Modified STOP-Bang Tool for Stratifying Obstructive Sleep Apnea Risk in Adolescent Children

Multidimensions of sleep health among in-school adolescents in rural and urban areas in southwestern Nigeria

INTRODUCTION

Previous studies have focused on sleep inequities among disadvantaged populations in high-income countries. However, little is known about the differences in sleep health among adolescents in Africa. We aimed to compare the multidimensions of sleep health in adolescents living in rural vs. urban communities in Nigeria.

METHODS

This cross-sectional study enrolled adolescents aged 13-19 in six rural and six urban schools in Osun State, Nigeria. We measured the prevalence of poor sleep quality (Pittsburgh Sleep Quality Index score >5), daytime sleepiness (Epworth Sleepiness Scale for Children and Adolescents score >10), and risk of sleep apnea (Teen STOPBANG). We compared the sleep health variables between the rural and urban populations using multivariable logistic regression.

RESULTS

Of the 900 participants (51% rural; 59% female; average age (SD)= 15.1(1.4) years), 79% had short sleep duration (<8.5 hours), 14.9% poor sleep quality, 9.6% excessive daytime sleepiness and 9.8% risk of sleep apnea. Urban adolescents had a higher prevalence of poor sleep quality (p = .004), short sleep duration (p < .001), daytime sleepiness (p = .044), and risk of sleep apnea (p = .006) compared to rural adolescents. The adjusted odds of having poor sleep quality (p = .008) and daytime sleepiness (p = .007) were about 2-fold higher among urban compared to rural adolescents. Later school end time, having single/separated parent(s), absence of parental setting of bedtime were independently associated with poorer sleep health.

CONCLUSION

Adolescents in rural communities had better sleep health than adolescents in urban communities. There is a need to develop interventions to improve the sleep quality and overall sleep health of urban-dwelling adolescents.

The First-Line Approach in Children with Obstructive Sleep Apnea Syndrome (OSA)

Obstructive sleep apnea syndrome (OSA) is the main manifestation of sleep-disordered breathing in children. Untreated OSA can lead to a variety of complications and adverse consequences mainly due to intermittent hypoxemia. The pathogenesis of OSA is multifactorial. In children aged 2 years or older, adenoid and/or tonsil hypertrophy are the most common causes of upper airway lumen reduction; obesity becomes a major risk factor in older children and adolescents since the presence of fat in the pharyngeal soft tissue reduces the caliber of the lumen. Treatment includes surgical and non-surgical options. This narrative review summarizes the evidence available on the first-line approach in children with OSA, including clinical indications for medical therapy, its effectiveness, and possible adverse effects. Literature analysis showed that AT is the first-line treatment in most patients with adenotonsillar hypertrophy associated with OSA but medical therapy in children over 2 years old with mild OSA is a valid option. In mild OSA, a 1- to 6-month trial with intranasal steroids (INS) alone or in combination with montelukast with an appropriate follow-up can be considered. Further studies are needed to develop an algorithm that permits the selection of children with OSA who would benefit from alternatives to surgery, to define the optimal bridge therapy before surgery, to evaluate the long-term effects of INS +/- montelukast, and to compare the impact of standardized approaches for weight loss.

Diagnosis of Paediatric Obstructive Sleep-Disordered Breathing beyond Polysomnography

Obstructive sleep-disordered breathing (SDB) has significant impacts on health, and therefore, a timely and accurate diagnosis is crucial for effective management and intervention. This narrative review provides an overview of the current approaches utilised in the diagnosis of SDB in children. Diagnostic methods for SDB in children involve a combination of clinical assessment, medical history evaluation, questionnaires, and objective measurements. Polysomnography (PSG) is the diagnostic gold standard. It records activity of brain and tibial and submental muscles, heart rhythm, eye movements, oximetry, oronasal airflow, abdominal and chest movements, body position. Despite its accuracy, it is a time-consuming and expensive tool. Respiratory polygraphy instead monitors cardiorespiratory function without simultaneously assessing sleep and wakefulness; it is more affordable than PSG, but few paediatric studies compare these techniques and there is optional recommendation in children. Nocturnal oximetry is a simple and accessible exam that has high predictive value only for children at high risk. The daytime nap PSG, despite the advantage of shorter duration and lower costs, is not accurate for predicting SDB. Few paediatric data support the use of home testing during sleep. Finally, laboratory biomarkers and radiological findings are potentially useful hallmarks of SDB, but further investigations are needed to standardise their use in clinical practice.

