Prevalence of habitual snoring and sleep-disordered breathing in preschool-aged children in an Italian community

Outpatient characteristics in a pediatric otolaryngology department during COVID-19 pandemic: A retrospective study

OBJECTIVES

To investigate the characteristics of outpatients in the pediatric otolaryngology department of a tertiary Japanese hospital before and during the COVID-19 pandemic.

METHODS

In this retrospective study conducted at a tertiary center in Japan, pediatric patients aged 0-15 years who visited the pediatric otolaryngology department between 2017 and 2022 were included. The number of outpatients in the department was compared between before and during the COVID-19 pandemic (January 2017-December 2022) by year, age, sex, and the disease for which the patient was examined. Additionally, the diseases that most substantially contributed to the change in outpatient visits were evaluated in detail regarding their severity.

RESULTS

Among a total of 9219 outpatients, there were no significant differences between 2017-2019 and 2020-2022 (4650 vs. 4569). In contrast, the number of new outpatients decreased by 27.5% (from 1242 to 900) in each of the three years during the COVID-19 pandemic. In particular, the number of patients aged 1-6 years decreased as did that of male patients. Of eight disease categories, oral cavity- and pharyngeal- related diseases decreased the most significantly, by approximately 50%, and the decrease in the number of patients with obstructive sleep apnea (OSA) is thought to have had an impact on the decrease in the number of patients. Furthermore, in cases in which polysomnography testing was performed for OSA, the proportion of patients with moderate and severe categories showed a significant decrease.

CONCLUSIONS

The number of new pediatric ORL patients, particularly those with severe OSA, reduced during the COVID 19 pandemic. These results may provide indications about the characteristics of OSA incidence and exacerbations.

A narrative review on obstructive sleep apnoea syndrome in paediatric population

Obstructive sleep apnoea syndrome is a respiratory sleep disorder that affects 1-5% of children. It occurs equally in males and females, with higher incidence in school age and adolescence. OSAS may be caused by several factors, but in children, adenotonsillar hypertrophy, obesity, and maxillo-mandibular deficits are the most common. In general, there is a reduction in the diameter of the airway with reduced airflow. This condition worsens during sleep due to the muscular hypotonia, resulting in apnoeas or hypoventilation. While snoring is the primary symptom, OSAS-related manifestations have a wide spectrum. Some of these symptoms relate to the nocturnal phase, including disturbed sleep, frequent changes of position, apnoeas and oral respiration. Other symptoms concern the daytime hours, such as drowsiness, irritability, inattention, difficulties with learning and memorisation, and poor school performance, especially in patient suffering from overlapping syndromes (e.g., Down syndrome). In some cases, the child's general growth may also be affected. Early diagnosis of this condition is crucial in limiting associated symptoms that can significantly impact a paediatric patient's quality of life, with the potential for the condition to persist into adulthood. Diagnosis involves evaluating several aspects, beginning with a comprehensive anamnesis that includes specific questionnaires, followed by an objective examination. This is followed by instrumental diagnosis, for which polysomnography is considered the gold standard, assessing several parameters, including the apnoea-hypopnoea index (AHI) and oxygen saturation. However, it is not the sole tool for assessing the characteristics of this condition. Other possibilities, such as night-time video recording, nocturnal oximetry, can be chosen when polysomnography is not available and even tested at home, even though with a lower diagnostic accuracy. The treatment of OSAS varies depending on the cause. In children, the most frequent therapies are adenotonsillectomy or orthodontic therapies, specifically maxillary expansion.

Classification and Epidemiology of Sleep Disorders in Children and Adolescents

Sleep disturbances are common in children and adolescents but still remain unrecognized and undertreated. Several classification systems of sleep disorders are available, which include recent attempts to develop more specific nosologic categories that reflect developmental aspects of sleep. The prevalence of sleep disorders has been studied across various samples of healthy, typically developing children and those with special medical, psychiatric, and neurodevelopmental needs. Sleep disorders are highly prevalent in children and adolescents with psychiatric disorders, making it important for mental health professionals to be aware of sleep problems and to address them in the context of psychiatric comorbidities.

Awareness and attitude among general dentists and orthodontists toward obstructive sleep apnea in children

Aim

This study aimed to investigate Italian dentists' knowledge of and attitudes toward obstructive sleep apnea (OSA) in children.

Methods

An anonymous questionnaire was prepared using Google Forms and sent to dentists in Italy through private social platforms. The first part of the questionnaire contained basic demographic data questions, and the second part included items about pediatric OSA.

Results

A total of 125 responses were collected within 1 month. The interviews revealed gaps in undergraduate and post-graduate training on OSA, and consequently, low self-evaluation of knowledge and self-confidence in managing young patients with OSA. Dentists showed unfavorable attitudes and poor knowledge of the general findings, risk factors, and consequences of pediatric OSA but demonstrated good knowledge of the beneficial effects of rapid maxillary expansion. Orthodontists showed a more favorable attitude and better recognition of the craniofacial features associated with OSA. In addition, a comparison was made between dentists who had graduated more than 5 years ago and new graduates, and differences were found in undergraduate education, which was better for new graduates, and a small number of questions were better answered by experienced dentists.

Conclusion

This study showed a lack of knowledge about pediatric OSA and its management among Italian dentists, revealing the need to update the dentistry curriculum and organize educational interventions.

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

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

Diagnosis of Paediatric Obstructive Sleep-Disordered Breathing beyond Polysomnography

Obstructive sleep-disordered breathing (SDB) has significant impacts on health, and therefore, a timely and accurate diagnosis is crucial for effective management and intervention. This narrative review provides an overview of the current approaches utilised in the diagnosis of SDB in children. Diagnostic methods for SDB in children involve a combination of clinical assessment, medical history evaluation, questionnaires, and objective measurements. Polysomnography (PSG) is the diagnostic gold standard. It records activity of brain and tibial and submental muscles, heart rhythm, eye movements, oximetry, oronasal airflow, abdominal and chest movements, body position. Despite its accuracy, it is a time-consuming and expensive tool. Respiratory polygraphy instead monitors cardiorespiratory function without simultaneously assessing sleep and wakefulness; it is more affordable than PSG, but few paediatric studies compare these techniques and there is optional recommendation in children. Nocturnal oximetry is a simple and accessible exam that has high predictive value only for children at high risk. The daytime nap PSG, despite the advantage of shorter duration and lower costs, is not accurate for predicting SDB. Few paediatric data support the use of home testing during sleep. Finally, laboratory biomarkers and radiological findings are potentially useful hallmarks of SDB, but further investigations are needed to standardise their use in clinical practice.

Association of Sleep-Disordered Breathing and Developing Malocclusion in Children: A Cross-Sectional Study

Background Sleep Disordered Breathing (SDB) in children and its role in health has received renewed interest in the recent past. Malocclusion is one of the most common multifactorial craniofacial disturbances widely prevalent in children. The primary objective of this study was to assess the association of SDB with developing malocclusion in six to 12-year-old children and the effect of modifiers like age, gender, and tonsillar enlargement. Materials and method One hundred and seventy-seven children aged six to 12 years were assessed for developing malocclusion using Angle classification and Index of Orthodontic Treatment Needs (IOTN) comprising of 5 grades. Their parents were administered a pre-validated Pediatric Sleep Questionnaire (PSQ) for assessing SDB, by a single, calibrated examiner. The primary outcomes were SDB score, Angle class of malocclusion, and IOTN grade, assessed as categorical variables. The modifying variables assessed were age, gender, and tonsillar enlargement (Brodsky's criteria). The data were subject to statistical analysis using Fischer's test and the odds ratio (OR) was estimated. The modifiers were assessed using logistic regression. Results The prevalence of SDB was 69%. SDB has significantly associated with angle class II and class III malocclusion (x² = 9.475, p < 0.05 OR=3.79) and with higher IOTN grades (x² = 109.799, p < 0.05, OR=53.64). Logistic regression revealed that gender and tonsillar enlargement had a significant modifying effect (p<0.05). Conclusion SDB had a significant association with developing malocclusion, the odds being higher in angle class II and III malocclusions and higher IOTN grades. Clinical relevance Both SDB and developing malocclusion are quite commonly seen in children, though the relation between the two has not been adequately explored. This study shows that they are strongly associated with each other and one could act as a marker for the other.

