Behavior and neurocognitive performance in children aged 5-10 years who snore compared to controls

Adenotonsillectomy for the treatment of OSA in children with mucopolysaccharidosis: A systematic review

OBJECTIVE

To study the role of adenotonsillectomy (ADT) for obstructive sleep apnea (OSA) in children with mucopolysaccharidosis (MPS).

METHODS

A systematic review were performed following the PRISMA guideline. PubMed and Embase were searched for studies regarding adenotonsillectomy for OSA in children with MPS. The MINOR Score were applied for quality assessment of the included studies.

RESULTS

Nineteen studies were eligible for inclusion: fifteen were retrospective and four prospective. A total of 1406 subjects were included. The samples size varied from 2 to 336, the male to female ratio is 1.2 and mean age varied from 2.4 to 11 years. Overall, 56.2 % (IC 95%: 53.6-58.8) of the included subjects underwent ADT. MPS I and II are the two most operated types. Three studies, including 50 children, reported improvement in polysomnographic parameters after surgery. Two authors described the duration of follow-up: 8.4 and 9.8 years, respectively.

CONCLUSIONS

More than half of children with MPS underwent ADT for the treatment of OSA, although few evidence demonstrated improvement in term of polysomnographic parameters. The two types of MPS most involved are type I and II. Considering the disease progression and anesthetic risks, multidisciplinary management may help identify the subgroup of children with MPS who benefit from ADT for the treatment of OSA.

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

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.

Longitudinal change in sleep, functional, and behavioural characteristics in a cohort of children with Down syndrome

This paper describes the longitudinal change in sleep, functional, and behavioural characteristics in a cohort of children with Down syndrome, including the effect of sleep interventions in a subset. A prospective longitudinal cohort study was undertaken in children with Down syndrome aged 3-16 years comparing (1) children referred to a tertiary sleep medicine clinic who received sleep hygiene advice and an additional sleep treatment (DSref_I) with (2) children attending the same clinic who only received sleep hygiene advice (DSref_N) and (3) children recruited from the community who, were not receiving any treatment (DScomm). Data collected included demographic and medical history information, Child Sleep Habits Questionnaire-Abbreviated (CSHQ-A), Life-Habits Questionnaire (Life-H) and Child Behaviour Checklist (CBCL) at baseline and then 6-monthly for a total of 18 months. Any sleep interventions during this time were recorded. A total of 57 children were included (DSref_I, n = 16; DSref_N, n = 25; DScomm, n = 16). At recruitment, the median CSHQ-A total score was high (>41) in all three subgroups, but highest in the DSref_I subgroup (median [interquartile range] Dsref_I score 58 [53-66] versus DSref_N score 49 [43-53], p = 0.019). Although improved, 80% of participants in the DSref_I subgroup still had a CSHQ-A total score >41 at the last assessment point. The median total Life-H and total CBCL scores were not significantly different between groups at baseline and there was no significant time, group, or interaction effect seen through the study. Over an 18-month period, sleep problems were seen to persist in children with Down syndrome. Treatment resulted in only modest improvements in sleep.

The Comparison of the Sleep Structure and Sleep Spindle Activity in Children With Primary Snoring and Sleep-Disordered Breathing

Obstructive sleep apnea syndrome (OSAS) in children is associated with changes in the structure of sleep. The possible effects of snoring on spindle activity have not been established. We analyzed the polysomnography recordings and sleep spindle activity in children with primary snoring and/or OSAS compared with healthy children. Fifty-one children were included; 8 had primary snoring, 16 had OSAS and snoring, 11 had OSAS without snoring, and 16 were healthy controls. The density (P = .034) and duration (P = .019) of sleep spindles were decreased in children with OSAS compared with controls. The sleep spindle activity did not show significant changes between children with primary snoring and healthy controls, or between OSAS with/without snoring. We conclude that it is not snoring per se but OSAS that affects sleep spindle activity. Obstructive sleep apnea syndrome with/without snoring deserves greater attention because it has different phenotypes of the disease with different pathophysiologies.

Ventilatory and Orthostatic Challenges Reveal Biomarkers for Neurocognition in Children and Young Adults With Congenital Central Hypoventilation Syndrome

BACKGROUND

Children and young adults with congenital central hypoventilation syndrome (CCHS) are at risk of cognitive deficits. They experience autonomic dysfunction and chemoreceptor insensitivity measured during ventilatory and orthostatic challenges, but relationships between these features are undefined.

RESEARCH QUESTION

Can a biomarker be identified from physiologic responses to ventilatory and orthostatic challenges that is related to neurocognitive outcomes in CCHS?

STUDY DESIGN AND METHODS

This retrospective study included 25 children and young adults with CCHS tested over an inpatient stay. Relationships between physiologic measurements during hypercarbic and hypoxic ventilatory challenges, hypoxic ventilatory challenges, and orthostatic challenges and neurocognitive outcomes (by Wechsler intelligence indexes) were examined. Independent variable inclusion was determined by significant associations in Pearson's analyses. Multivariate linear regressions were used to assess relationships between measured physiologic responses to challenges and neurocognitive scores.

RESULTS

Significant relationships were identified between areas of fluid intelligence and measures of oxygen saturation (SpO2) and heart rate (HR) during challenges. Specifically, perceptual reasoning was related to HR (adjusted regression [β] coefficient, -0.68; 95% CI, 1.24 to -0.12; P = .02) during orthostasis. Working memory was related to change in HR (β, -1.33; 95% CI, -2.61 to -0.05; P = .042) during the hypoxic ventilatory challenge. Processing speed was related to HR (β, -1.19; 95% CI, -1.93 to -0.46; P = .003) during orthostasis, to baseline SpO2 (hypercarbic and hypoxic β, 8.57 [95% CI, 1.63-15.51]; hypoxic β, 8.37 [95% CI, 3.65-13.11]; P = .002 for both) during the ventilatory challenges, and to intrachallenge SpO2 (β, 5.89; 95% CI, 0.71-11.07; P = .028) during the hypoxic ventilatory challenge.

INTERPRETATION

In children and young adults with CCHS, SpO2 and HR-or change in HR-at rest and as a response to hypoxia and orthostasis are related to cognitive outcomes in domains of known risk, particularly fluid reasoning. These findings can guide additional research on the usefulness of these as biomarkers in understanding the impact of daily physical stressors on neurodevelopment in this high-risk group.

Oxygen resaturation rate is significantly associated with objectively assessed excessive daytime sleepiness in suspected obstructive sleep apnoea patients

INTRODUCTION

Commonly utilised metrics such as the apnoea-hypopnoea index show limited correlation to excessive daytime sleepiness (EDS). Oxygen desaturation parameters show better predictive power, however oxygen resaturation parameters have not yet been investigated. Oxygen resaturation may represent increased cardiovascular fitness and thus we hypothesized that a higher resaturation rate would be protective against EDS.

METHODS

Oxygen saturation parameters were computed via ABOSA software for adult patients referred for polysomnography and multiple sleep latency test in Israel Loewenstein hospital 2001-2011. EDS was defined as a mean sleep latency (MSL) below 8 min.

RESULTS

1629 patients (75% male, 53% obese, median age of 54 years) were included for analysis. The average desaturation event nadir was 90.4% and resaturation rate 0.59%/second. Median MSL was 9.6 min, and 606 patients met criteria for EDS. Patients who were younger, female, and with larger desaturations had significantly higher resaturation rates (p < 0.001). In multivariate models, adjusted for age, sex, body mass index, and average desaturation depth, resaturation rate showed a significant negative correlation with MSL (z-score standardised beta, -1 (95%CI -0.49, -1.52)), and significantly increased odds ratio (OR) of EDS (OR, 1.28 (95%CI 1.07, 1.53)). The beta associated with resaturation rate was larger, though non-significantly, than that of desaturation depth (difference 0.36 (95% CI -1.34, 0.62), p = 0.470).

