Diagnostic accuracy of screening questionnaires for obstructive sleep apnea in children: A systematic review and meta-analysis

Practices and Perception of Paediatric Obstructive Sleep Apnea Among Orthodontists and Paediatric Dentists in Brazil: A Mixed-Methods Study

OBJECTIVES

To explore orthodontists' (OTs) and paediatric dentists' (PDs) practices and perceptions regarding the screening and management of paediatric obstructive sleep apnea (OSA).

METHODS

This explanatory sequential mixed methods design included OTs and PDs with active clinical practice in Brazil and encompassed a quantitative phase followed by a qualitative phase. In the quantitative phase, a survey assessing OSA screening and management practices was administered to OTs and PDs practicing in Brazil. Information-rich OTs and PDs were interviewed in the qualitative phase. Descriptive statistics and the chi-square test were used to analyse the survey data, while inductive content analysis was applied to the interview data. The results from both phases were integrated and reported narratively.

RESULTS

Three hundred eighty-one OTs and PDs completed the survey, and ten of them were interviewed. Nearly half of OTs and PDs administered sleep questionnaires and demonstrated some knowledge about paediatric OSA signs and symptoms. PDs and OTs primarily offered rapid maxillary expansion and functional mandibular advancement for managing selected children with OSA, with OTs being more frequently involved in this task than PDs. OTs and PDs identified several barriers and expressed the need for support regarding access to reliable screening tools and interprofessional care.

CONCLUSION

Brazilian OTs and PDs were aware of the main signs and symptoms of paediatric OSA and were somewhat involved in offering oral appliance management options. To further define the role of these professionals, increasing support for dental professionals in OSA management and updating existing clinical guidelines is warranted.

Risk of sleep-disordered breathing in orthodontic patients: comparison between children and adolescents

OBJECTIVE

The aim of this study was to assess the risk of sleep-disordered breathing (SDB) in orthodontic patients and to evaluate the influence of sex, age, and orthodontic treatment in a cohort of subjects using the Pediatric Sleep Questionnaire (PSQ) screening tool.

METHODS

Parents of 245 patients aged 5-18 years (11.4 ± 3.3 years) were invited to participate in the study by answering the PSQ, which has 22 questions about snoring, sleepiness, and behavior. The frequency of high and low risk was calculated for the full sample. Multiple logistic regression was used to assess the association among sex, age, orthodontic treatment, rapid maxillary expansion (RME), and body mass index (BMI) with SDB. A significance level of 5% (P < .05) was adopted in all tests.

RESULTS

A high risk of SDB was found in 34.3% of the sample. No sex and BMI difference was found for the risk of SDB. The high risk of SDB was significantly associated with younger ages (OR = 1.889, P = .047), pre-orthodontic treatment phase (OR = 3.754, P = .02), and RME (OR = 4.157, P = .001).

LIMITATIONS

Lack of ear, nose and throat-related medical history.

CONCLUSION

Children showed a 1.8 higher probability of having a high risk of SDB compared with adolescents. Patients before orthodontic treatment and patients submitted to RME showed a high risk of SDB.

An Interdisciplinary Approach: Presentation of the Pediatric Obstructive Sleep Apnea Diagnostic Examination Form (POSADEF)

This report emphasizes the need for interdisciplinary collaboration in diagnosing and treating pediatric obstructive sleep apnea (OSA). OSA, affecting 1% to 4% of children, often results from adenotonsillar hypertrophy, craniofacial disorders, or obesity. While adenotonsillectomy is the primary treatment, about 75% of children, especially those with craniofacial disorders or obesity, continue to experience OSA symptoms post-surgery. To address these cases, several medical fields emphasize the necessity and demand for interdisciplinary collaboration in managing pediatric OSA. Therefore, the authors aimed to develop the Pediatric Obstructive Sleep Apnea Diagnostic Examination Form (POSADEF). This form, based on clinical experience and the literature, captures craniofacial and functional characteristics linked to pediatric OSA. A case study of an eight-year-old girl with OSA, who was unsuccessfully treated with adenotonsillectomy, underlines the importance of the diagnostic examination form. The orthodontic assessment revealed craniofacial disorders and subsequent treatment with maxillary expansion and functional appliance therapy resolved her OSA symptoms. This case demonstrates the value of POSADEF in enabling comprehensive evaluation and treatment across medical disciplines. POSADEF is designed to assist health care professionals in diagnosing craniofacial and orofacial anomalies contributing to pediatric OSA.

