Treating acid reflux disease in patients with Down syndrome: pharmacological and physiological approaches

Prevalence, associated risk factors, and respiratory event distribution of obstructive sleep apnea in children with Down syndrome

PURPOSE

Children with Down Syndrome (DS) have a high prevalence of obstructive sleep apnea (OSA). We aimed to assess OSA prevalence in a single center cohort of children with DS, identify associated risk factors of obstructive respiratory events, and examine the influence of different sleep stages and body positions on respiratory events distribution.

METHODS

Single center retrospective study that included children with DS who underwent overnight polysomnogram (PSG). OSA severity was categorized by obstructive apnea-hypopnea index (OAHI) as mild (1.5-4.9 events/h), moderate (5-9.9 events/h), and severe (≥ 10 events/h). A logistic regression analysis was used to examine the association between OSA-related risk factors in normal and abnormal OAHI category and in REM and Non-REM predominant AHI groups.

RESULTS

PSG data were available for 192 children with a median age of 5 years (IQR 7). OSA prevalence was 82.3% (27.1% mild, 19.8% moderate, and 35.4% severe). A logistic regression model identified BMI and being an African American as significant predictors for OAHI severity. In children with OSA, the median OAHI was 7.6 and obstructive respiratory events were more common in REM sleep and in the supine position. The median REM OAHI was 20 events/h (IQR: 24.4), whereas the median Non-REM OAHI was 5.2 events/h (IQR: 12.6 p < 0.0001). Similarly, supine OAHI was 11.6 (IQR: 19.3) and off supine OAHI was 6.6 (IQR: 11.6, p = 0.0004). Age was a significant predictor (p = 0.012) for Non-REM predominant OSA which was present in 15.2% of children with OSA.

CONCLUSION

Children with DS have a high prevalence of OSA. Higher BMI and being an African American were significant associated risk factors for higher OAHI. Obstructive respiratory events in children with DS occur predominantly in REM sleep and in the supine position. Non-REM predominant distribution of respiratory events was noted in older children with DS.

Sleep and behavioral problems in Down syndrome: differences between school age and adolescence

Background

Individuals with Down syndrome (DS) are at risk of developing sleep problems. In spite of the well-established knowledge on the presence of sleep difficulties in DS individuals and the associated emotional and behavioral problems, less is known about the possible differences in the kind of associations between sleep and emotional/behavioral problems across different age ranges.

Methods

In this retrospective study, we included 289 participants with DS aged 6-18 years with the aims to explore differences in the distribution of sleep problems between specific age groups (school age vs. adolescence) and to identify specific age-based associations between sleep problems and emotional/behavioral problems.

Results

Some differences in the distribution of sleep problems have emerged between age groups. Moreover, differences in the patterns of association between emotional/behavioral difficulties and sleep problems-in particular, sleep-related breathing difficulties and parasomnias-have been observed. However, sleep-wake transition disorders and excessive daily somnolence appear to be related to emotional and behavioral problems (both internalizing and externalizing), in general, across school age and adolescence.

Discussion

These results remark the importance of appropriate neuropsychiatric and psychological evaluation taking into account the age-specific needs and features of individuals with DS.

Tooth wear prevalence in individuals with Down syndrome: a systematic review

OBJECTIVES

This systematic review investigated the prevalence of tooth wear between patients with and without Down syndrome.

METHODS

Six databases (Embase, LILACS, Livivo, PubMed, Scopus and Web of Science) and grey literature (Google Scholar, OpenGrey and ProQuest) were searched until March 7, 2022. Observational studies were included to assess the differences in tooth wear prevalence and/or severity in Down syndrome and non-syndromic controls. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations were followed. Three reviewers independently screened studies, extracted data, assessed the methodological quality (Joanna Briggs Institute) and graded the certainty of evidence through the Grading of Recommendations, Assessment, Development, Evaluation (GRADE) approach. Results were summarized through meta-analyses using a random-effects model. The protocol was registered at PROSPERO (CRD42021266997).

