Alternatives to surgery in children with mild OSA

Precision medicine requires coordinated and integrated evidence-based combinatorial approaches so that diagnosis and treatment can be tailored to the individual patient. In this context, the treatment approach to mild obstructive sleep apnea (OSA) is fraught with substantial debate as to what is mild OSA, and as to what constitutes appropriate treatment. As such, it is necessary to first establish a proposed consensus of what criteria need to be employed to reach the diagnosis of mild OSA, and then examine the circumstances under which treatment is indicated, and if so, whether and when anti-inflammatory therapy (AIT), rapid maxillary expansion (RME), and/or myofunctional therapy (MFT) may be indicated.

Past, present, and future of sleep medicine research in Latin America

NONE

Sleep medicine is a relatively young field with exponential growth in development and research in the last decades. Parallel to the advances in the United States, Latin America also had its beginnings in sleep medicine housed in neuroscience laboratories. Since the very first Latin American meeting in 1985, and the first sleep society in 1993, sleep research has undergone significant development in subsequent years. From contributions in animal research that allowed understanding of the activity of the brain during sleep to the studies that improved our knowledge of sleep disorders in humans, Latin America has become a scientific hub for expansion of sleep research. In this article, we present a historical account of the development of sleep medicine in Latin America, the current state of education and the achievements in research throughout history, and the latest advances in the trending areas of sleep science and medicine. These findings were presented during World Sleep Society meeting in Vancouver in 2019 and complement the work on sleep societies and training published by Vizcarra-Escobar et al in their article "Sleep societies and sleep training programs in Latin America" (J Clin Sleep Med. 2020;16(6):983-988).

Perinatal antecedents of sleep disturbances in schoolchildren

STUDY OBJECTIVES

Prematurity has been associated with an increased risk for sleep apnea. However, sleep disturbances in children born preterm have not been extensively investigated. Considering that determinants of sleep may originate early in life, the potential impact of prematurity on sleep disturbances later in life could be important. To establish the role of prematurity on sleep disturbances in a cohort of schoolchildren that were born preterm and compare them with healthy controls.

METHODS

A cohort of 147 schoolchildren, 45 born at term (≥37 weeks) and 102 very preterm (<32 weeks), was recruited and evaluated at school age (5-9 years). The Pediatric Sleep Questionnaire (PSQ) and the Sleep Disturbance Scale for Children (SDSC) were used to assess sleep disturbances in different domains.

RESULTS

PSQ score was significantly higher in former preterm children (0.26 ± 0.18 vs. 0.18 ± 0.14 in controls; p = 0.004), and SDSC total score was also significantly different among groups (21.7 ± 11.6 vs. 14.1 ± 12.6; p < 0.001). Regression models showed significant mean differences in PSQ score, total SDSC score, and two SDSC subscale scores (i.e. sleep-wake transition disorders, sleep-breathing disorders, and sleep hyperhidrosis) even after adjustment for confounders. Maternal age and type of delivery were not significantly associated with total PSQ scores.

CONCLUSIONS

Sleep disturbances may originate early in life since children born preterm exhibit an increased risk for developing long-term sleep problems. These findings may have important implications for management of preterm children and for implementation of early interventions focused on optimizing sleep habits.

[Bad sleeping habits in infants: Risk factor for sudden infant death syndrome. Pilot study]

INTRODUCTION

The American Academy of Pediatrics recommends, through the implementation of the "Back to Sleep (BTS)" campaign, the supine sleeping position for infant sleeping since it prevents to prevent Sudden Infant Death Syndrome (SIDS).

OBJECTIVE

To describe the sleeping position of a group of infants and the risk factors associated with sudden infant death syndrome (SIDS).

SUBJECTS AND METHOD

Prospective pilot study, including infants < 45 days of life in well-child care visits at a medical center.

EXCLUSION CRITERIA

Preterm-born infant (gestational age < 37 weeks) and/or comorbidities (pulmonary, metabolic, cardiologic). A brief parental questionnaire was conducted regarding general demographic data and sleep habits. The questioner was based on the BISQ - Spanish version, due to the lack of validated instruments for infants < 3-month-old.