Outcome of tonsillotomy in children with obstructive sleep-disordered breathing

OBJECTIVE/BACKGROUND

Most children treated for obstructive sleep disordered breathing (oSDB) are not systematically assessed by polysomnography (PSG) nor by structuredsymptom quantification before surgical treatment. The main objective of this study wasto investigate the effect of adeno-tonsillotomy (ATO) on symptom burden and PSGparameters.

METHODS

Children aged 2-10 years with oSDB were selected for ATO based uponclinical findings according to current standards of care in Denmark. Each childunderwent standardized assessment before and 3 months after surgery, including aPSG, tonsil size assessment, and the Pediatric Sleep Questionnaire -Sleep RelatedBreathing Disorder (PSQ) to quantify symptom burden. Obstructive sleep apnea (OSA)was defined as an obstructive apnea-hypopnea index (oAHI) ≥2/h. Successfultreatment was defined as post-surgery oAHI ≤5/h, and complete cure as oAHI ≤2/h.

RESULTS

Fifty-two children were included. Mean age was 5.0 years (SD ± 1.76). Thirteen children were identified with baseline oAHI <2/h. Significant improvement inOSA severity was observed in children with moderate-to-severe OSA, in whom oAHI decreased from 15.7/h to 2.6/h (p < 0.001). Treatment success was obtained in 85% and cure was obtained in 42% of children. PSQ-score significantly improved from 0.52 (CI 0.47-0.56) to 0.26 (CI 0.21-0.32) (p < 0.001). Baseline OSA severity was notcorrelated to baseline symptom burden nor to symptom relief after ATO. There were noserious adverse events.

CONCLUSIONS

Adeno-tonsillotomy significantly reduced symptom burden in otherwise healthy children with oSDB symptoms. Significant improvement in oAHI was observedonly in children with moderate-to-severe OSA. We recommend combining clinicalevaluation with PSQ and oAHI.

Malocclusions, Sleep Bruxism, and Obstructive Sleep Apnea Risk in Pediatric ADHD Patients: A Prospective Study

OBJECTIVES

Literature presents conflicting results regarding malocclusions, Obstructive Sleep Apnea (OSA) and sleep bruxism in children with ADHD. Aim of this study was to evaluate the prevalence of these parameters.

METHODS

A prospective study was conducted on 40 consecutive ADHD children referred to the Paediatric Dentistry Unit of Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome. All subjects underwent an orthodontic examination and were screened for OSA and sleep bruxism. Data were compared to a sex- and aged-matched control group.

RESULTS

Prevalence of high risk of OSA in children with ADHD was 62.5% compared to 10% in the control group (p < .00001). No differences were found in any of the occlusal variables examined between children with ADHD and controls (p > .05). An increased prevalence of sleep bruxism was observed in ADHD children (40%) compared to controls (7.5%) (p < .001).

CONCLUSIONS

A higher prevalence of OSA risk and probable sleep bruxism were observed in ADHD patients compared with controls. No significant differences were observed in malocclusions d.

Pediatric obstructive sleep apnea diagnosis: leveraging machine learning with linear discriminant analysis

Objective

The objective of this study was to investigate the effectiveness of a machine learning algorithm in diagnosing OSA in children based on clinical features that can be obtained in nonnocturnal and nonmedical environments.

Patients and methods

This study was conducted at Beijing Children's Hospital from April 2018 to October 2019. The participants in this study were 2464 children aged 3-18 suspected of having OSA who underwent clinical data collection and polysomnography(PSG). Participants' data were randomly divided into a training set and a testing set at a ratio of 8:2. The elastic net algorithm was used for feature selection to simplify the model. Stratified 10-fold cross-validation was repeated five times to ensure the robustness of the results.

Results

Feature selection using Elastic Net resulted in 47 features for AHI ≥5 and 31 features for AHI ≥10 being retained. The machine learning model using these selected features achieved an average AUC of 0.73 for AHI ≥5 and 0.78 for AHI ≥10 when tested externally, outperforming models based on PSG questionnaire features. Linear Discriminant Analysis using the selected features identified OSA with a sensitivity of 44% and specificity of 90%, providing a feasible clinical alternative to PSG for stratifying OSA severity.

