Growth after adenotonsillectomy for obstructive sleep apnea: an RCT

Efficacy of adenotonsillectomy on pediatric obstructive sleep apnea and related outcomes: A narrative review of current evidence

This review summarizes the current evidence in systematic reviews, meta-analysis and randomized controlled trials regarding adenotonsillectomy outcomes in pediatric obstructive sleep apnea (OSA). Adenotonsillectomy is effective in treating OSA in children without co-morbidities, despite postoperative residual OSA remained in roughly half of these children. For children with comorbidities such as Down syndrome, Prader-Willi syndrome, sickle cell disease, or cerebral palsy, adenotonsillectomy is less effective and associated with more postoperative complications than that in children without comorbidities. For other OSA-related outcomes, evidence from meta-analyses and randomized controlled trials confirm adenotonsillectomy results in improvement of subjective OSA-related outcomes (e.g. symptoms, behaviors, and quality of life), but the results in objective OSA-related outcomes (e.g. cardiometabolic parameters or neurocognitive functions) are inconsistent. Future studies should focus on randomized controlled trials comparing objective OSA-related outcomes and the long-term effects of adenotonsillectomy in children with OSA.

Short-Term Weight Gain after Tonsillectomy Does Not Lead to Overweight: A Systematic Review

Different studies and systematic reviews have reported weight increase after tonsillectomy. However, the odds of a child being overweight or obese after tonsillectomy were no different than before surgery, according to a few studies. This systematic review aims to analyze the impact of adenotonsillectomy (TA) on weight gain and identify subgroups of children and adolescents at risk of experiencing weight gain. A systematic search included studies published in the last ten years. The PICO framework was used in the selection process, and evidence was assessed using the GRADE system. A total of 26 studies were included, and moderate-high level quality ones showed that children who underwent TA could present an increase in BMI z-score. However, this weight gain was significant in individuals younger than six years old and was considered catch-up growth in underweight subjects at baseline. In contrast, for normal-weight or overweight individuals, TA did not lead to overweight per se. At the same time, diet changes and overfeeding did not have a leading role in weight gain. In conclusion, TA may not be an independent risk factor for unfavorable weight gain in children; however, individuals who were underweight pre-operatively or younger than six years reported more weight gain after TA than expected.

The Effects of Adenotonsillectomy for Obstructive Sleep Apnea on Growth Trajectory in Children With Obesity

OBJECTIVE

To analyze the growth trajectory of children with obesity before and after adenotonsillectomy (T&A). We hypothesize that T&A will not affect the growth trajectory but children in a multidisciplinary weight management program (MWMP) will have a healthier growth trajectory.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary Children's Hospital.

METHODS

Body mass index (BMI) trajectories of nonsyndromic children with obesity and obstructive sleep apnea (OSA) who underwent T&A were analyzed. A linear mixed effects model was fit to the BMI expressed as a percentage of the 95th percentile (%BMIp95 ) data. Covariates included demographic variables, pre- and postoperative participation in an MWMP, baseline obesity class, and time. We explored clinically meaningful interactions. BMI slope estimates before and after surgery were calculated and compared for baseline obesity classification and postoperative MWMP visits.

RESULTS

A total of 177 patients, 58% male with a mean age of 9.7 years at the time of surgery, were studied. Higher baseline obesity class (II and III), time, the interaction between obesity class III and elapsed time relative to surgical date, and the interaction between obesity class III and the postsurgical period were all significantly associated with the outcome of %BMIp95 (P < .05). There was a significantly higher %BMIp95 trajectory following surgery in patients with baseline obesity class III who did not have any postoperative MWMP visits (P < .001). Preoperative obesity visits, however, were not significantly associated with postoperative growth.

CONCLUSION

The association between T&A and weight trajectory depends upon obesity class and participation in a MWMP. Coordinated care of children with obesity between otolaryngologists and an MWMP may improve OSA and obesity outcomes.

LEVEL OF EVIDENCE

The level of evidence: 3.

Association between adenotonsillar hypertrophy and dentofacial characteristics of children seeking for orthodontic treatment: A cross-sectional study

OBJECTIVE

To compare the dentofacial characteristics of children with and without adenoid and/or tonsillar hypertrophy.

METHODS

A consecutive sample of orthodontic patients aged 6-12 that took pre-treatment lateral cephalograms were included in this study. Those with history of previous orthodontic treatment, adenoidectomy or tonsillectomy, or craniofacial anomalies were excluded. The diagnosis of adenoid and tonsillar hypertrophy was based on Fujioka's and Baroni's methods, according to which the subjects were divided into four groups: the adenoid hypertrophy only (AHO) group; tonsillar hypertrophy only (THO) group; combined adenoid and tonsillar hypertrophy (AH+TH) group; and no adenoid or tonsillar hypertrophy (NH) group. Cephalograms were used for skeletal and dental measurement. Data were analyzed using one-way ANOVA, LSD post-hoc tests and Chi-square test.

RESULTS

A total of 598 patients were included. Compared with the NH group, the THO group had significantly larger SNB angle (P < 0.001), as well as significantly smaller ANB angle (P<0.001) and Wits value (P = 0.001). The U1-L1 angle of AHO group was significantly smaller than that in the NH group (P = 0.035). The proportion of adenoid hypertrophy in Class II patients was significantly higher than that in Class III patients (P = 0.001). The proportion of tonsillar hypertrophy in Class III patients was significantly higher than that in Class I patients (P < 0.001) and Class II patients (P < 0.001).

CONCLUSION

Over 80 % of children seeking orthodontic treatment had either adenoid or tonsillar hypertrophy. Children with adenoid hypertrophy tend to have skeletal Class II malocclusion, while those with tonsillar hypertrophy tend to have skeletal Class III malocclusion.

Sleep quality, sleep apnea, and metabolic health in children treated with adenotonsillectomy

PURPOSE

The aim of this study was to determine if cardiopulmonary coupling (CPC) calculated sleep quality (SQI) may predict changes in metabolic health in children treated with early adenotonsillectomy (eAT) for obstructive sleep apnea (OSA).

METHODS

Secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) was performed including children 5.0-9.9 years with OSA assigned to eAT. The cohort was stratified based on SQI and AHI to evaluate (1) response to eAT in children with high sleep quality (SQI ≥ 75) and mild-OSA, AHI < 5.0 (group1) and children with moderate-OSA AHI ≥ 5.0 or SQI < 75 (group2) at baseline and (2) effect of eAT therapy on metabolic health, GroupRemission (AHI < 1.0, SQI ≥ 75) compared to GroupResidual.