RESULTS

We included a sample of 100 infants between 16.78 ± 12.88 days old (57% girls). Mothers were the main information source (84%). 79% of the infants slept in supine position, 19% slept on their sides, and 2% in prone position. Regarding the place where the infants slept, 66% did in their crib in the parents' room and 31% slept in parents' bed. 74% of infants fell asleep while being fed. 28% of infants were exposed to passive smoking at home. 91% of parents were informed about safe sleep positions, reporting that pediatricians were the main source of information (54%). Conclu sion: We found a high percentage of infants < 45 days of life who slept in an unsafe position, and frequently co-sleep with their parents. Thus, it is important to implement local SIDS prevention campaigns to reinforce safe infant sleep.

Association of sleep spindle activity and sleepiness in children with sleep-disordered breathing

STUDY OBJECTIVES

The association of snoring and sleep-disordered breathing (SDB) with daytime sleepiness is well documented; however, the exact mechanisms, and especially the role of sleep microstructure that may account for this association remain incompletely understood. In a cohort of children with SDB, we aimed to compare sleep spindle activity between children with daytime sleepiness versus those without daytime sleepiness.

METHODS

Children with SDB who reported daytime sleepiness were recruited and compared with age- and sex-matched SDB controls. Polysomnographic recordings were analyzed evaluating sleep spindle activity. A statistical comparison was carried out in both groups to assess the association between sleepiness and sleep spindle activity.

RESULTS

Thirty-three children with SDB (mean age: 7.5 ± 1.7 years) were included, 10 with and 23 without daytime sleepiness. Spindle activity was lower in children with daytime sleepiness compared with those without; in stage N2, median (interquartile range) sleep spindle indexes were 77.5 (37.3) and 116.9 (71.2) (P = .015), respectively.

CONCLUSIONS

Spindles were significantly reduced in children with SDB and daytime sleepiness. The exact mechanisms of this association remain unknown and future research is needed in order to establish the exact role of sleep spindle activity on daytime symptoms in children with SDB.

Sleep quality in children with atopic dermatitis during flares and after treatment

BACKGROUND

Little is known on sleep quality of children with atopic dermtitis (AD) during flares and how treatment impacts their sleep. The purpose of this study is to evaluate variations in sleep quality of children with AD during flares and its response to intensified treatment.

MATERIAL AND METHODS

Prospective case-crossover study in 10 children with moderate-severe AD. At baseline, AD severity was assessed using SCORAD and patients were prescribed intensified AD therapy. All subjects were monitored by actigraphy during 14 days and returned for SCORAD assessment.

RESULTS

Subjects' age was 5.6 ± 5.3 years; 50% were female. Sleep duration was decreased in all subjects and awakenings were increased in 90%. Parental perception of sleep significantly differed from actigraphy results: parents estimated less sleep duration and less awakenings. Nocturnal sleep efficiency at baseline was reduced in 50%. After intensified treatment, median SCORAD decreased from 58.5 to 31.3 (p=0.005), with significant improvement in sleep loss and pruritus visual analogue scales. Despite improvement of SCORAD and parental perception of sleep loss and pruritus, objective sleep duration and efficiency measured by actigraphy did not vary significantly after intensified treatment. Change in SCORAD, sleep loss and pruritus scales did not correlate significantly with change in sleep duration, efficiency or other actigraphic sleep quality measurements.

CONCLUSIONS

Children with moderate-severe AD have sleep quality abnormalities, with decreased sleep duration, low sleep efficiency and increased awakenings. Improvement in AD severity upon intensified AD treatment was associated with improved parental perception of sleep loss, but not of objective sleep quality assessed by actigraphy.

Reduced sleep spindle activity in children with primary snoring

BACKGROUND

Habitually snoring children are at risk of manifesting disease-related problems even if their sleep studies are overall within normal limits.

STUDY OBJECTIVES

To compare sleep spindle activity in children with primary snoring and healthy controls.

METHODS

Sleep spindle activity including analysis of fast and slow spindles (ie, >13 Hz and <13 Hz, respectively) was evaluated in polysomnographic (PSG) recordings of 20 randomly selected children with primary snoring (PS; normal PSG recordings except for objective presence of snoring; 12 boys, mean age 6.5 ± 2.1 years), and 20 age- and gender-matched PSG-confirmed non-snoring controls.

