Childhood obstructive sleep-disordered breathing: a clinical update and discussion of technological innovations and challenges

Macronutrient and Micronutrient Intake in Adolescents With Non-alcoholic Fatty Liver Disease: The Association With Disease Severity

OBJECTIVES

While dietary changes are recommended to treat pediatric non-alcoholic fatty liver disease (NAFLD), the role of specific nutrients in disease progression is unclear. The objective of this study is to (1) assess the macronutrient and micronutrient intake in adolescents with liver biopsy proven NAFLD [with and without non-alcoholic steatohepatitis (NASH)] and lean controls; (2) determine nutritional predictors of disease severity amongst these groups.

METHODS

Adolescents with biopsy-proven NAFLD and lean controls completed the Harvard Food Frequency Questionnaire.

RESULTS

Twenty-eight NAFLD and 15 lean controls were studied. NAFLD with (n = 20) and without NASH (n = 8) had similar total calorie, protein, fat, and carbohydrate intake. Subjects with NASH had higher total sugar (122.3 ± 48.3 vs 83.1 ± 38.8 g), glucose (24.3 ± 9.3 vs 15.2 ± 7.5 g), sucrose (42.3 ± 16.9 vs 28.8 ± 11.7 g), and fructose (29.4 ± 12.5 vs 18.1 ± 8.0 g) intake than those with NAFLD but without NASH ( P < 0.05). Both NAFLD groups had similar micronutrient intake. Alanine aminotransferase (ALT) correlated with total caloric intake ( ρ = 0.4; P = 0.04). Total carbohydrate calories correlated with a higher NAS summary score ( ρ = 0.38; P = 0.04) and lobular inflammation ( ρ = 0.50; P = 0.007). Percent calories from added sugar and glucose correlated with worsening NAS summary score ( ρ = 0.44, P = 0.02; ρ = 0.48, P = 0.009) and lobular inflammation ( ρ = 0.51, P = 0.006; ρ = 0.53, P = 0.004). Percent calories from fructose correlated with lobular inflammation ( ρ = 0.56; P = 0.002). Total daily calories, protein, fat, carbohydrate, and micronutrient intake were similar between NAFLD and lean controls.

CONCLUSIONS

NASH patients consume similar total calories, protein, and fat as those without NASH, but have significantly higher sugar intake. NAFLD and lean children, however, have similar macro/micronutrient intake. Histologic disease severity correlates with total carbohydrate and added sugar intake, supporting a role for simple sugar intake in NAFLD progression.

[Etiological treatment of Obstructive Sleep Apnea]

Research in the field of Obstructive Sleep Apnea (OSA) has been organized, and has profoundly transformed the quality of life of apneic patients, while even inviting dentofacial orthopedists to contribute to their symptomatic treatment. However, among the points still to be elucidated, the initial cause of the snoring that destabilizes the pharynx occupies a place apart. The objective of this article was to develop the proposal by Jacques Talmant regarding a mechanism capable of explaining the onset of OSA and for a therapy to treat pharyngeal destabilization during sleep. Based on published data, the etiopathogenesis of snoring and its consequences are described. Structural changes secondary to the vibratory trauma caused by snoring can affect each component of the pharyngeal structures and contribute to the collapsibility of this airway segment. By directly optimizing the development of ventilatory capabilities in their patients, orthodontists contribute, indirectly, to optimizing their cardiovascular and neuropsychological functions.

Nocturnal Hypoxia Activation of the Hedgehog Signaling Pathway Affects Pediatric Nonalcoholic Fatty Liver Disease Severity