RESULTS

At baseline group2 (n=124) had higher average heart rate during sleep (AHRSleep), 87 vs. 81 beats/minute (p < 0.001) compared to group1 (n=72). After surgery, group2 on average had less increase in BMI z-score 0.13 vs. 0.27, (p = 0.025), improved their SQI + 2.06 compared to decline - 3.75 in group1, (p = 0.015), decreased AHRSleep-- 2.90 vs. - 0.34 (p = 0.025) and AHI - 5.00 vs. - 0.36 (p = 0.002). GroupRemission was younger 6.59 vs. 7.41; p < 0.001; with lower BMI z-score 0.90 vs. 1.34; p = 0.021; AHRSleep 80.60 vs. 83.50; p = 0.032; fasting insulin (µIU/ml) 7.54 vs. 12.58; p = 0.017 and glucose (mmol/L) 4.45 vs. 4.60; p = 0.049, with better lipid metabolism though not statistically significantly, low-density-lipoprotein 90.26 mg/dL vs. 97.94; p = 0.081 and cholesterol 154.66 mg/dL vs. 164.36; p = 0.076.

CONCLUSION

The results may indicate that children with mild-OSA and high-SQI may be less likely to benefit from eAT than children with moderate-OSA. To improve metabolic health, successfully treating both AHI and SQI is likely needed. CPC-calculated SQI may have a role to identify children less likely to benefit from eAT and to evaluate success of therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00560859.

Effectiveness and safety of (adeno) tonsillectomy for pediatric obstructive sleep apnea in different age groups: A systematic review and meta-analysis

This meta-analysis aimed to assess the effectiveness and safety of (adeno)tonsillectomy (AT) for uncomplicated pediatric obstructive sleep apnea (OSA) across different age groups. Four electronic databases were searched until April 2022, and 93 studies (9087 participants) were selected, including before-after studies, cohort studies, and randomized controlled trials. It has been suggested that age, disease severity, and length of follow-up are associated with surgical effects. Compared with older children (>7 years), patients receiving AT surgery before the age of 7 exhibited a significantly greater release of disease severity, as well as a greater decrease in hypoxemic burden, improvement in sleep quality, and better cardiovascular function. Cognitive/behavioral performance also improved after AT, although it was more related to the length of follow-up than the age at surgery. Notably, the surgical complication rate was considerably higher in patients younger than 3 years old. Overall, we suggest that the age of 3-7 years might be optimal for AT in polysomnography-diagnosed uncomplicated OSA to maximize potential benefits for both disease and comorbidities and balance the risks of surgery.

Effect of surgical intervention for childhood OSA on blood pressure: A randomized controlled study

OBJECTIVE

To investigate the effect of surgical intervention on 24-h ABP in children with OSA. It was hypothesized that blood pressure would improve following adenotonsillectomy.

METHODS

This was a two-centered investigator-blinded randomized controlled trial. Non-obese pre-pubertal children aged 6-11 years with OSA (obstructive apnea-hypopnea index, OAHI >3/h) underwent 24-h ABP monitoring at baseline and 9 months after the randomly assigned intervention, i.e. Early Surgery (ES) or Watchful Waiting (WW). Intention-to-treat analysis was performed.

RESULTS

137 subjects were randomized. Sixty-two (Age: 7.9y ± 1.3, 71% boys) and 47 (Age: 8.5y ± 1.6, 77% boys) participants from the ES and WW groups, respectively completed the study. Changes in ABP parameters were similar in the ES and WW groups (nighttime systolic BP z-scores: +0.03 ± 0.93 vs. -0.06 ± 1.04, p = 0.65; nighttime diastolic BP z-scores: -0.20 ± 0.95 vs. -0.02 ± 1.00, p = 0.35) despite a greater improvement in OSA in the ES group. However, a reduction in nighttime diastolic BP z-score correlated with improvements in OSA severity indexes (r = 0.21-0.22, p < 0.05), and a significant improvement in nighttime diastolic BP z-score [-0.43 ± 1.01, p = 0.027] following surgery was observed in participants with severe preoperative OSA (OAHI ≥10/h). The ES group had a significant increase in body mass index z-score after surgery [+0.27 ± 0.57, p < 0.001], which correlated with the increase in daytime systolic BP z-score (r = 0.2, p < 0.05).

CONCLUSION

Surgical treatment did not lead to significant improvements in ABP in OSA children except in those with more severe disease. The improvement in BP was partially masked by the weight gain following surgery.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn.

REGISTRATION NUMBER

ChiCTR-TRC-14004131).

The role of rapid maxillary expansion in pediatric obstructive sleep apnea: Efficacy, mechanism and multidisciplinary collaboration

This review aims to provide current knowledge about the efficacy, mechanism, and multidisciplinary collaboration of rapid maxillary expansion (RME) treatment in pediatric obstructive sleep apnea (OSA). OSA is a chronic disease characterized by progressively increasing upper airway resistance, with various symptoms and signs. Increasingly the evidence indicates that RME is a non-invasive and effective therapy option for children with OSA. Besides, the therapeutic mechanism of RME includes increasing upper airway volume, reducing nasal resistance, and changing tongue posture. Recent clinical researches and case reports also show that a multidisciplinary approach improves sleep-disordered breathing in children. Applied with adenotonsillectomy, mandibular advancement, continuous positive airway pressure, and comprehensive orthodontic treatment, RME can be more effective in recurrent or residual OSA.

Investigating factors influencing post-operative growth in pre-pubertal children after adenotonsillectomy

PURPOSE

To check the change in growth-for-age after adenotonsillectomy in pre-pubertal children and investigate the affecting factors.

METHODS

Two hundred and six pediatric patients who underwent adenotonsillectomy by a single surgeon between January 2011 and December 2014 were included for the retrospective cohort study. The z-scores of height-, weight-, and body mass index (BMI)-for-age were measured before adenotonsillectomy and 1 year after the operation. The Korean version of the obstructive sleep apnea-18 questionnaire (OSA-18), symptom questionnaire, physical examinations, demographic data, and pre-operative z-scores were used to analyze the factors affecting z-score change.