CONCLUSION

Oxygen resaturation parameters show significant associations with objectively assessed EDS independent of desaturation parameters. Thus, resaturation and desaturation parameters may reflect differing underlying mechanistic pathways and both be considered novel and appropriate markers for assessing sleep-disordered breathing and associated outcomes.

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.

Neurocognitive Consequences in Children with Sleep Disordered Breathing: Who Is at Risk?

Sleep-disordered breathing (SDB) is a prevalent disease in children characterized by snoring and narrowing of the upper airway leading to gas exchange abnormalities during sleep as well as sleep fragmentation. SDB has been consistently associated with problematic behaviors and adverse neurocognitive consequences in children but causality and determinants of susceptibility remain incompletely defined. Since the 1990s several studies have enlightened these associations and consistently reported poorer academic performance, lower scores on neurocognitive tests, and behavioral abnormalities in children suffering from SDB. However, not all children with SDB develop such consequences, and severity of SDB based on standard diagnostic indices has often failed to discriminate among those children with or without neurocognitive risk. Accordingly, a search for discovery of markers and clinically useful tools that can detect those children at risk for developing cognitive and behavioral deficits has been ongoing. Here, we review the advances in this field and the search for possible detection approaches and unique phenotypes of children with SDB who are at greater risk of developing neurocognitive consequences.

Dental, oral pH, orthodontic and salivary values in children with obstructive sleep apnea

OBJECTIVES

Mouth breathing is a key feature of obstructive sleep apnea (OSA). The current study evaluated dental, salivary and orthodontic characteristics of children with OSA, and compared them to those of children without OSA.

MATERIALS AND METHODS

Twenty-two children (mean age 5.3 years, 13 males) with OSA and 21 children without OSA who served as a control group (mean age 6.8 years, 11 males) underwent dental examinations. The OSA group was classified according to the apnea-hypopnea Index. Clinical examination included plaque index, gingival index, caries status, pH at 7 oral sites, salivary carries bacterial counts and inflammatory cytokine levels. Orthodontics measurements were calculated as the percentage of children with values in the normal range, in each group.

RESULTS

The mean values of the decayed, missing and filled teeth (DMFT)/dmft index, the gingival index and the plaque index were higher in the OSA than the control group. Salivary Mutans streptococci and lactobacilli counts were significantly higher in the OSA than the control group; as were pH values in the hard and soft palate, and in the posterior and middle tongue. Significantly lower values were observed in the OSA than the control group for most of the orthodontic variables examined. Similarly, stratification of AHI according to severity shows the lowest values among those with mild OSA, and the highest among those with severe AHI.

CONCLUSIONS

Compared to a control group, mouth breathing children with obstructive sleep apnea had differences in oral microbiota, greater acidity and poorer dental status.

CLINICAL RELEVANCE

Clinicians should be aware of the various oral disturbances that may accompany OSA, and implement preventive measures.

The Effect of Adenotonsillectomy on Children's Behavior and Cognitive Performance with Obstructive Sleep Apnea Syndrome: State of the Art

(1) Background: This systematic review was designed to analyze adenotonsillectomy’s role in treating behavioural disorders and sleep-related quality of life in pediatric OSAS. (2) Methods: Papers that report pre-operative and post-operative outcomes by using the Epworth sleepiness scale, OSA-18, NEPSY, Conners’ rating scale, BRIEF, PSQ-SRBD, PedsQL and CBCL. We performed a comprehensive review of English papers published during the last 20 years regarding behavioural disorders in OSAS patients and adenotonsillectomy. (3) Results: We included 11 studies reporting behavioral outcomes and sleep related quality of life after surgery. We investigated changes in behavior and cognitive outcomes after AT, and we found significant improvements of the scores post-AT in almost all studies. After comparing the AT group and control group, only one study had no difference that reached significance at one year post-AT. In another study, it did not show any significant improvement in terms of all behavioural and cognitive outcomes. The questionnaires on sleep-related quality of life after AT (PSQ-SRBD or ESS or OSA-18 or KOSA) may improve with positive changes in sleep parameters (AHI, ODI and SpO2). Furthermore, there is a significantly higher decrease in OSAS symptoms than the pre-AT baseline score. (4) Conclusion: Future studies should pay more attention to characterizing patient populations as well as rapid surgical treatments through existing criteria.

Sleep, Function, Behaviour and Cognition in a Cohort of Children with Down Syndrome

Objective: To describe the sleep problems experienced by children with Down syndrome attending a tertiary sleep clinic and relationship with behaviour, function and cognition. Methods: Data were collected from children with Down syndrome aged 3–18 years old. Carers completed the Abbreviated Child Sleep Habits Questionnaire, Child Behaviour Checklist and Life-Habits Questionnaire at enrolment. Cognitive assessment (Stanford-Binet 5) was undertaken by a trained psychologist. Children received management for their sleep problem as clinically indicated. Results: Forty-two subjects with a median age of 6.8 years (Interquartile Range-IQR 4.5, 9.8) were enrolled. A total of 92% were referred with snoring or symptoms of Obstructive Sleep Apnoea (OSA), with 79% of those referred having had previous ENT surgery. Thus, 85% of all participants underwent a sleep study and 61% were diagnosed with OSA (OAHI ≥ 1/h). Based on questionnaires, 86% of respondents indicated that their child had a significant sleep disorder and non-respiratory sleep problems were common. Non-respiratory problems included: trouble going to sleep independently (45%), restless sleep (76%), night-time waking (24%) and bedtime resistance (22%). No significant correlations were found between sleep measures (behavioural and medical sleep problems) and the behavioural, functional or cognitive parameters. Conclusion: Sleep disorders were very common, especially non-respiratory sleep problems. OSA was common despite previous surgery. No association was found between sleep-related problems (snoring, sleep-study-confirmed OSA or non-respiratory sleep problem) and parent-reported behavioural problems, functional impairments or intellectual performance. This may reflect limitations of the measures used in this study, that in this population ongoing problems with daytime function are not sleep related or that a cross-sectional assessment does not adequately take into account the impacts of past disease/treatments. Further research is required to further evaluate the tools used to evaluate sleep disorders, the impact of those disorder on children with Down syndrome and interventions which improve both sleep and daytime function.

The impact of sleep problems on functional and cognitive outcomes in children with Down syndrome: a review of the literature

STUDY OBJECTIVES

The aim of this review was to summarize the existing literature on the association between sleep problems and cognition, function, and behavior in children with Down syndrome.

METHODS

Embase, PubMed, CINAHL, and PsychINFO databases were searched to retrieve all studies published between 1990 and 2018 that evaluated the relationship between sleep and cognition, function, or behavior in children with Down syndrome.

RESULTS

Fifteen articles were included, which were mostly of a cohort or case-controlled design. Five articles addressed sleep and cognition only, 6 reported on sleep and behavior, and only 1 reported on sleep and functional ability. Three papers evaluated sleep and both cognition and behavior. Findings varied across studies with methodological differences, making it difficult to directly compare results. The association between sleep and behavior or cognition in children with Down syndrome remains uncertain, but a large study in 110 children provides strong evidence of a negative impact of sleep disorders on the accomplishment of daily life habits.

CONCLUSIONS

The impact of coexisting sleep disorders in children with Down syndrome has not been widely studied, with only 15 relevant studies found through an extensive literature review. Large well-designed studies are required to fully understand this relationship further. This is important as sleep-disordered breathing and difficulties with sleep patterns and routines are highly prevalent in children with Down syndrome. Sleep may be one of the few treatable factors that can assist in improving long-term outcomes in this population.

Association Between Habitual Snoring and Cognitive Performance Among a Large Sample of Preadolescent Children

Importance

Previous studies have identified an association between habitual snoring and lower cognitive performance in children. However, whether and to what extent this association is confounded by pertinent demographic, anthropometric, and socioeconomic characteristics is unknown.