Conclusions

This study shows that a machine learning model based on children's clinical features effectively identifies OSA in children. Establishing a machine learning screening model based on the clinical features of the target population may be a feasible clinical alternative to nocturnal OSA sleep diagnosis.

Prevalence of obstructive sleep apnea (OSA) among preschool aged children in the general population: A systematic review

Untreated pediatric obstructive sleep apnea (OSA) is associated with significant morbidities affecting behavior, neurocognitive development, endocrine and metabolic health. This systematic review evaluated prevalence of OSA reported in population-based studies among preschoolers as early intervention may have positive effects on health and quality of life. Thirty studies were included. High degrees of heterogeneity in methods and definitions were observed between the studies. Seven studies confirmed OSA by implementing objective methods after screening for habitual snoring with only two studies utilizing polysomnography, the reference standard, testing 1.2% of the combined cohorts (n = 82/4575) to confirm disease. Diagnosis of OSA was based on utilizing retired thresholds of the apnea-hypopnea-index (AHI), AHI4%≥5/hour of sleep (hrSleep), reporting prevalence of 1.8% and 6.4%, respectively. The remaining five studies implemented relatively insensitive objective recording methods to confirm disease in a limited number of children (n = 449/2486; 18.0%), estimating prevalence in the range of 0.7%-13.0%. The remaining literature is based on implementing questionnaires only to evaluate OSA. Studies published before 2014 reported 3.3%-9.4% prevalence, while more recent studies published 2016-2023 report higher prevalence, 12.8%-20.4%, when excluding outliers. This trend suggests that prevalence of OSA may possibly have been increasing in preschoolers over the past decade.

The Overlap Syndrome: A Combination of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea

Chronic obstructive pulmonary disease (COPD) is a severe lung disease that results in persistent and progressively worsening airflow obstruction due to abnormalities in the airway and alveoli. Obstructive sleep apnea (OSA) is a critical condition characterized by obstructive apneas, hypopneas, and respiratory effort-related arousals. These events occur due to the repetitive collapse of the upper airway during sleep, and it is essential to address this condition. These two conditions, when co-occur, are known as overlap syndrome (OS), which is associated with a higher likelihood of morbidity and mortality compared to either condition alone. Effective management of overlap syndrome is critical to maintain normal oxygen levels during sleep and reduce the incidence of hypoxemia and hypoventilation while improving sleep quality. Positive pressure ventilation is a standard technique used to effectively lower hospitalizations, emergency room visits, moderate and severe exacerbations, and related healthcare expenses in patients diagnosed with COPD and OSA. Despite the lack of literature on overlap syndrome, it is imperative to understand that this condition requires prompt and effective management to prevent further complications. Therefore, this review provides a detailed discussion highlighting the importance of proactive measures to manage overlap syndrome.

Identification of obstructive sleep apnea in children with obesity: A cluster analysis approach

BACKGROUND

Obstructive sleep apnea (OSA) is a heterogeneous disorder with a prevalence of 25%-60% in children with obesity. There is a lack of diagnostic tools to identify those at high risk for OSA.

METHOD

Children with obesity, aged 8-19 years old, were enrolled into an ongoing multicenter, prospective cohort study related to OSA. We performed k-means cluster analysis to identify clinical variables which could help identify obesity related OSA.

RESULTS

In this study, 118 participants were included in the analysis; 40.7% were diagnosed with OSA, 46.6% were female and the mean (SD) body mass index (BMI) and age were 39.7 (9.6) Kg/m², and 14.4 (2.6) years, respectively. The mean (SD) obstructive apnea-hypopnea index (OAHI) was 11.0 (21.1) events/h. We identified two distinct clusters based on three clustering variables (age, BMI z-score, and neck-height ratio [NHR]). The prevalence of OSA in clusters 1 and 2, were 22.4% and 58.3% (p = 0.001), respectively. Children in cluster 2, in comparison to cluster 1, had higher BMI z-score (4.7 (1.1) versus 3.2 (0.7), p < 0.001), higher NHR (0.3 (0.02) versus 0.2 (0.01), p < 0.001) and were older (15.0 (2.2) versus 13.7 (2.9) years, p = 0.09), respectively. However, there were no significant differences in sex and OSA symptoms between the clusters. The results from hierarchical clustering were similar to k-means analysis suggesting that the resulting OSA clusters were stable to different analysis approaches.

