Effect of Sleep-disordered Breathing Severity on Cognitive Performance Measures in a Large Community Cohort of Young School-aged Children

Undergraduate dental sleep medicine teaching at German university dental schools - a questionnaire-based survey

PURPOSE

Diagnosing and treating obstructive sleep apnea (OSA) requires fundamental understanding of sleep medicine, including training and clinical experience. So far, dental sleep medicine (DSM) has not yet become a mandatory part of dental education in Germany. This questionnaire-based survey for both lecturers and students aimed to evaluate DSM education among undergraduate students.

METHODS

A structured questionnaire was sent to the managing directors and student councils of all 30 German university dental schools. The questionnaire contained 13 questions on teaching quantity and content, lecturers' knowledge, and future interest in DSM. For each university dental school, only one questionnaire should be completed by the student council and the managing director. A scoring system assessed lecturers' knowledge based on clinical experience and qualifications. Descriptive data and correlation coefficients were calculated (P < 0.05).

RESULTS

The responses of 24 lecturers (80%) and 28 students (93.3%) could be evaluated. DSM was reported to be included in the curriculum by 14 lecturers (58.3%) and 4 students (14.3%). Mean teaching hours per semester were 1.4 ± 1.4 h (lecturers) and 0.2 ± 0.6 h (students) accordingly. Greater knowledge of lecturers in DSM was positively correlated with the inclusion of DSM in the curriculum (P = 0.022) and with the number of teaching hours per semester (P = 0.001).

CONCLUSION

Postgraduate education and incorporating DSM knowledge into undergraduate education ("Teach the Teacher") seems to play a key role in fundamentally training future dentists in this field.

Respiratory and Neurodevelopmental Outcomes at 3 Years of Age of Neonates Diagnosed with Sleep-Disordered Breathing

Objectives: Understanding the long-term consequences of sleep-disordered breathing (SDB) in neonates is crucial. A lack of consensus on diagnostic and treatment thresholds has resulted in limited research in this area. Our study aims to describe the trajectory of SDB in a cohort of high-risk neonates and their respiratory and neurodevelopmental outcomes at 3 years of age, and explore the relationship between SDB during early infancy and neurocognitive outcomes. Methods: A retrospectively identified cohort of neonates with moderate-severe SDB were prospectively followed at 3 years of age. Data collected included last polysomnography (PSG) parameters up to the age of 3 years and sleep physician's recommendations, duration of CPAP use, compliance with treatment, timing of SDB resolution, and neurodevelopmental outcomes. Univariate and multivariate logistic regression analyses were performed to evaluate the association between important respiratory and sleep breathing parameters with the developmental outcomes. Results: Eighty neonates were included. Respiratory and developmental outcomes were available for 58 (72.5%) and 56 (70%) patients, respectively. In most patients (47/58, 81%), SDB had resolved by 3 years of age. Survival without major developmental delay was seen in 32/56 (57%), but a significant proportion (21/56, 37.5%) demonstrated global developmental delay. Following univariate analysis, primary diagnosis, apnoea-hypopnoea index (AHI) at the time of last PSG and SDB outcome was significantly associated with developmental delay. However, these associations were not seen in multivariate analysis. Conclusions: Despite severity at baseline, SDB resolved in the majority of patients with time and treatment. Although statistically insignificant, logistic regression analysis identified some clinically important associations between neonatal SDB and neurodevelopmental outcomes.

Associations between indoor fine particulate matter (PM2.5) and sleep-disordered breathing in an urban sample of school-aged children

OBJECTIVES

Environmental risk factors may contribute to sleep-disordered breathing. We investigated the association between indoor particulate matter ≤2.5µm in aerodynamic diameter (PM2.5) and sleep-disordered breathing in children in an urban US community.

METHODS

The sample consisted of children aged 6-12years living in predominantly low-income neighborhoods in Boston, Massachusetts. Indoor PM2.5 was measured in participants' main living areas for 7days using the Environmental Multipollutant Monitoring Assembly device. High indoor PM2.5 exposure was defined as greater than the sample weekly average 80th percentile level (≥15.6 μg/m3). Sleep-disordered breathing was defined as an Apnea-Hypopnea-Index (AHI) or Oxygen-Desaturation-Index (ODI) (≥3% desaturation) of ≥5 events/hour. Habitual loud snoring was defined as caregiver-report of loud snoring (most or all the time each week) over the past 4weeks. We examined the associations of PM2.5 with sleep-disordered breathing or snoring using logistic regression adjusting for potential confounders.

RESULTS

The sample included 260 children (mean age 9.6years; 41% female), with 32% (n = 76) classified as having sleep-disordered breathing. In a logistic regression model adjusted for socioeconomics and seasonality, children exposed to high indoor PM2.5 levels (n = 53) had a 3.53-fold increased odds for sleep-disordered breathing (95%CI: 1.57, 8.11, p = .002) compared to those with lower indoor PM2.5. This association persisted after additional adjustments for physical activity, outdoor PM2.5, environmental tobacco smoke, and health characteristics. Similar associations were observed for snoring and indoor PM2.5. CONCLUSIONS: Children with higher indoor PM2.5 exposure had greater odds of sleep-disordered breathing and habitual loud snoring, suggesting that indoor air quality contributes to sleep disparities.

Analysis of mandibular jaw movements to assess ventilatory support management of children with obstructive sleep apnea syndrome treated with positive airway pressure therapies

BACKGROUND

The polysomnography (PSG) is the gold-standard for obstructive sleep apnea (OSA) syndrome diagnosis and assessment under positive airway pressure (PAP) therapies in children. Recently, an innovative digital medicine solution, including a mandibular jaw movement (MJM) sensor coupled with automated analysis, has been validated as an alternative to PSG for pediatric application.

OBJECTIVE

This study aimed to assess the reliability of MJM automated analysis for the assessment of residual apnea/hypopnea events during sleep in children with OSA treated with noninvasive ventilation (NIV) or continuous PAP (CPAP).

METHODS

In this open-label prospective non-randomized multicentric trial, we included children aged from 5 to 18 years with a diagnosis of severe OSA. The children underwent in-laboratory PSG with simultaneous MJM monitoring and at-home recording with MJM monitoring 3 months later. Agreement between PSG and MJM analysis in measuring the residual apnea-hypopnea index (AHI) was evaluated by the Bland-Altman method. The treatment effect on residual AHI was estimated for both PSG and MJM analysis.

RESULTS

Fifteen (60% males) children were included with a median age of 12 years [interquartile range 8-15]. Two (17%) were ventilated with NIV and 13 (83%) with CPAP. There was a good agreement between MJM-AHI and PSG-AHI with a median bias of -0.25 (95% CI: -3.40 to +2.04) events/h. The reduction in AHI under treatment was consistently significant across the three measurement methods: in-laboratory PSG and MJM recordings in the laboratory and at home.

CONCLUSION

Automated analysis of MJM is a highly reliable alternative method to assess residual events in a small population treated with PAP therapies.

Role of High Flow Nasal Cannula as a Novel Therapy for Treatment of Severe Obstructive Sleep Apnea in a Child With Neuroendocrine Hyperplasia of Infancy: A Case Report and Review of Literature

Neuroendocrine hyperplasia of infancy is a rare form of pediatric interstitial lung disease presenting with hypoxemia, tachypnea, retractions, and persistent pulmonary crackles in the first year of life. As these children frequently require supplemental oxygen therapy and demonstrate nighttime hypoxemia, there is a concern for an increased prevalence of sleep-disordered breathing in this population, including obstructive sleep apnea. As untreated sleep-disordered breathing is associated with adverse developmental outcomes for children, it is essential to promptly diagnose and treat. However, treatment of obstructive sleep apnea is often challenging in children. In this report, we describe a case of a child diagnosed with neuroendocrine hyperplasia of infancy at 12 months of age who was subsequently found to have severe obstructive sleep apnea that persisted despite adenotonsillectomy. As continuous positive airway pressure was not well tolerated, the patient was initiated on a high-flow nasal cannula at nighttime, which resulted in improvement of his sleep apnea and daytime functioning with better adherence to treatment. Our case illustrates the importance of screening for sleep-disordered breathing in patients with neuroendocrine hyperplasia of infancy, as well as the utility of a high-flow nasal cannula as a novel, effective treatment for pediatric obstructive sleep apnea.

