Sleep disordered breathing in childhood

Evaluation of polysomnography findings in children with genetic skeletal disorders

Children with genetic skeletal disorders have variable conditions that can lead to sleep-disordered breathing, and polysomnography is the gold standard for diagnosing this condition. We aimed to review polysomnography findings, to assess the severity of sleep apnea, and to investigate the clinical variables predictive of sleep-disordered breathing in these patients. We retrospectively collected the medical records of patients with genetic skeletal disorders who underwent polysomnography for 5 years. Twenty-seven children with various genetic skeletal disorders, including achondroplasia (14), Crouzon syndrome (3), acromesomelic dysplasia Maroteaux type (3), Apert syndrome (2), osteopetrosis (1), Jeune dysplasia (1), Desbuquois dysplasia (1), acrodysostosis (1), and spondyloepiphyseal dysplasia (1) were enrolled. The median age at the first polysomnography was 58 (1st-3rd quartile: 31-113) months. The overall sleep-disordered breathing results were: 19 (70.3%) had obstructive sleep apneas (OSA) (4 mild, 6 moderate, 9 severe), 2 (7.4%) had central apneas, 4 (14.8%) had nocturnal hypoventilation. There was a significant correlation between non-ambulatory status with both total AHI and OSA (p < 0.001, rho: -0.66/p = 0.04, rho: 0.38, respectively). Nine patients received positive airway pressure titration, and the oAHI values of all returned to the normal range. These patients were started with positive airway pressure treatment. Our cohort showed that the majority of the patients with skeletal dysplasia had sleep apnea syndrome characterised mainly by OSA, highlighting the importance of polysomnography screening for sleep disorders. Positive airway pressure therapy represents an effective treatment for sleep-disordered breathing in those patients.

Pediatric sleep-disordered breathing in Shanghai: characteristics, independent risk factors and its association with malocclusion

OBJECTIVES

This study aimed to determine the prevalence and independent risk factors of SDB, and explore its association with malocclusion among 6-11-year-old children in Shanghai, China.

METHODS

A cluster sampling procedure was adopted in this cross-sectional study. Pediatric Sleep Questionnaire (PSQ) was applied to evaluate the presence of SDB. Questionnaires including PSQ, medical history, family history, and daily habits/environment were completed by parents under instruction, and oral examinations were implemented by well-trained orthodontists. Multivariable logistic regression was applied to identify independent risk factors for SDB. Chi-square tests and Spearman's Rank Correlation were used to estimate the relationship between SDB and malocclusion.

RESULTS

A total of 3433 subjects (1788 males and 1645 females) were included in the study. The SDB prevalence was about 17.7%. Allergic rhinitis (OR 1.39, 95% CI 1.09-1.79), adenotonsillar hypertrophy (OR 2.39, 95% CI 1.82-3.19), paternal snoring (OR 1.97, 95% CI 1.53-2.53), and maternal snoring (OR 1.35, 95% CI 1.05-1.73) were independent risk factors for SDB. The SDB prevalence was higher in children with retrusive mandibles than in proper or excessive ones. No significant difference was observed in the correlation between SDB and lateral facial profile, mandible plane angle, constricted dental arch form, the severity of anterior overjet and overbite, degree of crowding and spacing, and the presence of crossbite and open bite.

CONCLUSIONS

The prevalence of SDB in primary students in the Chinese urban population was high and highly associated with mandible retrusion. The independent risk factors included Allergic rhinitis, adenotonsillar hypertrophy, paternal snoring, and maternal snoring. More efforts should be made to enhance public education about SDB and related dental-maxillofacial abnormalities.

Does sleep-disordered breathing add to impairments in academic performance and brain structure usually observed in children with overweight/obesity?

Approximately 4-11% of children suffer from sleep-disordered breathing (SDB), and children with obesity are at increased risk. Both obesity and SDB have been separately associated with poorer brain health, yet whether SDB severity affects brain health in children with obesity remains unanswered. This study aimed to examine associations of SDB severity with academic performance and brain structure (i.e., total brain and gray and white matter volumes and gray matter volume in the hippocampus) in children with overweight/obesity. One hundred nine children aged 8-12 years with overweight/obesity were included. SDB severity and its subscales (i.e., snoring, daytime sleepiness, and inattention/hyperactivity) were evaluated via the Pediatric Sleep Questionnaire (PSQ), and academic performance was evaluated with the Woodcock-Muñoz standardized test and school grades. Brain structure was assessed by magnetic resonance imaging. SDB severity was not associated with academic performance measured by the standardized test (all |β|> 0.160, P > 0.076), yet it was associated with the school grade point average (β = -0.226, P = 0.007) and natural and social science grades (β = -0.269, P = 0.024). Intention/hyperactivity seemed to drive these associations. No associations were found between SDB severity and the remaining school grades (all β < -0.188, P > 0.065) or brain volumes (all P > 0.05).

CONCLUSION

Our study shows that SDB severity was associated with lower school grades, yet it was not associated with the standardized measurement of academic performance or with brain volumes in children with overweight/obesity. SDB severity may add to academic problems in children beyond the effects contributed by overweight/obesity status alone.

