Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

A case-control study to investigate the prevalence of obstructive sleep apnea and the utility of the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire in children and young people with epilepsy

STUDY OBJECTIVES

Epilepsy and obstructive sleep apnea syndrome (OSAS) are each relatively common in children. OSAS may affect cognition, such that recognition of OSAS is important for children and young people with epilepsy (CYPWE). Published pilot data reported 55% of CYPWE had symptoms suggestive of OSAS, compared with 7% of typically developing controls. The primary aim of this study was to ascertain OSAS prevalence by polysomnography in CYPWE, with secondary aims being to evaluate the utility of sleep questionnaires in CYPWE.

METHODS

CYPWE and age- and sex-matched typically developing controls were studied. A single night of level I attended polysomnography was undertaken, along with questionnaires (Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire, Pittsburgh Sleep Quality Index, and the childhood and adolescent Epworth Sleepiness Scale). OSAS was defined as obstructive apnea-hypopnea index of ≥ 1 event/h.

RESULTS

Polysomnography was performed in 72 children including 48 CYPWE (60% male) and 24 controls (54% male). Mean age (11 years) was similar for CYPWE and controls (P = .42), with slightly higher body mass index z scores (0.7 vs 0.1, P = .03) noted in CYPWE. Mean obstructive apnea-hypopnea index was 0.61 in CYPWE vs 0.42 in controls (P = .62). Despite higher Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire scores in CYPWE (0.38 vs 0.12, P < .001), no difference in OSAS prevalence (10% vs 4%, P = .78) was found. CYPWE had higher childhood and adolescent Epworth Sleepiness Scale (6 vs 3.5, P = .01) and Pittsburgh Sleep Quality Index (5 vs 3.3, P = .02) scores, indicating greater levels of daytime sleepiness and poorer sleep quality.

CONCLUSIONS

The study found no evidence for increased OSAS prevalence in CYPWE, and the utility of the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire in predicting OSAS appears limited for CYPWE. CYPWE are, however, demonstrably sleepier and have poorer sleep quality. The cause for these findings remains unclear.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Investigation of Sleep Quality and Prevalence of Sleep-disordered Breathing in Children and Young People With Epilepsy; URL: https://www.clinicaltrials.gov/study/NCT03103841; Identifier: NCT03103841.

CITATION

Urquhart DS, McLellan AE, Hill LE, et al. A case-control study to investigate the prevalence of obstructive sleep apnea and the utility of the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire in children and young people with epilepsy. J Clin Sleep Med. 2024;20(7):1039-1047.

Efficacy of adenotonsillectomy on pediatric obstructive sleep apnea and related outcomes: A narrative review of current evidence

This review summarizes the current evidence in systematic reviews, meta-analysis and randomized controlled trials regarding adenotonsillectomy outcomes in pediatric obstructive sleep apnea (OSA). Adenotonsillectomy is effective in treating OSA in children without co-morbidities, despite postoperative residual OSA remained in roughly half of these children. For children with comorbidities such as Down syndrome, Prader-Willi syndrome, sickle cell disease, or cerebral palsy, adenotonsillectomy is less effective and associated with more postoperative complications than that in children without comorbidities. For other OSA-related outcomes, evidence from meta-analyses and randomized controlled trials confirm adenotonsillectomy results in improvement of subjective OSA-related outcomes (e.g. symptoms, behaviors, and quality of life), but the results in objective OSA-related outcomes (e.g. cardiometabolic parameters or neurocognitive functions) are inconsistent. Future studies should focus on randomized controlled trials comparing objective OSA-related outcomes and the long-term effects of adenotonsillectomy in children with OSA.

Effects of childhood obstructive sleep apnea with and without daytime sleepiness on behaviors and emotions

OBJECTIVE

To investigate the relationship between obstructive sleep apnea (OSA) with and without excessive daytime sleepiness (EDS) and behavioral and emotional outcomes in non-obese prepubertal children.

METHODS

This was a retrospective analysis of children aged 5-11 years who presented to our unit for assessment of their sleep-related complaints. All children underwent polysomnography (PSG). They also completed the Pediatric Daytime Sleepiness Scale (PDSS) and a sleep diary. OSA was diagnosed if the obstructive apnea-hypopnea index (OAHI) was ≥1 event/hour. EDS was defined as PDSS >15. Behavioral and emotional outcomes were assessed using the Child Behavioral Checklist (CBCL).