Chronic intermittent hypoxia and hedgehog (Hh) pathway dysregulation are associated with nonalcoholic fatty liver disease (NAFLD) progression. In this study, we determined the relationship between obstructive sleep apnea (OSA)/nocturnal hypoxia and Hh signaling in pediatric NAFLD. Adolescents with histologic NAFLD (n = 31) underwent polysomnogram testing, laboratory testing, and Sonic Hh (SHh), Indian hedgehog (IHh), glioblastoma‐associated oncogene 2 (Gli2), keratin 7 (K7), α‐smooth muscle actin (α‐SMA), and hypoxia‐inducible factor 1α (HIF‐1α) immunohistochemistry. Aspartate aminotransferase (AST) correlated with SHh, r = 0.64; Gli2, r = 0.4; α‐SMA, r = 0.55; and K7, r = 0.45 (P < 0.01), as did alanine aminotransferase (ALT) (SHh, r = 0.51; Gli2, r = 0.43; α‐SMA, r = 0.51; P < 0.02). SHh correlated with NAFLD activity score (r = 0.39), whereas IHh correlated with inflammation (r = −0.478) and histologic grade (r = −0.43); P < 0.03. Subjects with OSA/hypoxia had higher SHh (4.0 ± 2.9 versus 2.0 ± 1.5), Gli2 (74.2 ± 28.0 versus 55.8 ± 11.8), and α‐SMA (6.2 ± 3.3 versus 4.3 ± 1.2); compared to those without (P < 0.03). OSA severity correlated with SHh (r = 0.31; P = 0.09) and Gli2 (r = 0.37; P = 0.04) as did hypoxia severity, which was associated with increasing SHh (r = −0.53), Gli2 (r = −0.52), α‐SMA (r = −0.61), and K7 (r = −0.42); P < 0.02. Prolonged O₂ desaturations <90% also correlated with SHh (r = 0.55) and Gli2 (r = 0.61); P < 0.05. Conclusion: The Hh pathway is activated in pediatric patients with NAFLD with nocturnal hypoxia and relates to disease severity. Tissue hypoxia may allow for functional activation of HIF‐1α, with induction of genes important in epithelial‐mesenchymal transition, including SHh, and NAFLD progression.

Tongue Lip Adhesion in the Treatment of Robin Sequence: Respiratory, Feeding, and Surgical Outcomes

OBJECTIVE

Objective evaluation of the efficacy of tongue lip adhesion (TLA) in the management of Robin sequence (RS).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital.

PATIENTS, PARTICIPANTS

The craniofacial database of Amsterdam UMC, Vrije Universiteit Amsterdam was searched to identify infants with RS who underwent tong lip adhesion (TLA). Forty-one RS infants who underwent TLA from 1993 to 2016 were identified.

INTERVENTIONS

TLA.

MAIN OUTCOME MEASURE

The outcome measures were pre- and postoperative polysomnography results, nutritional status, weight gain, age at operation, hospital stay length, extubation time after TLA, and complications.

RESULTS

Forty-one RS patients were included who had TLA at an average age of 26.6 days. In 16 cases a pre- and postoperative polysomnography was performed. In 13 of these cases (81.3%) improvement was observed, in 2 (12.5%) the results were inconclusive, and in 1 (6.3%) no improvement was seen. Patients were extubated after a mean of 2.2 days.The mean hospital stay was 40.2 days. Reintervention was needed in 7 patients because of a wound dehiscence. The mean age of TLA release was 9.7 months. At discharge, 9 (22%) children still needed total nutritional support for persistent feeding difficulties. The average growth from birth to adhesion release was 4.6 kg.

CONCLUSION

This cohort demonstrates that TLA is a successful procedure in children with RS in terms of respiratory, feeding, and growth outcome. Only minor complications were seen in our cohort.

Treating Obstructive Sleep Apnea and Chronic Intermittent Hypoxia Improves the Severity of Nonalcoholic Fatty Liver Disease in Children

OBJECTIVE

To determine the effects of treating obstructive sleep apnea/nocturnal hypoxia on pediatric nonalcoholic fatty liver disease (NAFLD) severity and oxidative stress.

STUDY DESIGN

Biopsy proven participants (n = 9) with NAFLD and obstructive sleep apnea/hypoxia were studied before and after treatment with continuous positive airway pressure (CPAP) for sleep disordered breathing, including laboratory testing and markers of oxidative stress, urine F(2)-isoprostanes.

RESULTS

Adolescents (age 11.5 ± 1.2 years; body mass index, 29.5 ± 3.8 kg/m²) with significant NAFLD (mean histologic necroinflammation grade, 2.3 ± 0.9; fibrosis stage, 1.4 ± 1.3; NAFLD Activity Score summary, 4.8 ± 1.6) had obstructive sleep apnea/hypoxia by polysomnography. At baseline, they had severe obstructive sleep apnea/hypoxia, elevated aminotransferases, the metabolic syndrome, and significant oxidative stress (high F(2)-isoprostanes). Obstructive sleep apnea/hypoxia was treated with home CPAP for a mean 89 ± 62 days. Although body mass index increased, obstructive sleep apnea/hypoxia severity improved on CPAP and was accompanied by reduced alanine aminotransferase, metabolic syndrome markers, and F(2)-isoprostanes.