Sleep habits and sleep disorders in Italian children and adolescents: a cross-sectional survey

STUDY OBJECTIVES

The aim was to describe sleep habits and epidemiology of the most common sleep disorders in Italian children and adolescents.

METHODS

This was a cross-sectional study in which parents of typically developing children and adolescents (1-18 years) completed an online survey available in Italy, gathering retrospective information focusing on sleep habits and disorders.

RESULTS

Respondents were 4,321 typically developing individuals (48.6% females). Most of our sample did not meet the age-specific National Sleep Foundation recommendations for total sleep duration (31.9% of toddlers, 71.5% of preschoolers, 61.6% of school-age children, and 41.3% of adolescents). Napping was described in 92.6% of toddlers and in 35.2% of preschoolers. Regarding geographical differences, children and adolescents of northern Italy showed more frequent earlier bedtimes and rise times than their peers of central and southern Italy. The most frequently reported sleep disorder in our sample was restless sleep (35.6%), followed by difficulties falling asleep (16.8%), > 2 night awakenings (9.9%), and bruxism (9.6%). Data also suggest that longer screen time is associated with later bedtimes on weekdays in all age groups.

CONCLUSIONS

The current study shows that Italian children are at risk of sleep disorders, particularly insufficient sleep, restless sleep, and difficulty falling asleep. The study also provides normative sleep data by age group in a large cohort of typically developing Italian children, emphasizing the importance of the developmentally, ecologically, and culturally based evaluation of sleep habits and disorders.

CITATION

Breda M, Belli A, Esposito D, et al. Sleep habits and sleep disorders in Italian children and adolescents: a cross-sectional survey. J Clin Sleep Med. 2023;19(4):659-672.

The effects of sleep disordered breathing on sleep spindle activity in children and the relationship with sleep, behavior and neurocognition

STUDY OBJECTIVES

Obstructive sleep disordered breathing (SDB), has adverse neurocognitive and behavioral sequelae in children, despite conventional measures of sleep disruption being unaffected. There is growing evidence that sleep spindles may serve as a more sensitive marker of sleep quality. We investigated the relationship between sleep spindles and sleep fragmentation and neurocognition across the spectrum of SDB severity in children.

METHODS

Children 3-12 years old referred for clinical assessment of SDB and age matched control children from the community were recruited and underwent polysomnography. Sleep spindles were identified manually during N2 and N3 sleep. Spindle activity was characterised as spindle number, density (number of spindles/h) and intensity (spindle density x average spindle duration). Children completed a battery of tests assessing global intellectual ability, language, attention, visuospatial ability, sensorimotor skills, adaptive behaviors and skills and problem behaviors and emotional difficulties.

RESULTS

Children were grouped into control, Primary Snoring, Mild OSA and Moderate/severe OSA, N = 10/group. All measures of spindle activity were lower in the SDB groups compared to the Control children and this reached statistical significance for Mild OSA (p < 0.05 for all). Higher spindle indices were associated with better performance on executive function and visual ability assessments but poorer performance on auditory attention and communication skills. Higher spindle indices were associated with better behavior.

CONCLUSION

The reduced spindle activity observed in the children with SDB, particularly Mild OSA, indicates that sleep micro-architecture is disrupted and that this disruption may underpin the negative effects of SDB on attention, learning and memory.

Night-to-night variability in respiratory sleep parameters to diagnose obstructive sleep apnea in children: A systematic review and meta-analysis

PURPOSE

This systematic review aims to assess the night-to-night variability (NtNV) in respiratory sleep parameters in children and the accuracy of diagnosing obstructive sleep apnea (OSA) in children based on a single-night sleep study.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched until March 8, 2021. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021239838).

RESULTS

Our study included 395 patients from 5 articles. The mean (SD) age of all included patients was 11.78 (4.05) years. AHI was reported for 325 participants in 4 studies, and the mean change between two consecutive nights was -0.13 [95% CI: -0.40, 0.14] events per hour. The mean change in OAI was -0.07 [95% CI: -0.27, 0.12] events per hour in 187 participants across 3 studies. Based on the diagnostic criteria used, three studies reported that the diagnostic rates of OSA patients in a single-night sleep study were 83%, 84.6%, and 91%. The NtNV in AHI in children with severe and moderate OSA was greater than that in children with mild OSA (3.35 [95% CI: 0.07, 6.62] events per hour vs -0.15 [95% CI: -0.42, 0.12] events per hour), and these children with more severe OSA may have shown a higher AHI on the first night.

CONCLUSIONS

The NtNV in AHI was not statistically significant in the group sample of children. However, there were significant differences in NtNV in AHI between children with mild and moderate-to-severe OSA. Individual NtNV in respiratory sleep parameters may cause children to be misdiagnosed by single-night diagnostic sleep studies.

Increased behavioral problems in children with sleep-disordered breathing

Background

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

Methods

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

Results

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

Conclusions

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

What is the association between secondhand smoke (SHS) and possible obstructive sleep apnea: a meta-analysis

BACKGROUND

Association between smoking and sleep apnea is well-known from previous studies. However, the influence of secondhand smoke (SHS), which is a potential risk factor of obstructive sleep apnea (OSA), remains unclear. Our aim was to investigate the relationship between SHS and OSA using a meta-analysis.

MATERIALS AND METHODS

For the meta-analysis, searches were performed in MEDLINE, EMBASE, and Web of Science databases on January 10, 2022, by combining various keywords including "SHS exposure" and "OSA". Data were extracted using defined inclusion and exclusion criteria. Fixed-effects model meta-analyses were used to pool risk ratio (RR) estimates with their 95% confidence intervals (CI). I² was used to assess heterogeneity. Moreover, we performed subgroup meta-analyses of children-adults, and smoker fathers and mothers.

RESULTS

In total, 267 articles were obtained through an electronic search. Twenty-six articles were included in our analysis according to the inclusion and exclusion criteria. We found evidence of an association between SHS exposure and possible OSA (RR 1.64, 95% CI 1.44-1.88). The results of the subgroup analyses showed that children passive smokers (RR 1.84, 95% CI 1.60-2.13) were at greater risks of possible OSA than adult passive smokers (RR 1.35, 95% CI 1.21-1.50). Also, significant differences were observed in mothers with smoking exposure (RR 2.61, 95% CI 1.62-4.21, p < 0.0001), as well as in fathers with smoking exposure (RR 2.15, 95% CI 0.98-4.72, p = 0.06).

SHORT CONCLUSION

Our meta-analysis confirmed that SHS exposure is significantly associated with OSA. In the subgroup analyses, the association of SHS and possible OSA was significant in both children and adults, as well as in smoker mothers and fathers.