RESULTS

Data from 391 children (mean age of 8.6 ± 1.7 years; 67 % male) were analyzed. Seventy children did not have OSA or EDS, 137 had OSA, 50 had reported having EDS but without OSA, and 134 children had both OSA and EDS. There were significantly higher CBCL total problems score in the combined group (61 ± 9) compared to the non-OSA/EDS group (54 ± 10), and the OSA-only group (54 ± 10) (p < 0.001). The presence of EDS was significantly associated with higher CBCL T score and higher odds for clinically significant behavioral problems (T score ≥65) after adjusting for age, sex, BMI z-score and average sleep duration (p < 0.001).

CONCLUSION

Excessive daytime sleepiness is an important contributory factor associated with suboptimal behavioral and emotional outcomes in children with OSA.

Short-Term Weight Gain after Tonsillectomy Does Not Lead to Overweight: A Systematic Review

Different studies and systematic reviews have reported weight increase after tonsillectomy. However, the odds of a child being overweight or obese after tonsillectomy were no different than before surgery, according to a few studies. This systematic review aims to analyze the impact of adenotonsillectomy (TA) on weight gain and identify subgroups of children and adolescents at risk of experiencing weight gain. A systematic search included studies published in the last ten years. The PICO framework was used in the selection process, and evidence was assessed using the GRADE system. A total of 26 studies were included, and moderate-high level quality ones showed that children who underwent TA could present an increase in BMI z-score. However, this weight gain was significant in individuals younger than six years old and was considered catch-up growth in underweight subjects at baseline. In contrast, for normal-weight or overweight individuals, TA did not lead to overweight per se. At the same time, diet changes and overfeeding did not have a leading role in weight gain. In conclusion, TA may not be an independent risk factor for unfavorable weight gain in children; however, individuals who were underweight pre-operatively or younger than six years reported more weight gain after TA than expected.

Effect of surgical intervention for childhood OSA on blood pressure: A randomized controlled study

OBJECTIVE

To investigate the effect of surgical intervention on 24-h ABP in children with OSA. It was hypothesized that blood pressure would improve following adenotonsillectomy.

METHODS

This was a two-centered investigator-blinded randomized controlled trial. Non-obese pre-pubertal children aged 6-11 years with OSA (obstructive apnea-hypopnea index, OAHI >3/h) underwent 24-h ABP monitoring at baseline and 9 months after the randomly assigned intervention, i.e. Early Surgery (ES) or Watchful Waiting (WW). Intention-to-treat analysis was performed.

RESULTS

137 subjects were randomized. Sixty-two (Age: 7.9y ± 1.3, 71% boys) and 47 (Age: 8.5y ± 1.6, 77% boys) participants from the ES and WW groups, respectively completed the study. Changes in ABP parameters were similar in the ES and WW groups (nighttime systolic BP z-scores: +0.03 ± 0.93 vs. -0.06 ± 1.04, p = 0.65; nighttime diastolic BP z-scores: -0.20 ± 0.95 vs. -0.02 ± 1.00, p = 0.35) despite a greater improvement in OSA in the ES group. However, a reduction in nighttime diastolic BP z-score correlated with improvements in OSA severity indexes (r = 0.21-0.22, p < 0.05), and a significant improvement in nighttime diastolic BP z-score [-0.43 ± 1.01, p = 0.027] following surgery was observed in participants with severe preoperative OSA (OAHI ≥10/h). The ES group had a significant increase in body mass index z-score after surgery [+0.27 ± 0.57, p < 0.001], which correlated with the increase in daytime systolic BP z-score (r = 0.2, p < 0.05).

CONCLUSION

Surgical treatment did not lead to significant improvements in ABP in OSA children except in those with more severe disease. The improvement in BP was partially masked by the weight gain following surgery.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn.

REGISTRATION NUMBER

ChiCTR-TRC-14004131).

Alterations in Inflammatory Markers and Cognitive Ability after Treatment of Pediatric Obstructive Sleep Apnea