RESULTS

PS children showed significantly lower spindle indices in all non-rapid eye movement (NREM) sleep stages (p < 0.05). In contrast, fast spindles were found in 40% (n = 8) children with PS and in 25% (n = 5) controls. Sleep spindle activity was particularly higher in NREM sleep stage 2 in controls compared PS (76% versus 43% of all marked sleep spindles events in NREM sleep stage 2, p < 0.001).

CONCLUSIONS

Children with PS exhibit significantly reduced spindle activity when compared to matched controls. Reduced sleep spindle activity may be an indicator of sleep disruption and, therefore, could be involved in the development of disease-related consequences in snoring children.

Association between air pollution and sleep disordered breathing in children

BACKGROUND AND OBJECTIVE

Similar to other respiratory diseases, sleep disordered breathing (SDB) may be exacerbated by air contaminants. Air pollution may have an impact on incidence and severity of SDB in children. The aims of this study were to examine potential associations between the exposure to different air pollutants and SDB symptoms in children.

METHODS

In this cross-sectional study, parents from first grade children of elementary schools throughout Chile were included. Data about clinical and family-related SDB risk factors, and the pediatric sleep questionnaire (PSQ) were obtained. Air pollution and meteorological data were obtained from the Chilean online air quality database.

RESULTS

A total of 564 children (44.9% males) aged (median) 6 years (5-9 year) were included. Prevalence of SDB based on PSQ was 17.7%. When examining air pollutants and conditions, only higher humidity (β = 0.005, 95%CI 0.001-0.009, P = 0.011) was significantly associated with higher PSQ scores after adjusting for demographic and household variables. Higher ozone (O₃ ) levels (OR = 1.693, 95%CI 1.409-2.035, P < 0.001), higher humidity (OR = 1.161, 95%CI 1.041-2.035, P = 0.008) and higher dioxide sulfur (SO₂ ) levels (OR = 1.16, 95%CI 1.07-1.94, P < 0.001]) were associated with increased odds of wheezing-related sleep disturbances after adjusting for confounders. Lower temperature was a significant predictor of snoring at least >3 nights/week, following adjustment (OR = 0.865, 95%CI 0.751-0.997, P < 0.05).

CONCLUSION

Sleep respiratory symptoms (wheezing and snoring) are significantly associated with air pollutants such as O₃ and SO₂ . In addition, meteorological conditions such as humidity and low temperatures may be also associated with SDB-related symptoms.

Preschoolers with recurrent wheezing have a high prevalence of sleep disordered breathing

Objective: Sleep-disordered breathing (SDB) is highly prevalent in school children with poorly-controlled asthma. However, this association has not been assessed in preschoolers with recurrent wheeze, nor in those at risk for asthma. We hypothesized that preschoolers with asthma risk (positive asthma predictive index [API]) have a higher prevalence of SDB and higher inflammatory biomarkers (blood-hsCRP and urinary-LTE4) levels than those with negative API.Method: Children 2 to 5 years of age with recurrent wheezing were classified as positive or negative API. SDB was determined by the pediatric sleep questionnaire (PSQ) and its subscale (PSQSub6). Demographic characteristics, spirometry, blood hsCRP and urinary LTE4 were assessed.Results: We enrolled 101 preschoolers: 70 completed all measurements, 55.4% were males, mean age 4.07 ± 0.87 years, 45% overweight or obese, 70% had positive API, 87.5% had rhinitis. The prevalence of SDB measured by PSQ was 40.8% and by PSQSub6 was 29.6%. However, the proportion of SDB was similar between positive and negative API groups. The hsCRP (mean ± SD) was higher in the positive than in negative API (3.58 ± 0.58 and 1.32 ± 0.36 mg/L, p = 0.69, respectively); moreover, no differences in urinary LTE4 were found between groups. No correlation of PSQ (+) or PSQSub6 (+) with hsCRP and uLTE4 was found. However, preschoolers with positive API had significantly more post-bronchodilator percentage change in FEF25-75 than negative API (24.14 ± 28.1 vs. 4.13 ± 21.8, respectively, p = 0.01).Conclusions: In preschoolers with recurrent wheezing, we should be investigating for the coexistence of SDB, using early screening methods for detecting those conditions.

[Prevalence and risk factors for sleep-disordered breathing in chilean schoolchildren]

OBJECTIVES

To describe the prevalence of sleep-disordered breathing (SDB) in Chilean schoolchil dren and study associated risk factors.

