Treatment of obstructive sleep apnea in children

Is there an increased risk of otitis media in children with obstructive sleep apnea?

INTRODUCTION

The purpose of this study was to investigate the prevalence of otitis media and other otolaryngologic disorders in children with Obstructive Sleep Apnea (OSA) compared to those without OSA in a large cohort.

METHODS

A retrospective cohort study was carried within the US Collaborative Network within TriNetX. The OSA group was defined by ICD-10 code G47.33 and non-OSA group excluded patients with OSA. Both groups were required to have a CPT code for an outpatient visit to act as a control: 99202-99215. Propensity score matching for age, sex, and race was performed. Prevalence of otitis media (ICD-10H65, H66), chronic otitis media (ICD-10H66.1, H66.2, H66.3, H65.2, H65.3, and H65.4), tympanostomy (CPT 69433, 69436), adenoidectomy (CPT 42830, 42831), tonsillectomy (CPT 42825, 42826), adenotonsillectomy (CPT 42820, 42821), and allergic rhinitis (ICD-10 J30.9) were compared in this cohort.

RESULTS

Propensity score matching yielded 165,665 (M = 95949, F = 69901) patients with a mean age of 10.7 (SD = 4.07) for each cohort. Children with OSA were 1.27x and 3.86x more likely to be diagnosed with otitis media and chronic otitis media, respectively (P<.0001). They were 3.81x more likely to undergo a tympanostomy (P<.0001). Children with OSA were 4.1x, 18.2x, and 24.7x more likely undergo an adenoidectomy, tonsillectomy, and adenotonsillectomy, respectively (P<.0001). Children with OSA were also 2.03x as likely to have a diagnosis of allergic rhinitis (P<.0001).

CONCLUSION

Children with OSA experience otitis media and related surgical intervention more than children without OSA. Since allergic rhinitis and adenoid hypertrophy are contributors to both OSA and AOM, their increased prevalence in children with OSA may explain their increased frequency of AOM.

Severe Pediatric Sleep Apnea: Drug-Induced Sleep Endoscopy Based Surgery

Although adenotonsillectomy is the recommended treatment of obstructive sleep apnea (OSA) in children, some patients with preoperative severe OSA (Apnea-hypopnea index/AHI > 10) remain symptomatic after surgery and may need further workup. This study aims to: (1) analyse preoperative factors and its relation with surgical failure/persistent OSA (AHI > 5 after adenotonsillectomy) in severe pediatric OSA; (2) determine the levels of airway collapse during DISE (drug induced sleep endoscopy) in cases of surgical failure; (3) evaluate the efficacy of targeted surgery based on DISE findings. This retrospective study was conducted between August and September 2020. Across 9 years (from 2011 to 2020), all children diagnosed with severe OSA in our Hospital underwent adenotonsillectomy and repeated type 1 polysomnography (PSG) 3 months after surgery. Cases of surgical failure underwent DISE for planning eventual directed surgery. Chi-square test was used to assess the relationship between persistent OSA and preoperative patients' characteristics. 80 cases of severe pediatric OSA were diagnosed (68.8% males; mean age: 4.3 years-standard deviation: 2.49; mean AHI: 16.3-standard deviation 7.14) in the aforementioned period. We found a significant association between surgical failure (11.3% of cases; mean AHI: 6.9-SD 0.91) and obesity (p = 0.002; confidence level of 95%). Neither preoperative AHI nor other PSG parameters were associated with surgical failure. In cases of surgical failure, epiglottis collapse was present in every DISEs and adenoid tissue was present in 66% of children. All cases of surgical failure had directed surgery and surgical cure (AHI ≤ 5) was obtained in 100% of cases. This study suggests that obesity is the strongest predictor of surgical failure in children with severe OSA who undergo adenotonsillectomy. Epiglottis collapse and presence of adenoid tissue are the most common findings in postoperative DISEs of children with persistent OSA after primary surgery. DISE based surgery seems a safe and effective tool to manage persistent OSA after adenotonsillectomy.

Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children

STUDY OBJECTIVES

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA.

METHODS

Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance.

RESULTS

Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home.

CONCLUSIONS

T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA.

CITATION

Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

Comparison of airway pressures and expired gas washout for nasal high flow versus CPAP in child airway replicas

Background

For children and adults, the standard treatment for obstructive sleep apnea is the delivery of continuous positive airway pressure (CPAP). Though effective, CPAP masks can be uncomfortable to patients, contributing to adherence concerns. Recently, nasal high flow (NHF) therapy has been investigated as an alternative, especially in CPAP-intolerant children. The present study aimed to compare and contrast the positive airway pressures and expired gas washout generated by NHF versus CPAP in child nasal airway replicas.

Methods

NHF therapy was investigated at a flow rate of 20 L/min and compared to CPAP at 5 cmH₂O and 10 cmH₂O for 10 nasal airway replicas, built from computed tomography scans of children aged 4–8 years. NHF was delivered with three different high flow nasal cannula models provided by the same manufacturer, and CPAP was delivered with a sealed nasal mask. Tidal breathing through each replica was imposed using a lung simulator, and airway pressure at the trachea was recorded over time. For expired gas washout measurements, carbon dioxide was injected at the lung simulator, and end-tidal carbon dioxide (EtCO₂) was measured at the trachea. Changes in EtCO₂ compared to baseline values (no intervention) were assessed.

Results

NHF therapy generated an average positive end-expiratory pressure (PEEP) of 5.17 ± 2.09 cmH₂O (mean ± SD, n = 10), similar to PEEP of 4.95 ± 0.03 cmH₂O generated by nominally 5 cmH₂O CPAP. Variation in tracheal pressure was higher between airway replicas for NHF compared to CPAP. EtCO₂ decreased from baseline during administration of NHF, whereas it increased during CPAP. No statistical difference in tracheal pressure nor EtCO₂ was found between the three high flow nasal cannulas.

Conclusion

In child airway replicas, NHF at 20 L/min generated average PEEP similar to CPAP at 5 cm H₂O. Variation in tracheal pressure was higher between airway replicas for NHF than for CPAP. The delivery of NHF yielded expired gas washout, whereas CPAP impeded expired gas washout due to the increased dead space of the sealed mask.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01880-z.

Dental, oral pH, orthodontic and salivary values in children with obstructive sleep apnea

OBJECTIVES

Mouth breathing is a key feature of obstructive sleep apnea (OSA). The current study evaluated dental, salivary and orthodontic characteristics of children with OSA, and compared them to those of children without OSA.

MATERIALS AND METHODS

Twenty-two children (mean age 5.3 years, 13 males) with OSA and 21 children without OSA who served as a control group (mean age 6.8 years, 11 males) underwent dental examinations. The OSA group was classified according to the apnea-hypopnea Index. Clinical examination included plaque index, gingival index, caries status, pH at 7 oral sites, salivary carries bacterial counts and inflammatory cytokine levels. Orthodontics measurements were calculated as the percentage of children with values in the normal range, in each group.

RESULTS

The mean values of the decayed, missing and filled teeth (DMFT)/dmft index, the gingival index and the plaque index were higher in the OSA than the control group. Salivary Mutans streptococci and lactobacilli counts were significantly higher in the OSA than the control group; as were pH values in the hard and soft palate, and in the posterior and middle tongue. Significantly lower values were observed in the OSA than the control group for most of the orthodontic variables examined. Similarly, stratification of AHI according to severity shows the lowest values among those with mild OSA, and the highest among those with severe AHI.

CONCLUSIONS

Compared to a control group, mouth breathing children with obstructive sleep apnea had differences in oral microbiota, greater acidity and poorer dental status.

CLINICAL RELEVANCE

Clinicians should be aware of the various oral disturbances that may accompany OSA, and implement preventive measures.