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.

Risk factors of sleep-disordered breathing and poor asthma control in children with asthma

BACKGROUND

Sleep-disordered breathing (SDB) may lead to poor asthma control in children.

OBJECTIVE

To identify risk factors of SDB in children with asthma and assess its impact on asthma control.

METHODS

In this cross-sectional study, we collected data of outpatients with asthma at the Children's Hospital of Chongqing Medical University from June 2020 to August 2021. The Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder and the age-appropriate asthma control tests Childhood Asthma Control Test and Test for Respiratory and Asthma Control in Kids were completed.

RESULTS

We enrolled 397 children with a male-to-female ratio of 1.7:1 and a mean age of 5.70 ± 2.53 years. The prevalence of SDB was 21.6%. Allergic rhinitis (odds ratio OR = 3.316), chronic tonsillitis (OR = 2.246), gastroesophageal reflux (OR = 7.518), adenoid hypertrophy (OR = 3.479), recurrent respiratory infections (OR = 2.195), and a family history of snoring (OR = 2.048) were risk factors for the development of combined SDB in children with asthma (p < 0.05). Asthma was poorly controlled in 19.6% of the children. SDB (OR = 2.391) and irregular medication use (OR = 2.571) were risk factors for poor asthma control (p < 0.05).

CONCLUSIONS

Allergic rhinitis, chronic tonsillitis, gastroesophageal reflux, adenoid hypertrophy, recurrent respiratory infections, and a family history of snoring were independent risk factors for the development of SDB in children with asthma. SDB and irregular medication use were independent risk factors for poor asthma control.

A rat model of adenoid hypertrophy constructed by using ovalbumin and lipopolysaccharides to induce allergy, chronic inflammation, and chronic intermittent hypoxia

BACKGROUND

Adenoid hypertrophy (AH) is a common pediatric disease that significantly impacts the growth and quality of life of children. However, there is no replicable and valid model for AH.

METHODS

An AH rat model was developed via comprehensive allergic sensitization, chronic inflammation induction, and chronic intermittent hypoxia (CIH). The modeling process involved three steps: female Sprague-Dawley rats (aged 4-5 weeks) were used for modeling. Allergen sensitization was induced via intraperitoneal administration and intranasal provocation using ovalbumin (OVA); chronic nasal inflammation was induced through intranasal lipopolysaccharide (LPS) administration for sustained nasal irritation; CIH akin to obstructive sleep apnea/hypopnea syndrome was induced using an animal hypoxia chamber. Postmodel establishment, behaviors, and histological changes in nasopharynx-associated lymphoid tissue (NALT) and nasal mucosa were assessed. Arterial blood gas analysis and quantification of serum and tissue levels of (interleukin) IL-4 and IL-13, OVA-specific immunoglobulin E (sIgE), eosinophil cationic protein (ECP), tumor necrosis factor (TNF-α), IL-17, and transforming growth factor (TGF)-β were conducted for assessment. The treatment group received a combination of mometasone furoate and montelukast sodium for a week and then was evaluated.

RESULTS

Rats exhibited notable nasal symptoms and hypoxia after modeling. Histopathological analysis revealed NALT follicle hypertrophy and nasal mucosa inflammatory cell infiltration. Elevated IL-4, IL-13, IL-17, OVA-sIgE, ECP, and TNF-α levels and reduced TGF-β levels were observed in the serum and tissue of model-group rats. After a week of treatment, the treatment group exhibited symptom and inflammatory factor improvement.

CONCLUSION

The model effectively simulates AH symptoms and pathological changes. But it should be further validated for genetic, immunological, and hormonal backgrounds in the currently used and other strains and species.

Pharmacological interventions for pediatric obstructive sleep apnea (OSA): Network meta-analysis

IMPORTANCE

Pediatric obstructive sleep apnea (OSA) is a common disease that can have significant negative impacts on a child's health and development. A comprehensive evaluation of different pharmacologic interventions for the treatment of OSA in children is still lacking.

OBJECTIVE

This study aims to conduct a comprehensive systematic review and network meta-analysis of pharmacological interventions for the management of obstructive sleep apnea in pediatric population.

DATA SOURCES

PubMed, Web of Science, Embase, The Cochrane Library, and CNKI were searched from 1950 to November 2022 for pediatric OSA.

STUDY SELECTION

Multiple reviewers included Randomized controlled trials (RCTs) concerning drugs on OSA in children.

DATA EXTRACTION AND SYNTHESIS

Multiple observers followed the guidance of the PRISMA NMA statement for data extraction and evaluation. Bayesian network meta-analyses(fixed-effect model) were performed to compare the weighted mean difference (WMD), logarithmic odds ratios (log OR), and the surface under the cumulative ranking curves (SUCRA) of the included pharmacological interventions. Our protocol was registered in PROSPERO website (CRD42022377839).

MAIN OUTCOME(S) AND MEASURE(S)

The primary outcomes were improvements in the apnea/hypopnea index (AHI), while secondary outcomes included adverse events and the lowest arterial oxygen saturation (SaO2).

RESULTS

17 RCTs with a total of 1367 children with OSA aged 2-14 years that met the inclusion criteria were eventually included in our systematic review and network meta-analysis. Ten drugs were finally included in the study. The results revealed that Mometasone + Montelukast (WMD-4.74[95%CrIs -7.50 to -2.11], Budesonide (-3.45[-6.86 to -0.15], and Montelukast(-3.41[-5.45 to -1.39] exhibited significantly superior therapeutic effects compared to the placebo concerning apnea hypopnea index (AHI) value with 95%CrIs excluding no effect. Moreover, Mometasone + Montelukast achieved exceptionally high SUCRA values for both AHI (85.0 %) and SaO2 (91.0 %).

CONCLUSIONS AND RELEVANCE

The combination of mometasone furoate nasal spray and oral montelukast sodium exhibits the highest probability of being the most effective intervention. Further research is needed to investigate the long-term efficacy and safety profiles of these interventions in pediatric patients with OSA.

Effect of sleep disordered breathing severity in children with Down syndrome on parental wellbeing and social support

INTRODUCTION

Sleep disorders, particularly sleep disordered breathing (SDB), are common in children with Down syndrome (DS). We investigated the relationship between SDB severity and parental psychological wellbeing and their perception of social support.

METHODS

44 children with DS (3-19 years) underwent overnight polysomnography and were categorised into three groups: primary snoring, Mild and Moderate/Severe obstructive sleep apnoea (OSA). Parents completed questionnaires about their child's behaviour (Child Behavior Checklist), sleep symptoms (Pediatric Sleep Survey Instrument) and SDB-related quality of life (OSA-18), together with the DUKE-UNC Functional Social Support (DUKE) and Psychological General Well-Being Index (PGWBI) questionnaires for themselves. 34 children completed a follow-up study after 2 years.

RESULTS

There were no significant differences between SDB severity groups for parental perceived social support or psychological wellbeing. Total scores on the DUKE were below average and PGWBI scores were indicative of moderate psychological distress in all three groups. Reduced perceived levels of social support were significantly correlated with externalising child behaviour and sleep disturbance. Diminished parental psychological wellbeing was also significantly correlated with increased sleep disturbances and reduced quality of life in children. At follow-up there were no significant changes in any questionnaire outcome, however parents of children with improved SDB severity had improved PGWBI vitality scores.

