Elevated morbidity and health care use in children with obstructive sleep apnea syndrome

The impact of adenotonsillectomy on healthcare utilization in children with obstructive sleep apnea: Experience of an integrated medical model

BACKGROUND AND OBJECTIVES

Studies suggest that children with obstructive sleep apnea (OSA) have increased healthcare utilization patterns in comparison to matched controls. However, the effect of adenotonsillectomy (AT) on utilization patterns in these children is poorly understood. Additionally, no previous studies have compared the effect of AT on healthcare utilization patterns across different OSA severity groups. The aim of this retrospective cohort study is to assess the effects of surgical treatment on the level of healthcare utilization among children with OSA at a large integrated multicenter healthcare system.

METHODS

Retrospective analysis was performed of children aged 3-12 diagnosed with OSA via an attended polysomnogram (PSG) between December 2016 and February 2019. Demographic variables including age (at time of PSG), body mass index (BMI), race, and ethnicity were obtained. Variables for healthcare utilization were assessed for 12 months prior to PSG, and for 12 months after PSG (or after AT, delayed for the first 30 days after surgery to account for surgery-related visits). Healthcare utilization variables assessed included the total number of outpatient visits, inpatient, and emergency department (ED) visits, visits involving diagnostic codes associated with upper respiratory infection (URI), otitis media (OM), and allergic rhinitis (AR), prescription data involving intranasal steroids or leukotriene receptor antagonists (LTRA), and communication data such as secure message load and specialty referrals. Repeated measure linear difference-in-difference (D-I-D) models were used to assess the causal impact of AT on healthcare utilization outcomes. Sensitivity analyses were performed using modeling with a Poisson distribution and as an unadjusted model, with statistical significance set to p < 0.05.

RESULTS

Analysis elicited 577 children identified with OSA. Of these, 336 (58.2 %) underwent observation while 241 (41.8 %) underwent AT. The mean age was 6.4 years, with a slight male predominance (60.5 %). Analysis of baseline healthcare utilization patterns revealed that the treatment group had a significantly higher number of baseline inpatient/ED visits and OM visits in comparison to the observation group, but no differences in regards to baseline outpatient visits, or in visits involving URI or AR. Analysis of the entire OSA cohort via D-I-D modelling showed a significantly larger reduction in outpatient visits, secure messages, specialty referrals, and the use of intranasal steroid and LTRA in the treatment group compared to the observation group. Stratification of children based on OSA severity showed that the significant differences in healthcare utilization attributed to surgical treatment were primarily driven by the severe OSA group. Children with severe OSA who underwent AT showed significant reductions in most variables including outpatient visits, inpatient/ED visits, and OM visits. Alternatively, the only significant reductions in healthcare utilization among children with mild OSA treated with AT were in AR visits, intranasal steroid use, and LTRA use. Pattern changes among children with moderate OSA compared similarly to those with mild OSA.

CONCLUSION

To the authors' knowledge this study represents the largest available study assessing the impact of AT on healthcare utilization in children with OSA that also considers the effect of OSA severity on utilization patterns. AT appears to decrease healthcare utilization patterns, particularly in children with severe OSA. Alternatively, children with mild or moderate OSA treated with AT had only modest reductions in healthcare utilization patterns.

Snoring, obstructive sleep apnea, and upper respiratory tract infection in elementary school children in Japan

PURPOSE

Both obstructive sleep apnea (OSA) and the common cold are disorders of the upper respiratory tract, and may be associated. However, studies on the association between OSA and upper respiratory tract infections (URTI) in children are scarce. The aim of this study was to investigate possible associations between snoring, the severity of OSA, and URTI in elementary school children.

METHODS

This was a cross-sectional study in a community cohort of elementary school children (first and second graders) in Japan. Information on sleep habits, history of URTI, and OSA risk was obtained from a parental questionnaire. Children underwent overnight tracheal sound recordings from which apnea-hypopnea index was estimated. Multivariable logistic analysis was employed to define the association between snoring, OSA, and URTI ≥ 3 episodes over six months.

RESULTS

Of the 922 potential enrollees, 653 children and their parents (71%) agreed to participate in the study. Multivariable-adjusted ORs for URTI were 1.73 (95%CI: 1.16 to 2.59) in children who snored 1 to 4 nights per week and 2.82 (95%CI: 1.26 to 6.28) in snoring ≥ 5 nights per week compared with never snoring (reference). Likewise, subjectively reported louder snoring, as well as objectively defined louder sound levels, were significantly associated with URTI. In addition, OR for URTI in children with an estimated apnea-hypopnea index ≥ 2.0 events/hour was 2.65 (95%CI: 1.32 to 5.31) compared to children with apnea-hypopnea index less than 1.0 events/hour (reference).

CONCLUSIONS

Snoring and severity of OSA as measured by nocturnal tracheal sound recordings were associated with increased susceptibility to URTI in elementary school children.

Healthcare utilization is increased in children living in urban areas, with ethnicity-related disparities: A big data analysis study

This study aimed to investigate differences in pediatric healthcare utilization in Israel over 10 years by examining differences across populations defined by living environment and ethnicity. Data was obtained from the Clalit Health Care data warehouse, covering over 250,000 children residing in Haifa and Western Galilee districts. The population groups were categorized based on ethnicity (Jewish vs Arab) and residential settings (urban vs rural). Healthcare utilization was consistently higher among Jewish than Arab children, irrespective of the specific dimension analyzed. Additionally, urban-dwelling children exhibited higher usage rates than those residing in rural areas in all investigated dimensions. However, Jewish children showed significantly about 18% lower hospitalization rates than Arab children across all years (P < 0.001). No significant differences in hospitalizations were observed between urban and rural children (RR 0.999, CI (0.987-1.011)). Notably, the study revealed reduced antibiotic consumption and hospitalizations over the years for all populations. Additionally, we found that Arab children and those living in rural areas had reduced access to healthcare, as evidenced by 10-40% fewer physician visits, laboratory tests, and imaging (P < 0.001).    Conclusion: This study highlights the substantial population-based disparities in healthcare utilization among children in Israel despite the equalizing effect of the national health insurance law. Rural and low socioeconomic populations seem to have reduced healthcare access, showing decreased healthcare utilization. Consequently, it is imperative to address these disparities and implement targeted interventions to enhance healthcare access for Arab children and rural communities. The decline in antibiotic usage and hospitalizations suggests positive trends in pediatric health care, necessitating ongoing efforts to ensure equitable access and quality of care for all populations. What is Known: • Healthcare systems worldwide vary in coverage and accessibility, including Israel, which stands out for its diverse population. • Existing research primarily focuses on healthcare utilization among adults, leaving a need for comprehensive data on children's healthcare patterns globally. What is New: • Investigating over 250,000 children, this study reveals higher healthcare utilization among Jewish and urban children across all dimensions. • Despite Israel's national health insurance law, the study underscores the significant population-based disparities in healthcare utilization.

Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea

RATIONALE

Lower respiratory tract infections (LRTI) during the first 2 years of life increase the risk of pediatric obstructive sleep apnea (OSA), but whether this risk varies by LRTI severity is unknown.