PATIENTS AND METHOD

We carried out a transversal and des criptive study. Questionnaires were sent to the parents of children attending first year of elementary school in the Metropolitan Region (Santiago), the Biobío Region (Concepción, Chillán, Yumbel) and the Magallanes Region (Porvenir and Puerto Natales). Anthropometric data, school performan ce, household characteristics, indoor pollutants, medical history, and current symptoms of asthma, allergic rhinitis, and atopic dermatitis were recorded. The nutritional status was determined accor ding to z-BMI. A pediatric sleep questionnaire validated in Spanish (PSQ) was applied.

RESULTS

564 questionnaires were analyzed, the median age was six years (range 5 to 9), 44.9% male. The SDB prevalence was 17.7% (n = 100): 6% in Vitacura (Metropolitan Region), 28.7% in Chillán (Biobío Region), and 36.4% in Puerto Natales (Magallanes Region) (p = 0.001). The group with SDB had a higher proportion of men (54.5 vs 42.8%, p = 0.033), lower academic performance (overall grade point average 6.36 ± 0.48 vs 6.56 ± 0.34, p = 0.001), lower maternal higher education (44.4% vs 69.9%, p = 0.001), and higher exposure to indoor pollutants than those without SDB. After the multivariate analysis, symptoms of rhinitis in the last 12 months (OR 4.79, 95% CI 2.20-10.43) and lower maternal educational level (OR 3.51; 95% CI 1.53-8.02) remained as predictors of SDB. Con clusions: Chilean schoolchildren have a high prevalence of SDB with demographic differences. It was associated with social risk factors, more specific factors of lung damage, and worse sleep quality and quantity.

Influence of age and gender on reference values for common pediatric sleep questionnaires: Results from a community-based study

OBJECTIVES

Sleep problems are often assessed using questionnaires, but it is unclear whether the responses given are influenced by age and gender. We addressed this question in several widely used pediatric sleep questionnaires and provide age-dependent percentile curves.

METHODS

Data of a community-based study in schoolchildren were reanalyzed (N = 163, 50% males, age 6-17 years). Children and their parents completed the Sleep-Related Breathing Disorder Scale (SRBDS) of the Pediatric Sleep Questionnaire, the Sleep Disturbance Scale for Children (SDSC), the Sleep Self Report (SSR) of the Children's Sleep Habits Questionnaire in a long and short version, the Epworth Sleepiness Scale in a parent- (ESSp) and self-report version for children (ESSc), and the Pediatric Daytime Sleepiness Scale (PDSS). Linear and quantile regression analysis was used to i) assess the influence of age and gender on scores of questionnaire scales/subscales, ii) to calculate age- and gender-appropriate reference values and iii) to provide age-depending percentile curves.

RESULTS

Only the PDSS showed relevant gender differences (β [95th confidence interval] = 0.155 [0.000; 0.270], p-value = 0.04, reference category: male), while the following subscales were all age dependent: SRBDS-somnolence and behavioral subscales, SDSC-somnolence subscale, SSR-long and short version; ESSp and ESSc, as well as the PDSS.

CONCLUSIONS

Age and gender should be taken into account for research purposes and individual patient assessments regarding sleep problems. Preliminary age- and gender-appropriate reference values and percentile curves are now available and may be used by researchers and clinicians.

Nocturnal Oximetry-based Evaluation of Habitually Snoring Children

RATIONALE

The vast majority of children around the world undergoing adenotonsillectomy for obstructive sleep apnea-hypopnea syndrome (OSA) are not objectively diagnosed by nocturnal polysomnography because of access availability and cost issues. Automated analysis of nocturnal oximetry (nSp_O2), which is readily and globally available, could potentially provide a reliable and convenient diagnostic approach for pediatric OSA.

METHODS

Deidentified nSp_O2 recordings from a total of 4,191 children originating from 13 pediatric sleep laboratories around the world were prospectively evaluated after developing and validating an automated neural network algorithm using an initial set of single-channel nSp_O2 recordings from 589 patients referred for suspected OSA.

MEASUREMENTS AND MAIN RESULTS

The automatically estimated apnea-hypopnea index (AHI) showed high agreement with AHI from conventional polysomnography (intraclass correlation coefficient, 0.785) when tested in 3,602 additional subjects. Further assessment on the widely used AHI cutoff points of 1, 5, and 10 events/h revealed an incremental diagnostic ability (75.2, 81.7, and 90.2% accuracy; 0.788, 0.854, and 0.913 area under the receiver operating characteristic curve, respectively).

