The snoring child

Severe Obesity and Sleep-Disordered Breathing as Risk Factors for Emergence Agitation in Pediatric Ambulatory Surgery

PURPOSE

Sleep-disordered breathing (SDB) may be a critical risk factor for emergence agitation (EA). We hypothesized that SDB diagnosis is a predictor of EA in children after general anesthesia for ambulatory surgery.

DESIGN

Prospective, observational, cohort study.

METHODS

Children aged 4 to 17 years were assessed for the occurrence of EA. Differences in probability of EA were assessed using multivariable logistic regression analyses.

FINDINGS

Of 1,076 children, 66 (6.1%) had EA. Compared with those without EA, children with EA were younger (P < .001), more likely to have had mask induction (P < .001) and a preoperative diagnosis of SDB (P = .008). On multivariable analysis, SDB, severe obesity, decreasing age in years, increasing first arousal pain score, and intraoperative use of sevoflurane were independently associated with EA.

CONCLUSIONS

SDB and severe obesity may be critical independent predictors of EA in children. Mechanisms underlying these observations deserve further elucidation.

Association of abdominal obesity in children with perioperative respiratory adverse events

BACKGROUND/PURPOSE

Waist circumference (WC), a measure of abdominal obesity, is associated with several chronic disorders. Less is known about the association between WC and acute perioperative adverse events. The purpose of the present investigation was to test the hypothesis that abdominal obesity increases the occurrence of perioperative adverse events in children undergoing elective, noncardiac surgeries.

DESIGN

Prospective observational study.

METHODS

We studied the association between WC and perioperative adverse events in children aged 6 to 18 years who underwent elective noncardiac surgeries at our institution. Patients were considered to have abdominal obesity if WC was 90th percentile or greater for age and gender. Subsequently, univariate factors associated with abdominal obesity were explored and then odds ratios for the occurrence of perioperative respiratory adverse events were calculated from logistic regression after controlling for clinically pertinent covariates.

RESULTS

Among 1,102 patients, the prevalence of abdominal obesity was 23.1%. WC was positively correlated with age and measured anthropometric parameters. Composite perioperative adverse events were more frequent in children with abdominal obesity. After adjusting for several clinically relevant risk factors, abdominal obesity independently predicted increased relative odds of respiratory adverse events (OR = 2.35, 95% CI = 1.6 to 3.5, P < .001). Abdominal obesity was also associated with prolonged postanesthesia care unit (PACU) length of stay.

CONCLUSION

WC, a measure of abdominal obesity, is an independent predictor of perioperative respiratory adverse events in children undergoing elective noncardiac surgery. Furthermore, abdominal obesity was associated with prolonged PACU length of stay.

Association of childhood high body mass index and sleep disordered breathing with perioperative laryngospasm

BACKGROUND

Childhood high body mass index (BMI) and sleep disordered breathing (SDB) are increasingly prevalent and both are associated with perioperative respiratory complications. Laryngospasm is one of the more serious respiratory complications with potentially devastating consequences. It is presently unclear whether high BMI and incident SDB in children significantly amplifies the risks of perioperative laryngospasm. This study examined the hypothesis that compared to controls; children with high BMI and SDB at the time of surgery have higher rates of perioperative laryngospasm.

METHODS

Children (6-18 yr) who underwent elective, non-cardiac operations at a tertiary care center were the subjects of this cross-sectional study. Rates of perioperative laryngospasm were compared between normal controls and children who were overweight/obese and had clinical history of SDB at the time of surgery. Stepwise logistic regression analysis was performed to identify independent predictors of perioperative laryngospasm (dependent variable) using high BMI/SDB as the primary predictor variable.

RESULTS

Among 642 children, those who were overweight/obese and had incident SDB (N = 197) were younger, and had higher indexes of central adiposity. Children with high BMI and SDB had 3.8 times higher unadjusted odds of developing intraoperative laryngospasm (OR = 3.8; 95% CI = 2.1-6.9, p < 0.001). After adjusting for several relevant covariates, the following factors were found to be independent predictors of perioperative laryngospasm: high BMI + SDB, male sex and increasing neck circumference.

CONCLUSION

High BMI and incident SDB in children is associated with increased rates of perioperative laryngospasm. The mechanism(s) underlying this propensity to laryngospasm deserve further elucidation.

Large clothing size in children is associated with high body mass index and clustering of medical comorbidities

Background. Since most people are aware of their clothing size (CS), this prospective study explored the potential utility of CS as a proxy for body size and as a predictor of incident obesity-related health conditions in children. Methods. This was a prospective, cross-sectional study of 725 children aged 6-18 yr. We collected clinical, anthropometric, and sartorial data on all study subjects. Parents reported their children's usual CS. This was compared with US clothing chart for children. Based on this we determined whether a child's CS was appropriate or large for age. Results. The prevalence of overweight/obese was 31.4%. Among the study subjects, 36% usually wore large CS. Children who wore large CS were more likely to be overweight/obese compared to those in the normal CS group (OR = 5.6; 95% CI = 4.0-8.0, P < 0.001). Similarly, large CS was associated with higher rates of incident asthma (P = 0.003), obstructive sleep apnea (P = 0.01), habitual snoring (P = 0.02), and elevated preoperative blood pressure (P = 0.03). Conclusion. CS in children is associated with higher indices of adiposity and increased rates of obesity-related comorbidities.

Clinical practice: diagnosis and treatment of childhood snoring

Obstructive sleep-disordered breathing in children is a relatively common problem, presenting in various ways, from primary snoring, without an apparent decrease in quality of life, to obstructive sleep apnea with cognitive, cardiac, and growth abnormalities. History, clinical examination, radiologic evaluations, sleep studies, and other diagnostic modalities are reviewed. Since application and interpretation of these methods are not consistent in studies of snoring, a consensus on optimal treatment options has not been established. Traditionally, adenotonsillectomy has long been the treatment of choice. Treatment failures or recurrences as well as the existence of causes and contributing factors other than adenotonsillar hypertrophy, like obesity, facial malformations, and Down syndrome, have changed the concept of adenotonsillectomy as the ultimate cure. Several other treatment options have been proposed on their own or in combination. Continuous positive airway pressure, anti-inflammatory medications, maxillofacial, and orthodontic treatments are reviewed suggesting the need of a multidisciplinary approach in some cases. Finally, at the end of the chapter, a diagnostic and treatment work up based on current evidence is proposed for otherwise normal children or children with specific conditions.