Objective

To assess the extent to which potential confounding factors modify the association between parent-reported habitual snoring and cognitive outcomes among a large and diverse sample of typically developing preadolescent children.

Design, Setting, and Participants

This cross-sectional analysis used a baseline data set (version 2.0.1) from children enrolled in the ongoing Adolescent Brain Cognitive Development study between September 1, 2016, and October 15, 2018. Children aged 9 to 10 years without serious psychiatric or neurological comorbidities were recruited at 21 research sites in the US. Study recruitment was designed to approximate the racial and socioeconomic diversity of the US population. Data were analyzed from February 1 to March 31, 2020.

Exposures

Parent-reported habitual snoring in children that occurs 3 or more nights per week.

Main Outcomes and Measures

Associations between habitual snoring and cognitive performance were assessed using the Sleep Disturbance Scale for Children and the National Institutes of Health Toolbox Cognition Battery, which includes 7 domain-specific and 3 composite (total cognitive function, fluid cognition, and crystallized cognition) standard scores that are uncorrected for covariates. Cognitive performance was examined before and after adjustment for covariates, which included age, sex, body mass index percentile, annual household income before taxes, and highest educational level of caregiver. The extent of confounding was assessed by the effect size, represented by Cohen d, before and after inclusion of covariates using linear mixed-effects models.

Results

A total of 11 873 children aged 9 to 10 years (6187 boys [52.1%]; 6174 White [52.0%]) with available data were included in the study. Of those, habitual snoring (≥3 nights per week) was reported in 810 children (6.8%), and nonhabitual snoring (1-2 nights per week) was reported in 4058 children (34.2%). In the unadjusted models, the total cognitive function composite score among children who habitually snored was significantly lower compared with children who never snored (Cohen d, 0.35; 95% CI, 0.28-0.42). Differences were also identified in the crystallized cognition (Cohen d, 0.34; 95% CI, 0.26-0.41) and fluid cognition (Cohen d, 0.28; 95% CI, 0.21-0.35) composite scores. The association between habitual snoring and cognitive performance was substantially attenuated after adjustment for covariates (Cohen d, 0.16 [95% CI, 0.09 to 0.24] for total cognitive function, 0.14 [95% CI, 0.07 to 0.21] for crystallized cognition, and 0.13 [95% CI, 0.06 to 0.21] for fluid cognition). Similar mitigation was also observed for all domain-specific scores.

Conclusions

In this cross-sectional study, when adjusted for baseline demographic, anthropometric, and socioeconomic characteristics, the association between parent-reported habitual snoring and cognitive performance was substantially attenuated among children aged 9 to 10 years.

Association of Sleep Apnea With Development and Behavior in Down Syndrome: A Prospective Clinical and Polysomnographic Study

BACKGROUND

The prevalence of sleep-disordered breathing is high in children with Down syndrome. Although the association between sleep-disordered breathing and developmental delay and behavioral abnormalities are proven among typically developing children, there are few such studies of children with Down syndrome. This study assesses the relationship between the severity of sleep apnea and development and behavioral abnormalities in individuals with Down syndrome.

METHODS

In a cross-sectional prospective study, 53 children with Down syndrome were assessed for sleep-disordered breathing by overnight polysomnography. Behavior was assessed using Child Behavior Checklist (CBCL) and developmental quotient (DQ) using Developmental Profile 3. The association between various domains of behavior and development with the Apnea-Hypopnea Index (AHI) was assessed using Spearman rank correlation. Multiple linear regression assessed the independent effects of various factors on development and behavior.

RESULTS

Of 53 subjects (three to 11.8 years), 51 (96%) were found to have obstructive sleep apnea (OSA). In both three to five year and six to 12 year age groups, there was a statistically significant positive correlation between the CBCL scores and the AHI (rho = 0.77 and 0.83, respectively). There was a statistically significant negative correlation between the DQ and the AHI (rho = -0.62). In multiple linear regression, AHI was the only independent variable that was associated with CBCL and DQ.

CONCLUSIONS

This study provides robust evidence that OSA can negatively influence the development and behavior in children with Down syndrome as in typically developing children. Moreover, with increasing severity of OSA, children with Down syndrome have more behavioral abnormalities, especially attention deficit and hyperactivity, and also have poorer development scores.

Editorial Commentary: Arthrosomnology and the Solution to Coxalgia Somnia: Arthroscopic Hip Surgeons and Patients Increasingly Appreciate the Role of Sleep as Good Medicine

It is increasingly recognized that a variety of musculoskeletal disorders significantly influence sleep. In individuals with sleep dysfunction caused by hip pain (coxalgia somnia) from osteoarthritis, total hip arthroplasty has reliably improved pain and sleep quality in most patients. In nonarthritic, nondysplastic individuals with femoroacetabular impingement syndrome caused by cam and/or pincer morphology and labral tears, hip arthroscopy has similarly reliably improved pain and function in most patients. In addition, there is now early short-term evidence showing significant improvements in both sleep quantity and quality in most patients after arthroscopic hip preservation surgery. Integrating the realms of hip arthroscopy and sleep medicine, known as arthrosomnology, there are dozens of subjective patient-reported and objective clinician-measured outcomes available to analyze the impact of interventions. The Pittsburgh Sleep Quality Index is the most common subjective questionnaire used in orthopaedic surgery literature. Integrating the realms of wearable technology (fitness trackers, smart watches) and machine learning and artificial intelligence has incredible potential to collect immense volumes of accurate sleep "big data."

Cognitive parameters in children with mild obstructive sleep disordered breathing

PURPOSE

Sleep disordered breathing (SDB) in children is commonly described as a continuum from primary snoring (PS) to obstructive sleep apnea (OSA), based on apnea indices from polysomnography (PSG). This study evaluated the difference in neurocognitive and behavioral parameters, prior to treatment, in symptomatic pre-school children with PSG-diagnosed OSA and PS.

METHODS

All children had positive Pediatric Sleep Questionnaire (PSQ) results and were deemed suitable for adenotonsillectomy by an ENT surgeon. Neurocognitive and behavioral data were analyzed in pre-school children at recruitment for the POSTA study (The Pre-School OSA Tonsillectomy Adenoidectomy Study). Data were compared between PS and OSA groups, with Obstructive Apnea-Hypopnea Index, OAHI < 1/h or 1-10/h, respectively.

RESULTS

Ninety-one children were enrolled, including 52 with OSA and 39 with PS. Distribution of IQ (using Brief Intellectual Ability, BIA) was slightly skewed towards higher values compared with the reference population. No significant differences were found in neurocognitive or behavioral parameters for children with OSA versus those with PS.

DISCUSSION

Neurocognitive and behavioral parameters were similar in pre-school children symptomatic for OSA, regardless of whether or not PSG diagnosed PS or OSA. Despite having identical symptoms, children with PS on PSG are often treated conservatively, whereas those with OSA on PSG are considered for adenotonsillectomy. This study demonstrates that, regardless of whether or not PS or OSA is diagnosed on PSG, symptoms, neurocognition, and behavior are identical in these groups. We conclude that symptoms and behavioral disturbances should be considered in addition to OAHI when determining the need for treatment.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials registration number ACTRN12611000021976.

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.

Quality of life related to residual snoring after adenotonsillectomy: a pilot study

INTRODUCTION

Few studies have addressed long-term quality of life related to residual snoring after adenotonsillectomy. The aim of this study was to compare scores from the OSA-18 questionnaire between children with residual snoring and non-snoring children two or more years after adenotonsillectomy.

MATERIAL AND METHODS

The sample comprised 25 children divided into two groups, a group of 14 snoring children, and a control group of 11 non-snoring children. The OSA-18 questionnaire was applied to the volunteers. In the control group, it was completed by the caregivers of the children, while in individuals with residual snoring it was completed by the caregivers of children in the presence of a doctor or dentist. A statistical comparison was made using a generalized linear model.

