Sleep-disordered breathing in children

Analysis of General Knowledge on Obstructive Sleep Apnea Syndrome (OSAS) among Italian Pediatricians

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a disorder characterized by partial or total airway obstruction during sleep. Studies have shown variability in the level of knowledge and awareness about OSAS among pediatricians. The management of childhood obstructive sleep apnea syndrome (OSAS) depends on the severity of the disease, the presence of comorbidities, and the child's age. The American Pediatric Academy recommends a multidisciplinary approach involving a pediatrician, a sleep specialist, and an otolaryngologist to provide comprehensive care for children with OSAS. The aim of this cross-sectional study is to evaluate the level of knowledge among pediatricians in Italy regarding the diagnosis of pediatric OSAS.

MATERIAL AND METHODS

An anonymized survey was conducted among Italian pediatricians. The survey was administered electronically using Google Forms, and a total of 350 pediatricians were invited to participate. Out of the 350 invitations, 299 pediatricians responded to the survey. The statistical analysis performed consisted of descriptive analysis. The study included 297 pediatricians.

RESULTS

Pediatricians demonstrated proficiency in identifying common nocturnal and day symptoms of OSAS. A majority (68.9%) considered the oral and otorhinolaryngologist areas during checkups. Approximately 70.6% took patient weight into account, and 62.8% were aware of the regional diagnostic-therapeutic-assistance pathway.

CONCLUSIONS

According to the results of this manuscript, there is evidence of a good level of knowledge about OSAS, but disseminating more information about OSAS and all the health issues associated with this syndrome is suggested. This study also has limitations caused by the complexity of the pathology.

Wireless broadband acousto-mechanical sensing system for continuous physiological monitoring

The human body generates various forms of subtle, broadband acousto-mechanical signals that contain information on cardiorespiratory and gastrointestinal health with potential application for continuous physiological monitoring. Existing device options, ranging from digital stethoscopes to inertial measurement units, offer useful capabilities but have disadvantages such as restricted measurement locations that prevent continuous, longitudinal tracking and that constrain their use to controlled environments. Here we present a wireless, broadband acousto-mechanical sensing network that circumvents these limitations and provides information on processes including slow movements within the body, digestive activity, respiratory sounds and cardiac cycles, all with clinical grade accuracy and independent of artifacts from ambient sounds. This system can also perform spatiotemporal mapping of the dynamics of gastrointestinal processes and airflow into and out of the lungs. To demonstrate the capabilities of this system we used it to monitor constrained respiratory airflow and intestinal motility in neonates in the neonatal intensive care unit (n = 15), and to assess regional lung function in patients undergoing thoracic surgery (n = 55). This broadband acousto-mechanical sensing system holds the potential to help mitigate cardiorespiratory instability and manage disease progression in patients through continuous monitoring of physiological signals, in both the clinical and nonclinical setting.

Correlation between craniofacial changes and respiratory improvement after nasomaxillary skeletal expansion in pediatric obstructive sleep apnea patients

PURPOSE

The aim of this study was to investigate the correlation between the changes in respiratory function and dimensions of the nasomaxillary complex (NMC) and upper airway (UA) compartments after nasomaxillary skeletal expansion (NMSE) treatment for pediatric patients with obstructive sleep apnea (OSA).

METHODS

Nonobese OSA patients (mean age, 13.6 ± 2.9 years; mean body mass index, 18.1 ± 3.0 kg/m²); mean apnea-hypopnea index (AHI, 7.0 ± 5.4 events/h) presenting with transverse nasomaxillary constriction were evaluated before and after NMSE using cone-beam computed tomography (CBCT), home sleep test, and modified pediatric sleep questionnaire (m-PSQ). Paired t tests were performed to examine the treatment-related changes in all the parameters, and a multiple regression analysis adjusted for age and sagittal and vertical skeletal patterns was conducted to determine the dimensional parameters to affect the functional improvement.

RESULTS

Among 26 patients, NMSE treatment significantly increased NMC dimensions at all tested levels and all UA compartments in CBCT, except glossopharyngeal airway. Concurrently, AHI, oxygen desaturation index, the lowest oxygen saturation (LSaO₂), flow limitation (FL), snoring, and m-PSQ were significantly improved. AHI reduction was correlated with UA enlargement with no correlation with NMC expansion, whereas FL reduction was affected by NMC expansion. The minimal cross-sectional area was the most predictive of functional improvement, presenting correlations with AHI, LSaO₂, and m-PSQ.

CONCLUSION

NMSE can be a good treatment for pediatric OSA patients when applied to enhance the nasal and pharyngeal airway patencies beyond the NMC, ultimately to improve pharyngeal collapsibility as well as nasal airflow.

TNF-α promotes insulin resistance in obstructive sleep apnea-hypopnea syndrome

Obstructive sleep apnea hypopnea syndrome (OSAHS) is the most serious among children with sleep disordered breathing. The present study aimed to investigate whether TNF-α could decrease the glucose transporter type 4 insulin-responsive (GLUT-4) expression to promote insulin resistance through the TNF-α/IKKβ/IKβ/NF-κB signaling pathway in OSAHS. In total, 30 obese children with OSAHS and 30 non-OSAHS obese children were enrolled into the present study. TNF-α expression in adenoid tissues was detected by western blot analysis and immunohistochemistry. The expression of inflammatory factors (IL-1β, IL-6 and IFN-γ) and TNF-α/IKKβ/IKβ/NF-κB signaling pathway-associated proteins was also detected by western blot analysis. The expression of insulin resistance-associated factors, insulin receptor substrate 1 (IRS1) and GLUT4, was determined by western blot analysis and immunohistochemistry. TNF-α expression was increased in adenoid tissues of children with OSAHS, which was also confirmed by immunohistochemistry. The expression levels of IL-1β, IL-6 and IFN-γ were all upregulated in adenoid tissues of children with OSAHS. The expression of IRS1 and GLUT4 was decreased in adenoid tissues of obese children with OSAHS and the result of immunohistochemistry was consistent with the result of western blot analysis. The protein level of TNF-α, and ratio of phosphorylated (p-)/total (t)-IKKβ, p/t-IKβ and p/t-NF-κB was increased in adenoid tissues of children with OSAHS. TNF-α could suppress the GLUT4 expression to promote insulin resistance by TNF-α/IKKβ/IKβ/NF-κB signaling pathway in OSAHS.

Identification of Breathing Patterns through EEG Signal Analysis Using Machine Learning

This study was to investigate the changes in brain function due to lack of oxygen (O₂) caused by mouth breathing, and to suggest a method to alleviate the side effects of mouth breathing on brain function through an additional O₂ supply. For this purpose, we classified the breathing patterns according to EEG signals using a machine learning technique and proposed a method to reduce the side effects of mouth breathing on brain function. Twenty subjects participated in this study, and each subject performed three different breathings: nose and mouth breathing and mouth breathing with O₂ supply during a working memory task. The results showed that nose breathing guarantees normal O₂ supply to the brain, but mouth breathing interrupts the O₂ supply to the brain. Therefore, this comparative study of EEG signals using machine learning showed that one of the most important elements distinguishing the effects of mouth and nose breathing on brain function was the difference in O₂ supply. These findings have important implications for the workplace environment, suggesting that special care is required for employees who work long hours in confined spaces such as public transport, and that a sufficient O₂ supply is needed in the workplace for working efficiency.