INTERPRETATION

BMI, NHR, and age are easily obtained in a clinical setting and can be utilized to identify children at high risk for OSA.

Optimizing Early Detection: Validating Obstructive Sleep Apnea-18 (OSA-18) in Turkish-Speaking Pediatric Patients

Objective

Quality of life (QoL) assessments are increasingly important for evaluating the well-being of children with Obstructive Sleep Apnea Syndrome (OSAS). This study's objective is to culturally adapt and validate the Turkish version of the OSA-18 questionnaire, a commonly used tool for assessing QoL in children with OSAS.

Methods

The OSA-18 questionnaire was translated and culturally adapted for use in the Turkish-speaking population. The study was conducted with 180 participants, 100 boys and 80 girls, with a mean age of 6.16±2.14 years. The participants were divided into two groups. The patient group comprised individuals with symptoms of OSAS based on clinical evaluation, including anamnesis, physical examination, and video recording of apnea and snoring. The patient group underwent adenotonsillectomy and their caregivers completed the Turkish version of the OSA-18 scale postoperatively. The control group comprised 90 children who were similar to the patient group in terms of gender and age. These children had no major complaints such as snoring, apnea, fatigue during the day, irritability, or distraction. In the physical examination of this group, no major tonsillar or adenoid hypertrophy, which causes significant stenosis in the upper airway, was observed. Internal consistency, reliability, validity, responsiveness, and factor analysis were assessed.

Results

The Turkish version of the OSA-18 questionnaire demonstrated excellent reliability, with a Cronbach's alpha of 0.929. The test-retest results were not statistically different. Validity was confirmed through a positive correlation between the OSA-18 score and external parameters, such as the Mallampati score, and tonsil and adenoid size. We found a statistically significant reduction in OSA-18 scores postoperatively, signifying a robust responsiveness to the intervention.

Conclusion

Our study confirms the suitability of the Turkish OSA-18 questionnaire for assessing the QoL in children with OSAS. This quick and easy-to-use tool will be valuable for future research on Turkish-speaking children with OSAS, aiding in the evaluation of pediatric OSAS and QoL.

Obstructive Sleep Apnea in Developmental Age: 22-Item Pediatric Sleep Questionnaire for an Observational Descriptive Investigation

The aim of this paper is to perform an observational descriptive study of the Obstructive Sleep Apnea Syndrome (OSAS) in a population of children by evaluating the prevalence and role of sex and age variables. The 22-item Pediatric Sleep Questionnaire (PSQ) was administered to parents of children aged 3 to 12 years. The questionnaire is a very simple tool since it allows for the indication of patients with possible OSAS diagnosis through a cut-off of 0.33. The anonymous diagnostic questionnaire, available in digital format, was administered to the population under study by a link or QR code. Only the questionnaires completed in all their parts were recorded and analyzed. Eight hundred and thirty-two questionnaires were collected. One hundred and fifty-four subjects obtained a PSQ score > 0.33 and the prevalence of OSAS was 18.51%. The Chi-square test showed a statistically significant association between the PSQ score > 0.33 and male sex. The higher prevalence of subjects with a value of PSQ > 0.33 (n = 277) are aged 3-4-5 years, followed by the 6-7-8 range in the group with PSQ score > 0.33, p < 0.05. The prevalence of OSAS was 18.51% in children aged 3 to 12 years. The variables male biological sex and the age group 3-8 year were statistically significant for subjects with OSAS diagnosis. This study underlines the use of the 22-item Pediatric Sleep Questionnaire as a first screening tool to identify children at risk of OSAS.

Mental Health and Cognitive Development in Symptomatic Children and Adolescents Scoring High on Habitual Snoring: Role of Obesity and Allergy

BACKGROUND

Obstructive sleep apnea can have a negative impact on children's and adolescents' neurocognitive abilities and hinder their academic and adaptive progress in academic, social, and/or behavioral dimensions. In this retrospective cross-sectional study, we investigated the influence of body weight conditions and allergy status on long-term mental health, cognitive development, and quality of life in children and adolescents who snored.