RESULTS

The snorer group had a higher total OSA-18 score, and a higher score in all five domains compared to the control group.

CONCLUSION

Children with residual snoring two or more years after adenotonsillectomy may have a worse quality of life compared to the control group.

Consequences of paediatric sleep disordered breathing: contributions from Australian and New Zealand investigators

AIMS

To highlight the contributions of Australian and New Zealand researchers to the identification of the consequences of paediatric sleep disordered breathing (SDB).

METHODS

A search was conducted in PubMed using the terms "sleep disordered breathing" "child" and "Australia or New Zealand". All abstracts were reviewed and those which focused on the consequences of SDB have been included.

RESULTS

Australasian research into the consequences of SDB has grown exponentially over the last 35 years. SDB has significant adverse consequences for quality of life, behaviour, neurocognition and the cardiovascular system and the Australasian research studies investigating these are summarised.

CONCLUSIONS

Australian and New Zealand researchers have played a significant role in understanding the consequences of paediatric SDB and the mechanisms which underpin these. The research conducted "Downunder" has led the world in this field of research and will continue to provide evidence to improve the lives of children not only in Australasia but around the world.

Impact of adenotonsillectomy in children with severe obstructive sleep apnea: A systematic review

OBJECTIVES

To determine the impact of adenotonsillectomy for treatment of severe obstructive sleep apnea (OSA) in children without comorbidities.

METHODS

A systematic review was performed to identify studies regarding adenotonsillectomy for treatment of children with severe sleep apnea. Polysomnographic parameters were considered as metric of cure and the number of patients of persistent apnea was calculated. Quality of evidence was graded using OCEBM (Oxford Center for Evidence Based Medicine) and MINORS (Methodological Index for Nonrandomized Studies) scores.

RESULTS

The systematic review included nine studies. Five studies were prospective and four retrospectives. No one was controlled. The number of subjects with severe OSA included was 499 with a prevalence of male. The mean age varied from 4.3 to 8.2. The follow-up period ranges from 1 to 23 months. The criteria for considering severe OSA ranges from AHI or RDI ≥10 to ≥30. All the trials have found a statistically significant reduction of postoperative AHI or RDI values in patients who had undergone adenotonsillectomy for severe OSA. The AHI and RDI improving varied from 57.7% to 93.3%. All the studies documented persistent OSA after adenotonsillectomy. The number of residual OSA considering AHI≥5 varied from 30 to 55.5%, in case of AHI ≥1 from 60 to 90.6%.

CONCLUSION

To the best of our knowledge, this is the first review regarding the effectiveness of adenotonsillectomy for severe OSA in otherwise healthy children. Adenotonsillectomy is partially effective in the treatment of severe OSA in children without comorbidities. However, it reduces the severity of OSA determining a significant reduction of polysomnographic parameters. These results suggest a clinical and polysomnographic follow-up after surgery in order to manage the residual mild and moderate OSA.

Brain Cortex Activity in Children With Anterior Open Bite: A Pilot Study

Anterior open bite (AOB) is related to functional alterations of the stomatognathic system. There are no studies concerning brain activation of the cortex comparing children with and without AOB during rest and activities such as deglutition and phonation. The aim of this study was to determine the activity of the brain cortex of children with AOB at rest and during phonation and deglutition and to evaluate the association of intelligence quotient (IQ), attention (Test of Variables of Attention, known as TOVA), beats per minute (BPM), and oxygen saturation measurement (SpO₂) with brain activity in subjects with AOB. Fourteen children (seven with AOB and seven without AOB) with mixed dentition, aged 10–13 years, underwent an IQ test, TOVA, SpO₂, and quantitative electroencephalography (QEEG). Electrodes were set in the scalp, according to the 10–20 protocol. Data were analyzed using statistical tests to assess comparisons between children with and without AOB. The results showed that IQ, TOVA, SpO₂, or BPM did not show any statistically significant differences between the groups, except for the response time (contained in TOVA) (p = 0.03). Significant differences were found for the brain activity during rest (Condition 1) of the tongue, between children with and without AOB (p < 0.05 for alpha/theta and alpha peaks), whereas there were no differences during function (Condition 2). The findings of this investigation provide insights about the cortex activity of the brain while the tongue is in the resting position in children with AOB. This may imply an altered activity of the brain cortex, which should be considered when diagnosing and treating AOB. Other diagnostic techniques derived from investigations based on neuroscience could develop new diagnostic and therapeutic techniques to give better solutions to children with malocclusions. Treatments should be focused not only on the teeth but also on the brain cortex.

Evaluation of symptoms of preopoperative and postoperative psychosomatic screening in children with adenoidectomy and adenotonsillectomy

INTRODUCTION

Adenoidectomy and adenotonsillectomy are very common operations in childhood. It is important to clarify their effects on this age group; in this study, we aimed to investigate the effects of the causative agent on children's mental health by using scales that help to screen for indications of mental disorders in children, who have had adenoidectomy or adenotonsillectomy, both before and after surgery. In this way, we aimed to investigate the effects of this factor on children's mental health.

MATERIALS AND METHODS

The study included 82 children aged 6-12 years with signs of upper respiratory tract obstruction or recurrent adenotonsilitis. Adenotonsillectomy was performed in 41 patients included in the study and adenoidectomy was performed in 41 patients included in the study. 40 healthy children matched with the patient groups in terms of age and gender were included in the control group. Patients, were divided into three groups, those who underwent adenoidectomy, patients undergoing adenotonsillectomy and those in the control group Preoperative and postoperative questionnaires were used to investigate the effect of tonsillectomy or adenoidectomy on the mental health of children. The Parents' Form for the Strengths and Difficulties Questionnaire, the Parental Form for the Children's Anxiety Screening Scale, the Sleeping Scale for Children and the Quality of Life Scale for Children were used in the screening.

RESULTS

In children, who underwent adenoidectomy/adenotonsillectomy due to recurrent infection and adeno/adenotonsillar hypertrophy; it was seen that there was a significant decrease in the scores for the Strengths and Difficulties Questionnaire, the Anxiety Screening Scale in Children, and the Sleep Scale in Children, and a significant increase in Quality of Life Scale for Children scores.

OUTCOME

In conclusion, adenoidectomy/adenotonsillectomy in children with sleep apnea due to recurrent episodes of infection and adeno/adenotonsillar hypertrophy was thought to prevent further neurobehavioral problems, likely to become more complex in the future, and to improve quality of life.

Neurobehavioral Outcomes in School-Aged Children with Primary Snoring

OBJECTIVE

We assess behavioral and attentional problems and neurocognitive functioning in school-aged children with primary snoring (PS).

METHODS

Seventeen children with PS and 27 non-snoring peers aged 6-10 years took part in the study. All children underwent a polysomnography (PSG) at the Sleep Laboratory. Snoring was defined by parents and with PSG. Children with obstructive sleep apnea were excluded. The parents completed the Sleep Disturbance Scale for Children. Parents and teachers assessed behavioral and attentional problems with the Child Behavior Checklist and the Conners' Rating Scale-Revised. Neuropsychological assessment included the Wechsler Intelligence Scale for Children and the Developmental Neuropsychological Assessment (NEPSY test).

RESULTS

The PS group had significantly more parent-reported internalizing, total, and attentional problems than the control group. Teachers did not report behavioral problems in the PS group. The PS and control groups had equal IQ scores and similar core neurocognitive functions, except for one visuospatial subtest. The PS group had significantly more inspiratory flow limitation and increased diaphragmatic electromyography compared with the controls. Parents reported significantly more daytime sleepiness in the PS group. Daytime sleepiness and snoring time were consistently associated with more behavioral and attentional problems. Flow limitation and more oxygen saturation values under 90% were associated with attentional problems, higher oxygen desaturation index, and lower mean oxygen saturation percentage with reduced language functions.