Obstructive sleep apnea risk factors and symptoms in children with a known parental obstructive sleep apnea diagnosis

OBJECTIVE

To document symptoms and risk factors of obstructive sleep apnea (OSA) in children who have a parent diagnosed with OSA and compare them to an age and sex matched sample where parents are low risk for OSA.

METHODS

We recruited 25 children with a parent diagnosed with OSA (P-OSA) and 29 age and gender matched children from the community whose parents scored low risk for OSA (P-NOSA). Comparisons were made using the OSA-18 questionnaire, anthropometric measurements, and mallampati score. Statistical analysis included t-tests for OSA-18 score and BMI measures and non parametric analysis for mallampati score. OSA-18 domain scores were analysed using T-test and Bonferroni correction for multiple comparisons.

RESULTS

Fifty-six percent of the P-OSA group had a mallampati score of III/IV compared to 11% in the P-NOSA sample (p = 0.005). There was a significant difference in BMI between the P-OSA sample (mean ± SD 19.5 ± 5.7 kg/m²) and the P-NOSA sample (16.95 ± 2.08 kg/m², p = 0.002). Forty-four percent of P-OSA children were found to be either overweight or obese (BMI z-score). None of the P-NOSA children fell into this category. No significant difference was found between the P-OSA and P-NOSA samples on the OSA-18 score (P-OSA 36.5 ± 8.1, P-NOSA 29.2 ± 9.1, p = 0.07). Five children in the P-OSA sample scored >60 but no P-NOSA children scored >60.

CONCLUSIONS

This study suggests that children with a parent diagnosed with OSA are more likely to have risk factors of pediatric OSA compared to age and sex matched children of parents without OSA but do not have more symptoms.

Prevalence of Sleep-Disordered Breathing in Children Referring for First Dental Examination. A Multicenter Cross-Sectional Study Using Pediatric Sleep Questionnaire

Background: Sleep-related breathing disorders (SRDB) are a group of pathological conditions characterized by a dysfunction of the upper airways. The value of SRDB's prevalence, in the pediatric population, ranges from 2 to 11% depending on the different methodologies used in measure and the difficulties in the diagnosis. The aim of this study was to assess the prevalence of SRDB using the Pediatric Sleep Questionnaire (PSQ). Methods: 668 patients were enrolled from the Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Italy and from the Unit of Integrated Pediatric Dentistry, University of Murcia, Spain. The questionnaires were administered to patients with no previous orthodontic and surgical treatment who attended on the first visit at the two units of pediatric dentistry. Data regarding general health status were extracted from the standard anamnestic module for first visit. Prevalence and logistic regression models were computed. Results: The ages ranged from 2 to 16 years old (average 7 years old). The prevalence of SRDB was 9.7% for the entire sample. The models showed a positive correlation between three variables (snoring, bad habits, and anxiety) and SRDB. Conclusions: The prevalence obtained demonstrates the relevance of sleep disorders in the pediatric population and highlights the central role of pediatric dentists in the earlier diagnosis of these disorders.

Correlations between disease-specific quality of life and polysomnographic findings in children with obstructive sleep apnea

OBJECTIVES

Obstructive sleep apnea (OSA) can have a negative impact on quality of life in children. The OSA-18 is a disease-specific quality of life questionnaire for children. The questionnaire has been found to be a poor predictor of OSA diagnosed with polysomnography (PSG), yet OSA-18 scores do markedly improve after adenotonsillectomy. The aim of this study was to examine the correlations between OSA-18 and PSG findings, beyond the apnea hypopnea index (AHI).

METHODS

This study was a prospective study of children 2-6 years of age who were referred to an Ear, Nose and Throat department for adenoidectomy and/or tonsillectomy. Prior to surgery, all of the children underwent PSG and a physical examination, and their parent completed the OSA-18 questionnaire. Spearman correlations were used to determine the associations between OSA-18 scores and PSG parameters.

RESULTS

The sample consisted of 97 children who underwent PSG and their parents who answered the OSA-18 questionnaire. We found positive correlations between the AHI and both the OSA-18 total score (rho = 0.21, p = 0.04) and the sleep disturbance subscale (rho = 0.51, p < 0.01). The only other PSG parameter that significantly correlated with the OSA-18 was the number of awakenings and arousals per hour of sleep (rho = 0.29, p < 0.01).

CONCLUSION

We only found weak correlations between the OSA-18 score and PSG findings, suggesting the two methods are measuring different aspects of pediatric OSA.

CLINICAL TRIAL

NCT02233166.

EEG signals during mouth breathing in a working memory task

Background: Continuous mouth breathing results not only morphological deformations but also poor learning outcomes. However, there were few studies that observed correlations between mouth breathing and cognition. This study aimed at investigating the changes in brain activity during mouth breathing while the participant simultaneously performed a cognitive task using electroencephalography (EEG).Methods: Twenty subjects participated in this study, and EEG electrodes (32 channels, 250-Hz sampling rate) were placed on their scalp. Brain waves during a resting state and n-back tasks (0-back and 2-back) and physiological parameters such as SpO2, ETCO2, and the airway respiratory rate were measured. The pre-processed EEG signals were analyzed based on their frequencies as delta waves (0.5 ∼ 4 Hz), theta waves (4 ∼ 8 Hz), alpha waves (8 ∼ 13 Hz), beta waves (13 ∼ 30 Hz) and gamma waves (30 ∼ 50 Hz) using fast Fourier transform (FFT).Results: When compared with nose breathing, theta and alpha powers were lower during mouth breathing at rest and alpha wave presented low power at 0-back and 2-back tasks. Furthermore, beta and gamma waves exhibited low powers at 2-back task. However, the behavioral results (accuracy and response time) have no significant difference between two breathing methods (mouth and nose). Mouth breathing showed different brain activity patterns, compared to nose breathing, and these changes are related to cognitive regions.Conclusion: The reason for this change seems to relate to the decreased oxygen saturation during mouth breathing, suggesting that when cognitive abilities are required, mouth breathing can act as one of the variables that cause different outcomes in brain activities.

Sleep in Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder

Sleep problems are common in autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). Sleep problems in these disorders may not only worsen daytime behaviors and core symptoms of ASD and ADHD but also contribute to parental stress levels. Therefore, the presence of sleep problems in ASD and ADHD requires prompt attention and management. This article is presented in 2 sections, one each for ASD and ADHD. First, a detailed literature review about the burden and prevalence of different types of sleep disorders is presented, followed by the pathophysiology and etiology of the sleep problems and evaluation and management of sleep disorders in ASD and ADHD.

Mandibular movements identify respiratory effort in pediatric obstructive sleep apnea

STUDY OBJECTIVES

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

METHODS

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Weight Gain after Adenotonsillectomy

Objective

To study the association between adenotonsillectomy (T&A) and weight gain in children.

Study Design

Retrospective case-control series.

Setting

Tertiary academic children’s medical center.