RESULTS

Of the 1382 records identified, six cross-sectional studies were included. Individuals with Down syndrome had a higher prevalence and were more likely to have tooth wear than individuals without Down syndrome (44% × 15%; OR = 4.43; 95% CI 3.17-6.18; p < 0.00001; I² = 8%). Also, the severity of tooth wear was higher in the Down syndrome group (n = 275) compared with the controls (n = 294). The certainty of evidence analysis was very low.

CONCLUSIONS

Based on very low certainty of the evidence, patients with Down syndrome had a higher prevalence and likelihood and severity of tooth wear when compared to those without Down syndrome.

CLINICAL RELEVANCE

Screening early tooth wear lesions should be carefully done in the Down syndrome population since its occurrence is remarkable compared to the general population.

Effect of trisomy 21 on long-term gastrointestinal outcomes in duodenal atresia

PURPOSE

We aimed to determine if Trisomy 21 (T21) affected gastrointestinal outcomes for children with duodenal atresia (DA).

METHODS

We identified children born with DA between 1991 and 2017. Cases were divided into DA with T21 and DA without T21. Ten healthy controls per case were included. Esophageal, ulcerative, obstructive and stomach complaints were assessed. Risk ratios (RR), rate ratios (RaR) and Cox models were constructed. Analyses were performed for cases versus controls, and for T21 cases versus non-T21 cases.

RESULTS

DA cases totaled 52: 22 had T21 and 30 did not. There were 520 controls. DA cases had more gastrointestinal complaints than controls. T21 cases were at greater risk and frequency of esophageal disease than non-T21 cases (RR = 4.08, p = 0.002, RaR = 69.8, p < 0.001). T21 and non-T21 cases were equally likely to present with obstruction (RR = 0.91, p = 1), but T21 cases complained of obstructive symptoms less (RaR = 0.57, p = 0.003). T21 and non-T21 cases had the same risk of stomach diseases, but T21 cases complained more frequently (RaR = 6.20, p < 0.001). Cox models supported these observations. T21 did not affect ulcerative diseases.

CONCLUSION

DA cases had more gastrointestinal problems than controls. T21 increased esophageal and gastric complaints in DA cases but did not affect ulcerative and obstructive complaints.

Single-minded 2 is required for left-right asymmetric stomach morphogenesis

The morphogenesis of left-right (LR) asymmetry is a crucial phase of organogenesis. In the digestive tract, the development of anatomical asymmetry is first evident in the leftward curvature of the stomach. To elucidate the molecular events that shape this archetypal laterality, we performed transcriptome analyses of the left versus right sides of the developing stomach in frog embryos. Besides the known LR gene pitx2, the only gene found to be expressed asymmetrically throughout all stages of curvature was single-minded 2 (sim2), a Down Syndrome-related transcription factor and homolog of a Drosophila gene (sim) required for LR asymmetric looping of the fly gut. We demonstrate that sim2 functions downstream of LR patterning cues to regulate key cellular properties and behaviors in the left stomach epithelium that drive asymmetric curvature. Our results reveal unexpected convergent cooption of single-minded genes during the evolution of LR asymmetric morphogenesis, and have implications for dose-dependent roles of laterality factors in non-laterality-related birth defects.

The impact of obstructive sleep apnea on bronchiolitis severity in children with Down syndrome

OBJECTIVES

Acute bronchiolitis commonly causes respiratory failure in children ≤2 years, and is particularly severe in those with Down syndrome (DS). Obstructive sleep apnea (OSA), common in DS, is also associated with respiratory complications. However, it is unknown whether OSA is associated with worse outcomes in children with and without DS, hospitalized with bronchiolitis. We hypothesized that in children with bronchiolitis, OSA is associated with worse outcomes in those with DS, independent of DS-related comorbidities.

