Behavior problems associated with sleep disordered breathing in school-aged children--the Tucson children's assessment of sleep apnea study

Drug-Induced Sleep Endoscopy Predicts Subjective Outcomes of Adenotonsillectomy

OBJECTIVES

Persistent obstructive sleep apnea (OSA) after adenotonsillectomy (AT) has been reported in 20%-30% of children. The aim of this study was to determine the predictive value of drug-induced sleep endoscopy (DISE) at the time of AT on subjective AT outcomes.

METHODS

This was a prospective cohort study of children aged 2-18 years being treated with AT for sleep disordered breathing (SDB) with one or more risk factors for AT failure: age >7 years, obesity, severe baseline OSA, Black race. All underwent DISE at the time of AT. Potential predictors of subjective AT outcome included age, sex, obesity, and DISE patterns. Multivariable linear regression was used to model predictors of post-AT Pediatric Sleep Questionnaire (PSQ) and OSA-18 outcomes.

RESULTS

Pre- and post-AT PSQ/OSA-18 responses were available from 194 children. Mean age was 9.3 ± 3.5 years, with 59% obese, 50% female, and 67% White. After AT, mean PSQ score decreased from 0.60 ± 0.19 to 0.28 ± 0.22, p < 0.001 and mean OSA-18 score decreased from 66 ± 21 to 37 ± 18, p < 0.001. The most frequent sites of obstruction were the tonsils (92%), nasal airway (77%), adenoids (64%), and velopharynx (65%). Multivariable regression modeling demonstrated worse outcomes with obesity, male gender, and multilevel obstruction that included the nasal airway and tongue base in addition to adenotonsillar obstruction.

CONCLUSIONS

Persistent OSA and symptom burden after AT was common in this population. Obesity, male gender, and multilevel obstruction during DISE were all associated with worse subjective outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Sleep disordered breathing and neurobehavioral deficits in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Sleep disordered breathing (SDB) is broadly recognized to be associated with neurobehavioral deficits, which have significant impacts on developing-aged children and adolescents. Therefore, our study aimed to quantify the proportion of neurobehavioral impairments attributed to SDB in general children and adolescents by population attributable fraction (PAF).

METHODS

The study was registered at PROSPERO (ID: CRD42023388143). We collected two types of literature on the prevalence of SDB and the risk of SDB-related neurobehavioral deficits from ten electronic databases and registers, respectively. The pooled effect sizes (Pe, Pc, RR) by random-effects meta-analysis were separately substituted into Levin's formula and Miettinen's formula to calculate PAFs.

RESULTS

Three prevalence literature and 2 risk literature, all with moderate/high quality, were included in the quantitative analysis individually. The prevalence of SDB was 11% (95%CI 2%-20%) in children and adolescents (Pe), while the SDB prevalence was 25% (95%CI 7%-42%) in neurobehavioral patients (Pc). SDB diagnosis at baseline was probably associated with about threefold subsequent incidence of neurobehavioral deficits (pooled RR 3.24, 95%CI 1.25-8.41), after multi-adjustment for key confounders. Up to 19.8% or 17.3% of neurobehavioral consequences may be attributed to SDB from Levin's formula and Miettinen's formula, respectively.

CONCLUSIONS

A certain number of neurobehavioral consequences may be attributable to SDB. It is essential for clinicians to identify and treat SDB timely, as well as screen for SDB in patients with neurobehavioral impairments. More longitudinal studies of SDB and neurobehavioral deficits are needed in the future to further certify the association between them.

Resting-State Cerebral Hemodynamics is Associated With Problem Behaviors in Pediatric Sleep-Disordered Breathing

OBJECTIVE

Untreated sleep-disordered breathing (SDB) is associated with problem behaviors in children. The neurological basis for this relationship is unknown. We used functional near-infrared spectroscopy (fNIRS) to assess the relationship between cerebral hemodynamics of the frontal lobe of the brain and problem behaviors in children with SDB.

STUDY DESIGN

Cross-sectional.

SETTING

Urban tertiary care academic children's hospital and affiliated sleep center.

METHODS

We enrolled children with SDB aged 5 to 16 years old referred for polysomnography. We measured fNIRS-derived cerebral hemodynamics within the frontal lobe during polysomnography. We assessed parent-reported problem behaviors using the Behavioral Response Inventory of Executive Function Second Edition (BRIEF-2). We compared the relationships between (i) the instability in cerebral perfusion in the frontal lobe measured fNIRS, (ii) SDB severity using apnea-hypopnea index (AHI), and (iii) BRIEF-2 clinical scales using Pearson correlation (r). A p < .05 was considered significant.

RESULTS

A total of 54 children were included. The average age was 7.8 (95% confidence interval, 7.0-8.7) years; 26 (48%) were boys and 25 (46%) were Black. The mean AHI was 9.9 (5.7-14.1). There is a statistically significant inverse relationship between the coefficient of variation of perfusion in the frontal lobe and BRIEF-2 clinical scales (range of r = 0.24-0.49, range of p = .076 to <.001). The correlations between AHI and BRIEF-2 scales were not statistically significant.

CONCLUSION

These results provide preliminary evidence for fNIRS as a child-friendly biomarker for the assessment of adverse outcomes of SDB.