Comorbid insomnia and sleep apnea in children: a preliminary explorative study

Insomnia and sleep-disordered breathing (SDB) are prevalent sleep disorders. These disorders can therefore be concurrently present - comorbid insomnia and sleep apnea (COMISA). The prevalence of COMISA in the paediatric age range is unclear. As such, phenotypic constructs should help better define this comorbid condition if it exists in children and improve both diagnostic sensitivity and ultimately clinical care outcomes. We aimed to evaluate the frequency of insomnia in children and adolescents referred for evaluation of sleep symptoms suggestive of SDB in one initial (Cohort#1) and verify such findings in an independent cohort (Cohort#2) using a retrospective cross-sectional approach in patients aged 9-19 years presenting at a sleep centre to be evaluated for symptoms of SDB. Cohort #1 comprised 50 consecutive children (58% males; mean [SD] age 13.6 [3.3] years; median [interquartile range, IQR] Epworth Sleepiness Scale score 10 [6-12]) who were evaluated using validated SDB and insomnia questionnaires. Cohort#2 was extracted from electronic medical records and included 384 polysomnographically evaluated children (mean [SD] age 12.9 [3.6] years; mean [SD] body mass index z score 1.27 [0.28]; median Epworth Sleepiness Scale score 9.7 [4-17]). In Cohort #1, 56% were at high risk of SDB, 36% had insomnia alone, and 18% were at high risk of COMISA. The prevalence of COMISA in Cohort #2 was 16%, 72% had SDB alone, and 12% had insomnia alone. In both cohorts, COMISA manifested as increased propensity for sleepiness and fatigue during both waking and daytime. Thus, the presence of COMISA is frequent in the paediatric age range and accompanied by a more prominent symptomatic phenotype.

Sleep disordered breathing and its relation to stroke and pulmonary hypertension in children with sickle cell disease: a single-center cross-sectional study

Sleep disordered breathing (SDB) is a common underdiagnosed sequela of sickle cell disease (SCD) that has been linked to the frequency of vaso-occlusive crises. To determine the frequency of SDB in children with SCD and its association to SCD-related complications, thirty children and adolescents with SCD at their steady state underwent clinical, laboratory, and radiological assessment using transcranial duplex (TCD) and echo assessment of tricuspid regurge velocity (TRV). All participants had an overnight polysomnography after completing the modified STOP-Bang questionnaire. The mean age of the studied cohort was 10.2 years, with male: female ratio 1.7:1. Six children (20%) had high-risk for obstructive sleep apnea (OSA), while nine (30%) were at intermediate risk. Sleep apnea defined as apnea (AHI) > 1 event/hour was found among 18/30 (60%) subjects (14 males and 4 females). Children with AHI > 5 (moderate to severe OSA) had significantly higher TRV (p = 0.007) and left MCA flow velocity (p = 0.049) when compared to those with AHI < 5. Children with AHI > 5 were at higher risk of OSA according to the modified STOP-Bang questionnaire (p = 0.02). AHI positively correlated with TRV (r = 0.53, p = 0.003), right MCA flow velocity (r = 0.45, p = 0.013), and left MCA flow velocity (r = 0.55, p = 0.002), and negatively correlated to BMI-SDS (r =  - 0.48, p = 0.008). The high frequency of OSA in the studied cohort with SCD and its association with increasing risk of PH and TCD changes highlights the importance of early detection and management of OSA in children with SCD.