Subjects and Methods

A total of 154 children who underwent T&A at a tertiary care children’s hospital between December 2010 and March 2011 were included. They were compared with 182 children with similar demographics who were seen in primary care clinics at the same institution (control group). Height and weight were compared at 6-month intervals over a 24-month period. Patients were divided into normal weight, overweight, and obese. A multilevel mixed-effects regression model was used for analysis. Significance was set at P ≤ .05.

Results

Children who underwent T&A gained more weight than controls at every interval. At 24 months, they gained an additional 2.6 kg (confidence interval [CI], 0.9-3.9) but were an additional 1.8 cm (CI, 0.1-3.5) taller. There was no difference in weight gain at 6 months for obese children. At 12, 18, and 24 months, the obese group outgained the control group. At 24 months, the obese T&A group had gained an average of 14.3 kg, while the control had gained 10.1 kg, for a difference of 4.2 kg (CI, 1.3-6.1) with no difference in height changes. There were no differences in weight or height changes for the normal-weight and overweight groups at the conclusion of the study.

Conclusions

T&A leads to a significant increase in weight in obese but not normal-weight or overweight children. Efforts should be made to provide weight reduction counseling prior to T&A in obese children.

Association of the 5-HT2A receptor gene polymorphisms with obstructive sleep apnea hypopnea syndrome in Chinese Han population

CONCLUSIONS

The -1438G/A polymorphism of 5-HT2A receptor gene may associate with obstructive sleep apnea hypopnea syndrome (OSAHS) in a Chinese Han population. Different genotypes of -1438G/A polymorphism may influence the ventilatory activity in response to hypoxia, and in turn the sleep breath status.

OBJECTIVE

This study was designed to assess the association of polymorphisms in all exons and promoter region of the 5-HT2A receptor gene with OSAHS in a Chinese Han population.

METHODS

A total of 315 subjects (210 patients and 105 controls) were included for genetic analyses of polymorphisms in all exons and promoter region of the 5-HT2A receptor gene.

RESULTS

Six single nucleoside polymorphism (SNP) sites were identified in the sequencing of the promoter and exons of the 5-HT2A receptor gene; however, genotypes and allele frequencies of the SNPs did not show significant differences between the patients and controls except the -1438G/A polymorphism. For SNP of -1438G/A, the A/A genotype was over-represented and the allele A was more frequent in the patients, while the G/A genotype was over-represented and the allele G was more frequent in the controls (p < 0.001, p = 0.005, respectively). In the patients, the A/A and G/A genotypes were over-represented in the subgroups with lowest nocturnal SaO(2) (LSaO(2)) ≤75% and LSaO(2) >75%, respectively (p = 0.006).

Association of prepro-orexin polymorphism with obstructive sleep apnea/hypopnea syndrome

BACKGROUND

Because of the potential role of orexin neuronal circuitry in the regulation of sleep and wakefulness and arousal and breathing, it seems reasonable to speculate that abnormalities in the prepro-orexin gene could be relevant to studies of obstructive sleep apnea/hypopnea syndrome (OSAHS); and it might be a candidate gene in the pathogenesis of OSAHS.

OBJECTIVE

The present study investigated whether single nucleotide polymorphisms (SNPs) in the human prepro-orexin gene are associated with OSAHS in Han Chinese people.

METHODS

A total of 394 subjects (217 cases and 177 control subjects) were recruited from China. Diagnostic polysomnography was performed in all patients and control subjects. SNPs in potentially functional regions of the gene were identified; and genotypes, determined by direct sequencing.

RESULTS

By sequencing the promoter, 2 exons, and the exon-intron junctions of the prepro-orexin gene, the g11182C>T SNP was identified. Statistical analysis showed that there were significant differences in the genotype distribution between patients with OSAHS and the control group (χ(2)(2) = 6.437, P = .04). Variant allele T of the g1182C>T polymorphism was more commonly found in patients with OSAHS as compared with control subjects (χ(2)(1) = 5.648, P = .017; odds ratio, 1.449; 95% confidence interval, 1.0466-1.968).

CONCLUSIONS

Our results suggest that the prepro-orexin gene polymorphism g1182C>T is associated with susceptibility to OSAHS in Han Chinese. This study provides insights into the genetic information for future studies regarding this gene in OSAHS.

Prevalence of habitual snoring and symptoms of sleep-disordered breathing in adolescents

OBJECTIVE

Sleep-disordered breathing is an important public health problem in adolescents. The aim of this study was to investigate the prevalence and risk factors of habitual snoring and symptoms of sleep-disordered breathing in adolescents.

METHODS

A cross-sectional study was conducted with children from primary schools and high schools that the ages ranged from 12 to 17 years. Data were collected by physical examination and questionnaires filled in by parents regarding sleep habits and possible risk factors of snoring. According to answers, children were classified into three groups: non-snorers, occasional snorers, and habitual snorers.

RESULTS

The response rate was 79.2%; 1030 of 1300 questionnaires were fully completed and analyzed. The prevalence of habitual snoring was 4.0%. Habitual snorers had significantly more nighttime symptoms including observed apneas, difficulty breathing, restless sleep and mouth breathing during sleep compared to occasional and non-snorers. Prevalence of habitual snoring was increased in children who had had tonsillar hypertrophy, allergic rhinitis, and maternal smoking.

CONCLUSION

We found the prevalence of habitual snoring to be 4.0% in adolescents from the province of Manisa, Turkey which is low compared to previous studies. Habitual snoring is an important problem in adolescents and habitual snorers had significantly more nighttime symptoms of sleep-disordered breathing compared to non-snorers.

Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood

The purpose of this article is to review human craniofacial growth and development, especially the growth of the mandible, to clarify the relationship between obstructive sleep apnea (OSA) syndrome and craniofacial abnormality, and finally, to propose the hypothesis that negative pressure produced in the chest of the OSA child inhibits the growth of the mandible. Recently, the development of diagnosis and treatment of OSA syndrome has progressed rapidly; however, the prevention of OSA syndrome was merely seen. Craniofacial abnormality is reported as one of the causes of OSA syndrome. If craniofacial abnormality is determined only by genetics, it is difficult to manage the craniofacial skeleton to prevent OSA syndrome. The role of epigenetic factors on craniofacial growth and development is still controversial. However, if we stand on the functional matrix hypothesis, we can manage not only growth of the mandible but also the craniofacial skeleton as a whole. The author proposes the hypothesis that the negative pressure produced in the chest prohibits the growth of the mandible even if the patients have a capacity for growth and development; therefore, if this negative pressure disappears because of the removal of the tonsil and/or adenoids or by an orthodontic treatment to make a patency of the airway, the mandible may grow normally, and we can prevent or reduce a number of OSA syndromes in the future.

Sleep patterns and habits in high school students in Iran

BACKGROUND

Sleep patterns and habits in high school students in Iran have not been well studied to date. This paper aims to re-address this balance and analyse sleep patterns and habits in Iranian children of high school age.

METHODS

The subjects were 1,420 high school students randomly selected by stratified cluster sampling. This was a self-report study using a questionnaire which included items about usual sleep/wake behaviours over the previous month, such as sleep schedule, falling asleep in class, difficulty falling asleep, tiredness or sleepiness during the day, difficulty getting up in the morning, nightmares, and taking sleeping pills.