METHODS

We analyzed data from 2962 children, aged 0-5 years, with early-life LRTI requiring hospitalization (severe LRTI, n = 235), treated as outpatients (mild LRTI, n = 394) and without LRTI (reference group, n = 2333) enrolled in the Boston Birth Cohort. Kaplan-Meier survival estimates and Cox proportional hazards models adjusted by pertinent covariables were used to evaluate the risk of pediatric OSA.

RESULTS

Compared to children without LRTI, those with mild LRTI were at a higher risk of having OSA (hazard ratio [HR] 1.44, 95% confidence interval [CI]: 1.01-2.05), and those with severe LRTI were at the highest risk (HR 2.06, 95% CI: 1.41-3.02), independently of relevant covariables (including maternal age, race, gestational age, and type of delivery). Additional risk factors linked to a higher risk of OSA included prematurity (HR 1.34, 95% CI 1.01-1.77) and maternal obesity (HR 1.82, 95% CI 1.32-2.52). The time elapsed between LRTI and OSA diagnosis was similar in mild and severe LRTI cases, with medians of 23 and 25.5 months, respectively (p = .803).

CONCLUSION

Infants with severe early-life LRTI have a higher risk of developing OSA, and surveillance strategies to identify OSA need to be particularly focused on this group. OSA monitoring should continue throughout the preschool years as it may develop months or years after the initial LRTI hospitalization.

Comparison of Epworth Sleepiness Scale and OSA-18 Scores With Polysomnography in Children

OBJECTIVE

Our goal is to determine if there is a correlation between Modified Epworth Sleepiness Scale (M-ESS) scores, obstructive sleep apnea (OSA)-18 scores, and polysomnography (PSG) outcomes in children.

STUDY DESIGN

Retrospective chart review.

SETTING

Pediatric otolaryngology clinic.

METHODS

Charts of consecutive children presenting from July 2021 to July 2023 were reviewed. Demographics, body mass index (BMI), BMI Z score, M-ESS score, OSA-18 score, PSG results, and sleep apnea severity were included. One-way analysis of variance and Pearson/Spearman correlation coefficients were calculated.

RESULTS

Three hundred sixty-seven children were included, 162 (44.1%) girls and 205 (55.9%) boys. Mean patient age was 7.8 (95% confidence interval [CI]: 7.3-8.3) years. M-ESS score was 6.3 (n = 348, 95% CI: 5.8-6.8), mean OSA-18 score was 56.2 (n = 129, 95% CI: 53.0-59.4). Mean apnea-hypopnea index (AHI) was 10.1 (95% CI: 8.7-11.4) events/h, obstructive AHI 9.3 (95% CI: 8.0-12.7) events/h, respiratory distress index 14.6 (95% CI: 8.4-20.8) events/h, and oxygen saturation nadir 89.8% (95% CI: 89.1-90.4). Sixty-two children (17.2%) had mild, 192 (53.5%) moderate, and 105 (29.2%) severe sleep apnea. M-ESS score correlated weakly to AHI (r = .19, P = <.001), and OSA-18 score to oxygen saturation nadir (r = -.16, P = .002). After logistic regression adjusted for age and BMI, neither clinical scores were independently associated with AHI.

CONCLUSION

M-ESS and OSA-18 scores have a weak correlation with OSA severity in children. More reliable, age-appropriate screening tools are needed in pediatric sleep apnea.

Sociodemographic disparities and healthcare utilization in pediatric obstructive sleep apnea management

OBJECTIVES

We examined (1) disparities in obstructive sleep apnea (OSA) care by insurance coverage, and by child race and ethnicity among Medicaid-insured children (MIC), and (2) healthcare utilization changes after OSA care.

METHODS

IBM MarketScan insurance claims were used to index OSA care 1-year before and after initial OSA diagnosis in 2017 among 2-17-year-old children (n = 31,787, MIC: 59%). OSA care and healthcare utilization analyses adjusted for child age, sex, obesity, and complex chronic conditions.

RESULTS

We identified 8 OSA care pathways, including no care, which occurred in 34.4% of the overall sample. MIC had 13% higher odds of no OSA care compared to commercially-insured children (CIC). MIC had 32-48% lower odds of any treatment pathway involving specialty care, but a 13-46% higher likelihood of receiving surgical care without polysomnogram (PSG) and PSG only. In MIC, non-Latinx Black/African American (Black) and Hispanic/Latinx children were 1.3-2.2 times more likely than White children to receive treatment involving specialty care and/or PSG, while Black children were 31% less likely than White youth to undergo surgery. In the full sample, surgical care was associated with less outpatient and emergency healthcare utilization compared to those untreated or not surgically treated.

CONCLUSIONS

Varied OSA management by insurance coverage suggests disparities in access to and engagement in care and potentially greater disease burden among MIC. Surgical care is associated with reduced healthcare utilization. The lower odds of surgery in Black MIC should be further evaluated in the context of OSA severity, healthcare biases, and family preferences.

Unveiling the Enigmatic Adenoids and Tonsils: Exploring Immunology, Physiology, Microbiome Dynamics, and the Transformative Power of Surgery

Within the intricate realm of the mucosal immune system resides a captivating duo: the adenoids (or pharyngeal tonsils) and the tonsils (including palatine, tubal, and lingual variations), which harmoniously form the Waldeyer's ring. As they are strategically positioned at the crossroads of the respiratory and gastrointestinal systems, these exceptional structures fulfill a vital purpose. They function as formidable "gatekeepers" by screening microorganisms-both bacteria and viruses-with the mission to vanquish local pathogens via antibody production. However, under specific circumstances, their function can take an unsettling turn, inadvertently transforming them into reservoirs for pathogen incubation. In this review, we embark on a fascinating journey to illuminate the distinctive role of these entities, focusing on the local immune system inside their tissues. We delve into their behavior during inflammation processes, meticulously scrutinize the indications for surgical intervention, and investigate the metamorphosis of their microbiota in healthy and diseased states. We explore the alterations that occur prior to and following procedures like adenoidectomy, tonsillectomy, or their combined counterparts, particularly in pediatric patients. By comprehending a wealth of data, we may unlock the key to the enhanced management of patients with otorhinolaryngological disorders. Empowered with this knowledge, we can embrace improved therapeutic approaches and targeted interventions/surgeries guided by evidence-based guidelines and indications.

Diagnosis of obstructive sleep apnea in children based on the XGBoost algorithm using nocturnal heart rate and blood oxygen feature

PURPOSE

Obstructive sleep apnea (OSA) is a serious type of obstructive sleep-disordered breathing (SDB) that can cause a series of adverse effects on children's cardiovascular, growth, cognition, etc. The gold standard for diagnosis is polysomnography (PGS), which is used to assess the prevalence of OSA by obtaining the apnea-hypopnea index (AHI), but this diagnosis method is expensive and needs to be performed in a specialized laboratory, making it difficult to be of benefit to children with suspected OSA on a large scale. Our goal was to use a machine learning method to identify children with OSA of varying severity using data on children's nighttime heart rate and blood oxygen data.