RESULTS

Among 206 pediatric patients, 167 patients were normal growth; 19 were undergrowth; and 20 were obese. After the operation, height, weight, and BMI z-scores all increased both in 167 normal-growth patients and 19 undergrowth patients (p value < 0.05). However, in 20 obese patients, only height z-score significantly increased (p value = 0.028). The multiple regression test showed that the sleep disturbance domain of OSA-18 was positively correlated with height z-score change (p value = 0.041), and age was negatively correlated with weight z-score change (p value = 0.016). Pre-operative BMI z-score was negatively correlated (p value = 0.019) and adenoid grade was positively correlated (p value = 0.023) with BMI z-score change.

CONCLUSIONS

These findings suggest that adenotonsillectomy may positively affect growth in pre-pubertal children, without undesirable weight gain. Additionally, the sleep disturbance domain of OSA-18 may play a role in predicting post-operative height increase in pre-pubertal children.

Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea

STUDY OBJECTIVES

Adenotonsillectomy (AT) forms part of first-line management for pediatric obstructive sleep apnea. In nonrandomized studies of preschool-aged children, postoperative weight gain has been seen following AT, raising concerns regarding later obesity. Using longitudinal data from a multicenter randomized controlled trial, we assessed the impact of AT on growth trajectories in preschool-aged children with mild-moderate obstructive sleep apnea.

METHODS

A total of 190 children (aged 3-5 years) with obstructive apnea-hypopnea index ≤ 10 events/h were randomly assigned to early (within 2 months) or routine (12-month wait) AT. Anthropometry and polysomnography were performed at baseline, 12-month, and 24-month time points for 126 children. Baseline characteristics were compared using a Mann-Whitney or t test for continuous variables and Fisher's exact test for categorical variables. Longitudinal data underwent linear mixed modeling.

RESULTS

For body mass index (BMI) z-score there was a significant increase in the early surgery group between 0 and 12 months (0.4, 95% confidence interval 0.1-0.8) but not from 12-24 months. For the routine surgery group there was an identical significant BMI z-score increase in the first 12 months following surgery, ie, between 12- and 24-month time points (0.45, 95% confidence interval 0.1-0.8) but not from 0-12 months (preoperative time). Final BMI z-score was similar between groups. Findings for weight-for-age z-score were similar to the findings for BMI z-score. Height-for-age z-score was not significantly different between different time points or intervention groups.

CONCLUSIONS

This study provides randomized controlled trial evidence of notable, but time-limited, increase in the BMI and weight of preschool children with mild-moderate obstructive sleep apnea in the months immediately following AT.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: POSTA Child Study (Preschool Obstructive Sleep Apnea Tonsillectomy Adenoidectomy Study); URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336273&isReview=true; Identifier: ACTRN12611000021976.

CITATION

Kevat A, Bernard A, Harris M-A, et al. Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea. J Clin Sleep Med. 2023;19(1):55-62.

Adenotonsillectomy: the good, the bad and the unknown

PURPOSE OF REVIEW

Adenotonsillar hypertrophy is the most common pathogenetic contributor to obstructive sleep apnea syndrome (OSAS) in childhood, and adenotonsillectomy is the standard initial treatment. Here, we summarize the most recent evidence on the efficacy and complications of adenotonsillectomy and explore knowledge gaps in clinical management.

RECENT FINDINGS

Favorable adenotonsillectomy effects have been reported in children with very severe OSAS [apnea-hypopnea index (AHI) >20 episodes/h] and extremely severe OSAS (AHI >100 episodes/h), without postoperative mortality, need for endotracheal intubation, prolonged hospital stay or re-admission after hospital discharge. However, the risk of residual OSAS after adenotonsillectomy, which may reach 30-60%, has not been thoroughly established. Behavior, OSAS-related symptoms and quality of life improve postoperatively even in children with AHI 1-5 episodes/h. Natural history of enuresis resolution is accelerated postadenotonsillectomy and office-based systemic blood pressure is decreased in OSAS and hypertension. However, which children younger than 2 years should undergo adenotonsillectomy instead of adenoidectomy only to prevent recurrence of OSAS symptoms and revision surgery remains unclear. Adenotonsillectomy in children with Prader-Willi syndrome is frequently accompanied by postoperative residual OSAS while complications are not uncommon.

SUMMARY

In the last 2 years, several studies have provided evidence supporting the efficacy and safety of adenotonsillectomy as treatment intervention for otherwise healthy children with OSAS.

Secondary Analyses of the Childhood Adenotonsillectomy Trial: A Narrative Review

Importance

Adenotonsillectomy, performed for approximately 500 000 children annually in the US alone, is the first line of treatment of pediatric obstructive sleep apnea (OSA). The Childhood Adenotonsillectomy Trial (CHAT), the first randomized clinical trial to test the efficacy of adenotonsillectomy, compared the management of pediatric nonsevere OSA by early adenotonsillectomy (eAT) vs watchful waiting with supportive care. Since the publication of the primary article in 2013, the CHAT study data set were made available via the National Sleep Research Resource, which allowed researchers to address a range of additional clinical questions relevant to the care of children with OSA. This review focuses on secondary analyses associated with the CHAT data set as grouped by the outcome of interest.

Observations

The results of most secondary analyses suggest that children who underwent eAT experienced the greatest improvements in symptom burden, sleepiness, parent-reported behavior, and quality of life. Changes in other domains, such as cognition, cardiovascular physiology, and metabolic indicators, were modest and selective. The associations between most treatment outcomes and polysomnographic parameters were weak. Symptoms were poor predictors of OSA severity. The results from these secondary analyses benefitted from the rigor of multicenter design and centralized polysomnography interpretation in CHAT. However, the exclusion of younger preschool-aged children and children with primary snoring limited the generalizability of findings. In addition, because caregivers were not masked, some of the parent-reported outcomes may have been inflated.

Conclusions and Relevance

The results of this narrative review suggest that CHAT provides a model for future OSA-related studies in children for design, conduct, and subsequent reuse of the study data set, and its findings have advanced our understanding of the pathophysiology and management of pediatric nonsevere OSA. Directions for future research include whether the findings from this landmark study are generalizable to younger children and children with primary snoring and severe OSA. Similar studies may help address practice variability associated with pediatric OSA and help identify children who are most likely to benefit from undergoing eAT.

OSAHS Growth Impairment and Resolution after Adenotonsillectomy in Children

INTRODUCTION

One of the most important complications of OSAHS in children is growth delay. The aim of this study was to investigate changes in clinical body growth, and laboratory growth in children with OSAHS after adeno-tonsillar surgery.