RESULTS

The mean duration of night sleep was 7.7 h, with no difference between girls, boys, and school year (grade). The mean time of waking in the morning was not different between genders. About 9.9% of the girls and 4.6% of the boys perceived their quality of sleep as being bad, and 58% of them reported sleepiness during the day. About 4.2% of the subjects had used medication to enhance sleep. The time of going to bed was associated with grade level and gender. Sleep latency was not associated with gender and grade level, l and 1.4% experienced bruxism more than four times a week.

CONCLUSION

Our results are in contrast with that of previous studies that concluded sleep duration is shorter in Asia than in Europe, that boys woke-up significantly later than girls, and that the frequency of sleep latency category was associated with gender and grade level. The magnitude of the daytime sleepiness, daytime sleepiness during classes, sleep latency, and incidences of waking up at night represent major public health concerns for Iran.

Quality of life in children with sleep-disordered breathing: evaluation by OSA-18

Sleep-disordered breathing (SDB) is prevalent. There is evidence of their effect on quality of life.

AIM

To assess the quality of life in children with SDB before and after adenoidectomy or adenotonsillectomy.

METHODS

A prospective before and after interventional study, with a component for assessment. A consecutive sample of children referred to adenoidectomy or adenotonsillectomy was recruited from the otolaryngology clinic; guardians answered a specific survey for the evaluation of quality of life in children with SDB, the OSA-18, before and at least 30 days after surgery. Nasofibroscopic and otolaryngological exams and a semi-structured survey on the childs social and clinical profile were done on both appointments.

RESULTS

48 children with a mean age of 5.93 years (SD=2.43) were evaluated. The mean number of schooling years for guardians was 8.29 years (SD=3.14). The most frequent symptoms were: agitated sleep, apnea and snoring. The total mean score of the initial OSA-18 was 82.83 (major impact); following surgery, the total mean score was 34.15. The differences in the total scores and in the domains between the initial OSA-18 and post-surgery scores were all significant (p<0.00).

CONCLUSION

SDB has a relevant impact on quality of life, and patients show dramatic improvements after surgical treatment.

Influence of gender and age on upper-airway length during development

OBJECTIVE

Obstructive sleep apnea has a strong male predominance in adults but not in children. The collapsible portion of the upper airway is longer in adult men than in women (a property that may increase vulnerability to collapse during sleep). We sought to test the hypothesis that in prepubertal children, pharyngeal airway length is equal between genders, but after puberty boys have a longer upper airway than girls, thus potentially contributing to this change in apnea propensity.

METHODS

Sixty-nine healthy boys and girls who had undergone computed tomography scans of their neck for other reasons were selected from the computed tomography archives of Rambam and Carmel hospitals. The airway length was measured in the midsagittal plane and defined as the length between the lower part of the posterior hard palate and the upper limit of the hyoid bone. Airway length and normalized airway length/body height were compared between the genders in prepubertal (4- to 10-year-old) and postpubertal (14- to 19-year-old) children.

RESULTS

In prepubertal children, airway length was similar between boys and girls (43.2 +/- 5.9 vs 46.8 +/- 7.7 mm, respectively). When normalized to body height, airway length/body height was significantly shorter in prepubertal boys than in girls (0.35 +/- 0.03 vs 0.38 +/- 0.04 mm/cm). In contrast, postpubertal boys had longer upper airways (66.5 +/- 9.2 vs 52.2 +/- 7.0 mm) and normalized airway length/body height (0.38 +/- 0.05 vs 0.33 +/- 0.05 mm/cm) than girls.

CONCLUSIONS

Although boys have equal or shorter airway length compared with girls among prepubertal children, after puberty, airway length and airway length normalized for body height are significantly greater in boys than in girls. These data suggest that important anatomic changes at puberty occur in a gender-specific manner, which may be important in explaining the male predisposition to pharyngeal collapse in adults.

The development of snoring and sleep related breathing distress from 4 to 6 years in a cohort of Swedish children

BACKGROUND

Snoring is common among both children and adults and a sign of sleep disordered breathing (SDB). Adenotonsillectomy is often the solution offered, although the effect is uncertain. There are also some who say that young children who snore will outgrow it even without treatment. The present investigation compares snoring and co-founding symptoms in parental reports for a cohort of children at age 4 and at age 6 years.

METHOD

A cohort of 4 year old chidren (615) was investigated with respect to SDB [B. Löfstrand-Tideström, B. Thilander, J. Ahlqvist-Rastad, O. Jakobsson, E. Hultcrantz, Breathing obstruction in relation to craniofacial and dental arch morphology in 4 year old children, Eur. J. Orthod. 21 (1999) 323-332]. Each child was given a questionnaire. Those reporting significant symptoms also received a clinical and an orthodontic examination. Forty-eight children were diagnosed with SDB; of these 28 were operated with adenoidectomy and/or tonsillectomy. After 2 years, the same questionnaire was administered and the same children as before were further examined as well as those newly reporting significant symptoms. The results from the two occasions were compared.

RESULTS

Eighty-three percent (509) of the original cohort participated. The frequency of snoring had changed from 53 to 46% for the group as a whole (p<0.05). Significant gender differences in co-founding symptoms were seen. Severity of snoring had changed on an individual basis in half of the cases; some recovered, others got worse. Of the children with SDB at 4 years who were operated, 14/28, did not snore at all, compared to 3/18 of the non-operated (p<0.05).

CONCLUSION

Children who snore at the age 4 seldom "grow out of it" by age 6 and still show other signs of sleep related distress as well. Surgery does not always cure the snoring, thus postoperative follow-up is important. Since new cases develop during this age period, early intervention is not enough.

[Severe obstructive sleep apnea syndrome in a toddler]

We report the case of a 3-year-old boy who had experienced intense snoring, frequent awakenings, intense respiratory effort during sleep, and delayed growth starting at the age of 15 months. He underwent adenoidectomy at 18 months. Symptoms initially improved but reappeared 3 months after surgery. He underwent a second adenoidectomy, this time with tonsillectomy, but there was no significant clinical improvement. Polysomnography revealed severe sleep apnea-hypopnea with an apnea-hypopnea index of 45. Continuous positive airway pressure improved sleep quality, although some symptoms, mainly snoring, persisted. A third adenoidectomy was necessary to normalize his breathing pattern during sleep.