METHODS

This study included 3139 children who received diagnostic PSG with suspected OSA. Age, sex, BMI, 3 % oxygen depletion index (ODI), average nighttime heart rate and fastest heart rate were used as predictive features. Data sets were established with AHI ≥ 1, AHI ≥ 5, and AHI ≥ 10 as the diagnostic criteria for mild, moderate and severe OSA, and the samples of each data set were randomly divided into a training set and a test set at a ratio of 8:2. An OSA diagnostic model was established based on the XGBoost algorithm, and the ability of the machine learning model to diagnose OSA children with different severities was evaluated through different classification ability evaluation indicators. As a comparison, traditional classifier Logistic Regression was used to perform the same diagnostic task. The SHAP algorithm was used to evaluate the role of these features in the classification task.

RESULTS

We established a diagnostic model of OSA in children based on the XGBoost algorithm. On the test set, the AUCs of the model for diagnosing mild, moderate, and severe OSA were 0.95, 0.88, and 0.88, respectively, and the classification accuracy was 90.45 %, 85.67 %, and 89.81 %, respectively, perform better than Logistic Regression classifiers. ODI is the most important feature in all classification tasks, and a higher fastest heart rate and ODI make the model tend to classify samples as positive. A high BMI value caused the model to tend to classify samples as positive in the mild and moderate classification tasks and as negative in the classification task with severe OSA.

CONCLUSION

Using heart rate and blood oxygen data as the main features, a machine learning diagnostic model based on the XGBoost algorithm can accurately identify children with OSA at different severities. This diagnostic modality reduces the number of signals and the complexity of the diagnostic process compared to PSG, which could benefit children with suspected OSA who do not have the opportunity to receive a diagnostic PSG and provide a diagnostic priority reference for children awaiting a diagnostic PSG.

Increased P-wave dispersion in patients with obstructive sleep apnea syndrome: a meta-analysis

PURPOSE

Prolonged atrial conduction and inhomogeneous sinus impulse propagation may play a role in the initiation and maintenance of atrial tachyarrhythmias. Such a process could be reflected in inter-lead P-wave duration differences known as "P-wave dispersion" (PWD). Abnormal PWD may be related to obstructive sleep apnea syndrome (OSAS). A meta-analysis of the available publications was conducted.

METHODS

A MEDLINE, Web of Science, and Google Scholar search from 2000 to 2021 was performed. The keywords used for search were apnea AND "P wave dispersion." Case-control studies and surveys were selected as long as they included healthy subjects and subjects with diagnosed OSAS who did not have any other major health problems. PWD values and correlations between apnea-hypopnea indices (AHI) and PWD were used as outcome measures.

RESULTS

Ten studies met the inclusion creteria, encompassing 773 patients with OSAS and 347 healthy controls. The mean ages of the patients with OSAS ranged from 6.9 to 58.8 years. The estimated average Hedges's g standardized mean difference in PWD values was equal to 1.883 (95% CI: 1.140 to 2.626, p < 0.001). The estimated average Fisher r-to-z transformed correlation coefficient between AHI and PWD was equal to 0.530 (95% CI: 0.075 to 0.985, p = 0.0225). Meta-regression analysis failed to find statistically significant correlations between the effect sizes and the mean age, male proportion, and the body mass index in the OSAS groups.

CONCLUSION

OSAS is associated with increased PWD, which may predispose to atrial tachyarrythmias.

Health disparities in pediatric sleep-disordered breathing

Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Persistent obstructive sleep apnoea in children: treatment options and management considerations

Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.

Impact of OSA treatment success on changes in hypertension and obesity: A retrospective cohort study

OBJECTIVE

Pediatric obstructive sleep apnea (OSA) has been shown to lead to the development of chronic cardiometabolic conditions, including obesity and cardiovascular disease. We sought to describe the impact of the success of continuous positive airway pressure (CPAP) and surgery, common treatment options for pediatric OSA, on cardiometabolic conditions.

METHODS

A retrospective review of patients (≤18 years) diagnosed with OSA based on a polysomnogram at a tertiary care pediatric otolaryngology practice from 2015 to 2019 was conducted. Clinical data, including the systolic blood pressure (SBP) values, body mass index (BMI), overall apnea/hypopnea index (AHI) values, and CPAP compliance, were collected. Linear mixed-effects models were developed to observe the relationship between the clinical measurements of each comorbidity and OSA treatment modalities.

RESULTS

414 patients were included. BMI and SBP measures were collected for 230 and 184 patients respectively. The difference-in-difference estimate for the SBP z-score percentile after successful treatment was -5.5 ± 2.1 percentile units per 100 days. The difference-in-difference estimate for SBP z-score percentile after successful CPAP treatment was -13.2 ± 5.1 percentile units per 100 days while the estimate after successful surgical treatment was -4.6 ± 2.4 percentile units per 100 days. No significant differences were found between clinical measures for obese patients in any treatment cohort.

CONCLUSIONS

Successful OSA management was shown to have a positive impact on SBP in hypertensive patients and no impact on BMI in obese patients. In hypertensive patients, CPAP success tripled improvements in SBP z-score percentile compared to surgical treatment success.

Sleep-related breathing disorders in young orthodontic patients

INTRODUCTION

This study aimed to find out the frequency of sleep-related breathing disorders (SRBD) in young orthodontic patients in Israel. SRBD is characterized by prolonged upper airway obstruction during sleep.

METHODS

The study group consisted of 309 children aged 6-17 years who attended the Orthodontic Clinic at Hadassah Medical Center. Parents were asked to complete a translated validated Pediatric Sleep Questionnaire.

RESULTS

Of the examined children, 10% were at high risk for SRBD. Boys were at higher risk for SRBD and were at high risk at a younger age than girls. Girls had a low risk of SRBD after adenotonsillectomy, whereas 50% of the boys that underwent adenotonsillectomy were at high risk for SRBD.

CONCLUSIONS

Our findings propose that 10% of the children aged 6-17 years, who were seeking orthodontic consultation at our medical center, were at high risk for SRBD. Boys were significantly at a higher risk for SRBD than girls and were at high risk at a younger age. It is important to screen young orthodontic patients for SRBD and to refer high-risk patients to their physicians for further evaluation and treatment.

Patients with Obstructive Sleep Apnea Symptoms Referral to Otolaryngologists in Iranian Residency Entrance Examination Volunteers: The Effect of Source of Education and Level of Knowledge

Obstructive sleep apnea (OSA) has various complications for individuals' health. This study aimed to evaluate the factors for referring obstructive sleep apnea patients to otolaryngologists in Iranian residency entrance examination volunteers. This cross-sectional study recruited volunteer participants from the Iranian Residency Entrance Examination on March 2, 2018. The Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA)/the Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) Questionnaires were distributed among residents attending exam preparation. Number of years working as a physician, number of adult and pediatric patients visited during the academic rank in residency examination, and the main specialty during general physician education in which they get familiar with obstructive sleep apnea were documented. The effect of the mentioned variables evaluated on patient referral preference specialty. Of the 95 volunteers, 57.9% were female; mean age was 29.6 ± 3.3 years. The overall knowledge score of the OSAKA questionnaire was 9.85 ± 3.9 and for the OSAKA-KIDS questionnaire was 9.2 ± 4.9. In patients under 18 years of age, the most frequent referrals were from otolaryngology specialists (51.2%). The only factor which had positive significant effect on adult patient referral preference was source of obstructive sleep apnea knowledge during general physician taring (p < 0.001). Given the low awareness about OSA in candidates for the residency entrance exam and the high importance of this treatable disease, the need for comprehensive training courses during residency is warranted and the adequacy of sleep apnea education through all involved specialty during general physician education should be improved.