Metabolic, behavioral health, and disordered eating comorbidities associated with obesity in pediatric patients: An Obesity Medical Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. This CPS will be followed by a companion CPS covering further comorbidities, including genetics and social consequences related to overweight and obesity. These CPSs are intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices greater than or equal to the 95th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. It provides clinical information regarding identifying and treating metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children over the 95th percentile of weight/height for age.

Conclusions

This OMA clinical practice statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children and provides an overview of current recommendations. These recommendations lay out a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

Diagnostic and Therapeutic Approach to Children and Adolescents with Obstructive Sleep Apnea Syndrome (OSA): Recommendations in Emilia-Romagna Region, Italy

Obstructive sleep apnoea syndrome (OSA) in paediatrics is a rather frequent pathology caused by pathophysiological alterations leading to partial and prolonged obstruction (hypoventilation) and/or intermittent partial (hypopnoea) or complete (apnoea) obstruction of the upper airways. Paediatric OSA is characterised by daytime and night-time symptoms. Unfortunately, there are few data on shared diagnostic-therapeutic pathways that address OSA with a multidisciplinary approach in paediatric age. This document summarizes recommendations from the Emilia-Romagna Region, Italy, developed in order to provide the most appropriate tools for a multidisciplinary approach in the diagnosis, treatment and care of paediatric patients with OSA. The multidisciplinary group of experts distinguished two different 'step' pathways, depending on the age group considered (i.e., under or over two years). In most cases, these pathways can be carried out by the primary care paediatrician, who represents the first filter for approaching the problem. For this reason, it is essential that the primary care paediatrician receives adequate training on how to formulate the diagnostic suspicion of OSA and on what criteria to use to select patients to be sent to the hospital centre. The relationship between the paediatrician of the patient and her/his parents must see a synergy of behaviour between the various players in order to avoid uncertainty about the diagnostic and therapeutic decisions as well as the follow-up phase. The definition and evaluation of the organizational process and outcome indicators of the developed flow-chart, and the impact of its implementation will remain fundamental.

A multicenter study on the prevalence of adults and children seeking orthodontic treatment at high risk of obstructive sleep apnea

OBJECTIVE

To investigate the prevalence of adults and children seeking orthodontic treatment at high risk of obstructive sleep apnea (OSA) and pediatric OSA (POSA) and its association with demographic variables.

METHODS

One hundred-eleven adults and 105 children were consecutively recruited from three centers. The Epworth Sleepiness Scale (ESS) and ESS for Children and Adolescents were used for Risk stratifications for OSA and POSA.

RESULTS

The prevalence of patients seeking orthodontic treatment at high risk of OSA/POSA was 27.8%, where 26.1% were adults, and 29.5% were children. High risk for OSA/POSA was not associated with gender, ethnicity, age, Body Mass Index, or neck circumference.

CONCLUSION

Approximately 26% of adults and 30% of children seeking orthodontic care were at high risk for OSA and POSA. Screening for OSA and POSA among adults and children seeking orthodontic treatment is imperative.

Translation and cross-cultural adaptation of the sleep-related breathing disorder scale of the Pediatric Sleep Questionnaire into Danish language

OBJECTIVE/BACKGROUND

Sleep-disordered breathing (SDB) is common but often underestimated in children. The gold standard for assessing SDB is polysomnography, but it is expensive and time-consuming. The Paediatric Sleep Questionnaire (PSQ/SRDB) is a validated screening tool for SDB, which represents an efficient and alternative tool for screening SDB among children. However, a translated and validated Danish version of the PSQ/SRDB is not available yet. Our aim was to cross-culturally translate the PSQ/SRDB into Danish language for use in clinical and research settings.

PATIENTS/METHODS

The translation was carried out through forward-backward translation techniques performed by a panel of experts, and the cross-cultural adaptation was achieved by pretesting of the pre-final version. Internal consistency of the Danish PSQ/SRDB version was measured by Cronbach's alpha coefficients, while Cohen's kappa was used to evaluate test-retest reliability. Construct validity was assessed by factor analysis of the principal components.