Nasal cavity structural anomalies in children and adolescents at high risk of sleep-disordered breathing: An exploratory cone-beam computed tomography study

INTRODUCTION

In this study, we investigated the presence of structural anomalies in the nasal cavity (deviated nasal septum [DNS] and turbinate hypertrophy [TH]) in patients at high risk or not of sleep-disordered breathing (SDB).

METHODS

A retrospective study considering available cone-beam computed tomography scans of 99 patients was conducted. Dolphin Imaging software (Dolphin Imaging and Management Solutions, Chatsworth, Calif) was used to process the craniofacial scans. A pediatric sleep questionnaire (PSQ) was used to suggest a high risk of SDB. Subjective and objective assessments of DNS and TH were considered.

RESULTS

Good to excellent intrareliability and interreliability were attained. The prevalence of a PSQ score suggestive of a high risk of SDB in this sample was 59%. The prevalence of subjective DNS and TH assessment was 64% and 70%, respectively. In contrast, on the basis of objective assessments, 27% of patients presented with DNS and 25% with TH. Cross-tabulation of DNS and TH with PSQ score indicated a statistically significant association between subjective DNS and subjective TH and subjective TH and positive PSQ. A positive correlation between age and subjective and objective DNS assessments was also observed.

CONCLUSIONS

Older patients are more likely to present with DNS. Only the presence of subjectively determined TH in patients is associated with a high risk for SDB. The study reveals that assessment of DNS and TH using cone-beam computed tomography imaging is not likely suitable to strongly suggest patients at high risk for SDB. DNS subjective assessments were capable of identifying less than 5% of deviation.

Maxillomandibular advancement effectively treats obstructive sleep apnea in adolescents at short-term follow-up

OBJECTIVE

To evaluate the efficacy of maxillomandibular advancement (MMA) surgery for the treatment of malocclusion and obstructive sleep apnea (OSA) in an adolescent population.

STUDY DESIGN

A retrospective cohort study was designed using electronic medical record chart review.

RESULTS

Fifteen patients aged 20 years or younger (range, 14-20) were included. All patients underwent MMA surgery for the primary correction of malocclusion and secondary treatment of OSA. Mean preoperative apnea-hypopnea index (AHI) was 28.9 ± 16.0 events/h (range, 7.1-54.7), and mean postoperative AHI was 5.7 ± 4.6 events/h (range, 1.5-18.4), reflecting a reduction of 23.2 events/h, an 80.6% reduction (P < .001). Fourteen patients (93.3%) experienced improvement in AHI. Mean minimal posterior airway space increased from 4.6 mm to 8.6 mm (P < .001). Mean posterior airway space at the level of the uvular tip increased from 6.7 mm to 11.5 mm (P < .001). Patients who underwent adjunct genioglossus advancement (GGA) had a mean decrease in AHI of 35.3 events/h (P = .004), which was not significantly different from the decrease in those who did not receive GGA.

CONCLUSIONS

MMA surgery with or without GGA is an effective treatment option for adolescents with a malocclusion and an AHI >5.0 events/h. In this population, it is shown to decrease AHI and increase posterior airway space. More research is required to determine the ideal adolescent candidate for MMA surgery.

Obstructive sleep apnea in children aged 3 years and younger: Rate and risk factors

OBJECTIVE

Undiagnosed and untreated obstructive sleep apnea (OSA) can predispose children to neurobehavioural consequences. However, there is a lack of data identifying rate of, and risk factors for, OSA in very young healthy children. The objective of this study was to determine the rate of OSA and identify risk factors associated with the presence and severity of OSA in children aged 3 years and younger.

METHODS

This was a retrospective chart review of healthy children between 1 and 3 years old who had a baseline polysomnogram (PSG) between January 2012 and June 2017. Patient demographics, referral history, and PSG data were recorded.

RESULTS

One hundred and thirteen children were referred for a PSG, of which 66 (58%) were diagnosed with OSA and 47 (42%) did not have OSA. In the OSA group, 13 (20%) were mild and 53 (80%) were moderate-severe. Nasal congestion (P=0.001), adenoid hypertrophy (P=<0.001), and tonsillar hypertrophy (P=0.04) reported at the time of referral were more common in the OSA group compared to the no-OSA group. Binary logistic regression analysis showed that referral from an otolaryngologist (odds ratio=2.6, 95% confidence interval=1.1 to 6.0) were associated with moderate-severe OSA.

