Adenotonsillectomy in the morbidly obese child

Causal Relationship Between Childhood Obesity and Sleep Apnea Syndrome: Bidirectional Two-Sample Mendelian Randomization Analysis

Background

Childhood obesity has become a global pandemic, leading to a range of diseases. Childhood obesity appears to be associated with an increased prevalence of sleep apnea syndrome. Sleep apnea is an inestimable risk factor for thrombosis, hypertension, cardiomyopathy and many other diseases. Therefore, exploring the relationship between childhood obesity and sleep apnea syndrome will help to understand the potential link between the two and provide research directions for future disease prevention and treatment. However, no studies have confirmed whether there is a causal relationship between childhood obesity and sleep apnea syndrome.

Methods

The IEU OpenGWAS project provided the GWAS-aggregated data for childhood obesity and sleep apnea syndrome. Inverse-variance weighted (IVW) was used as the main method to evaluate the causal relationship between childhood obesity and sleep apnea syndrome. Single nucleotide polymorphisms (SNPs) were regarded as instrumental variables, and the screening threshold was P <5.0×10-6. Leave-one-out method was performed to confirm the robustness of the results.

Results

IVW analysis confirmed a causal relationship between genetic susceptibility to childhood obesity and an increased risk of sleep apnea syndrome [odds ratio (OR)=1.12, 95% confidence interval (CI): 1.02-1.23, P=0.016]. However, two-sample MR results also showed no causal relationship between genetic susceptibility to sleep apnea syndrome and an increased risk of childhood obesity (OR=1.50, 95% CI: 0.95-2.38, P=0.083). The intercept of MR-Egger regression was close to 0, which implies that there are no confounding factors in the analysis to affect the results of two-sample MR analysis. The leave-one-out results show that the bidirectional two-sample MR analysis results were robust.

Conclusion

There is a causal relationship between genetic susceptibility to childhood obesity and increased risk of sleep apnea syndrome. People with a history of childhood obesity should pay more attention to physical examination to early prevention and management of sleep apnea syndrome.

Evaluating obesity as a risk factor for complications after pediatric adenotonsillectomy

OBJECTIVES

To evaluate associations between childhood obesity and post-adenotonsillectomy complications, informing guidelines for postoperative management.

METHODS

The retrospective review assessed outpatient pediatric tonsillectomy/adenoidectomy cases performed at 2 ambulatory surgery centers in 2020. Complications in the recovery unit and within 2 weeks of surgical discharge were reviewed along with clinical and demographic variables. Obesity was defined as sex-specific body mass index-for-age, or weight-for-age if height data were unavailable, at/above the 95th percentile. The 99th percentile served as the threshold for severe obesity. Analyses used Chi-square/Fisher's exact tests and independent-samples t-tests with relative risk or effect sizes.

RESULTS

The review included 707 cases (180 patients with obesity). Overall incidence of complications in the recovery unit was 9.1%. Patients with obesity were significantly more likely to require supplemental blow-by oxygen (P = .02); relative risk was 1.65 (95% CI: 1.16-2.35) times greater in the cohort with obesity. Obesity had a small effect on postoperative oxygen saturation nadirs, which were significantly lower among patients with obesity (d = -0.34; P < .001). No differences emerged between cohorts with and without obesity in the incidence of any other complications before or after surgical discharge. Overall incidence of post-discharge returns was 7.9%. Incidence of complications did not vary by obesity severity.

CONCLUSION

From this cohort, childhood obesity without other significant comorbidities may not warrant routine inpatient care following adenotonsillectomy. Patients with obesity should receive additional monitoring for oxygen desaturation events during the first hours of recovery. Further prospective studies should continue to address this important topic.

Improving the Pediatric Floor Discharge Process Following Tonsillectomy

OBJECTIVES/HYPOTHESIS

Over 300,000 tonsillectomies are performed nationwide every year. In 2017, half of children undergoing tonsillectomy at our institution were admitted to the pediatric floor, with only 10.4% being discharged before 11 AM on postoperative day 1 (POD1). Our primary objective was to increase the percentage of patients discharged before 11 AM on POD1 to at least 50% within 1 year.