RESULTS

The Danish PSQ/SRDB was administered to the caregivers of 348 children. An overall Cronbach's alpha of 0.72 was found, confirming the survey's consistency, with the results for the domains ranging 0.52-0.70. The Danish PSQ/SRDB showed moderate to perfect reliability for all items, except for one question (C14). Factor analysis performed on the Danish PSQ/SRDB showed that the predetermined four factors were similar with the original version of the PSQ/SRDB.

CONCLUSIONS

The Danish version of the PSQ/SRDB has been successfully translated and cross-culturally adapted, suggesting that it can be used as an appropriate paediatric screening tool for SDB in Denmark.

Selection of Screening Tool for Sleep-Disordered Breathing or Obstructive Sleep Apnea in Pediatric Patients in the Perianesthesia Setting

PURPOSE

This study was undertaken to select an appropriate tool to predict risk of obstructive sleep apnea (OSA) among pediatric patients in the preoperative setting.

DESIGN/METHODS

A retrospective chart review and a survey of nursing staff to compare two tools that were determined to be valid in assessing risk of OSA and postanesthesia complications in pediatric patients aged 6 months to 18 years was conducted. About 300 pediatric patients presenting for elective surgery were screened for OSA using STBUR (Snoring, Trouble Breathing during sleep, struggling to Breathe during Sleep, and waking UnRefreshed) and ST(1)OP-BANG (Snoring, Tonsillar hypertrophy, sleep Obstruction, BMI, Age, Neuromuscular disorders, and Genetic/congenital deformities) concurrently. Six preoperative nurses were then surveyed to compare ease of use and time to complete the screening tools.

FINDINGS

The STBUR tool was found to predict complications in 37.5% patients versus 22.7% patients with the pediatric ST(1)OP-BANG. Nursing staff found that although both tools were quick and easy to use, the STBUR tool was easier for parents to answer.

CONCLUSIONS

Use of a screening tool to help predict risk of OSA and postanesthetic complications also helps to dictate anesthesia technique, nursing staffing requirements, and plans of care for postoperative management of pediatric patients.

Sleep-disordered breathing in cystic fibrosis

Sleep-disordered breathing (SBD) is an under recognized comorbidity in the cystic fibrosis (CF) population across the lifespan. Nocturnal hypoxemia, obstructive sleep apnea, and nocturnal hypoventilation are respiratory abnormalities that occur commonly during sleep in patients with lung disease, and have deleterious consequences to the quality of life in people with CF. Effective screening for these abnormalities is needed to allow for timely initiation of treatment, which has been reported to be efficacious. Lack of treatment leads to worsened pulmonary, cardiovascular, and metabolic outcomes in patients. In this review, we give an overview of SBD for the CF clinician, including prevalence, treatment, and suggestions for future research. We strongly encourage the CF community to incorporate evaluation for SBD in CF clinical care so that outcomes for the subset of the CF patients with comorbid SBD improve.

[German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]

Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.

Screening of obstructive sleep apnea (OSA) risk in adolescent population and study of association with craniofacial and upper airway morphology

Background

Obstructive sleep apnea (OSA) is a common form of sleep-disordered breathing with high prevalence and associated co-morbidities. It still goes largely under-reported due to events occurring in sleep and difficulty in identifying predisposing factors.

Aims

To perform questionnaire-based screening of OSA-risk in adolescents and study association of OSA-risk with craniofacial and upper airway morphology.

Material and methods

Modified STOP-BANG questionnaire was used for screening OSA-risk in adolescent orthodontic patients (10-19 years) in a government dental hospital in India. Patients were categorised into two groups: OSA-risk and non-risk, based on the questionnaire scores, and were subsequently evaluated for craniofacial and upper airway morphology, both on examination and on lateral cephalometric radiographs.