CONCLUSIONS

Snoring with an increase in respiratory effort without apneas and hypopneas and parent-reported daytime sleepiness may be linked to daytime symptoms. School-aged children with PS are at risk for behavioral and attentional problems, but not cognitive impairments.

Association of sleep spindle activity and sleepiness in children with sleep-disordered breathing

STUDY OBJECTIVES

The association of snoring and sleep-disordered breathing (SDB) with daytime sleepiness is well documented; however, the exact mechanisms, and especially the role of sleep microstructure that may account for this association remain incompletely understood. In a cohort of children with SDB, we aimed to compare sleep spindle activity between children with daytime sleepiness versus those without daytime sleepiness.

METHODS

Children with SDB who reported daytime sleepiness were recruited and compared with age- and sex-matched SDB controls. Polysomnographic recordings were analyzed evaluating sleep spindle activity. A statistical comparison was carried out in both groups to assess the association between sleepiness and sleep spindle activity.

RESULTS

Thirty-three children with SDB (mean age: 7.5 ± 1.7 years) were included, 10 with and 23 without daytime sleepiness. Spindle activity was lower in children with daytime sleepiness compared with those without; in stage N2, median (interquartile range) sleep spindle indexes were 77.5 (37.3) and 116.9 (71.2) (P = .015), respectively.

CONCLUSIONS

Spindles were significantly reduced in children with SDB and daytime sleepiness. The exact mechanisms of this association remain unknown and future research is needed in order to establish the exact role of sleep spindle activity on daytime symptoms in children with SDB.

Sleep disordered breathing (SDB) in neonates and implications for its long-term impact

Sleep-disordered breathing (SDB) is a significant cause of morbidity in neonates and young infants. SDB occurs more commonly in preterm infants and in neonates with underlying syndromes. Recent evidence shows that infants with obstructive sleep apnoea (OSA) or SDB have greater health care resource utilization, including longer hospital stay. Management of SDB includes non-invasive ventilation or surgical interventions tailored to the patient. Screening high risk newborns should allow for early diagnosis and timely therapeutic intervention for this population. However, the thresholds for diagnosing SDB and for guiding and implementing treatment in neonates remain unclear. A collective effort is required to standardize the practice worldwide. This article will discuss neonatal sleep physiology and characteristics of neonatal sleep, with an emphasis on the epidemiology and diagnosis of SDB in neonates and its implications for long term outcomes.

The Inconsistent Nature of Heart Rate Variability During Sleep in Normal Children and Adolescents

Introduction: Cardiac function is modulated by multiple factors including exogenous (circadian rhythm) and endogenous (ultradian 90–110 min sleep cycle) factors. By evaluating heart rate variability (HRV) during sleep, we will better understand their influence on cardiac activity. The aim of this study was to evaluate HRV in the dark phase of the circadian rhythm during sleep in healthy children and adolescents.

Methods: One 3 min segment of pre-sleep electrocardiography (EEG) and 3, 6 min segments of electrocardiography recorded during polysomnography from 75 healthy children and adolescents were sampled during progressive cycles of slow wave sleep (SWS1, SWS2, SWS3). Three, 3 min segments of rapid eye movement sleep (REM) were also assessed, with REM1 marked at the last REM period before awakening. Studies that recorded REM3 prior to SWS3 were used for assessment. HRV variables include the following time domain values: mean NN (average RR intervals over given time), SDNN (Standard Deviation of RR intervals), and RMSSD (root Mean Square of beat-to-beat Differences). Frequency domain values include: low frequency (LF), high frequency (HF), and LF:HF.

Results: Mixed linear effects model analysis revealed a significant difference in time and frequency domain values between sleep cycles and stages. Mean NN was lowest (highest heart rate) during pre—sleep then significantly increased across SWS1-3. Mean NN in SWS1 was similar to all REM periods which was significantly lower than both SWS2 and SWS3. SDNN remained at pre-sleep levels until SWS3, and then significantly increased in REM1&2. There was a large drop in LF from pre-sleep to SWS1. As cycles progressed through the night, LF remains lower than awake but increases to awake like levels by REM2. RMSSD and HF were lowest in pre-sleep and increased significantly by SWS1 and remain high and stable across stages and cycles except during the REM3 period where RMSSD decreased.

Conclusion: Our results demonstrate that there are considerable changes in the spectral analysis of cardiac function occurring during different sleep stages and between sleep cycles across the night. Hence, time of night and sleep stage need to be considered when reporting any HRV differences.

Sleep endoscopy-directed management of Arnold-Chiari malformation: a child with persistent obstructive sleep apnea

None

Arnold-Chiari malformations are structural defects in the base of the skull and cerebellum, when part of the cerebellar tonsils herniates through the foramen magnum into the upper spinal canal, compressing against the brainstem. This anatomical defect can be asymptomatic but often presents with symptoms such as headaches, stridor, dysphagia, and nystagmus. It also presents with a variety of sleep-related breathing disorders such as snoring, obstructive sleep apnea, central sleep apnea, bradypnea, and sleep hypoventilation. Sometimes these conditions can coexist in one patient. Although obstructive sleep apnea can be a manifestation of Arnold-Chiari malformation, identifying causality and the site of obstruction in these children can be a diagnostic challenge. We review the case of a 14-month-old male who presented with noisy breathing and obstructive sleep apnea diagnosed on sleep study that was refractory to initial upper airway surgery. Although a brain computed tomography scan done in the emergency room for altered mental status revealed a type 1 Arnold-Chiari malformation, and a flexible awake laryngoscopy was normal, subsequent drug-induced sleep endoscopy was helpful in justifying surgical decompression of the Arnold-Chiari malformation that resulted in complete resolution of the obstructive sleep apnea.

Sustained auditory attention ability in children based on the breathing mode

ABSTRACT Purpose: to analyze the auditory behavior and the performance in the Sustained Auditory Attention Ability Test (SAAAT) of children with different breathing modes. Methods: a total of 30 individuals (19 males and 11 females), ranging from seven to 11 years old, participated in the research. They were distributed into nasal-breathers, mouth-breathers, and oronasal-breathers groups. The Scale of Auditory Behaviors (SAB) questionnaire was applied to those responsible for the children, so as to characterize their auditory behavior. In the SAAAT, the following error patterns were analyzed: inattention, decreased vigilance, impulsivity, and total errors. For the inferential analysis, the Mann-Whitney, chi-square, and Kruskal-Wallis statistical tests were used. Results: the individuals with mouth- and oronasal-breathing modes had more complaints in the SAB questionnaire when compared with nasal-breathers. Regarding the SAAAT, it was found that the age group of seven to eight years was the one that had the worst performance in the test. The groups with oral and oronasal breathing had more errors, with a statistically significant difference between the groups for inattention and total errors. Conclusion: it can be concluded that individuals with oral and oronasal breathing had more complaints in the auditory behavior and worse performance in the SAAAT, especially for inattention and total errors.