Assessment of event-related evoked potentials and China-Wechsler intelligence scale for cognitive dysfunction in children with obstructive sleep apnea

OBJECTIVE

To explore the relationship between obstructive sleep apnea (OSA) and cognitive impairment by combining event-related evoked potentials (ERPs) and China-Wechsler Younger Children Scale (C-WISC) in children with sleep-disordered breathing (SDB) with vs. without OSA.

METHODS

This was a retrospective case-control study of all consecutive children (n = 148) with adenoid tonsil hypertrophy between July 2017 and March 2019 at the Hospital.

RESULTS

The children were divided into the OSA (n = 102) and non-OSA (n = 46) groups. The apnea-hypopnea index (AHI), obstructive apnea index (OAI), and obstructive apnea-hypopnea index (OAHI) in the OSA group were elevated compared with those of the non-OSA group (all P < 0.001). The mean oxygen saturation (SaO₂) and SaO₂ nadir were lower in the OSA group compared with the non-OSA group (both P < 0.001). The respiratory arousal index (RAI) values in the OSA group were larger than those of the non-OSA group (P < 0.001). The P300 and N100 latencies in the OSA group were longer than those of the non-OSA group (both P < 0.001). Pearson's correlation analysis revealed correlations of the P300 peak latency with full-scale intelligence quotient (FIQ) (P < 0.001 and r = -0.527), verbal intelligence quotient (VIQ) (P < 0.001 and r = -0.448), and performance intelligence quotient (PIQ) (P < 0.001 and r = -0.515). There was a correlation between the N100 peak latency and PIQ (P = 0.026 and r = -0.183).

CONCLUSION

ERPs, as an objective measurement, might help assess cognitive impairment in children with OSA.

Development and Validation of SDBeasy Score as a Predictor of Behavioral Outcomes in Childhood

Rationale: There are limited tools to identify which children are at greatest risk for developing sleep-disordered breathing (SDB)-associated behavioral morbidity.Objectives: To examine associations between age of onset and duration of parent-reported symptoms of SDB and behavioral problems at the age of 5 years.Methods: Data were collected and analyses were completed for participants in the CHILD (Canadian Healthy Infant Longitudinal Development) cohort at the Edmonton and Toronto sites. We generated an SDBeasy score on the basis of the age of onset and duration of SDB symptoms as reported by parents completing the Pediatric Sleep Questionnaire. Using CHILD-Edmonton data, we completed multivariate linear regression to determine whether the SDBeasy score was associated with behavioral problems at the age 5 years of age as assessed by using the Child Behavior Checklist (CBCL). We then validated the SDBeasy score using CHILD-Toronto data.Measurements and Main Results: At the 5-year visit, 581 of 716 (81%) CHILD-Edmonton participants still enrolled had CBCL data. Of the 581 children with data, 77% (446 of 581) had an SDBeasy score of 0 (never had SDB symptoms), whereas 20 of 581 children (3.4%) had persistent SDB symptoms from infancy through 5 years of age (SDBeasy score of 24). Children had a 0.35-point-higher CBCL total behavioral score at 5 years for each 1-point increase in their SDBeasy score (95% confidence interval, 0.24-0. 5; P < 0.01). We found consistent results among CHILD-Toronto participants; children had a 0.26-point-higher CBCL total behavioral score at 5 years for each 1-point increase in their SDBeasy score (95% confidence interval, 0.08-0.44; P = 0.005).Conclusions: The SDBeasy score, based on the Pediatric Sleep Questionnaire, enables identification of children with higher behavioral-problem scores.

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

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

Nocturnal dipping of heart rate is impaired in children with Down syndrome and sleep disordered breathing

BACKGROUND

Children with Down syndrome (DS) are at increased risk for sleep disordered breathing (SDB), which can have adverse effects on the cardiovascular system. In adults with SDB, nocturnal dipping of heart rate (HR) and blood pressure (BP) is reduced, and this is associated with an increased risk of future cardiovascular events. We aimed to compare nocturnal dipping of HR and pulse transit time (PTT) (a surrogate inverse measure of BP change) in children with DS and SDB to those of typically developing (TD) children with and without SDB.

METHODS

19 children with DS (3-18 years) were age and sex matched with 19 TD children without SDB (TD-) and with 19 TD children with matched severity of SDB (TD+). Nocturnal dipping was assessed as the percentage change in HR and PTT from wake before sleep onset to total sleep, N2, N3 and REM sleep across the night and to the first cycle of sleep.

RESULTS

Children with DS exhibited reduced nocturnal dipping of HR during total sleep, N2, N3 and REM sleep and increased PTT (reduced BP dipping) in N2 sleep. Fewer children with DS exhibited a greater than 10% fall in HR between wake and N2 or REM sleep compared to TD+ children.

CONCLUSIONS

Our findings demonstrate significantly reduced nocturnal dipping of HR in children with DS compared to TD children matched for SDB severity, suggesting SDB has a greater cardiovascular effect in these children. Further studies are required to fully understand the mechanisms involved and to assess if treatment of SDB improves nocturnal dipping.

Classification and Epidemiology of Sleep Disorders in Children and Adolescents

Sleep disturbances are common in children and adolescents but still remain unrecognized and undertreated. Several classification systems of sleep disorders are available, which include recent attempts to develop more specific nosologic categories that reflect developmental aspects of sleep. The prevalence of sleep disorders has been studied across various samples of healthy, typically developing children and those with special medical, psychiatric, and neurodevelopmental needs. Sleep disorders are highly prevalent in children and adolescents with psychiatric disorders, making it important for mental health professionals to be aware of sleep problems and to address them in the context of psychiatric comorbidities.

Prevalence and Determinants of Bad Sleep Perception among Italian Children and Adolescents

Although sleep problems at young ages are well investigated, the prevalence of bad sleepers and the determinants of sleep quality perception remain unexplored in these populations. For this purpose, we addressed these issues in a sample of children (n = 307), preadolescents (n = 717), and adolescents (n = 406) who completed the School Sleep Habits Survey, addressing sleep quality perception, sleep habits, sleep features, daytime behavior and sleep disturbances, circadian preference, and dreaming. The sample was split in “good sleepers” and “bad sleepers”, based on the answer to the question item assessing overall subjective sleep quality. Being a bad sleeper was reported by 11.7% of the sample, with significant between-groups differences (children: 8.3%; preadolescents: 11.3%; adolescents: 15.3%; p = 0.01). At all ages, relative to good sleepers, bad sleepers showed higher eveningness, sleepiness, and depression, longer sleep latency, more frequent insufficient sleep, nocturnal awakenings, sleep–wake behavioral problems, and unpleasant dreams (all p’s ≤ 0.01). Sleep quality perception was predicted: in children, by depressed mood, eveningness, and unpleasant dreams (all p’s ≤ 0.01); in preadolescents, by sleep latency, awakening frequency, depressed mood, sufficiency of sleep, and unpleasant dreams (all p’s < 0.01); in adolescents, by awakening frequency, depressed mood, and sufficiency of sleep (all p’s < 0.001). In children, bad subjective sleep quality appears to be mainly determined by daytime psychological features, for example, depressed mood, whereas at later ages, sleep characteristics, such as frequent awakenings, add to the former determinants. This could depend on (a) the appearance, with increasing age, of objective sleep modifications and (b) a greater attention paid by adolescents to their sleep characteristics.

Tobacco smoke exposure as a risk factor for obstructive sleep apnea in children

BACKGROUND

The most common respiratory disturbance in sleeping children is obstructive sleep apnea syndrome (OSAS). Passive smoking is one of factors predisposing to OSAS. The aim of this study was to determine the correlations between exposure to tobacco smoke (passive smoking) and development of respiratory disorders in children during sleep.