Results

Documented a high prevalence of 14% for OSA-risk in adolescent orthodontic patients. The extra-oral and intra-oral parameters found significantly associated with OSA-risk were convex profile [Odd's ratio (OR) - 3.824], steep mandibular plane angle [MPA] (OR- 79.75), Type 3/4 faucial pillars (OR- 11.227), Class II molar relationship (OR - 4.518), ovoid upper arch form (OR - 13.750). In addition, the cephalometric parameters: ANB (p- 0.025), SN-MP (p- 0.007), BA-SN (p- 0.020), PNS-AD1 (p < 0.001), PNS-AD2 (p - 0.001) also showed highly significant association to OSA-risk. The ROC curves demonstrated high sensitivity and specificity for PNS-AD1 (60%,83.3%), PNS-AD2 (73.3%, 70%) and SN-MP (60%,70%), respectively for OSA-risk.

Conclusions

The study supported applicability of modified STOP-BANG questionnaire for OSA-risk in Indian adolescents. The parameters [extra-oral, intra-oral, cephalometric and upper airway (PNS-AD1, PNS-AD2, SN-MP)] significantly associated with OSA-risk, were identified.

Diagnostic paths for a mouth-breathing patient

INTRODUCTION

The clinical choice of diagnostic tests or treatment options is determined by the probability that the value of their execution (called the warrant for the test) exceeds their cost, and by their usefulness. The purpose of this study was to determine the warrant and usefulness of STOP-Bang, an obstructive sleep apnea screening questionnaire, and cone-beam computed tomography (CBCT) information about the minimal cross-sectional area for referring a mouth-breathing patient to a sleep specialist and for modifying planned orthodontic treatment.

METHODS

A branching survey was used to identify the prominence of paths between the presenting situation, 2 diagnostic tests, and 2 referral and/or treatment options. A description was given of a hypothetical patient: an overweight, mouth-breathing female teenager. Path analysis was used as a method for quantifying diagnostic warrant and usefulness.

RESULTS

There was a wide variation among the 125 orthodontists who responded to the survey. All paths were chosen. The use of tests altered the referral (χ² = 8.039; P = 0.03) and/or treatment decisions (χ² = 12.636; P = 0.005). Ownership of a CBCT system significantly influenced the use of this diagnostic test, with owning a CBCT system resulting in greater use in-office (χ² = 50.416; P <0.001) and greater use in the study (χ² = 22.959; P <0.001). The usefulness of the diagnostic tests could not be determined directly because common values were used for each test, but the variation in the use of this standard stimulus was very large, indicating personal differences in the interpretation of actual data.

CONCLUSIONS

Wide variation in the choice and interpretation of diagnostic tests for referral and orthodontic treatment modification relative to airway condition exists among orthodontists. Diagnostic path analysis is a potentially useful model for studying how practitioners make decisions independent of research evidence.

Preoperative identification of children at high risk of obstructive sleep apnea

Obstructive sleep apnea is a common childhood disorder which can lead to serious health problems if left untreated. Enlarged adenoid and tonsils are the commonest causes, and adenotonsillectomy is the recommended first line of treatment. Obstructive sleep apnea poses as an anesthetic challenge, and it is a well-known risk factor for perioperative adverse events. The presence and severity of an obstructive sleep apnea diagnosis will influence anesthesia, pain management, and level of monitoring in recovery period. Preoperative obstructive sleep apnea assessment is necessary, and anesthetists are ideally placed to do so. Currently, there is no standardized approach to the best method of preoperative screening for obstructive sleep apnea. Focused history, clinical assessments, and knowledge regarding the strengths and limitations of available obstructive sleep apnea assessment tools will help recognize a child with obstructive sleep apnea in the preoperative setting.

Sleep-related disorders in patients with type 1 diabetes mellitus: current insights