STUDY DESIGN

Prospective observational (quality improvement).

METHODS

A multidisciplinary quality improvement (QI) team was assembled. The primary outcome was "timely discharges," defined as percentage of patients discharged before 11 AM on POD1; secondary outcomes were percentage of patients discharged before 1 PM and mean length of stay (hours). Seven-day readmission rate served as our balancing measure. Prior year data served as baseline. A process map, Ishikawa diagram, and Pareto chart were utilized to identify specific target areas for improvement. Key interventions included announcement of our initiative, an electronic health record-based handoff text prompt, discharge checklist, automated discharge instructions, encouragement to place discharge orders by 9 AM and implementation of early POD1 rounds. Data were collected on a biweekly basis and the primary and secondary outcomes were plotted on control charts and analyzed using rules for special cause variation.

RESULTS

Within 12 months, POD1 discharges before 11 AM and before 1 PM increased to 44.9% and 83.8%, respectively, with sustained improvement for the first 6 months of the subsequent year. Mean length of stay decreased, and 7-day readmission rates were unchanged.

CONCLUSIONS

By understanding the factors influencing timely POD1 discharges after tonsillectomy, key interventions were implemented to achieve an increase in timely discharges.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Outcomes intensive care unit placement following pediatric adenotonsillectomy

INTRODUCTION

Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care.

METHODS

This is a retrospective chart review from the years of 2009-2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU.

RESULTS

There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement.

CONCLUSIONS

This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.

Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children

Importance

The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children.

Objective

To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery.

Design, Setting, and Participants

This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded.

Main Outcomes and Measures

Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding.

Results

Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66).

Conclusions and Relevance

Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.

Peri-operative management of overweight and obese children and adolescents

Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.

INFLUENCE OF OVERWEIGHT AND OBESITY IN CHILDREN ON ANESTHESIOLOGICAL COMPLICATIONS APPEARANCE DURING ADENOIDECTOMY AND ADENOTONSILLECTOMY

INTRODUCTION

Obesity in children is becoming from year to year enormous medical and socio-epidemilogical problem according to increasing number of overweight and obese children. Overweight and obesity in children mostly affects on cardiovascular, respiratory and endocrine system disturbances. Adenoidectomy and adenotonsillectomy belong to group of most often done operation in children population. Anesthesiology complications during adenodecotomy and adenotonsillectomy in children are known as very disturbing and dramatic.

METHODS

Retrospective-prospective study includes 162 children, both genders, 3 to 12 years old, who are hospitalized and operated (adenoidectomies and adenotonsillectomies) on Otorihinolaryngolic clinic of University clinical centre Tuzla in the four year period. Purpose of the study is to show the influence of overweight in children on appearance of anesthesiology complications such as difficult intubation, bronchospasm and laryngospasm. Body mass index (BMI), which is used as universal measure, is adapted with gender specific scales of National statistic centre of United States of America. All children with BMI over 25 are referred as overweight and those over 30 as obese. These children categories were compared to those with normal BMI according to anesthesiology complications incidence.

RESULTS

Overweight in operated children is noticed in 21%, and 11% of children was obese and there wasn't distinction between boys and girls. Anesthesiology complications are evaluated in 12 of them (7.4%). Total analyzed sample show significant connection and influence of overweight with appearance of anesthesiology complications. Separate comparison for two types of operations is indicating that during adenoidectomies there hasn't been noticed connection between overweight and anestehesiological complications, while in case of adenotonsillectomies direct and significant correlation is proven.

CONCLUSIONS

According to increased risk of anesthesiology complications in overweight and obese children during adenodectomies and adenotonsillectomies it is important for anesthesiologists to do much serious preoperative evaluation of obese children, and to be more prepared for every of possible unwished supersize during perioperative period.

Is routine pre-operative cardiac evaluation necessary in obese children undergoing adenotonsillectomy for OSA?

BACKGROUND

Adenotonsillectomy (T&A) is a common surgery performed for obstructive sleep apnea (OSA) in children. Obese children are at increased risk for OSA, but are also at increased risk for cardiovascular changes that might heighten their risk of undergoing a general anesthetic. There is currently no standard of care recommendation for cardiac workup prior to T&A.