METHODS

One hundred and sixty school-aged children (6-18 years) were included in the study. The inclusion criterion was exposure to tobacco smoke at home (n = 90). The control group were school-aged children who had had no contact with tobacco smoke at home (n = 70). Exclusion criteria were obesity and children with impaired patency of the nose. Each child had a polygraphic examination performed at home. The children and their parents completed a questionnaire to assess the level of child's exposure to tobacco smoke. The study ran from December 15, 2012 to February 26, 2016.

RESULTS

OSAS was observed in 12% of children with an apnea-hypopnea index >1.5 (<13 years of age) and an apnea-hypopnea index >5 (for children >13 years), and with diurnal and nocturnal symptoms. Children exposed to tobacco smoke presented more apnea-hypopnea events (n = 17) than the control group (n = 3; P < 0.001). In the group exposed to tobacco smoke the following issues were noted: concentration problems (38.9%), tiredness/lethargy (46.7%), and irritability/hyperactivity (36.7%). No statistically significant differences were found in waking up, snoring, or sleep apnea.

CONCLUSIONS

OSAS occurs more often in children exposed to tobacco smoke and these children demonstrate concentration problems, tiredness, and irritability/hyperactivity to a greater extent than control group.

Evaluation of neurocognitive abilities in children affected by obstructive sleep apnea syndrome before and after adenotonsillectomy

Obstructive sleep apnoea syndrome (OSAS) is the most severe form of sleep-related disordered breathing (SRDB) and is characterised by snoring, apnoeas, and/or hypopnoeas associated to hypoxia, hypercarbia, or repeated arousals from sleep. OSAS has three major categories of morbidities: neurobehavioural, cardiovascular and somatic growth failure. The gold standard for objective diagnosis of obstructive-SRDB severity is polysomnography (PSG). The indication for surgical treatment in children is moderate-severe OSAS (AHI, apnoea hypopnoea index > 5/h) and in mild OSAS (AHI 2-5/h) with complications or morbidity. The entire spectrum of PSG-defined SRDB (ranging from Primary Snoring to severe OSAS) may correlate with behavioural, attentional and executive function deficits relating to hypoxia and sleep disruption: in some cases, these alterations may mimic attention deficit hyperactivity disorder (ADHD). The aim of this research was to evaluate visuoperceptual and constructional abilities, paediatric sleep questionnaire and polysomnographic scores before and 6 months after adenotonsillectomy with objective and subjective information. We included 59 children who underwent neuropsychiatric and otolaryngologist clinical evaluation and the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI); children parents were asked to fill in the Paediatric Sleep Questionnaire (PSQ); each child underwent PSG. At 6 months after adenotonsillectomy, all patients were evaluated again. There is a significant difference in PSQ parameters, VMI standard, visual tests scores and PSG parameters before and after adenotonsillectomy in children affected by OSAS. These results showed the achievement of therapeutic benefits with improvement of the quality of life for both children and their parents.

Risk factors of obstructive sleep apnea syndrome in children

Background

The known risk factors of childhood OSAS include tonsillar and adenoidhypertrophy, obesity, craniofacial anomalies, neuromuscular disorders and African-American (AA) ancestry. Whether other factors such as allergic rhinitis (AR), premature, environmental tobacco smoking (ETS) are associated with OSAS are inconsistent in different studies. Our study enrolled children of a broad age range and included potential risk factors of OSAS derived from previous studies and our own experience. Our objective is to identify risk factors of OSAS in children in a clinical setting.

Methods

Children between 2 and 15 years of age exhibiting snoring symptoms who visited the sleep center for polysomnography (PSG) were enrolled. All children completed a questionnaire, physical examination and PSG. The questionnaire included demographic data and information related to potential risk factors for sleep disorders. A physical examination included measurements of height, weight, neck circumference, waist and hip ratio, visual evaluation of the tonsils and the degree of adenoid obstruction. Children with obstructive apnea-hypopnea index (OAHI) ≥ 1 were defined as OSAS.

Results

A total of 1578 children were enrolled and1009 children exhibited OSAS. Univariate analyses showed that snoring occurring for ≥ 3 months, male gender, preterm birth, breastfeeding, obesity, neck circumference ≥ 30 cm, waist/hip ratio ≥ 0.95, tonsillar hypertrophy, and adenoid hypertrophy were associated with OSAS. The proportion of low educational level was higher in parents who breastfed their babies than those who didn’t. Multivariate analysis showed that snoring for ≥ 3 months, male gender, obesity, breastfeeding, tonsillar hypertrophy, and adenoid hypertrophy were associated with OSAS. Confounders such as socioeconomic status, parental occupation, and health-related behaviors should be explored further to investigate the relationship between breastfeeding and OSAS.

Conclusion

The independent risk factors for OSAS in children included snoring ≥ 3 months, male gender, obesity, breastfeeding, tonsillar and adenoid hypertrophy.

The study was registered on Clinical Trials government (NCT02447614). The name of the trial is “Follow-up Studies of Primary Snoring (PS) and Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) in Chinese Children” and the URL is https://clinicaltrials.gov/.

Application of latent class analysis in assessing the awareness, attitude, practice and satisfaction of paediatricians on sleep disorder management in children in Italy

AIM

To identify subgroups regarding paediatricians' awareness, attitude, practice and satisfaction about management of Sleep-Disordered Breathing (SDB) in Italy using Latent Class Analysis (LCA).

METHODS

A cross-sectional study was conducted on a large sample of Italian paediatricians. Using a self-administered questionnaire, the study collected information on 420 Paediatric Hospital Paediatricians (PHPs) and 594 Family Care Paediatricians (FCPs). LCA was used to discover underlying response patterns, thus allowing identification of respondent groups with similar awareness, attitude, practice and satisfaction. A logistic regression model was used to investigate which independent variables influenced latent class membership. Analyses were performed using R 3.5.2 software. A p-value<0.05 was considered statistically significant.

RESULTS

Two classes were identified: Class 1 (n = 368, 36.29%) "Untrained and poorly satisfied" and Class 2 (n = 646, 63.71%) "Trained and satisfied." Involving paediatric pneumologists or otorhinolaryngologists in clinical practice was associated with an increased probability of Class 2 membership (OR = 5.88, 95%CI [2.94-13.19]; OR = 15.95, 95% CI [10.92-23.81] respectively). Examining more than 20 children with SDB during the last month decreased the probability of Class 2 membership (OR = 0.29, 95% CI [0.14-0.61]). FCPs showed a higher probability of Class 2 membership than PHPs (OR = 4.64, 95% CI [3.31-6.55]).

CONCLUSIONS

These findings suggest that the LCA approach can provide important information on how education and training could be tailored for different subgroups of paediatricians. In Italy standardized educational interventions improving paediatricians' screening of SDB are needed in order to guarantee efficient management of children with SDB and reduce the burden of disease.

Are there gender differences in the severity and consequences of sleep disordered in children?

OBJECTIVES

In adults there is a distinct gender difference in the prevalence and severity of sleep disordered breathing (SDB), however there have been limited studies examining the effects of gender in children with SDB. We aimed to compare the effects of gender on severity of SDB, blood pressure, sleep and respiratory characteristics, quality of life, behavior and executive function.

METHODS

We included 533 children aged 3-18 years, who underwent standard pediatric overnight polysomnography (PSG) between 2004 and 2016. Blood pressure was recorded prior to each study. Quality of life, behavior and executive function were assessed with parental questionnaires. Children were grouped by gender and SDB severity based on their obstructive apnea hypopnea index (OAHI) into non-snoring controls, Primary Snoring (PS) (OAHI≤1 event/h), Mild obstructive sleep apnea (OSA) (OAHI>1-≤5 events/h) and moderate/severe (MS) OSA (OAHI>5 events/h) and data compared with 2-way ANOVA.