Executive Functioning, Language, and Behavioral Abilities Related to Obstructive Sleep Apnea in Down Syndrome

OBJECTIVES

Obstructive sleep apnea (OSA) is highly prevalent among individuals with Down syndrome (DS), and the nonphysiological consequences of OSA require examination to inform treatment planning. This study aimed to investigate the association between OSA and aspects of language, executive functioning, behavioral, social abilities, and sleep problems in youth with DS aged 6 to 17 years.

METHODS

Multivariate analysis of covariance was used to compare 3 groups adjusted for age, participants with DS with untreated OSA (n = 28), participants with DS without OSA (n = 38), and participants with DS with treated OSA (n = 34). To be eligible for the study, participants had to have an estimated mental age of 3 years. No children were excluded based on estimated mental age.

RESULTS

After adjusting for age, participants with untreated OSA showed a common pattern of lower estimated marginal mean scores than those with treated OSA and those with no OSA in expressive and receptive vocabulary and higher estimated marginal mean scores with executive functions, everyday memory, attention, internalizing and externalizing behavior, social behavior, and sleep problems. However, only the group differences for executive function (emotional regulation) and internalizing behavior were statistically significant.

CONCLUSION

Study findings corroborate and extend prior findings related to OSA and clinical outcomes for youth with DS. The study highlights the importance of OSA treatment in youth with DS and provides clinical recommendations for this population. Additional studies are necessary to control the effects of health and demographic variables.

Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective

STUDY OBJECTIVES

Recurrent/residual adenoid hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the role of soft tissue neck X-ray (STN-XR) in evaluating recurrent/residual adenoid tissue hypertrophy.

METHODS

This was a single-center retrospective study that included children with sleep study-confirmed OSA and a known history of adenotonsillectomy who underwent STN-XR to evaluate for recurrent/residual adenoid tissue hypertrophy. STN-XR nasopharyngeal obliteration and baseline polysomnographic data were analyzed. Multiple linear regression was used to assess the independent relationship between the results of STN-XR and the total apnea-hypopnea index, while controlling for relevant characteristics.

RESULTS

The study included 160 participants with a median age of 10 years (quartile [Q] 1 = 7, Q3 = 12.25). More than half of the children were male (59.4%) and the median body mass index z-score was 2.11 (Q1 = 1.23, Q3 = 2.54). STN-XR was normal in 39.4%, and it showed mild, moderate, and complete nasopharyngeal obliteration in 20.6%, 32.5%, and 7.5% of the participants, respectively. Multiple regression analysis showed that moderate and complete nasopharyngeal obliteration was associated with an increase in the mean total apnea-hypopnea index by 109% (P = .0002) and 185% (P = .001), respectively, when compared with children without nasopharyngeal obliteration. However, mild nasopharyngeal obliteration, body mass index z-score, age, sex, and race were not significantly associated with an increase in the total apnea-hypopnea index.

CONCLUSIONS

STN-XR was useful in assessing recurrent/residual adenoid tissue hypertrophy in children with OSA and a history of adenotonsillectomy. Moderate and complete nasopharyngeal obliteration were associated with significantly increased apnea-hypopnea index. Pediatric sleep physicians may consider STN-XR in the evaluation of children with OSA and previous history of adenotonsillectomy.

CITATION

Senthilvel E, Nguyen QL, Gunaratnam B, Feygin YB, Palani R, El-Kersh K. Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective. J Clin Sleep Med. 2023;19(6):1027-1033.

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.

Associations Between Sleep-Disordered Breathing and Behavioral and Cognitive Functions in Children With and Without Attention-Deficit/Hyperactivity Disorder

BACKGROUND

Sleep-related problems are highly prevalent comorbidities in Attention-Deficit/Hyperactivity Disorder (ADHD).

OBJECTIVE

This study aimed to investigate the associations between sleep-disordered breathing (SDB) and behavioral and cognitive functions in children with and without ADHD.

METHODS

A total of 341 children were included (ADHD group: 155, control group: 186; age: 6-10 years). The participants' sleep-related symptoms were assessed using a parent-rated questionnaire, and they were categorized into low- and high-risk SDB groups based on their scores. Behavioral symptoms were assessed using the Behavioral Assessment System for Children, Second Edition (BASC-2), and cognitive sustained attention and inhibitory control were assessed using a computer-based continuous performance test.

RESULTS

In the ADHD group, the high-risk SDB children showed significantly higher scores than the low-risk SDB group in externalizing problems (F = 4.22; P = 0.042), including hyperactivity (F = 4.65; P = 0.033) and attention problems (F = 8.19; P = 0.005), but not internalizing problems. Meanwhile, in the control group, the high-risk SDB children showed significantly higher scores than the low-risk SDB group in internalizing problems (F = 9.89; P = 0.002), depression (F = 9.45; P = 0.002), and somatization (F = 7.83; P = 0.006), as well as in externalizing problems (F = 7.72; P = 0.006), including hyperactivity (F = 6.23; P = 0.013), aggression (F = 5.00; P = 0.027), and conduct problems (F = 6.79; P = 0.010). Contrary to the behavioral outcomes, none of the attention performance subscale scores showed significant differences between the high- and low-risk SDB groups in either the ADHD or control group.