CONCLUSION

A high rate of OSA was found among children aged 3 years and younger. Children referred by an otolaryngologist are more likely to be diagnosed with moderate-severe OSA. Children aged 3 years and younger with symptoms of OSA should be considered high-risk for OSA and be prioritized for early PSG and management.

Oxycodone preemptive analgesia after endoscopic plasma total adenotonsillectomy in children: A randomized controlled trial

BACKGROUND

Endoscopic tonsillectomy is associated with postoperative pain. Postoperative pain management remains to be improved in children. We aimed to investigate oxycodone preemptive analgesia in children undergoing endoscopic plasma total adenotonsillectomy.

METHODS

166 children with adenotonsillar hypertrophy were recruited at Wuhan Children's Hospital between 08/2016 and 03/2017. They were randomly assigned to receive SPOA (postoperative sufentanil), SPEA+SPOA (preemptive sufentanil and postoperative sufentanil), and OPEA+SPOA (preemptive oxycodone and postoperative sufentanil). The primary endpoint was serum c-fos levels. The secondary endpoints were the response entropy (RE) value, Pediatric Anesthesia Emergence Delirium (PAED) score, FLACC score, and adverse events.

RESULTS

c-fos mRNA levels were increased significantly after surgery in the SPOA and SPEA+SPOA groups (P < .05). Postoperatively, c-fos mRNA levels were higher in the SPOA group compared with the OPEA+SPOA group (P = .044). The RE values increased in all groups after surgery (P < .05). At extubation, RE values were higher in the SPOA group compared with the SPEA+SPOA and OPEA+SPOA groups (P < .05). The PAED scores were higher in the SPOA group compared with the OPEA+SPOA group (P = .045). In the SPOA group, the FLACC scores were decreased at 24 h after surgery vs 4 hours (P = .044). Prediction probability (Pk) values indicated that RE and c-fos mRNA levels were quantitative predictors for early postoperative stress reaction after surgery.

CONCLUSIONS

The subanalgesic dose of oxycodone (0.1 mg/kg) as preemptive analgesia could improve pain after endoscopic plasma total adenotonsillectomy in children.

Are obstructive sleep apnea and sleep improved in response to multidisciplinary weight loss interventions in youth with obesity? A systematic review and meta-analysis

BACKGROUND

Pediatric obesity is closely associated with obstructive sleep apnea (OSA) and short sleep duration. While multidisciplinary weight loss interventions are recommended for pediatric obesity management, the evidence for their effects on OSA severity and overall sleep in youth have not been systematically examined.

OBJECTIVES

To conduct a systematic review and meta-analysis investigating the effects of multidisciplinary weight loss interventions on OSA severity and prevalence, and on overall sleep health in youth with obesity.

METHODS

A systematic search of interventional studies (participants age range: 10-19 yrs) was performed using PubMed, CENTRAL and Embase, from inception to May 2019. The quality of the evidence was assessed using the Cochrane risk of bias tool.

RESULTS

Ten studies were included by the end of the screening process. Ninety percent of the included studies reported a decrease in OSA prevalence post-intervention, and OSA was normalized for 46.2-79.7% of the youth. The meta-analysis comprising seven longitudinal studies revealed significant reductions in apnea-hypopnea index (effect size: -0.51, 95%CI -0.94 to -0.08, p = 0.019), and oxygen desaturation index (effect size: -0.28, 95%CI = -0.50 to -0.05, p = 0.016). Seventy-five percent of the studies reported improved sleep duration in youth with OSA.

CONCLUSIONS

Evidence suggests that multidisciplinary weight loss interventions result in improvements in OSA severity and sleep duration in youth with obesity. Future randomized controlled trials are warranted to better assess and understand the independent implications of weight loss, fat mass decrease and chronic exercise on OSA and sleep health in this population.

