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Zhang Y, Leng S, Hu Q, Li Y, Wei Y, Lu Y, Qie D, Yang F. Pharmacological interventions for pediatric obstructive sleep apnea (OSA): Network meta-analysis. Sleep Med 2024; 116:129-137. [PMID: 38460418 DOI: 10.1016/j.sleep.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/15/2024] [Accepted: 01/29/2024] [Indexed: 03/11/2024]
Abstract
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.
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Affiliation(s)
- Yuxiao Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Siqi Leng
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qian Hu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Yingna Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Yumeng Wei
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - You Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Di Qie
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Fan Yang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China.
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Ersu R, Chen ML, Ehsan Z, Ishman SL, Redline S, Narang I. Persistent obstructive sleep apnoea in children: treatment options and management considerations. THE LANCET. RESPIRATORY MEDICINE 2023; 11:283-296. [PMID: 36162413 DOI: 10.1016/s2213-2600(22)00262-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 05/15/2022] [Accepted: 07/05/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Refika Ersu
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Maida L Chen
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Zarmina Ehsan
- Division of Pulmonary and Sleep Medicine, Children's Mercy Hospital, Kansas City, MO, USA; Department of Pediatrics, University of Missouri, Kansas City, KS, USA
| | - Stacey L Ishman
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Division of HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada.
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Economou NT, Ferini-Strambi L, Steiropoulos P. Sleep-Related Drug Therapy in Special Conditions: Children. Sleep Med Clin 2022; 17:531-542. [PMID: 36150812 DOI: 10.1016/j.jsmc.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pharmacologic treatment of the most common pediatric sleep disorders lacks evidence, and alternative methods, which have been proved to alleviate the symptoms, are preferred in most cases. The implementation of specific guidelines is of great importance because sleep disorders in children are not rare and they can negatively affect children's development and their cognitive and social skills. This article summarizes the current therapeutic management of sleep disorders in children, bearing in mind the absence of evidence-based guidelines on this topic.
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Affiliation(s)
- Nicholas-Tiberio Economou
- Sleep Unit, Department of Psychiatry, University of Athens, 74 Vas Sofias Avenue, Athens 11528, Greece; Enypnion Sleep-Epilepsy Center, Bioclinic Hospital Athens, 15 M. Geroulanou Street, Athens 11524, Greece
| | - Luigi Ferini-Strambi
- Division of Neuroscience, University Vita-Salute San Raffaele, Via Stamira d'Ancona 20, Milan 20127, Italy
| | - Paschalis Steiropoulos
- Department of Pulmonology, Medical School, Democritus University of Thrace, University Campus, Dragana, Alexandroupolis 68100, Greece.
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Sharma AV, Padhya T, Nallu S. Management of Pediatric Obstructive Sleep Apnea After Failed Tonsillectomy and Adenoidectomy. Adv Pediatr 2022; 69:95-105. [PMID: 35985719 DOI: 10.1016/j.yapd.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pediatric obstructive sleep apnea (OSA) represents a different entity from its adult counterpart and therefore requires a different therapeutic approach. Adenotonsillectomy (AT) is the primary treatment of pediatric OSA, and evidence shows it is very effective. However, there is a growing understanding that residual OSA is common, and next steps for patients who fail primary AT are less certain. This article reviews current methods of evaluating and treating these complex patients.
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Affiliation(s)
- Abhay Varun Sharma
- Department of Otolaryngology Head and Neck Surgery, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, MDC 73 Tampa, FL 33612, USA.