Type 1 diabetes mellitus (T1DM) is an autoimmune condition that results from destruction of beta cells in the pancreas. Several reviews have concluded that sleep contributes to poor glycemic control, diabetes management, and diabetes-related complications in individuals with T1DM and represents an untapped opportunity for intervention. However, at the current juncture, the American Diabetes Association's Standards of Medical Care are devoid of recommendations about how to address sleep in the management of T1DM. This article summarizes reviews of sleep in youth and adults with T1DM and empirical studies that have examined various sleep parameters ranging from sleep disturbances (general, perceived sleep quality, sleepiness, awakenings, and sleep efficiency), sleep duration, sleep consistency, sleep-disordered breathing (SDB), and sleep architecture. The data show that many individuals with T1DM sleep less than recommendations; individuals with the poorest sleep have difficulties with diabetes management; and sleep deficiency including SDB often corresponds to several disease morbidities (neuropathy, nephropathy, etc). Mixed findings exist regarding direct associations of various sleep parameters and glycemic control. SDB appears to be just as prevalent, if not more, than other conditions that have been recommended for universal screening in individuals with T1DM. The article concludes with recommendations for collaborative research efforts to further elucidate the role of sleep in diabetes-related outcomes; investigations to test behavioral strategies to increase sleep quantity and consistency; and considerations for clinical care to address sleep.

Accuracy of clinical scoring tools for the diagnosis of pediatric obstructive sleep apnea

OBJECTIVES

To assess the diagnostic test accuracy of questionnaire and clinical examination-based scoring tools in the diagnosis of pediatric obstructive sleep apnea (OSA).

METHODS

A comprehensive literature search was performed to identify studies published from 1960 to 2018 that evaluated the accuracy of clinical scoring tools in the diagnosis of pediatric OSA. Studies that did not include attended polysomnography as a reference standard were excluded. The study populations were children under 18 years old without craniofacial abnormalities, congenital syndromes, or other complex medical conditions. Outcomes measures were diagnostic test accuracy (DTA) statistics including sensitivity, specificity, and area under the curve (AUC) from receiver operating characteristic curve analysis.

RESULTS

Fifteen different scoring tools were identified. Authors chose different polysomnographic criteria to diagnose OSA. Four of the tools had undergone multiple DTA studies by different authors (OSA Score, Sleep-Related Breathing Disorder [SRBD] scale, Severity Score, and OSA-18). The Pediatric Sleep Questionnaire SRBD scale, which is widely used, has a sensitivity of 71% to 84% in included studies, but specificity as low as 13% and a low AUC of 0.57-0.69, indicating poor diagnostic accuracy. None of the 15 scoring tools performed well enough to be considered accurate diagnostic tests for pediatric OSA.

CONCLUSIONS

A well-designed questionnaire can provide crucial information on the impact of sleep-disordered breathing on a child's physical and psychological health, which may not be adequately reflected in objective polysomnography outcomes measures. However, DTA results indicate that published clinical scoring tools do not accurately predict a diagnosis of pediatric OSA as defined by polysomnography outcome measures. Laryngoscope, 130:1034-1043, 2020.

Mother Knows Best? Comparing Child Report and Parent Report of Sleep Parameters With Polysomnography

STUDY OBJECTIVES

Parent report or child report is commonly used to obtain information on sleep in children. Data are lacking comparing the validity of parent-reported versus child-reported sleep parameters.

METHODS

A total of 285 children (age 9 to 17 years) from the Tucson Children's Assessment of Sleep Apnea community cohort study were assessed. Parent report and child report of total sleep time (TST), sleep latency (SL), and sleep efficiency (SE) for a single night were compared to polysomnography (PSG). Intraclass correlations (ICCs) were used to evaluate agreement between child report, parent report, and PSG findings.

RESULTS

When compared to PSG, children overestimated TST by a median of 32 minutes (interquartile range [IQR] 6 to 68), whereas parents overestimated TST by 36 minutes (IQR 13-70) (P = .006). Children overestimated SL by 4 minutes (IQR -8 to 20), whereas parents overestimated SL by 2 minutes (IQR -10 to 13) (P = .001). Children overestimated SE by 5% (IQR 0% to 11%), whereas parents overestimated SE by 6% (IQR 2% to 11%, P = .04). Both child-reported TST (ICC 0.722, P < .001) and parent-reported TST (ICC 0.776, P < .001) agreed substantially with PSG. Child-reported SL (ICC 0.467, P < .001) and parent-reported SL (r = .419, P < .001) moderately agreed with PSG. Least agreement with PSG was seen between child-reported SE (ICC 0.404, P < .001) and parent-reported SE (ICC 0.473, P < .001), but significant agreement was still present.