CONCLUSIONS

The present findings suggest that SDB is associated with behavioral problems in children with ADHD and controls, with stronger associations in control children. On the contrary, SDB has no association with cognitive attention performance. This study extends our understanding of the associations of SDB with behavioral symptoms and cognitive functions in children.

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 among High Risk for Sleep-disordered Breathing, Related Risk Factors, and Attention Deficit/Hyperactivity Symptoms in Elementary School Children

Objective

: Habitual snoring is a common problem in children. We evaluated the association between a high risk for sleep-disordered breathing and attention deficit/hyperactivity symptoms.

Methods

Parents of 13,560 children aged 6 to 12 years responded to questionnaires including items on habitual snoring and the Korean attention deficit/hyperactivity disorder rating scale. The snoring score comprised the number of "yes" responses to habitual-snoring items, and a high risk for sleep-disordered breathing was defined as a snoring score ≥ 2.

Results

The odds ratio (OR) of a high risk for sleep-disordered breathing was significantly higher in boys (OR = 1.47; p < 0.001), overweight children (OR = 2.20; p < 0.001), and children with current secondhand-smoking exposure (OR = 1.38; p < 0.001). The Korean attention deficit/hyperactivity disorder rating scale score increased significantly with the snoring score (0 vs. 1, B = 1.56, p < 0.001; 0 vs. 2, B = 2.44, p < 0.001; 0 vs. 3, B = 2.48, p < 0.001; 0 vs. 4, B = 3.95; p < 0.001).

Conclusion

Our study confirms several risk factors of sleep-disordered breathing, namely male sex, overweight, and exposure to tobacco smoking, and found a positive association between habitual snoring and attention deficit/hyperactivity symptoms.

Caregivers' absence from work before and after tonsil surgery in children with sleep-disordered breathing

Purpose

Sleep-disordered breathing, SDB, in children is associated with morbidity that can result in caregivers having to stay at home from work. The aim of this study was to investigate whether the number of days when caregivers are reimbursed, temporary parental benefit (TPB) to stay at home from work to care for their sick child is increased among children with SDB before and after tonsil surgery.

Methods

This is a retrospective, cross-sectional study of children (n = 440), aged 2–11 years, that underwent tonsil surgery for SDB in day surgery at Sahlgrenska University Hospital in 2014 and 2015. TPB, was provided by the Swedish Social Insurance Agency. The expected days of TPB in the general population of the region were calculated. The number of days with TPB was compared 2 years before and 2 years after surgery and compared with the expected days of TPB.

Results

Two years before surgery, the children had no more days of TPB than expected. Two years after surgery, the children with SDB had 4.8 more days with TPB (p < 0.001) than expected, but, when the 1st month after surgery was excluded from the analysis, there was no difference in days of TPB compared with the general population.

Conclusion

Children with SDB who had tonsil surgery had no more days of parental benefits 2 years before and 2 years after surgery than expected. SDB is associated with increased morbidity, but it does not appear to cause caregivers to stay at home in the majority of children.

Diagnostic meta-analysis of the Pediatric Sleep Questionnaire, OSA-18, and pulse oximetry in detecting pediatric obstructive sleep apnea syndrome

The aim of this meta-analysis was to compare the pooled sensitivity and specificity of the Pediatric Sleep Questionnaire (PSQ), Obstructive Sleep Apnea Questionnaire (OSA-18), and pulse oximetry (PO) according to OSAS severity. Three electronic databases were searched for studies evaluating sensitivity and specificity of the three tools against the apnea-hypopnea index measured using overnight in-laboratory or in-home polysomnography in children and adolescents from inception until January 11, 2020. A random-effects bivariate model was used to estimate the summary sensitivity and specificity of the tools. We identified 39 studies involving 6131 clinical and community children (aged 2.9-16.7 y). The PSQ exhibited the highest sensitivity (74%) for detecting symptoms of mild pediatric OSAS. The PSQ and PO had comparable sensitivity in screening moderate and severe pediatric OSAS (0.82 and 0.89 vs 0.83 and 0.83, respectively). PO yielded superior specificity in detecting mild, moderate, and severe pediatric OSAS (86%, 75%, and 83%, respectively) than did the PSQ and OSA-18 (all p < 0.05). Age, percentage of girls, index test criteria, methodology quality, and sample size significantly moderated sensitivity and specificity. For early detection of pediatric OSAS, the combined use of PSQ and PO is recommended when polysomnography is not available. PROSPERO REGISTRATION NUMBER: CRD42018090571.