| | - Tapan Padhya
- Department of Otolaryngology Head and Neck Surgery, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, MDC 73 Tampa, FL 33612, USA
| | - Sagarika Nallu
- USF Health Department of Pediatrics, Division of Neurology, 13101 Bruce B Downs Boulevard, Tampa, FL 33612, USA
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Li C, Kou YF, Ishman SL. Pediatric OSA: Evidence-Based Review of Treatment Results. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00348-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bhattacharjee R. Question 5: Which children with OSA should be considered for medical therapy? Paediatr Respir Rev 2021; 37:64-67. [PMID: 33342726 DOI: 10.1016/j.prrv.2020.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Rakesh Bhattacharjee
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
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Alternative Approaches to Adenotonsillectomy and Continuous Positive Airway Pressure (CPAP) for the Management of Pediatric Obstructive Sleep Apnea (OSA): A Review. SLEEP DISORDERS 2020; 2020:7987208. [PMID: 32695520 PMCID: PMC7355373 DOI: 10.1155/2020/7987208] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022]
Abstract
Continuous positive airway pressure (CPAP) is considered first-line treatment in the management of pediatric patients without a surgically correctible cause of obstruction who have confirmed moderate-to-severe obstructive sleep apnea (OSA). The evidence supports its reduction on patient morbidity and positive influence on neurobehavioral outcome. Unfortunately, in clinical practice, many patients either refuse CPAP or cannot tolerate it. An update on alternative approaches to CPAP for the management of OSA is discussed in this review, supported by the findings of systematic reviews and recent clinical studies. Alternative approaches to CPAP and adenotonsillectomy for the management of OSA include weight management, positional therapy, pharmacotherapy, high-flow nasal cannula, and the use of orthodontic procedures, such as rapid maxillary expansion and mandibular advancement devices. Surgical procedures for the management of OSA include tongue-base reduction surgery, uvulopalatopharyngoplasty, lingual tonsillectomy, supraglottoplasty, tracheostomy, and hypoglossal nerve stimulation. It is expected that this review will provide an update on the evidence available regarding alternative treatment approaches to CPAP for clinicians who manage patients with pediatric OSA in daily clinical practice.
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Gozal D, Tan HL, Kheirandish-Gozal L. Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision. J Clin Med 2020; 9:jcm9030888. [PMID: 32213932 PMCID: PMC7141493 DOI: 10.3390/jcm9030888] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/06/2020] [Accepted: 03/18/2020] [Indexed: 12/18/2022] Open
Abstract
Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.
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Affiliation(s)
- David Gozal
- Department of Child Health and the Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA;
- Correspondence:
| | - Hui-Leng Tan
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK;
| | - Leila Kheirandish-Gozal
- Department of Child Health and the Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA;
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Kuhle S, Hoffmann DU, Mitra S, Urschitz MS. Anti-inflammatory medications for obstructive sleep apnoea in children. Cochrane Database Syst Rev 2020; 1:CD007074. [PMID: 31978261 PMCID: PMC6984442 DOI: 10.1002/14651858.cd007074.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is characterised by partial or complete upper airway obstruction during sleep. Approximately 1% to 4% of children are affected by OSA, with adenotonsillar hypertrophy being the most common underlying risk factor. Surgical removal of enlarged adenoids or tonsils is the currently recommended first-line treatment for OSA due to adenotonsillar hypertrophy. Given the perioperative risk and an estimated recurrence rate of up to 20% following surgery, there has recently been an increased interest in less invasive alternatives to adenotonsillectomy. As the enlarged adenoids and tonsils consist of hypertrophied lymphoid tissue, anti-inflammatory drugs have been proposed as a potential non-surgical treatment option in children with OSA. OBJECTIVES To assess the efficacy and safety of anti-inflammatory drugs for the treatment of OSA in children. SEARCH METHODS We identified trials from searches of the Cochrane Airways Group Specialised Register, CENTRAL and MEDLINE (1950 to 2019). For identification of ongoing clinical trials, we searched ClinicalTrials.gov and the World Health Organization (WHO) trials portal. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing anti-inflammatory drugs against placebo in children between one and 16 years with objectively diagnosed OSA (apnoea/hypopnoea index (AHI) ≥ 1 per hour). DATA COLLECTION AND ANALYSIS Two authors independently performed screening, data extraction, and quality assessment. We separately pooled results for the comparisons 'intranasal steroids' and 'montelukast' against placebo using random-effects models. The primary outcomes for this review were AHI and serious adverse events. Secondary outcomes included the respiratory disturbance index, desaturation index, respiratory arousal index, nadir arterial oxygen saturation, mean arterial oxygen saturation, avoidance of surgical treatment for OSA, clinical symptom score, tonsillar size, and adverse events. MAIN RESULTS We included five trials with a total of 240 children aged one to 18 years with mild to moderate OSA (AHI 1 to 30 per hour). All trials were performed in specialised sleep medicine clinics at tertiary care centres. Follow-up time ranged from six weeks to four months. Three RCTs (n = 137) compared intranasal steroids against placebo; two RCTs compared oral montelukast against placebo (n = 103). We excluded one trial from the meta-analysis since the patients were not analysed as randomised. We also had concerns about selective reporting in another trial. We are uncertain about the difference in AHI (MD -3.18, 95% CI -8.70 to 2.35) between children receiving intranasal corticosteroids compared to placebo (2 studies, 75 participants; low-certainty evidence). In contrast, children receiving oral montelukast had a lower AHI (MD -3.41, 95% CI -5.36 to -1.45) compared to those in the placebo group (2 studies, 103 participants; moderate-certainty evidence). We are uncertain whether the secondary outcomes are different between children receiving intranasal corticosteroids compared to placebo: desaturation index (MD -2.12, 95% CI -4.27 to 0.04; 2 studies, 75 participants; moderate-certainty evidence), respiratory arousal index (MD -0.71, 95% CI -6.25 to 4.83; 2 studies, 75 participants; low-certainty evidence), and nadir oxygen saturation (MD 0.59%, 95% CI -1.09 to 2.27; 2 studies, 75 participants; moderate-certainty evidence). Children receiving oral montelukast had a lower respiratory arousal index (MD -2.89, 95% CI -4.68 to -1.10; 2 studies, 103 participants; moderate-certainty evidence) and nadir of oxygen saturation (MD 4.07, 95% CI 2.27 to 5.88; 2 studies, 103 participants; high-certainty evidence) compared to those in the placebo group. We are uncertain, however, about the difference in desaturation index (MD -2.50, 95% CI -5.53 to 0.54; 2 studies, 103 participants; low-certainty evidence) between the montelukast and placebo group. Adverse events were assessed and reported in all trials and were rare, of minor nature (e.g. nasal bleeding), and evenly distributed between study groups. No study examined the avoidance of surgical treatment for OSA as an outcome. AUTHORS' CONCLUSIONS There is insufficient evidence for the efficacy of intranasal corticosteroids for the treatment of OSA in children; they may have short-term beneficial effects on the desaturation index and oxygen saturation in children with mild to moderate OSA but the certainty of the benefit on the primary outcome AHI, as well as the respiratory arousal index, was low due to imprecision of the estimates and heterogeneity between studies. Montelukast has short-term beneficial treatment effects for OSA in otherwise healthy, non-obese, surgically untreated children (moderate certainty for primary outcome and moderate and high certainty, respectively, for two secondary outcomes) by significantly reducing the number of apnoeas, hypopnoeas, and respiratory arousals during sleep. In addition, montelukast was well tolerated in the children studied. The clinical relevance of the observed treatment effects remains unclear, however, because minimal clinically important differences are not yet established for polysomnography-based outcomes in children. Long-term efficacy and safety data on the use of anti-inflammatory medications for the treatment of OSA in childhood are still not available. In addition, patient-centred outcomes like concentration ability, vigilance, or school performance have not been investigated yet. There are currently no RCTs on the use of other kinds of anti-inflammatory medications for the treatment of OSA in children. Future RCTs should investigate sustainability of treatment effects, avoidance of surgical treatment for OSA, and long-term safety of anti-inflammatory medications for the treatment of OSA in children and include patient-centred outcomes.