RESULTS

A total of 298 boys and 235 girls were studied. There were no differences in age, BMI z-score, SDB severity sleep characteristics or blood pressure between genders. Diastolic blood pressure was elevated in females with MS OSA compared to males (P < 0.05). Quality of life, behavior and executive function scores were all elevated in the SDB groups compared to controls. Females with MS OSA exhibited more internalizing behavioral problems compared to males (59.2 ± 2.4 vs. 51.4 ± 2.3, P < 0.05).

CONCLUSIONS

In contrast to studies in adults, we identified no gender differences in the severity or consequences of SDB in children, other than females with moderate-severe OSA exhibiting more internalizing problems and higher diastolic blood pressure.

Obstructive sleep apnea and hypertension in pediatric chronic kidney disease

BACKGROUND

Children with chronic kidney disease (CKD) are at risk for obstructive sleep apnea (OSA) and hypertension. The objectives of this study were to explore associations between OSA severity using the apnea-hypopnea-index(AHI) and obstructive apnea-hypopnea-index(OAHI) on polysomnography (PSG), OSA symptoms, and measures of hypertension in children with CKD.

METHODS

One-night in-laboratory PSGs and 24-h ambulatory blood pressure monitoring (ABPM) were performed on children with CKD stages 2-5 (non-dialysis dependent). Sleep questionnaires, including the modified Epworth Sleepiness Scale (ESS) and the Pediatric Sleep Questionnaire (PSQ), were administered during the sleep study.

RESULTS

Nineteen children and adolescents completed a PSG and questionnaires and thirteen completed ABPMs. Mean (standard deviation) age at the time of the sleep study was 14.1 (3.2) years. Eleven (58%) participants had CKD stage two, and eight (42%) had stage 3-4. None of the participants were found to have OSA on PSG. One participant had a positive ESS score (≥ 11) and five participants had positive PSQ scores (≥  eight). Night systolic and diastolic pressures were strongly correlated with the OAHI (r = 0.67 and r = 0.69, respectively, p < 0.05), while the AHI was not correlated with any blood pressure measures.

CONCLUSIONS

Our study did not find OSA on PSG in children with predominantly mild to moderate CKD. The OAHI was found to be strongly correlated with nighttime blood pressures. Future prospective studies with a larger sample size are needed to monitor for potential progression of symptoms and findings on PSG in pediatric patients as they evolve across the spectrum of CKD.

Parent report of children's sleep disordered breathing symptoms and limited academic progress in reading, writing, and math

OBJECTIVES

To estimate via questionnaire within a population sample of New Zealand (NZ) children aged 6-to-10 years, the prevalence of sleep disordered breathing (SDB) and those struggling academically, and to identify individual and shared risk factors (health and demographic) for parent-reported SDB symptoms and academic difficulties.

METHODS

In this cross-sectional study, parents/caregivers of children were recruited through schools and social media to complete an online questionnaire covering health and demographic factors, their children's SDB symptoms (Pediatric Sleep Questionnaire; PSQ) and parental ratings of academic performance based on teacher feedback relative to expected progress in the national curriculum (well below/below/at/above) in reading, writing, and math.

RESULTS

A total of 1205 children (53% male) aged (mean) eight years two months were included, comprising 79.4% NZ European/other and 15.0% Māori. The survey-weighted prevalence of SDB (based on the PSQ) was 17.5%. This was higher amongst those with academic difficulties rated 'below/well below' expected progress for reading, writing and math (estimated at 24.0%, 31.0% and 27.5% respectively), with increased odds (adjusted odds ratios) for poor progress of 1.9 (95% CI: 1.2, 3.0), 1.8 (95% CI: 1.2, 2.7) and 2.4 (95% CI: 1.6, 3.7) respectively. There were no shared risk factors common to both SDB and academic difficulties identified from multivariate analyses.

CONCLUSIONS

The findings suggest that children with parent-reported SDB symptoms may be at high risk for poor progress in reading, writing, and math. Future research could examine whether treatment of SDB reduces barriers to learning and offsets educational risk.

Preschoolers with recurrent wheezing have a high prevalence of sleep disordered breathing

Objective: Sleep-disordered breathing (SDB) is highly prevalent in school children with poorly-controlled asthma. However, this association has not been assessed in preschoolers with recurrent wheeze, nor in those at risk for asthma. We hypothesized that preschoolers with asthma risk (positive asthma predictive index [API]) have a higher prevalence of SDB and higher inflammatory biomarkers (blood-hsCRP and urinary-LTE4) levels than those with negative API.Method: Children 2 to 5 years of age with recurrent wheezing were classified as positive or negative API. SDB was determined by the pediatric sleep questionnaire (PSQ) and its subscale (PSQSub6). Demographic characteristics, spirometry, blood hsCRP and urinary LTE4 were assessed.Results: We enrolled 101 preschoolers: 70 completed all measurements, 55.4% were males, mean age 4.07 ± 0.87 years, 45% overweight or obese, 70% had positive API, 87.5% had rhinitis. The prevalence of SDB measured by PSQ was 40.8% and by PSQSub6 was 29.6%. However, the proportion of SDB was similar between positive and negative API groups. The hsCRP (mean ± SD) was higher in the positive than in negative API (3.58 ± 0.58 and 1.32 ± 0.36 mg/L, p = 0.69, respectively); moreover, no differences in urinary LTE4 were found between groups. No correlation of PSQ (+) or PSQSub6 (+) with hsCRP and uLTE4 was found. However, preschoolers with positive API had significantly more post-bronchodilator percentage change in FEF25-75 than negative API (24.14 ± 28.1 vs. 4.13 ± 21.8, respectively, p = 0.01).Conclusions: In preschoolers with recurrent wheezing, we should be investigating for the coexistence of SDB, using early screening methods for detecting those conditions.

The OSA-5: Development and validation of a brief questionnaire screening tool for obstructive sleep apnea in children

OBJECTIVE

To develop and test a screening tool based on the OSA-18 questionnaire for triage of referrals for sleep-disordered breathing (SDB) in children.

STUDY DESIGN

Consecutive children aged >2y without major comorbidities referred for polysomnography (PSG) or overnight oximetry for suspected obstructive sleep apnea (OSA) between 11 January and 31 May 2017 were included. OSA was defined by an obstructive apnea/hypopnea index (OAHI) >1event/h on PSG or an abnormal overnight oximetry (McGill Oximetry Score 2-4). An 11-item questionnaire derived from a previous validation study of the OSA-18 underwent exploratory factor analysis (EFA) with varimax rotation. ANOVA identified questions associated with the presence of OSA. This informed a 5-question, 4-category instrument, scored 0-15 (the OSA-5), that was tested prospectively on 112 children having PSG.

RESULTS

420 children (2.0-17.9y, 43% female) met the inclusion criteria, including 366 complete questionnaires. EFA resulted in a 3-factor structure. ANOVA identified 5 questions from one factor that were independently associated with a diagnosis of OSA: snoring, breath holding, choking, mouth breathing and parental concern. Mean OSA-5 scores with and without OSA were 7.7 vs 4.5 (p < 0.001). Thirty-four percent (60/178) had a total score <5/15, with a sensitivity at this threshold for OSA of 82% and negative predictive value (NPV) of 70%. Similar results were obtained when tested prospectively, including a sensitivity of 82% and NPV of 81% for the presence of moderate/severe OSA (OAHI>5/h).

