The effect of weight loss on sleep-disordered breathing in obese teenagers

Pediatric obstructive sleep apnea-related risk factors: A cross-sectional study

OBJECTIVES

This study investigated obstructive sleep apnea (OSA)-related risk factors in children and adolescents.

MATERIALS AND METHODS

Records of 187 subjects from a private medical clinic were reviewed. Overnight polysomnography recordings and self/parent reports were gathered. Descriptive analysis of sociodemographic, anthropometric, sleep quality and sleep architecture variables and OSA diagnosis were performed. Associations between independent variables and OSA diagnosis were assessed through multivariable logistic regression with robust variance, with a significance level of 5%.  Results: 132 participants were diagnosed with OSA, and 55 were classified as "no OSA" (29.41%). Those overweight or obese were 4.97 times more likely to have OSA than those with normal weight (P =  0.005). Those who reported loud snoring were 2.78 times more likely to have OSA than those who reported mild or moderate snoring intensity. A one-unit increase in arousal index leads to 1.39 increase in the odds ratio (OR) of individuals diagnosed with OSA (P < 0.001), and each one-unit increase in sleep efficiency leads to 1.09 higher odds of not having OSA (P =  0.002).

CONCLUSIONS

Significantly increased OSA-related risk factors among overweight/obese children and adolescents and among those who had a parental/self-report of loud snoring were found.

Non-Pharmacological Treatment for Cardiovascular Risk Prevention in Children and Adolescents with Obesity

In younger generations, excess weight has reached very alarming levels. Excess weight in adults is associated with increased mortality and morbidity from cardiovascular disease. However, it is not easy to distinguish to what extent these effects are the result of obesity itself or how much is due to the various cardiovascular risk factors that often accompany excess weight. Several risk factors, such as hypertension, dyslipidemia, hyperuricemia, glucose intolerance, and type 2 diabetes mellitus, are already present in pediatric age. Therefore, early intervention with the goal of correcting and/or eliminating them is particularly important. In the child and adolescent with obesity, the first approach to achieve weight reduction and correct the risk factors associated with severe excess weight should always be non-pharmacologic and based on changing poor eating habits and unhealthy lifestyles. The purpose of this review is to give an update on non-pharmacological interventions to be implemented for cardiovascular prevention in children and adolescents with obesity, and their effectiveness. In particular, interventions targeting each individual cardiovascular risk factor will be discussed.

Screening for obstructive sleep apnea (OSA) in children and adolescents with obesity: A scoping review of national and international pediatric obesity and pediatric OSA management guidelines

Obstructive sleep apnea (OSA) is a prevalent complication that affects up to 60% of children and adolescents with obesity. It is associated with poorer cardiometabolic outcomes and neurocognitive deficits. Appropriate screening and intervention for OSA are crucial in the management of children with obesity. We performed a scoping review of international and national pediatric obesity (n = 30) and pediatric OSA (n = 10) management guidelines to evaluate the recommendations on OSA screening in pediatric obesity. Sixteen (53%) of the pediatric obesity guidelines had incorporated OSA screening to varying extents, with no consistent recommendations on when and how to screen for OSA, and subsequent management of OSA in children with obesity. We provide our recommendations that are based on the strength and certainty of evidence presented. These include a clinical-based screening for OSA in all children with body mass index (BMI) ≥ 85th percentile or those with rapid BMI gain (upward crossing of 2 BMI percentiles) and the use of overnight polysomnography to confirm the diagnosis of OSA in those with high clinical suspicion. We discuss further management of OSA unique to children with obesity. An appropriate screening strategy for OSA would facilitate timely intervention that has been shown to improve cardiometabolic and neurocognitive outcomes.

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.

Effect of Obesity on the Respiratory Parameters in Children with Obstructive Sleep Apnea Syndrome

The aim of the study was to investigate how obesity can influence sleep respiratory parameters in obstructive sleep apnea syndrome (OSAS) in children.

METHODS

The study analyzes 56 Caucasian children and adolescents aged 11 ± 2.79 years with a BMI > 5th percentiles and a PSQ value ≥ 0.33. Children were divided into Obesity Group (OG) with BMI ≥ 95th and Control Group (CG) with 5th < BMI > 95th percentile. All selected children underwent PG. Respiratory parameters AHI (Apnea-Hypopnea Index), SaO2 (Saturation of Oxygen), ODI (Oxygen Desaturation Index), and Nadir (the lowest value of SaO2 registered during PG) were extracted from the PG. AHI was used to divide the severity of OSAS into four levels: snoring (AHI ≤ 1), mild (AHI > 1 and ≤5), moderate (AHI > 5 and <10), and severe (AHI ≥ 10).

RESULTS

The comparison analysis between the OG and CG showed a statistical significance only for ODI (p = 0.02). A statistically significant correlation between BMI and AHI (r = 0.02), SaO2 (r = 0.01), and Nadir O2 (r = 0.02) was found.

CONCLUSIONS

There was no strong correlation between obesity and OSAS, but a positive association was found between BMI and AHI severity.

Weight Loss and Sleep, Current Evidence in Animal Models and Humans

Sleep is a vital process essential for survival. The trend of reduction in the time dedicated to sleep has increased in industrialized countries, together with the dramatic increase in the prevalence of obesity and diabetes. Short sleep may increase the risk of obesity, diabetes and cardiovascular disease, and on the other hand, obesity is associated with sleep disorders, such as obstructive apnea disease, insomnia and excessive daytime sleepiness. Sleep and metabolic disorders are linked; therefore, identifying the physiological and molecular pathways involved in sleep regulation and metabolic homeostasis can play a major role in ameliorating the metabolic health of the individual. Approaches aimed at reducing body weight could provide benefits for both cardiometabolic risk and sleep quality, which indirectly, in turn, may determine an amelioration of the cardiometabolic phenotype of individuals. We revised the literature on weight loss and sleep, focusing on the mechanisms and the molecules that may subtend this relationship in humans as in animal models.

Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: A systematic review and meta-analysis

There is a need for a detailed understanding of effective dietary interventions for children with obesity. This systematic review examined the effectiveness of diets of varying energy content as a component of weight treatment in children and adolescents with obesity, severe obesity and obesity-related comorbidity. A systematic search of six databases, from 2000 to 2021, for intervention studies of targeted dietary treatment for obesity in children aged 2-18 years identified 125 studies. Dietary interventions were grouped according to diet type and energy target. Risk of bias was assessed using the Effective Public Healthcare Panacea Project assessment tool. Meta-analysis examined change in body mass index (BMI) at intervention end. A broad array of diet types were effective at reducing BMI in children with obesity. When dietary types were considered by energy target, a gradient effect was observed. Very-low energy diets were most effective with a - 4.40 kg/m² (n = 3; 95% CI -7.01 to -1.79). While dietary interventions with no specified energy target were ineffective, resulting in a BMI gain of +0.17 kg/m² (n = 22; 95% CI 0.05 to 0.40). Practical definitions of dietary energy target in the management of obesity and severe obesity are urgently required to ensure treatment seeking children have timely access to efficacious interventions.

Impact of OSA treatment success on changes in hypertension and obesity: A retrospective cohort study

OBJECTIVE

Pediatric obstructive sleep apnea (OSA) has been shown to lead to the development of chronic cardiometabolic conditions, including obesity and cardiovascular disease. We sought to describe the impact of the success of continuous positive airway pressure (CPAP) and surgery, common treatment options for pediatric OSA, on cardiometabolic conditions.