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Affiliation(s)
- Stefan Kuhle
- Dalhousie UniversityDepartments of Pediatrics and Obstetrics & GynaecologyHalifaxNSCanada
| | - Dorle U Hoffmann
- University Medical Centre of the Johannes Gutenberg UniversityDivision of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)Langenbeckstrausse 1MainzRhineland‐PalatinateGermany55131
| | - Souvik Mitra
- Dalhousie University & IWK Health CentreDepartments of Pediatrics, Community Health & EpidemiologyG‐2214, 5850/5980 University AvenueHalifaxNova ScotiaCanadaB3K 6R8
| | - Michael S Urschitz
- University Medical Centre of the Johannes Gutenberg UniversityDivision of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)Langenbeckstrausse 1MainzRhineland‐PalatinateGermany55131
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Howard JJM, Sarber KM, Yu W, Smith DF, Tikhtman RO, Simakajornboon N, Ishman SL. Outcomes in children with down syndrome and mild obstructive sleep apnea treated non-surgically. Laryngoscope 2019; 130:1828-1835. [PMID: 31603543 DOI: 10.1002/lary.28325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 08/27/2019] [Accepted: 09/06/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Nasal steroids, oral anti-leukotrienes and supplemental oxygen are effective in the treatment of mild obstructive sleep apnea (OSA) in otherwise healthy children. However, their efficacy is unknown in children with Down syndrome (DS). Here we examine the effect of single medication therapy versus observation versus oxygen on polysomnographic outcomes in these children. METHODS We reviewed children (<18 years) diagnosed with DS and mild OSA (obstructive apnea-hypopnea index [oAHI] ≥1 to <5 events/hour) treated non-surgically (with supplemental oxygen, one medication, or observation) between 2012 and 2017. Demographic data, comorbid diagnoses, and pre- and posttreatment polysomnograms were analyzed. We assessed pre- and posttreatment oAHI, oxyhemoglobin saturation nadir, percent total sleep time (%TST) in rapid eye movement (REM), and end-tidal carbon dioxide (ETCO2 ) >50 mmHg. RESULTS Twenty-four children met inclusion criteria; 10 treated with medication, one with oxygen, and 13 with observation (baseline oAHI was 3.5, 3.3, and 2.9 events/hour, respectively). There was no significant change in oAHI, oxyhemoglobin saturation nadir, ETCO2 , or percent TST in REM after treatment for any treatment group (P = .21-.94). There was no association between reported symptoms and AHI severity or change in AHI. OSA resolved in one patient treated with observation and two treated with medication, but worsened in two each in the medication and observation groups. Resolution of OSA occurred in 20% treated with medication, 7.7% with observation, and 0% with oxygen (P = .82). CONCLUSION In our cohort, resolution of mild OSA was low. This suggests that consideration should be given to multimodality treatments in children with DS and mild OSA. Prospective studies will help establish effectiveness in this cohort. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1828-1835, 2020.
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Affiliation(s)
- Javier J M Howard
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Kathleen M Sarber
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Wenwen Yu
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Oral and Craniomaxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - David F Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Raisa O Tikhtman
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Narong Simakajornboon
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
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Bluher AE, Ishman SL, Baldassari CM. Managing the Child with Persistent Sleep Apnea. Otolaryngol Clin North Am 2019; 52:891-901. [PMID: 31301824 DOI: 10.1016/j.otc.2019.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA.
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Affiliation(s)
- Andrew E Bluher
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive, Suite 1100, Norfolk, VA 23507, USA
| | - Stacey L Ishman
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC# 2018, Cincinnati, OH 45229-2018, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC# 2018, Cincinnati, OH 45229-2018, USA
| | - Cristina M Baldassari
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive, Suite 1100, Norfolk, VA 23507, USA; Departments of Pediatric Otolaryngology and Pediatric Sleep Medicine, Children's Hospital of the King's Daughters, 601 Children's Lane, 2nd Floor, Norfolk, VA 23507, USA.