CONCLUSION

The OSA-5 is a simple questionnaire that performs well as a triage screening tool to identify those children at risk of OSA among large numbers of referrals for SDB.

The evaluation of the relationship between cervical vertebral anomalies with skeletal malocclusion types and upper airway dimensions

Objectives: To compare the prevalence of cervical vertebral anomalies (CVAs) in different skeletal malocclusions and to evaluate the relationship between upper airway dimension and vertebral anomalies. Methods: A retrospective study was performed on lateral cephalometric radiographs of 2062 patients aged 7-49 years. Skeletal malocclusion type, presence of CVAs, and upper airway area of 1856 patients who met the inclusion criteria of the study were recorded. The obtained data were transferred to the SPSS program for statistical analysis. Results: The mean age of the patients was 13.8 ± 3.7 years. The prevalence of CVAs was 45.7%. There was no significant difference in prevalence between skeletal malocclusions (p = 0.89). According to airway measurements, no significant difference was found between patients with and without CVAs (p = 0.718). Conclusion: The present results suggest that there is no direct effect of skeletal malocclusion type and upper airway dimension in the etiology of CVAs.

Environmental tobacco smoke exposure and risk of habitual snoring in children: a meta-analysis

BACKGROUND

The association between environmental tobacco smoke (ETS) exposure and habitual snoring (HS) risk in children remains controversial. Therefore, a meta-analysis was carried out to evaluate and compare the effect of ETS by different family members and prenatal smoke exposure on the risk of HS in children.

METHODS

Relevant studies published in English were identified by a search of PubMed, Embase and Web of Science up to December 2017. Random effect model and fixed effect model were used to pool the findings. Restricted cubic splines were used to assess the dose-response relationship.

RESULTS

A total of 24 studies with 87 829 participants were included in the present meta-analysis. When comparing ETS exposed with non-ETS exposed, the pooled OR of HS were 1.46 (95% CI, 1.29 to 1.65) for household smoking exposure, 1.45 (95% CI, 1.27 to 1.65) for paternal smoking exposure, 1.87 (95% CI, 1.56 to 2.23) for maternal smoking exposure and 1.95 (95% CI, 1.63 to 2.34) for prenatal tobacco smoke exposure. For dose-response analysis, evidence of a linear association was found between household smoking exposure and HS, and the risk of HS increased by 2.1% (OR=1.02, 95% CI, 1.00 to 1.04, p=0.022) for every 1 cigarette/day increment of smoking by people living with children.

CONCLUSIONS

This meta-analysis of observational studies indicates that exposure to ETS, in particularly prenatal tobacco smoke exposure and maternal smoking, is associated with an increased risk of HS.

Sleep Disorders and Their Management in Children With Ehlers-Danlos Syndrome Referred to Sleep Clinics

STUDY OBJECTIVES

The nature of sleep disorders in children with Ehlers-Danlos syndrome (EDS) is unknown. We aimed to describe the type, the management, and the short-term outcome of sleep disorders in children with EDS referred to sleep clinics.

METHODS

This is a retrospective review of medical records and polysomnography tests of children with EDS younger than 18 years who were referred to the sleep clinic. Demographic information and medical history were collected, and polysomnography tests were reviewed. Questionnaires completed during previous clinic visits, including the Pediatrics Sleep Questionnaire (PSQ), Epworth Sleepiness Scale (ESS), and Pediatric Quality of Life Inventory (PedsQL), were also evaluated.

RESULTS

Sixty-five patients with EDS-hypermobility type were included. The mean age was 13.15 ± 3.9 years. There were 68% of patients who were female, and 91% of patients were Caucasian. The mean follow-up period was 1.14 ± 1.55 years. Common sleep diagnoses included insomnia (n = 14, 22%), obstructive sleep apnea (OSA) (n = 17, 26%), periodic limb movement disorder (PLMD) (n = 11, 17%), and hypersomnia (n = 10, 15%). In addition, 65% required pharmacologic treatment and 29% were referred to behavioral sleep medicine. For OSA, two patients required continuous positive airway pressure. A significant improvement was observed in the PSQ, ESS, and PedsQL scores during follow-up visits after treatment (n = 34; P = .0004, 0.03, and 0.01, respectively).

CONCLUSIONS

There is a high prevalence of sleep disorders, including OSA, insomnia, PLMD, and hypersomnia in children with EDS referred to sleep clinics. Specific management can improve quality of life and questionnaire scores of this patient population. Our study emphasizes the importance of screening for sleep disorders in children with EDS.

Cognitive and Behavioral Consequences of Sleep Disordered Breathing in Children

There is now a plethora of evidence that children with sleep disordered breathing (SDB) show deficits in neurocognitive performance, behavioral impairments, and school performance. The following review will focus on the neurobehavioral impacts of SDB, pediatric sleep investigation challenges, potential mechanisms of behavioral and cognitive deficits in children with SDB, and the impact of SDB treatment.

Increased severity of sleep-disordered breathing is associated with insomnia and excessive somnolence in primary school children

OBJECTIVE

The aim of the study was to investigate the prevalence of difficulty with initiation or maintenance of sleep (DIMS) and excessive daytime sleepiness (EDS) in a general pediatric population, and to evaluate the relationship between these conditions and sleep-disordered breathing (SDB) symptom intensity.

METHODS

This population-based cross-sectional study from 27 primary schools in a medium-sized city in Poland was based on use of a questionnaire regarding demographic data, symptoms of SDB, DIMS, and EDS. Data were collected between September and December 2014. In all, 2940 caregivers were recruited and were asked to fill-out questionnaires and written consent.

RESULTS

A total of 68% of the questionnaires (n = 1987) were returned and analyzed. Habitual snoring (HS) was reported in 104 (5.3%) children. DIMS and EDS were seen in 137 children (6.9%) and 117 children (5.9%), respectively. The prevalence of DIMS increased from 3.5% in children who never snored to 28.6% in children who snored very often or always. Similarly, the prevalence of EDS was 2.7% in children who did not snore and increased to 19% in children who snored very often or always. No correlation was seen between increasing DIMS (r = 0.006, p > 0.05) or EDS (r = -0.031, p > 0.05) scores and body mass index.

CONCLUSIONS

This study is the first to measure the symptoms of both DIMS and EDS in a general pediatric population and to assess the relationship between both DIMS and EDS and SDB in children. We found that children with more frequent snoring had a higher prevalence of DIMS as well as EDS; however, there was no correlation between body mass index and either DIMS or EDS symptom severity.

Comparison of Clinical Symptoms and Severity of Sleep Disordered Breathing in Children With and Without Cleft Lip and/or Palate

OBJECTIVE

To determine whether the clinical presentation or severity of sleep disordered breathing differs between children with or without a history of cleft lip and/or palate (CL/P) presenting for sleep assessment.

DESIGN

Retrospective chart review.

SETTING

Tertiary care pediatric hospital cleft clinic, sleep clinic.

PATIENTS

Children >6 months of age presenting to the cleft clinic with sleep concerns and children without CL/P presenting to the sleep clinic in the same 2-year period.

MAIN OUTCOMES MEASURES

Clinical symptoms and overnight polysomnography (PSG) results.