PURPOSE

To ascertain whether a preoperative cardiac workup is predictive of postoperative complications in obese children undergoing T&A for OSA.

DESIGN

Retrospective cohort review.

MATERIAL AND METHODS

241 children with BMI ≥ 25 kg/m(2) underwent T&A for OSA. This cohort was divided into three groups - those who had no preoperative cardiac evaluation, those who had a preoperative cardiac evaluation but no significant findings and those who had a preoperative cardiac evaluation with at least one significant finding. Postoperative cardiac-related complications were compared between the three groups.

RESULTS

There were significantly more postoperative complications in Group 3, the group with findings on preoperative cardiac evaluation. However, these were heavily weighted toward "hospital stay > 24 hours" without clear cardiac sequelae. Notably there were no incidents of pulmonary edema, re-intubation postoperatively or death.

CONCLUSION

In obese children undergoing T&A at a tertiary care center, a preoperative cardiac workup was not shown to be beneficial in predicting postoperative complications.

Complications of adenotonsillectomy for obstructive sleep apnea in school-aged children

INTRODUCTION

Adenotonsillectomy is the treatment of choice for most children with obstructive sleep apnea syndrome, but can lead to complications. Current guidelines recommend that high-risk children be hospitalized after adenotonsillectomy, but it is unclear which otherwise-healthy children will develop post-operative complications. We hypothesized that polysomnographic parameters would predict post-operative complications in children who participated in the Childhood AdenoTonsillectomy (CHAT) study.

METHODS

Children in the CHAT study aged 5-9 years with apnea hypopnea index 2-30/h or obstructive apnea index 1-20/h without comorbidities other than obesity/asthma underwent adenotonsillectomy. Associations between demographic variables and surgical complications were examined with Chi square and Fisher's exact tests. Polysomnographic parameters between subjects with/without complications were compared using Mann-Whitney tests.

RESULTS

Of the 221 children (median apnea hypopnea index 4.7/h, range 1.2-27.7/h; 31% obese), 16 (7%) children experienced complications. 3 (1.4%) children had respiratory complications including pulmonary edema, hypoxemia and bronchospasm. Thirteen (5.9%) had non-respiratory complications, including dehydration (4.5%), hemorrhage (2.3%) and fever (0.5%). There were no statistically significant associations between demographic parameters (gender, race, and obesity) or polysomnographic parameters (apnea hypopnea index, % total sleep time with SpO2<92%, SpO2 nadir, % sleep time with end-tidal CO2>50Torr) and complications.

CONCLUSIONS

This study showed a low risk of post-adenotonsillectomy complications in school-aged healthy children with obstructive apnea although many children met published criteria for admission due to obesity, or polysomnographic severity. In this specific population, none of the polysomnographic or demographic parameters predicted post-operative complications. Further research could identify the patients at greatest risk of post-operative complications.

Recognizing pediatric sleep apnea

Obstructive sleep apnea is a common condition in childhood and has a significant impact on health, learning, academic performance, and quality of life. The purpose of this article is to review the epidemiology, etiology, risk factors, clinical presentation, diagnostic procedures, and treatment of obstructive sleep apnea.

Otolaryngologic findings in prepubertal obese children with sleep-disordered breathing

OBJECTIVE

To evaluate otolaryngologic findings in obese prepubertal children with sleep-disordered breathing.

METHODS

We prospectively evaluated 29 obese children referred by pediatric endocrinologist, complaining of snoring and without a history of nasal surgery or removal of the palatine tonsils and/or adenoids. Patients underwent ear, nose and throat (ENT) examination, endoscopy, measurements of weight, height, calculation of body mass index (BMI), assessment of BMI z-score and polysomnography, from which were divided into two groups: those with obstructive sleep apnea syndrome (nine children) and those with primary snoring (20 children). Then we proceeded to the statistical analysis of the data collected.

RESULTS

The groups did not differ in age, gender, weight, height, BMI and BMI z-score. Among the findings of the ENT examination, the adenoid size was the only one that differed between the groups (p = 0.01).