CONCLUSION

The degree of parent-reported sleep disturbance in children with DS was linked to suboptimal perceived parental social support and poor psychological wellbeing. Our results emphasise the need for enhanced awareness of the detrimental effects of sleep problems in children with DS on parental wellbeing.

Poor sleep quality and its associated neurocognitive function in children with obesity with or without obstructive sleep apnea

OBJECTIVE

To evaluate the associations of OSA severity, snoring symptoms, subjective sleep quality, and daytime sleepiness with executive functioning and behaviors in children with obesity.

METHODS

This was a cross-sectional study of children aged 8-18 years with obesity and symptoms suggestive of OSA. All participants underwent an overnight polysomnography and completed a set of questionnaires to assess their sleep-related breathing disordered (SRBD) symptoms [Pediatric Sleep Questionnaire (SRBD-PSQ)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], executive function [Behavior Rating Inventory of Executive Function (BRIEF)], and inattention and hyperactivity symptoms (Conners-3 Parent Short Form).

RESULTS

A total of 85 children (62% male, mean age: 13.9 ± 3.0 years) were included in this analysis, of whom 36, 16, and 33 were categorized into the non-OSA (obstructive apnea hypopnea index, OAHI < 1.5/h), mild OSA (OAHI 1.5-5/h), and moderate-severe OSA (OAHI ≥ 5/h) groups, respectively. Of 85 participants, 27 (32%) were classified with poor sleep quality (PSQI composite score ≥ 8). From multiple linear regression analyses, poor sleep quality and sleepiness were both independently associated with higher BRIEF behavioral regulation T-score, metacognition T-score, and global executive composite T-score in the fully adjusted model. In addition, poor sleep quality was also independently associated with higher Conners-3 inattention and executive functioning T-scores, while greater sleepiness was also associated with a higher learning problem T-score. The presence of OSA and snoring were not associated with any cognitive outcomes.

CONCLUSIONS

Subjective sleep quality and daytime sleepiness, but not OSA severity and snoring symptoms, were independently associated with executive functioning and behavioral problems in children with obesity.

Sleep-Disordered Breathing in an Infant With Achondroplasia and Foramen Magnum Stenosis

Sleep-disordered breathing (SDB) is a frequently recognized comorbidity in infants and children with achondroplasia due to alterations in craniofacial and upper airway anatomy. Foramen magnum stenosis and cervicomedullary compression can be associated with SDB in this population, requiring prompt evaluation by multidisciplinary teams. Untreated SDB is associated with adverse cardiovascular, metabolic, and behavioral effects in children, necessitating early screening and treatment of underlying causes. Cervicomedullary compression is also associated with increased mortality and sudden infant death in infants with achondroplasia. Management of SDB in children with achondroplasia may involve a combination of neurosurgical intervention, adenotonsillectomy, and/or continuous positive airway pressure (CPAP). We recognize a need for increased physician awareness of the recommended screening guidelines to optimize health outcomes for children with achondroplasia. In this report, we describe a case of a five-month-old infant with achondroplasia and severe SDB diagnosed by polysomnography and was found to have moderate-to-severe foramen magnum stenosis identified by MRI. Subsequently, this infant underwent foramen magnum decompression, which improved the severe SDB and was followed up for five years. Our case illustrates the importance of early screening in infants with achondroplasia for SDB to prevent further sequelae.

Characteristics of ADHD Symptoms and EEG Theta/Beta Ratio in Children With Sleep Disordered Breathing

Objectives. This study aimed to explore parent-reported symptoms of attention deficit-hyperactivity disorder (ADHD) and sleep electroencephalogram (EEG) theta/beta ratio (TBR) characteristics in children with sleep disordered breathing (SDB). Methods. The parents of children (aged 6-11 years) with SDB (n = 103) and healthy controls (n = 28) completed the SNAP-IV questionnaire, and children underwent overnight polysomnography. Children with SDB were grouped according to obstructive apnea/hypopnea index: primary snoring, mild, and moderate-severe obstructive sleep apnea (OSA) groups. The TBR in non-rapid eye movement (NREM) periods in three sleep cycles was analyzed. Results. Children with SDB showed worse ADHD symptoms compared with the healthy control. There was no intergroup difference in TBR. The time-related decline in TBR observed in the control, primary snoring and mild OSA groups, which was not observed in the moderate-severe OSA group. Overnight transcutaneous oxygen saturation was negatively associated with the hyperactivity/impulsivity score of ADHD symptom. The global TBR during the NREM period in the first sleep cycle was positively correlated with inattention score. Conclusion. Children with SDB showed more ADHD inattention symptoms than the healthy control. Although we found no difference in TBR among groups, we found significant main effect for NREM period. There existed a relationship between hypoxia, TBR, and scores of ADHD symptoms. Hence, it was speculated that TBR can reflect the nocturnal electrophysiological manifestations in children with SDB, which may be related to daytime ADHD symptoms.

Acetylome analyses provide novel insights into the effects of chronic intermittent hypoxia on hippocampus-dependent cognitive impairment

Introduction

Chronic intermittent hypoxia (CIH) can negatively affect hippocampal function through various molecular mechanisms. Protein acetylation, a frequently occurring modification, plays crucial roles in synaptic plasticity and cognitive processes. However, the global protein acetylation induced by CIH in the hippocampus and its specific effects on hippocampal function and behavior remain poorly understood.

Methods

To address this gap, we conducted a study using liquid chromatography-tandem mass spectrometry to analyze the lysine acetylome and proteome of the hippocampus in healthy adult mice exposed to intermittent hypoxia for 4 weeks (as a CIH model) compared to normoxic mice (as a control).

Results

We identified and quantified a total of 2,184 lysine acetylation sites in 1,007 proteins. Analysis of these acetylated proteins revealed disturbances primarily in oxidative phosphorylation, the tricarboxylic acid (TCA) cycle, and glycolysis, all of which are localized exclusively to mitochondria. Additionally, we observed significant changes in the abundance of 21 proteins, some of which are known to be associated with cognitive impairments.

Discussion

This study helps to elucidate the molecular mechanisms underlying CIH-induced changes in protein acetylation in the hippocampus. By providing valuable insights into the pathophysiological processes associated with CIH and their impacts on hippocampal function, our findings contribute to a better understanding of the consequences of CIH-induced changes in protein acetylation in the hippocampus and the potential role of CIH in cognitive impairment.

Development and Validation of a Nomogram for Predicting Obstructive Sleep Apnea Severity in Children

Purpose

The clinical presentation of Obstructive Sleep Apnea (OSA) in children is insidious and harmful. Early identification of children with OSA, particularly those at a higher risk for severe symptoms, is essential for making informed clinical decisions and improving long-term outcomes. Therefore, we developed and validated a risk prediction model for severity in Chinese children with OSA to effectively identify children with moderate-to-severe OSA in a clinical setting.

Patients and Methods

From June 2023 to September 2023, we retrospectively analyzed the medical records of 367 Children diagnosed with OSA through portable bedside polysomnography (PSG). Predictor variables were screened using the least absolute shrinkage and selection operator (LASSO) and logistic regression techniques to construct nomogram to predict the severity of OSA. Receiver operating characteristic curve (ROC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to determine the discrimination, calibration, and clinical usefulness of the nomogram.