CONCLUSIONS

When compared to PSG, children overestimate TST to a smaller degree than their parents and overestimate SL to a larger degree than their parents, but these differences appear small. Child and parent reports appear to be equally valid for TST, SL, and SE.

High Negative Predictive Value of Normal Body Mass Index for Obstructive Sleep Apnea in the Lateral Sleeping Position

STUDY OBJECTIVES

Obesity is a major risk factor for obstructive sleep apnea (OSA). Patients who are not obese and who have OSA usually present with a low apnea-hypopnea index (AHI) in the lateral sleeping position. Hence, sleep-disordered breathing (SDB) seems more dependent on body mass index (BMI) in the lateral sleeping position than the supine sleep position. This makes obesity a better predictor of SDB in the lateral sleeping position. The objective of this study was to find a negative predictive value of normal BMI for SDB in relation to sleep positions, thus defining a group of patients who could be treated by positional intervention, and prioritizing the use of polysomnography diagnostics.

METHODS

This study comprises a retrospective and prospective part run on groups of 1,181 and 821 consecutive patients, respectively. All had been referred to the university-based sleep laboratory because of suspected OSA and underwent polysomnography.

RESULTS

In the retrospective study, areas under the receiver operating characteristic curves for normal BMI at AHI ≥ 5 and AHI ≥ 15 events/h were found to be larger in the lateral sleeping positing than supine: 0.79 versus 0.69 and 0.80 versus 0.68, respectively (P < .05). Comparable results were obtained in the prospective study. For normal BMI, the negative predictive value for AHI < 15 events/h in the lateral sleep position was 97.5% and 97.1% in the retrospective and prospective study, respectively.

CONCLUSIONS

Normal BMI offers a high negative predictive value for moderate or severe OSA in the lateral sleeping position.

Pediatric sleep-disordered breathing: an update on diagnostic testing

PURPOSE OF REVIEW

Recent advances in diagnostic testing for obstructive sleep apnea in children have refined the standard tests while identifying several new tools that hold promise to radically change how we diagnose sleep apnea.

RECENT FINDINGS

Studies have demonstrated that the polysomnogram may be modified to permit home assessment of sleep disturbed breathing in children to ensure more widespread access to the test. Alternately, questionnaires, nocturnal oximetry, and diagnostic urinary biomarkers have shown great promise as both sensitive and specific tools to diagnose sleep apnea in children as well as track the severity of the disease.

SUMMARY

The gold standard polysomnogram has been refined to permit its application in a modified form at home and for brief examinations in children. This standard has been challenged on several fronts, including questionnaires, nocturnal oximetry, drug-induced sleep endoscopy, and noninvasive urinary biomarkers that may ultimately supplant polysomnography as the gold standard to diagnose obstructive sleep apnea syndrome in children.

Association of pediatric obstructive sleep apnea with poor academic performance: A school-based study from India

BACKGROUND

Pediatric obstructive sleep apnea (OSA) is a highly prevalent but often neglected disorder. There is paucity of reports on the prevalence of pediatric OSA from India. This study was done to estimate the prevalence of OSA in school children aged 5-10 years and its association with academic performance.

METHODOLOGY

This school-based cross-sectional epidemiological study was conducted from July 2015 to November 2015. A questionnaire seeking information on sociodemographic variables, school performance, sleeping pattern, and a validated 22-item pediatrics sleep-related breathing disorder (SRBD) scale was distributed to 1820 pupils in three primary schools. The prevalence of OSA (defined as SRBD score >33%) was reported as proportion and its 95% confidence interval (CI).

RESULTS

We received 1520 questionnaires out of 1820 distributed and of which 1346 were complete and were analyzed. The prevalence of OSA among children in our study was 9.6% (95% CI: 8.1%-11.7%). On multivariate analysis, working mother (adjusted odds ratio [OR]: 1.8; 95% CI: 1.2-2.7), sleep bruxism (adjusted OR: 1.7; 95% CI: 1.1-2.6), and sleep talking (adjusted OR: 3.0; 95% CI: 1.9-4.7) were found to be independently associated with OSA. Students with positive SRBD were more prone to nocturnal enuresis (NE) (OR 3.48; 95% CI 2.27-5.26) and poor academic performance in all subjects.