Qualidade de vida em crianças com distúrbios obstrutivos do sono: avaliação pelo OSA-18

Distúrbios obstrutivos do sono (DOS) são prevalentes e existem evidências de afetarem a qualidade de vida das crianças. OBJETIVO: Avaliar a qualidade de vida de crianças com DOS antes e após adenoidectomia ou adenotonsilectomia. MATERIAL E MÉTODOS: Estudo prospectivo de intervenção, tipo antes e após, com componente avaliativo. Foi recrutada uma amostra consecutiva de crianças com indicação de adenoidectomia ou adenotonsilectomia em um ambulatório de otorrinolaringologia e aplicado aos cuidadores um questionário específico para a avaliação da qualidade de vida, o OSA-18, antes da cirurgia e com pelo menos 30 dias após. Foi realizado exame nasofibroscópico, otorrinolaringológico e questionário semi-estruturado sobre o perfil clínico e social da criança, em ambas as consultas. RESULTADOS: Foram avaliadas 48 crianças com média de idade de 5,93 anos (DP=2,43). A média de escolaridade do cuidador foi de 8,29 anos (DP=3,14). Os sintomas mais freqüentes foram: sono agitado, apnéia e ronco. A média de escore total do OSA-18 basal foi de 82,83 (grande impacto) e no pós-operatório, de 34,15. As diferenças nos escores total e dos domínios entre o OSA-18 basal e pós-operatório foram todas significantes (p<0,00). CONCLUSÃO: DOS apresentam impacto relevante na qualidade de vida e melhoram consideravelmente após o tratamento cirúrgico.

An update on childhood snoring

Habitual snoring or daily snoring is a symptom of sleep-disordered breathing (SDB) in children and it is reported in about 10% of children. SDB includes primary snoring, upper airway resistance syndrome (UARS), obstructive hypoventilation syndrome and obstructive sleep apnea syndrome (OSAS). Classification of SDB in a particular snoring child requires an overnight polysomnography (PSG). Manual scoring of PSG is mandatory in children. Risk factors for SDB include allergic rhinitis, passive smoking, obesity, dysmorphic syndromes and neuromuscular disorders.

CONCLUSION

Treatment includes general measures like treatment of allergic rhinitis, weight reduction in obese children, and avoidance of sleep deprivation. Specific measures include removal of adenoid and tonsils. Complications of SDB include neurocognitive impairment, hypertension and failure to thrive.

Growth failure and sleep disordered breathing: a review of the literature

OBJECTIVE

While otolaryngologists consider growth failure an absolute indication for tonsillectomy and adenoidectomy (T&A), they may not be accustomed to screening for poor growth, and thus unlikely to consider it when recommending a T&A. This paper will (a) familiarize otolaryngologists with the definition, prevalence, and etiology of growth failure and (b) review the published findings that examine the inter-relationship among sleep disordered breathing, growth failure, and adentonsillar hypertrophy in children.

METHODS

This paper is divided into three sections. The first section presents a brief overview of growth failure for the otolaryngologist. The second section reviews the evidence base linking sleep disordered breathing, growth failure, and adenotonsillar hypertrophy in children. The anthropometric outcomes of children presenting for T&A, or having sleep symptoms assessed, are presented. The third section presents pilot data (n=28) on the prevalence of growth failure and sleep disordered breathing among children presenting for T&A at our institution.

RESULTS

Among children presenting for T&A or having sleep symptoms assessed, growth failure was at least twice the expected rate in six of eight published studies. Across these six studies, this rate ranged from a low of 6% of children <3rd percentile for weight and 6% <3rd percentile for height in one study, to a high of 52% who were <3rd percentile in weight in a second study, and 44% who were <or= 5th percentile for height in a third. Among children presenting for T&A at our own institution, 14% were <or=5th percentile in height, and 11% were <or=5th percentile in weight. Among children under 6 years of age, 21% were either <or= 5th percentile in weight and/or height.

CONCLUSIONS

Published studies, as well as our own pilot data support the hypothesis that SDB, secondary to adenotonsillar hypertrophy increases the risk of growth failure in children. Adenotonsillar hypertrophy and sleep disordered breathing may be unrecognized risk factors in the etiology of growth failure. Otolaryngologists can play an important role in identifying growth failure, and referring children to the appropriate specialists.

The effect of polysomnography on pediatric adenotonsillectomy postoperative management

OBJECTIVE

We retrospectively investigated the effect and predictability of preoperative polysomnography (PSG) on the postoperative course of younger pediatric patients undergoing adenotonsillectomy.

STUDY DESIGN AND SETTING

A retrospective chart review was performed for patients 3 years of age and younger who had undergone adenotonsillectomy between July 1997 and July 2002 at the Children's Hospital of Wisconsin.

RESULTS

Two hundred eighty-two patients were identified. Forty-three patients had preoperative PSG. No correlation between the severity of PSG results and postoperative course was identified.

CONCLUSIONS

The role of PSG in upper airway obstruction and OSA remains controversial. This study suggests that although the complication rate may be higher in this younger population, these complications do not appear to have a large impact on their length of stay.

SIGNIFICANCE

This study suggests that the 3-years-and-younger group, in the absence of other comorbidities, can safely undergo adenotonsillectomy without undergoing preoperative PSG. EBM raing: C.

Melhora da qualidade de vida em crianças após adenoamigdalectomia

O aumento de volume das tonsilas palatina e faríngea é um dos problemas mais freqüentes do consultório do otorrinolaringologista e é a principal causa de apnéia obstrutiva do sono em crianças. OBJETIVO: Avaliar o impacto da adenoamigdalectomia na qualidade de vida em crianças com hiperplasia adenoamigdaliana. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Trinta e seis pais ou responsáveis de crianças submetidas a adenoamigdalectomia foram entrevistados antes e após a cirurgia através do questionário sobre qualidade de vida específica desenvolvido por Serres et al., 2000, que inclui os domínios: sofrimento físico, distúrbios do sono, problemas de fala e deglutição, desconforto emocional, limitação das atividades e preocupação do responsável. RESULTADOS: A qualidade de vida de todas as crianças melhorou após a cirurgia. Foi observada correlação direta entre o grau de obstrução e distúrbios do sono, preocupação paterna, e na média dos domínios. Correlacionando-se os domínios entre si, observamos relação estatística entre sofrimento emocional e distúrbios do sono, preocupação paterna e distúrbios do sono, limitação das atividades físicas e desconforto emocional. CONCLUSÃO: O aumento das tonsilas e a apnéia obstrutiva do sono pioram a qualidade de vida das crianças, principalmente pelo sofrimento físico e distúrbios do sono. A adenoamigdalectomia realmente traz uma melhora importante na qualidade de vida destes pacientes.

Parasomnias and sleep disordered breathing in Caucasian and Hispanic children - the Tucson children's assessment of sleep apnea study

BACKGROUND

Recent studies in children have demonstrated that frequent occurrence of parasomnias is related to increased sleep disruption, mental disorders, physical harm, sleep disordered breathing, and parental duress. Although there have been several cross-sectional and clinical studies of parasomnias in children, there have been no large, population-based studies using full polysomnography to examine the association between parasomnias and sleep disordered breathing. The Tucson Children's Assessment of Sleep Apnea study is a community-based cohort study designed to investigate the prevalence and correlates of objectively measured sleep disordered breathing (SDB) in pre-adolescent children six to 11 years of age. This paper characterizes the relationships between parasomnias and SDB with its associated symptoms in these children.

METHODS

Parents completed questionnaires pertaining to their child's sleep habits. Children had various physiological measurements completed and then were connected to the Compumedics PS-2 sleep recording system for full, unattended polysomnography in the home. A total of 480 unattended home polysomnograms were completed on a sample that was 50% female, 42.3% Hispanic, and 52.9% between the ages of six and eight years.