METHODS

A retrospective review of patients (≤18 years) diagnosed with OSA based on a polysomnogram at a tertiary care pediatric otolaryngology practice from 2015 to 2019 was conducted. Clinical data, including the systolic blood pressure (SBP) values, body mass index (BMI), overall apnea/hypopnea index (AHI) values, and CPAP compliance, were collected. Linear mixed-effects models were developed to observe the relationship between the clinical measurements of each comorbidity and OSA treatment modalities.

RESULTS

414 patients were included. BMI and SBP measures were collected for 230 and 184 patients respectively. The difference-in-difference estimate for the SBP z-score percentile after successful treatment was -5.5 ± 2.1 percentile units per 100 days. The difference-in-difference estimate for SBP z-score percentile after successful CPAP treatment was -13.2 ± 5.1 percentile units per 100 days while the estimate after successful surgical treatment was -4.6 ± 2.4 percentile units per 100 days. No significant differences were found between clinical measures for obese patients in any treatment cohort.

CONCLUSIONS

Successful OSA management was shown to have a positive impact on SBP in hypertensive patients and no impact on BMI in obese patients. In hypertensive patients, CPAP success tripled improvements in SBP z-score percentile compared to surgical treatment success.

Adenotonsillectomy outcomes in obese adolescents with obstructive sleep apnea

STUDY OBJECTIVES

(1) To assess adenotonsillectomy (AT) outcomes in adolescents with obesity and with obstructive sleep apnea (OSA); (2) To identify clinical factors predicting OSA in adolescents following AT.

METHODS

Adolescents 12 to 18 years old with obesity who underwent AT for OSA were included. Subjects had pre-AT and post-AT polysomnogram. Nonobese adolescents with OSA that underwent AT were included as a comparison.

RESULTS

Seventy adolescents with obesity with a mean age of 14.2 years and a mean body mass index of 38.0 kg/m2 were included. Patients in the nonobese group (n = 32) were similar demographically to the obese group, with the exception of body mass index. The majority of adolescents with obesity (74%) had severe OSA (apnea-hypopnea index [AHI] ≥ 10 events/h) with a mean baseline AHI of 33.9 events/h (standard deviation 28.5). The obese and control groups experienced clinically meaningful improvements in AHI following AT, with median change scores of 18.3 (95% confidence interval -29.2, -11.2, P < .001) and 14.6 (95% confidence interval -25.5, -8.5, P < .001), respectively. In the adolescents with obesity, 48% had an AHI < 5 events/h on postoperative PSG. However, adolescents with obesity were 7 times more likely (odds ratio = 7.1, 95% confidence interval [2.24, 22.48], P = .001) to have moderate or severe persistent OSA (AHI > 5 events/h) after AT compared with patients who were not obese. The need for post-AT positive airway pressure therapy was significantly higher in adolescents with obesity, with 37.1% of participants requiring this therapy (odds ratio = 8.3, 95% confidence interval 1.8, 37.6, P < .001).

CONCLUSIONS

AT results in improvement in polysomnogram parameters in adolescents with obesity and OSA. However, patients with obesity are at high risk for persistent OSA. Future research should include prospective trials to compare outcomes between AT and positive airway pressure therapy for adolescents with obesity.

CITATION

Kearney TC, Vazifedan T, Baldassari CM. Adenotonsillectomy outcomes in obese adolescents with obstructive sleep apnea. J Clin Sleep Med. 2022;18(12):2855-2860.

The Association between Asthma and OSA in Children

Obstructive sleep apnea (OSA) and asthma are two of the most prevalent and commonly co-existing respiratory conditions seen in the pediatric population. Studies linking asthma and OSA in children are limited but indicate that there is a bi-directional relationship between them with significant overlap in the symptoms, risk factors, pathophysiology, comorbidities, and management. It is suggested that there is a reciprocal association between asthma predisposing to OSA, and OSA worsening symptom control and outcomes from asthma. It stands to reason that inflammation in the upper and/or lower airways can influence each other. Most of the pediatric literature that is available evaluates each aspect of this relationship independently such as risk factors, mechanisms, and treatment indications. This article highlights the relationship between OSA and asthma in the context of shared risk factors, pathophysiology, and available management recommendations in the pediatric population. Early recognition of the co-existence and association between OSA and asthma could ideally improve the treatment outcomes for these two conditions. Gaining a better understanding of the mechanism of this relationship can help identify nuances for medical management, optimize treatment and protect this population at risk from associated morbidity.

Correlation of cephalometric variables with obstructive sleep apnea severity among children: a hierarchical regression analysis

OBJECTIVE

To evaluate the correlation between cephalometric parameters and apnea-hypopnea index (AHI) after controlling gender, body mass index (BMI), and adenoid size in children with obstructive sleep apnea (OSA).

METHODS

Sixty-four children with OSA (40 males, 24 females, 8.72 ± 0.899 years) were chosen by simple random sampling for a cross-sectional study from January 2018 to March 2022. They were diagnosed with OSA, assessed by Obstructive Sleep Apnea-18 questionnaire and home polysomnography and underwent lateral cephalograms.

RESULTS

Hierarchical regression analysis indicated that cephalometric parameters (except adenoid size) were associated with OSA severity, explaining 18.1% of the AHI variance. Among cephalometric measurements, AHI was positively associated with H-RGn and N-Go-Me angle (p < 0.05) and negatively associated with NP (p < 0.05).

CONCLUSION

The sagittal diameter of the oropharynx, lower gonial angle, and hyoid position are significant AHI predictors in children with OSA, independent of demographic characteristics and adenoid size.

Progression of Obstructive Sleep Apnea Syndrome in Pediatric Patients with Prader-Willi Syndrome

Obstructive sleep apnea syndrome (OSAS) is one of the most common comorbidities in patients with Prader-Willi syndrome (PWS) and causes significant consequences. This observational study was conducted to investigate the progression of OSAS in pediatric patients with PWS, who had not undergone upper airway surgery, through a longitudinal follow-up of their annual polysomnography results. Annual body mass index (BMI), BMI z-score, sleep efficiency and stages, central apnea index (CAI), obstructive apnea-hypopnea index (OAHI), and oxygen saturation nadir values were longitudinally analyzed. At enrollment, of 22 patients (10 boys and 12 girls) aged 11.7 ± 3.9 years, 20 had OSAS. During the 4-year follow-up, only two patients had a spontaneous resolution of OSAS. The average BMI and BMI z-score increased gradually, but CAI and OAHI showed no significant differences. After statistical adjustment for sex, age, genotype, growth hormone use, and BMI z-score, OAHI was associated with the BMI z-score and deletion genotype. In conclusion, OSAS is common in patients with PWS, and rarely resolved spontaneously. Watchful waiting may not be the best OSAS management strategy. Weight maintenance and careful selection of surgical candidates are important for OSAS treatment in patients with PWS.

Pediatric Sleep Medicine Cases

Purpose of the Review

In this review, we will discuss commonly encountered pediatric sleep disorders, their clinical presentations, evaluation, and management.