A usability study of an internet-delivered behavioural intervention tailored for children with residual insomnia symptoms after obstructive sleep apnea treatment

Better Nights, Better Days (BNBD) is a 5-session online intervention designed to treat insomnia in 1-10-year-old children (Corkum et al. 2016). Obstructive sleep apnea (OSA) and insomnia commonly occur in children and, after surgical treatment for OSA, it is estimated that up to 50% of children may continue to suffer from insomnia symptoms. Access to insomnia interventions following OSA treatment is limited as there are few programs available, few trained practitioners to deliver these programs, and limited recognition that these problems exist. The current study involved the usability testing of an internet-based parent-directed session of BNBD tailored towards the needs of children (ages 4-10 years) who experience residual insomnia symptoms after treatment of OSA. This new session was added to the BNBD program. Participants (n = 43) included 6 parents, 17 sleep experts, and 20 front-line healthcare providers who completed and provided feedback on the new session. Participants completed a feedback questionnaire, with both quantitative and qualitative questions, after reviewing the session. Quantitative responses analyzed via descriptive statistics suggested that the session was primarily viewed as helpful by most participants, and open-ended qualitative questions analyzed by content analyses generated a mix of positive and constructive feedback. The results provide insights on how to optimally tailor the BNBD program to meet the needs of the target population and suggest that testing the session on a larger scale would be beneficial.

[Surgical treatment for sleep disorders breathing in children and teenagers]

Adenotonsillectomy is the standard surgery for moderate and severe sleep disorders breathing (SDB) in 2 to 6-year-old children, often due to tonsillar and adenoidal hypertrophy. Recently, partial subtotal intracapsular tonsillotomy has been developed to prevent risks linked to surgery, especially haemorrhages leading to death in extreme cases. Children with apnea, poor quality of life (sleep problems, daytime tiredness), poor academic performance or late growth are candidates for adenotonsillectomy. The management of children with mild SDB is still evolving. Adenotonsillectomy is usually not recommended for adenoidal hypertrophy. Treatment options with mild OSA include watchful waiting, inhaled nasal corticosteroids, and adeno-tonsillectomy. The treatment decision should be made after a discussion between the patient, caregivers and the surgeon regarding the risks and benefits of possible therapies. The surgical procedure is efficient in more than 75% of cases. Close clinical follow-up is necessary, especially in obese children. Primary and secondary haemorrhaging, as well as postoperative pain, are considerably reduced in partial tonsillotomy. Tonsillotomy (intracapsular or subtotal tonsillectomy) is a modern technique because it has been suggested that perioperative pain and postoperative haemorrhage are reduced with the tonsillotomy technique. There is no significant difference in subjective outcome between tonsillotomy and tonsillectomy. These findings may support wider use of tonsillotomy for the treatment of sleep disorders breathing in children. Children with residual disorder may be candidates for surgical procedures such as nasal disobstruction, pharyngoplasty, lingual tonsillectomy or maxillofacial surgery.

Can CPAP Therapy in Pediatric OSA Ever Be Stopped?

STUDY OBJECTIVES

Continuous positive airway pressure (CPAP) has been increasingly used in children with obstructive sleep apnea (OSA), though it is unclear whether it can ever be ceased. We describe the clinical, demographic, and polysomnographic (PSG) characteristics of a cohort of children with OSA who were successfully weaned off CPAP.

METHODS

From a pediatric cohort on CPAP for OSA at the Queensland Children's Hospital between January 2016 and December 2017, a subgroup of children who were taken off CPAP were retrospectively studied.