METHODS

Hospital discharge records of children with bronchiolitis aged ≤2 years were obtained for 1997-2012 from the Kid's Inpatient Database. The primary outcome was invasive mechanical ventilation (IMV), and secondary outcomes were non-invasive mechanical ventilation (NIMV), length of hospital stay, and inflation-adjusted cost of hospitalization (IACH). Multivariable regression was conducted to ascertain the associations between OSA and primary and secondary outcomes accounting for DS-associated comorbidities.

RESULTS

There were 928,961 hospitalizations for bronchiolitis. The DS group with bronchiolitis (n = 8697) was more likely to have OSA [241 (2.77%) vs 1293 (0.14%), p < 0.001] compared to the non-DS group (n = 920,264). Multivariable logistic regression showed that OSA was associated with IMV (adjusted odds ratio [OR], 3.32 [95% CI 2.54-4.35], p < 0.0001) in all children with bronchiolitis; and in those with DS, it was associated with IMV (adjusted OR, 2.34 [95% CI 1.38-3.97], p = 0.002), NIMV (adjusted OR, 8.21 [95% CI 4.48-15.04], p < 0.0001) and IACH (adjusted β, 0.18 [95% CI 0.02-0.34], p = 0.031).

CONCLUSIONS

OSA is independently associated with assisted ventilation in all children hospitalized with bronchiolitis, regardless of DS-associated comorbidities in those with DS. The severity of bronchiolitis in children with DS may be driven by the high prevalence of OSA.

Outcomes in children with down syndrome and mild obstructive sleep apnea treated non-surgically

OBJECTIVES

Nasal steroids, oral anti-leukotrienes and supplemental oxygen are effective in the treatment of mild obstructive sleep apnea (OSA) in otherwise healthy children. However, their efficacy is unknown in children with Down syndrome (DS). Here we examine the effect of single medication therapy versus observation versus oxygen on polysomnographic outcomes in these children.

METHODS

We reviewed children (<18 years) diagnosed with DS and mild OSA (obstructive apnea-hypopnea index [oAHI] ≥1 to <5 events/hour) treated non-surgically (with supplemental oxygen, one medication, or observation) between 2012 and 2017. Demographic data, comorbid diagnoses, and pre- and posttreatment polysomnograms were analyzed. We assessed pre- and posttreatment oAHI, oxyhemoglobin saturation nadir, percent total sleep time (%TST) in rapid eye movement (REM), and end-tidal carbon dioxide (ETCO₂ ) >50 mmHg.

RESULTS

Twenty-four children met inclusion criteria; 10 treated with medication, one with oxygen, and 13 with observation (baseline oAHI was 3.5, 3.3, and 2.9 events/hour, respectively). There was no significant change in oAHI, oxyhemoglobin saturation nadir, ETCO₂ , or percent TST in REM after treatment for any treatment group (P = .21-.94). There was no association between reported symptoms and AHI severity or change in AHI. OSA resolved in one patient treated with observation and two treated with medication, but worsened in two each in the medication and observation groups. Resolution of OSA occurred in 20% treated with medication, 7.7% with observation, and 0% with oxygen (P = .82).

CONCLUSION

In our cohort, resolution of mild OSA was low. This suggests that consideration should be given to multimodality treatments in children with DS and mild OSA. Prospective studies will help establish effectiveness in this cohort.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1828-1835, 2020.

The use of proton pump inhibitors among older adults with intellectual disability: A cross sectional observational study

BACKGROUND

Older people with Intellectual Disability (ID) have a high prevalence of gastrointestinal conditions such as Gastro-Oesophageal Reflux Disease (GORD). However, despite this, information about treatment, in particular the use of Proton Pump Inhibitors (PPIs), in this population is sparse and limited.

OBJECTIVE

To investigate the prevalence and pattern of PPI use among older people with ID.

