Pierre Robin sequence causes position-dependent obstructive sleep apnoea in infants

Micrognathia and cleft palate as a cause of obstructive sleep apnoea in infants

AIM

Obstructive sleep apnoea (OSA) is common in Robin sequence (RS). We investigated the significance of micrognathia, cleft palate and sleep positioning on OSA in infants.

METHODS

We analysed our 13-year national reference centre polysomnography (PSG) dataset. PSG was performed as daytime recordings (97%) in the supine-, side- and prone sleeping position at the median age of 5 weeks (interquartile range 3-8 weeks).

RESULTS

Our study included 113 infants with RS and cleft palate, 10 infants with RS but intact palate and 32 infants with cleft palate without micrognathia. The degree of OSA in infants with cleft palate without micrognathia was less severe than in infants with RS in terms of obstructive events (median OAHI 4 vs. 32 h-1, respectively), SpO2 desaturations (ODI≥3OAH 0.4 vs. 3 h-1), transcutaneous pCO2 levels (TcCO2P95, 41 vs. 46 mmHg) (p < 0.0001) and work of breathing (p = 0.01). In the RS group, OSA was sleep-position dependent, with fewer obstructive events apparent in the side (18 vs. 24 h-1, p = 0.005) and prone (39 vs. 27 h-1, p = 0.003) sleeping positions than when supine.

CONCLUSIONS

The degree of OSA in RS infants is more dependent on micrognathia than on cleft palate.

Management of Obstructive Sleep Apnea in the Infant: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the improvement in respiratory parameters of infants with obstructive sleep apnea (OSA) treated with medical or surgical intervention.

DATA SOURCES

A comprehensive review was completed using the PubMed, Web of Science, Embase, and Cochrane libraries including articles published from 1975 to 2024.

REVIEW METHODS

Interventions studied included adenotonsillectomy, mandibular distraction osteogenesis (MDO), tongue/lip adhesion, partial glossectomy, floor-of-mouth release, supraglottoplasty, oral appliances, tracheostomy, and positioning. Continuous positive airway pressure (CPAP) served as a control. Outcomes studied included pre- and postintervention obstructive apnea-hypopnea index. Studies included randomized controlled trials and case-control trials. A total of 2161 records were identified, and 59 studies were included in the analysis. Data was extracted following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and pooled using a random-effects model. The primary study outcome established prior to data collection was a change in the apnea-hypopnea index.

RESULTS

A meta-analysis of MDO performed in infants for OSA demonstrated an overall pooled mean difference (pre-apnea-hypopnea index minus post-apnea hypopnea index) of 30.1 (95% confidence interval: 22.9, 37.4; 10 studies, 373 patients). No other data was pooled for analysis due to study heterogeneity. All CPAP studies showed apnea resolution. Tailored therapies including supraglottoplasty and tongue-lip adhesion reduced but did not resolve apneic events.

CONCLUSION

Current investigations of the evaluation and treatment of infant OSA are limited by heterogeneity in reporting and study. Mandibular distraction and CPAP are promising.

Diagnosis and Early Management of Robin Sequence

The results of a survey of twenty-four neonatal units in the United Kingdom and Ireland are presented. A structured ten-item questionnaire was used, and demonstrated the variation in how infants with RS are diagnosed and managed. Notably, the survey revealed that a minority of infants were diagnosed antenatally. There were significant discrepancies in diagnostic criteria used and 79% of the units referred the patients to tertiary services. A preference for minimally invasive approaches to managing upper airway obstruction, such as a trial of prone positioning before progressing to a nasopharyngeal airway, was reported by 96% of the centers. A narrative review was undertaken which discusses the current practices for diagnosis and early management of Robin sequence (RS). The challenges of antenatal diagnosis, strategies to enhance outcomes through early detection and controversies surrounding the management of neonatal upper airway obstruction associated with RS are included. The results of the survey and our comprehensive review of the literature emphasize that there remains uncertainty regarding the best approach to treating Robin sequence.