METHODS

The study sample included 47 subjects (age range 4.1 to 15.3 years) who exhibited high levels of snoring and underwent home-based polysomnography between 2015 and 2019. Follow-up assessments (3 years on average between baseline and follow-up) entailed phone interviews with the subject's parents/caregivers who completed three validated questionnaires investigating sleep, quality of life, and parental ratings.

RESULTS

We found a correlation between age at diagnosis and being retrospectively overweight and high levels of snoring. In addition to a higher risk of developing emotional symptoms (8.2% increase in retrospective overweight status for each unit increase in the emotional score at follow-up) and oppositional behavior (9% increase in retrospective overweight status for each unit of oppositional T points at follow-up), we also noted reduced long-term social symptoms (11% decrease in retrospective overweight status for each unit increase in the social score at follow-up) and cognitive symptoms (10.6% decrease in retrospective overweight status for each unit increase in the cognitive score at follow-up), as well as a 6.1% increase in retrospective allergy status for each unit increase in academic performance at follow-up.

CONCLUSIONS

Snoring can have negative impacts on mental health and cognitive development in the long term. Early detection and intervention for neuropsychological disorders is important in children and adolescents who score high on snoring. In the long term, the effects of snoring on neuropsychological disorders may vary based on previous body weight and allergy status.

Global trends and hotspots on childhood obstructive sleep apnea: a 10-year bibliometric analysis

Background

Obstructive sleep apnea (OSA) is children's most common sleep-related breathing disorder. It may develop a wide range of severe complications if not diagnosed promptly and treated effectively. However, Childhood OSA has not specifically been analyzed using a bibliometric approach.

Methods

We respectively collected the research results of childhood OSA from 2013 to 2022 through Web of Science and PubMed. Vosviewer, CiteSpace, and bibliometric online analysis platforms were used for visualizing and analyzing the literature. The MeSH terms were bi-clustered using the Bibliographic Item co-occurrence Matrix Builder (BICOMB) and graph clustering toolkit (gCLUTO) to identify the hotspots.

Results

4022 publications were finally identified on childhood OSA from 2013 to 2022. The United States has the largest number of publications (1902), accounting for 47.29%. University of Cincinnati is the most productive organization (196), followed by the University of Pennsylvania (151). The most prolific journal was the International Journal of Pediatric Otorhinolaryngology, with 311 documents published. In comparison, Pediatrics is the most cited journal (6936). Gozal D ranked highest among all authors in publication (192). Burst detection shows continuous positive airway pressure, Robin sequence, and nocturnal oximetry are recent keywords of great interest to researchers. Five hotspots were identified by co-word biclustering.

Conclusion

Research over the past ten years has been fruitful, establishing the foundation for childhood OSA. Clusters (0-4) of high-frequency Major Mesh topics have attracted extensive attention. Evaluation and treatment methods of childhood OSA remain major focuses. We believe this article will provide other researchers with new directions and may contribute to a future breakthrough in this field.

Rapid maxillary expansion in pediatric patients with obstructive sleep apnea: an umbrella review

OBJECTIVE

To compare polysomnographic parameters with others from the literature in order to provide more accurate information about Rapid Maxillary Expansion (RME) for treating Obstructive Sleep Apnea (OSA) in children, through raising the question: Is RME a good option for treating OSA in children? Prevention of mouth breathing during children's growth remains a challenge with significant clinical consequences. In addition, OSA induces anatomofunctional changes during the critical period of craniofacial growth and development.

METHODS

The Medline, PubMed, EMBASE, CINAHL, Web of Science, SciELO and Scopus electronic databases were searched up to February 2021 for systematic reviews with meta-analysis in the English language. Among 40 studies on RME for treating OSA in children, we selected seven in which polysomnographic measurements of the Apnea-Hypopnea Index (AHI) had been made. Data were extracted and examined in order to clarify whether any consistent evidence exists for indicating RME as a treatment for OSA in children.

RESULTS

We found no consistent evidence favoring RME for long-term treatment of OSA in children. All the studies presented considerable heterogeneity due to variability of age and length of follow-up.