Results

A total of 367 children with a median age of 84 months were included in this study. Neck circumference, ANB, gender, learning problem, and level of obstruction were identified as independent risk factors for moderate-severe OSA. The consistency indices of the nomogram in the training and validation cohorts were 0.841 and 0.75, respectively. The nomogram demonstrated a strong concordance between the predicted probabilities and the observed probabilities for children diagnosed with moderate-severe OSA. With threshold probabilities ranging from 0.1 to 1.0, the predictive model demonstrated strong predictive efficacy and yielded improved net benefit for clinical decision-making. ROC analysis was employed to classify the children into high and low-risk groups, utilizing the Optimal Cutoff value of 0.39.

Conclusion

A predictive model using LASSO regression was developed and validated for children with varying levels of OSA. This model identifies children at risk of developing OSA at an early stage.

Mouth breathing reduces oral function in adolescence

Although humans breathe naturally through the nostrils, mouth breathing in children has recently gathered attention. In this study, we hypothesized that tongue function and its related maxillofacial morphology would affect breathing in adolescence. To verify this hypothesis, we examined the association between breathing patterns, including mouth and nasal breathing; oral functions, including tongue motor function; and craniofacial morphology during adolescence, which has not been investigated till date. C3-H, which indicates the anteroposterior position of the hyoid bone in relation to the third cervical vertebra, was significantly smaller in mouth-breathers than in nasal-breathers. Lip-closing force, tongue pressure, and masticatory efficiency were lower in the order of nasal-breathers, oronasal-breathers, and mouth-breathers, and the values for mouth-breathers were significantly lower than those for nasal-breathers. Tongue pressure alone was identified as a significant independent variable, with an odds ratio of 1.063 (95% confidence interval, 1.006-1.123; p < 0.05). Our results indicate a relationship between mouth breathing and the lip-closing force, tongue pressure, and masticatory efficiency, as well as the significance of tongue pressure on mouth breathing in adolescents. The findings highlight the importance of clarifying the pathophysiology of mouth breathing and its underlying causes.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Post-tonsillectomy outcomes in children with mucopolysaccharidosis and obstructive sleep apnea

OBJECTIVE

To describe the incidence of respiratory complications, postoperative hemorrhage, length of stay, and cost of care in children with mucopolysaccharidosis (MPS) undergoing adenotonsillectomy (AT).

METHODS

Analysis of the 2009, 2012, and 2016 editions of the Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP KID) identified 24,700 children who underwent AT (40 children with MPS). Demographics, respiratory complications, postoperative hemorrhage, length of stay, and total cost were compared across children with and without MPS.

RESULTS

Children with MPS had a higher likelihood of being male (P < 0.017). There was a higher rate of respiratory complications in children with MPS compared with children without MPS [6/40 (15%) vs. 586/24,660 (2.4%), P < 0.001], which remained significant after adjusting for sex [adjusted odds ratio 6.88 (95% CI 2.87-16.46)]. There was also a higher risk of postoperative hemorrhage [4/40 (10%) vs. 444/24,660 (1.8%), P < 0.001), with sex-adjusted odds ratio of 5.97 (95% CI 2.12-16.86). Median (IQR) length of stay was increased in children with MPS (3 days, 1-4) compared with children without MPS (1 day, 1-2, P < 0.001). There was an increase in median (IQR) charges for hospital stay in children with MPS compared with their peers [$33,016 ($23,208.50-$72,280.50 vs. $15,383 ($9937-$24,462), P < 0.001].

CONCLUSIONS

Children with MPS undergoing AT had an increased risk of respiratory complications, postoperative hemorrhage, longer length of stay, and a higher cost of treatment when compared with children without MPS. This information may help inform interventional, perioperative, and postoperative decision making.

Can portable sleep monitors replace polysomnography for diagnosis of pediatric OSA: a systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnoea (OSA) is an increasing health problem in children. The "gold standard" for OSA diagnosis at the moment is overnight polysomnography (PSG). Some researchers think portable monitors (PMs) are promising methods for diagnosing OSA, which make children more comfortable and lower costs. Compared with PSG, our comprehensively evaluated the diagnostic accuracy of PMs for diagnosing OSA in pediatrics.

RESEARCH QUESTION

This study aims to determine whether PMs can replace PSG in pediatric OSA diagnosis.

STUDY DESIGN AND METHODS

The PubMed, Embase, Medline databases Scopus, Web of Science, and Cochrane Library databases were searched systematically for studies published up to December 2022, evaluating the ability of PMs to diagnose OSA in children. For estimating the pooled sensitivity and specificity of the PMs in the included studies, we used a random-effects bivariate model. Studies included in this meta-analysis were evaluated systematically according to QUADAS-2 guidelines for assessing diagnostic accuracy studies. Two independent investigators conducted each stage of the review independently.

RESULTS

A total of 396 abstracts and 31 full-text articles were screened, and 41 full-text articles were chosen for final review. There were 707 pediatric patients enrolled in these twelve studies, and 9 PMs were evaluated. There was a wide range of diagnostic sensitivity and specificity among PM systems as compared to AHI measured by PSG. The pooled sensitivity and specificity in diagnosing pediatric OSA were, respectively, 0.91 [0.86, 0.94] and 0.76 [0.58, 0.88] for PMs. According to the summary receiver operating characteristic (SROC) curve, the AUC of PMs in diagnosing OSA in pediatric population was 0.93 [0.90, 0.95].

INTERPRETATION

PMs were more sensitive but slightly less specific for pediatric OSA. The combination of PMs and questionnaires appeared to be a reliable tool for the diagnosis of pediatric OSA. This test may be used for screening subjects or populations at high risk of OSA when there is a high demand for PSG, but the quantity is limited. No clinical trial was involved in the current study.

Sleep Disordered Breathing in Children with Autism Spectrum Disorder: An In-Depth Review of Correlations and Complexities

Sleep-disordered breathing is a significant problem affecting the pediatric population. These conditions can affect sleep quality and children's overall health and well-being. Difficulties in social interaction, communication, and repetitive behavioral patterns characterize autism spectrum disorder. Sleep disturbances are common in children with ASD. This literature review aims to gather and analyze available studies on the relationship between SDB and children with autism spectrum disorder. We comprehensively searched the literature using major search engines (PubMed, Scopus, and Web of Science). After removing duplicates, we extracted a total of 96 records. We selected 19 studies for inclusion after a thorough title and abstract screening process. Seven articles were ultimately incorporated into this analysis. The research findings presented herein emphasize the substantial influence of sleep-disordered breathing on pediatric individuals diagnosed with autism spectrum disorder (ASD). These findings reveal a high incidence of SDB in children with ASD, emphasizing the importance of early diagnosis and specialized treatment. Obesity in this population further complicates matters, requiring focused weight management strategies. Surgical interventions, such as adenotonsillectomy, have shown promise in improving behavioral issues in children with ASD affected by OSA, regardless of their obesity status. However, more comprehensive studies are necessary to investigate the benefits of A&T treatment, specifically in children with ASD and OSA. The complex relationship between ASD, SDB, and other factors, such as joint hypermobility and muscle hypotonia, suggests a need for multidisciplinary treatment approaches. Physiotherapy can play a critical role in addressing these intricate health issues. Early sleep assessments and tailored weight management strategies are essential for timely diagnosis and intervention in children with ASD. Policy initiatives should support these efforts to enhance the overall well-being of this population. Further research is crucial to understand the complex causes of sleep disturbances in children with ASD and to develop effective interventions considering the multifaceted nature of these conditions.

Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing

STUDY OBJECTIVES

Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors.

METHODS

298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures.

RESULTS

Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old.

CONCLUSIONS

Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040.