MATERIALS AND METHODS

In our study, among 102 children suffering from sleep-disordered breathing, 70 met the inclusion criteria because they were affected by OSAHS and adenotonsillar hypertrophy. In total, 96 children affected by adeno-tonsillar hypertrophy (55 males and 41 females) underwent nocturnal cardiorespiratory monitoring with Embletta MPR, monitoring for post-operative 24 hours. Patients underwent blood sampling to evaluate preoperative GH and IGF-1 serum levels, "placement" in Cacciari's growth charts and adenotonsillectomy and saturation monitoring for post-operative 24 hours. According to auxological parameters, 82.86% of the patients were below the fiftieth percentile of BMI Cacciari's growth charts and IGF-1 preoperative serum levels were below the normal range. All patients underwent adenotonsillectomy.

RESULTS

All 70 patients recovered from OSAHS according to the results of nocturnal cardiorespiratory monitoring after six months. IGF-1 serum levels significantly increased after three months and one year after. All the auxological parameters showed a significant increase after surgery. We calculated the average annual growth in height of the patients before and after adenotonsillectomy (AT): the growth rate was impaired by OSAHS (5.4±1.3 cm/year), while in the following year post-surgery we found a significant growth speed acceleration (9.9±1.7 cm/year, P=0.001).

CONCLUSIONS

In conclusion, growth delay in children can be caused by OSAHS, and when it is due to adenotonsillar hypertrophy, adenotonsillectomy is to be considered as the therapy of choice.

The impact of sleep events on weight gain following early adenotonsillectomy compared to supportive care for pediatric OSA

OBJECTIVES

Children with obstructive sleep apnea (OSA) who undergo adenotonsillectomy (AT) often experience post-operative weight gain, although the mechanism remains unclear. Our aim is to understand how changes in sleep events impact changes in weight in children with OSA following adenotonsillectomy compared to watchful waiting with supportive care.

METHODS

We performed a secondary analysis of the Childhood adenotonsillectomy trial (CHAT) dataset in which children with OSA were randomized to undergo early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC). The primary outcome measures included changes in body mass index (BMI) percentile, apnea-hypopnea index (AHI) and arousal index (AI) during rapid eye movement (REM) sleep. The change in BMI percentile attributable to changes in AHI and AI during REM sleep was determined using causal mediation analysis.

RESULTS

Of the 453 children with OSA randomized to eAT or WWSC, 397 children were included in the analysis. Children in the eAT arm experienced a greater increase in their weight as measured by BMI percentile, compared to children who received WWSC (WWSC 4.12 (2.70, 5.55) vs. eAT 6.62 (4.87, 8.38), Cohen's d = 0.22 (0.02, 0.42), p = 0.02). A significant proportion of the weight gain was attributable to decreases in apneic events (proportion mediated 19% (2-97%), p = 0.03) and arousals (proportion mediated 20% (5-78%), p = 0.01) during REM sleep.

CONCLUSION

A significant proportion of post-adenotonsillectomy weight gain in children with OSA is attributable to polysomnographic changes during REM sleep, potentially due to the mitigation of REM-related sleep fragmentation and subsequent reduction in metabolic expenditure.

Obese Patients Experience More Severe CSA than Non-Obese Patients

Objective: To investigate whether central sleep apnea (CSA) is associated with an increased risk of obesity. Materials and methods: From 1 January 2000 to 31 December 2015, we screened 24,363 obese patients from the 2005 longitudinal health insurance database, which is part of the Taiwan National Health Insurance Research Database. From the same database, 97,452 non-obese patients were also screened out. Age, gender, and index dates were matched. Multiple logistic regression was used to analyze the previous exposure risk of obese and CSA patients. A p-value of <0.05 was considered significant. Results: Obese patients were more likely to be exposed to CSA than non-obese patients would (AOR = 2.234, 95% CI = 1.483–4.380, p < 0.001). In addition, the closeness of the exposure time to the index time is positively correlated with the severity of obesity and has a dose–response effect (CSA exposure < 1 year, AOR = 2.386; CSA exposure ≥ 1 year and <5 years, AOR = 1.725; CSA exposure time ≥ 5 years, AOR = 1.422). The CSA exposure time of obese patients was 1.693 times that of non-obese patients. Longer exposure time is associated with more severe obesity and has a dose-response effect (CSA exposure < 1 year, AOR = 1.420; CSA exposure ≥ 1 year and <5 years, AOR = 2.240; CSA ≥ 5 years, AOR = 2.863). Conclusions: In this case-control study, patients with CSA had a significantly increased risk of obesity. Long-term exposure to CSA and obesity is more likely and has a dose-response effect.

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.

The impact of obstructive sleep apnea on growth in patients with syndromic and complex craniosynostosis: a retrospective study

Given the high prevalence of OSA in children with syndromic and complex craniosynostosis (SCC) and the consequences of untreated OSA, it is important to assess their nutritional status and growth. Yet, literature regarding growth in children with SCC remain scarce. Therefore, this study aimed to (1) illustrate the growth pattern in SCC, (2) determine the impact of OSA on this growth pattern, and (3) evaluate the effect of surgical treatment of OSA on growth over time. A retrospective study was performed in children with SCC, who were treated at the Dutch Craniofacial Center (Rotterdam, Netherlands). Growth variables (height, weight, weight-for-age standard-deviation-score (SDS), weight-for-height SDS, and height-for-age SDS) and degree of OSA (obstructive apnea-hypopnea index) were assessed. Of the 153 children with SCC, 38 (25%) were acutely malnourished at some point during follow-up, of whom 21 had disease-related acute malnutrition. Children with moderate-severe OSA had significant lower weight-for-height SDS compared to children without OSA (p = 0.0063). Growth parameters (weight-for-age SDS, weight-for-height SDS, height-for-age SDS) in children with SCC without OSA were not impaired as they did not differ from the normal healthy population, with exception of the patients with Saethre-Chotzen syndrome (SCS) who had a significantly lower SDS for height-for-age.   Conclusion: Children with SCC have a substantial chance of developing acute malnutrition at some point during growth. Additionally, in children with moderate-severe OSA, a significant lower SDS for weight-for-height is present, indicating the importance of assessing the weight and growth pattern in children who are clinically suspected for OSA. What is Known: • Obstructive sleep apnea is seen in up to two-thirds of the children with syndromic and complex craniosynostosis. • Presence of obstructive sleep apnea is associated with intracranial hypertension and an increased risk of metabolic, cardiovascular, and neurocognitive consequences later in life. Untreated obstructive sleep apnea may lead to impaired growth and weight gain, which can result in growth failure. What is New: • Craniosynostosis patients with moderate-severe obstructive sleep apnea had significant lower weight-for-height standard deviation scores (SDS), compared to children without obstructive sleep apnea.  • Children with syndromic and complex craniosynostosis without OSA did not significantly differ from the normal healthy population in regard to weight-for-age SDS, weight-for-height SDS, and height-for-age SDS.