The Relationship between Obesity and Clinical Outcomes in Young People with Duchenne Muscular Dystrophy

Background: Duchenne muscular dystrophy (DMD) is a severe X-linked neuromuscular disorder. Young people with DMD have high rates of obesity. There is emerging evidence that a higher BMI may negatively affect clinical outcomes in DMD. This study aimed to explore the relationship between obesity and clinical outcomes in DMD. Methods: This was a retrospective clinical audit of young people (two–21 years) with DMD. Height and weight were collected to calculate BMI z-scores to classify obesity, overweight and no overweight or obesity (reference category). Cox proportional hazards models determined the impact of obesity at five to nine years on clinical milestones including time to: loss of ambulation, timed function test cut-offs, obstructive sleep apnoea (OSA) diagnosis and first fracture. Results: 158 young people with DMD were included; most (89.9%) were steroid-treated. Mean follow-up was 8.7 ± 4.7 years. Obesity prevalence increased from age five (16.7%) to 11 years (50.6%). Boys with obesity at nine years sustained a fracture earlier (hazard ratio, HR: 2.050; 95% CI: 1.038–4.046). Boys with obesity at six to nine years were diagnosed with OSA earlier (e.g., obesity nine years HR: 2.883; 95% CI: 1.481–5.612). Obesity at eight years was associated with a 10 m walk/run in 7–10 s occurring at an older age (HR: 0.428; 95% CI: 0.207–0.887), but did not impact other physical function milestones. Conclusions: Although 50% of boys with DMD developed early obesity, the impact of obesity on physical function remains unclear. Obesity puts boys with DMD at risk of OSA and fractures at a younger age. Early weight management interventions are therefore important.

Investigating differences in symptomatology and age at diagnosis of obstructive sleep apnea in children with and without autism

INTRODUCTION

Obstructive sleep apnea (OSA) is common in autism spectrum disorder (ASD). Children with OSA can present with a range of symptoms including loud snoring, excessive daytime sleepiness, and changes in cognitive function. Some of these symptoms can overlap with and exacerbate symptoms of ASD, potentially delaying OSA diagnosis in children with both conditions.

OBJECTIVE

The primary objective of this study was to assess between-group difference in OSA symptomatology and age at OSA diagnosis in children with and without ASD.

METHODS

A retrospective chart review was conducted on 166 pediatric patients (<18 years) with OSA undergoing adenotonsillectomy at a single academic institution between 2019 and 2021. The control group consisted of 91 patients (54.9% male) without ASD. The ASD group included 75 patients (88.0% male). Autism severity was scored on a 1-4 scale using a novel methodology. Statistical analyses included Wilcoxon rank sum tests for continuous variables, chi-squared tests for categorical variables, and multivariable analyses as needed.

RESULTS

There was a significant between-group difference in total number of reported OSA symptoms (p < 0.001), with more symptoms reported in patients with ASD. Within the ASD group, lower autism severity was associated with an increased number of reported OSA symptoms (p = 0.006). There was not a significant between-group difference in age at OSA diagnosis (p = 0.999); however, lower autism severity was associated with an increased age at diagnosis (p = 0.002).

CONCLUSION

These findings suggest that OSA may present with a higher symptom burden in children with ASD, particularly for children with lower ASD severity, who often experience delays in OSA diagnosis. These findings and their clinical implications merit further explanation.

Examining Associations Between Neighborhood-Level Social Vulnerability and Care for Children With Sleep-Disordered Breathing

OBJECTIVE

We aim to investigate the impact of neighborhood-level social vulnerability on otolaryngology care for children with obstructive sleep-disordered breathing (SDB).

STUDY DESIGN

Retrospective cohort study.

SETTING

A tertiary children's hospital.

METHODS

Children aged 2 to 17 years with SDB were included. Residential addresses were geocoded with geographic information systems, and spatial overlays were used to assign census tract-level social vulnerability index (SVI) scores to each participant. Multivariable logistic regression models were used to estimate associations of neighborhood SVI scores and individual factors with attendance of otolaryngology referral appointment and interventions.

RESULTS

The study included 397 patients (mean ± SD age, 5.9 ± 3.7 years; 51% male, n = 203). After adjustment for age and sex, children with higher overall SVI scores (odds ratio [OR], 0.40; 95% CI, 0.16-0.92) and higher socioeconomic vulnerability scores (OR, 0.34; 95% CI, 0.14-0.86) were less likely to attend their referral appointments. The odds of attending referrals were 83% lower (OR, 0.17; 95% CI, 0.09-0.34) for Black children and 73% lower (OR, 0.27; 95% CI, 0.11-0.65) for Hispanic children than for non-Hispanic White children. Medicaid beneficiaries had lower odds of attending their referrals (OR, 0.20; 95% CI, 0.08-0.48) than privately insured children. Overall SVI score was not associated with receiving recommended polysomnography or tonsillectomy.

CONCLUSION

In our study, children living in areas of greater social vulnerability were less likely to attend their otolaryngology referral appointments for SDB evaluation, as were children of Black race, Hispanic ethnicity, and Medicaid beneficiaries. These results suggest that neighborhood conditions, as well as patient-level factors, influence patient access to SDB care.

Trends in Diagnosing Obstructive Sleep Apnea in Pediatrics

Obstructive sleep apnea in children has been linked with behavioral and neurocognitive problems, impaired growth, cardiovascular morbidity, and metabolic consequences. Diagnosing children at a young age can potentially prevent significant morbidity associated with OSA. Despite the importance of taking a comprehensive sleep history and performing thorough physical examination to screen for signs and symptoms of OSA, these findings alone are inadequate for definitively diagnosing OSA. In-laboratory polysomnography (PSG) remains the gold standard of diagnosing pediatric OSA. However, there are limitations related to the attended in-lab polysomnography, such as limited access to a sleep center, the specialized training involved in studying children, the laborious nature of the test and social/economic barriers, which can delay diagnosis and treatment. There has been increasing research about utilizing alternative methods of diagnosis of OSA in children including home sleep testing, especially with the emergence of wearable technology. In this article, we aim to look at the presentation, physical exam, screening questionnaires and current different modalities used to aid in the diagnosis of OSA in children.

Impact of tonsillotomy versus tonsillectomy on health-related quality of life and healthcare costs in children with sleep-disordered breathing

Objective

This study aimed to explore health-related quality of life and use of healthcare services and ensuing costs before and after tonsillotomy in children with sleep-disordered breathing and to compare the results to an earlier cohort of children who had undergone tonsillectomy.

Method

Children undergoing tonsillotomy answered the 17-dimensional, standardised health-related quality of life instrument questionnaire and a questionnaire on use of healthcare services and sick leave before and after surgery. Costs of specialist care were obtained pre- and post-operatively. The data were compared with similar data collected previously from children with tonsillectomy.

Results

Tonsillotomy improved mean total health-related quality of life score significantly at 6 and 12 months. Healthcare costs and number of sick-leave days diminished significantly from 3 months pre-operatively to 12 months after surgery. Tonsillotomy had similar positive effects compared with tonsillectomy regarding health-related quality of life and healthcare costs.

Conclusion

Tonsillotomy improves health-related quality of life in children with sleep-disordered breathing and reduces healthcare service needs and sick leave similarly to tonsillectomy.