RESULTS

Children with a Respiratory Disturbance Index of one or greater were more likely to have sleep walking (7.0% versus 2.5%, p < 0.02), sleep talking (18.3% versus 9.0%, p < 0.006), and enuresis (11.3% versus 6.3%, p < 0.08) than children with an Respiratory Disturbance Index of less than one. A higher prevalence of other sleep disturbances as well as learning problems was observed in children with parasomnia. Those with parasomnias associated with arousal were observed to have increased number of stage shifts. Small alterations in sleep architecture were found in those with enuresis.

CONCLUSIONS

In this population-based cohort study, pre-adolescent school-aged children with SDB experienced more parasomnias than those without SDB. Parasomnias were associated with a higher prevalence of other sleep disturbances and learning problems. Clinical evaluation of children with parasomnias should include consideration of SDB.

Improvement of bruxism after T & A surgery

Bruxism or tooth grinding is an oral habit that frequently occurs during sleep. Some authors suggest it is associated to sleep apnea.

OBJECTIVES

The main goal of this study is compare the incidence of bruxism before and after adenotonsillectomy (T & A surgery) in children with sleep-disordered breathing.

METHODS

This is a prospective study in which we evaluated 69 consecutive children from the Otolaryngology Department of the University of São Paulo Medical School in pre- and post-surgical periods of adenotonsillectomy. Before and after surgery parents answered a questionnaire about sleep-disturbed breathing and bruxism. Children were submitted to E.N.T. examination and speech pathologist evaluation. The orthodontist inspected malocclusion. Before surgery all the 69 children presented sleep apnea and 45.6% presented bruxism. Malocclusion could be found in 60.71%. Three months after surgery none of the children presented breathing problems and only 11.8% presented bruxism. There was no difference in malocclusion.

CONCLUSIONS

This study suggests that there is a positive correlation between sleep-disordered breathing and bruxism. There was an important improvement of bruxism after T & A surgery. Otolaryngologists must be aware that this pernicious sleep disorder is associated to airway obstruction and so, it must be considered when evaluating T & A hyperplasia.

Neurologic disorders masquerading as pediatric sleep problems

Neurologic disorders may present or masquerade as pediatric sleep problems and fool the pediatrician, which may delay diagnosis and treatment. Many of the sleep problems in children with neurologic disorders arise directly from primary dysfunction or delayed maturation of their sleep-wake regulation systems. It is important to realize that nocturnal frontal lobe seizures or cluster headaches can be mistaken for night terrors, and craniopharyngiomas or myotonic dystrophy may present as narcolepsy-cataplexy. Hypothalamic dysfunction may explain not only the impaired circadian rhythm disorders in children with profound mental retardation but also excessive sleepiness and hyperphagia in Prader-Willi and Kleine-Levin syndromes. Intellectually challenged children perform better, learn more, and are better behaved with sufficient restorative sleep.

Obstructive Sleep Apnea Syndrome in Children

Snoring and obstructive sleep apnea are a frequent problem not only in adults, but also in children and adolescents, as can be seen from current epidemiological data. The epidemiology, etiology, diagnosis, and management of obstructive sleep apnea syndrome (OSAS) in adults have been adequately established on the basis of evidential data. As a result of this, both physicians and the public are increasingly aware of OSAS in adults. Although there are numerous parallels between pediatric and adult OSAS, the situation in children differs that in adults. There is a greater variety of symptoms in children with OSAS, diagnosis is often more difficult with serious consequences for growth and development of children. Treatment of OSAS in children is also different from that of the adult patient. There are many possible causes for the development of obstructive sleep apnea in children. These include hypertrophy of the tonsils and syndromes such as Down syndrome, Pickwickian syndrome, Prader-Willi syndrome or Marfan syndrome. OSAS can, however, also be the result of obesity, midfacial dysplasia, retro- or micrognathia, allergic rhinitis or muscular dystrophy. Epidemiological data presented in the literature concerning the incidence of OSAS in children is extremely varied. This wide range is probably due to the fact that snoring may be misdiagnosed as OSAS. The diagnosis of OSAS in children may only be made by considering clinical history (such as rate of growth, tendency to fall asleep during the day, sleep disturbances, susceptibility to infection, etc.), polysomnography (if possible during several nights) and accompanying instrumental diagnosis including cephalometry or laryngoscopy. One of the problems of polysomnography in childhood is that performance and interpretation of the results have not yet been standardized or evaluated for different age groups. Treatment depends on the cause of OSAS and require multidisciplinary management involving the pediatrician, pediatric or adolescent psychiatrist, ear, nose, and throat specialist, maxillofacial surgeons, and neurosurgeons. Adenotonsillectomy (ATE) is the therapy generally chosen if the child has adenoidal vegetations and/or tonsillar hypertrophy. Corrective surgery is possible for rare malformation syndromes. Nocturnal masks for continuous positive airway nasal pressure or procedures for mask respiration are effective in children, but are only used in exceptional cases, such as when ATE is contraindicated or when symptoms of OSAS remain after surgery. The success of pharmacological treatment of OSAS in children has not been evaluated in controlled clinical trials.

Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis

Although nocturnal voiding is frequently attributed to urologic disorders, nocturia and enuresis are also important symptoms of sleep-disordered breathing. However, polyuria can be elicited by obstructive sleep apnea as well as bedrest, microgravity and other experimental conditions where the blood volume is shifted centrally to the upper body. The nocturnal polyuria of sleep apnea is an evoked response to conditions of negative intrathoracic pressure due to inspiratory effort posed against a closed airway. The mechanism for this natriuretic response is the release of atrial natriuretic peptide due to cardiac distension caused by the negative pressure environment. This cardiac hormone increases sodium and water excretion and also inhibits other hormone systems that regulate fluid volume, vasopressin and the rennin-angiotensin-aldosterone complex. Treatment of sleep apnea and airway compromise has been shown to reverse nocturnal polyuria and thereby reduce or eliminate nocturia and enuresis. Thus, careful evaluation of nocturia and enuresis for evidence of nocturnal polyuria can increase the diagnostic certainty of referring primary care providers and sleep specialists. In addition, the resolution of these bothersome symptoms after treatment can contribute to patient satisfaction as well as reinforce treatment compliance.

Cephalometric assessment of the posterior airway space in patients with cleft palate after palatoplasty

OBJECTIVE

Upper airway obstruction and mouth breathing influence facial growth and development, which may result in breathing disorders while asleep. The purpose of the present investigation was to analyze cephalometric alterations between patients with cleft palate and a noncleft control group in an obstructive sleep disordered breathing-specific tracing.

SETTING

The study was conducted in the cleft palate clinic of a university hospital.

PARTICIPANTS

Fifty-three subjects with a mean age of 12.3 +/- 3.7 years (range 6.3 to 17.2 years). The cohort included 33 subjects (13 females, 20 males; mean age 12.1 +/- 3.8 years, mean body mass index 17.5 +/- 2.9 kg/m(2)) with surgical closure of a unilateral or bilateral cleft palate and a matched control of noncleft participants. None of the subjects suffered from sleep disordered breathing syndrome.