CONCLUSIONS

Neural network-based automated analyses of nSp_O2 recordings provide accurate identification of OSA severity among habitually snoring children with a high pretest probability of OSA. Thus, nocturnal oximetry may enable a simple and effective diagnostic alternative to nocturnal polysomnography, leading to more timely interventions and potentially improved outcomes.

Relation between asthma and sleep disordered breathing in children: is the association causal?

Over the last few decades, asthma and sleep disordered breathing (SDB) in children have experienced similar increases in prevalence, and have both been shown to have airway inflammation, leading investigators to postulate an association between asthma and SDB. However, whether this relationship is causal or not needs to be proven. In this manuscript, we use the most widely accepted epidemiologic criteria for causality, the Bradford Hill criteria, to test step-by-step whether the relation between asthma and SBD in children is causal or not. We found studies supporting 8 of the 9 criteria (strength, consistency, specificity, biological gradient, coherence and biological plausibility, experiment, and analogy) for association between asthma and SDB. However, we did not find any study showing temporality or directionality between asthma and SDB. Therefore, establishing a causal association between asthma and SDB is not yet possible.

Long-term effects of adenotonsillectomy in children with obstructive sleep apnoea: protocol for a systematic review

INTRODUCTION

Adenotonsillar hypertrophy is the most important anatomical factor associated with obstructive sleep apnoea syndrome in children. The American Academy of Pediatrics recommends adenotonsillectomy as the first line of treatment. AT can reduce the apnoea hypopnoea index; however, its effect on long-term outcomes remains unclear.

METHODS AND ANALYSIS

We will conduct an electronic search for randomised controlled trials in MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE. We will also identify literature by reviewing the references included in the selected studies and relevant reviews, screening through important scientific conferences, and searching for ongoing trials in the WHO International Clinical Trials Registry Platform. Two researchers will independently undertake selection of studies, data extraction and assessment of the risk of bias of included studies. We will estimate pooled risk ratios for dichotomous data, and mean difference or standardised mean difference for continuous outcomes. A random-effects model will be used for meta-analyses. Data synthesis and other analyses will be conducted using RevMan V.5.3 software.

ETHICS AND DISSEMINATION

No ethics approval is considered necessary. The results of this study will be disseminated via peer-reviewed publications and social networks.

TRIAL REGISTRATION NUMBER

CRD42015022102.

Sleep-disordered breathing in children with asthma: a systematic review on the impact of treatment

Background

The objective was to perform a systematic review in order to describe the relationship between asthma and sleep-disordered breathing (SDB) in children, especially regarding the impact of treatment and management.

Methods

We performed an electronic search in MEDLINE, EMBASE, and LILACS database. Study inclusion criteria were the following: 1) studies that examined the relationship between asthma/wheezing and SDB/obstructive sleep apnea (OSA); and 2) studies conducted in children <18 years of age. Primary outcomes were the prevalence of asthma and SDB, the tests used for diagnosis, and the influence of their treatment and management.

Results

One thousand and twenty studies were identified, among which 32 were selected (n=143,343 children; 51% males; age [mean ± standard deviation] 8.4±2.5 years). Most studies (n=26) diagnosed SDB using questionnaires or clinical history. Nine studies performed a sleep study for diagnosing OSA. The diagnosis of asthma was based on clinical history (n=16), previous medical diagnosis (n=4), questionnaires (n=12), and spirometry (n=5). Children with asthma were more likely to develop habitual snoring and OSA, and children with SDB were more likely to develop asthma. Moreover, asthma was associated with more severe OSA, and the presence of SDB was associated with severe asthma. Treatment of SDB with adenotonsillectomy was associated with significant asthma improvement.

Conclusion

The relationship between asthma and SDB appears to be bidirectional, and adenotonsillectomy appears to improve asthma control. Future trials on how asthma treatment could impact on SDB are needed.

Sleep-Disordered Breathing in Adolescents and Younger Adults: A Representative Population-Based Survey in Chile

BACKGROUND

Prevalence and potential risk contributors of sleep-disordered breathing (SDB) in adolescents and younger adults remain unclear. We hypothesized that SDB prevalence in younger Hispanic adults is higher than the limited evidence indicates.