Association between Sleep Disturbances and Emotional/Behavioral Problems in Chinese and Japanese Preschoolers

Objectives: Sleep disturbances are often associated with emotional/behavioral problems in young children, but whether the association differs among Asian countries remains unknown. This study aimed to investigate the association between sleep disturbances and emotional/behavioral problems in Chinese and Japanese preschoolers and to explore potential differences.Methods: Participants were 1,020 Chinese preschoolers from 10 cities and 438 Japanese preschoolers from 1 city aged 4 to 5 years. Parents filled out the Children's Sleep Habits Questionnaire (CSHQ) and the Strengths and Difficulties Questionnaire (SDQ).Results: Chinese children with sleep disturbances (defined as total CSHQ score >41) demonstrated more peer problems than children without, while there was no such difference in Japanese preschoolers. Domains of sleep disturbances associated with emotional/behavioral problems in Chinese children were sleep disordered breathing and daytime sleepiness, yet in Japanese children were sleep anxiety and night wakings. Children with a higher score of sleep anxiety showed more emotional problems in Japan, but fewer conduct problems in China.Conclusions: Sleep disturbances were associated with emotional/behavioral problems in preschoolers with differences between China and Japan, indicating subcultural differences in preschoolers' sleep within Asian countries.Abbreviations: CSHQ: Children's Sleep Habits Questionnaire; SDQ: Strengths and Difficulties Questionnaire; ANCOVA: analysis of covariance; SD: standard deviation; CI: confidence interval.

[Obstructive sleep apnea syndrome and cognitive impairment]

Sleep-disordered breathing is associated with sleep fragmentation and reduced blood oxygenation due to apnea and hypopnea episodes. Multiple studies indicate that obstructive sleep apnea syndrome (OSAS) can have negative impact on cognitive functioning, primarily executive functions, attention, and episodic memory. The attention is also focused on cognition in patients with neurologic and psychiatric comorbidities. There are different explanatory models, which show the mechanisms of OSAS influence on cognition. However, it is still unclear how the initial severity of the disease and clinical outcomes interrelate, and which factors play role in the compensation of cognitive dysfunction. Better understanding of these issues is crucial for the prevention of cognitive impairment and rehabilitation of cognitive functioning.

The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-Analysis

BACKGROUND

Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness.

METHODS

PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale.

RESULTS

Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes (P = .6572).

CONCLUSIONS

Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.

Prenatal, Perinatal, and Early Childhood Factors Associated with Childhood Obstructive Sleep Apnea

OBJECTIVES

To investigate prenatal, perinatal, and early childhood factors, including cord and early childhood plasma leptin, on a clinical diagnosis of obstructive sleep apnea (OSA) among children in the Boston Birth Cohort.

STUDY DESIGN

We conducted a secondary analysis of 2867 mother-child pairs from the Boston Birth Cohort who were enrolled between 1998 and 2014 at Boston Medical Center and followed from birth to age 16 years. Child's OSA was defined based on clinical diagnoses documented in the medical record. Plasma leptin was measured in cord and early childhood blood samples. Logistic regression was used to examine individual and combined effects of early life factors on the risk of OSA, adjusting for potential confounders.

RESULTS

The mean age of the study children was 6.39 years (SD = 3.77); 49.3% were girls, and 209 (7.3%) had ever been diagnosed with OSA. Four significant risk factors for OSA were identified: maternal obesity/diabetes during pregnancy (OR, 1.63; 95% CI, 1.21-2.21; P = .001), preterm/low birth weight (OR, 1.74; 95% CI, 1.30-2.32; P < .001), early childhood obesity (OR, 1.89; 95% CI, 1.37-2.62; P < .001), and high leptin levels in early childhood (OR, 1.94; 95% CI, 1.22-3.09; P = .005). The presence of all these 4 risk factors significantly amplified the odds of OSA by about 10 times (OR, 9.95; 95% CI, 3.42-28.93; P < .001) compared with those lacking these factors.

CONCLUSIONS

Our findings, if further confirmed, provide new insight into the early life risk factors of pediatric OSA and underscore the need for early screening and prevention of OSA among children with those risk factors.

Home oximetry to screen for obstructive sleep apnoea in Down syndrome

OBJECTIVE

Children with Down syndrome are at high risk of obstructive sleep apnoea (OSA) and screening is recommended. Diagnosis of OSA should be confirmed with multichannel sleep studies. We aimed to determine whether home pulse oximetry (HPO) discriminates children at high risk of OSA, who need further diagnostic multichannel sleep studies.

DESIGN

Cross-sectional prospective study in a training sample recruited through three UK centres. Validation sample used single-centre retrospective analysis of clinical data.

PATIENTS

Children with Down syndrome aged 0.5-6 years.

INTERVENTION

Diagnostic multichannel sleep study and HPO.

MAIN OUTCOME MEASURES

Sensitivity and specificity of HPO to predict moderate-to-severe OSA.

RESULTS

161/202 children with Down syndrome met quality criteria for inclusion and 25 had OSA. In this training sample, the best HPO parameter predictors of OSA were the delta 12 s index >0.555 (sensitivity 92%, specificity 65%) and 3% oxyhaemoglobin (SpO₂) desaturation index (3% ODI)>6.15 dips/hour (sensitivity 92%, specificity 63%). Combining variables (delta 12 s index, 3% ODI, mean and minimum SpO₂) achieved sensitivity of 96% but reduced specificity to 52%. All predictors retained or improved sensitivity in a clinical validation sample of 50 children with variable loss of specificity, best overall was the delta 12 s index, a measure of baseline SpO₂ variability (sensitivity 92%; specificity 63%).

CONCLUSIONS

HPO screening could halve the number of children with Down syndrome needing multichannel sleep studies and reduce the burden on children, families and health services alike. This approach offers a practical universal screening approach for OSA in Down syndrome that is accessible to the non-specialist paediatrician.