RESULTS

Compared with the controls, patients with cleft palate had a significant narrow anterior-posterior dimension of the pharynx at the level of the maxillary plane and the narrowest width, a more downward hyoid position, and a longer uvula.

CONCLUSIONS

Patients with cleft palate appear to present pharyngeal and craniofacial distinctive features that characterize patients with obstructive sleep disordered breathing and differ from those of a noncleft control.

Echocardiographic parameters in adolescents with sleep-related breathing disorders

Few data are known about the effects of sleep-related breathing disorders (SRBD) on the cardiovascular system in adolescents. Forty healthy adolescents (mean age, 13.7 +/- 1.6 years) answered a questionnaire regarding symptoms of sleep-related breathing disorders (SRBD) and underwent a cardiorespiratory polygraphy and echocardiography. Echocardiographic data in snorers with polygraphic abnormalities suggestive of SRBD (positive group, n = 29) were compared with the results in nonsnorers without polygraphic abnormalities (n = 11) who were included in the control group. Ventricular dimensions and indices of left ventricular systolic function were within normal limits and were not significantly different between the two groups. Indices of left ventricular diastolic function were also within normal limits, but isovolumetric relaxation time (IVRT) was significantly longer among the positive group (72.5 +/- 8.4 msec) than among the controls (65.1 +/- 7.9 msec) (P = 0.018). Multiple regression analysis showed that posterior wall thickness was predicted by a model that included cardiac events related with respiratory events and/or desaturations, and respiratory disturbance index (RDI) in supine position. Deceleration of early diastolic flow was predicted by RDI, percentage of total recording time with SaO(2) < 90% (CT(90)), and age; the variability of isovolumetric relaxation time was predicted by a model that included RDI in supine position. We found a significant relationship between polygraphic parameters suggestive of SRBD and echocardiographic measurements of ventricular dimensions and diastolic function. Also, echocardiographic parameters suggestive of some degree of left ventricular diastolic dysfunction were found in snoring adolescents with polygraphic abnormalities.

Obstructive sleep-disordered breathing in children: new controversies, new directions

Although it may seem that confusion and uncertainty reign in the field of pediatric sleep medicine, the recent realizations that the scope of childhood SDB is wider, the symptomatology is broader, and the prevalence is higher than previously believed are major advances. Likewise, recent acknowledgment of the lack of true "gold standards" for diagnosing UARS and OSAS in children is also a major advancement in this field. Critical assessment of the current "state of the art" by the 2002 AAP Technical Report on the Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome [37] is another major advance that sets the stage for the next steps. The field needs an evidence-based definitions conference, standardization of definitions across all research studies, and much more research on clinical features, pathophysiology, diagnosis, and treatment of the "new" obstructive SDB, including the full range of morbidity caused by increased upper airway resistance. This should include further inquiry into the origins of adult morbidity that resulted from childhood SDB and how it can be prevented.

Genomic approaches to understanding obstructive sleep apnea

Obstructive sleep apnea (OSA) is an increasingly recognized, common chronic disease in the developed nations and is a complex disease that has high social and economic costs. OSA and its associated 'intermediate' phenotypes-craniofacial structure, body fat distribution and metabolism, and neurological control of the upper airway muscles and of sleep and circadian rhythm-are under a substantial degree of genetic control. Investigating the genetic aetiology of OSA offers a means of better understanding its pathogenesis, with the goal of improving preventive strategies, diagnostic tools and therapies. Molecular studies of OSA itself are in their infancy, but considerable effort and expense has already been expended in attempts to detect genetic loci contributing to OSA-associated intermediate phenotypes, such as obesity. However, many of the fundamental questions relating to the genetic epidemiology of OSA and associated factors remain unanswered. This chapter reviews the current state of knowledge of the genetics of OSA, with a focus on genomic approaches to understanding sleep disorders.

Sleep apnoea: Finnish National guidelines for prevention and treatment 2002-2012

(1) After negotiations with the Finnish Ministry of Social Affairs and Health, a national programme to promote prevention, treatment and rehabilitation of sleep apnoea for the years 2002-2012 has been prepared by the Finnish Lung Health Association on the basis of extensive collaboration. The programme needs to be revised as necessary, because of the rapid development in medical knowledge, and in appliance therapy in particular. (2) Sleep apnoea deteriorates slowly. Its typical features are snoring, interruptions of breathing during sleep and daytime tiredness. Sleep apnoea affects roughly 3% of middle-aged men and 2% of women. In Finland, there are approx. 150,000 sleep apnea patients, of which 15,000 patients have a severe disease, 50,000 patients are moderate and 85,000 have a mild form of the disease. Children are also affected by sleep apnea. A typical sleep apnea patient is a middle-aged man or a postmenopausal woman. (3) The obstruction of upper airways is essential in the occurrence of sleep apnoea. The obstruction can be caused by structural and/or functional factors. As for structural factors, there are various methods of intervention, such as to secure children's nasal respiration, to remove redundant soft tissue, as well as to correct malocclusions. It is possible to have an effect on the functional factors by treating well diseases predisposing to sleep apnoea, by reducing smoking, the consumption of alcohol and the use of medicines impairing the central nervous system. The most important single risk factor for sleep apnoea is obesity. (4) Untreated sleep apnoea leads to an increase morbidity and mortality through heart circulatory diseases and through accidents by tiredness. Untreated or undertreated sleep apnoea deteriorates a person's quality of life and working capacity. (5) The goals of the Programme for the prevention and treatment of sleep apnoea are as follows: (1) to decrease the incidence of sleep apnoea, (2) to ensure that as many patients as possible with sleep apnoea recover, (3) to maintain capacity for work and functional capacity of patients with sleep apnoea, (4) to reduce the percentage of patients with severe sleep apnoea, (5) to decrease the number of sleep apnoea patients requiring hospitalisation and (6) to improve cost effectiveness of prevention and treatment of sleep apnoea. (6) The following means are suggested for achieving the goals: (1) to promote prevention of obesity, weight loss and weight control; (2) to promote securing of nasal respiration in child patients and removal of obstructing redundant soft tissues; (3) to promote the correction of children's malocclusions, (4) to enhance knowledge about risk factors and treatment of sleep apnoea in key groups, (5) to promote early diagnosis and active treatment, (6) to commence rehabilitation early and individually as a part of treatment and (7) to encourage scientific research. (7) On the national level, the occurrence of sleep apnoea can be prevented, for example, by encouraging weight control. The programme gives examples of such measures and appeals to various authorities and voluntary organisations to reinforce their collaboration. Preventive measures should be individualised, and based on due consideration. (8) The efficacy of diagnosing sleep apnoea should be increased. Attention should be paid to the symptoms of risk group patients at different units of the primary and occupational health care. Even mild forms of the disease should be treated appropriately. Diagnosis and treatment of the disease involve cooperation between the primary and specialised health-care sectors. Methods of treatment are (1) treatment of obesity, (2) positional therapy, (3) reduction of the use of medicines impairing the central nervous system, (4) reduction of smoking and the consumption of alcohol, (5) devices affecting the position of the tongue and lower jaw, (6) treatment with Continuous Positive Airway Pressure (CPAP-treatment), (7) surgical methods of treatment and (8) rehabilitation. (9) The hierarchy of referrals in the prevention and treatment of sleep apnoea should be revised to accord a greater role to the primary health-care sector. Good exchanges of information and cooperation between the primary health care and specialised medical-care sectors should be developed. Hospitals districts in cooperation with provincial governments and municipalities should ensure that different levels of the health-care system are capable of fulfilling the tasks assigned to them appropriately. (10) Rehabilitation of sleep apnoea should be goal-orientated and cover all forms of rehabilitation: medical, occupational and social. Rehabilitation should prevent the effects caused by the disease. Thus, it is possible to support self-care, increase the patient's resources and improve quality of life. (11) Information and training should be directed primarily towards health-care personnel, patients and their families. Organisations should produce materials for health and patient education as well as organising training events. To support the activities. financing will be needed from organisations such as Finland's Slot Machine Association. The Social Insurance Institution should disseminate information about questions of social security. Regional direction and training will mainly be the responsibilities of hospital districts, provincial governments and local health centres. The media will play an important role in the dissemination in-depth information about prevention and treatment of sleep apnoea.