Background and Objectives: Determination of the impact of obstructive sleep apnea (OSA) on the cognitive function (CF), and serum tumor necrosis factor-α (TNF-α), interleukin (IL)-6 and 1β levels and the effect of OSA management on these variables in children. Materials and Methods: A total of 224 patients were evaluated using the Pediatric Sleep Questionnaire, the NEPSY score for CF, and polysomnography (PSG) to grade OSA severity according to the apnea/hypopnea index (AHI). Adentonsillectomy (AT) was performed for patients with adenotonsillar hypertrophy grade > 2. Patients with overweight or obesity with mild or moderate OSAS underwent a 6-month protocol of lifestyle intervention (LSI). Blood samples were obtained for an enzyme-linked immunosorbent assay (ELISA) estimation of cytokine levels. All variables were re-evaluated at the end of the 6-month follow-up period. Results: A total of 181 patients had surgical interference and 43 patients underwent a LSI trial; 15 patients failed to respond and underwent surgery. At the end of the follow-up, 33 patients had residual OSAS with a significantly higher incidence among patients with severe OSAS, the mean score of the pediatric sleep questionnaire was significantly decreased in all patients, 181 patients showed an improved NESPY score, and cytokine levels were decreased. The baseline NESPY score, AHI index and sleep questionnaire score were negatively correlated. The percentage of change in the NESPY score and serum cytokine levels showed a positive correlation. Conclusions: OSAS is associated with cognitive dysfunction that significantly improves after adenotonsillectomy. LSI as a therapeutic line is satisfactory for children with mild OSAS and minimal cognitive dysfunction and is of value preoperatively to improve the surgical outcomes of AT.

Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea

STUDY OBJECTIVES

Adenotonsillectomy (AT) forms part of first-line management for pediatric obstructive sleep apnea. In nonrandomized studies of preschool-aged children, postoperative weight gain has been seen following AT, raising concerns regarding later obesity. Using longitudinal data from a multicenter randomized controlled trial, we assessed the impact of AT on growth trajectories in preschool-aged children with mild-moderate obstructive sleep apnea.

METHODS

A total of 190 children (aged 3-5 years) with obstructive apnea-hypopnea index ≤ 10 events/h were randomly assigned to early (within 2 months) or routine (12-month wait) AT. Anthropometry and polysomnography were performed at baseline, 12-month, and 24-month time points for 126 children. Baseline characteristics were compared using a Mann-Whitney or t test for continuous variables and Fisher's exact test for categorical variables. Longitudinal data underwent linear mixed modeling.

RESULTS

For body mass index (BMI) z-score there was a significant increase in the early surgery group between 0 and 12 months (0.4, 95% confidence interval 0.1-0.8) but not from 12-24 months. For the routine surgery group there was an identical significant BMI z-score increase in the first 12 months following surgery, ie, between 12- and 24-month time points (0.45, 95% confidence interval 0.1-0.8) but not from 0-12 months (preoperative time). Final BMI z-score was similar between groups. Findings for weight-for-age z-score were similar to the findings for BMI z-score. Height-for-age z-score was not significantly different between different time points or intervention groups.

CONCLUSIONS

This study provides randomized controlled trial evidence of notable, but time-limited, increase in the BMI and weight of preschool children with mild-moderate obstructive sleep apnea in the months immediately following AT.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: POSTA Child Study (Preschool Obstructive Sleep Apnea Tonsillectomy Adenoidectomy Study); URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336273&isReview=true; Identifier: ACTRN12611000021976.

CITATION

Kevat A, Bernard A, Harris M-A, et al. Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea. J Clin Sleep Med. 2023;19(1):55-62.

Sleep Complaints Among School Children

Sleep complaints are common among children. These include both night-time and daytime symptoms, such as trouble falling asleep, problems in maintaining sleep, snoring, and unusual events during sleep and daytime functioning impairment. However, sleep complaints in children are often overlooked and undertreated in clinical practice. Untreated sleep problems may further impact on children's development and will persist into adulthood in some cases. This review summarizes the common sleep complaints and disorders in school children, and provides an overview of the epidemiology, clinical features, consequences, and treatment of the sleep problems.

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 Monitoring of Children With Nocturnal Enuresis: A Narrative Review

The purpose of this article is to provide a succinct summary of the sleep monitoring efforts that have been used in nocturnal enuresis (NE) and an overview of the knowledge that has accrued. This is not intended to be a comprehensive review, but rather is intended to highlight how polysomnography (PSG), a common sleep detection tool, has contributed to our understanding of NE, as arousal disorder is considered to be one of the important mechanisms. The authors have organized this report by analysis and display of different ingredients of PSG, starting with comparing the electroencephalogram (EEG) of controls and the enuretic children and then moving to evaluation of respiratory patterns of NE and comorbid disease obstructive sleep apnea (OSA). In addition, the authors' goal is to better understand the mechanism of NE by integrating various levels of sleep monitoring; those sleep-related clinical scale scores for NE are presented to date. Finally, we propose further research of NE to explore the microstructure alterations via PSG combined with EEG-fMRI or to use novel technology like portable device internet and deep learning strategy.