Short-term metabolic control and sleep in children and adolescents with type 1 diabetes mellitus

AIMS

The aim of this study was to examine sleep in T1D children and in healthy controls by polysomnographic (PSG) examination and to determine the influence of short-term metabolic compensation on sleep quality and sleep disordered breathing (SDB).

METHODS

The prospective cross-sectional study included 44 T1D subjects and 60 healthy controls, aged 10-19 years. Subjects underwent anthropometric measurements, laboratory testing and standard overnight in-laboratory video polysomnography with continuous glucose monitoring (CGM).

RESULTS

No significant differences were found in total sleep time, sleep efficiency, percentage of sleep stages and respiratory parameters between T1D and healthy group. T1D children with more optimal short-term metabolic control (AvgSG < 10 mmol/l, n = 18) had a significantly lower apnea-hypopnea index (AHI) (0.3(0-0.5) vs. 0.6 (0.2-0.9) events/h, p < 0.05)and respiratory arousal index (0(0-0,1) vs. 0.2(0-0.3)), p < 0.01) compared to children with suboptimal short-term control(n = 26), no significant differences were found in parameters of sleep architecture. Obstructive sleep apnea (OSA) was diagnosed in only one T1D patient, nine T1D children had mild central apnea.

CONCLUSIONS

There may be an association between short-term metabolic compensation and SDB in T1D children without chronic complications, obesity or overweight and hypoglycemia. Further research is needed to confirm this result.

Neurocognitive and behavioral functioning in adolescents with sleep-disordered breathing: a population-based, dual-energy X-ray absorptiometry study

BACKGROUND/OBJECTIVES

Sleep-disordered breathing (SDB) has been associated with neurocognitive and behavioral problems in young children; however, this association is less studied in adolescents. Evidence suggests that obesity plays a key role in the development of SDB, although its relative association with neurobehavioral functioning remains unclear. We examined whether SDB and obesity are associated with neurocognitive and behavioral problems in adolescents.

SUBJECTS/METHODS

A total of 421 adolescents (17.0±2.2y, 53.9% male) from the Penn State Child Cohort, a general population sample, underwent a 9-h polysomnography, clinical history, physical examination, neurocognitive evaluation and Dual-energy X-ray Absorptiometry (DXA) scan, and completed the Child or Adult Behavior Checklist. Obstructive sleep apnea (OSA) was defined as an apnea-hypopnea index (AHI)⩾2, primary snoring (PS) as AHI<2+snoring and no-SDB as AHI<2 without snoring. Body weight measures included body mass index (BMI) percentile, waist circumference (WC) and DXA-measured total adipose tissue (TAT).

RESULTS

WC and TAT were significantly associated with impaired vigilance, processing speed, working memory, and control interference and greater internalizing and externalizing behaviors, while BMI percentile was marginally associated. SDB per se (PS, AHI or OSA) was not significantly associated with impaired neurocognitive outcomes or greater behavioral problems. However, TAT was significantly associated with impaired vigilance and greater internalizing and externalizing behaviors and, to a lesser extent, slower processing speed and greater control interference, only in adolescents with OSA.

CONCLUSIONS

Central obesity, an etiopathogenic mechanism of OSA, is more strongly associated with neurocognitive and behavioral problems in adolescents than SDB alone. Deficits in low-order (vigilance) and high-order (executive) functions and behavioral problems observed in adolescents with OSA are primarily associated with increased central adiposity, a finding not entirely captured with less precise measures of obesity. These data support that OSA and its associated neurocognitive and behavioral morbidity are related to underlying metabolic dysfunction as early as adolescence.

Parent-Reported Symptoms of Sleep-Disordered Breathing Are Associated With Increased Behavioral Problems at 2 Years of Age: The Canadian Healthy Infant Longitudinal Development Birth Cohort Study

Study Objectives

To examine the association between the age of onset and duration of parent-reported symptoms of sleep-disordered breathing (SDB) and behavioral problems at age 2.

Methods

Parent-reported SDB symptoms were assessed quarterly between 3 months and 2 years among 583 Canadian Healthy Infant Longitudinal Development Edmonton-site participants. Parent-reported SDB symptoms were clustered into phenotypes using group-based trajectory analysis based on age of onset and duration of symptoms. Home-based polysomnography (PSG) was completed at 1 year. The Child Behavior Checklist preschool-version (Mean T-score 50, standard deviation 10 points) assessed total, externalizing (attention), and internalizing (anxiety, depression) behaviors at 2 years.

Results

Four phenotypes were identified: no SDB (64.7%), early-onset SDB (15.7%, peak symptoms at 9 months), late-onset (14.2%, peak symptoms at 18 months), and persistent SDB symptoms (5.3%, peak symptoms from 3 through 24 months). Persistent SDB (9.5 points, 95% CI 1.7, 17.2; p = .02) predicted the greatest magnitude of effect of total behavior problems, compared with children without SDB. Children with early-onset SDB (3.5 points, 95% CI 1.6, 5.4; p ≤ .001) and late-onset SDB (6.1 points 95% CI 4.0, 8.3; p ≤ .001) had increased total behavioral problems than children without SDB to 2 years. Additional analyses showed that the SDB phenotypes' trajectories were important for internalizing but not for externalizing behavior problems. There were no significant associations between home-PSG and parent-reported behavior problems.

