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

Advances in Sleep-Disordered Breathing in Children

Pediatric sleep-disordered breathing disorders are a group of common conditions, from habitual snoring to obstructive sleep apnea (OSA) syndrome, affecting a significant proportion of children. The present article summarizes the current knowledge on diagnosis and treatment of pediatric OSA focusing on therapeutic and surgical advancements in the field in recent years. Advancements in OSA such as biomarkers, improving continuous pressure therapy adherence, novel pharmacotherapies, and advanced surgeries are discussed.

Is oxidative stress - antioxidants imbalance the physiopathogenic core in pediatric obesity?

Despite the early recognition of obesity as an epidemic with global implications, research on its pathogenesis and therapeutic approach is still on the rise. The literature of the 21st century records an excess weight found in up to 1/3 of children. Both the determining factors and its systemic effects are multiple and variable. Regarding its involvement in the potentiation of cardio-vascular, pulmonary, digestive, metabolic, neuro-psychic or even dermatological diseases, the information is already broadly outlined. The connection between the underlying disease and the associated comorbidities seems to be partially attributable to oxidative stress. In addition to these, and in the light of the recent COVID-19 pandemic, the role played by oxidative stress in the induction, maintenance and potentiation of chronic inflammation among overweight children and adolescents becomes a topic of interest again. Thus, this review's purpose is to update general data on obesity, with an emphasis on the physiopathological mechanisms that underlie it and involve oxidative stress. At the same time, we briefly present the latest principles of pathology diagnosis and management. Among these, we will mainly emphasize the impact played by endogenous and exogenous antioxidants in the evolutionary course of pediatric obesity. In order to achieve our objectives, we will refer to the most recent studies published in the specialized literature.

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.

Persistent Obstructive Sleep Apnea Post-adenotonsillectomy in Children

Background Childhood obstructive sleep apnea (OSA) is a common disorder in children mostly due to adenotonsillar hypertrophy. Therefore, adenotonsillectomy is the mainstay of treatment. However, the outcome of adenotonsillectomy is limited in some patients who develop persistent OSA (POSA). We aim to evaluate the prevalence, risk factors, and treatments of POSA in the pediatric population in Qatar. Methodology This is a retrospective review of medical electronic records of patients aged 1-18 years, who underwent adenoidectomy and/or tonsillectomy at Sidra Medicine (Doha, Qatar) between June 2017 and September 2022. Demographic, clinical, and polysomnography (PSG) data were collected. POSA was defined as the persistence of at least one of the following OSA symptoms: snoring, gasping, mouth breathing or witnessed sleep apnea during post-surgery clinic visits, and/or post-surgical diagnosis of OSA by PSG. The prevalence of POSA was defined as the number of patients who had persistent symptoms divided by patients who were followed at outpatient clinics (ENT/pulmonology) post-surgery. Risk factors for POSA were evaluated using multivariate regression analysis. Results A total of 410 patients (259 males and 151 females) underwent adenotonsillectomy during the study period. The average age at surgery was 3.6 ± 2.5 years. The majority of patients (85.9%) had no history of underlying medical conditions. The rest of the patients (14.1%) were diagnosed with chromosomal abnormalities or neuromuscular disorders. All patients (100%) had a history of snoring before surgery, and 32.4% of patients had a history of witnessed sleep apnea. A total of 52 patients had persistent symptoms four months post-surgery. POSA prevalence was estimated at 15.4%. Univariate analysis showed young age at the time of surgery (p = 0.015), history of asthma (23%, 12/52) (p = 0.002), allergic rhinitis (13%, 7/52) (p = 0.001), gastroesophageal reflux disease ((11%, 6/52) (p < 0.001), and genetic syndromes (17%, 9/52) (p < 0.005) as significant risk factors for POSA. Multiple regression analysis showed that syndromic disorders and allergic rhinitis were significantly correlated with persistent OSA (p = 0.021 and p = 0.000, respectively). Conclusions POSA is prevalent in children post-tonsillectomy and adenoidectomy, especially in patients with genetic syndromes and those with symptoms of allergic rhinitis. Future studies are needed to better define the condition and provide evidence-based diagnostic and therapeutic approaches.

Evaluation of Sleep Quality in Asthmatic Children with the Paediatric Sleep Questionnaire (PSQ)

Considering the high prevalence of sleep-related breathing disorders (SRBD) in asthmatic patients, we aimed to compare asthmatic children and healthy children in terms of SRBD according to Paediatric Sleep Questionnaire (PSQ) scores. A questionnaire covering sociodemographic characteristics of the patients and the PSQ, which evaluates sleep quality and consists of 22 questions, was administered. During the data collection process, 180 patients in the patient group and 170 patients in the control group were included. The patient group showed statistically significantly higher total scores and subscale scores for snoring, sleepiness, and inattention compared to the control group. Statistically significant correlations were found between the sleepiness subscale and body mass index z score in a negative direction and between age at presentation and duration of asthma in a positive direction. Our findings endorse employing the PSQ as a screening instrument in the outpatient environment to ensure timely referral of asthma patients to a sleep specialist for SRBD evaluation. Considering the widespread occurrence of snoring and asthma, this tool could aid in identifying patients with an elevated risk of SRBD and expedite the scheduling of nocturnal polysomnography for these children.