CITATION

Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

Paediatric sleep apnea event prediction using nasal air pressure and machine learning

Sleep-disordered breathing is an important health issue for children. The objective of this study was to develop a machine learning classifier model for the identification of sleep apnea events taken exclusively from nasal air pressure measurements acquired during overnight polysomnography for paediatric patients. A secondary objective of this study was to differentiate site of obstruction exclusively from hypopnea event data using the model. Computer vision classifiers were developed via transfer learning to either normal breathing while asleep, obstructive hypopnea, obstructive apnea or central apnea. A separate model was trained to identify site of obstruction as either adeno-tonsillar or tongue base. In addition, a survey of board-certified and board-eligible sleep physicians was completed to compare clinician versus model classification performance of sleep events, and indicated very good performance of our model relative to human raters. The nasal air pressure sample database available for modelling comprised 417 normal, 266 obstructive hypopnea, 122 obstructive apnea and 131 central apnea events derived from 28 paediatric patients. The four-way classifier achieved a mean prediction accuracy of 70.0% (95% confidence interval [67.1-72.9]). Clinician raters correctly identified sleep events from nasal air pressure tracings 53.8% of the time, whereas the local model was 77.5% accurate. The site of obstruction classifier achieved a mean prediction accuracy of 75.0% (95% confidence interval [68.7-81.3]). Machine learning applied to nasal air pressure tracings is feasible and may exceed the diagnostic performance of expert clinicians. Nasal air pressure tracings of obstructive hypopneas may "encode" information regarding the site of obstruction, which may only be discernable by machine learning.

Medical Treatment of Obstructive Sleep Apnea in Children

Obstructive sleep apnea (OSA) is characterized by recurrent complete or partial obstruction of the upper airway. The prevalence is 1-4% in children aged between 2 and 8 years and rising due to the increase in obesity rates in children. Although persistent OSA following adenotonsillectomy is usually associated with obesity and underlying complex disorders, it can also affect otherwise healthy children. Medical treatment strategies are frequently required when adenotonsillectomy is not indicated in children with OSA or if OSA is persistent following adenotonsillectomy. Positive airway pressure treatment is a very effective modality for persistent OSA in childhood; however, adherence rates are low. The aim of this review article is to summarize medical treatment options for OSA in children.

Polysomnographic study in pediatric neurofibromatosis type 1

Background

Neurofibromatosis type 1 (NF1) is a genetic disease that alters neurodevelopment. We aimed to analyze the sleep macrostructure of a sample of children affected by NF1 without neurocognitive co-morbidities and MRI reports of unidentified bright objects (UBOs).

Methods

A 100 pre-pubertal children participated in the cross-sectional study: 50 subjects were children diagnosed with NF1 and 50 subjects were typically developing healthy children (TDC). All participants underwent polysomnographic evaluation through which conventional sleep parameters were collected: Total sleep time (TST), Sleep latency (SOL), first REM latency (FRL), number of stage shifts/h (SS/h), number of awakenings/h (AWN/h), wake after sleep onset (WASO%), sleep efficiency percentage (SE%), percentage of sleep time spent in sleep stages 1 (N1%) and 2 (N2%), slow-wave sleep (N3%), and REM sleep (REM%). Additionally, nocturnal respiratory events such as apnea/hypopnea index (AHI), oxygen desaturation index (ODI), and periodic limb movement index (PLMI) were recorded.

Results

Neurofibromatosis type 1 children showed a reduction in sleep duration parameters (TST; p < 0.001), sleep efficiency (SE%; p < 0.001), and stage N2% (p < 0.001). Moreover, the number of awakenings per hour (AWN/h), wake after sleep onset (WASO%), and respiratory events such as AHI, ODI, and PLMI resulted higher in NF1 vs. TDC children.

Conclusion

The data showed that the sleep macrostructure differs between NF1 and TDC children. These findings suggest that the evaluation of sleep may provide useful support in corroborating the diagnosis and offers additional therapeutic management perspectives in NF1 and genetic neurodevelopmental disorders in general.

Mental Health and Cognitive Development in Symptomatic Children and Adolescents Scoring High on Habitual Snoring: Role of Obesity and Allergy

BACKGROUND

Obstructive sleep apnea can have a negative impact on children's and adolescents' neurocognitive abilities and hinder their academic and adaptive progress in academic, social, and/or behavioral dimensions. In this retrospective cross-sectional study, we investigated the influence of body weight conditions and allergy status on long-term mental health, cognitive development, and quality of life in children and adolescents who snored.

METHODS

The study sample included 47 subjects (age range 4.1 to 15.3 years) who exhibited high levels of snoring and underwent home-based polysomnography between 2015 and 2019. Follow-up assessments (3 years on average between baseline and follow-up) entailed phone interviews with the subject's parents/caregivers who completed three validated questionnaires investigating sleep, quality of life, and parental ratings.

RESULTS

We found a correlation between age at diagnosis and being retrospectively overweight and high levels of snoring. In addition to a higher risk of developing emotional symptoms (8.2% increase in retrospective overweight status for each unit increase in the emotional score at follow-up) and oppositional behavior (9% increase in retrospective overweight status for each unit of oppositional T points at follow-up), we also noted reduced long-term social symptoms (11% decrease in retrospective overweight status for each unit increase in the social score at follow-up) and cognitive symptoms (10.6% decrease in retrospective overweight status for each unit increase in the cognitive score at follow-up), as well as a 6.1% increase in retrospective allergy status for each unit increase in academic performance at follow-up.

CONCLUSIONS

Snoring can have negative impacts on mental health and cognitive development in the long term. Early detection and intervention for neuropsychological disorders is important in children and adolescents who score high on snoring. In the long term, the effects of snoring on neuropsychological disorders may vary based on previous body weight and allergy status.

Predictive Power of Oxygen Desaturation Index (ODI) and Apnea-Hypopnea Index (AHI) in Detecting Long-Term Neurocognitive and Psychosocial Outcomes of Sleep-Disordered Breathing in Children: A Questionnaire-Based Study

Pediatric obstructive sleep apnea can negatively affect children's neurocognitive function and development, hindering academic and adaptive goals. Questionnaires are suitable for assessing neuropsychological symptoms in children with sleep-disordered breathing. The study aimed to evaluate the effectiveness of using the Oxygen Desaturation Index compared to the Obstructive Apnea-Hypopnea Index in predicting long-term consequences of sleep-disordered breathing in children. We conducted a retrospective analysis of respiratory polysomnography recordings from preschool and school-age children (mean age: 5.8 ± 2.8 years) and followed them up after an average of 3.1 ± 0.8 years from the home-based polysomnography. We administered three validated questionnaires to the parents/caregivers of the children by phone. Our results showed that children with an Oxygen Desaturation Index (ODI) greater than one event per hour exhibited symptoms in four domains (physical, school-related, Quality of Life [QoL], and attention deficit hyperactivity disorder [ADHD]) at follow-up, compared to only two symptoms (physical and school-related) found in children with an Obstructive Apnea-Hypopnea Index greater than one event per hour at the time of diagnosis. Our study also found a significant correlation between the minimum SpO₂ (%) recorded at diagnosis and several outcomes, including Pediatric Sleep Questionnaire (PSQ) scores, physical, social, and school-related outcomes, and ADHD index at follow-up. These results suggest that the Oxygen Desaturation Index could serve as a valuable predictor of long-term symptoms in children with sleep-disordered breathing, which could inform treatment decisions. Additionally, measuring minimum SpO₂ levels may help assess the risk of developing long-term symptoms and monitor treatment outcomes.