RESULTS

CPAP therapy was stopped for 53 children over a 2-year period; 29 of these were excluded from analysis due to change to bilevel support (n = 2), transition to adult care (n = 12), or cessation due to poor adherence (n = 15). A total of 24 children [median (interquartile range, IQR) age 4.1 years (1.0-10.5); 18 males] were successfully weaned off CPAP therapy based on improvement in clinical and PSG parameters; and were included in the analysis. These children had a median (IQR) apnea-hypopnea index (AHI) of 9.8 (5.7-46.0) at CPAP initiation, which improved to 3.3 (0.4-2.2) at CPAP cessation after a median (IQR) duration of 1.0 (0.5-2.0) year. The reasons for CPAP cessation included improved symptoms and/or PSG parameters with time (n = 11); improvement after airway surgery (n = 7), and improvement of body mass index (n = 2). In four children, CPAP therapy was ceased after initial trial due to low physician perceived clinical benefit.

CONCLUSIONS

This is the first study describing the characteristics of children and likely reasons for successful CPAP cessation. Children on CPAP should be regularly screened for ongoing CPAP need.

Comparative intraindividual ablative tissue effects of diode laser 980 nm versus radiofrequency in tonsillar hypertrophy management

Tonsillotomy (tonsillar ablation) using diode laser and radiofrequency has been introduced for management of tonsillar hypertrophy as it is associated with fewer hazards to deep structures. We compared tissue volume and histological changes in the tonsils following radiofrequency tonsillotomy versus diode laser tonsillotomy in tonsillar hypertrophy. 40 tonsils excised from 20 patients were included in this study. Twenty tonsils were subjected to radiofrequency tonsillotomy (RFT) group 1, and the other 20 tonsils were subjected to diode laser 980 nm tonsillotomy (DLT) group 2. Both procedures were followed by cold dissection tonsillectomy for macroscopic and histological examination of tonsils. Tonsillar volume reduction was evident in both groups with a non-significant difference between groups. Histological changes were evident in both groups. In our study, both radiofrequency and diode laser were effective in tonsillar ablation in terms of volume reduction and keeping the histological pattern intact.

Risk factors associated with obstructive sleep apnea-hypopnea syndrome in Chinese children: A single center retrospective case-control study

Pediatric obstructive sleep apnea-hypopnea syndrome is caused by multiple factors. The present study aimed to investigate the potential risks of pediatric obstructive sleep apnea hypopnea syndrome (OSAHS) and their correlation with the disease severity. A total of 338 pediatric patients with OSAHS (polysomnography (PSG) diagnosis) were enrolled between June 2008 and October 2010. These pediatric patients were divided into mild, moderate and severe subgroups according to the obstructive apnea index (OAI) and/or apnea hypoventilation index (AHI). A total of 338 pediatric patients with vocal nodules who were without obstruction of the upper respiratory tract were enrolled as the control group. The patients were analyzed retrospectively. The average number of upper respiratory tract infections each year and tonsil hypertrophy, adenoid hypertrophy, positive serum tIgE, chronic sinusitis, nasal stenosis, craniofacial features and obesity were significantly higher in OSAHS compared with controls (P<0.01). The parameters the average number of upper respiratory tract infections each year (OR: 1.395, 95% CI: 1.256–1.550), adenoid hypertrophy (OR: 8.632, 95% CI: 3.990–18.672), tonsil hypertrophy (OR: 9.138, 95% CI: 4.621–18.073), nasal stenosis (8.023, 95% CI: 3.633–17.717) and chronic sinusitis (OR: 27.186, 95% CI: 13.310–55.527) were independent factors of pediatric OSAHS (P<0.01). The distribution of chronic sinusitis, nasal stenosis, craniofacial features and obesity indicated a gradual increasing trend in the severity of OSAHS (P<0.01). Number of upper respiratory tract infections per year, adenoid hypertrophy, tonsil hypertrophy, chronic sinusitis, nasal stenosis, infections, allergic reactions, craniofacial features and obesity may be potential risk factors of pediatric OSAHS.

Sleep-disordered breathing and cognitive functioning in preschool children with and without Down syndrome

BACKGROUND

Sleep affects children's cognitive development, preparedness for school and future academic outcomes. People with Down syndrome (DS) are particularly at risk for sleep-disordered breathing (SDB). To our knowledge, the association between SDB and cognition in preschoolers with DS is unknown.