Changes in childhood growth after adenotonsillectomy: a population-based cohort study

OBJECTIVES

This study aimed to investigate the association between adenotonsillectomy (T&A) and serial changes in growth in children through a population-based nationwide study as well as the national health insurance service (NHIS) database.

METHODS

Propensity score (PS) matched children with and without T&A were selected in NHIS database, which includes all individuals born in Korea in 2008-2009. Serial changes of BMI and height were compared in children with and without T&A, and growth changes depending on the time of operation were also considered. The outcomes were differences in age-/sex-standardized BMI (BMI-z) and height (height-z) between the groups. Changes in BMI-z and height-z were further analyzed according to the timing of operation.

RESULTS

Of 919,707 individuals born in Korea in 2008-2009, 3172 children were included in the operation group and 31,663 PS-matched children were included in the control group. T&A was related to increased weight and height in the operation group than in the control group. At 66-71 months of age, BMI-z and height-z were 0.41 (0.02) and 0.42 (0.02), respectively, in the operation group and 0.18 (0.01) and 0.35 (0.01), respectively, in the control group. On adjustment with preoperative BMI-z, more weight gain was noted in the operation group (p < 0.001). Shortly after T&A, BMI-z increased significantly in the operation group; a significant increase in height-z was observed more than 1 year after T&A.

CONCLUSIONS

Children who underwent T&A tended to experience a growth spurt; when surgical intervention such as T&A is required, care should be taken to minimize or reverse the anticipated weight gain.

Prevalence of PErioperAtive CHildhood obesitY in children undergoing general anaesthesia in the UK: a prospective, multicentre, observational cohort study

BACKGROUND

Childhood obesity has become a serious global healthcare challenge. No UK data currently define its anaesthetic and perioperative implications. We aimed to determine obesity prevalence amongst UK children undergoing general anaesthesia and the incidence of predefined adverse perioperative events, and to compare perioperative obesity rates with National Child Measurement Programme (NCMP) data.

METHODS

During a site-selected consecutive 7-day study period, all children (2-16 yr) undergoing general anaesthesia were included. Anonymised hospital, surgical, and procedural details; demographic data; and adverse perioperative events were collected prospectively by Paediatric Anaesthesia Trainee Research Network (PATRN) collaborators.

RESULTS

For this study, 102 UK hospitals participated and 4232 cases were included in the final analysis; 76% of hospitals did not routinely calculate BMI. In addition, 3030 (71.6%; 95% confidence interval [CI]: 70.2-73.0%) children of healthy weight were compared with 537 (12.7%; 11.7-13.7%) children who were overweight and 478 (11.3%; 10.3-12.2%) children with obesity. Children with obesity (n=71; 14.9%) more commonly underwent (adeno)tonsillectomy than children of healthy weight (n=282; 9.3%; P<0.001; odds ratio [OR] 2.15; 95% CI: 1.58-2.92). Fewer children with obesity (n=365; 77% vs n=2552; 85%) were anaesthetised by consultant anaesthetists (OR 0.62; 95% CI: 0.48-0.79). Mask ventilation was difficult for 3.7% of children with obesity vs 0.6% of children of healthy weight (difference 3.0%; 95% CI: 1.3-4.7%; P<0.001). Comparison with NCMP data demonstrated an over-representation of obesity amongst the paediatric surgical population.

CONCLUSIONS

This large multicentre cohort study suggests a concerning prevalence of children with obesity presenting for anaesthesia. These results should be used to inform optimal provision of care for this population and support perioperative healthcare initiatives to address the burden of childhood obesity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03994419.

Changes in energy metabolism and respiration in different tracheal narrowing in rats

Why obstructive sleep apnea (OSA) treatment does not completely restore healthy metabolic physiology is unclear. In rats, the need for respiratory homeostasis maintenance following airway obstruction (AO) is associated with a loss of thermoregulation and abnormal metabolic physiology that persists following successful obstruction removal. Here, we explored the effect of two different types of tracheal narrowing, i.e., AO and mild airway obstruction (mAO), and its removal on respiratory homeostasis and metabolic physiology. We show that after ten weeks, mAO vs. AO consumes sufficient energy that is required to maintain respiratory homeostasis and thermoregulation. Obstruction removal was associated with largely irreversible increased feeding associated with elevated serum ghrelin, hypothalamic growth hormone secretagogue receptor 1a, and a phosphorylated Akt/Akt ratio, despite normalization of breathing and energy requirements. Our study supports the need for lifestyle eating behavior management, in addition to endocrine support, in order to attain healthy metabolic physiology in OSA patients.

Growth After Adenotonsillectomy for Obstructive Sleep Apnea: Revisited

OBJECTIVES/HYPOTHESIS

To reanalyze the growth trajectory and assess longitudinal changes of children undergoing adenotonsillectomy (AT) versus watchful waiting (WW) enrolled in the Childhood Adenotonsillectomy Trial (CHAT) study and to determine if an AT increases the risk of obesity in children.

STUDY DESIGN

Reanalysis of prospective cohort investigation.

METHODS

The study analyzed publicly available data from CHAT, including 3 months visit data not previously included in a prior publication. Statistical comparisons and mixed-effects modeling were done using age- and sex-specific BMI expressed as a percentage of the 95th percentile (%BMIp95). P < .05 was considered significant.

RESULTS

Children in the AT group, especially if underweight at baseline, had an increased rate of weight gain, with 100% of underweight children in the AT group becoming normal weight compared to 20% for WW. However, the rate of weight gain, as measured by the %BMIp95 trajectory for both AT and WW groups, was not significantly different when baseline weight status and obstructive sleep apnea (OSA) resolution were accounted for. Comparisons of %BMIp95 between treatment groups at baseline, 3- and 7-month follow-up visits also failed to identify statistically significant differences (P > .05). Overall for the entire cohort, resolution of OSA was associated with a decreased weight trajectory (P < .001).

CONCLUSIONS

AT compared to WW is not associated with an increased risk of excessive weight gain. Otolaryngologists should be aware of this updated analysis when discussing AT surgical outcomes with families.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

Weight gain in children after adenotonsillectomy: undesirable weight gain or catch-up growth?