Conclusions

Findings suggest that the age of onset and duration of parent-reported SDB symptoms prior to age 2 have adverse consequences for overall behavior problems.

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.

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.

Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management

This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h(-1), those with an AHI of 1-5 episodes·h(-1) and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).

Sleep Disordered Breathing and Academic Performance: A Meta-analysis

BACKGROUND AND OBJECTIVE

Sleep-disordered breathing (SDB) in children is associated with daytime functioning decrements in cognitive performance and behavioral regulation. Studies addressing academic achievement are underrepresented. This study aimed to evaluate the strength of the relationships between SDB and achievement in core domains and general school performance.

METHODS

Data sources included PubMed, Web of Science, CINAHL, and PsycINFO. Studies of school-aged children investigating the relationships between SDB and academic achievement were selected for inclusion in a systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data extracted were converted into standardized mean differences; effect sizes (ES) and statistics were calculated by using random-effects models. Heterogeneity tests (I(2)) were conducted.

RESULTS

Of 488 studies, 16 met eligibility criteria. SDB was significantly associated with poorer academic performance for core academic domains related to language arts (ES -0.31; P < .001; I(2) = 74%), math (ES -0.33; P < .001; I(2) = 55%), and science (ES -0.29; P = .001; I(2) = 0%), and with unsatisfactory progress/learning problems (ES -0.23; P < .001; I(2) = 0%) but not general school performance.

CONCLUSIONS

Variable definitions of both academic performance and SDB likely contributed to the heterogeneity among published investigations. Clear links between SDB and poorer academic performance in school-age children are demonstrated. ES statistics were in the small to medium range, but nevertheless the findings serve to highlight to parents, teachers, and clinicians that SDB in children may contribute to academic difficulties some children face.

Obstructive sleep apnea and sickle cell anemia

OBJECTIVE

To ascertain the prevalence of and risk factors for obstructive sleep apnea syndrome (OSAS) in children with sickle cell anemia (SCA).

METHODS

Cross-sectional baseline data were analyzed from the Sleep and Asthma Cohort Study, a multicenter prospective study designed to evaluate the contribution of sleep and breathing abnormalities to SCA-related morbidity in children ages 4 to 18 years, unselected for OSAS symptoms or asthma. Multivariable logistic regression assessed the relationships between OSAS status on the basis of overnight in-laboratory polysomnography and putative risk factors obtained from questionnaires and direct measurements.

RESULTS

Participants included 243 children with a median age of 10 years; 50% were boys, 99% were of African heritage, and 95% were homozygous for β(S) hemoglobin. OSAS, defined by obstructive apnea hypopnea indices, was present in 100 (41%) or 25 (10%) children at cutpoints of ≥1 or ≥5, respectively. In univariate analyses, OSAS was associated with higher levels of habitual snoring, lower waking pulse oxygen saturation (Spo2), reduced lung function, less caretaker education, and non-preterm birth. Lower sleep-related Spo2 metrics were also associated with higher obstructive apnea hypopnea indices. In multivariable analyses, habitual snoring and lower waking Spo2 remained risk factors for OSAS in children with SCA.

CONCLUSIONS

The prevalence of OSAS in children with SCA is higher than in the general pediatric population. Habitual snoring and lower waking Spo2 values, data easily obtained in routine care, were the strongest OSAS risk factors. Because OSAS is a treatable condition with adverse health outcomes, greater efforts are needed to screen, diagnose, and treat OSAS in this high-risk, vulnerable population.

The relationship between depressive symptoms and obstructive sleep apnea in pediatric populations: a meta-analysis

BACKGROUND

A higher incidence of depressive disorders and symptoms has been suggested among children suffering from obstructive sleep apnea (OSA). Yet, the extent to which OSA is related to increased depression is unclear.

OBJECTIVES

To evaluate (a) the relationship between depressive symptoms and OSA in pediatric populations, and (b) the efficacy of adenotonsillectomy (AT) for decreasing depressive symptoms among children with OSA.

METHODS

A meta-analysis was conducted to assess the relationship between depressive symptoms and OSA, and the efficacy of AT for decreasing depressive symptoms. Studies reporting depressive symptoms of children with OSA through January 2013 were included.

RESULTS

Eleven studies assessed depressive symptoms in both children diagnosed with OSA (n = 894) and a comparison group (n = 1,096). A medium relationship was found between depressive symptoms and OSA (Hedges' g = 0.43, 95% CI: 0.22-0.64; p = 0.0005). Addressing the second question, 9 studies (n = 379 children) examined depressive symptoms pre- and post-AT. A medium improvement in depressive symptoms was found at follow-up (Hedge's g = 0.41, 95% CI: 0.20-0.62; p ≤ 0.001).

CONCLUSION

Our findings suggest that depressive symptoms are higher among children with OSA. Therefore, patients with depressive symptomatology should receive screening for sleep disordered breathing. Treatment of OSA with AT might decrease clinical symptoms of depression, reduce pharmacotherapy, improve sleep patterns, and promote better health.

Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing

OBJECTIVES

To examine the rates of behavioral and adaptive functioning difficulties among youth who never had sleep disordered breathing (SDB), had remitted SDB, had incident SDB, or had persistent SDB; and to determine if there were increased odds of behavioral difficulties among youth with varying SDB histories relative to those who never had SDB.