Plasma Extracellular Vesicles in Children with OSA Disrupt Blood-Brain Barrier Integrity and Endothelial Cell Wound Healing in Vitro

Pediatric obstructive sleep apnea (P-OSA) is associated with neurocognitive deficits and endothelial dysfunction, suggesting the possibility that disruption of the blood-brain barrier (BBB) may underlie these morbidities. Extracellular vesicles (EVs), which include exosomes, are small particles involved in cell-cell communications via different mechanisms and could play a role in OSA-associated end-organ injury. To examine the roles of EVs in BBB dysfunction, we recruited three groups of children: (a) absence of OSA or cognitive deficits (CL, n = 6), (b) OSA but no evidence of cognitive deficits (OSA-NC(-), n = 12), and (c) OSA with evidence of neurocognitive deficits (OSA-NC(+), n = 12). All children were age-, gender-, ethnicity-, and BMI-z-score-matched, and those with OSA were also apnea-hypopnea index (AHI)-matched. Plasma EVs were characterized, quantified, and applied on multiple endothelial cell types (HCAEC, HIAEC, human HMVEC-D, HMVEC-C, HMVEC-L, and hCMEC/D3) while measuring monolayer barrier integrity and wound-healing responses. EVs from OSA children induced significant declines in hCMEC/D3 transendothelial impedance compared to CL (p < 0.001), and such changes were greater in NC(+) compared to NC(-) (p < 0.01). The effects of EVs from each group on wound healing for HCAEC, HIAEC, HMVED-d, and hCMEC/D3 cells were similar, but exhibited significant differences across the three groups, with evidence of disrupted wound healing in P-OSA. However, wound healing in HMVEC-C was only affected by NC(+) (p < 0.01 vs. NC(-) or controls (CO). Furthermore, no significant differences emerged in HMVEC-L cell wound healing across all three groups. We conclude that circulating plasma EVs in P-OSA disrupt the integrity of the BBB and exert adverse effects on endothelial wound healing, particularly among OSA-NC(+) children, while also exhibiting endothelial cell type selectivity. Thus, circulating EVs cargo may play important roles in the emergence of end-organ morbidity in pediatric OSA.

Pharyngeal dysfunction associated with early and late onset sleep disordered breathing in children

OBJECTIVE

To compare the frequency and type of diagnoses associated with pharyngeal dysfunction (PD) in children presenting with early versus late onset sleep disordered breathing (SDB).

METHODS

This was a retrospective, cross-sectional study. A consecutive series of children ≤3 years old who underwent management for SDB were retrospectively identified from a prospectively kept surgical database. The early onset group was compared with two separate late onset (≥4years old) groups. Diagnoses associated with PD included gastroesophageal reflux disease (GERD), swallowing dysfunction, prematurity, asthma, and obesity. Distribution of PD diagnoses, airway lesions, syndromic conditions, pulse oximetry scores, and endoscopic pattern of airway obstruction were compared.

RESULTS

73 patients with early onset SDB were identified (51 boys, mean age 2.25 ± 0.64 years, range 1.75-3 years) and compared with two groups of later onset SDB consisting of 75 and 72 patients with mean ages of 7.58 ± 2.40 years and 8.04 ± 3.34 years respectively (range 4-16 years). The early onset SDB group had a higher prevalence of PD diagnoses compared to the later onset group with 35 of 73 patients being diagnosed compared to 41 of 147 children (p = 0.01). Early onset SDB patients were more likely to have GERD or swallowing dysfunction (p < 0.01) while later onset patients more commonly presented with associated asthma or obesity (p < 0.01). There was no statistically significant difference in airway lesions between groups.

CONCLUSION

Early-onset SDB is associated with conditions causing PD more often than later-onset SDB. Identifying these conditions and optimizing their management may impact outcomes in treating pediatric SDB.

Habitual Snoring at Age 3 Years: Links with Parent-Rated Remembering in Daily Life and Academic Achievement at Age 7 Years

OBJECTIVE

Habitual snoring in school-aged children is well known to link with poorer cognitive functioning and academic performance, but few studies have explored later developmental outcomes related to snoring initiated in early childhood. The aims of this study were to examine whether habitual snoring at age 3 years predicted perceived memory and academic functioning at age 7 years.

METHODS

Parents (n = 460) of children aged 7 years 2 ± 5 months completed a community follow-up survey about their perceptions of their child's sleep and health, memory in daily activities, and academic performance relevant to numeracy and literacy skills. The first survey was completed by 839 parents 4 years prior when children were aged 3 years (54.8% response rate at age 7 years). Parents rated their child's academic performance twice. First, they rated performance based on teachers' feedback relative to national standard ratings for numeracy and literacy, and second, based on their own observations.

RESULTS

Children reported to snore habitually at age 3 years received lower memory and academic composite score ratings at age 7 years. Age 3 years habitual snoring history predicted small but significant unique variation in age 7 years memory (p = 0.005), literacy (p < 0.001), and overall achievement ratings (p = 0.016) in regressions controlling for covariates, with evidence suggesting that memory may mediate links between snoring history and academic performance.

CONCLUSION

The findings suggest that habitual snoring in early childhood may adversely affect success in beginning schooling. More research is still needed to determine the best time for treatment so that longer-term consequences of sleep-disordered breathing may be prevented.

Reduction in Parasympathetic Tone During Sleep in Children With Habitual Snoring

Introduction: Changes in the autonomic nervous system due to Obstructive Sleep Apnea (OSA) during the life span have been described. Some pediatric studies have shown cardiovascular effects in children who do not fit the criteria for OSA; namely children with mild sleep disordered breathing. Objective: We investigated heart rate variability (HRV) during sleep in children with chronic snoring and flow limitation events during sleep. Methods: Ten children and adolescents with chronic snoring and an apnea hypopnea index < 1, associated to high Respiratory Index, and 10 controls matched for age, gender, and Tanner stage were monitored following one night of habituation in the sleep laboratory. HRV was studied at each sleep stage. The time and frequency domains were calculated for each 5-min period. Results: All patients were chronic heavy snorers. They presented an apnea hypopnea index = 0.8, respiratory disturbance index = 10.2/h with lowest O2 saturation 96.1 ± 2.4%. The total power of HRV was decreased in all stages (p < 0.05). There was also a decrease in NN50 and pNN50 during all sleep stages compared to healthy controls (p = 0.0003 and p = 0.03, respectively). Conclusion: A reduction in parasympathetic tone was found in the patient group. This may represent an autonomic impairment during sleep in children with mild SDB. A reduction in HRV in children with habitual snoring could be associated with possible increases in cardiovascular risk in adulthood. Significance: The study indicates that children with habitual snoring have important parasympathetic tone changes during sleep.

Sleep disordered breathing in children disrupts the maturation of autonomic control of heart rate and its association with cerebral oxygenation

KEY POINTS

Sleep disordered breathing (SDB) affects 4-11% of children and is associated with adverse neurocognitive, behavioural and cardiovascular outcomes, including reduced autonomic control. The relationship between heart rate variability (HRV; a measure of autonomic control) and age found in non-snoring control children was absent during sleep in children with SDB. Age significantly predicted increasing cerebral oxygenation during wake in non-snoring control children, whereas during sleep, HRV significantly predicted decreasing cerebral oxygenation. Cerebral oxygenation was not associated with either age or HRV in children with SDB during both wake and sleep. SDB significantly disrupts the normal maturation of autonomic control and the positive association between autonomic control and cerebral oxygenation found in non-snoring children, and we speculate that the dampened autonomic control exhibited by children with SDB may have an attenuating effect on cerebral autoregulation via the moderating influence of HRV on cerebral blood flow.

ABSTRACT

The repetitive episodes of hypoxia that are features of sleep disordered breathing (SDB) in children are associated with alterations in autonomic control of heart rate in an age-dependent manner. We aimed to relate heart rate variability (HRV) parameters to age and measures of cerebral oxygenation in children (3-12 years old) with SDB and non-snoring controls. Children (SDB, n = 117; controls, n = 42; 3-12 years) underwent overnight polysomnography. Total (TP), low- (LF) and high-frequency (HF) power, tissue oxygenation index (TOI) and fractional tissue oxygen extraction (FTOE) were analysed during wake and sleep. Pearson's correlations determined the association between age and HRV parameters, and multiple linear regressions between HRV, age and cerebral oxygenation parameters. During wake, age had a positive association with LF power, reflecting increased parasympathetic and sympathetic activity with increasing age for both control and SDB groups. This association was also evident during sleep in controls, but was absent in children with SDB. In controls, during wake TOI had a positive, and FTOE a negative association with age. During sleep, TP, LF and HF power were significant, negative determinants of TOI and positive determinants of FTOE. These associations were not seen in children with SDB during wake or sleep. SDB disrupts the normal maturation of the autonomic control of heart rate and the association between HRV and cerebral oxygenation exhibited by non-snoring control children of primary school age. These results highlight the impact SDB has on cardiovascular control and the potential impact on adverse cardiovascular outcomes.