CONCLUSION

Through this umbrella review, the need for methodologically better studies on RME is supported. Moreover, it can be considered that RME is not recommended for treating OSA in children. Further studies and more evidence identifying early signs of OSA are necessary in order to achieve consistent healthcare practice.

The Effects of Orofacial Myofunctional Therapy on Children with OSAHS’s Craniomaxillofacial Growth: A Systematic Review

Orofacial myofunctional therapy (OMT) is one of the therapeutic methods for neuromuscular re-education and has been considered as one of the auxiliary methods for obstructive sleep apnea hypopnea syndrome (OSAHS) and orthodontic treatment. There is a dearth of comprehensive analysis of OMT’s effects on muscle morphology and function. This systematic review examines the literature on the craniomaxillofacial effects of OMT in children with OSAHS. This systematic analysis was carried out using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards, and the research was scanned using PICO principles. A total of 1776 articles were retrieved within a limited time, with 146 papers accepted for full-text perusing following preliminary inspection and 9 of those ultimately included in the qualitative analysis. Three studies were rated as having a severe bias risk, and five studies were rated as having a moderate bias risk. Improvement in craniofacial function or morphology was observed in most of the 693 children. OMT can improve the function or morphology of the craniofacial surface of children with OSAHS, and its effect becomes more significant as the duration of the intervention increases and compliance improves. In the majority of the 693 infants, improvements in craniofacial function or morphology were seen. The function or morphology of a kid’s craniofacial surface can be improved with OMT, and as the duration of the intervention lengthens and compliance rises, the impact becomes more pronounced.

Development and validation of moderate to severe obstructive sleep apnea screening test (ColTon) in a pediatric population

OBJECTIVE

Development and validation of a machine learning algorithm to predict moderate to severe obstructive sleep apnea syndrome (OSAS) in otherwise healthy children.

DESIGN

Multivariable logistic regression and cforest algorithm of a large cross-sectional data set of children with sleep-disordered breathing.

SETTING

An university pediatric sleep centre.

PARTICIPANTS

Children underwent clinical examination, acoustic rhinometry and pharyngometry, and surveying through parental sleep questionnaires, allowing the recording of 14 predictors that have been associated with OSAS. The dataset was nonrandomly split into a training (development) versus test (external validation) set (2:1 ratio) based on the time of the polysomnography. We followed the TRIPOD checklist.

RESULTS

We included 336 children in the analysis: 220 in the training set (median age [25th-75th percentile]: 10.6 years [7.4; 13.5], z-score of BMI: 1.96 [0.73; 2.50], 89 girls) and 116 in the test set (10.3 years [7.8; 13.0], z-score of BMI: 1.89 [0.61; 2.46], 51 girls). The prevalence of moderate to severe OSAS was 106/336 (32%). A machine learning algorithm using the cforest with pharyngeal collapsibility (pharyngeal volume reduction from sitting to supine position measured by pharyngometry) and tonsillar hypertrophy (Brodsky scale), constituting the ColTon index, as predictors yielded an area under the curve of 0.89, 95% confidence interval [0.85-0.93]. The ColTon index had an accuracy of 76%, sensitivity of 63%, specificity of 81%, negative predictive value of 84%, and positive predictive value of 59% on the validation set.

CONCLUSION

A cforest classifier allows valid predictions for moderate to severe OSAS in mostly obese, otherwise healthy children.

Effect of orthopedic and functional orthodontic treatment in children with obstructive sleep apnea: A systematic review and meta-analysis

Orthodontic treatment is suggested in growing individuals to correct transverse maxillary deficiency and mandibular retrusion. Since, as a secondary effect, these orthodontic procedures may improve pediatric obstructive sleep apnea (OSA), this systematic review assessed their effects on apnea-hypopnea index (AHI) and oxygen saturation (SaO2). Twenty-five (25) manuscripts were included for qualitative synthesis, 19 were selected for quantitative synthesis. Five interventions were analyzed: rapid maxillary expansion (RME, 15 studies), mandibular advancement (MAA, five studies), myofunctional therapy (MT, four studies), and RME combined with MAA (one study). RME produced a significant AHI reduction and minimum SaO2 increase immediately after active treatment, at six and 12 months from baseline. A significant AHI reduction was also observed six and 12 months after the beginning of MAA treatment. MT showed positive effects, with different protocols. In this systematic review and meta-analysis of data from mainly uncontrolled studies, interceptive orthodontic treatments showed overall favorable effects on respiratory outcomes in pediatric OSA. However, due to the low to very low level of the body evidence, this treatment cannot be suggested as elective for OSA treatment. An orthodontic indication is needed to support this therapy and a careful monitoring is required to ensure positive improvement in OSA parameters.