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12
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Amaddeo A, Khirani S, Frapin A, Teng T, Griffon L, Fauroux B. High-flow nasal cannula for children not compliant with continuous positive airway pressure. Sleep Med 2019; 63:24-28. [PMID: 31604152 DOI: 10.1016/j.sleep.2019.05.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Continuous positive airway pressure (CPAP) is an effective treatment of severe obstructive sleep apnea (OSA) but poor compliance is a major limitation. High-flow nasal cannula (HFNC) has been used as an alternative but data about efficacy and objective long-term compliance are scarce; this study aims to address this lack of data. PATIENTS/METHODS All consecutive patients, aged 0-18 years, treated with CPAP for a severe OSA defined as an apnea-hypopnea index (AHI) > 10 events/h, and not compliant with home CPAP therapy, defined by a CPAP use of <2 h/night, after at least four weeks from CPAP initiation were considered eligible for the study. HFNC was started during an outpatient visit. Study outcomes were the objective compliance (number of hours use/night) after one month and the improvement of OSA on a respiratory polygraphy (RP) with HFNC. RESULTS Eight patients (two boys, mean age 8.9 ± 6.2 years, mean AHI 33 ± 22 events/h) were included in the study: Down syndrome (N = 6), Pierre Robin syndrome (N = 1), Pfeiffer syndrome (N = 1). After one month, five (62%) patients slept with HFNC more than 4 h/night (mean compliance 7 h 10 min ± 0 h 36 min/night). HFNC corrected OSA in the five compliant patients (mean AHI 2 ± 2 events/h with HFNC). HFNC was not accepted by the three oldest patients with Down syndrome. CONCLUSION A good compliance as well as a correction of OSA may be obtained with HFNC in selected children with OSA not compliant to CPAP. HFNC may be used as a rescue therapy for children not compliant with CPAP.
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Affiliation(s)
- Alessandro Amaddeo
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, EA 7330 VIFASOM (Vigilance Fatigue Sommeil et Santé Publique), Paris, France.
| | - Sonia Khirani
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, EA 7330 VIFASOM (Vigilance Fatigue Sommeil et Santé Publique), Paris, France; ASV Santé, Gennevilliers, France
| | - Annick Frapin
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France
| | - Theo Teng
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France
| | - Lucie Griffon
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, EA 7330 VIFASOM (Vigilance Fatigue Sommeil et Santé Publique), Paris, France
| | - Brigitte Fauroux
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, EA 7330 VIFASOM (Vigilance Fatigue Sommeil et Santé Publique), Paris, France
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New Options in Pediatric Obstructive Sleep Apnea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Liming BJ, Ryan M, Mack D, Ahmad I, Camacho M. Montelukast and Nasal Corticosteroids to Treat Pediatric Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2018; 160:594-602. [DOI: 10.1177/0194599818815683] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To systematically review the literature on anti-inflammatory medications for treating pediatric obstructive sleep apnea and perform meta-analysis of the available data. Data Sources PubMed/MEDLINE and 4 additional databases. Review Methods Three authors independently and systematically searched through June 28, 2018, for studies that assessed anti-inflammatory therapy for treatment of pediatric obstructive sleep apnea (OSA). Data were compiled and analyzed using Review Manager 5.3 (Nordic Cochrane Centre). Results After screening 135 studies, 32 were selected for review with 6 meeting inclusion criteria. In total, 668 patients aged 2 to 5 years met inclusion criteria for meta-analysis. Of these, 5 studies (166 children) that evaluated montelukast alone as treatment for pediatric OSA found a 55% improvement in the apnea-hypopnea index (AHI) (mean [SD] 6.2 [3.1] events/h pretreatment and 2.8 [2.7] events/h posttreatment; mean difference [MD] of −2.7 events/h; 95% confidence interval [CI], –5.6 to 0.3) with improvement in lowest oxygen saturation (LSAT) from 89.5 (6.9) to 92.1 (3.6) (MD, 2.2; 95% CI, 0.5-4.0). Two studies (502 children) observing the effects of montelukast with intranasal corticosteroids on pediatric OSA found a 70% improvement in AHI (4.7 [2.1] events/h pretreatment and 1.4 [1.0] events/h posttreatment; MD of −4.2 events/h; 95% CI, –6.3 to −2.0), with an improvement in LSAT from 87.8 (3.1) to 92.6 (2.2) (MD, 4.8; 95% CI, 4.5-5.1). Conclusions Treatment with montelukast and intranasal steroids or montelukast alone is potentially beneficial for short-term management of mild pediatric OSA.