METHODS

We assessed sleep by using cardiorespiratory polygraphy in 22 typically developing (TD) preschoolers and 22 with DS. Cognition was assessed by using the Mullen Scales of Early Learning and behaviour by using the Strengths and Difficulties Questionnaire (SDQ). The MacArthur Communicative Development Inventory (MCDI) measured language level. We predicted that sleep problems would be associated with lower cognitive and behavioural functioning.

RESULTS

In TD children, longer sleep duration was associated with higher scores on MCDI expressive language and fewer emotional symptoms such as fear and unhappiness on the SDQ, whilst SDB was associated with increased conduct problems and less prosocial behaviour on the SDQ. Conversely, for children with DS, SDB was associated with increased language understanding and use of actions and gestures on the MCDI.

CONCLUSIONS

The findings in the TD group support our hypotheses. We recommend that sleep problems are screened for and treated as even mild SDB may prompt poorer cognition and behaviour. For children with DS, we expect that multiple factors in this complex syndrome mask or mediate the association between sleep and cognitive development and tighter controls are necessary to uncover effects of sleep. We propose longitudinal studies as a necessary tool to assess the precise impact of sleep on cognitive development in accounting for individual differences in DS.

The safety and efficacy of pediatric lingual tonsillectomy

OBJECTIVE

Lingual tonsillar hypertrophy is recognized as a cause of persistent obstructive sleep apnea (OSA) after adenotonsillectomy in children. However, little has been reported regarding the complications, postoperative course and effectiveness of lingual tonsillectomy (LT). Our objective was to review the safety and effectiveness of LT in children.

METHODS

Retrospective review of children undergoing LT from January 2009 to December 2015 at a tertiary children's hospital. Complications, postoperative course and polysomnographic (PSG) outcomes were recorded for all patients.

RESULTS

We identified 92 children (mean age = 8.6 years, 50% female) who underwent LT; 43.5% had a syndromic diagnosis. The most common complications were emergency department presentation for bleeding (4.4%) and poor oral intake (3.3%). The readmission rate was 4.4% including 2 children (2.2%) who required operative control of hemorrhage. No children required unplanned reintubation or ICU admission. In children with PSG data (n = 18), the median apnea-hypopnea index (AHI) decreased from 8.5 to 3.8 events/hour (p = 0.022) and the median obstructive AHI (oAHI) decreased from 8.3 to 3.1 events/hour (p = 0.021). In addition, the oxygen saturation nadir increased from 83.8% to 89.0% (p = 0.0007). After surgery the percentage of patients with oAHI<5 events/hour increased from 27.8% to 61.1% (p = 0.08).

CONCLUSIONS

Readmission and bleeding rates after lingual tonsillectomy in children were similar to that seen with tonsillectomy. Polysomnographic data showed that lingual tonsillectomy resulted in a significant reduction of both AHI and oAHI with a postoperative oAHI <5 achieved in 61% of patients.

Obstructive Sleep Apnea Resolution in Hypopnea- versus Apnea-Predominant Children after Adenotonsillectomy

OBJECTIVE

Given that 30% to 40% of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether children with hypopnea-predominant OSA were more likely to have complete disease resolution after adenotonsillectomy than those with apnea-predominant disease. We also identified risk factors that might modify the relationship between disease resolution and polysomnographic event type (ie, hypopnea vs apnea).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary pediatric hospital.

SUBJECTS/METHODS

Consecutive 1- to 18-year-old typically developing children diagnosed with OSA from March 2011 to December 2012 underwent adenotonsillectomy and completed pre- and postoperative polysomnography within 1 year of surgery.