Recent Findings

Sleep problems are common complaints in the pediatric population with an estimated prevalence of at least 25%. This review examines frequently seen pediatric sleep disorders including insomnia, obstructive sleep apnea, hypersomnolence, circadian rhythm sleep–wake disorders, parasomnias, and movement disorders. Their clinical manifestations vary, but left untreated, these sleep disorders result in significant impairment. A detailed sleep history is key component in the evaluation process. Other useful tools include sleep diaries, questionnaires, and actigraphy. Polysomnography is often required for diagnosis. Treatment varies depending on the underlying sleep disorder. Pharmacologic treatment is often limited due to the lack of studies of safety and efficacy in the pediatric population.

Summary

Sleep disorders are commonly encountered in the pediatric population. Their clinical manifestations vary, though without treatment, many result in significant impairment. Detailed sleep history is an essential part of the evaluation process, though polysomnography is often required. Treatment depends on the underlying diagnosis.

Evaluation of obesity and asthma as risk factors for moderate to severe obstructive sleep apnea in children

STUDY OBJECTIVES

Asthma and obesity are risk factors for obstructive sleep apnea (OSA) in children but their link to OSA severity is uncertain. We aimed at determining whether asthma or obesity were associated with an increased risk of moderate/severe OSA.

METHODS

Children undergoing a one-night polysomnography for suspicion of OSA were retrospectively included. Univariate and multivariate analyses were conducted to assess the clinical and demographic characteristics linked to moderate/severe OSA (obstructive apnea-hypopnea index ≥ 5/h of sleep) with odds ratio (OR) and 95% confidence interval reported.

RESULTS

490 children (311 (64%) boys) were included with a median [25th; 75th percentile] age of 8.7 [5.4; 12.9] years, 164 (33%) non-asthmatics non-obese, 122 (25%) obese non-asthmatics, 125 (26%) asthmatics non-obese, 79 (16%) asthmatics and obese. Moderate/severe OSA was present in 157 (32%) children (75/157 (48%) obese and 52/157 (33%) asthmatics). Independent factors associated with increased or decreased risk of moderate/severe OSA were: obesity and male sex (OR 1.82 [1.16; 2.87], P = 0.01, and 1.55 [1.02; 2.36], P = 0.04, respectively), and current asthma, age >6 years or behavioral disorders (OR 0.45 [0.29; 0.70], P < 0.001; 0.44 [0.27; 0.73], P < 0.001; and 0.55 [0.33; 0.92], P = 0.02, respectively). Abnormal resistance of the respiratory system (measured in 241 children), but not abnormal spirometry (measured in 213 children), increased the risk of moderate/severe OSA (OR 2.95 [1.46-5.96], P = 0.003).

CONCLUSIONS

In our cohort enriched in obese and asthmatic children, obesity was associated with higher risk of moderate/severe OSA whereas current asthma was not.

Polysomnographic comparison of sleep in children with obesity and normal weight without suspected sleep-related breathing disorder

Short sleep and obstructive apneas/hypopneas have been shown to be associated with childhood obesity. Still, few studies have compared sleep in children with obesity, without suspected sleep disordered breathing and normal weight peers by objective sleep measures and compared results with subjective parent assessment of sleep. Children with obesity aged 7-13 years (N = 44) and a matched group of normal weight children (N = 42) completed clinical polysomnography (Embla A10 Recording System). Parents scored their children's sleep on the Children's Sleep Habits Questionnaire (CSHQ). Mann-Whitney U tests were used to compare groups. There was a higher obstructive apnea/hypopnea index (AHI) (median obesity = 1.20 vs. median normal  = 0.66; z = -1.33, U = 560.50, p = 0.002) and number of oxygen desaturation events per hour (median obesity = 0.7 vs. median normal  = 0.2; z = -3.45, U = 402.50, p = 0.001) in the children with obesity compared to children with normal weight. The children with obesity had a significantly longer sleep duration (median obesity 8:50 h = vs. median normal = 8:32 h; z = -2.05, U = 687.00, p = 0.041), longer stage N2 sleep (median obesity = 87 min vs. median normal = 52 min; z = -2.87, U = 576.50, p = 0. 004) and shorter REM sleep (median obesity = 94 min vs. median normal = 121 min; z = 5.05, U = 1477.00, p ≤ .001). No differences were observed for time in sleep stage N1 and N3, wake time after sleep onset or the total arousal index . Further, no group differences were found on the CSHQ sleep-disordered breathing sub-scale (p = 0.399). The children with obesity demonstrated significantly more mild to moderate sleep disordered breathing than children with normal weight, although this was not corroborated by parent report.

Innovations in the Treatment of Pediatric Obstructive Sleep Apnea

Obstructive sleep apnea affects a large proportion of otherwise healthy children in the context of interactions between craniofacial elements, adenotonsillar hypertrophy and other anatomical factors, and neuromuscular reflexes of the upper airway. In light of the adverse consequences of sleep apnea, it is important not only to proceed with early diagnosis but also to implement adequate treatment that is guided by the pathophysiological determinants of the disease in each child. Here, we will describe the current standard of care approaches to the treatment of pediatric obstructive sleep apnea, and will also explore novel management strategies that should enable more personalized therapy in the near future.

Prevalence of PErioperAtive CHildhood obesitY in children undergoing general anaesthesia in the UK: a prospective, multicentre, observational cohort study

BACKGROUND

Childhood obesity has become a serious global healthcare challenge. No UK data currently define its anaesthetic and perioperative implications. We aimed to determine obesity prevalence amongst UK children undergoing general anaesthesia and the incidence of predefined adverse perioperative events, and to compare perioperative obesity rates with National Child Measurement Programme (NCMP) data.

METHODS

During a site-selected consecutive 7-day study period, all children (2-16 yr) undergoing general anaesthesia were included. Anonymised hospital, surgical, and procedural details; demographic data; and adverse perioperative events were collected prospectively by Paediatric Anaesthesia Trainee Research Network (PATRN) collaborators.

RESULTS

For this study, 102 UK hospitals participated and 4232 cases were included in the final analysis; 76% of hospitals did not routinely calculate BMI. In addition, 3030 (71.6%; 95% confidence interval [CI]: 70.2-73.0%) children of healthy weight were compared with 537 (12.7%; 11.7-13.7%) children who were overweight and 478 (11.3%; 10.3-12.2%) children with obesity. Children with obesity (n=71; 14.9%) more commonly underwent (adeno)tonsillectomy than children of healthy weight (n=282; 9.3%; P<0.001; odds ratio [OR] 2.15; 95% CI: 1.58-2.92). Fewer children with obesity (n=365; 77% vs n=2552; 85%) were anaesthetised by consultant anaesthetists (OR 0.62; 95% CI: 0.48-0.79). Mask ventilation was difficult for 3.7% of children with obesity vs 0.6% of children of healthy weight (difference 3.0%; 95% CI: 1.3-4.7%; P<0.001). Comparison with NCMP data demonstrated an over-representation of obesity amongst the paediatric surgical population.

CONCLUSIONS

This large multicentre cohort study suggests a concerning prevalence of children with obesity presenting for anaesthesia. These results should be used to inform optimal provision of care for this population and support perioperative healthcare initiatives to address the burden of childhood obesity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03994419.