The sleep and wake electroencephalogram over the lifespan

Both sleep and wake encephalograms (EEG) change over the lifespan. While prior studies have characterized age-related changes in the EEG, the datasets span a particular age group, or focused on sleep and wake macrostructure rather than the microstructure. Here, we present sex-stratified data from 3372 community-based or clinic-based otherwise neurologically and psychiatrically healthy participants ranging from 11 days to 80 years of age. We estimate age norms for key sleep and wake EEG parameters including absolute and relative powers in delta, theta, alpha, and sigma bands, as well as sleep spindle density, amplitude, duration, and frequency. To illustrate the potential use of the reference measures developed herein, we compare them to sleep EEG recordings from age-matched participants with Alzheimer's disease, severe sleep apnea, depression, osteoarthritis, and osteoporosis. Although the partially clinical nature of the datasets may bias the findings towards less normal and hence may underestimate pathology in practice, age-based EEG reference values enable objective screening of deviations from healthy aging among individuals with a variety of disorders that affect brain health.

Adenoid hypertrophy in children: a narrative review of pathogenesis and clinical relevance

Adenoids (nasopharyngeal tonsils), being part of Waldeyer's ring, are masses of lymphoid tissues located at the junction of the roof and the posterior wall of the nasopharynx. Adenoids play an important role in the development of the immune system and serve as a defence against infections, being the first organs that come into contact with respiratory and digestive antigens. The causes of adenoid hypertrophy are not fully known. They are most likely associated with aberrant immune reactions, infections, environmental exposures and hormonal or genetic factors. The aim of this review is to summarise the current knowledge of adenoid hypertrophy in children and associated diseases. Adenoid hypertrophy has many clinical manifestations that are frequent in the paediatric population and is accompanied by various comorbidities.

Alterations in Amygdala/Hippocampal Volume Ratios in Children with Obstructive Sleep Apnea Syndrome Caused by Adenotonsillar Hypertrophy

BACKGROUND Intermittent hypoxemia can cause changes in certain brain structures. However, in pediatric patients with obstructive sleep apnea (OSA) caused by adenotonsillar hypertrophy (ATH), there is only limited information on the effect of ATH-induced OSA on brain structures. This study sought to investigate alterations in amygdala and hippocampal volumes in children with OSA by ATH. MATERIAL AND METHODS Magnetic resonance imaging scans were applied in children who had ATH-induced OSA (ATH/OSA) and in healthy children. Amygdala and hippocampus volumes and adenoid sizes were measured on MRI volumetric images. The ratio of adenoid size/nasopharyngeal depth was used to describe the severity of adenoid hypertrophy. The clinical variables of the involved subjects were investigated. RESULTS One hundred ATH/OSA children and 100 healthy children without ATH/OSA participated in the study. The ATH/OSA children had higher amygdala volumes and amygdala/hippocampus volume ratios but lower hippocampus volumes than healthy controls, and the amygdala/hippocampus volume ratios were correlated with disease duration and hypoxemia conditions. However, our data showed that amygdala/hippocampus volume ratios were not correlated with the ratios of adenoid size/nasopharyngeal depth in the ATH/OSA children. In addition, the ratio of adenoid size/nasopharyngeal depths in ATH/OSA children was higher than that in healthy children in each subgroup based on the age of participants. CONCLUSIONS Compared to healthy controls, amygdala/hippocampus volume ratios are increased in children with ATH/OSA.

Behavioral and cognitive outcomes of habitual snoring in children aged 2-14 years in Chengdu, Sichuan

PURPOSE

Habitual snoring is associated with cognitive, behavioral, and other physiological problems of children. Few studies have reported specifically on the relationships between snoring and those problems in children as noticed by their parents. We aimed to identify the cognitive, behavioral, and sleep-related nocturnal problems in children with HS as noted by their parents.

MATERIALS AND METHODS

A cross-sectional survey was performed in Chengdu, Sichuan, China. Children aged 2-14 years from four districts were randomly chosen to participate. Questionnaires were completed voluntarily by the children's parents/guardians.

RESULTS

A total of 1548 questionnaires were analyzed and classified those children as 463 habitual snorers (HS group, 30.4 %), 683 occasional snorers (OS group, 44.8 %), and 402 non-snorers (NS group, 26.4 %). The percentages of children with sleep-related nocturnal symptoms were 94.6 %, 87.3 %, and 66.9 % in the HS, OS, and NS groups. Percentages of children with cognitive problems were 76.2 %, 74.6 %, and 64.9 % in the HS, OS, and NS groups, respectively (P < 0.001). The frequencies of daytime behavioral problems were 68.3 %, 61.5 %, and 46.8%in the HS, OS, and NS groups, respectively (P < 0.001).The average number of sleep-related nocturnal symptoms, cognitive symptoms and daytime behavioral problems was higher in the HS group than in the OS and NS groups.

CONCLUSIONS

HS is a significant contributor to sleep-related nocturnal symptoms and daytime cognitive and behavioral problems in children, as reported by their parents/guardians. HS and OS are important contributors to poor sleep quality and daytime cognitive and behavioral problems in children.

Neurocognitive, mood changes, and sleepiness in patients with REM-predominant obstructive sleep apnea

PURPOSE

This article focuses on recent evidence linking rapid eye movement (REM) obstructive sleep apnea (OSA) (REM-OSA) to neurocognitive dysfunction and mood changes; the proposed mechanisms for increased risk of neurocognitive dysfunction in REM-OSA, and future research prospects.

METHODS

PubMed and Google Scholar records were examined for articles utilizing pre-defined keywords. In this work, we mainly included studies published after 2017; nevertheless, critical studies published prior to 2017 were considered.

RESULTS

REM-OSA is an under-recognized stage-related sleep-disordered breathing in which obstructive respiratory events happen chiefly in stage REM. The disorder is commonly seen amongst younger patients and females and has recently been linked to cardiometabolic complications. Although less symptomatic than non-REM-OSA and non-stage-specific OSA, current findings indicate that REM-OSA may have neurocognitive repercussions and mood changes and could be linked to insomnia, increased dreams, and nightmares.

CONCLUSION

Currently available evidence indicates that REM-OSA may present with insomnia and nightmares and could affect cognitive function and mood.

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.

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

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

Clinical and functional characteristics of OSA in children with comorbid asthma treated by leukotriene receptor antagonist: A descriptive study

Background

Obstructive sleep apnea (OSA) is the most common form of respiratory disorders during sleep in children, especially those with severe asthma. However, optimal treatment of asthma might significantly improve OSA severity.

Methods

It was a cohort study including children aged >5 years old and diagnosed with asthma according to GINA (Global Initiative for Asthma). The data related to age, gender, height, weight, body mass index (BMI), clinical symptoms and medical history of asthma, spirometry (FEV₁: forced expiratory in 1 s), and exhaled nitric oxide (F_ENO) were recorded for analysis. Respiratory polygraphy (RPG) was done for each study subject to diagnose OSA and its severity.

Results

Among 139 asthmatic children, 99 patients with OSA (71.2%) were included in the present study (9.3 ± 0.2 years): 58.6% with uncontrolled asthma and 32.3% with partial controlled asthma. The mean ACT (asthma control testing) score was 19.0 ± 3.4. The most frequent night-time symptoms were restless sleep (76.8%), snoring (61.6%), sweating (52.5%), and trouble breathing during sleep (48.5%). The common daytime symptoms were irritable status (46.5%) and abnormal behavior (30.3%). The mean AHI (apnea-hypopnea index) was 3.5 ± 4.0 events/h. There was a significant correlation between BMI and snoring index (R = 0.189 and P = 0.027), bronchial and nasal F_ENO with AHI (R = 0.046 and P < 0.001; R = 0.037 and P < 0.001; respectively). There was no significant correlation between asthma level, FEV₁ and AHI. The severity of asthma and respiratory function were improved significantly after 3 months and 6 months of asthma treatment in combination with leukotriene receptor antagonist (LRA) treatment. The symptoms related to OSA were significantly improved after treatment with LRA. The severity of OSA was decreased significantly after 3 months and 6 months of treatment.