RESULTS

Fifty-eight children were included (27 female; mean ± SD: age, 5.6 ± 3.1 years; body mass index z score, 1.1 ± 1.7). Overall, adenotonsillectomy resulted in significant improvement in obstructive apnea-hypopnea index (oAHI) from 23.3 ± 40.0 to 4.3 ± 8.2 events per hour (P < .001), obstructive apnea index (5.1 ± 7.4 to 0.4 ± 0.8, P < .001), and obstructive hypopnea index (oHI; 18.1 ± 37.5 to 3.7 ± 8.1, P < .001). There was complete response (oAHI <1.0 event/h) in 24 of 58 patients (41%) but no difference by event type (P = .11). On univariate analysis, only race, sex, oxygen saturation nadir, and oHI were predictive of response to adenotonsillectomy, while multivariate analysis found that prematurity, age, oxygen saturation nadir, oHI, obstructive apnea index, and oAHI were predictive. Event type was not significant, even in a model controlling for age, race, sex, prematurity, asthma, body mass index, and baseline polysomnographic variables.

CONCLUSION

This small study demonstrated no difference in disease resolution between children with hypopnea- and apnea-predominant OSA who underwent adenotonsillectomy. Additionally, adenotonsillectomy significantly improved OSA in most children, and high preoperative oAHI was associated with persistent postoperative OSA.

Stability of Modified Maxillomandibular Advancement Surgery in a Patient With Preadolescent Refractory Obstructive Sleep Apnea

Maxillomandibular advancement (MMA) surgery can be considered a primary single-stage treatment for improving the quality of life in patients with preadolescent refractory obstructive sleep apnea (OSA). The aim of the present report was to evaluate the treatment efficacy and stability of modified MMA surgery in a growing patient with morbidly severe symptoms and medical complications. Using the follow-up results from the questionnaire, polysomnography, 2-dimensional cephalometry, and 3-dimensional cone-beam computed tomography measurements, the success of modified MMA surgery was assessed in terms of the postoperative improvements of functions and esthetics and postretentive stability of the improvements throughout the growth period. The present report provides some clinical recommendations when considering skeletal surgery in preadolescent patients with OSA: 1) the decision criteria of MMA surgery as definite treatment; 2) the proper surgical design for both maximum enlargement of the airway and esthetic improvement; and 3) the postoperative facial growth for long-term stability of airway function and skeletal improvement. With a systematic multidisciplinary approach, early surgical intervention can be used to treat OSA in children successfully and permanently.

Childhood obstructive sleep apnea syndrome: a review of the 2012 American Academy of Pediatrics guidelines

On a busy day at the pediatric office, child health care practitioners may see children of different ages present with symptoms such as inattentiveness, hyperactivity, aggression, behavioral problems, excessive sleepiness, difficulty waking up in the morning, learning problems, frequent awakening at night, restless sleep, morning headaches, and nocturnal enuresis. Children with these symptoms may be underweight or morbidly obese; healthy; or suffering from asthma, seasonal allergies, or other ailments. What they will likely have in common is a fairly well-known and yet under-recognized condition - obstructive sleep apnea syndrome (OSA). The American Academy of Pediatrics first published "Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome" in 2002. However, with the increase in obstructive sleep apnea syndrome research, they revised these guidelines in 2012. These new guidelines evaluate obstructive sleep apnea syndrome diagnostic techniques, describe available treatment options, and provide follow-up recommendations. This article explores those revisions.

Pulmonary hypertension due to obstructive sleep apnea in a child with Rubinstein-Taybi syndrome

Rubinstein-Taybi syndrome (RTS) is characterized by peculiar facies, mental retardation, broad thumbs, and great toes. Approximately one-third of the affected individuals have a variety of congenital heart diseases. They can also have upper airway obstruction during sleep, due to hypotonia and the anatomy of the oropharynx and airway, which make these patients susceptible to obstructive sleep apnea (OSA). In our case, pulmonary hypertension was caused, successively, by congenital heart defects (a large patent ductus arteriosus and arch hypoplasia) and obstructive sleep apnea during early infancy. The congenital heart defects were surgically corrected, but persistent pulmonary hypertension was identified 2 months after the operation. This pulmonary hypertension was due to OSA, and it was relieved by nasal continuous positive airway pressure. This case is the first report of pulmonary hypertension from OSA in a young infant with RTS.