CONCLUSIONS

This study provides strong evidence that treatment of obstructive sleep apnea/nocturnal hypoxia with CPAP in children with NAFLD may reverse parameters of liver injury and reduce oxidative stress. These data also suggest CPAP as a new therapy to prevent progression of NAFLD in those children with obesity found to have obstructive sleep apnea/nocturnal hypoxia.

Nocturnal hypoxia-induced oxidative stress promotes progression of pediatric non-alcoholic fatty liver disease

BACKGROUND & AIMS

Oxidative stress is proposed as a central mediator in NAFLD pathogenesis, but the specific trigger for reactive oxygen species generation has not been clearly delineated. In addition, emerging evidence shows that obesity related obstructive sleep apnea (OSA) and nocturnal hypoxia are associated with NAFLD progression in adults. The aim of this study was to determine if OSA/nocturnal hypoxia-induced oxidative stress promotes the progression of pediatric NAFLD.

METHODS

Subjects with biopsy proven NAFLD and lean controls were studied. Subjects underwent polysomnograms, liver histology scoring, laboratory testing, urine F(2)-isoprostanes (measure of lipid peroxidation) and 4-hydroxynonenal liver immunohistochemistry (in situ hepatic lipid peroxidation).

RESULTS

We studied 36 adolescents with NAFLD and 14 lean controls. The OSA/hypoxia group (69% of NAFLD subjects) had more severe fibrosis (64% stage 0-2; 36% stage 3) than those without OSA/hypoxia (100% stage 0-2), p=0.03. Higher F(2)-isoprostanes correlated with apnea/hypoxia index (r=0.39, p=0.03), % time SaO2 <90% (r=0.56, p=0.0008) and inversely with SaO2 nadir (r=-0.46, p=0.008). OSA/hypoxia was most severe in subjects with the greatest 4HNE staining (p=0.03). Increasing F(2)-isoprostanes(r=0.32, p=0.04) and 4HNE hepatic staining (r=0.47, p=0.007) were associated with worsening steatosis. Greater oxidative stress occurred in subjects with definite NASH as measured by F(2)-isoprostanes (p=0.06) and hepatic 4HNE (p=0.03) compared to those with borderline/not NASH.

CONCLUSIONS

These data support the role of nocturnal hypoxia as a trigger for localized hepatic oxidative stress, an important factor associated with the progression of NASH and hepatic fibrosis in obese pediatric patients.

LAY SUMMARY

Obstructive sleep apnea and low nighttime oxygen are associated with NAFLD progression in adults. In this study, we show that adolescents with NAFLD who have OSA and low oxygen have significant scar tissue in their livers. NAFLD subjects affected by OSA and low oxygen have a greater imbalance between the production of free radicals and their body's ability to counteract their harmful effects than subjects without OSA and low oxygen. This study shows that low oxygen levels may be an important trigger in the progression of pediatric NASH.

Friedman tongue position: age distribution and relationship to sleep-disordered breathing

PURPOSE

Friedman tongue position (FTP) may play an important role in the evaluation of children with sleep-related breathing disorders (SRBD), but there are no previous data on FTP distribution by age. The objective of the current study was to determine the distribution of FTP by age and examine the relationship between FTP and snoring in children.

METHODS

Prospective cross-sectional study of 199 children (mean age, 6.8 years; 59% male) had tongue position assessed by FTP as part of their clinical examination of the oral cavity during routine ENT visits at a tertiary care children's hospital. The FTP and snoring frequency of participants was examined across the entire age range as well as by comparing those older (middle childhood and above) and younger than 5 years of age.

RESULTS

Tongue position did not correlate with age or snoring frequency. The proportion of children with FTP III/IV was not significantly different in children younger than five years of age compared to older than five. Habitual snoring was not associated with having a higher FTP. Among children who snored <3 times per week, those who had previously undergone tonsillectomy did have higher FTP compared to those who had not (p=0.007). BMI-%-for-age was significantly correlated with FTP (p=0.003). The percent of children having FTP class III/IV differed significantly between ethnicities (22% of whites, 26% of others, 45% of hispanics, 53% of African-Americans; p=0.011). Inter-rater reliability among pediatric otolaryngologist was excellent (kappa=0.93, p<0.001).