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.

Positional device therapy for the treatment of positional obstructive sleep apnea in children: a pilot study

BACKGROUND

There is a critical gap in identifying effective interventions for children with obstructive sleep apnea (OSA) who do not tolerate continuous positive airway pressure therapy. Positional OSA (POSA) is a common clinical phenotype whereby OSA occurs predominantly while sleeping in supine position. POSA may be amenable to treatment with a positional device, a belt worn around the chest with cushions on the back to prevent supine positioning, but no data exists in children. The primary aim of this study was to evaluate the efficacy of positional device therapy for the treatment of POSA in children.

METHODS

This observational study included children aged 4-18 years with POSA and an obstructive apnea-hypopnea index (OAHI) ≥ 5 events/hour on baseline polysomnogram (PSG) who underwent a second PSG to evaluate the efficacy of a positional device. The primary outcome was the change in OAHI.

RESULTS

Ten children were included (8 male, median age 11.2 years, median body mass index z-score 1.6). Compared to the baseline PSG, PSG data obtained while using a positional device showed a reduced median (interquartile range) OAHI (15.2 [8.3-25.6] versus 6.7 [1.0-13.7] events/hour respectively; p = 0.004) and percentage of total sleep time in supine position (54.4 [35.0-80.6]% versus 4.2 [1.1-25.2]% respectively; p = 0.04). Despite observed improvements in the oxygen desaturation index, these results were not statistically significant.

SIGNIFICANCE AND CONCLUSIONS

In this novel pilot study, positional device therapy was effective for the treatment of POSA. Positional device therapy may potentially change clinical practice as a cost-efficient and non-invasive treatment option for POSA.

Racial and Ethnic Disparities in Utilization of Tonsillectomy among Medicaid-Insured Children

OBJECTIVE

To examine racial differences in tonsillectomy with or without adenoidectomy (T&A) for sleep-disordered breathing (SDB) among Medicaid-insured children.

STUDY DESIGN

Retrospective analysis of the 2016 MarketScan Multistate Medicaid Database was performed for children ages 2 to <18 years with a diagnosis of SDB. Patients with medical complexity and infectious indications for surgery were excluded. Racial groups were categorized into non-Hispanic White, non-Hispanic Black, Hispanic, and other. Adjusted multivariate logistic regression was used to determine if race/ethnicity was a significant predictor of obtaining T&A, polysomnography, and time to intervention.

RESULTS

There were 83 613 patients with a diagnosis of SDB that met inclusion criteria, of which 49.2% were female with a mean age of 7.9 ± 3.8 years. The cohort consisted of White (49.2%), Black (30.0%), Hispanic (8.0%), and other (13.2%) groups. Overall, 15.4% underwent T&A. Black (82.2%) and Hispanic (82.3%) children had significantly higher rates of no intervention and White patients had the lowest rate of no intervention (76.9%; P < .0001) and the highest rate of T&A (18.7%; P < .0001). Mean time to surgery was shortest in White compared with Black children (P < .0001). Logistic regression adjusting for age and sex showed that Black children had 45% reduced odds of surgery (95% CI 0.53-0.58), Hispanic 38% (95% CI 0.58-0.68), and other 35% (95% CI 0.61-0.70) compared with White children with Medicaid insurance.

CONCLUSIONS

Racial and ethnic disparities exist in the utilization of T&A for children with SDB enrolled in Medicaid. Future studies that investigate possible sources for these differences and more equitable care are warranted.

Respiratory morbidity in very low birth weight infants through childhood and adolescence

OBJECTIVE

To describe the long-term (up to 18 years of age) respiratory outcomes of children and adolescents born at very low birth weight (VLBW; ≤1500 g) in comparison with that of children born >1500 g.

METHODS

An observational, longitudinal, retrospective study comparing VLBW infants with matched controls, registered at a large health maintenance organization in Israel. Pulmonary outcomes collected anonymously from the electronic medical files included respiratory illness diagnoses, purchased medications for respiratory problems, office visits with either a pediatric pulmonologist or cardiologist and composite respiratory morbidity combining all these parameters.

RESULTS

Our study included 5793 VLBW infants and 11,590 matched controls born between 1998 and 2012. The majority (99%) of VLBW infants were premature (born < 37 weeks' gestation), while 93% of controls were born at term. The composite respiratory morbidity was significantly higher in VLBW infants compared with controls in all age groups (relative risk [95% confidence interval]: 1 year: 1.22 [1.19-1.26], <2 years: 1.30 [1.27-1.34], 2-6 years: 1.29 [1.27-1.32], 6-12 years: 1.53 [1.47-1.59], 12-18 years: 1.46 [1.35-1.56]; respectively). Both VLBW infants and controls demonstrated a steady decline in the composite respiratory morbidity with aging. In VLBW infants, lower gestational age was associated with higher respiratory morbidity only until 2 years of age and the morbidity declined in each gestational age group until adolescence.

CONCLUSION

Our study confirmed a strong association between VLBW and pulmonary morbidity. The higher prevalence of respiratory composite morbidity in VLBW infants persists over the years until adolescence. The respiratory morbidity is most evident in the first year of life and declines afterward.

Small sleepers, big data: leveraging big data to explore sleep-disordered breathing in infants and young children

STUDY OBJECTIVES

Infants represent an understudied minority in sleep-disordered breathing (SDB) research and yet the disease can have a significant impact on health over the formative years of neurocognitive development that follow. Herein we report data on SDB in this population using a big data approach.

METHODS

Data were abstracted using the Cerner Health Facts database. Demographics, sleep diagnoses, comorbid medication conditions, healthcare utilization, and economic outcomes are reported.

RESULTS

In a cohort of 68.7 million unique patients, over a 9-year period, there were 9,773 infants and young children with a diagnosis of SDB (obstructive sleep apnea [OSA], nonobstructive sleep apnea, and "other" sleep apnea) who met inclusion criteria, encompassing 17,574 encounters, and a total of 27,290 diagnoses across 62 U.S. health systems, 172 facilities, and 3 patient encounter types (inpatient, clinic, and outpatient). Thirty-nine percent were female. Thirty-nine percent were ≤1 year of age (6,429 infants), 50% were 1-2 years of age, and 11% were 2 years of age. The most common comorbid diagnoses were micrognathia, congenital airway abnormalities, gastroesophageal reflux, chronic tonsillitis/adenoiditis, and anomalies of the respiratory system. Payor mix was dominated by government-funded entities.

CONCLUSIONS

We have used a novel resource, large-scale aggregate, de-identified EHR data, to examine SDB. In this population, SDB is multifactorial, closely linked to comorbid medical conditions and may contribute to a significant burden of healthcare costs. Further research focusing on infants at highest risk for SDB can help target resources and facilitate personalized management.

Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ*) into Brazilian Portuguese

INTRODUCTION

Obstructive sleep apnea is a frequent entity in childhood that can lead to important consequences for the health and children's quality of live. Polysomnography is the gold-standard exam to diagnose obstructive sleep apnea, but it is expensive, complex, and poorly affordable in Brazil. The pediatric sleep questionnaire has shown to be a valuable screening test for obstructive sleep apnea. It is a simple questionnaire with good sensitivity and specificity compared to polysomnography in the countries where it has been validated.