METHOD

Data on PPI use and key demographics was analysed from Wave 2 (2013/2014) of IDS-TILDA, a nationally representative longitudinal study of 677 participants aged 40 years and above in Ireland. Descriptive statistics, bivariate analyses and binary logistic regression were carried out.

RESULTS

Just over a quarter, 27.9% (n = 189), of participants reported use of PPIs, and 53.4% (n = 101) were female. The largest proportion of PPI users (53.4%) were aged between 50 and 64 yrs. Most of the PPIs were used in maximum doses (66.7%). However only 43.9% of PPI users had an indication for PPI use (GORD, stomach ulcer or/and an NSAID use), and further 13.2% were also taking an antiplatelet agent. Use among those in residential care homes (54.3%) was much higher than for those living independently or with family (7%). PPI use among those who have severe/profound ID was 25% higher than those with mild ID. Information about the length of PPI use was missing for 31.2%, but of those with data, just over half recorded using the PPIs for more than a year. Apart from an indication, the factors associated with PPI use were older ages (≥50 years), severe/profound level of ID.

CONCLUSION

PPI use among older people with intellectual disability is prevalent and frequently long term, often without a clear indication. PPI use especially among those with severe/profound ID and those who live in residential care homes, could predispose these individuals to additional comorbidities and in order to avoid inappropriate long term of use regular review is required.

Underlying factors of recurrent infections in patients with down syndrome

Down syndrome is the most common chromosomal aberration. Patientswith Down syndrome suffer more infections than those without the disease. Underlying immunological disorders are consideredto be the reason for the increasing frequency of infections in patients with Down syndrome. In addition, some anatomical abnormalities in the respiratory tractaccompanying Down syndrome can disturb the innate immunity and contribute to the increase in infection rate. Respiratory tract infections are one of the most common causes of mortality in patients with Down syndrome. Awareness of the underlying reason for frequent respiratory tract infections should result in a decrease in mortality among these patients and contribute to an improvementin their quality of life.

Obstructive sleep apnea in patients with Down syndrome: current perspectives

For individuals with Down syndrome (DS), obstructive sleep apnea (OSA) is a complex disorder with significant clinical consequences. OSA is seen frequently in DS, and when present, it tends to be more severe. This increased prevalence is likely related to common anatomic abnormalities and a greater risk of additional comorbidities such as hypotonia and obesity. Because signs and symptoms do not often correlate with disease, all children and adults with DS should receive routine screening for OSA. Similar to the general population, polysomnography remains the gold standard for diagnosis. Because individuals with DS may be more susceptible to cardiovascular and neurocognitive sequelae, early diagnosis and treatment of OSA is becoming increasingly important. Treatment options generally involve upper airway surgery (primarily adenotonsillectomy) and continuous positive airway pressure (CPAP); however, various adjunctive therapies including intranasal steroids, palatal expansion, and oropharyngeal exercises are also available. Residual disease status post adenotonsillectomy is common, and further evaluation (eg, drug-induced sleep endoscopy [DISE]) is often needed. More advanced and directed airway surgery can be performed if additional sites of obstruction are observed. Novel therapies including hypoglossal nerve stimulation are emerging as effective treatments for refractory OSA. Due to the diversity among individuals with DS, personalized treatment plans should be developed. Within this arena, opportunities for research remain abundant and should include areas involving patient risk factors, alternative diagnostic methods, and outcome analysis.

Scintigraphic Evaluation of Gastroesophageal Reflux and Pulmonary Aspiration in Children

Gastroesophageal reflux (GER) and pulmonary aspiration are encountered in children of all ages. Signs, symptoms, and complications vary from mild and transient to severe life-threatening conditions. This review will present relevant clinical information on these conditions as well as common diagnostic procedures. The role of scintigraphic techniques used in the evaluation of these conditions will be discussed in detail including protocols and performance in comparison to other diagnostic methods.