CONCLUSIONS

There does not appear to be an association between FTP with age or snoring frequency in children. The excellent inter-rater reliability for FTP among pediatric ENT providers suggests the null findings are not due to rater bias. These findings may serve as an important reference for those studying the role of tongue position in pediatric SRBD and complement previous studies examining FTP among children with known OSA or snoring.

Mandibular movements identify respiratory effort in pediatric obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea-hypopnea (OAH) diagnosis in children is based on the quantification of flow and respiratory effort (RE). Pulse transit time (PTT) is one validated tool to recognize RE. Pattern analysis of mandibular movements (MM) might be an alternative method to detect RE. We compared several patterns of MM to concomittant changes in PTT during OAH in children with adenotonsillar hypertrophy.

METHODS

PARTICIPANTS

33 consecutive children with snoring and symptoms/signs of OAH.

MEASUREMENTS

MMs were measured during polysomnography with a magnetometer device (Brizzy Nomics, Liege, Belgium) placed on the chin and forehead. Patterns of MM were evaluated representing peak to peak fluctuations > 0.3 mm in mandibular excursion (MML), mandibular opening (MMO), and sharp MM (MMS), which closed the mouth on cortical arousal (CAr).

RESULTS

The median (95% CI) hourly rate of at least 1 MM (MML, or MMO, or MMS) was 18.1 (13.2-36.3) and strongly correlated with OAHI (p = 0.003) but not with central apnea-hypopnea index (CAHI; p = 0.292). The durations when the MM amplitude was > 0.4 mm and PTT > 15 ms were strongly correlated (p < 0.001). The mean (SD) of MM peak to peak amplitude was larger during OAH than CAH (0.9 ± 0.7 mm and 0.2 ± 0.3 mm; p < 0.001, respectively). MMS at the termination of OAH had larger amplitude compared to MMS with CAH (1.5 ± 0.9 mm and 0.5 ± 0.7 mm, respectively, p < 0.001).

CONCLUSIONS

MM > 0.4 mm occurred frequently during periods of OAH and were frequently terminated by MMS corresponding to mouth closure on CAr. The MM findings strongly correlated with changes in PTT. MM analysis could be a simple and accurate promising tool for RE characterization and optimization of OAH diagnosis in children.

Usefulness of cerebral NIRS in detecting the effects of pediatric sleep apnea

BACKGROUND

Children with sleep apnea have increased morbidity if the sleep apnea is untreated. Polysomnography (PSG) is used to detect sleep apnea, but in children, there are technical difficulties that make the diagnosis more difficult. Cerebral near infrared spectroscopy (NIRS) has the ability to detect tissue hypoxia by measuring regional oxygen saturation (rSO2 ). We hypothesized that when used as an adjunct to PSG testing, cerebral NIRS would better detect the effects of sleep apnea in children than arterial pulse oximetry (SpO2 ). Specifically, we aimed to show that the apnea/hypopnea index (AHI) calculated with rSO2 from the NIRS would be greater than that calculated with SpO2 .

METHODS

Forty-seven patients under 18 years of age who underwent PSG testing for sleep apnea were evaluated. Cerebral NIRS was utilized in addition to PSG. The AHI was calculated using SpO2 and compared to the AHI calculated using the rSO2 . A pediatric pulmonologist who was unaware of the NIRS data evaluated each patient for sleep apnea. Data are median (interquartile range).

RESULTS

The median AHI(rSO2 ) was 2.4(1.2,5.1), significantly greater (P < 0.0001) than the AHI(SpO2 ) of 0.7(0.4,1.2). Four patients were diagnosed with sleep apnea; however, only one had an AHI(SpO2 ) ≥ 5, a typical threshold for the diagnosis of sleep apnea. All 4 subjects had an AHI(rSO2 ) ≥ 5 but 10 patients without sleep apnea had a value ≥5. The sensitivity and specificity for using the AHI(rSO2 ) to diagnose sleep apnea was 100% and 76.7%, respectively.