Conclusion

The treatment of asthmatic children with comorbid OSA by LRA in combination with standard therapy for asthma could improve the control of asthma and the symptoms and severity of OSA.

Validity and reliability of the Japanese version of the severity hierarchy score for pediatric obstructive sleep apnea screening

OBJECTIVE

This study aimed to evaluate the validity and reliability of the Japanese version of the severity hierarchy score (J-SHS) in the screening of pediatric obstructive sleep apnea (OSA) among Japanese community children.

METHODS

A total of 922 children from elementary schools in Tokyo were recruited. Their parents completed the J-SHS questionnaire, and the children underwent an overnight Tracheal Sound (TS) recording. The reliability of the J-SHS was assessed by Cronbach's alpha coefficients and Spearman's correlation. Construct validity was determined by factor analysis. The discriminative ability to diagnose OSA was evaluated by constructing ROC curves.

RESULTS

Five hundred and seventeen children (51.8% male, mean age 7.1 ± 0.7 years) were included. Cronbach's alpha coefficient was 0.80. Factor analysis resulted in a two-factor structure, with factor loadings all above 0.4. A J-SHS score of >1.88 exhibited a 60% sensitivity, 93% specificity, and an area under the curve (AUC) of 0.78 for detecting an apnea-hypopnea index (AHI) of ≥5/h; a J-SHS score of >2.06 exhibited a 75% sensitivity, 84% specificity and AUC of 0.84 for detecting an AHI of ≥3/h among the children with a snoring frequency above two nights/wk.

CONCLUSION

The J-SHS exhibits good performance as a screening tool providing a quick and straightforward approach for identifying Japanese children at risk for OSA.

Factors affecting pediatric adherence to positive airway pressure: Patient- and caregiver-reported treatment barriers and sleep difficulties

OBJECTIVE/BACKGROUND

Adherence to positive airway pressure (PAP) treatment among children and adolescents is often suboptimal. Little is understood about modifiable determinants of PAP adherence. We evaluated whether patient and caregiver-perceived treatment barriers (across behavioral, environmental, emotional, and physical domains), as well as insomnia severity, were associated with PAP adherence among youth with sleep disordered breathing (SDB).

PATIENTS/METHODS

We conducted a retrospective review of 188 patients prescribed PAP, ages 2-19 years. At the clinical visit, PAP adherence was assessed via objective download/smartcard and patients and their caregivers completed validated standardized questionnaires on barriers to PAP adherence and sleep onset and maintenance difficulties. We tested predictors of PAP adherence using linear regression.

RESULTS

On average, patients wore their PAP 2/3 of nights for 5.3 ± 3.4 h. Patients reported more barriers overall compared to caregivers, and specifically more behavioral and emotional barriers (e.g., over a third of patients reported they just want to forget about sleep apnea). After controlling for demographic/treatment characteristics, patient-reported barriers accounted for a significant proportion of the variance in percent nights used (51%) and average nightly use (42%). Greater difficulties with sleep maintenance predicted poorer PAP adherence (percent nights and nightly duration).

CONCLUSIONS

Study findings suggest that assessment of both patient and caregiver-perceived barriers to PAP adherence, as well as evaluating for sleep maintenance concerns, may provide important treatment targets for promoting PAP adherence among youth. Results also support the potential benefit of a multi-disciplinary team-based approach to managing SDB and promoting PAP adherence.

Facial Emotion Recognition Deficit in Children with Moderate/Severe Obstructive Sleep Apnea

Although previous studies have reported a facial expression classification deficit among adults with SDB, we do not know whether these findings can be generalized to children. In our study, children with sleep-disordered breathing (SDB) were divided into three groups: primary snoring (n = 51), mild obstructive sleep apnea (OSA) (n = 39), and moderate/severe OSA (n = 26). All participants, including 20 healthy controls, underwent an overnight polysomnography recording and the Emotional Expression Recognition Task. Psychosocial problems were evaluated using the parent-reported Strengths and Difficulties Questionnaire (SDQ). There was a borderline significant interaction between expression category and group on reaction times. Further analysis revealed that positive classification advantage (PCA) disappeared in the moderate/severe OSA group, whereas it persisted in the control, primary snoring, and mild OSA groups. Emotional symptoms were positively correlated with OAHI. In both the happy and sad conditions, RT was negatively related to age and body mass index (BMI) but was independent of the obstructive apnea-hypopnea index (OAHI), arterial oxygen (SaO2) and total sleep time. The accuracy of identifying a sad expression was negatively related to conduct problems. Children with moderate/severe OSA exhibited dysfunction in facial expression categorization, which could potentially affect social communication ability.

Neurocognitive evaluation of children with down syndrome and obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) treatment has been shown to improve cardiac behavioral and cognitive functions in typically developing children. Early OSAS diagnosis in children with Down syndrome (DS) would be important to prevent its complications, especially cognitive ones, but remains overlooked. The main objective of our study was to assess the cognitive function of children with DS, with and without OSAS. The second objective was to determine the impact of the therapeutic intervention on the cognitive function of children with OSAS. This study included 41 children with DS who underwent polysomnography for OSAS diagnosis and a cognitive evaluation. They were aged between 3.4 and 17.3 years and 24 (59%) were boys. Their median OAHI was 2.6 (0-31)/h of sleep, 30 (73%) were diagnosed with OSAS (15 had mild OSAS, and 15 had moderate/severe OSAS). Some scores of the Raven's colored progressive matrices were negatively correlated with the respiratory arousal index, OAHI tended to be positively correlated with Reiss behavioral problems. 24 (59%) patients received a treatment. Even if we were unable to demonstrate this formally due that only 16 children (39%) accepted a follow-up visit, some displayed improvement in their neuropsychological scores, especially those with moderate/severe OSAS after treatment. Children with DS have low intellectual abilities and more risk of developing OSAS compared to the general population, which may lead to further neurocognitive impairment. Early screening and management are important in this population to prevent any further neurocognitive delay in their development.

Cluster Analysis of Home Polygraphic Recordings in Symptomatic Habitually-Snoring Children: A Precision Medicine Perspective

(1) Background: Sleep-disordered breathing (SDB) is a frequent problem in children. Cluster analyses offer the possibility of identifying homogeneous groups within a large clinical database. The application of cluster analysis to anthropometric and polysomnographic measures in snoring children would enable the detection of distinctive clinically-relevant phenotypes; (2) Methods: We retrospectively collected the results of nocturnal home-based cardiorespiratory polygraphic recordings and anthropometric measurements in 326 habitually-snoring otherwise healthy children. K-medoids clustering was applied to standardized respiratory and anthropometric measures, followed by Silhouette-based statistics. Respiratory Disturbance Index (RDI) and oxygen desaturation index (≤3%) were included in determining the optimal number of clusters; (3) Results: Mean age of subjects was 8.1 ± 4.1 years, and 57% were males. Cluster analyses uncovered an optimal number of three clusters. Cluster 1 comprised 59.5% of the cohort (mean age 8.69 ± 4.14 years) with a mean RDI of 3.71 ± 3.23 events/hour of estimated sleep (e/ehSleep). Cluster 2 included 28.5% of the children (mean age 6.92 ± 3.43 years) with an RDI of 6.38 ± 3.92 e/ehSleep. Cluster 3 included 12% of the cohort (mean age 7.58 ± 4.73 years) with a mean RDI of 25.5 ± 19.4 e/ehSleep. Weight z-score was significantly lower in cluster 3 [-0.14 ± 1.65] than in cluster 2 [0.86 ± 1.78; p = 0.015] and cluster 1 [1.04 ± 1.78; p = 0.002]. Similar findings emerged for BMI z scores. However, the height z-score was not significantly different among the 3 clusters; (4) Conclusions: Cluster analysis of children who are symptomatic habitual snorers and are referred for clinical polygraphic evaluation identified three major clusters that differed in age, RDI, and anthropometric measures. An increased number of children in the cluster with the highest RDI had reduced body weight. We propose that the implementation of these approaches to a multicenter-derived database of home-based polygraphic recordings may enable the delineation of objective unbiased severity categories of pediatric SDB. Our findings could be useful for clinical implementation, formulation of therapeutic decision guidelines, clinical management, prevision of complications, and long-term follow-up.