[Diagnostic criteria for obstructive sleep apnea syndrome in adolescent]

The obstructive sleep apnoea syndrome (OSAS) affects 1-4% of adolescents. It represents a transitional stage between paediatric and adult OSA and is characterized by specific symptoms. BACKGROUND: The persistence of childhood OSAS during adolescence is not frequent. Risk factors are male sex, obesity and a history of tonsillectomy or adenoidectomy. Symptoms may be misleading such as tiredness and depressive disorders. In adolescence, untreated OSAS may result in neuro-behavioural and cognitive deficits, systemic inflammation, cardiovascular and metabolic disorders. The French Society of Research and Sleep Medicine organized a meeting on OSAS in adolescents. A multidisciplinary group of specialists (pulmonologists, pediatricians, ENT and maxillo-facial surgeons, dentofacial orthopedists/orthodontists, myofunctional therapists and sleep specialists) exchanged their experience, discussed publications and drew up a consensus document on the diagnosis and polysomnographic criteria for OSAS in adolescents. They proposed a practical diagnostic guideline and follow-up for these adolescents. OUTLOOK AND CONCLUSION: A good knowledge of the particularities of this pathology by the physician will lead to an early diagnosis, propose adapted multifactorial treatments and avoid the deleterious consequences of this pathology at adult age.

Parental Perception of Weight Status for Adenotonsillectomy Patients

OBJECTIVE

Weight status can affect outcomes in pediatric adenotonsillectomy performed for obstructive sleep disordered breathing. Parents frequently underestimate their child's weight and are unaware weight status may affect adenotonsillectomy success. Accurate understanding of a child's weight status is important for shared decision making with the family and perioperative care. The purpose of this study is to analyze the accuracy of the parent's perception of their child's weight status.

METHODS

A retrospective analysis was performed of prospective data collected from families of children undergoing adenotonsillectomy from June 2018 through June 2019.

RESULTS

A total of 522 children met the inclusion criteria. Two hundred and thirty-two children were either overweight (n = 46, 9%) or obese (n = 186, 36%). Among parents of this cohort whose children were overweight or obese, 74 (32%) erroneously reported that their child was normal weight. For the 290 nonoverweight children, 99% of parents accurately reported weight status. After adjusting for ethnicity, race, BMI%, and sex, for every 1-year increase in age of the child, the odds of the parent correctly identifying their child as overweight increased by a factor of 1.18 (95% CI: 1.09, 1.27).

CONCLUSION

One-third of families with children who were overweight or obese undergoing adenotonsillectomy for obstructive sleep disordered breathing underestimated their child's weight. This study highlights the need to facilitate family understanding of weight status' potential impact on both obstructive sleep disordered breathing severity and adenotonsillectomy success, especially for younger children.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2121-2125, 2021.

The impact of obstructive sleep apnea on endothelial function during weight loss in an obese pediatric population

BACKGROUND

Childhood obesity is an increasing problem with substantial comorbidities such as obstructive sleep apnea (OSA) and increased cardiovascular morbidity. Endothelial dysfunction is an underlying mechanism related to both obesity and OSA.

RESEARCH QUESTION

To investigate the effect of weight loss on endothelial function and OSA in obese children and to determine whether a change in endothelial function can be linked to an improvement in OSA.

METHODS

Obese children between 8 and 18 years of age were recruited while entering a 12-month inpatient weight loss program. Patients were followed at 3 study visits: baseline, after 10 months of weight loss, and 6 months after ending the program (18 months). Anthropometry and endothelial function (EndoPAT) were determined at all study visits. At baseline, sleep screening with a portable device (ApneaLink) was performed. This was repeated after 10 months if OSA was diagnosed at baseline.

RESULTS

At baseline, 130 children were included, of which 87 had OSA (67%). Seventy-two patients attended the follow-up visit at 10 months, and 28 patients attended the follow-up visit at 18 months. The BMI z-score decreased after 10 months (from 2.7 (1.4-3.4) to 1.7 (0.5-2.7); p < 0.001) and remained stable at 18 months. Endothelial function improved significantly after weight loss, evidenced by a shorter time to peak response (TPR) and higher reactive hyperemia index (p = 0.02 and p < 0.001), and remained improved after 18 months (p < 0.001 and p = 0.007). After 10 months of weight loss, 10 patients had residual OSA. These patients had a higher TPR at 10 months (225 (75-285)s) than those without OSA (135 (45-225)s) and patients with a normalized sleep study (105 (45-285)s; p = 0.02). Linear mixed models showed that more severe OSA was associated with a worse TPR at baseline and less improvement after weight loss.

CONCLUSION

Weight loss improves endothelial function in an obese pediatric population. However, even after weight loss, endothelial function improved less in the presence of OSA.

Metabolic alterations and systemic inflammation in overweight/obese children with obstructive sleep apnea

Aim and objective

Systemic inflammation has been documented in obstructive sleep apnea (OSA). However studies on childhood OSA and systemic inflammation are limited. This study aimed to determine the relation between OSA in overweight/obese children and various inflammatory markers.

Material and methods

In this cross sectional study, we enrolled 247 overweight/ obese children from pediatric outpatient services. We evaluated demographic and clinical details, anthropometric parameters, body composition and estimation of inflammatory cytokines such as interleukin (IL) 6, IL-8, IL-10, IL-17, IL-18, IL-23, macrophage migration inhibitory factor (MIF), high sensitive C-reactive protein (Hs-CRP), tumor necrosis factor-alpha (TNF-α), plasminogen activator inhibitor-1 (PAI-1) and leptin levels. Overnight polysomnography was performed.

Findings

A total of 247 children (190 with OSA and 57 without OSA) were enrolled. OSA was documented on polysomnography in 40% of patients. We observed significantly high values body mass index, waist circumference (WC), % body fat, fasting blood glucose (FBG), alanine transaminase (ALT), alkaline phosphate, fasting insulin and HOMA-IR in children with OSA. Inflammatory markers IL-6, IL-8, IL-17, IL-18, MIF, Hs CRP, TNF- α, PAI-1, and leptin levels were significantly higher in OSA patients (p<0.05). There was strong positive correlation of IL-6, IL-8, IL-17, IL-23, MIF, Hs CRP, TNF-A, PAI-1 and leptin with BMI, % body fat, AHI, fasting Insulin, triglyceride, FBG, WC, HOMA-IR, AST and ALT.

Conclusion

Children with OSA have increased obesity, insulin resistance and systemic inflammation. Further studies are require to confirm our findings and evaluate their utility in diagnosis of OSAs, assessing severity and possible interventions.

Night-to-night variability in respiratory parameters in children and adolescents examined for obstructive sleep apnea

INTRODUCTION

The diagnosis of obstructive sleep apnea (OSA) is routinely based on just a single night's sleep examination. The night-to-night variability in children and adolescents has previously been investigated using type 4 sleep monitors or PSG. However, there is a lack of studies investigating the night-to-night variability when using type 3 sleep monitors. Therefore, the main purpose was to investigate the night-to-night variability in respiratory parameters in children and adolescents using a portable type 3 monitor. Furthermore, the purpose was to investigate the clinical relevance of night-to-night variability.