OBJECTIVE

Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ), into Brazilian Portuguese.

METHODS

The translation of the PSQ into Brazilian Portuguese was carried out in accordance with good practices. The validated and adapted questionnaire was applied to parents/caregivers of 60 children (40 of them with obstructive sleep apnea and 20 controls) aged 2-18 years. Retest was applied to 30 children with obstructive sleep apnea. The following tests were performed: internal consistency, test-retest, validation of questionnaire (the latter by ROC curve).

RESULTS

Brazilian PSQ has shown high internal consistency by Cronbach's alpha (0.86 for the total test, 0.83 for subscale "snoring", 0.64 for "sleepiness" and 0.65 for "behavior"). Test-retest presented a correlation of 0.89 for subscale "snoring", 0.93 for "sleepiness" and 0.86 for "behavior". Accuracy by ROC curve was 0.99. Nine was considered the optimal value to discriminate patients with obstructive sleep apnea from controls, with a sensitivity of 0.92 and specificity of 1.0.

CONCLUSION

The translation and cross-cultural adaptation of the PSQ into Brazilian Portuguese proved to be successful. In places with difficult access to polysomnography, PSQ can be a useful tool in screening and follow-up of children with obstructive sleep apnea.

Adenotonsillectomy as a treatment for sleep-disordered breathing in children with ADHD

Sleep-disordered breathing (SDB) and attention deficit hyperactivity disorder (ADHD) are common disorders diagnosed in children. Although these diagnoses were previously considered unrelated, research now is showing that some symptoms of ADHD, specifically oppositional behavior, hyperactivity, and impulsivity, can be related to SDB in children and differs from bona fide ADHD. This article explores the connection between the two disorders and the importance of identifying and screening for SDB in children presenting with similar symptoms related to ADHD. The article also examines symptom improvement in patients with ADHD symptoms after an adenotonsillectomy, one of the first-line treatments for children diagnosed with SDB; this procedure may reduce the need for long-term stimulant use in some children with ADHD.

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

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

OBJECTIVE

Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy.

STUDY DESIGN

Cross-sectional study.

SETTING

Health claims database from a third-party payer.

METHODS

Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression.

RESULTS

A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types (P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time (P = .98).

CONCLUSION

A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

Diagnosis and management of childhood sleep-disordered breathing. Clinical approach

Sleep-disordered breathing (SDB) includes disorders of breathing that affect airway patency, which impair children's sleep and lead to negative consequences. Obstructive sleep apnea, hypoventilation and upper airway resistance syndrome are common causes of morbidity and mortality in childhood. These clinical practice guidelines, intended for use by pediatricians and primary care clinicians, provide a clear recommendation for the diagnosis and management of sleep-disordered breathing, focusing on the most serious disorder, obstructive sleep apnea syndrome (OSAS). These clinical guidelines formulate clear recommendations to identify patients with suspected OSAS. Further, the manuscript will highlight the potential consequences of SBD in children, and how to overcome such difficulties, what could be the therapeutic options, a 12 recommendations and what are the future direction for pediatric sleep medicine.

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.

Long-term Impact of Adenotonsillectomy on the Quality of Life of Children with Sleep-disordered breathing

Introduction  Adenotonsillectomy is the first-line treatment for obstructive sleep apnea secondary to adenotonsillar hypertrophy in children. The physical benefits of this surgery are well known as well as its impact on the quality of life (QoL), mainly according to short-term evaluations. However, the long-term effects of this surgery are still unclear.

Objective  To evaluate the long-term impact of adenotonsillectomy on the QoL of children with sleep-disordered breathing (SDB).

Method  This was a prospective non-controlled study. Children between 3 and 13 years of age with symptoms of SDB for whom adenotonsillectomy had been indicated were included. Children with comorbities were excluded. Quality of life was evaluated using the obstructive sleep apnea questionnaire (OSA-18), which was completed prior to, 10 days, 6 months, 12 months and, at least, 18 months after the procedure. For statistical analysis, p -values lower than 0.05 were defined as statistically significant.

Results  A total of 31 patients were enrolled in the study. The average age was 5.2 years, and 16 patients were male. The OSA-18 scores improved after the procedure in all domains, and this result was maintained until the last evaluation, done 22 ± 3 months after the procedure. Improvement in each domain was not superior to achieved in other domains. No correlation was found between tonsil or adenoid size and OSA-18 scores.

Conclusion  This is the largest prospective study that evaluated the long-term effects of the surgery on the QoL of children with SDB using the OSA-18. Our results show adenotonsillectomy has a positive impact in children's QoL.

Psychometric Properties and Predictive Value of a Screening Questionnaire for Obstructive Sleep Apnea in Young Children With Down Syndrome

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is common in children with Down syndrome (DS) and is associated with adverse health and cognitive outcomes. Daytime clinical assessment is poorly predictive of OSA, so regular screening with sleep studies is recommended. However, sleep studies are costly and not available to all children worldwide. We aimed to evaluate the psychometric properties and predictive value of a newly developed screening questionnaire for OSA in this population.

METHODS

202 children aged 6 months to 6^th birthday with DS were recruited, of whom 188 completed cardio-respiratory sleep studies to generate an obstructive apnea hypopnea index (OAHI). Parents completed the 14-item Down syndrome OSA screening questionnaire. Responses were screened, a factor analysis undertaken, internal consistency calculated and receiver operator characteristic (ROC) curves drawn to generate an area under the curve (AUC) to assess criterion related validity.

RESULTS

Of 188 children who completed cardiorespiratory sleep studies; parents completed the screening questionnaire for 186. Of this study population 15.4% had moderate to severe OSA defined by an OAHI of ≥5/h. Sixty-three (33.9%) participants were excluded due to "unsure" responses or where questions were not answered. Using the remaining 123 questionnaires a four-factor solution was found, with the 1^st factor representing breathing related symptoms, explaining a high proportion of the variance. Internal consistency was acceptable with a Cronbach alpha of 0.87. ROC curves for the total score generated an AUC statistic of 0.497 and for the breathing subscale an AUC of 0.603 for moderate to severe OSA.

CONCLUSION

A well designed questionnaire with good psychometric properties had limited predictive value to screen for moderate to severe OSA in young children with DS. The use of a screening questionnaire is not recommended. Screening for OSA in this population requires objective sleep study measures.

Clinical Practice Guideline: Tonsillectomy in Children (Update)

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

(1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.

Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.

Polysomnography Parameters Assessing Gas Exchange Best Predict Postoperative Respiratory Complications Following Adenotonsillectomy in Children With Severe OSA

STUDY OBJECTIVES

Adenotonsillectomy (AT) is the treatment of choice for obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy. Severe OSA, identified by the apnea-hypopnea index (AHI), is a risk factor for surgical complications and AHI thresholds are used by surgeons to decide elective postoperative hospital admissions. The objective of this study was to identify the prevalence of surgical complications of AT in children with severe OSA and determine their association with specific parameters of polysomnography (PSG).

METHODS

Retrospective evaluation of respiratory and nonrespiratory complications in children undergoing AT for severe OSA was performed. Events were then compared to several individual PSG indices. PSG indices included classic parameters such as AHI, and obstructive apnea indexes (OAI) as well as gas exchange parameters including the oxygen desaturation index (ODI), lowest oxyhemoglobin saturation (lowest SpO₂), peak end-tidal CO₂ (peak ETCO₂), the percentage of the total sleep time (%TST) with ETCO₂ > 50 mmHg (%TST ETCO₂ > 50 mmHg) and oxygen saturation < 90% (%TST O₂ < 90%).