CONCLUSION

The evaluation of the adenoid size is an important in obese children with symptoms of sleep-disordered breathing and is related to the presence of obstructive sleep apnea syndrome.

Diagnosis and management of childhood obstructive sleep apnea syndrome

OBJECTIVE

This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).

METHODS

The literature from 1999 through 2011 was evaluated.

RESULTS AND CONCLUSIONS

A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

[Childhood obesity and sleep-related breathing disorders]

INTRODUCTION

The increasing prevalence of childhood obesity leads to an increase risk of sleep-disordered breathing and may exacerbate their comorbidities.

PURPOSE

To assess the rate of obesity in children with sleep-disordered breathing and to study the possible clinical and epidemiological differences between children with and without overweight in a private hospital in the Mediterranean area.

MATERIALS AND METHODS

We prospectively studied 340 children between 2 and 10 years. There were 170 children with sleep-disordered breathing (study group) and 170 healthy children (control group). In the problem group, the apnea-hypopnea index was around 7.61 ± 6.3.

RESULTS

The comparison of the percentage of cases with a BMI percentile ≥85 (overweight) between problem and control groups (44: 25.9% vs 34: 20%) or with a BMI ≥95 (obesity) (30: 17.6% vs 20: 11.8%) showed no statistically-significant differences. In addition, the comparison of clinical and epidemiological variables in the problem group, cases with (44/170: 25.9%) and without (126/170: 74.1%) overweight, did not show significant differences in any of the parameters analysed.

CONCLUSION

In the population studied, it does not appear that the group of children with sleep breathing disorders presents higher rates of obesity, nor does obesity influence its presentation clinically. These results had probably been influenced by the characteristics of the studied population and therefore should not be an obstacle for being attentive to the possible association of respiratory disease to obesity and its negative consequences.

Challenge! Health promotion/obesity prevention mentorship model among urban, black adolescents

OBJECTIVES

The objective of this study was to evaluate a 12-session home/community-based health promotion/obesity prevention program (Challenge!) on changes in BMI status, body composition, physical activity, and diet.

METHODS

A total of 235 black adolescents (aged 11-16 years; 38% overweight/obese) were recruited from low-income urban communities. Baseline measures included weight, height, body composition, physical activity (PA), and diet. PA was measured by 7-day play-equivalent physical activity (> or =1800 activity counts per minute). Participants were randomly assigned to health promotion/obesity prevention that is anchored in social cognitive theory and motivational interviewing and was delivered by college-aged black mentors or to control. Postintervention (11 months) and delayed follow-up (24 months) evaluations were conducted. Longitudinal analyses used multilevel models with random intercepts and generalized estimating equations, controlling for baseline age/gender. Stratified analyses examined baseline BMI category.

RESULTS

Retention was 76% over 2 years; overweight/obese status declined 5% among intervention adolescents and increased 11% among control adolescents. Among overweight/obese youth, the intervention reduced total percentage of body fat and fat mass and increased fat-free mass at delayed follow-up and increased play-equivalent physical activity at postintervention but not at delayed follow-up. Intervention adolescents declined significantly more in snack/dessert consumption than control adolescents at both follow-up evaluations.

CONCLUSIONS

At postintervention, there were intervention effects on diet and PA but not BMI category or body composition. At delayed follow-up, dietary changes were sustained and the intervention prevented an increase in BMI category. Body composition was improved for overweight/obese youth. Changes in body composition follow changes in diet and PA and may not be detected immediately after intervention.

Postoperative respiratory complications and recovery in obese children following adenotonsillectomy for sleep-disordered breathing: A case-control study

Objective: To compare postoperative respiratory complications in obese and nonobese children following surgery for sleep-disordered breathing.

Study Design: Case-control study.

Setting: Pediatric tertiary care center.

Subjects and Methods: All obese children who had undergone adenotonsillectomy for sleep-disordered breathing from 2002 to 2007 were compared with age- and gender-matched controls. Subjects were identified from a prospective surgical database. Length of hospital stay and the incidence, severity, and location of respiratory complications were compared. Multivariable analysis was performed to identify predictive factors.