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Affiliation(s)
- Bryan J. Liming
- Otolaryngology Head and Neck Surgery, Tripler Army Medical Center, Hawaii, USA
| | - Matthew Ryan
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Douglas Mack
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Iram Ahmad
- Department of Otolaryngology, Stanford University, Stanford, California, USA
| | - Macario Camacho
- Otolaryngology Head and Neck Surgery, Tripler Army Medical Center, Hawaii, USA
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Abstract
Sleep disorders in children may lead to neurodevelopmental and neurocognitive deficits; it is important to diagnose and treat them properly. Apart from the existing challenges in diagnosis, another drawback is that few therapies are currently approved. In this article, a comprehensive summary of the most common pediatric sleep disorders, along with the various pharmacologic and nonpharmacologic approaches for their management, is presented. Special attention has been paid to the currently available treatment options for pediatric insomnia, obstructive sleep apnea, parasomnias, narcolepsy, and restless legs syndrome, and comparisons are made with the corresponding treatment options for sleep disorders in adults.
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Simpson R, Oyekan AA, Ehsan Z, Ingram DG. Obstructive sleep apnea in patients with Down syndrome: current perspectives. Nat Sci Sleep 2018; 10:287-293. [PMID: 30254502 PMCID: PMC6143127 DOI: 10.2147/nss.s154723] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
For individuals with Down syndrome (DS), obstructive sleep apnea (OSA) is a complex disorder with significant clinical consequences. OSA is seen frequently in DS, and when present, it tends to be more severe. This increased prevalence is likely related to common anatomic abnormalities and a greater risk of additional comorbidities such as hypotonia and obesity. Because signs and symptoms do not often correlate with disease, all children and adults with DS should receive routine screening for OSA. Similar to the general population, polysomnography remains the gold standard for diagnosis. Because individuals with DS may be more susceptible to cardiovascular and neurocognitive sequelae, early diagnosis and treatment of OSA is becoming increasingly important. Treatment options generally involve upper airway surgery (primarily adenotonsillectomy) and continuous positive airway pressure (CPAP); however, various adjunctive therapies including intranasal steroids, palatal expansion, and oropharyngeal exercises are also available. Residual disease status post adenotonsillectomy is common, and further evaluation (eg, drug-induced sleep endoscopy [DISE]) is often needed. More advanced and directed airway surgery can be performed if additional sites of obstruction are observed. Novel therapies including hypoglossal nerve stimulation are emerging as effective treatments for refractory OSA. Due to the diversity among individuals with DS, personalized treatment plans should be developed. Within this arena, opportunities for research remain abundant and should include areas involving patient risk factors, alternative diagnostic methods, and outcome analysis.
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Affiliation(s)
- Ryne Simpson
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA,
| | - Anthony A Oyekan
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA,
| | - Zarmina Ehsan
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA, .,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA,
| | - David G Ingram
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA, .,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA,
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Adenoidectomy and chronic nasal obstruction developing after failure of nasal steroid therapy. Am J Otolaryngol 2018; 39:75-76. [PMID: 29132731 DOI: 10.1016/j.amjoto.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/06/2017] [Indexed: 11/21/2022]
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Min HJ, Kim KS. In Reference to "The Effect of Montelukast on Mild Persistent OSA after Adenotonsillectomy in Children: A Preliminary Study". Otolaryngol Head Neck Surg 2017; 157:909. [PMID: 29090646 DOI: 10.1177/0194599817711693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Management of Pediatric OSA Beyond Adeno-Tonsillectomy. CURRENT SLEEP MEDICINE REPORTS 2017. [DOI: 10.1007/s40675-017-0083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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