CONCLUSION

OSA is highly prevalent (9.6%) in Indian children. OSA is associated with NE and poor academic performance in all subjects. This study found association of maternal occupation and OSA which needs to be confirmed in larger studies.

Sleep and obesity risk in adults: possible mechanisms; contextual factors; and implications for research, intervention, and policy

Obesity is a major public health problem among US adults. Insufficient sleep and sleep disorders are prevalent and may contribute to the public health problem of obesity. This review addresses several key questions regarding sleep and obesity in adults, including the following: (1) What constitutes adequate sleep in adults? (2) What are the consequences of inadequate sleep in adults? (3) What factors influence sleep in adults? (4) How can adults improve their sleep? (5) How can we implement these in adults? (6) How can these issues be addressed in future research and policy decisions? Although a comprehensive review of all of these is beyond the scope of this article, this review brings these concepts together toward a discussion of the role of sleep in the health of US adults.

How do we recognize the child with OSAS?

Obstructive sleep-disordered breathing includes a spectrum of clinical entities with variable severity ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). The clinical suspicion for OSAS is most often raised by parental report of specific symptoms and/or abnormalities identified by the physical examination which predispose to upper airway obstruction (e.g., adenotonsillar hypertrophy, obesity, craniofacial abnormalities, neuromuscular disorders). Symptoms and signs of OSAS are classified into those directly related to the intermittent pharyngeal airway obstruction (e.g., parental report of snoring, apneic events) and into morbidity resulting from the upper airway obstruction (e.g., increased daytime sleepiness, hyperactivity, poor school performance, inadequate somatic growth rate or enuresis). History of premature birth and a family history of OSAS as well as obesity and African American ethnicity are associated with increased risk of sleep-disordered breathing in childhood. Polysomnography is the gold standard method for the diagnosis of OSAS but may not be always feasible, especially in low-income countries or non-tertiary hospitals. Nocturnal oximetry and/or sleep questionnaires may be used to identify the child at high risk of OSAS when polysomnography is not an option. Endoscopy and MRI of the upper airway may help to identify the level(s) of upper airway obstruction and to evaluate the dynamic mechanics of the upper airway, especially in children with combined abnormalities. Pediatr Pulmonol. 2017;52:260-271. © 2016 Wiley Periodicals, Inc.

Insomnia, Health-Related Quality of Life and Health Outcomes in Children: A Seven Year Longitudinal Cohort

Insomnia is common in children, and is associated with decreased school performance and increased psychopathology. Although adult insomnia is linked to worsened health-related quality of life (HRQOL), there is insufficient data evaluating insomnia and HRQOL in children. We examined the HRQOL and health associations of insomnia in a longitudinal cohort of 194 children (96 girls, age at study start 8.7 ± 1.6 years, age at data analysis 15.0 ± 1.8 years) over 7 years. International Classification of Sleep Disorders, second edition (ICSD2) derived insomnia was seen intermittently in 27% of children, and was persistent in 4%. Children reporting ICSD2-derived insomnia had lower HRQOL. Additionally, the presence of insomnia was associated with an increased risk of reporting a new medical condition (intermittent insomnia odds ratio 5.9 [95% CI 1.3–26.7, p = 0.04], persistent insomnia odds ratio 8 [95% CI 2.3–27.7, p = 0.001]). Persistent ICSD2-derived insomnia was associated with an increased risk of reporting a new medication (odds ratio 4.9 (95% CI 1.0–23.6), p = 0.049), and reporting a new psychiatric medication (odds ratio 13.7, 95% CI: 2.6–73.5, p = 0.002). These associations were present even after adjusting for socioeconomic factors and the presence of obstructive sleep apnea. Insomnia in children is associated with worsened HRQOL and health outcomes.