RESULTS

A total of 158 children were identified with severe OSA. Major respiratory complications occurred in 21.5% and were only associated with the ODI (P = .014), lowest SpO₂ (P = .001) and %TST O₂ < 90% (P < .001). Minor respiratory complications occurred in 19.6% and these were not associated with any PSG parameters. Major nonrespiratory complications occurred in 4.4% and also were not associated with any PSG parameters; however, minor nonrespiratory complications occurring in 37.3%, and were associated with %TST O₂ < 90% (P < 0.001).

CONCLUSIONS

PSG measures of gas exchange are strongly associated with postoperative complications of AT and are better suited for postoperative planning than classic indices such as AHI.

CITATION

Molero-Ramirez H, Tamae Kakazu M, Baroody F, Bhattacharjee R. Polysomnography parameters assessing gas exchange best predict postoperative respiratory complications following adenotonsillectomy in children with severe OSA. J Clin Sleep Med. 2019;15(9):1251-1259.

Caregiver support and positive airway pressure therapy adherence among adolescents with obstructive sleep apnea

Introduction

Positive airway therapy (PAP) adherence rates are suboptimal among adolescents with obstructive sleep apnea (OSA) and strategies to increase PAP adherence is a clinical priority. This study evaluates if caregiver support is associated with PAP adherence rates among adolescents with OSA.

Methods

We conducted a retrospective study and evaluated PAP adherence rates among adolescents with OSA from 2012 to 2017. Adherence was measured as continuous variables: average PAP usage (minutes per night) and average PAP usage >4 hours/night (% of all nights). We evaluated if adolescents with OSA who were receiving practical caregiver support with PAP had higher adherence than adolescents with OSA without caregiver support.

Results

One hundred and seven adolescents with OSA (mean age=14.1±2.5 years, 64.5% male, mean BMI percentile=89.0±21.8) seen between January 2012 and August 2017 at our institution were included. In this study, 60.7% (n=65) of adolescents with OSA were receiving practical caregiver support with PAP therapy. Adolescents with OSA receiving practical caregiver support with PAP used therapy for a significantly greater duration each night compared to adolescents who were not receiving practical caregiver support (298.5±206.7 versus 211.9±187.2 minutes; P=0.02). Greater time since the initial PAP prescription was independently associated with PAP adherence.

Conclusion

Focusing on PAP adherence early may help adolescents with OSA incorporate therapy into their nightly routine, which may improve adherence and lead to improved health outcomes in adolescents with OSA. Practical caregiver support may be an essential component of ensuring optimal PAP adherence among adolescents with OSA.

Positive airway pressure in pediatric obstructive sleep apnea

Obstructive sleep apnea (OSA) is characterized by snoring, recurrent obstruction (apneas) of the upper airway which disrupts normal ventilation during sleep. In the last decade, there has been a increase in children diagnosed with persistent, severe OSA attributed to (1) the obesity epidemic as 25-60% of obese children will have obesity related OSA (2) advances in medical technology that have increased life expectancy of medically complex children (3) improved diagnostics and (4) increased awareness. Positive airway pressure (PAP) is commonly used to treat persistent, severe OSA. PAP devices deliver pressurized air via nasal or oronasal interfaces to distend the upper airway and ameliorate OSA. Although effective in treating OSA, PAP adherence is suboptimal. This review article provides an overview of (1) PAP use in pediatric OSA (2) PAP devices (3) PAP adherence, (4) strategies and interventions to improve adherence and (5) Optimizing PAP delivery during pediatric to adult transition.

The Feasibility and Utility of Level III Portable Sleep Studies in the Pediatric Inpatient Setting

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) may significantly impact the course of medical illness in hospitalized children. Polysomnography (PSG) is the gold standard for establishing diagnosis of SDB, but its availability is limited. The aim of this study was to explore the feasibility and utility of level III portable sleep studies in hospitalized children with SDB.

METHODS

A retrospective study was conducted at a tertiary hospital over the preceding 2 years in hospitalized children < 18 years who had undergone a level III sleep study using the Nox T3 system. The information obtained included demographic data, comorbidities, indication for admission and sleep study, time interval between the study ordered and done, adequacy of technical data from sleep study, study diagnosis, and subsequent management interventions for SDB.

RESULTS

A total of 51 hospitalized children had these studies; 32 were female and mean age was 4.3 years. Approximately 90% of children had significant comorbidities, including neurological and craniofacial abnormalities. The majority (80%) of studies were conducted within 24 hours of the time requested and 92.1% studies had technically adequate data for analysis. Thirty-nine (76.5%) children were identified with SDB; all but one patient underwent therapy for SDB during that same hospitalization, including supplemental oxygen (48.7%), positive airway pressure therapy (23%), surgical intervention (38.2%) or caffeine (10.2%). Twelve percent of children had more than one intervention done.

CONCLUSIONS

The level III portable sleep study is readily available, sufficient to diagnose SDB, and help to provide appropriate medical and/or surgical therapies in hospitalized children with complex medical conditions.

Sleep-Disordered Breathing Is Associated with Reduced Mandibular Cortical Width in Children

INTRODUCTION

Evidence from the adult population suggests that sleep-disordered breathing (SDB) (i.e., obstructive sleep apnea [OSA]) is negatively associated with bone mineral density. Whether a similar association exists in children with SDB has not been investigated. Using the mandibular cortical width (MCW) as a proxy for skeletal bone density, we investigated if children at risk of SDB or diagnosed with OSA have a reduced mandibular cortical width compared to children without SDB.

METHODS

Two retrospective cross-sectional studies were performed. The first study included comparison of MCW between 24 children with polysomnographically (PSG) diagnosed OSA and 72 age- and sex-matched control children. The second study included a cohort of children in which SDB was suggested by the Pediatric Sleep Questionnaire (PSQ) ( n = 101). MCW was measured from panoramic radiographs.

RESULTS

Multiple-predictors regression analysis from the first study indicated that in children with a severe form of SDB, as induced by OSA severity, there was a negative association with MCW (β = -0.290, P = 0.049). Moreover, PSG-diagnosed OSA children had thinner MCW (2.9. ± 0.6mm) compared to healthy children (3.5 ± 0.6 mm; P = 0.002). These findings were further supported by the second study illustrating that PSQ total scores were negatively associated with MCW (β = -0.391, P < 0.001).

CONCLUSIONS

Findings suggest that children at risk for or diagnosed with SDB exhibit reduced mandibular cortical width that purportedly may reflect alterations in bone homeostasis.

KNOWLEDGE TRANSFER STATEMENT

We report that sleep-disordered breathing (including its severe form, obstructive sleep apnea) in children is associated with reduced mandibular cortical width. This association might be a direct consequence of reduced bone health to sleep-disordered breathing or a reflection that reduced bone formation underlies the development of sleep-disordered breathing. Our findings suggest that mandibular cortical width can be used as an adjunct diagnostic parameter for the diagnosis of sleep-disordered breathing.