Clinical Characteristics Combined with Craniofacial Photographic Analysis in Children with Obstructive Sleep Apnea

Purpose

Distinguishing obstructive sleep apnea (OSA) in a high-risk population remains challenging. This study aimed to investigate clinical features to identify children with OSA combined with craniofacial photographic analysis.

Methods

One hundred and forty-five children (30 controls, 62 with primary snoring, and 53 with OSA) were included. Differences in general demographic characteristics and surface facial morphology among the groups were compared. Risk factors and prediction models for determining the presence of OSA (obstructive sleep apnea-hypopnea index>1) were developed using logistic regression analysis.

Results

The BMI (z-score), tonsil hypertrophy, and lower face width (adjusted age, gender, and BMI z-score) were showed significantly different in children with OSA compared with primary snoring and controls (adjusted p<0.05). The screening model based on clinical features and photography measurements correctly classified 79.3% of the children with 64.2% sensitivity and 89.1% specificity. The area under the curve of the model was 81.0 (95% CI, 73.5-98.4%).

Conclusion

A screening model based on clinical features and photography measurements would be helpful in clinical decision-making for children with highly suspected OSA if polysomnography remains inaccessible in resource-stretched healthcare systems.

Lax eyelid condition (LEC) and floppy eyelid syndrome (FES) prevalence in obstructive sleep apnea syndrome (OSA) patients: a systematic review and meta-analysis

Purpose

Lax eyelid condition (LEC) and floppy eyelid syndrome (FES) represent two distinct conditions which have been associated with several ocular and systemic comorbidities. The main aim of this systematic review and meta-analysis is to explore the available literature to estimate the prevalence rate of LEC and FES in obstructive sleep apnea (OSA).

Methods

The protocol of this systematic review and meta-analysis has been registered in PROSPERO. Four electronic databases (PubMed/MEDLINE, Google Scholar, Cochrane Library, Web of Science) were searched from inception to December 24, 2021. A random intercept logistic regression model was carried out for the analysis of overall proportions. Odds ratio and mean difference were reported as measures of the effect size in the presence of binary and continuous outcomes, respectively. The estimated numbers of LEC/FES patients in OSA were calculated by multiplying the prevalence rate determined by our random-effects model and the corresponding Benjafield et al.’s population prospect.

Results

We included 11 studies comprising 1225 OSA patients of whom 431 and 153 affected by LEC and FES, respectively. Our model estimated a pooled prevalence rate for LEC and FES in OSA patients of 40.2% (95%CI: 28.6–53.1%) and of 22.4% (95%CI: 13.8–34.2%), respectively. The number of LEC/FES affected individuals among OSA patients is expected to peak up to 376 and to 210 million, respectively. OSA patients appeared to have a 3.4 (95%CI: 2.2–5.2) and a 3.0 (95%CI: 1.7–5.5) increased risk of developing LEC and FES than the healthy counterpart.

Conclusion

Prevalence of LEC and FES is higher in OSA-affected patients compared to controls. More studies are warranted to investigate the mechanisms leading to the development of LEC and/or FES in OSA patients, as well as the feasibility of the adoption of these clinical findings as screening tools for OSA.

Association of Apnea vs Hypopnea Predominance With Pediatric Sleep Apnea Outcomes: A Secondary Analysis of the Childhood Adenotonsillectomy Trial

Importance

Children with apnea-predominant obstructive sleep apnea (OSA) are hypothesized to have a more severe form of the disease. However, research is lacking as to whether there is a significant difference in outcomes between children with apnea-predominant vs hypopnea-predominant OSA.

Objective

To assess the association between baseline apnea-predominant or hypopnea-predominant OSA on polysomnography and quality of life (QOL) outcomes in children with obstructive sleep apnea managed by watchful waiting with supportive care (WWSC) or adenotonsillectomy (AT).