Adenotonsillectomy and adenoidectomy in children: The impact of timing of surgery and post-operative outcomes

AIM

To investigate the impact of adenotonsillectomy (ADT) and adenoidectomy (AD) on child health and evaluated their post-operative complications.

METHODS

We included all children aged <16 years undergoing ADT (tonsillectomy ± adenoidectomy) or AD in New South Wales, Australia, 2008-2017. Health information was obtained from administrative hospitalisation data. Rates of post-operative complications and reoperation were evaluated using generalised estimating equations and Kaplan-Meier methods, respectively.

RESULTS

Out of 156 500 included children, 112 361 had ADT and 44 139 had AD. Population rates increased during 2008-2017 (ADT: 68-79 per 10 000 children; AD: 25-34 per 10 000), and children were increasingly operated on at a younger age. Overall, 7262 (6.5%) and 1276 (2.9%) children had post-operative complications (mostly haemorrhage), and 4320 (3.8%) and 5394 (12.2%) required reoperation, following ADT and AD, respectively. Complication rates were highest among children aged 0-1 years, lowest for those 2-5 years and increased with age thereafter. Three-year reoperation rates for children aged 0-1 years were 9.0% and 25.9% following ADT and AD, respectively, decreasing thereafter to 0.5% and 2.1% in children aged 12-13 years.

CONCLUSIONS

ADT and AD in Australian children have both increased in frequency and are being done at a younger age. Post-operative complications and reoperation rates highlight surgery is not without risk, especially for children under 2 years old. These findings support a more conservative approach to management of upper respiratory symptoms, with surgery reserved for cases where potential benefits are most likely to outweigh harms.

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

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

Cognition in pediatric SDB-Yes, no, maybe?

Numerous studies in the past 10 years have reported on the neurocognitive sequalae of pediatric sleep disordered breathing (SDB). Variations in criteria used to define SDB in conjunction with the wide variety of neuropsychological measures selected to evaluate cognitive consequences of SDB have resulted in discrepancies within the literature. This review summarizes the extent literature regarding cognitive effects of pediatric SDB across domains of global intelligence, attention, executive function, memory, language, and visuospatial ability. This review also addresses the proposed etiology underlying neurocognitive consequences of pediatric SDB. The differences in findings across the literature are highlighted and discussed throughout.

Reliability of machine learning to diagnose pediatric obstructive sleep apnea: Systematic review and meta-analysis

BACKGROUND

Machine-learning approaches have enabled promising results in efforts to simplify the diagnosis of pediatric obstructive sleep apnea (OSA). A comprehensive review and analysis of such studies increase the confidence level of practitioners and healthcare providers in the implementation of these methodologies in clinical practice.

OBJECTIVE

To assess the reliability of machine-learning-based methods to detect pediatric OSA.

DATA SOURCES

Two researchers conducted an electronic search on the Web of Science and Scopus using term, and studies were reviewed along with their bibliographic references.

ELIGIBILITY CRITERIA

Articles or reviews (Year 2000 onwards) that applied machine learning to detect pediatric OSA; reported data included information enabling derivation of true positive, false negative, true negative, and false positive cases; polysomnography served as diagnostic standard.

APPRAISAL AND SYNTHESIS METHODS

Pooled sensitivities and specificities were computed for three apnea-hypopnea index (AHI) thresholds: 1 event/hour (e/h), 5 e/h, and 10 e/h. Random-effect models were assumed. Summary receiver-operating characteristics (SROC) analyses were also conducted. Heterogeneity (I ² ) was evaluated, and publication bias was corrected (trim and fill).

RESULTS

Nineteen studies were finally retained, involving 4767 different pediatric sleep studies. Machine learning improved diagnostic performance as OSA severity criteria increased reaching optimal values for AHI = 10 e/h (0.652 sensitivity; 0.931 specificity; and 0.940 area under the SROC curve). Publication bias correction had minor effect on summary statistics, but high heterogeneity was observed among the studies.

Clinical validation of a mandibular movement signal based system for the diagnosis of pediatric sleep apnea

BACKGROUND

Given the high prevalence and risk for outcomes associated with pediatric obstructive sleep apnea (OSA), there is a need for simplified diagnostic approaches. A prospective study in 140 children undergoing in-laboratory polysomnography (PSG) evaluates the accuracy of a recently developed system (Sunrise) to estimate respiratory efforts by monitoring sleep mandibular movements (MM) for the diagnosis of OSA (Sunrise™).

METHODS

Diagnosis and severity were defined by an obstructive apnea/hypopnea index (OAHI) ≥ 1 (mild), ≥ 5 (moderate), and ≥ 10 events/h (severe). Agreement between PSG and Sunrise™ was assessed by Bland-Altman method comparing respiratory disturbances hourly index (RDI) (obstructive apneas, hypopneas, and respiratory effort-related arousals) during PSG (PSG_RDI), and Sunrise RDI (Sr_RDI). Performance of Sr_RDI was determined via ROC curves evaluating the device sensitivity and specificity at PSG_OAHI ≥ 1, 5, and 15 events/h.

RESULTS

A median difference of 1.57 events/h, 95% confidence interval: -2.49 to 8.11 was found between Sr_RDI and PSG_RDI. Areas under the ROC curves of Sr_RDI were 0.75 (interquartile range [IQR]: 0.72-0.78), 0.90 (IQR: 0.86-0.92) and 0.95 (IQR: 0.90-0.99) for detecting children with PSG_OAHI ≥ 1, PSG_OAHI ≥ 5, or PSG_ OAHI ≥ 10, respectively.

CONCLUSION

MM automated analysis shows significant promise to diagnose moderate-to-severe pediatric OSA.

Slow EEG Oscillation to Characterize Pediatric Sleep Apnea and Associated Cognitive Impairments

Previous studies have suggested that the typical slow oscillations (SO) characteristics during sleep could be modified in the presence of pediatric obstructive sleep apnea (OSA). Here, we evaluate whether these modifications are significant and if they may reflect cognitive deficits. We recorded the overnight electroencephalogram (EEG) of 294 pediatric subjects (5-9 years old) using eight channels. Then, we divided the cohort in three OSA severity groups (no OSA, mild, and moderate/severe) to characterize the corresponding SO using the spectral maximum in the slow wave sleep (SWS) band δ₁: 0.1-2 Hz (Maxs o), as well as the frequency where this maximum is located (FreqMaxso). Spectral entropy (SpecEn) from δ₁ was also included in the analyses. A correlation analysis was performed to evaluate associations of these spectral measures with six OSA-related clinical variables and six cognitive scores. Our results indicate that Maxso could be used as a moderate/severe OSA biomarker while providing useful information regarding verbal and visuo-spatial impairments, and that FreqMaxso emerges as an even more robust indicator of visuospatial function. In addition, we uncovered novel insights regarding the ability of SpecEn in δ₁ to characterize OSA-related disruption of sleep homeostasis. Our findings suggest that the information from SO may be useful to automatically characterize moderate/severe pediatric OSA and its cognitive consequences. Clinical Relevance- This study contributes towards reaching an objective quantifiable and automated assessment of the potential cognitive consequences of pediatric sleep apnea.