Sleep in Infants and Children with Prenatal Alcohol Exposure

Prenatal exposure to alcohol can result in a range of neurobehavioral impairments and physical abnormalities. The term "fetal alcohol spectrum disorders (FASD)" encompasses the outcomes of prenatal alcohol exposure (PAE), the most severe of which is fetal alcohol syndrome. These effects have lifelong consequences, placing a significant burden on affected individuals, caregivers, and communities. Caregivers of affected children often report that their child has sleep problems, and many symptoms of sleep deprivation overlap with the cognitive and behavioral deficits characteristic of FASD. Alcohol-exposed infants and children demonstrate poor sleep quality based on measures of electroencephalography, actigraphy, and questionnaires. These sleep studies indicate a common theme of disrupted sleep pattern, more frequent awakenings, and reduced total sleep time. However, relatively little is known about circadian rhythm disruption and the neurobehavioral correlates of sleep disturbance in individuals with PAE. Furthermore, there is limited information available to healthcare providers about identification and treatment of sleep disorders in patients with FASD. This review consolidates the findings from studies of infant and pediatric sleep in this population, providing an overview of typical sleep characteristics, neurobehavioral correlates of sleep disruption, and potential avenues for intervention in the context of PAE.

Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease?

Over the last three to four decades, it has been observed that the average total number of hours of sleep obtained per night by normal individuals have decreased. Concomitantly, global figures indicate that insufficient sleep is associated with serious adverse health and social outcomes. Moreover, insufficient sleep has been linked to seven of the fifteen leading causes of death. Additionally, current evidence suggests that sleep plays a significant role in determining cognitive performance and workplace productivity. There is a great need for a systematic analysis of the economic impact of insufficient sleep, particularly given current evidence that this phenomenon, as well as the poor sleep hygiene practices which produce it, is increasing worldwide. This paper takes the view that health authorities around the world need to raise the general awareness of benefits of sleep. There is considerable scope for research into both the public health impact as well as the macroeconomic consequences of insufficient sleep syndrome (ISS). Additionally, various models which estimate the undiagnosed burden of ISS on the GDP (gross domestic product) are needed to prioritize health issues and to highlight the national policies that are necessary to combat this medical problem. Sleep insufficiency has been declared to be a 'public health epidemic'; therefore, we propose ISS as a potential noncommunicable disease. This review elaborates on this topic further, exploring the causes and consequences of insufficient sleep, and thus providing a perspective on the policies that are needed as well as the research that will be required to support and justify these policies.

Correlates to Problem Behaviors in Pediatric Narcolepsy: A Pilot Study

STUDY OBJECTIVE

Excessive daytime sleepiness, the hallmark of narcolepsy, predisposes patients to serious performance decrements in multiple areas of function. Psychosocial dysfunction has been demonstrated in adults and children with narcolepsy. Several factors could influence psychosocial functioning in children. The objective of this study was to examine neurobehavioral problems in children with narcolepsy and to define associations with these problem behaviors.

METHODS

A cross-sectional study was performed where the Child Behavior Checklist (CBCL) was completed by guardians of children (age 18 years or younger) in whom narcolepsy with or without cataplexy was diagnosed (based on the International Classification of Sleep Disorders, Second Edition) between July 2008 and October 2014. Spearman correlations (continuous variables) and Wilcoxon rank-sum tests (categorical variables) were performed for the CBCL findings and narcolepsy factors previously shown to influence psychosocial functioning.

RESULTS

The participants' current age correlated significantly with multiple CBCL scales. Caregivers of younger participants reported higher total psychosocial problems and externalizing problems. In addition, caregivers of younger participants reported higher scores on indices measuring inattention, withdrawal, thought problems, aggression, and rule-breaking behaviors. Values of P < .001 were found for total psychosocial problems, externalizing behaviors, and thought problems (negative correlations of 0.66, 0.65, and 0.64, respectively).

CONCLUSIONS

Patients with pediatric narcolepsy have high rates of attention and emotional/behavior problems. These problems strongly correlated with age. Younger children expressed higher emotional, behavioral, and attention problems. Sleep physicians need to be aware of and assess the mental and behavioral health of their pediatric patients with narcolepsy.

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.

Impaired memory consolidation in children with obstructive sleep disordered breathing

Memory consolidation is stabilized and even enhanced by sleep (and particularly by 12-15 Hz sleep spindles in NREM stage 2 sleep) in healthy children but it is unclear what happens to these processes when sleep is disturbed by obstructive sleep disordered breathing. This cross-sectional study investigates differences in declarative memory consolidation among children with primary snoring (PS) and obstructive sleep apnea (OSA) compared to controls. We further investigate whether memory consolidation group differences are associated with NREM stage 2 (N2) sigma (12-15 Hz) or NREM slow oscillation (0.5-1 Hz) spectral power bands. In this study, we trained and tested participants on a spatial declarative memory task with cued recall. Retest occurred after a period of daytime wake (Wake) or a night of sleep (Sleep) with in-lab polysomnography. 36 participants ages 5-9 years completed the protocol: 14 with OSA as defined by respiratory disturbance index (RDI) > 1/hour, 12 with primary snoring (PS) and 10 controls. OSA participants had poorer overall memory consolidation than controls across Wake and Sleep conditions [OSA: mean = -18.7% (5.8), controls: mean = 1.9% (7.2), t = -2.20, P = 0.04]. In contrast, PS participants and controls had comparable memory consolidation across conditions (t = 0.41; P = 0.38). We did not detect a main effect for condition (Sleep, Wake) or group x condition interaction on memory consolidation. OSA participants had lower N2 sigma power than PS (P = 0.03) and controls (P = 0.004) and N2 sigma power inversely correlated with percentage of time snoring on the study night (r = -0.33, P<0.05). Across all participants, N2 sigma power modestly correlated with memory consolidation in both Sleep (r = 0.37, P = 0.03) and Wake conditions (r = 0.44, P = 0.009). Further observed variable path analysis showed that N2 sigma power mediated the relationship between group and mean memory consolidation across Sleep and Wake states [Bindirect = 6.76(3.5), z = 2.03, P = 0.04]. NREM slow oscillation power did not correlate with memory consolidation. All results retained significance after controlling for age and BMI. In sum, participants with mild OSA had impaired memory consolidation and results were mediated by N2 sigma power. These results suggest that N2 sigma power could serve as biomarker of risk for cognitive dysfunction in children with sleep disordered breathing.

Acoustics of snoring and automatic snore sound detection in children

OBJECTIVE

Acoustic analyses of snoring sounds have been used to objectively assess snoring and applied in various clinical problems for adult patients. Such studies require highly automatized tools to analyze the sound recordings of the whole night's sleep, in order to extract clinically relevant snore- related statistics. The existing techniques and software used for adults are not efficiently applicable to snoring sounds in children, basically because of different acoustic signal properties. In this paper, we present a broad range of acoustic characteristics of snoring sounds in children (N  =  38) in comparison to adult (N  =  30) patients.

APPROACH

Acoustic characteristics of the signals were calculated, including frequency domain representations, spectrogram-based characteristics, spectral envelope analysis, formant structures and loudness of the snoring sounds.

MAIN RESULTS

We observed significant differences in spectral features, formant structures and loudness of the snoring signals of children compared to adults that may arise from the diversity of the upper airway anatomy as the principal determinant of the snore sound generation mechanism. Furthermore, based on the specific audio features of snoring children, we proposed a novel algorithm for the automatic detection of snoring sounds from ambient acoustic data specifically in a pediatric population. The respiratory sounds were recorded using a pair of microphones and a multi-channel data acquisition system simultaneously with full-night polysomnography during sleep. Brief sound chunks of 0.5 s were classified as either belonging to a snoring event or not with a multi-layer perceptron, which was trained in a supervised fashion using stochastic gradient descent on a large hand-labeled dataset using frequency domain features.