RESULTS

A total of 168 children (55 from cleft clinic, 113 from sleep clinic) were identified. Age at clinical review (6.6 ± 4.1 years versus 6.8 ± 4.0 years, P = ns), sex distribution (64.6% versus 58.4%, P = ns), and the presence of syndromes or significant medical conditions (12% versus 16%, P = ns) were similar between groups. Snoring was the reason for referral in 59% of children with CL/P and 69% of non-CL/P children (P = ns). The only presenting feature that differentiated between the groups was a lower incidence of tonsillar enlargement in children with CL/P (33% versus 79%, chi-square 30.4, P < 0.001). Sleep study results showed similar apnea-hypopnea indices (6.2 ± 6.9 versus 7.9 ± 7.1 events/hr, P = ns) with more central apnea in children with CL/P (1.5 ± 1.5 versus 1.0 ± 1.0 events/hr, P = 0.017).

CONCLUSIONS

Snoring and obstructive sleep apnea are common in CL/P with less tonsillar enlargement than non-CL/P children. Children with CL/P have similar OSA severity compared to non-cleft children but more central apnea which may indicate differences in the control of breathing.

Obstructive sleep apnea in preschool-aged Japanese children - efficiency of screening using lateral neck radiography

Conclusions The prevalence of obstructive sleep apnea (OSA) in preschool-aged children diagnosed by the International Classification of Sleep Disorders (ICSD) version 3 criteria was relatively higher than that diagnosed by ICSD-2. Although the assessment of the upper airway by lateral neck radiography was effective for detecting OSA in this age group, this assessment is not recommended for all children as a screening method because of parental concern related to radiation exposure. Objective This study investigated the prevalence of OSA and the screening capacity of lateral neck radiography in community-based preschool-aged children. Methods Parents of 211 children aged 3-6 years were requested to complete the sleep-related questionnaire. Subjects who agreed to further investigations were invited to undergo home type 3 portable monitoring and clinical examination, including radiography. We estimated the prevalence of OSA and evaluated the detection power of radiography for predicting OSA. Results One hundred and eighty-eight (89.1%) subjects completed the questionnaire and 67 (31.8%) agreed to further examinations. The weighted prevalence was 7.3% and 12.8% by ICSD-2 and 3, respectively. Area under the receiver operator curve for the adenoidal/nasopharyngeal and tonsil/pharyngeal ratios measured using radiography was slightly larger than that for tonsil size graded by visual inspection.

Sleep-disordered breathing in orthodontic practice: Prevalence of snoring in children and morphological findings

OBJECTIVES

The purpose of this work was to evaluate the prevalence of snoring and its correlation with cranial and upper airway morphology in young individuals with orthodontic treatment need.

PATIENTS AND METHODS

Parents of 379 children were consecutively interviewed, using eight questions from a more comprehensive questionnaire about sleep behavior. A total of 100 patients (54 girls, 46 boys, average age 11.3 years) met the inclusion criteria. Based on the parents' interviews, the sample was divided into snorers (n = 53) and nonsnorers (n = 47). Using cephalograms obtained for initial orthodontic diagnostics, airway morphology was measured based on hyoid position and on the posterior airway space (PAS) dimensions at the maxillary, occlusal, and mandibular plane levels (PAS_NL, PAS_OCCL, PAS_ML). Mann-Whitney U testing, ANOVA, and Spearman's rank correlation coefficient were used for statistical analysis.

RESULTS

Snoring was reported by 53 % of parents for 63 % (n = 29) of the boys and 44 % (n = 24) of the girls. Significant morphological differences were noted between snorers and nonsnorers. PAS dimensions were significantly reduced in the snorers compared to the nonsnorers at all three anatomical levels tested, which remained statistically significant when adjusted for age and gender. No differences between the two groups emerged for hyoid position or any of the vertical cranial parameters. A significant correlation between sagittal maxillary position (SNA) and PAS_NL was noted, indicating that larger SNA values were mildly associated with larger sagittal PAS dimensions at the maxillary level.

CONCLUSION

This random sample of young patients with orthodontic treatment need was found to involve a high prevalence of parent-reported snoring. Characteristic features in cranial and upper airway morphology and thus differences between the snorers and nonsnorers were found.

Association between Asthma and Primary Nocturnal Enuresis in Children

PURPOSE

Enuresis, sleep respiratory disorders and asthma compromise the quality of sleep in children and may occur in association with each other. An association between sleep respiratory disorders and enuresis has already been demonstrated. According to united airways disease abnormalities of the upper and lower airways may coexist. A child who wheezes has a greater chance of snoring and having obstructive sleep apnea. Since asthma and sleep respiratory disorders may be associated, and sleep respiratory disorders are associated with enuresis, we determined the possibility of an association between asthma and enuresis.

MATERIALS AND METHODS

Between August 20 and March 2015 parents/guardians of children 6 to 14 years old from 16 elementary schools in our area were randomly chosen for study. Children with nonmonosymptomatic enuresis and urological or neurological disease were excluded. The Tucson and ISAAC (International Study of Asthma and Allergies in Childhood) questionnaires were used to assess sleep respiratory disorders and asthma, respectively.

RESULTS

A total of 523 children (283 males and 240 females) with a mean ± SD age of 9.42 ± 2.46 years were included in analysis. The overall prevalence of enuresis was 15.87% (95% CI 12.98-19.26). Asthmatic children with wheezing in the last 12 months were 2.33 times more likely to have had enuresis at some point in life (OR 2.33, 95% CI 1.37-3.95, p = 0.0017). If enuresis was present, the chance increased to 2.78 (95% CI 1.38-5.61, p = 0.0041). Enuretic children were 5.34 times more prone to have apnea reported by parents (95% CI 2.19-13.03, p = 0.0002).

CONCLUSIONS

These findings demonstrate that asthma as well as sleep respiratory disorders is associated with primary nocturnal enuresis.

Association Between Childhood Sleep-Disordered Breathing and Disruptive Behavior Disorders in Childhood and Adolescence

We examined the association between sleep-disordered breathing (SDB) and disruptive behavior disorders in 605 children participating in a population-based cohort study. Nineteen percent of children snored (sometimes or often) and 10% had obstructive sleep apnea (OSA) symptoms. Thirteen percent had an ADHD diagnosis or symptoms and 5-9% had behavioral problems or a conduct disorder. Snoring or OSA symptoms were associated with a twofold difference in the odds of ADHD diagnosis or symptoms. OSA symptoms were associated with a threefold to fourfold difference in the odds of behavioral problems or conduct disorder. Clinicians should consider inquiring about SDB in children with disruptive behavior disorders and should also consider disruptive behavior disorders as potential sequelae of SDB.

Obesity in children with different risk factors for obstructive sleep apnea: a community-based study

This study investigated the association between obesity and obstructive sleep apnea (OSA) in preschool and school-age children. Parents of obese and randomly chosen normal weight children completed a questionnaire on sleep-related symptoms, demography, family, and medical history. All subjects were invited to undergo polysomnography (PSG). OSA cases were defined as obstructive apnea hypopnea index (OAHI) ≥1. A total of 5930 children were studied with 9.5% obese (11.9% boys/6.1% girls), 205/2680 preschool and 360/3250 school children. There were 1030 children (535 obese/495 normal weight) who underwent PSG. OSA was higher in obese children and obese school children had higher OAHI, arousal index, and shorter total sleep time. However, there was no positive correlation between OSA and body mass index (BMI). The main risk factors for OSA in preschool children were adenotonsillar hypertrophy and recurrent respiratory tract infection. The main cause for OSA in school children was a history of parental snoring and obesity. Mallampati scores and sleep-related symptoms were found to be associated with OSA in both preschool and school children.

CONCLUSION

We demonstrated differential risk factors for OSA in obese children, which suggest that a different mechanism may be involved in OSA development in preschool and school-age children.

WHAT IS KNOWN

Various risk factors have been reported in obese children with OSA owing to the different age and different study design. Obese children have a higher prevalence and severity of obstructive sleep apnea (OSA). OSA risk factors in obese children are affected by different ages and study designs.

