 (1.63 to 2.36) in boys who showed unrefreshing sleep 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Significant associations between NE and snoring frequency emerged among children who did not report unrefreshing sleep (P-trend for boys and girls were <0.0001 and <0.01, respectively), while significant associations between NE and frequency of unrefreshing sleep were detected among children who snored ≥1 nights per week (P for trend >0.1).

CONCLUSIONS

The pathogenic mechanisms linking snoring and unrefreshing sleep to increased risk of NE are unknown. However, snoring, a surrogate reporter of SDB, is associated with increased urine production, while unrefreshing sleep may result from disrupted sleep facilitating increased sleep pressure and elevated arousal thresholds. Thus, both SDB and unrefreshing sleep are potential independent risk factors of NE in school age children.

Altered Regional Brain Cortical Thickness in Pediatric Obstructive Sleep Apnea

Rationale

Obstructive sleep apnea (OSA) affects 2–5% of all children and is associated with cognitive and behavioral deficits, resulting in poor school performance. These psychological deficits may arise from brain injury, as seen in preliminary findings of lower gray matter volume among pediatric OSA patients. However, the psychological deficits in OSA are closely related to functions in the cortex, and such brain areas have not been specifically assessed. The objective was to determine whether cortical thickness, a marker of possible brain injury, is altered in children with OSA.

Methods

We examined regional brain cortical thicknesses using high-resolution T1-weighted magnetic resonance images in 16 pediatric OSA patients (8 males; mean age ± SD = 8.4 ± 1.2 years; mean apnea/hypopnea index ± SD = 11 ± 6 events/h) and 138 controls (8.3 ± 1.1 years; 62 male; 138 subjects from the NIH Pediatric MRI database) to identify cortical thickness differences in pediatric OSA subjects.

Results

Cortical thinning occurred in multiple regions including the superior frontal, ventral medial prefrontal, and superior parietal cortices. The left side showed greater thinning in the superior frontal cortex. Cortical thickening was observed in bilateral precentral gyrus, mid-to-posterior insular cortices, and left central gyrus, as well as right anterior insula cortex.

Conclusion

Changes in cortical thickness are present in children with OSA and likely indicate disruption to neural developmental processes, including maturational patterns of cortical volume increases and synaptic pruning. Regions with thicker cortices may reflect inflammation or astrocyte activation. Both the thinning and thickening associated with OSA in children may contribute to the cognitive and behavioral dysfunction frequently found in the condition.

Sleep disorders in patients with ADHD: impact and management challenges

Attention deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders in childhood, enduring through adolescence and adulthood and presenting with symptoms of inattention, hyperactivity, and/or impulsivity and significantly impairing functioning. Primary sleep disorders such as sleep-disordered breathing, restless leg syndrome, circadian rhythm sleep disorder, insomnia, and narcolepsy are commonly comorbid in these individuals but not often assessed and are therefore often left untreated. Sleep disturbances in individuals with ADHD can result in significant functional impairments that affect mood, attention, behavior, and ultimately school/work performance and quality of life. Previous reviews have described findings related to sleep but have neglected to examine potential impacts of these sleep disorders and ADHD on daytime functioning. This review investigates empirical findings pertaining to sleep abnormalities and related cognitive, behavioral, emotional, and physical impairments in individuals with ADHD and comorbid primary sleep disorders across the life span. It discusses implications to management and highlights existing limitations and recommended future directions.

A retrospective analysis on patients at high-risk for obstructive sleep apnea undergoing ear, nose, and throat surgeries

Background

Obstructive sleep apnea (OSA) may be related to episodes of oxygen de‐saturation, hypercapnia, cardiovascular dysfunction, cor‐pulmonale, and pulmonary hypertension. STOP‐BANG is an acronym for eight specific questions used to assess the likelihood of OSA. If the individual exhibits three or more of these indicators, he/she should be considered to be at high risk for OSA complications. Therefore, the decision of proceeding with inpatient versus outpatient ENT surgery still remains controversial. The primary objective of the study was to identify and correlate desaturation (SPO2 <90%) episodes and risk factors.

Methods

We conducted a single‐center retrospective study between October 1, 2011 and August 31, 2014 in order to identify postoperative complications during the first 24 hours that justify postoperative monitoring and hospital admission. A total of 292 subjects were included for data analysis. Patients were divided into two groups based on the number of OSA risk factors: group A with 3–4 risk factors (n = 166), and group B with ≥5 risk factors (n = 126). The following information was collected: demographics, ASA, preoperative STOP‐BANG score, length of surgery, intraoperative complications, opioid consumption, post anesthesia care unit (PACU) and overall length of stay, supplemental oxygen requirement, oxygen desaturation, and postoperative opioid consumption.

Results

No statistically significant difference was found when comparing demographic variables between both groups. All STOP‐BANG variables showed statistical significance. PACU and inpatient variables were similar among both groups, with the exception of length of hospital stay (longer stay in group B when compared to group A [p = 0.003]). Desaturation differences between both groups during PACU were statistically significant (p = 0.008). A post‐hoc analysis showed a 0% incidence of overall desaturation in the group with three STOP‐BANG indicators.

Conclusions

Our retrospective analysis concluded that patients diagnosed with three STOP‐BANG risk factors did not experience postoperative complications and hospital admission was not justified.

Level of Evidence

4

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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