METHODS

263 youth had valid polysomnography and neurobehavioral data at two time points approximately 5 years apart from the prospective Tucson Children's Assessment of Sleep Apnea study. Primary outcomes were the behavior assessment scale for children-2(nd) Edition parent report form (BASC-PRF) and Self-Report of Personality (SRP), and the Adaptive Behavior Assessment System-2(nd) Edition (ABAS-2).

RESULTS

Compared to those who never had SDB, individuals with persistent SDB had significant odds and met more cutoff scores on the BASC-2-PRF externalizing problems composite (odds ratio [OR] 3.29; 8.92% vs. 35.3%), behavioral symptoms index (OR 6.82; 7.4% vs. 35.3%) and Hyperactivity subscale (OR 6.82; 11.1% vs. 41.2%). Similarly, greater difficulties was seen for the group with persistent SDB (relative to never) on the ABAS-2 social domain (OR 3.39; 22% vs. 50%), and Communication (OR 4.26; 15% vs. 42.9%) and Self-Care subscales (OR = 2.97; 25.2% vs. 50%). Relative to youth who never had SDB, youth who developed SDB at Time 2 had compromised adaptive skills as evidenced by the BASC-2 PRF adaptive behavior composite (OR 3.34; 15.6% vs. 38.1%) and the ABAS-2 general adaptive composite (OR 2.83; 20.5% vs. 42.1%).

CONCLUSIONS

Youth with current SDB exhibited hyperactivity, attention problems, aggressivity, lower social competency, poorer communication, and/or diminished adaptive skills.

Diagnosis and management of childhood obstructive sleep apnea syndrome

OBJECTIVE

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

METHODS

The literature from 1999 through 2011 was evaluated.

RESULTS AND CONCLUSIONS

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

Attention in children with obstructive sleep apnoea: an event-related potentials study

BACKGROUND

Obstructive sleep apnoea (OSA) in children has been causally implicated in neurobehavioural and cognitive dysfunction. Consequently, the American Academy of Paediatrics highlighted the need to study pertinent functional cognitive outcomes before and after treatment. However, neurocognitive function has thus far only been assessed by caregiver-completed questionnaires, which can be labour intensive and time consuming, such that the need for complementary and more objective measures has emerged.

OBJECTIVE

The study aimed to identify electrophysiological correlates of neurocognitive alterations in children with OSA and investigate utility as a predictive tool.

PATIENTS AND METHODS

Twenty-eight children (14 OSA and 14 matched controls) underwent overnight sleep studies and neurocognitive testing, as well as the oddball attention task while event-related potentials (ERPs) were recorded. ERPs were analysed using temporal principal components and source analyses that provided dependent variables for the subsequent repeated measures analysis of variance (ANOVA) and multiple regressions. Time-locked waveforms formed spatial models that localised electrical activity in the brain. ERP differences between groups were then correlated to neurocognitive outcomes.

RESULTS

OSA children exhibited significantly altered ERP patterns of neural activation and impaired neurocognitive performance. Specific ERP variables exhibited accurate predictive ability regarding performance on neurobehavioural measures.

CONCLUSION

Specific ERP events during a single attention task can reliably identify the presence of OSA-associated cognitive dysfunction. Electrophysiological approaches during specific cognitive tasks may serve as simple, complementary, and reliable reporters of cognitive dysfunction associated with OSA in children.

Poor sleep as a potential causal factor in aggression and violence

Clinical observations suggest that sleep problems may be a causal factor in the development of reactive aggression and violence. In this review we give an overview of existing literature on the relation between poor sleep and aggression, irritability, and hostility. Correlational studies are supporting such a relationship. Although limited in number, some studies suggest that treatment of sleep disturbances reduces aggressiveness and problematic behavior. In line with this is the finding that sleep deprivation actually increases aggressive behavior in animals and angriness, short-temperedness, and the outward expression of aggressive impulses in humans. In most people poor sleep will not evoke actual physical aggression, but certain individuals, such as forensic psychiatric patients, may be particularly vulnerable to the emotional dysregulating effects of sleep disturbances. The relation between sleep problems and aggression may be mediated by the negative effect of sleep loss on prefrontal cortical functioning. This most likely contributes to loss of control over emotions, including loss of the regulation of aggressive impulses to context-appropriate behavior. Other potential contributing mechanisms connecting sleep problems to aggression and violence are most likely found within the central serotonergic and the hypothalamic-pituitary-adrenal-axis. Individual variation within these neurobiological systems may be responsible for amplified aggressive responses induced by sleep loss in certain individuals. It is of great importance to identify the individuals at risk, since recognition and adequate treatment of their sleep problems may reduce aggressive and violent incidents.

Sleep, glucose, and daytime functioning in youth with type 1 diabetes

STUDY HYPOTHESES: 1) Youth with evidence of SDB (total apnea-hypopnea index [Total-AHI] ≥ 1.5) would have significantly worse glucose control than those without SDB; 2) Elevated self-reported sleepiness in youth with T1DM would be related to compromised psychosocial functioning; and 3) Youth with T1DM would have significantly less slow wave sleep (SWS) than controls.