Computerized Surgical Planning for Mandibular Distraction Osteogenesis

Mandibular distraction osteogenesis is a technically challenging procedure due to complex mandibular anatomy, especially in the treatment of Pierre-Robin Sequence due to variable bone thickness in the infant mandible and the presence of tooth buds. Computerized surgical planning (CSP) simplifies the procedure by preoperatively visualizing critical structures, producing cutting guides, and planning distractor placement. This paper describes the process of using CSP to plan mandibular distraction osteogenesis, including discussion of recent advances in the use of custom distractors.

Minimally-invasive airway management and early cleft palate repair in infants born with Robin sequence

The objective of this study was to report outcomes of early cleft palate repair in infants born with Robin sequence (RS). A retrospective case series in a tertiary referral paediatric hospital was carried out, examining a consecutive series of 69 infants born with RS and cleft palate. A minimally invasive approach was taken to upper airway obstruction, with liberal nasopharyngeal airway (NPA) and non-invasive ventilation (NIV) use, guided by sleep studies. The palate was repaired between 6 and 9 months with a modified Malek technique. The most frequently used airway adjunct (59.4% of patients) was an NPA and the median duration of use was 5.6 months. All patients underwent a modified Malek cleft palate repair at a median of 7 months of age. Overnight oximetry demonstrated higher mean oxygen saturation (SpO2) across the group from initial neonatal admission to discharge (median 96.5% (interquartile range [IQR] 95-98%) vs 97.45% (IQR 96.5-98%) (P = 0.2, N = 34). Of those with a cardiorespiratory polysomnogram, the obstructive apnoea-hypopnea index (OAHI) was significantly lower postoperatively (5.9 vs 2.8, P = 0.028). This study supports the use of non-surgical airway strategies and early cleft palate repair in infants born with RS and cleft palate.

Obstructive sleep apnea is position dependent in young infants

BACKGROUND

Obstructive sleep apnea in infants with Pierre Robin sequence is sleep-position dependent. The influence of sleep position on obstructive events is not established in other infants.

METHODS

We re-evaluated ten-year pediatric sleep center data in infants aged less than six months, with polysomnography performed in different sleep positions. We excluded infants with syndromes, genetic defects, or structural anomalies.

RESULTS

Comparison of breathing between supine and side sleeping positions was performed for 72 infants at the median corrected age of 4 weeks (interquartile range (IQR) 2-8 weeks). Of the infants, 74% were male, 35% were born prematurely, and 35% underwent study because of a life-threatening event or for being a SIDS sibling. Upper airway obstruction was more frequent (obstructive apnea-hypopnea index (OAHI), p < 0.001), 95th-percentile end-tidal carbon dioxide levels were higher (p = 0.004), and the work of breathing was heavier (p = 0.002) in the supine than in the side position. Median OAHI in the supine position was 8 h-1 (IQR 4-20 h-1), and in the side position was 4 h-1 (IQR 0-10 h-1).

CONCLUSIONS

Obstructive upper airway events in young infants are more frequent when supine than when sleeping on the side.

IMPACT

The effect of sleep position on obstructive sleep apnea is not well established in infants other than in those with Pierre Robin sequence. A tendency for upper airway obstruction is position dependent in most infants aged less than 6 months. Upper airway obstruction is more common, end-tidal carbon dioxide 95th-percentile values higher, and breathing more laborious in the supine than in the side-sleeping position. Upper airway obstruction and obstructive events have high REM sleep predominance. As part of obstructive sleep apnea treatment in young infants, side-sleeping positioning may prove useful.

Obstructive sleep apnea in young infants: Sleep position dependence and spontaneous improvement

OBJECTIVES

The natural evolution of obstructive sleep apnea (OSA) in young infants is not established.

METHODS

We re-evaluated 10-year pediatric sleep center infant polysomnography (PSG) data, excluding infants with syndromes, genetic defects, structural anomalies or periodic breathing > 5% of sleep time.