The latest on positive airway pressure for pediatric obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is an important and evolving area in the pediatric population, with significant sequelae when not adequately managed. The use of positive airway pressure (PAP) therapy is expanding rapidly and is being prescribed to patients with persistent OSA post adenotonsillectomy as well as those children who are not surgical candidates including those with medical complexity.

AREAS DISCUSSED

This article provides a state-of-the-art review on the diagnosis of pediatric OSA and treatment with positive airway pressure (PAP). The initiation of PAP therapy, pediatric interface considerations, PAP mode selection, administration and potential complications of PAP therapy, factors influencing PAP adherence, the use of remote ventilation machine downloads, considerations surrounding follow-up of patients post PAP initiation and evaluation of weaning off PAP will be reviewed. The literature search was conducted via PubMed, Cochrane Library and Google Scholar databases through to March 2024.

EXPERT OPINION

Further research is required to address barriers to adherence. Further innovation of home monitoring devices for both the diagnosis and assessment of OSA is required, given the limited pediatric sleep medicine resources in several countries worldwide.

Sleep and Autism: Current Research, Clinical Assessment, and Treatment Strategies

Autism spectrum disorder is associated with a high rate of sleep problems, affecting over 80% of autistic individuals. Sleep problems have pervasive negative effects on health, behavior, mood, and cognition but are underrecognized in autistic children. Problems initiating and maintaining sleep-hallmarks of insomnia-are common. Sleep-disordered breathing and restless legs syndrome have also been described in autism at a higher prevalence than in community populations. The authors describe current research on sleep in autistic children and potential pathophysiologic mechanisms. They describe practical approaches to sleep assessment and synthesize approaches to addressing sleep problems in autistic children.

Comparing Sleep Patterns and Clinical Features between Preschool and School-Age Children with OSA

OBJECTIVE

This study aimed to evaluate sleep patterns and investigate differences in clinical features among young individuals with snoring and obstructive sleep apnea (OSA).

METHODS

Data from 213 children and adolescents who underwent polysomnography (PSG) for primary snoring or OSA were collected between July 2017 and December 2021. To analyze differences in sleep architecture, hypoxia levels, and other clinical features, the participants were divided into two age groups: a preschool group and a school-age group.

RESULTS

The school-age group had significantly higher apnea-hypopnea index, obstructive apnea index, oxygen desaturation index, and body mass index than the preschool group. Both the lowest and average oxygen saturation levels were lower in the school-age group. Adenoid hypertrophy was more prevalent in the preschool group. The rate of overweight or obesity was 35.6% in the preschool group and even 94.2% in the school-age group. There were higher percentages of N1 and N2 sleep stages, and lower percentages of N3 and REM sleep stages in the school-age group. The groups exhibiting moderate to severe OSA demonstrated significant alterations in the difference between sleeping and waking diastolic blood pressure.

CONCLUSION

There is a higher frequency of respiratory events among school-age children compared with their preschool peers. Moreover, alterations in sleep structure are more prominent in the school-age group. Adenoid hypertrophy may serve as the primary instigator of OSA in preschool children, whereas the predominant causes in school-age children may be obesity or excessive weight.

LEVEL OF EVIDENCE

Retrospective chart review, 3 Laryngoscope, 134:1472-1478, 2024.

Association of allergic rhinitis with persistent obstructive sleep apnea: A secondary analysis of the childhood adenotonsillectomy trial

STUDY OBJECTIVES

Allergic rhinitis (AR) is frequently reported in children suffering from obstructive sleep apnea (OSA). This study aimed to assess whether children with AR are more likely to experience persistent OSA after AT.

METHODS

This study is a secondary analysis of a multi-center randomized clinical trial, the Childhood Adenotonsillectomy Trial. Children were categorized into the AR group or Non-AR group according to AR response. A subgroup analysis was conducted using a logistic regression model.

RESULTS

A total of 372 children (177 boys [47.6%]; median [IQR] age, 6.0 [5.0-8.0] years) were analyzed. Approximately 25% (93/372) of children presented with AR. Baseline data indicated higher PSQ scores and OSA-18 scores in the AR group. Children with AR demonstrated lower OSA resolution rates after AT (aOR, 0.43; 95% CI, 0.19 to 0.96). However, there was no significant difference in OSA resolution between the AR and Non-AR groups who underwent watchful waiting (aOR, 0.98; 95% CI, 0.50 to 1.93). Also, the AR group was more likely to maintain a PSQ score greater than 0.33 after AT (OR, 2.16; 95% CI, 1.01 to 4.61). There was no significant association between AR and higher follow-up OSA-18 scores after AT and watchful waiting.