CONCLUSION

Consistent with the ability of NIRS to detect tissue hypoxia, we found that the AHI calculated with rSO2 was greater than that using SpO2 . We conclude that NIRS has potential as a valuable adjunct to PSG in evaluating patients for sleep apnea and warrants further investigation for this purpose.

Obstructive sleep apnea and hypoxemia are associated with advanced liver histology in pediatric nonalcoholic fatty liver disease

OBJECTIVE

To determine whether obstructive sleep apnea (OSA) and/or nocturnal hypoxemia are associated with the severity of liver injury in patients with pediatric nonalcoholic fatty liver disease (NAFLD).

STUDY DESIGN

Obese children aged 10-18 years with liver biopsy-proven NAFLD were enrolled. Demographic, clinical, and laboratory data were collected, polysomnography was performed, and liver histology was scored. Subjects were divided into those with OSA/hypoxemia and those without OSA/hypoxemia for analysis.

RESULTS

Of 25 subjects with NAFLD, OSA/hypoxemia was present in 15 (60%) (mean age, 12.8 ± 1.9 years; 68% male; 88% Hispanic; mean body mass index z-score, 2.3 ± 0.3). Subjects with and without OSA/hypoxemia had similar levels of serum aminotransferases, serum lipids, and inflammatory and insulin resistance markers. Although there were no differences between groups in the histological severity of steatosis, inflammation, ballooning degeneration, NAFLD activity score, or histological grade, subjects with OSA/hypoxemia had significantly more severe hepatic fibrosis. Moreover, oxygen saturation nadir during polysomnography was related to hepatic fibrosis stage (r = -0.49; P = .01) and aspartate aminotransferase level (r = 0.42; P < .05). Increasing percentage of time with oxygen saturation ≤90% was related to NAFLD inflammation grade (r = 0.44; P = .03), degree of hepatic steatosis (r = -0.50; P = .01), NAFLD activity score (r = 0.42; P = .04), aspartate aminotransferase level (r = 0.56; P = .004), and alanine aminotransferase level (r = 0.44; P = .03).

CONCLUSION

Moderate OSA/hypoxemia is common in pediatric patients with biopsy-proven NAFLD. OSA and the severity/duration of hypoxemia are associated with biochemical and histological measures of NAFLD severity.

Pycnodysostosis with novel gene mutation and severe obstructive sleep apnoea: management of a complex case

Pycnodysostosis is a rare genetic disease. Impaired osteoclastic function is the basis for typical phenotypic features and bone fragility. The main differential diagnosis is osteopetrosis, also associated with altered bone remodelling, but with a more severe prognosis. We describe the case of an 8-year-old boy who presented life-threatening obstructive sleep apnoea successfully managed with non-invasive ventilation. Haematological overlap phenotype included anaemia and altered bone marrow, more common in osteopetrosis. Molecular analysis of the CTSK gene revealed a mutation not previously described in the literature.

Deep cervical lymph node hypertrophy: a new paradigm in the understanding of pediatric obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy.

STUDY DESIGN

Prospective case control study.

METHODS

A total of 70 screened patients (mean age 7.47 years) underwent polysomnography to confirm OSA, and then underwent MRI of the upper airway. Seventy-six matched controls (mean age 8.00 years) who already had an MRI underwent polysomnography. Volumetric analysis of lymphoid tissue volumes was carried out. Chi-square analysis and Student's t test were used to compare demographic data and lymph node volumes between cohorts. Fisher's Exact test and Chi-square analysis were used to compare sleep data.

RESULTS

Patients and controls demonstrated no significant difference in mean age (7.47 vs. 8.00 yrs), weight (44.87 vs. 38.71 kg), height (124.68 vs. 127.65 cm), or body-mass index (23.63 vs. 20.87 kg/m(2)). OSA patients demonstrated poorer sleep measures than controls (P < 0.05) in all polysomnography categories (sleep efficiency, apnea index, apnea-hypopnea index, baseline SpO2, SpO2 nadir, baseline ETCO2, peak ETCO2 , and arousal awakening index). Children with OSA had higher lymphoid tissue volumes than controls in the retropharyngeal region (3316 vs. 2403 mm(3), P < 0.001), upper jugular region (22202 vs. 16819 mm(3), P < 0.005), and adenotonsillar region (18994 vs. 12675 mm(3), P < 0.0001).