OBJECTIVE/BACKGROUND

Obesity and obstructive sleep apnea (OSA) are consequential conditions with significant overlap in the pediatric population. Early studies documented catch-up growth in underweight children after adenotonsillectomy, but more recent studies suggested that normal and even overweight children may experience excess weight gain after adenotonsillectomy. We performed a secondary analysis of Childhood Adenotonsillectomy Trial (CHAT) data to test whether there was an effect of early adenotonsillectomy on undesirable weight gain, defined as an increase in body mass index (BMI) Z score in an already overweight or obese child or a change from baseline normal or underweight to a follow up BMI Z score classified as overweight.

PATIENTS/METHODS

We included 398 children with moderate OSA and complete anthropomorphic data randomized to adenotonsillectomy versus watchful waiting with supportive care. Pearson's χ² and independent t tests were used to compare demographic, activity, sleep and anthropomorphic characteristics between children who did and did not experience undesirable weight gain over seven months. Logistic regression was used to test for an association between adenotonsillectomy and undesirable weight gain, both unadjusted and adjusted for age, sex, Black race, average parent-reported weekly activity level, mother's body mass index, average nightly sleep duration and either baseline or follow up AHI (in separate models).

RESULTS

Forty three percent (n = 172) experienced undesirable weight gain. A similar percentage of children in both arms experienced undesirable weight gain (45% adenotonsillectomy vs 41% watchful waiting). Neither unadjusted nor adjusted regression analysis demonstrated a significant effect of adenotonsillectomy on undesirable weight gain.

CONCLUSION

Adenotonsillectomy may not be an independent risk factor for undesirable weight gain in children.

Prevalence of malocclusions and oral dysfunctions in children with persistent sleep-disordered breathing after adenotonsillectomy in the long term

STUDY OBJECTIVES

To evaluate the prevalence of craniofacial/orthodontic abnormalities and oral dysfunctions in a population of children with persistent sleep-disordered breathing despite adenotonsillectomy.

METHODS

Medical charts of 4,000 children with sleep-disordered breathing operated on in a tertiary hospital were retrospectively reviewed. Patients reporting persistent sleep-disordered breathing symptoms were invited to an orthodontic/myofunctional evaluation following the Sleep Clinical Score), followed by a 1-night ambulatory type III sleep study.

RESULTS

One hundred nonsyndromic symptomatic patients were examined (mean age 8.8 ± 3.5 years), from 1 to 12 years after surgery (mean 4.6 ± 3.1 years); 24% were overweight/obese; 69 had a sleep study. Although prevalent, oronasal abnormalities and malocclusions were not specifically associated with pathological sleep parameters (cartilage hypotonia 18%, septal deviation 5%, short lingual frenulum 40%). Malocclusions were associated with a higher respiratory event index in children under 8 years only, whereas an impaired nasal dilator reflex and tongue immaturity were associated with an increased obstructive respiratory event index in all patients (1.72 ± 2.29 vs 0.72 ± 1.22 events/h, P = .011) and Respiratory Event Index, respectively (3.63 ± 3.63 vs 1.19 ± 1.19 events/h). Male sex, phenotype, nasal obstruction, oral breathing, and young age at surgery (< 3 years) were significantly related to higher respiratory event index. Using the Sleep Clinical Score > 6.5 cut-off, patients with persistent sleep apnea were significantly distinct from chronic snoring (2.72 ± 2.67 vs 0.58 ± 0.55, P < .01).

CONCLUSIONS

Oronasal anatomical and functional abnormalities were quite prevalent and various in persistent sleep-disordered breathing after adenotonsillectomy. Nasal disuse and tongue motor immaturity were associated with a higher obstructive respiratory event index in the long term, whereas craniofacial risk factors might have a more pronounced impact at younger age.

Improvement in BMI z-score following adenotonsillectomy in adolescents aged 12-18 years: a retrospective cohort study

BACKGROUND

Characteristics of obstructive sleep apnea (OSA) changes with age. Infants, toddlers and prepubertal children with OSA are usually underweight and may suffer from failure to thrive (FTT). Adenotonsillectomy (T&A) is the first line of treatment for OSA in childhood. In adults OSA is commonly associated with obesity and the metabolic syndrome. The change in body mass index (BMI) in adolescents with OSA following T&A was only sporadically studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.

METHODS

Clalit Health Services is the largest health care organization in Israel with the largest patient registry (more than 50% of the population). Two hundred and forty two adolescents aged 12-18 who underwent T&A between 2006 and 2015 were identified in the Clalit registry and their characteristics including height and weight were retrieved. The BMI z-score of these adolescents at baseline (up to 3 months prior to T&A) and during the consecutive 3 years after T&A were analyzed and compared.

RESULTS

Changes in BMI Z-score were observed to all directions following T&A with overall small increase, not statistically significant (P = 0.26) from a median of 0.79 prior to T&A to a median of 0.835 after it. There was a minimal trend toward BMI z-score reduction in overweight children (n = 74) from 1.508 to 1.48 following T&A (p = NS), and in obese children (n = 33) from 2.288 to 2.000 (P = 0.06, 2 tailed). Interestingly thin individuals (n = 6) increased their BMI z-score following T&A from - 2.4 to - 0.59 (p = 0.046).

CONCLUSIONS

Adolescents show variable changes in their BMI z-score following T&A. In this aspect their BMI z-score change is closer to the change seen in adults treated for OSA and not that of young children. The changes observed show a trend toward normalization of the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.

Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

Surgery for obstructive sleep apnea in young children: Outcome evaluated by polysomnograhy and quality of life

PURPOSE

Hypertrophy of adenoid and tonsils is the most common risk factor for OSA in children, and adenotonsillectomy is considered the first-line treatment. The effect of surgery for OSA in children varies considerably between studies, and few studies have focused on the effect in young children under 5 years of age. Thus, the aim of this study was to: 1) evaluate the effect of surgery for OSA in young children using objective data from polysomnography and parent-reported symptoms using questionnaires, and 2) identify predictors of residual OSA following surgery.

METHODS

This is a prospective cohort study of children aged 2-4 years who were referred for surgery to treat OSA. Measures collected before and after surgery included polysomnography (PSG), Pediatric Sleep Questionnaire (PSQ), OSA-18 and clinical data.