METHODS

The study population was recruited from an ongoing research project concerning the effect of weight loss in children and adolescents with OSA and overweight/obesity. The inclusion criterion was the successful recording of two consecutive nights of sleep. Sleep examinations were recorded at home using the Nox T3 device and then blindly scored by the same registered polysomnographic technologist. To compare the respiratory parameters measured each night, a paired t-test or a Wilcoxon signed-rank test was used. The apnea-hypopnea index (AHI) was further described graphically with a scatter plot and a Bland-Altman plot. The presence and severity of OSA were described in tables.

RESULTS

A total of 30 children and adolescents with a median age of 14.8 years were included. When comparing respiratory parameters between nights, all p-values derived from paired t-tests and Wilcoxon signed-rank tests were >0.05. When considering the graphical depictions of AHI, it was evident that for some participants AHI measurements varied widely from night to night. Regarding the presence of OSA, 27% of participants changed diagnostic category between nights and 40% of those with a normal AHI on the first night had OSA on the second night. Regarding OSA severity, 50% of participants changed severity category between nights.

CONCLUSIONS

AHI measurements varied widely between nights in some children and adolescents leading to frequent changes in both diagnosis and severity of OSA from night to night. We therefore suggest the presence of a clinically relevant night-to-night variability which should be taken into account when diagnosing pediatric OSA.

A multidisciplinary weight loss intervention in obese adolescents with and without sleep-disordered breathing improves cardiometabolic health, whether SDB was normalized or not

OBJECTIVES

Pediatric obesity and sleep-disordered breathing (SDB) are strongly associated, and both promote metabolic impairments. However, the effects of a lifestyle intervention on the overall metabolic syndrome (MetS) are unknown. The objectives were i) to evaluate the effects of a lifestyle intervention on cardiometabolic risk (CMR), assessed with a dichotomous (MetS) and a continuous (MetScore_FM) instrument, in obese adolescents with and without SDB and ii) to compare the post-intervention cardiometabolic responses between adolescents with persistent (apnea-hypopnea index; AHI≥2) or normalized-SDB (AHI<2).

METHODS

Seventy-six adolescents with obesity recruited from two specialized institutions underwent a 9-12month diet and exercise intervention. Sleep and SDB (AHI≥2) were studied by polysomnography. Anthropometric parameters, fat mass (FM), glucose, insulin, lipid and leptin profiles, blood pressure (BP), MetScore_FM and MetS were assessed pre- and post-intervention. We performed comparisons between Non-SDB and SDB groups and between Normalized-SDB and Persistent-SDB subgroups.

RESULTS

Fifty participants completed the study. Pre-intervention, twenty youth had SDB (40%) with higher insulin concentrations and systolic BP than Non-SDB participants (p < 0.01), for a similar degree of obesity. Post-intervention, MetScore_FM (p < 0.001) and MetS prevalence (p < 0.05) were decreased in both groups. Eleven participants (55%) normalized SDB along with a decrease in insulin concentrations and BP (p < 0.05). Triglycerides, total cholesterol and LDL-cholesterol concentrations (p < 0.01) improved equally in the Normalized and Persistent-SDB subgroups.

CONCLUSION

SDB was associated with lower insulin sensitivity and higher BP but did not affect the lipid profile. A diet and exercise lifestyle intervention is effective in decreasing the CMR whether or not SDB was normalized in obese adolescents.

Positional obstructive sleep apnea in an obese pediatric population

STUDY OBJECTIVES

Positional obstructive sleep apnea (POSA) is a phenotype of obstructive sleep apnea (OSA) where sleep-related obstructive events occur predominantly in the supine position. Limited knowledge exists regarding the presence of POSA in children with obesity. The study objective was to determine the prevalence of POSA while identifying factors associated with POSA in children with obesity.

METHODS

This was a cross-sectional study of children with obesity, aged 8 to 18 years, with a diagnostic polysomnogram (PSG) between 2012 to 2019, who were referred for the evaluation of sleep-related breathing. POSA was defined as an overall obstructive apnea-hypopnea index (OAHI) ≥5 events/h and a supine OAHI to nonsupine OAHI ratio of ≥2. Patient demographics, anthropometrics, and PSG data were recorded.

RESULTS

Of the 112 children with obesity with a diagnostic PSG, 43 (38%) had OSA. Among those with OSA, 25 of 43 (58%) had POSA (mean age: 14.6 ± 2.3 years; mean body mass index: 37.7 ± 7.6 kg/m²; 68% male) and 18 of 43 (42%) had non-POSA (mean age: 13.9 ± 2.8 years; mean body mass index: 37.9 ± 7.2 kg/m²; 78% male). Among those with POSA, 13 of 25 (52%) had mild OSA, 7 of 25 (28%) had moderate OSA, and 5 of 25 (20%) had severe OSA. No significant differences were found in age, sex, and anthropometric measures between POSA and non-POSA groups. Time spent in supine and nonsupine sleep did not differ significantly between groups.

CONCLUSIONS

In children with obesity and OSA, POSA occurs frequently. Identifying POSA allows for potential targeted positional therapy for children with obesity.

Home Respiratory Polygraphy is Useful in the Diagnosis of Childhood Obstructive Sleep Apnea Syndrome

The utility of home respiratory polygraphy (HRP) was assessed as an alternative to polysomnography (PSG) in the diagnosis of childhood obstructive sleep apnea syndrome (OSAS). PSG was indicated only in patients with concomitant disease or where HRP results were questionable. The follow-up period was 1 year. We recorded clinical and anthropometric data, physical examination findings, respiratory variables, severity level and choice of therapy. We assessed 121 children, 70 boys and 51 girls, with mean age 7 ± 4 years, mean body mass index (BMI) 19 ± 5 kg/m², and mean BMI percentile 62 ± 38%. We included 104 HRP and 24 PSG recordings. Of the latter, 7 were preceded by HRP (false negatives) and 17 were indicated as the first-choice method owing to concomitant disease. Of the initial HRP recordings, 93% were technically valid. All technically valid HRPs and 96% of PSGs resulted in a diagnosis of OSAS (apnea-hypopnea index 9.5 ± 9.1/h). Thirty-three percent of cases were moderate and 22% severe. Apnea-hypopnea index showed no correlation with BMI or BMI percentile. Adenotonsillectomy was indicated in 93 patients (77%), conservative treatment in 17 (14%), and conservative treatment combined with CPAP/BiPAP in 11 (9%). There were no significant differences between children diagnosed by HRP and by PSG in terms of treatment choice. The prevalence of OSAS in our sample was 96.7%. In conclusion, when the probability of OSAS is high, HRP is usually sufficient for diagnosing the syndrome and establishing therapy in children. PSG is advisable in complex or questionable cases.

Sleep-disordered breathing in adolescents with obesity: When does it start to affect cardiometabolic health?

BACKGROUND AND AIMS

Pediatric obesity and sleep-disordered breathing (SDB) are associated with cardiometabolic risk (CMR), but the degree of severity at which SDB affects cardiometabolic health is unknown. We assessed the relationship between the CMR and the apnea-hypopnea index (AHI), to identify a threshold of AHI from which an increase in the CMR is observed, in adolescents with obesity. We also compared the clinical, cardiometabolic and sleep characteristics between adolescents presenting a high (CMR+) and low CMR (CMR-), according to the threshold of AHI.