Respiratory syncytial virus prophylaxis in Down syndrome: a prospective cohort study

BACKGROUND AND OBJECTIVES

Children with Down syndrome (DS) are at significant risk for respiratory syncytial virus (RSV) infection and related hospitalization. We compared hospitalization rates due to respiratory tract infection in children with DS aged <2 years who prospectively received palivizumab during the RSV season with a previously published, similar untreated DS birth cohort.

METHODS

A total of 532 children with DS who prospectively received palivizumab were assembled from the prospective Canadian RSV Evaluation Study of Palivizumab registry between 2005 and 2012. The untreated group included 233 children with DS derived from a nationwide Dutch birth cohort from 2003 to 2005. Events during the RSV seasons were counted. Poisson regression analysis was performed to compare incidence rate ratios (95% confidence intervals [CIs]) between groups while controlling for observation length and known risk factors for severe RSV infection.

RESULTS

In total, 31 (23 untreated, 8 treated) RSV-related hospitalizations were documented. The adjusted risk of RSV-related hospitalizations was higher in untreated subjects than in palivizumab recipients (incidence rate ratio 3.63; 95% CI, 1.52-8.67). The adjusted risk of hospitalization for all respiratory tract infection (147 events; 73 untreated, 74 treated) was similar (incidence rate ratio untreated versus palivizumab 1.11; 95% CI, 0.80-1.55).

CONCLUSIONS

These results suggest that palivizumab is associated with a 3.6-fold reduction in the incidence rate ratio for RSV-related hospitalization in children with DS during the first 2 years of life. A randomized trial is needed to determine the efficacy of RSV immunoprophylaxis in this specific high-risk patient population.

Hospitalization for respiratory syncytial virus illness in Down syndrome following prophylaxis with palivizumab

BACKGROUND

Down syndrome (DS) is a risk factor for respiratory syncytial virus (RSV) hospitalization, but little is known about prophylaxis in these children.

METHODS

CARESS is a prospective registry of children who received ≥1 dose of palivizumab during the 2006-2012 RSV seasons across 32 sites in Canada. The objective was to compare respiratory illness hospitalization and RSV hospitalization (RSVH) hazard ratios in DS children aged <2 years who received palivizumab versus children who received prophylaxis for standard indications (SI) and for other medical illnesses (MI).

RESULTS

13,310 children were enrolled; DS (600; 4.5%), SI (11,081; 83.3%) and MI (1629, 12.2%), with DS children increasing over the duration from 0.1% (2006) to 4.5% (2012). Participants were significantly different in mean birth weight, gestational and enrollment age and risk factors. Children in each group received an average of 4.3 ± 1.4 (DS), 4.1 ± 1.6 (SI) and 4.5 ± 1.4 (MI) palivizumab injections per RSV season, with DS, differing significantly from SI [F(2, 13,307) = 43.6, P = 0.01] but not MI [F(2, 13 307) = 43.6, P = 0.07]. Compliance rates were similar across the groups. While a significantly greater proportion of SI children had RIHs compared with DS, [hazard ratio: 0.64 (0.48-0.84); P = 0.001] hazard ratios were similar for DS and MI. RSVH incidence rates were: 1.53%, 1.45% and 2.27% for DS, SI and MI, respectively. Neither group nor compliance affected time to RSVH.

CONCLUSIONS

The proportion of DS children who received palivizumab in CARESS has increased almost 45-fold. RSVH rates were low in DS following prophylaxis and hazards were similar to those found in SI and MI.

An overview of respiratory problems in children with Down's syndrome

Respiratory disease is a common cause of morbidity and mortality in children with Down's syndrome (DS). Causes range from those problems common to many children with DS, such as a narrow airway or impaired immunity, to rare structural lesions, such as tracheal bronchus. Additionally, other organ systems or extrinsic factors may play a role. A thorough understanding of the range of potential problems will aid in the evaluation and management of children with DS and respiratory symptoms.