Results: Forty-nine obese children were identified (20:29, female:male). There were no differences in mean age or type of surgical procedures ( P > 0.05). Overall, 37 obese children (75.5%) and 13 controls (26.5%) incurred complications ( P = 0.000, OR 8.54 [95% CI 3.44-21.19]). Ten obese patients and two controls incurred major events ( P = 0.012, OR 6.03 [95% CI 1.25-29.15]); 36 obese children had minor complications versus 12 controls ( P = 0.000, OR 8.54 (95% CI 3.44-21.19). Obese children had significantly more upper airway obstruction (19 vs 4, P = 0.0003, OR 7.13 [95% CI 2.20-23.03]), particularly during the immediate postoperative period. The mean hospital stay was significantly longer for the obese group (18 vs 8 hours, P = 0.000, mean difference of 10 hours [95% CI 2.01-17.99]). Male gender, tonsillectomy, and body mass index were significant predictive factors.

Conclusion: Obesity in children significantly increases the risk of respiratory complications following surgery for sleep-disordered breathing. Overnight hospitalization for obese children is recommended.

Childhood obesity and obstructive sleep apnea syndrome

The increasing prevalence of obesity in children seems to be associated with an increased prevalence of obstructive sleep apnea syndrome (OSAS) in children. Possible pathophysiological mechanisms contributing to this association include the following: adenotonsillar hypertrophy due to increased somatic growth, increased critical airway closing pressure, altered chest wall mechanics, and abnormalities of ventilatory control. However, the details of these mechanisms and their interactions have not been elucidated. In addition, obesity and OSAS are both associated with metabolic syndrome, which is a constellation of features such as hypertension, insulin resistance, dyslipidemia, abdominal obesity, and prothrombotic and proinflammatory states. There is some evidence that OSAS may contribute to the progression of metabolic syndrome with a potential for significant morbidity. The treatment of OSAS in obese children has not been standardized. Adenotonsillectomy is considered the primary intervention followed by continuous positive airway pressure treatment if OSAS persists. Other methods such as oral appliances, surgery, positional therapy, and weight loss may be beneficial for individual subjects. The present review discusses these issues and suggests an approach to the management of obese children with snoring and possible OSAS.

Obesity and Obstructive Sleep Apnoea Hypopnoea Syndrome in Singapore Children

Introduction: Obesity affects about 10% to 15% of our school-going population in Singapore and is a risk factor for development of obstructive sleep apnoea hypopnoea syndrome (OSAHS). This article reviews the prevalence, aetiology, pathophysiology, diagnosis, complications and treatment of obese children with OSAHS with particular reference to children in Singapore. Methods: Review of articles or conference papers reporting data with regards to OSAHS in Singapore children. Results: Prevalence of OSAHS was high in obese children in Singapore and was more common in males with no racial predisposition. Hypersomnolence as a presenting symptom was uncommon. Cognitive function, behaviour, attention and processing speed was affected and improved after intervention. Abnormalities of glucose metabolism were also found with the respiratory disturbance index (RDI) as an independent predictor of insulin resistance. Tonsillectomy and or adenoidectomy was efficacious as treatment and risk of complications was low. No significant increase in weight occurred post intervention in those enrolled in concurrent weight management programmes. Conclusions: Prevalence of OSAHS is high in obese Singapore children and many are ‘asymptomatic’. A low threshold for evaluation is necessary for early diagnosis and intervention for prevention of morbidity. Tonsillectomy and/or adenoidectomy is safe and efficacious and remains the first-line treatment in most obese patients. Key words: Complications, Diagnosis, Prevalence, Treatment

Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary

Morbidly obese children undergoing adenotonsillectomy, often with co-morbid obstructive sleep apnoea, may be considered at a higher risk of postoperative respiratory compromise. This retrospective study aimed to assess the frequency and severity of postoperative respiratory complications in these patients and to identify preoperative risks factors for such morbidity. Medical and nursing chart review of all consecutive elective post-adenotonsillectomy admissions of morbidly obese children (defined as >95th centile for body mass index adjusted for age and gender) to our intensive care unit over a 30-month period was performed. A total of 26 morbidly obese children were identified. The majority (14/26) had an uncomplicated recovery following surgery. Of those cases that required postoperative intervention, 10 patients required supplemental oxygen with or without suctioning and/or repositioning alone, whilst two required continuous positive airway pressure therapy. No patient required re-intubation. An oxygen saturation nadir of < 70% and the presence of more than one central apnoea, noted on preoperative overnight polysomnography, were associated with postoperative respiratory complications requiring intervention. Although the intervention group were younger, more obese and had a higher respiratory disturbance index, none of these factors were statistically significant. Routine admission to the paediatric intensive care unit of all morbidly obese children undergoing adenotonsillectomy may be unnecessary, once a suitable high level of nursing is available in an alternative setting, to administer simple positional and suctioning intervention and to perform regular patient observation. Special consideration should be given to the postoperative nursing environment for those patients with a SaO2 nadir < 70% noted preoperatively, indicating the presence of a significant central disease component.

Obesity and obstructive sleep apnea in children

The prevalence and severity of obesity in children and adolescent is dramatically increasing worldwide with a corresponding increase in the prevalence of obesity-associated morbidities particularly those involving OSAS and metabolic and cardiovascular sequelae. Obstructive sleep apnea and obesity hypoventilation syndrome are important and serious consequences of obesity, and may in fact mediate components of the association between obesity and metabolic and cardiovascular morbidities, most likely via potentiation of inflammatory cascades. It is anticipated that the increased prevalence of obesity in children and adolescents in our society will be accompanied by a steady increase in the incidence of OSAS. In this review, we will examine our current understanding of sleep-disordered breathing and associated morbidities in obese children, and summarize the range of therapeutic modalities currently available for this high-risk population.

Sleep apnea in children--treatment considerations

The prevalence of obstructive sleep apnea (OSA) is clearly increasing in the pediatric population. However, the polysomnographic criteria for treatment still remain to be defined by appropriate scientific methodology. Furthermore, the overall efficacy of currently available interventions such as surgical removal of enlarged tonsils and adenoids (T&A) is unknown, such that we are currently unable to precisely define who the high risk patients are, and the cost and benefits associated with any given treatment. Here, we review the available approaches to the management of OSA in the pediatric population, and examine the potential complementary role of anti-inflammatory therapy, mask ventilation, and intra-oral appliances in the context of mild OSA or residual OSA following T&A.

Behavior, neurocognition and quality-of-life in children with sleep-disordered breathing

OBJECTIVES

To summarize current evidence that sleep-disordered breathing in children is associated with behavioral, neurocognitive and quality-of-life problems and to suggest new lines of investigation for future research on sleep-disordered breathing and behavior.

METHODS

A comprehensive review of the medical literature between January 1990 and December 2004 was performed using the National Library of Medicine's PUBMED database.

RESULTS

Analysis revealed 33 articles that satisfied the inclusion and exclusion criteria. The total study population in these articles was 22,255 children. Sample sizes per study ranged from 12 to 5728 children. The age range was 2-18 years (mean 6.8+/-2.8). The majority of studies examined behavior, neurocognition or quality-of-life as a single outcome measure. Behavioral problems included reduced attention, hyperactivity, increased aggression, irritability, emotional and peer problems, and somatic complaints. The following neurocognitive skills were affected: memory; immediate recall; visual-spatial functions; attention and vigilance; mental flexibility; and intelligence. The quality-of-life of children with sleep-disordered breathing was similar that of children with asthma or rheumatoid arthritis. Improvements in behavior, neurocognition and quality-of-life scores for children with sleep-disordered breathing were seen after adenotonsillectomy.

CONCLUSIONS

There is compelling evidence that sleep-disordered breathing in children is associated with behavioral and neurocognitive problems and leads to reduced quality-of-life. In addition to improvements in sleep, adenotonsillectomy is associated with improvements in behavior, neurocognition and quality-of-life in these children. However, the lack of uniform criteria for the diagnosis of sleep-disordered breathing in children and variation in methods used to assess the outcome of surgical therapy limit our current knowledge and should be addressed by future research. The high prevalence of sleep-disordered breathing in children should make this research a public health priority.