SIGNIFICANCE

The method proposed here has been used to extract snore-related statistics that can be calculated from the detected snore episodes for the whole night's sleep, including number of snore episodes (total snoring time), ratio of snore to whole sleep time, variation of snoring rate, regularity of snoring episodes in time and amplitude and snore loudness. These statistics will ultimately serve as a clinical tool providing information for the objective evaluation of snoring for several clinical applications.

Cosleeping, sleep disturbances, children's behavioral problems, and parenting self-efficacy among Korean American families

The purpose of this study was to compare sleep disturbances of children and their mothers, children's behavioral problems, and parenting self-efficacy between Korean American families who coslept and those who did not cosleep. Forty-eight mothers of children between 3 and 8 years of age completed the following surveys: Children's Sleep Habits Questionnaire, Pediatric Symptom Checklist, Pittsburgh Sleep Quality Index, Parenting Self-Efficacy Questionnaire, and Acculturation Rating Scale for Mexican Americans II. Overall, 48% (n = 23) of families coslept, and families with younger children coslept more than families with older children (x2=12.48,p<.05). When the families were divided into non-cosleeping (i.e., rarely) and cosleeping (i.e., sometimes and usually) groups, 100% of the cosleeping children had sleep disturbances compared to 56% of the non-cosleeping children (x2=8.67,p<.01). For mothers, 28% (n = 7) of the non-cosleeping mothers reported sleep disturbances, compared to 52% (n = 12) of the cosleeping mothers (x2=2.93,p=.08). Children's behavioral problems were not different between the two groups (F = 1.78, p = NS). Cosleeping mothers reported lower parenting self-efficacy than non-cosleeping mothers (F = 6.26, p < .05). When providing care to Korean American families with young children, their cosleeping, sleep disturbances, and parenting self-efficacy need to be addressed.

Pediatric sleep apnea and depressive disorders risk: A population-based 15-year retrospective cohort study

Background

Studies have shown a higher risk of depressive disorders in children with sleep apnea than in those without sleep apnea. However, the association between sleep apnea and subsequent depressive disorders in the pediatric population remains undetermined. Thus, this study investigated the risk of depressive disorders among pediatric patients with sleep apnea.

Methods

In this study, the population-based National Health Insurance Research Database of Taiwan was used to identify patients who had first been diagnosed with sleep apnea between 1999 and 2013. Patients with sleep apnea who were younger than 18 years were included in the sleep apnea group. Controls (those without sleep apnea) were matched to patients with sleep apnea at a 1:10 ratio by age, sex, and index year. Patients who had baseline or inherited depressive disorders before the enrollment date were excluded. The two groups were followed up until December 31, 2013. The primary endpoint was the occurrence of one or more depressive disorders.

Results

At the end of this study, 6,237 children had been enrolled, comprising 567 children with sleep apnea and 5,670 children without sleep apnea. During the mean follow-up period of 5.87 years, a total of 77 children (1.23%) developed one or more depressive disorders; 14 (2.46%) from the sleep apnea group and 63 (1.11%) from the control group. Kaplan–Meier analysis showed that children with sleep apnea had a significantly higher risk of depressive disorders (log-rank test, p = 0.002). After adjusting for covariates, the risk of subsequent depressive disorders among children with sleep apnea was still significantly higher (hazard ratio [HR] = 2.25; 95% confidence interval [CI] = 1.25–4.05; p = 0.006). Moreover, boys with sleep apnea had a significantly higher risk than those without sleep apnea (adjusted HR = 3.77; 95% CI, 1.82–7.54; p < 0.001). Furthermore, in sleep apnea group, children older than 12 years of age had more risk to depression (hazard ratio (HR) = 7.1833, 95% confidence interval (CI), 2.3734 to 21.7411; p = 0.0004).

Conclusions

This study found a significantly higher subsequent risk of depressive disorders in children with sleep apnea, particularly boys and those older than 12 years of age. The study findings strongly suggest that clinicians should provide psychological evaluation and supportive care for children with sleep apnea, in addition to medical treatment.

Evaluation of behavioral change after adenotonsillectomy for obstructive sleep apnea in children with autism spectrum disorder

BACKGROUND AND OBJECTIVE

Obstructive sleep apnea (OSA) may affect daily cognitive functioning in children. The aims of our study were two-fold. The first aim was to detect, using the Child Behavior Checklist (CBCL), whether adenotonsillectomy (AT) for the treatment of OSA improved the behavior of children with autism spectrum disorder (ASD). The second aim was to identify characteristics for behavioral improvement following the treatment of OSA in these children with ASD.

METHODS

The behaviors of ASD children aged 5-14 years diagnosed as having OSA (n=30) were evaluated using CBCL before and after AT. CBCL evaluation of ASD children without OSA at two time points with the same interval served as a control (n=24). We statistically examined the two groups. In addition, we conducted a paired t-test to assess changes in CBCL Tscores between the improved group and unchanged/deteriorated group to identify characteristics that may affect behavioral changes following OSA treatment.

RESULTS

After AT, T-scores of the CBCL scales were significantly improved in the OSA group, but no change was observed in the control. A paired t-test revealed that the improved group had significantly higher scores on the CBCL pre-AT than the unchanged/deteriorated group in ASD children with OSA after OSA treatment.

CONCLUSIONS

Behavioral problems were significantly improved following AT in ASD children with OSA. Early detection and treatment of children with OSA is essential to prevent behavioral problems and to support mental development.

The watch-pat in pediatrics sleep disordered breathing: Pilot study on children with negative nocturnal pulse oximetry

OBJECTIVES

The main purpose of this study was to determine the efficacy of Watch-PAT in Pediatric Sleep Disordered Breathing (PSDB) diagnosis in children with symptoms suggestive of PSDB, in which the nocturnal pulse oximetry was negative according to the Brouilette criteria.

METHODS

We enrolled 28 patients aged between 5 and 12 years (mean age: 7.75 ± 1.69), who underwent the registration with Watch-PAT, that utilizes the Peripheral Arterial Tone (PAT), AHI, RDI, body position, snoring, pulse oximetry and actigraphy.

RESULTS

Recording Watch-PAT was indicative of PSDB in 10/28 (35.7%) patients; when it was placed the threshold of AHI > 1 the number of positive patients for PSDB increased to 17/28 (60.7%). Exists a positive correlation between pat-RDI (rho = 0.798, p = 0.005) and the snoring > 40% of the time (rho = 0.656, p < 0.001) were correlated with the pat-AHI values.

CONCLUSION

The recording Watch-PAT appears to permit the defection of a certain number of SDB that might escape to the clinical evaluation and pulse oximetry only.

When and why to treat the child who snores?

Obstructive sleep-disordered breathing (SDB) can result in cardiovascular and neurocognitive morbidity as well as adversely affect behavior, growth, quality of life, and nocturnal continence. This article summarizes the latest evidence regarding the morbidity related to obstructive SDB, commenting on the impact of severity of obstruction, that is, the difference in effects seen of moderate to severe obstructive sleep apnea syndrome (OSAS) compared to those of mild OSAS or primary snoring. The impact of therapy is discussed, focusing on which children are likely to benefit from treatment interventions; namely those with moderate or severe OSAS irrespective of the presence of morbidity, children with mild OSAS with associated morbidity or predictors of SDB persistence such as obesity, and children with complex conditions accompanied by upper airway obstruction like craniosynostosis and Prader-Willi syndrome. The co-existing conditions which may improve when treatment for obstructive SDB is offered are reviewed, while the clinical parameters associated with spontaneous improvement or resolution of obstructive SDB are discussed. The intention being to enable clinicians to make informed decisions on who should be treated, when and why. Pediatr Pulmonol. 2017;52:399-412. © 2016 Wiley Periodicals, Inc.