Design, Setting, and Participants

This case-control study is a secondary analysis of a randomized clinical trial, the Childhood Adenotonsillectomy Trial, which was conducted at multiple tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to WWSC or AT and underwent polysomnography and completed validated QOL and symptom assessments at baseline and 7 months. The current data analysis was performed from October 2020 to February 2022.

Main Outcomes and Measures

Apnea-predominant OSA was defined as an apnea hypopnea index (AHI) greater than 2 with more than 50% of the obstructive events being apneas. Patients were considered to have hypopnea-predominant OSA if they had an AHI greater than 2 and more than 50% of the obstructive events were hypopneas.

Results

A total of 386 children (185 boys [48%]; mean [SD] age, 6.56 [1.4] years) were analyzed. The mean (SD) obstructive AHI for patients was 6.98 (5.62), with 198 patients (51%) having mild disease. Thirty-seven children (10%) had apnea-predominant OSA at baseline. Black children were at increased risk for apnea-predominant OSA vs White children (odds ratio [OR], 13.40; 95% CI, 5.70-33.90). Children with apnea predominance were more likely to have severe OSA (AHI >10) compared with children with hypopnea predominance (OR, 2.30; 95% CI, 1.03-5.03); baseline Pediatric Sleep Questionnaire and OSA-18 QOL scores were similar between the 2 groups. Among children undergoing AT, those with baseline apnea predominance were more likely to have a Pediatric Sleep Questionnaire score greater than 0.33 at follow-up (OR, 3.30; 95% CI, 1.01-10.80). Rates of OSA resolution and improvements in QOL scores following AT or WWSC were similar between the apnea-predominant and hypopnea-predominant groups.

Conclusions and Relevance

In children with OSA, apnea-predominant disease is uncommon. Apnea predominance was not associated with symptom resolution and cure rates in children undergoing AT or WWSC for OSA. Further research is needed to assess how apnea predominance affects AT outcomes in children with more severe disease.

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.

Recent advances in paediatric sleep disordered breathing

This article reviews the latest evidence pertaining to childhood sleep disordered breathing (SDB), which is associated with negative neurobehavioural, cardiovascular and growth outcomes. Polysomnography is the accepted gold standard for diagnosing SDB but is expensive and limited to specialist centres. Simpler tests such as cardiorespiratory polygraphy and pulse oximetry are probably sufficient for diagnosing obstructive sleep apnoea (OSA) in typically developing children, and new data-processing techniques may improve their accuracy. Adenotonsillectomy is the first-line treatment for OSA, with recent evidence showing that intracapsular tonsillectomy results in lower rates of adverse events than traditional techniques. Anti-inflammatory medication and positive airway pressure respiratory support are not always suitable or successful, although weight loss and hypoglossal nerve stimulation may help in select comorbid conditions.

Educational aims

To understand the clinical impact of childhood sleep disordered breathing (SDB).To understand that, while sleep laboratory polysomnography has been the gold standard for diagnosis of SDB, other diagnostic techniques exist with their own benefits and limitations.To recognise that adenotonsillectomy and positive pressure respiratory support are the mainstays of treating childhood SDB, but different approaches may be indicated in certain patient groups.

Trends in Diagnosing Obstructive Sleep Apnea in Pediatrics

Obstructive sleep apnea in children has been linked with behavioral and neurocognitive problems, impaired growth, cardiovascular morbidity, and metabolic consequences. Diagnosing children at a young age can potentially prevent significant morbidity associated with OSA. Despite the importance of taking a comprehensive sleep history and performing thorough physical examination to screen for signs and symptoms of OSA, these findings alone are inadequate for definitively diagnosing OSA. In-laboratory polysomnography (PSG) remains the gold standard of diagnosing pediatric OSA. However, there are limitations related to the attended in-lab polysomnography, such as limited access to a sleep center, the specialized training involved in studying children, the laborious nature of the test and social/economic barriers, which can delay diagnosis and treatment. There has been increasing research about utilizing alternative methods of diagnosis of OSA in children including home sleep testing, especially with the emergence of wearable technology. In this article, we aim to look at the presentation, physical exam, screening questionnaires and current different modalities used to aid in the diagnosis of OSA in children.