RESULTS

56 children completed a preoperative and postoperative PSG. Their median age was 3.1 (IQR 2.6-3.1) years. After surgery, 63% had an obstructive apnea hypopnea index (OAHI) < 1, 82% had an OAHI < 2 and 95% had an OAHI < 5. Parent-reported OSA-18 and PSQ scores improved significantly after surgery. In logistic regression analyses, higher preoperative OAHI was the only significant clinical predictor of residual OSA after surgery.

CONCLUSION

There was a high resolution rate after surgery for OSA in this group of young children, with significant improvements in both the OAHI measured with PSG and parent-reported symptoms. The only clinical predictor of residual OSA after surgery was higher preoperative OAHI.

Parental Perception of Weight Status for Adenotonsillectomy Patients

OBJECTIVE

Weight status can affect outcomes in pediatric adenotonsillectomy performed for obstructive sleep disordered breathing. Parents frequently underestimate their child's weight and are unaware weight status may affect adenotonsillectomy success. Accurate understanding of a child's weight status is important for shared decision making with the family and perioperative care. The purpose of this study is to analyze the accuracy of the parent's perception of their child's weight status.

METHODS

A retrospective analysis was performed of prospective data collected from families of children undergoing adenotonsillectomy from June 2018 through June 2019.

RESULTS

A total of 522 children met the inclusion criteria. Two hundred and thirty-two children were either overweight (n = 46, 9%) or obese (n = 186, 36%). Among parents of this cohort whose children were overweight or obese, 74 (32%) erroneously reported that their child was normal weight. For the 290 nonoverweight children, 99% of parents accurately reported weight status. After adjusting for ethnicity, race, BMI%, and sex, for every 1-year increase in age of the child, the odds of the parent correctly identifying their child as overweight increased by a factor of 1.18 (95% CI: 1.09, 1.27).

CONCLUSION

One-third of families with children who were overweight or obese undergoing adenotonsillectomy for obstructive sleep disordered breathing underestimated their child's weight. This study highlights the need to facilitate family understanding of weight status' potential impact on both obstructive sleep disordered breathing severity and adenotonsillectomy success, especially for younger children.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2121-2125, 2021.

[Tonsillectomy and tonsillotomy]

The number of operations for tonsillectomy have been significantly decreasing for many years in Germany. In children the number of adenotonsillectomies has decreased by two thirds within a decade. This phenomenon is mirrored by a significant increase in the number of annually performed tonsillotomies, a surgical procedure which is preferably performed for volume reduction in cases of tonsillar hypertrophy. The aim of this article is to elucidate the different interventional procedures, their typical indications and risks.

Weight change before and after adenotonsillectomy in children: An analysis based upon pre-surgery body mass category

OBJECTIVES

To determine the standardised body mass index (BMIz) trajectory before and after adenotonsillectomy/tonsillectomy between children in different weight classifications in a larger sample than has been studied previously, and to identify which patient factors would explain the difference in these outcomes.

DESIGN

We used a retrospective chart review and leveraged data of weight status pre- and post-adenotonsillectomy/tonsillectomy from a cohort of paediatric patients seen between May 2004 and April 2017.

SETTING

Data were collected from an electronic medical record at a single Midwest paediatric health system.

PARTICIPANTS

The study population included a convenience sample of 1,751 paediatric patients who underwent adenotonsillectomy or tonsillectomy and had at least two height and weight measurements recorded on the same date both before and after surgery.

MAIN OUTCOME MEASURES

Change in BMIz trajectories before and after surgery.

RESULTS

Of 1751 paediatric patients (ages 3-11) underwent adenotonsillectomy/tonsillectomy procedures. Age at time of surgery and gender were not significant predictors. Children in different weight classifications demonstrated differences in BMIz trajectory after surgery. Children with overweight/obesity experience a decrease in BMIz, whereas children with underweight or normal weight experience an increase in BMIz.

CONCLUSIONS

Improvement in weight status is seen after surgery: increased BMI for those underweight and decreased BMI for those with overweight/obesity. We advocate for behavioural strategies as a first-line treatment in children with underweight or overweight/obesity, and results suggest that coordinating these efforts alongside adenotonsillectomy/tonsillectomy when indicated for medical reasons may be warranted. However, further research is needed to confirm these findings due to the observational nature of this study.

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.

Upper Airway Obstruction Elicited Energy Imbalance Leads to Growth Retardation that Persists after the Obstruction Removal

Upper airway obstruction can lead to growth retardation by unclear mechanisms. We explored the effect of upper airway obstruction in juvenile rats on whole-body energy balance, growth plate metabolism, and growth. We show that after seven weeks, obstructed animals’ ventilation during room air breathing increased, and animals grew less due to abnormal growth plate metabolism. Increased caloric intake in upper airway-obstructed animals did not meet increased energy expenditure associated with increased work of breathing. Decreased whole-body energy balance induced hindrance of bone elongation following obstruction removal, and array pathways regulating growth plate development and marrow adiposity. This is the first study to show that rapidly growing animals cannot consume enough calories to maintain their energy homeostasis, leading to an impediment in growth in the effort to save energy.

Time-Course Evaluation of Body Mass Index in Japanese Children With Obstructive Sleep Apnea Syndrome After Adenotonsillectomy: A Three-Years Follow-Up Study

Delayed physical growth is a common complication of pediatric obstructive sleep apnea syndrome (OSAS). Adenotonsillectomy (AT) is the first-line treatment for pediatric OSAS. Only a few studies have performed time-course BMI evaluation in pediatric OSAS patients post-operatively. Thus, we aimed to evaluate the time-course changes in pediatric OSAS patients after AT. Thirty-three children with OSAS who underwent AT were included and divided into two groups on the basis of their BMI z-scores (delayed physical growth group, n = 15; non-delayed physical growth group, n = 18). Clinical records of height and weight were collected before AT and at 6, 12, 24, and 36 months after AT. Changes in the mean BMI z-scores of the two groups were assessed up to 36 months. The mean BMI z-score was significantly increased in the delayed physical growth group at 6 months after AT. In contrast, the increase in mean BMI z-score was not observed in the non-delayed physical growth group. Growth improvement was noted in pediatric OSAS patients with delayed physical growth after AT. Our results suggest that AT is a promising therapy for improving the physical growth of pediatric OSAS patients with such problems.

Irreversible metabolic abnormalities following chronic upper airway loading

STUDY OBJECTIVES

Treatment of obstructive sleep apnea increases obesity risk by an unclear mechanism. Here, we explored the effects of upper airway obstruction and its removal on respiratory homeostasis, energy expenditure, and feeding hormones during the sleep/wake cycle from weaning to adulthood.