CONCLUSIONS

In this secondary analysis, children with AR were more likely to experience persistent OSA, highlighting the importance of effective AR management even post-adenotonsillectomy. A purposefully designed, prospective randomized trial is needed to verify the association between AR and persistent OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00560859.

New Approaches to the Management of Cardiovascular Risk Associated with Sleep Respiratory Disorders in Pediatric Patients

Exposure to risk factors in youth can exacerbate the development of future cardiovascular disease (CVD). Obstructive sleep apnea (OSA), characterized by repetitive episodes of airway obstructions, could trigger said CVD acting as a modifiable risk factor. Measurements from echocardiography have shown impairments in the anatomy and function of the heart related to the severity of OSA. Therefore, the aim of this review was to propose a new clinical approach to the management of cardiovascular risk (CVR) in children based on treating OSA. The review includes studies assessing echocardiographic parameters for cardiac function and structure in pediatric OSA diagnosed using the apnea-hypopnea index (AHI) ≥ 1/h using polysomnography (PSG) and conducted within a year. Based on the reviewed evidence, in addition to PSG, echocardiography should be considered in OSA children in order to indicate the need for treatment and to reduce their future CVR. A follow-up echocardiography after treatment could be performed if impairments in the anatomy and function were found. Prioritizing parameters intimately connected to comorbidity could propel more effective patient-centered care. In conclusion, a reevaluation of pediatric OSA strategies should be considered, emphasizing comorbidity-related parameters in the cardiovascular field. Further studies are needed to assess this approach, potentially leading to enhanced protocols for more effective pediatric OSA treatment and CVR prevention.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Dysphagia Outcomes Before and After Adenotonsillectomy in Children With Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial

Importance

Obstructive sleep apnea (OSA) and tonsil hypertrophy may be associated with dysphagia. However, randomized clinical trials assessing dysphagia outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting with supportive care (WWSC) are lacking.

Objective

To assess dysphagia outcomes in children with OSA and tonsil hypertrophy managed with AT or WWSC.

Design, Setting, and Participants

This secondary analysis of a multicenter randomized clinical trial, the Childhood Adenotonsillectomy Trial (CHAT), was conducted at tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to AT or WWSC and underwent polysomnography at baseline and 7 months. Caregivers completed the OSA-18 questionnaire, which includes an item on difficulty in swallowing at baseline and 7 months. The current secondary analysis was conducted from December 1, 2022, to January 10, 2023.

Interventions

AT vs WWSC.

Main Outcomes and Measures

Prevalence of dysphagia, based on parental responses to the difficulty in swallowing item on the OSA-18 questionnaire, was redefined as a binary outcome at baseline and 7-month follow-up.

Results

In total, 386 children were included (199 female [51.6%]; median [IQR] age, 6.0 [5.0-8.0] years). Of the total, 207 children were Black (53.6%). At baseline, the number of children with dysphagia was similar (4.0%; 95% CI, -4.9% to 12.9%) between the AT group (56 [29.8%]) and the WWSC group (51 [25.8%]). Following AT, a decrease was observed (21.3%; 95% CI, 13.5%-28.9%) in the prevalence of dysphagia among the children. In contrast, the prevalence of dysphagia did not change significantly (1.0%; 95% CI, -7.6% to 9.6%) in the WWSC group. Children in the AT group were more likely to experience a resolution of dysphagia than those in the WWSC group (adjusted odds ratio, 4.84; 95% CI, 1.91-12.25). Higher baseline AHI was associated with a lower resolution of dysphagia (AOR, 0.91; 95% CI, 0.83-0.98).

Conclusions and Relevance

This secondary analysis of the CHAT randomized clinical trial suggested that children with dysphagia and OSA undergoing AT may experience dysphagia improvement. A prospective randomized trial that uses a validated dysphagia survey is needed to verify the effectiveness of AT in treating dysphagia.

Trial registration

ClinicalTrials.gov Identifier: NCT00560859.

Medical Treatment of Obstructive Sleep Apnea in Children

Obstructive sleep apnea (OSA) is characterized by recurrent complete or partial obstruction of the upper airway. The prevalence is 1-4% in children aged between 2 and 8 years and rising due to the increase in obesity rates in children. Although persistent OSA following adenotonsillectomy is usually associated with obesity and underlying complex disorders, it can also affect otherwise healthy children. Medical treatment strategies are frequently required when adenotonsillectomy is not indicated in children with OSA or if OSA is persistent following adenotonsillectomy. Positive airway pressure treatment is a very effective modality for persistent OSA in childhood; however, adherence rates are low. The aim of this review article is to summarize medical treatment options for OSA in children.

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.