WHAT IS KNOWN

• Sleep-disordered breathing (SDB) may affect brain structure and academic performance in children. • Children with overweight/obesity are at higher risk for the development of SDB, yet the comorbid obesity-SDB relationship with brain health has not been investigated thus far.

WHAT IS NEW

• To our knowledge, this is the first study examining the associations of comorbid obesity-SDB severity with brain volumes and academic performance in children. • SDB symptoms may adversely affect academic performance at school in children with overweight/obesity, beyond the effects of weight status alone.

Prevalence of sleep-disordered breathing and associated risk factors in primary school children in urban and rural environments

INTRODUCTION

Sleep-disordered breathing (SDB) in primary school children is a significant problem, yet its prevalence is not well known outside large urban settings. Information on the burden and risk factors of SDB in children could be used to improve resource allocation when providing care across a large country. The objectives of this study were to assess the prevalence of SDB among school-aged children comparing rural and urban settings, and to investigate associated risk factors.

METHODS

In this cross-sectional study, a random sample of primary school students in Turkey were selected from urban and rural areas and data were collected using the Pediatric Sleep Questionnaire, asthma, and allergic rhinitis questionnaires completed by the parents.

RESULTS

Questionnaires were collected from a total of 139 schools from 58 provinces. A total of 11,013 students were contacted, and 9045 (73%) completed the study. There was no difference in the prevalence of SDB between rural and urban settings (16% vs. 15%, p = 0.612). Multivariate logistic regression analysis revealed that current wheezing, current rhinoconjunctivitis, being overweight, parental snoring, and current mold at home were significant risk factors for SDB in both rural and urban children. Current tobacco smoke exposure (OR = 1.48, 95%CI = 1.19-1.85), near roadway air pollution exposure (OR = 1.40, 95%CI = 1.108-1.791), and mold at home in the first year of life (OR = 1.68, 95%CI = 1.26-2.23) were associated with SDB in urban children. History of maternal/paternal adenotonsillectomy was a significant predictor of SDB in the rural setting (OR = 1.63, 95%CI = 1.12-2.39).

CONCLUSION

The prevalence of SDB is high in children living in both settings but associated risk factors may vary. Children residing in rural areas should also be screened for sleep-disordered breathing during routine health visits.

Beyond the growth delay in children with sleep-related breathing disorders: a systematic review

INTRODUCTION

The availability of high-quality studies on the association between sleep-disordered breathing in children and delayed growth associated with the hormonal profile recorded before surgery and at follow-up is limited.

EVIDENCE ACQUISITION

Medline PubMed, Scopus and WebOfScience databases were searched for relevant publications published between January 2008 to January 2020 and a total of 261 potentially eligible studies were identified.

EVIDENCE SYNTHESIS

Following review 19 papers were eligible for inclusion: seven reported a significant postsurgical increase in growth regardless of initial weight status, type of surgery, type of study design, and length of follow-up period. The only high-quality study was a randomized controlled trial that found an increased risk of obstructive sleep apnea syndrome relapse in overweight children. Twelve studies reported the significant increase in growth parameters showing that IGF-1, IGFBP-3, and ghrelin may boost growth after surgery.

CONCLUSIONS

The current systematic review demonstrates a scarcity of high-quality studies on growth delay in children with sleep-disordered breathing. Significant catch-up growth after surgery in the short term and changes in IGF-1, IGFBP-3, ghrelin, and leptin levels has been reported in most published studies.

Short-term effect of adenotonsillectomy on growth and nutritional anthropometric parameters of children with obstructive adenotonsillar enlargement

Background

Obstructive adenotonsillar enlargement is known to cause failure to thrive in children. The effect of adenotonsillectomy is not well documented on the growth of affected children. The study was carried out to investigate the effect of adenotonsillectomy on growth of children with obstructive adenotonsillar enlargement. It was a quasi-experimental study consisting of 62 children (≤ 12 years) with obstructive adenotonsillar enlargement and 62 healthy controls. Variables measured at baseline, sixth week and 13th week post adenotonsillectomy, were weight, height, mid-upper arm circumference, and triceps skinfold thickness. The percent of weight-for-age and height-for-age were, respectively, calculated by dividing the child’s weight and height by the median expected weight and height (i.e., the 50th percentile) based on the child’s chronological age. The obtained weight-for-age and height-for-age values were used to determine the presence of failure to thrive and stunting, respectively.

Results

Majority (70.6%) of the patients with malnutrition were from a low socioeconomic class. At baseline, failure to thrive and stunting were found among 17 (26.4%) cases and 11 (17.7%) controls, but the proportion reduced to six (9.7%) and three (4.8%), respectively, at the 13th week post adenotonsillectomy. There was a steady increase in weight-for-age, height-for-age, mid-upper arm circumference, and triceps skinfold thickness in both cases and controls from baseline to the 13th week. However, there was a significant difference in percentage variation of these variables between the two groups.

Conclusions

Adenotonsillectomy improved the growth of children with obstructive adenotonsillar enlargement and hence recommended in cases with failure to thrive and stunting.