METHODS

The tracheas of 22-day-old rats were narrowed, and obstruction removal was performed on post-surgery day 14. Energy expenditure, ventilation, and hormone-regulated feeding were analyzed during 49 days before and after obstruction.

RESULTS

Energy expenditure increased and body temperature decreased in upper airway obstruction and was only partially recovered in obstruction removal despite normalization of airway resistance. Increased energy expenditure was associated with upregulation of ventilation. Decreased body temperature was associated with decreased brown adipose tissue uncoupling protein 1 level, suppressed energy expenditure response to norepinephrine, and decreased leptin level. Upper airway obstructed animals added less body weight, in spite of an increase in food intake, due to elevated hypothalamic orexin and neuropeptide Y and plasma ghrelin. Animals who underwent obstruction removal fed more due to an increase in hypothalamic neuropeptide Y and plasma ghrelin.

CONCLUSIONS

The need to maintain respiratory homeostasis is associated with persistent abnormal energy metabolism and hormonal regulation of feeding. Surgical treatment per se may not be sufficient to correct energy homeostasis, and endocrine regulation of feeding may have a larger effect on weight change.

Clinical Practice Guideline: Tonsillectomy in Children (Update)

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

(1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.

Assessing the need for adenotonsillectomy for sleep-disordered breathing in a community setting: A secondary outcome measures analysis of a randomized controlled study

OBJECTIVE

To assess whether children with sleep-disordered breathing (SDB) symptom severity above a certain level, measured by a validated questionnaire, improve after adenotonsillectomy (AT) compared to no intervention.

METHODS

Children with snoring and tonsillar hypertrophy (4 to 10-years old), who were candidates for AT, were randomly assigned to two evaluation sequences (baseline and 3-month follow-up): (a) evaluation immediately before AT and at 3 months postoperatively (AT group); or (b) evaluation at the initial visit and at the end of the usual 3-month waiting period for surgery (control group). Outcomes were (a) Pediatric Sleep Questionnaire sleep-related breathing disorder scale (PSQ-SRBD); (b) modified Epworth Sleepiness Scale (mESS); and (c) proportion of subjects achieving PSQ-SRBD <0.33 (low-risk for apnea-hypopnea index ≥5/h) if they had score ≥0.33 at baseline.

RESULTS

Sixty-eight children were assigned to the AT and 72 to the control group and two-thirds of them had PSQ-SRBD ≥0.33. The AT group experienced significantly larger improvement between follow-up and baseline than controls (between-group difference [95% CI] for PSQ-SRBD: -0.31 [-0.35 to -0.27]; and mESS: -2.76 [-3.63 to -1.90]; P < .001 for both). Children with baseline PSQ-SRBD ≥0.33 in the AT group had an eight-times higher probability of achieving PSQ-SRBD <0.33 at follow-up than controls with similar baseline score (risk ratio [95% CI]: 8.33 [3.92-17.54]; P < .001).

CONCLUSION

Among children with snoring, tonsillar hypertrophy, and clinical indications for AT, those with preoperative PSQ-SRBD score ≥0.33 show measurable clinical benefit postoperatively.

Effects of adenotonsillectomy on the growth of children with obstructive sleep apnoea-hypopnea syndrome (OSAHS): protocol for a systematic review

INTRODUCTION

Obstructive sleep apnoea-hypopnea syndrome (OSAHS) is characterised by recurring episodes of complete or partial upper airway collapse during sleep. Persistent OSAHS is associated with long-term consequences, such as growth failure, cardiovascular and neurocognitive problems in children. Different from the aetiology of OSAHS in adults, the most common cause of paediatric OSAHS is adenotonsillar hypertrophy. Adenotonsillectomy (AT) has been recommended as the first-line treatment of paediatric OSAHS. Several studies have suggested that retarded growth caused by OSAHS can improve after AT during the prepubertal period. This review will systematically search and summarise the available evidence on the effects of AT on children's growth.

METHODS AND ANALYSIS

We will conduct electronic searches in MEDLINE (via PubMed), Embase, Google Scholar and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) or cohort studies that included a control group. Additional records will be searched by checking the references included in the selected studies and relevant reviews. At least two authors will undertake selection of studies and data extraction independently and in duplicate. The Cochrane Risk of Bias tool and Risk Of Bias In Non-randomised Studies-of Interventions will be used to assess the risk of bias of RCT and cohort studies, respectively. A random-effects model will be used for meta-analyses. Data synthesis and other analyses will be carried out using the RevMan V.5.3 software. The Grades of Recommendation, Assessment, Development and Evaluation will be used to assess the quality of the supporting evidence behind each main comparison.

ETHICS AND DISSEMINATION

There is no ethical issue in this systematic review given that we will only include published studies. The results will be disseminated via peer-reviewed publications and social networks.

PROSPERO REGISTRATION NUMBER

CRD42019125882.

[Sleep-Disordered Breathing in Childhood]

Sleep-Disordered Breathing in Childhood Abstract. One out of ten healthy children is a habitual snorer, and one fourth of snoring children suffer from obstructive sleep apnea syndrome (OSAS). While OSAS is widely recognized as a relevant social and health problem due to its negative impact on behavior and neurocognitive development, the medical significance of habitual snoring remains debated. Sleep-disordered breathing remains underestimated and underdiagnosed in childhood, in part due to the variability of clinical manifestations. This is particularly true for children with an underlying syndromal morbidity such as Down syndrome or Prader-Willi syndrome. This review summarizes the essential key points of Sleep-Disordered Breathing (SDB) in childhood.

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review

OBJECTIVES

For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.

RESULTS

We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.

CONCLUSIONS

We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.

Use of Noninvasive Ventilation with Volume-Assured Pressure Support to Avoid Tracheostomy in Severe Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder in children but can occasionally present with life-threatening hypoxemia. Obesity is a significant risk factor for poor outcomes of OSA treatment. Continuous positive airway pressure (CPAP) is indicated in children who are not candidates for or have an unsatisfactory response to adenotonsillectomy. Children acutely at risk for significant morbidity with other therapies are candidates for a tracheostomy. An eight-year-old patient with morbid obesity and severe OSA refractory to CPAP therapy was treated successfully with a novel noninvasive ventilation (NIV) mode with volume-assured pressure support (VAPS) and avoided tracheostomy.