METHODS AND RESULTS

114 adolescents with obesity were recruited from three institutions specialized in obesity management. Sleep and SDB as assessed by polysomnography, anthropometric parameters, fat mass (FM), glucose and lipid profiles, and blood pressure (BP) were measured at admission. Continuous (MetScore_FM) and dichotomous (metabolic syndrome, MetS) CMR were determined. Associations between MetScore_FM and AHI adjusted for BMI, sex and age were assessed by multivariable analyses. Data of 82 adolescents were analyzed. Multivariable analyses enabled us to identify a threshold of AHI = 2 above which we observed a strong and significant association between CMR and AHI (Cohen's d effect-size = 0.57 [0.11; 1.02] p = 0.02). Adolescents with CMR+ exhibited higher MetScore_FM (p < 0.05), insulin resistance (p < 0.05), systolic BP (p < 0.001), sleep fragmentation (p < 0.01) and intermittent hypoxia than CMR- group (p < 0.0001). MetS was found in 90.9% of adolescents with CMR+, versus 69.4% in the CMR- group (p < 0.05).

CONCLUSIONS

The identification of a threshold of AHI ≥ 2 corresponding to the cardiometabolic alterations highlights the need for the early management of SDB and obesity in adolescents, to prevent cardiometabolic diseases.

CLINICAL TRIALS

NCT03466359, NCT02588469 and NCT01358773.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.

Obstructive sleep apnea in pediatric obesity and the effects of sleeve gastrectomy

The prevalence of severe pediatric obesity is rising and poses many adverse health risks. Children with obesity are at increased risk of several cardiovascular and metabolic diseases. They are also more likely to have obstructive sleep apnea (OSA), which increases the risk of cardiovascular and metabolic problems. In this review, we examine the relationship between OSA and obesity, improvements in OSA after non-surgical and surgical weight loss, and explore potential directions for future research.

Are obstructive sleep apnea and sleep improved in response to multidisciplinary weight loss interventions in youth with obesity? A systematic review and meta-analysis

BACKGROUND

Pediatric obesity is closely associated with obstructive sleep apnea (OSA) and short sleep duration. While multidisciplinary weight loss interventions are recommended for pediatric obesity management, the evidence for their effects on OSA severity and overall sleep in youth have not been systematically examined.

OBJECTIVES

To conduct a systematic review and meta-analysis investigating the effects of multidisciplinary weight loss interventions on OSA severity and prevalence, and on overall sleep health in youth with obesity.

METHODS

A systematic search of interventional studies (participants age range: 10-19 yrs) was performed using PubMed, CENTRAL and Embase, from inception to May 2019. The quality of the evidence was assessed using the Cochrane risk of bias tool.

RESULTS

Ten studies were included by the end of the screening process. Ninety percent of the included studies reported a decrease in OSA prevalence post-intervention, and OSA was normalized for 46.2-79.7% of the youth. The meta-analysis comprising seven longitudinal studies revealed significant reductions in apnea-hypopnea index (effect size: -0.51, 95%CI -0.94 to -0.08, p = 0.019), and oxygen desaturation index (effect size: -0.28, 95%CI = -0.50 to -0.05, p = 0.016). Seventy-five percent of the studies reported improved sleep duration in youth with OSA.

CONCLUSIONS

Evidence suggests that multidisciplinary weight loss interventions result in improvements in OSA severity and sleep duration in youth with obesity. Future randomized controlled trials are warranted to better assess and understand the independent implications of weight loss, fat mass decrease and chronic exercise on OSA and sleep health in this population.

Long Term Continuous Positive Airway Pressure and Non-invasive Ventilation in Obstructive Sleep Apnea in Children With Obesity and Down Syndrome

This review will focus on non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) therapy in children with obstructive sleep apnea (OSA) due to obesity and underlying syndromes. These children have a high prevalence of OSA and residual OSA after adenotonsillectomy. Therefore, a high proportion of these children are treated with CPAP or NIV. This review will focus on treatment selection tools and will subsequently cover specific issues on CPAP treatment in obese and syndromic children with a major focus on Down syndrome.

Non-invasive Ventilation and CPAP Failure in Children and Indications for Invasive Ventilation

Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) are effective treatments for children with severe sleep disordered breathing (SBD). However, some patients may present too severe SDB that do not respond to NIV/CPAP or insufficient compliance to treatment. A careful revaluation of the interface and of ventilator settings should be performed before considering alternative treatments. In patients with obstructive sleep apnea (OSA), alternatives to CPAP/NIV rely on the underlying disease. Ear-nose-throat (ENT) surgery such as adeno-tonsillectomy (AT), turbinectomy or supraglottoplasty represent an effective treatment in selected patients before starting CPAP/NIV and should be reconsidered in case of CPAP failure. Rapid maxillary expansion (RME) is restricted to children with OSA and a narrow palate who have little adenotonsillar tissue, or for those with residual OSA after AT. Weight loss is the first line therapy for obese children with OSA before starting CPAP and should remain a priority in the long-term. Selected patients may benefit from maxillo-facial surgery such as mandibular distraction osteogenesis (MDO) or from neurosurgery procedures like fronto-facial monobloc advancement. Nasopharyngeal airway (NPA) or high flow nasal cannula (HFNC) may constitute efficient alternatives to CPAP in selected patients. Hypoglossal nerve stimulation has been proposed in children with Down syndrome not tolerant to CPAP. Ultimately, tracheostomy represents the unique alternative in case of failure of all the above-mentioned treatments. All these treatments require a multidisciplinary approach with a personalized treatment tailored on the different diseases and sites of obstruction. In patients with neuromuscular, neurological or lung disorders, non-invasive management in case of NIV failure is more challenging. Diaphragmatic pacing has been proposed for some patients with central congenital hypoventilation syndrome (CCHS) or neurological disorders, however its experience in children is limited. Finally, invasive ventilation via tracheotomy represents again the ultimate alternative for children with severe disease and little or no ventilatory autonomy. However, ethical considerations weighting the efficacy against the burden of this treatment should be discussed before choosing this last option.

[Medical treatment of obstructive sleep-disordered breathing in children and adolescents]

Obstructive sleep disordered breathing (OSDB), in children and adolescents, need to be treated quite soon to avoid complications. A paediatrician, a sleep specialist, an orthodontist, an ENT and a myofunctional therapist will examine together the children with OSDB and determine the best personalised surgical and medical treatments for each of them. Only medical treatments are reviewed in this article. An international consensus recommended adenotonsillectomy as the first line therapy in young with OSDB. Usually adenotonsillectomy is combined with several important adjunctive medical treatments. Overweight and obesity frequent in adolescents, worsen OSDB and increase persistent OSDB after adenotonsillectomy. Weight loss is obtained by dietary restriction, physical activity, psychological support and sleep hygiene rules. Anti-inflammatory drugs (corticosteroids and leukotriene receptor antagonists) have shown their efficacy in children with moderate OSDB. Orthodontic treatments, rapid maxillary expansion or oral appliance, are used in selected patients according to their maxillo-facial disturbances in adjunction to adenotonsillectomy. Nasal CPAP is rarely useful except in severe OSDB specially in persistent OSDB after adenotonsillectomy. Finally, active or passive, myofunctional therapy is, according to some authors, an indispensable adjunct treatment to avoid persistent OSDB after adenotonsillectomy. These personalized medical treatments of OSDB are either administered jointly with adenotonsillectomy or in a hierarchal order.