CONCLUSIONS

Children with OSA have larger volumes of deep cervical lymph nodes and adenotonsillar tissue than controls. This finding suggests a new paradigm in the understanding of pediatric OSA, and has ramifications for future research and clinical care.

Treatment of childhood obstructive sleep apnea

OPINION STATEMENT

An array of surgical, medical and orthodontic treatments is available for treating childhood obstructive sleep apnea. Adenotonsillectomy remains the first choice in treatment, with a need for subsequent clinical and polysomnographic reassessment in selected cases to determine residual sleep-disordered breathing. Residual obstructive sleep apnea is more likely in patients with craniofacial abnormalities or obesity. It may require the use of a positive airway pressure breathing device. Topical corticosteroids, leukotriene antagonists, weight reduction, and positional therapy also play a role in ameliorating childhood obstructive sleep apnea. The published evidence for the efficacy of various treatment modalities consists largely of case-controlled studies and case reports.

The surgical treatment of sleep-related upper airway obstruction

BACKGROUND

Obstructive sleep apnea (OSA) is a very common disorder among adults: the prevalence of mild OSA is 20%, and that of moderate or severe OSA is 6% to 7%. Simple snoring is even more common. Conservative treatments such as nocturnal ventilation therapy and oral appliances are successful as long as the patient actually uses them, but they do not eliminate the underlying obstruction of the upper airway.

METHOD

The relevant literature up to 2008 on the surgical treatment of OSA was selectively reviewed.

RESULTS

Five types of surgical treatment for OSA are available, each for its own indications: optimization of the nasal airway to support nasal ventilation therapy, (adeno-)tonsillectomy as first-line treatment for OSA in children, minimally invasive surgery for simple snoring and mild OSA, invasive surgery as first- and second-line treatment for mild OSA, and invasive multilevel surgery as second-line treatment of moderate to severe OSA that remains refractory to ventilation therapy.

CONCLUSION

Surgical treatment for OSA is appropriate for specific indications as a complement to the established conservative treatment methods.

Severity assessment of obstructive sleep apnea syndrome (OSAS) in pediatric patients

OBJECTIVE

To assess obstructive sleep apnea syndrome (OSAS) severity among pediatric patients. Design. A retrospective review of charts and polysomnography (PSG) results.

MEASUREMENTS AND MAIN RESULTS

Apnea-hypopnea index (AHI) and the cumulative duration of sleep while O(2)SAT was <91% were determined in 389 patients with OSAS. Patients with AHI ranging <5, 5 to 15, 16 to 30, and >30, had mean lowest observed O(2)SAT values of 88% +/- 8%, 85% +/- 9%, 78% +/- 12%, and 69% +/- 13%, respectively. The patients spent a mean of 3.5% +/- 9.2 % of their sleep time with O(2)SAT < 91%. AHI values showed a poor linear correlation with the lowest measured O(2)SAT values. Body mass index percentiles showed no significant linear correlation with AHI values or with the lowest measured values of O(2)SAT.

CONCLUSION

Values of AHI cannot accurately predict severity of oxyhemoglobin desaturation in pediatric OSAS and vice versa. No significant correlation between body mass index percentiles and severity of OSAS was established.

Treatment alternatives for sleep-disordered breathing in the pediatric population

PURPOSE FOR REVIEW: Childhood sleep-disordered breathing (SDB) is associated with a myriad of health problems that underscore the need for early diagnosis and treatment. Children with SDB present with behavior problems, deficits of general intelligence, learning and memory deficits, evidence of brain neuronal injury, increased cardiovascular risk, and poor quality of life. Children are in a rapid state of cognitive development; therefore, alterations of health and brain function associated with SDB could permanently alter a child's social and economic potential, especially if the disorder is not recognized early in life or is treated inadequately.

RECENT FINDINGS

There is evidence that the majority of the problems associated with SDB improve with treatment. Treatment strategies are now being aimed at mechanisms underlying the disorder. There are multiple treatment options available to children; some are novel, with pending treatments on the horizon that may replace age-old therapies such as adenotonsillectomy or nasal positive pressure.

SUMMARY

It is imperative that healthcare workers actively seek out signs and symptoms of SDB in patients to improve early detection and treatment for prevention of long-term morbidity.