WHAT IS NEW

A differential prevalence and risk factors for obese preschool and school-age children with OSA has been demonstrated.

Rationale, design and methods for the 22 year follow-up of the Western Australian Pregnancy Cohort (Raine) Study

BACKGROUND

Young adulthood is a critical life period for health and health behaviours. Related measurements collected before and after birth, and during childhood and adolescence can provide a life-course analysis of important factors that contribute to health and behaviour in young adulthood. The Western Australian Pregnancy Cohort (Raine) Study has collected a large number of such measurements during the fetal, perinatal, infancy, childhood and adolescence periods and plans to relate them to common health issues and behaviours in young adults, including spinal pain, asthma, sleep disorders, physical activity and sedentary behaviour and, work absenteeism and presenteeism. The aim of this paper is to describe the rationale, design and methods of the 22 year follow-up of the Raine Study cohort.

METHODS/DESIGN

The Raine Study is a prospective cohort study. Participants still active in the cohort (n = 2,086) were contacted around the time of their 22nd birthday and invited to participate in the 22 year follow-up. Each was asked to complete a questionnaire, attend a research facility for physical assessment and an overnight sleep study, wear activity monitors for a week, and to maintain a sleep and activity diary over this week. The questionnaire was broad and included questions related to sociodemographics, medical history, quality of life, psychological factors, lifestyle factors, spinal pain, respiratory, sleep, activity and work factors. Physical assessments included anthropometry, blood pressure, back muscle endurance, tissue sensitivity, lung function, airway reactivity, allergic status, 3D facial photographs, cognitive function, and overnight polysomnography.

DISCUSSION

Describing the prevalence of these health issues and behaviours in young adulthood will enable better recognition of the issues and planning of health care resources. Providing a detailed description of the phenotype of these issues will provide valuable information to help educate health professionals of the needs of young adults. Understanding the life-course risk factors of health issues and behaviours in young adulthood will have important health planning implications, supporting the development of targeted interventions to improve current health status and reduce the onset and development of further ill-health across adulthood.

Cognitive function in preschool children with sleep-disordered breathing

PURPOSE

The purposes of this study were to assess cognitive functions in preschool children with sleep-disordered breathing (SDB) and to compare them with matched control children.

METHODS

A clinical sample of 2.5- to 6-year-old children with SDB was recruited. All children underwent sleep clinical record (SCR), which is a polysomnography (PSG)-validated questionnaire for diagnosing SDB, a polysomnography and a neurocognitive assessment. Normal controls were recruited from a kindergarten. They underwent the SCR and the cognitive assessment.

RESULTS

We studied 41 children with primary snoring (PS)-mild obstructive sleep apnea syndrome (OSAS; M/F = 15/26, mean age 4.43 ± 0.94), 36 children with moderate-severe OSAS (M/F = 22/14, mean age 4.33 ± 1.02), and 83 controls (M/F = 33/50, mean age 4.5 ± 0.64). In the two groups, no differences were found in duration and age of onset of SDB, while a significant difference emerged in SCR score (p < 0.005). No differences emerged in the three groups in Verbal IQ, Performance IQ, and Global IQ scores, nor in any cognitive subtests.

CONCLUSIONS

We demonstrated that SDB of all severities is not associated with cognitive impairment compared to the control group in preschool age.

Natural history of snoring and other sleep-disordered breathing (SDB) symptoms in 7-year-old New Zealand children: a follow-up from age 3

PURPOSE

We aimed to examine the natural history of snoring and associated symptoms in a community sample of New Zealand children at ages 3 and 7 years, and identify factors associated with habitual snoring at age 7 years.

METHODS

Parent/s of children (n = 839) who completed the community survey about their child's sleep and breathing at age 3 years were re-contacted via mail 4 years later when children were aged 7 years. Parents were asked to complete a follow-up questionnaire which included items relating to their child's sleep and health, and family demographic information. There was a 54.8% (n = 460) response rate.

RESULTS

At follow-up, habitual snoring was prevalent in 9.2% of the sample, similar to the 11.3% reported at age 3 years. However, habitual snoring status changed over time; 36.2% (n = 21/58) remained habitual snorers; 63.8% (n = 37/58) were no longer snoring habitually, while 5.3% (n = 21/397) had started habitual snoring since the initial survey. Overall, the reported severity of SDB-related symptoms decreased over time, regardless of initial habitual snoring status. Nonetheless, habitual snoring at follow-up was significantly associated with mouth breathing, sleeping with the neck extended, sweating profusely, night waking, and parent-reported child irritability.

CONCLUSIONS

Our findings highlight the dynamic nature of SDB, where habitual snoring and related symptoms can develop, remain present, or resolve at different times, over early-mid-childhood years. Given the dynamic nature of habitual snoring over the early childhood years, pediatricians should continue to screen for snoring and sleep apnea on an annual basis throughout childhood.

Sleep disordered breathing in children with mitochondrial disease

A retrospective chart review study was performed to determine the presence of sleep disordered breathing (SDB) in children with primary mitochondrial disease (MD). The symptoms, sleep-related breathing, and movement abnormalities are described for 18 subjects (ages 1.5 to 18 years, 61% male) with MD who underwent polysomnography in our pediatric sleep center from 2007 to 2012. Of the 18 subjects with MD, the common indications for polysomnography were excessive somnolence or fatigue (61%, N = 11), snoring (44%, N = 8), and sleep movement complaints (17%, N = 3). Polysomnographic measurements showed SDB in 56% (N = 10) (obstructive sleep apnea in 60% (N = 6), hypoxemia in 40% (N = 4), and sleep hypoventilation in 20% (N = 2)). There was a significant association between decreased muscle tone and SDB (P: 0.043) as well as obese and overweight status with SDB (P = 0.036). SDB is common in subjects with MD. Early detection of SDB, utilizing polysomnography, should be considered to assist in identification of MD patients who may benefit from sleep-related interventions.

Serum resistin levels in children with primary snoring

Primary Snoring (PS) has been positioned at the milder end of the Sleep-Disordered Breathing severity continuum characterized by snoring and it is usually underestimated. PS is defined as snoring without apnea, frequent arousals, or gas exchange abnormalities and recent studies demonstrated that children with PS have increased blood pressure and reduced arterial distensibility. The association between adipokines and SDB has been recently investigated, though most of the studies were focused on OSAS where intermittent hypoxia characterizing the disease may lead to an inflammatory cascade and to the release of several adipokines, contributing to oxidative stress. Resistin, initially described s an adipokine increasing insulin resistance, has been recently identified as a novel important member of the cytokine family involved in the regulation of inflammation. The aim of our study was to investigate circulating resistin levels in normal weight children with PS. Sixty-five children of normal weight aged between 4 and 14 years of age were selected for habitual snoring. Children with positive polysomnography were excluded from the study. Serum resistin levels were detected in all children with PS. Thirty-three healthy non-snorer children with similar age, sex and BMI were selected as a control group. A significantly higher level of resistin was observed in patients with PS compared to the control group (4.67±1.91 ng/ml vs 3.98±1.58 ng/ml; p<0.01). Patients with inconclusive pulse oximetry showed significantly higher resistin levels than those with negative recordings recordings (5.29±1.91 ng/ml vs 4.20±1.93 ng/ml; p<0.008). Moreover, there was a significant increasing trend between sieric adipokine level and the frequency of snoring (p<0.006). Our results suggest that systemic inflammation and oxidative stress may also play a significant role in the pathophysiology of PS.