Characterizing pediatric inpatient sleep duration and disruptions

OBJECTIVE

To contextualize inpatient sleep duration and disruptions in a general pediatric hospital ward by comparing in-hospital and at-home sleep durations to recommended guidelines and to objectively measure nighttime room entries.

METHODS

Caregivers of patients four weeks - 18 years of age reported patient sleep duration and disruptions in anonymous surveys. Average at-home and in-hospital sleep durations were compared to National Sleep Foundation recommendations. Objective nighttime traffic was evaluated as the average number of room entries between 11:00pm and 7:00am using GOJO brand hand-hygiene room entry data.

RESULTS

Among 246 patients, patients slept less in the hospital than at home with newborn and infant cohorts experiencing 7- and 4-h sleep deficits respectively (Newborn: 787 ± 318 min at home vs. 354 ± 211 min in hospital, p < 0.001; Infants: 703 ± 203 min at home vs. 412 ± 152 min in hospital, p < 0.01). Newborn children also experienced >2 h sleep deficits at home when compared to NSF recommendations (Newborns: 787 ± 318 min at home vs. 930 min recommended, p < 0.05). Objective nighttime traffic measures revealed that hospitalized children experienced 7.3 room entries/night (7.3 ± 0.25 entries). Nighttime traffic was significantly correlated with caregiver-reported nighttime awakenings (Spearman Rank Correlation Coefficient: 0.83, p < 0.001).

CONCLUSION

Hospitalization is a missed opportunity to improve sleep both in the hospital and at home.

The Accuracy of an Ambulatory Level III Sleep Study Compared to a Level I Sleep Study for the Diagnosis of Sleep-Disordered Breathing in Children With Neuromuscular Disease

STUDY OBJECTIVES

Polysomnography (PSG) surveillance recommendations are not being met for children with neuromuscular disease (NMD) because of limited diagnostic facilities. We evaluated the diagnostic accuracy of an ambulatory level III device as compared to a level I PSG.

METHODS

A cross-sectional study was conducted at a tertiary pediatric institution. Eligibility criteria included: (1) children with NMD; (2) age 6 to 18 years; (3) booked for a clinically indicated overnight level I PSG. Participants were randomized to an overnight level I PSG followed by an ambulatory level III study with end tidal carbon dioxide (etCO₂) or vice versa. Sensitivity and specificity of the ambulatory level III device to diagnose sleep-disordered breathing (SDB) at an apnea-hypopnea index (AHI) cutoff of > 1.0 events/h was the primary outcome.

RESULTS

Moderate to severe SDB was found in 46% of participants (13/28). The device's sensitivity and specificity to detect SDB was 61.5% and 86.7%, respectively. The positive predictive value of the level III study was 80.0% and the negative predictive value was 72.0%. Fifty percent of the cohort were either missing or had incomplete or falsely low ambulatory etCO₂ data.

CONCLUSIONS

A level III device with etCO₂ is not yet able to be implemented in clinical practice as a diagnostic tool for SDB in pediatric patients with NMD.

COMMENTARY

A commentary on this article appears in this issue on page 1973.

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.

Abnormal Growth and Feeding Behavior in Upper Airway Obstruction in Rats

Pediatric obstructive sleep apnea (OSA) is a syndrome manifesting with snoring and increased respiratory effort due to increased upper airway resistance. In addition to cause the abnormal sleep, this syndrome has been shown to elicit either growth retardation or metabolic syndrome and obesity. Treating OSA by adenotonsillectomy is usually associated with increased risk for obesity, despite near complete restoration of breathing and sleep. However, the underlying mechanism linking upper airways obstruction (AO) to persistent change in food intake, metabolism, and growth remains unclear. Rodent models have examined the impact of intermittent hypoxia on metabolism. However, an additional defining feature of OSA that is not related to intermittent hypoxia is enhanced respiratory loading leading to increased respiratory effort and abnormal sleep. The focus of this mini review is on recent evidence indicating the persistent abnormalities in endocrine regulation of feeding and growth that are not fully restored by the chronic upper AO removal in rats. Here, we highlight important aspects related to abnormal regulation of metabolism that are not related to intermittent hypoxia per se, in an animal model that mimics many of the clinical features of pediatric OSA. Our evidence from the AO model indicates that obstruction removal may not be sufficient to prevent the post-removal tendency for abnormal growth.

Adenotonsillectomy for Obstructive Sleep Apnea in Children with Complex Chronic Conditions

Objective To estimate the prevalence of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Study Design A retrospective cohort study. Setting The Hospital for Sick Children Sleep laboratory. Subjects Children ≤18 years of age who had moderate to severe obstructive sleep apnea and had polysomnography pre- and postadenotonsillectomy. Methods Medical and polysomnographic data were reviewed. The prevalence of persistent obstructive sleep apnea postadenotonsillectomy was determined for the following groups: no complex chronic conditions, single-system complex chronic conditions, and multisystem complex chronic conditions. Results We reviewed data of 133 (84 male) children. Their mean (standard deviation) age was 5.5 (3.8) years. The persistent obstructive sleep apnea rate postadenotonsillectomy was highest in children with multisystem complex chronic conditions (57%), intermediate in children with single-system complex chronic conditions (29%), and lowest in children without complex chronic conditions (15%), P = .0004. The odds (confidence interval) of having persistent obstructive sleep apnea postadenotonsillectomy was 7.42 (2.16-25.51) times higher in children with multisystem complex chronic conditions vs no complex chronic conditions and 3.35 (1.16-9.64) times higher in children with multisystem complex chronic conditions vs single-system complex chronic conditions. Conclusions Although adenotonsillectomy is considered first-line therapy in healthy children older than 2 years for the treatment of obstructive sleep apnea, there is a significantly greater risk of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Therefore, other surgical procedures or nonsurgical management may need to be considered as first-line treatment for this cohort.

Financial Analysis of an Intensive Pediatric Continuous Positive Airway Pressure Program

Study Objectives

Continuous positive airway pressure (CPAP) is effective in treating obstructive sleep apnea in children, but adherence to therapy is low. Our center created an intensive program that aimed to improve adherence. Our objective was to estimate the program's efficacy, cost, revenue and break-even point in a generalizable manner relative to a standard approach.

Methods

The intensive program included device consignment, behavioral psychology counseling, and follow-up telephone calls. Economic modeling considered the costs, revenue and break-even point. Costs were derived from national salary reports and the Pediatric Health Information System. The 2015 Medicare reimbursement schedule provided revenue estimates.

Results

Prior to the intensive CPAP program, only 67.6% of 244 patients initially prescribed CPAP appeared for follow-up visits and only 38.1% had titration polysomnograms. In contrast, 81.4% of 275 patients in the intensive program appeared for follow-up visits (p < .001) and 83.6% had titration polysomnograms (p < .001). Medicare reimbursement levels would be insufficient to cover the estimated costs of the intensive program; break-even points would need to be 1.29-2.08 times higher to cover the costs.

Conclusions

An intensive CPAP program leads to substantially higher follow-up and CPAP titration rates, but costs are higher. While affordable at our institution due to the local payer mix and revenue, Medicare reimbursement levels would not cover estimated costs. This study highlights the need for enhanced funding for pediatric CPAP programs, due to the special needs of this population and the long-term health risks of suboptimally treated obstructive sleep apnea.