DESIGN

The study utilized home-based polysomnography, actigraphy, and questionnaires to assess sleep, and continuous glucose monitors and hemoglobin A1C (HbA1C) values to assess glucose control in youth with T1DM. We compared sleep of youth with T1DM to sleep of a matched control sample.

SETTING

Diabetic participants were recruited in a pediatric endocrinology clinic.

PARTICIPANTS

Participants were youth (10 through 16 years) with T1DM. Controls, matched for sex, age, and BMI percentile, were from the Tucson Children's Assessment of Sleep Apnea study.

RESULTS

Participants with a Total-AHI ≥ 1.5 had higher glucose levels. Sleepiness and/or poor sleep habits correlated with reduced quality of life, depressed mood, lower grades, and lower state standardized reading scores. Diabetic youth spent more time (%) in stage N2 and less time in stage N3. Findings related to sleep architecture included associations between reduced SWS and higher HbA1C, worse quality of life, and sleepiness. More time (%) spent in stage N2 related to higher glucose levels/hyperglycemia, behavioral difficulties, reduced quality of life, lower grades, depression, sleep-wake behavior problems, poor sleep quality, sleepiness, and lower state standardized math scores.

Risk for sleep-disordered breathing and home and classroom behavior in Hispanic preschoolers

Pediatric sleep-disordered breathing (SDB) is known to negatively impact home and classroom behavior. Preschool-age Hispanic children from Spanish-speaking households are at elevated risk for poor school readiness. The authors used a multi-informant approach to assess home and preschool behavior among Hispanic children at risk for SDB (n = 67). Higher parent-reported SDB risk and elevated snoring were associated with parent- and teacher-reported problem behaviors and poorer teacher-reported classroom executive function among boys; elevated snoring was associated with internalizing behaviors among girls. Elevated snoring may be associated with problems related to impaired inhibitory self-control, suggesting the need for early intervention in order to improve school readiness among these a priori defined at-risk Hispanic children.

The association between sleep disordered breathing, academic grades, and cognitive and behavioral functioning among overweight subjects during middle to late childhood

STUDY OBJECTIVES

(1) to determine the associations of sleep disordered breathing (SDB) with behavioral functioning, cognitive test scores, and school grades during middle- to late-childhood, an under-researched developmental period in the SDB literature, and (2) to clarify whether associations between SDB and school grades are mediated by deficits in cognitive or behavioral functioning.

DESIGN

cross-sectional correlative study.

SETTING

Office/hospital, plus reported functioning at home and at school.

PARTICIPANTS

163 overweight subjects aged 10-16.9 years were divided into 4 groups based upon their obstructive apnea+hypopnea index (AHI) during overnight polysomnography and parent report of snoring: Moderate-Severe OSA (AHI > 5, n = 42), Mild OSA (AHI = 1-5, n = 58), Snorers (AHI < 1 + snoring, n = 26), and No SDB (AHI < 1 and nonsnoring, n = 37).

MEASUREMENTS

inpatient overnight polysomnography, parent- and self-report of school grades and sleep, parent- and teacher-report of daytime behaviors, and office-based neuropsychological testing.

RESULTS

The 4 groups significantly differed in academic grades and parent- and teacher-reported behaviors, particularly inattention and learning problems. These findings remained significant after adjusting for subject sex, race, socioeconomic status, and school night sleep duration. Associations with SDB were confined to reports of behavioral difficulties in real-world situations, and did not extend to office-based neuropsychological tests. Findings from secondary analyses were consistent with, but could not definitively confirm, a causal model in which SDB affects school grades via its impact on behavioral functioning.

CONCLUSIONS

SDB during middle- to late-childhood is related to important aspects of behavioral functioning, especially inattention and learning difficulties, that may result in significant functional impairment at school.

Incidence and remission of sleep-disordered breathing and related symptoms in 6- to 17-year old children--the Tucson Children's Assessment of Sleep Apnea Study

OBJECTIVE

To determine the incidence and remission of sleep-disordered breathing in adolescent children.

STUDY DESIGN

A total of 319 children completed 2 home polysomnograms approximately 5 years apart. Sleep-disordered breathing (SDB) was determined to be present if a child had a respiratory disturbance index>or=1 event per hour associated with >or=3% oxygen desaturation. Subjective symptoms such as witnessed apnea, excessive daytime sleepiness, difficulty initiating and maintaining sleep, and habitual loud snoring were considered present if they occurred frequently or almost always. Body mass index percentiles were calculated with childhood growth charts from the Centers for Disease Control and Prevention adjusted for sex and age.

RESULTS

The mean age at assessment was 8.5 years at baseline and 13.7 years at follow-up, respectively. Incident SDB was more common in boys (odds ratio [OR]=3.93, P=.008, confidence interval [CI]=1.41-10.90). Children with prevalent SDB were more likely to be boys (OR=2.48, P=.006) and had a greater increase in body mass index percentile change (OR 1.01, P=.034). Children with prevalent SDB also had 3.41 greater odds for development of obesity from baseline to follow-up in comparison with children with prevalent NoSDB.

CONCLUSIONS

Adolescent boys are more likely to have persistent and incident SDB than girls. Children with prevalent SDB are more likely to have development of obesity. These risks are similar to those observed in adults.