Obstructive Sleep Apnea and Inflammation: Proof of Concept Based on Two Illustrative Cytokines

Obstructive sleep apnea syndrome (OSAS) is a markedly prevalent condition across the lifespan, particularly in overweight and obese individuals, which has been associated with an independent risk for neurocognitive, behavioral, and mood problems as well as cardiovascular and metabolic morbidities, ultimately fostering increases in overall mortality rates. In adult patients, excessive daytime sleepiness (EDS) is the most frequent symptom leading to clinical referral for evaluation and treatment, but classic EDS features are less likely to be reported in children, particularly among those with normal body-mass index. The cumulative evidence collected over the last two decades supports a conceptual framework, whereby sleep-disordered breathing in general and more particularly OSAS should be viewed as low-grade chronic inflammatory diseases. Accordingly, it is assumed that a proportion of the morbid phenotypic signature in OSAS is causally explained by underlying inflammatory processes inducing end-organ dysfunction. Here, the published links between OSAS and systemic inflammation will be critically reviewed, with special focus on the pro-inflammatory cytokines tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6), since these constitute classical prototypes of the large spectrum of inflammatory molecules that have been explored in OSAS patients.

Polysomnographic correlates of endothelial function in children with obstructive sleep apnea

OBJECTIVES

To evaluate endothelial function in a large cohort of children clinically referred for suspected obstructive sleep apnea syndrome (OSAS), and to identify risk factors contributing to the presence of endothelial dysfunction (ED).

METHODS

Habitually snoring children (age range, 3-11 years) were recruited. All participants underwent overnight polysomnography (PSG). Endothelial function test used peripheral arterial tonometry (PAT) to derive the reactive hyperemia index (RHI). Subjects were then divided into mild OSA, moderate-severe OSA and primary snorers (PS), according to their obstructive apnea-hypopnea index (OAHI).

RESULTS

A total of 355 subjects were recruited. There were no differences in age, gender, or BMI z score among the three groups. Both mild and moderate-severe OSA groups had lower RHI than PS (P < 0.001, P = 0.001, respectively). Linear regression analysis revealed that RHI was positively correlated with age (r = 0.17, P = 0.002), BMI z score (r = 0.14, P = 0.008) and oxygen saturation nadir (r = 0.15, P = 0.006), but negatively correlated with oxygen desaturation index (ODI_3%; r = -0.19, P = 0.001) and respiratory-related arousal index (ArI-resp) (r = -0.24, P < 0.001). In stepwise regression analysis, age, BMI z score, and ArI-resp were independently associated with endothelial function (r = 0.34, P < 0.001).

CONCLUSION

Children with OSA are at increased risk for abnormal endothelial function than habitually snoring children. Furthermore, in addition to age and BMI, which are well-established factors affecting endothelial function, both intermittent hypoxia and sleep fragmentation during sleep also emerge as candidate risk factors contributing to endothelial dysfunction in snoring children.

CLINICAL TRIAL

Follow up of PS and OSAHS in Chinese children, https://clinicaltrials.gov/, Clinical number: NCT02447614.

Clinical and polysomnographic features of children evaluated with polysomnography in pediatric sleep laboratory

AIM

Sleep disordered breathing is a common problem in childhood that encompasses a spectrum of disorders extending from primary snoring to obstructive sleep apnea. This study aims to investigate the results of children undergoing evaluation with polysomnography in the sleep laboratory of a tertiary care hospital.

MATERIAL AND METHODS

Demographic and clinical features as well as sleep associated symptoms, scores of pediatric sleep questionnaire and Pittsburgh sleep quality index and polysomnography results are retrospectively evaluated.

RESULTS

Totally 131 patients were evaluated, of which 47.3% (n=62) were females and 52.7% (n=69) were males. Mean age was 101.85±59.15 months at the time of the study. Fifty percent (n=59) of patients complained of snoring and 43.7% (n=52) of patients complained of apnea during sleep. Mean obstructive hypopnea-apnea index was 5.12±11.72. Mean obstructive hypopnea-apnea index of snorers (6.93±13.53) was significantly higher than the mean obstructive hypopnea-apnea index of nonsnorers (2.32±5.43) (p=0.011). Mean obstructive hypopnea-apnea index of patients experiencing apnea during sleep (7.52±14.25) was significantly higher than the mean obstructive hypopnea-apnea index of the children who do not experience apnea (2.61±5.84) (p=0.008). No significant correlation was observed between obstructive hypopnea-apnea index and scores of pediatric sleep questionnaire and Pittsburgh sleep quality index. The prevalence of obstructive sleep apnea was 33.6% (n=44). Forty nine patients (39.8%) were treated after polysomnography. Frequently suggested treatment options were noninvasive mechanical ventilation (n=23, 46.9%), intranasal steroid (n=15, 30.6%), montelukast (n=11, 22.4%) and adenotonsillectomy (n=9, 18.4%).

CONCLUSIONS

Polysomnography is the gold standard in the diagnosis of sleep disordered breathing in children. Pediatricians should be able to recognize early signs and symptoms of sleep disordered breathing and refer the patients in risk to centers where evaluation with polysomnography is available.