Updates on management of pediatric obstructive sleep apnea

Obstructive sleep apnea (OSA) affects about 1%-5% of the pediatric population. The consequences of untreated OSA in children include neurocognitive deficits, behavioral problems, poor school performance as well as systemic and pulmonary hypertension. The treatment options for pediatric OSA are numerous with a variety of surgical and non-surgical interventions. As our understanding of the complexities of OSA grows, the options for management have continued to expand as well. The objectives of this review are to describe the commonly prescribed treatments for pediatric OSA including adenotonsillectomy as well as use of positive airway pressure. We also highlight other surgical and non-surgical interventions available. In addition, we provide updates on current research focusing on newer diagnostic and experimental treatment modalities.

Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of the Art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management.

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

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

Impact of weight-loss management on children and adolescents with obesity and obstructive sleep apnea

OBJECTIVES

To evaluate the impact of weight-loss management on obstructive sleep apnea (OSA) in children and adolescents with obesity. We hypothesized that a reduction in the degree of obesity was associated with a reduction in the apnea-hypopnea index (AHI).

METHODS

OSA (AHI ≥2) was investigated using a type 3 portable sleep device (Nox T3) in children and adolescents aged 7-18 years with overweight or obesity (body mass index standard deviation score (BMI SDS) > 1.28) at enrollment in a chronic care multidisciplinary overweight- and obesity treatment clinic. Individuals with OSA were included prospectively and longitudinally. A follow-up sleep examination was performed after 6 and 12 months from baseline accompanied by anthropometric measurements.

RESULTS

At baseline, 62 children with OSA were included (median age = 13.4 years, median BMI SDS = 3.16). A total of 55 out of 62 children (89%) attended the first follow-up, and 29 out of 34 children (85%) with residual OSA attended the second follow-up. By the end of the study, the AHI was normalized in 27 out of 62 children (44%). In a multiple linear regression analysis, the decrease in BMI SDS was associated with the decrease in AHI upon the first follow-up (p = 0.02) independently of sex; age; baseline puberty stage; baseline tonsillar hypertrophy; baseline AHI; baseline BMI SDS; and time to follow-up. There was no association between change in BMI SDS and change in AHI from the first to the second follow-up (p = 0.81).

CONCLUSIONS

OSA improved during obesity treatment, and the reduction in BMI SDS was significantly associated with the reduction in AHI after approximately six months of treatment. This indicates that obesity treatment should be considered among the first-line treatments of OSA in children and adolescents affected by overweight or obesity.

High-intensity interval training combined with resistance training improved apnea-hypopnea index but did not modify oxygen desaturation index and oxygen saturation nadir in obese children with obstructive sleep apnea

PURPOSE

To investigate the effect of high-intensity interval training (HIIT) combined with resistance training (RT) on sleep indices and vascular functions in obese children with obstructive sleep apnea (OSA).

METHODS

A quasi-experimental study. Forty-four obese children with OSA were allocated into either an exercise intervention (n = 22) or a usual care control group (n = 22). The exercise group received 24 min of HIIT (> 60% heart rate reserved) and 20 min of RT (50-80% one-repetition maximum), three times per week for 8 weeks. Primary outcomes included the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and oxygen saturation (SaO₂) nadir. Secondary outcomes included the Sleep-Related Breathing Disorder-Pediatric Sleep Questionnaire (SRBD-PSQ) scores, vascular functions (flow-mediated dilation and mean blood flow velocity), and anthropometric variables. Outcomes were measured at baseline, at week 8, and at week 16.

RESULTS

No baseline differences were observed between groups. The compliance rate of exercise training was 99.47%. The AHI significantly decreased in the exercise group compared with the control group at week 16 (median AHI 1.30 to 0.60 and 1.00 to 1.60 episode/h, p = 0.01), but not at week 8. There were no differences between the groups in regard to the ODI and SaO₂ nadir and any secondary outcomes at weeks 8 and 16 (all p > 0.05).

CONCLUSIONS

The eight-week HIIT combined with RT decreased AHI in obese children with OSA at week 16 follow-up. No changes in the ODI, SaO₂ nadir, SRBD-PSQ, vascular function, and anthropometric outcomes were revealed at any time point. Further research is warranted.

[Adolescent obstructive sleep apnoea syndrome: Characteristics and treatment]

Although the prevalence of the obstructive sleep apnoea syndrome (OSAS) is high in adolescents, studies pertaining to adolescent OSAS are less numerous than childhood studies. Cases of adolescent OSAS may consist of residual OSAS after adenotonsillectomy, but most often are de novo cases. Major pathophysiological factors are weight excess or even high-grade obesity, and the association of upper airway narrowing and tonsillar hypertrophy (pharyngeal, palatal or even lingual). ENT and systematic orthodontic assessments are the main points. In case of predisposing factors such as dental, occlusal or dento-facial abnormalities, a specific orthodontic treatment can be discussed. First line treatment is surgical adenotonsillectomy; surgical reduction of the lingual tonsils is seldom required. CPAP treatment may be indicated in the case of severe comorbidities (craniofacial malformations, neuromuscular diseases…) or in obese adolescents with severe residual OSAS. Treatment of adolescent OSAS has to be comprehensive and multidisciplinary, taking into account the specific treatments of obesity and abnormal sleep/wake rhythms.

Agreement between manual and automatic analyses of home sleep examinations in pediatric obstructive sleep apnea

Aim: Home sleep testing is becoming more common in the diagnostics of pediatric obstructive sleep apnea. The aim was to examine the agreement between manual and automatic analyses of home sleep examinations in children and adolescents. Materials & methods: Sleep examinations recorded with a type 3 sleep monitor (Nox T3) were analyzed manually by a registered polysomnographic technologist and automatically with Noxturnal version 5.1. Results: 51sleep examinations on children and adolescents with a median age of 13.6 years were included. The median manual apnea–hypopnea index (AHI) was 2.7 (range 0.2 to 28.2), while the median automatic AHI was 11.9 (range 4.2 to 45.6; p < 0.001). Conclusion: The agreement between manual and automatic analyses was poor. The AHI was consistently overestimated by automatic analysis.

Obstructive sleep apnea in children and adolescents with and without obesity

PURPOSE

To investigate the prevalence of obstructive sleep apnea (OSA) in children referred for obesity treatment, and to compare the prevalence with that of a normal-weight group. Moreover, we examined the association between Body Mass Index Standard Deviation Score (BMI SDS) and the Apnea-Hypopnea Index (AHI).

METHODS

This cross-sectional study included 139 children aged 7-18 years with overweight/obesity (BMI SDS >1.28) recruited from an obesity treatment clinic. The normal-weight group consisted of 33 children (BMI SDS ≤ 1.28) aged 7-18 years recruited from schools. Sleep examinations were performed using a type 3 portable sleep monitor (Nox T3). OSA was defined as AHI ≥ 2. Height and weight were measured and the tonsillar size was clinically estimated using the Brodsky scale.