RESULTS

Obstructive events > 1 h^-1 were evident in 255 infants, of which 91 were eligible for the study. Of the 38 infants in a follow-up study, 30 (79%) were male, 15 (40%) were born prematurely, 25 (66%) had observed apneas, and 13 (33%) had experienced a brief, unexplained event or had a sibling of the infant died suddenly. The first PSG was performed at a median corrected age of 4 weeks (interquartile range [IQR] 2-7) and the second at 11 weeks (IQR 9-14). The obstructive apnea and hypopnea index (OAHI) was greater in the supine compared to side-sleeping position in both recordings (p < 0.001), whereas OAHI dropped from 10 h^-1 (IQR 6-24) in the first PSG to 3 h^-1 (IQR 1-9) in the second PSG (p < 0.001). OSA alleviation was also observable as a decrease in the number of oxygen desaturations (p < 0.001), as a decrease in transcutaneous (p = 0.001) and end-tidal carbon dioxide (p = 0.01) 95th percentile levels, and work of breathing (p = 0.002). Seven infants had a third PSG to verify a satisfactory improvement of OSA.

CONCLUSIONS

OSA in young infants without a clear syndrome or structural anomaly is sleep position dependent and shows improvement during the following few months.

Humidified versus nonhumidified low-flow oxygen therapy in children with Pierre-Robin syndrome: A randomized controlled trial

BACKGROUND

Humidification is an important process in clinical oxygen therapy. We aimed to evaluate the effects and safety of humidified versus nonhumidified low-flow oxygen therapy in children with Pierre-Robin syndrome.

METHODS

This study was an open-label, single-centered randomized controlled trial (RCT) with a parallel group design. The study protocol has been registered in Chinese Clinical Trial Registry (ChiCTR1900021584). The children were randomized to the humidified versus nonhumidified groups. Average arterial oxygen partial pressure (PaO2) and carbon dioxide partial pressure (PaCO2), incidence of ventilator-associated pneumonia (VAP), nasal cavity dryness, nasal mucosal bleeding and bacterial contamination of the humidified bottle, the cost of nasal oxygen therapy and duration of intensive care unit (ICU) stay were analyzed.

RESULTS

A total of 213 children with Pierre-Robin syndrome were included. There were no significant differences in the gender, age, weight, prematurity, duration of anesthesia and surgery duration of mandibular traction between humidified group and nonhumidified group (all P > .05). No significant differences in the average arterial PaO2 and PaCO2 level on the postoperative day 1, 2, and ICU discharge between humidified group and nonhumidified group were found (all P > .05). There were no significant differences in the incidence of nasal cavity dryness, nasal mucosal bleeding, bacterial contamination and VAP, the duration of ICU stay between humidified group and nonhumidified group (all P > .05). The cost of nasal oxygen therapy in the humidified group was significantly less than that of nonhumidified group (P = .013).

CONCLUSIONS

Humidifying the oxygen with cold sterile water in the low-flow oxygen therapy in children may be not necessary. Future RCTs with lager sample size and rigorous design are warranted to further elucidate the effects and safety of humidified versus nonhumidified low-flow oxygen therapy.

Positioning as a conservative treatment option in infants with micrognathia and/or cleft

Evaluation and management of airway obstruction in prone position were reviewed from studies in infants with micrognathia and/or cleft palate, using polysomnography (PSG) or similar measures, and comparing prone against other positions. Most studies identified were case series from specialist referral centres. Airway obstruction appears more severe on PSG than clinical assessment, but there is no consensus for PSG definitions of mild, moderate or severe airway obstruction. Infants show individual variability in responses to positioning; sleep quality tends to improve when prone, but 22-25% have better respiratory outcomes when supine. Most centres recommend home monitoring if advising that an infant be placed prone to manage their airway obstruction. In conclusion, in case series, success rates for managing infant airway obstruction by prone positioning vary from 12 to 76%. PSG studies comparing prone with other sleep positions can help differentiate which infants show improved airway obstruction and/or sleep quality when positioned prone.