Prevalence of habitual snoring and sleep-disordered breathing in preschool-aged children in an Italian community

OBJECTIVE

To measure the prevalence of habitual snoring and sleep-disordered breathing in preschool-aged children.

STUDY DESIGN

Cross-sectional survey with parental report and overnight ambulatory monitoring of children 3 to 6 years of age in 8 kindergartens (n = 604). Parents reported the child's information through an interviewer-based questionnaire or by a brief telephone interview. Snoring, oxygen saturation, body position, and heart rate were recorded for 1 night at home.

RESULTS

Data were obtained on 98.5% of 604 children (447 questionnaires, 74%; 148 telephone interviews, 24.5%); groups were similar for sex and age. Two hundred sixty-five children had ambulatory monitoring at home. Habitual snoring (always and often) was reported in 34.5% and breathing cessation in 18.6%. Habitual snoring was associated with parental report of daytime symptoms (P =.001) and daytime somnolence (P =.032). Pathologic snoring was present in 12% of children (95% CI, 7.9-16.1). On multivariate analysis, parental report of habitual snoring was the strongest determinant of pathologic snoring (OR, 12.23; 95% CI, 3.56-41.94). Oxygen desaturation index > or =5 per hour was found in 13% of children (95% CI, 8.7-17.3).

CONCLUSIONS

Parental report of habitual snoring is very common. Children with habitual snoring are more likely to have objectively measured snoring and daytime morbidity.

Crescimento pôndero-estatural de crianças após adenoamigdalectomia

A hiperplasia adenoamigdaliana é a principal causa de obstrução das vias aéreas superiores em crianças, sendo muitas vezes associada à apnéia do sono. Esta, por sua vez, resulta em uma série de comprometimentos: baixo rendimento escolar, cor pulmonale, distúrbios de comportamento não específicos, hiperatividade, sonolência diurna, distração e atrasos de desenvolvimento, sendo o déficit pôndero-estatural o mais grave. A adenoamigdalectomia é o tratamento de escolha. O objetivo deste trabalho é mensurar o crescimento e desenvolvimento das crianças antes e depois da adenoamigdalectomia através da comparação dos percentis pré e pós operatórios. FORMA DE ESTUDO: Clínico prospectivo randomizado. MATERIAL E MÉTODO: Cinquenta e cinco crianças de 2 a 12 anos, com história de obstrução das vias aéreas superiores por hiperplasia adenoamigdaliana foram submetidas a exame antropométrico (peso e altura), antes e 6 meses após a adenoamigdalectomia. Os dados foram transformados em percentil para peso e altura, de acordo com a idade e comparados através de análise estatística. RESULTADOS: No pré-operatório, encontramos a seguinte distribuição para o percentil altura: 78,2%, abaixo de p75 e para peso 70,9% abaixo de p50. No pós-operatório observou-se melhor distribuição das crianças: para altura 34,6% abaixo de p75, 32,8% entre p75-95 e 32,6% para p95 e acima e para peso: 35,5% abaixo de p50, 36,4% para p50-95 e 29,1% acima de p95. CONCLUSÃO: Observou-se uma melhora considerável do desenvolvimento pôndero-estatural das crianças após a adenoamigdalectomia.

A whole-genome scan for obstructive sleep apnea and obesity

Obstructive sleep apnea (OSA) is a common, chronic, complex disease associated with serious cardiovascular and neuropsychological sequelae and with substantial social and economic costs. Along with male gender, obesity is the most characteristic feature of OSA in adults. To identify susceptibility loci for OSA, we undertook a 9-cM genome scan in 66 white pedigrees (n=349 subjects) ascertained on the basis of either an affected individual with laboratory-confirmed OSA or a proband who was a neighborhood control individual. Multipoint variance-component linkage analysis was performed for the OSA-associated quantitative phenotypes apnea-hypopnea index (AHI) and body mass index (BMI). Candidate regions on chromosomes 1p (LOD score 1.39), 2p (LOD score 1.64), 12p (LOD score 1.43), and 19p (LOD score 1.40) gave the most evidence for linkage to AHI. BMI was also linked to multiple regions, most significantly to markers on chromosomes 2p (LOD score 3.08), 7p (LOD score 2.53), and 12p (LOD score 3.41). Extended modeling indicated that the evidence for linkage to AHI was effectively removed after adjustment for BMI, with the exception of the candidate regions on chromosomes 2p (adjusted LOD score 1.33) and 19p (adjusted LOD score 1.45). After adjustment for AHI, the primary linkages to BMI remained suggestive but were roughly halved. Our results suggest that there are both shared and unshared genetic factors underlying susceptibility to OSA and obesity and that the interrelationship of OSA and obesity in white individuals may be partially explained by a common causal pathway involving one or more genes regulating both AHI and BMI levels.

Schlafstörungen bei kinder- und jugendpsychiatrischen Erkrankungen

Zusammenfassung: Schlafstörungen als Symptom zahlreicher kinder- und jugendpsychiatrischer Störungsbilder komplizieren häufig den Verlauf und die Behandlung der Grunderkrankung. Organische Störungen wie die Narkolepsie oder das Kleine-Levin-Syndrom können zu differentialdiagnostischen Schwierigkeiten und Fehleinschätzungen führen. Unklar ist, ob spezifische Veränderungen der Schlafarchitektur bereits im Kindes- und Jugendalter bestehen und damit als biologischer Trait-Marker für psychiatrische Erkrankungen zu verstehen sind. Während für das Erwachsenenalter die Bedeutung von Schlafstörungen vor allem für die Entwicklung späterer depressiver Störungen belegt werden konnte, ist derzeit offen, ob es sich bei persistierenden Schlafstörungen im Kindesalter um Vulnerabilitätsmarker für psychiatrische Erkrankungen handelt. In der vorliegenden Literaturübersicht sollen Wechselwirkungen zwischen Schlafstörung und psychischer Störung aufgezeigt und die Bedeutung der Berücksichtigung von Schlafstörungen für Diagnostik und Therapie kinder- und jugendpsychiatrischer Störungsbilder unterstrichen werden.