RESULTS

The OSA prevalence was 44.6% in children with overweight/obesity compared with 9.1% in the normal-weight group (p = 0.0002), and the relative risk of OSA was 4.9 (95% CI 1.6-14.7). In a logistic regression, a one-unit increase in the BMI SDS increased the odds of having OSA by a factor of 1.92 independent of age, sex, tonsillar hypertrophy, and asthma (95% CI 1.33-2.76, p = 0.0005). A generalized linear regression adjusted for the same variables revealed an association between BMI SDS and AHI (a one-unit increase in the BMI SDS equaled an average increase in the AHI of 35% (95% CI 19-53%, p < 0.0001)).

CONCLUSIONS

In this study, children with overweight/obesity had a significantly higher prevalence of OSA compared with a normal-weight group. Increased BMI SDS was associated with increased AHI.

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review

OBJECTIVES

For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.

RESULTS

We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.

CONCLUSIONS

We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.

Effects of obesity therapies on sleep disorders

Obesity is a significant risk factor for obstructive sleep apnea syndrome (OSAS), and has also been linked to reductions in sleep quality and quantity. Weight loss has been shown to be an effective treatment for improving OSAS; however, there is a high degree of variability in improvements of OSAS in response to weight loss. There are three modalities of obesity therapies: 1) lifestyle modification, which includes changes in dietary intake and physical activity, along with behavioral interventions; 2) pharmacologic agents; and 3) bariatric surgery. Individuals have a highly variable response to the various obesity interventions, and maintenance of weight loss can be especially challenging. These factors influence the effect of weight loss on sleep disorders. There is still a need for large, well-controlled studies examining short- and long-term efficacy of weight loss modalities and their impact on long-term treatment of OSAS and other sleep parameters, particularly in youth. Nonetheless, given our current knowledge, weight reduction should always be encouraged for people coping with obesity, OSAS, and/or sleep disruptions and resources identified to assist patients in choosing a weight loss approach that will benefit them the most.

Obstructive Sleep Apnea and Sleep Architecture in Adolescents With Severe Obesity: Effects of a 9-Month Lifestyle Modification Program Based on Regular Exercise and a Balanced Diet

STUDY OBJECTIVES

Physical exercise and lifestyle modification are recognized as adjunct therapy for obstructive sleep apnea (OSA) in overweight adults. The objectives of this study were to investigate the effects of long-term physical exercise combined with a balanced diet on sleep architecture, sleep duration, and OSA in adolescents with severe obesity.

METHODS

This interventional study was conducted in a nursing institution. Participants were aged 14.6 ± 1.2 years with obesity (body mass index (BMI) = 40.2 ± 6.5 kg/m2). At admission and at 9 months, participants underwent ambulatory polysomnography and incremental maximal exercise testing to determine cardiorespiratory fitness.

RESULTS

Twenty-four subjects completed the study. Analyses were performed on the whole population and on a subgroup of subjects with OSA (OSA-subgroup). OSA, defined as obstructive apnea-hypopnea index (OAHI) ≥ 2 events/h, was diagnosed in 58.3% of the population. OAHI was only associated with fat mass in males (r = .75, P < .05). At 9 months postintervention, weight loss (-11.1 kg, P < .0001) and improved cardiorespiratory fitness (VO2peak: +4.9 mL/min/kg, P < .001) were found in the whole population. Sleep duration was increased (+34 minutes, P < .05) and sleep architecture was changed with an increase of rapid eye movement sleep (+2.5%, P < .05) and a decrease of stage N3 sleep (-3.1%, P < .001). Similar results were found in the OSA subgroup. However, OAHI remained unchanged (P = .18).

CONCLUSIONS

A combination of supervised aerobic exercise and a balanced diet led to weight loss, improved aerobic capacity, and modified sleep architecture without changes in OSA.

COMMENTARY

A commentary on this article appears in this issue on page 907.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Title: Exercise and Venous Compression on Upper Airway Resistance in Obese Teenagers With OSA (OBESOMAC), URL: https://clinicaltrials.gov/ct2/show/NCT02588469, Identifier: NCT02588469.

Clinical Predictors of Residual Sleep Apnea after Weight Loss Therapy in Obese Adolescents

OBJECTIVE

To investigate clinical factors that could predict residual sleep-disordered breathing (SDB) after weight loss.

STUDY DESIGN

Obese subjects between 10 and 19 years of age were recruited while entering an in-patient weight loss treatment program. All subjects underwent anthropometry and sleep screening using a portable device at baseline and after 4-6 months of therapy. Sleep and International Study of Asthma and Allergies in Childhood questionnaires were completed at baseline.

RESULTS

A total of 339 patients were included. Median age was 15.4 years (10.1-19.1). Body mass index z score at baseline was 2.75 ± 0.42, and 35% of subjects were boys. SDB was present in 32%. After a mean decrease in body mass index z score of 32%, residual SDB was found in 20% of subjects with SDB at baseline. Subjects with more severe SDB (OR 1.18; CI 1.01-1.34; P = .02) and respiratory allergies (OR 7.85; CI 1.20-51.39; P = .03) were at higher risk of developing residual SDB, unlike age, sex, and anthropometric variables.

CONCLUSIONS

Weight loss was successful for treating SDB in 80% of patients. More severe SDB and the presence of respiratory allergies at baseline were associated with a higher risk of residual SDB after weight loss.

Predictors of Obstructive Sleep Apnea Severity in Adolescents

Importance

Untreated obstructive sleep apnea has severe health consequences, yet little is known about predictors of sleep apnea severity in the adolescent population.

Objective

To evaluate clinical and demographic factors associated with obstructive sleep apnea severity in adolescents.

Design, Setting, and Participants

A retrospective case series of 224 children (53% male), ages 12 to 17 years who underwent polysomnography from January 1, 2013, to June 4, 2015. The study was carried out in a large tertiary referral children's hospital associated with an academic medical center in Dallas, Texas. Children were excluded if they were missing clinical data (eg, tonsil size), had major comorbidities (eg, chromosomal abnormalities), or had previously undergone tonsillectomy and adenoidectomy. The mean (SD) age was 14.6 (1.7) years (range, 12.0-17.9 years), and the patients were 55% Hispanic, 30% African American, 13% white, and 2% other.

Exposures

Electronic medical records were reviewed for demographic, clinical, and polysomnographic parameters.

Main Outcomes and Measures

Correlation between demographic and clinical characteristics and the apnea hypopnea index.

Results

In 224 adolescents (53% male) aged 12 to 17 years, the mean (SD) apnea hypopnea index was 14.9 (28.7) (range, 0.0-187.7) and was positively correlated with CDC-defined weight categories (P = .04) and tonsillar hypertrophy (P < .001). Sex, ethnicity, and age were not associated with the apnea hypopnea index. Severe obstructive sleep apnea (apnea hypopnea index >10) was more common in males (OR, 1.8; 95% CI, 1.0-3.2), patients with tonsillar hypertrophy (OR, 3.2; 95% CI, 1.8-5.8), and patients in a heavier CDC weight class (OR, 2.0; 95% CI, 1.3-3.2). Age and ethnicity did not predict severe obstructive sleep apnea.

Conclusions and Relevance

Obstructive sleep apnea in adolescents is associated with obesity and tonsillar hypertrophy in this study. Severe obstructive sleep apnea is more likely in adolescents who are male or obese, or who have tonsillar hypertrophy. This study supports routine polysomnography in obese male adolescents with tonsillar hypertrophy and symptoms of sleep-disordered breathing to screen for and treat severe obstructive sleep apnea.