METHODS

This is a population-based study of Hispanic subjects surveyed as part of the Chilean National Health Survey database. For this study, only subjects aged 15 to 40 years were included. Sleep and demographic questionnaires were used to assess SDB prevalence and its risk factors. Anthropometric measurements were performed in each subject. Prevalence was calculated for each SDB-related symptom. A regression model was constructed to investigate demographic risk factors of SDB.

RESULTS

A total of 2,147 subjects were included. Mean age (± SD) was 27.2 ± 7.2 years, n = 899 (42%) were men. Habitual snoring was highly prevalent, with an average of 53.8% in men and 38.3% in women. Snoring, witnessed apneas, and daytime somnolence increased continuously with age, with an abnormal SDB questionnaire score detected in 2.5%. Reported sleep duration was 7.61 ± 1.67 hours during weekdays and 8.27 ± 2.11 hours during weekends. Snoring frequency was significantly higher in men than women at nearly all age groups, and an adjusted regression model (OR [95% CI]) identified male sex (2 [1.6-2.5]; P < .001) and BMI (1.08 [1.03-1.12]; P < .001) as independent risk factors for snoring.

CONCLUSION

The risk of SDB is highly prevalent in younger adults, even in females, and increases with age and BMI. The high prevalence and low awareness justify active screening and treatment of SDB in this population.

Elevated IL-3 and IL-12p40 levels in the lower airway of infants with RSV-induced bronchiolitis correlate with recurrent wheezing

Respiratory Syncytial Virus (RSV) is the first cause of hospitalization due to bronchiolitis in infants. RSV bronchiolitis has been linked to asthma and recurrent wheezing, however the mechanisms behind this association have not been elucidated. Here, we evaluated the cytokine and chemokine profiles in the airways in infants with RSV bronchiolitis. Nasopharyngeal Aspirates (NPA) and Bronchoalveolar Lavage Fluids (BALF) from infants hospitalized due to RSV bronchiolitis and healthy controls were analyzed for cytokine and chemokine production. We observed elevated levels of Th2 cytokines (IL-3, IL-4, IL-10 and IL-13), pro-inflammatory cytokines and chemokines (IL-1β, IL-6, TNF-β, MCP-1/CCL2, MIP-1α/CCL3 and IL-8/CXCL8) in BALF from infants with RSV bronchiolitis, as compared to controls. We found a direct correlation of IL-3 and IL-12p40 levels with the development of recurrent wheezing later in life. These results suggest that IL-3 and IL-12p40 could be considered as molecular predictors for recurrent wheezing due to RSV infection.

Predicting poor school performance in children suspected for sleep-disordered breathing

OBJECTIVE

Habitually snoring children are at a greater risk of poor school performance (PSP). We investigated the ability of conventional sleep-disordered breathing (SDB) measures for predicting PSP in habitually snoring children.

METHODS

The dataset of Hannover Study on Sleep Apnea in Childhood (HASSAC), a large community-based study in primary school children, was retrospectively analyzed. All habitual snorers were included. Based on their grades, children were grouped into good and poor school performers. SDB measures obtained by a parental questionnaire, a home pulse oximetry, and a home polysomnography were evaluated for their accuracy in predicting poor school performance by calculating receiver operating characteristic curves and area under this curve (AUC). The most predictive single factors were identified and entered into a prediction model.

RESULTS

Of 114 habitual snorers (mean age 9.6 years, 51 boys), 59 had PSP. All investigated SDB measures showed low accuracy (ie, AUC <0.8). The highest AUC observed was 0.686 for a questionnaire score, 0.565 for an oximetry factor, and 0.624 for a polysomnography factor. Of 20 single significant predictors for PSP, five were selected for inclusion into a prediction model. The model reached an unadjusted AUC of 0.826 and an adjusted AUC of 0.851.

CONCLUSIONS

Conventional SDB measures obtained with questionnaire, oximetry, or polysomnography may not be sufficiently predictive of PSP in children suspected for SDB. However, combining factors in a clinical prediction model may improve prediction. Results of such a model may be used to assess the risk of developing neurocognitive impairment and to decide whether a child suspected for SDB might benefit from treatment.

Under-recognition of alarms in a neonatal intensive care unit

BACKGROUND

Treatment decisions for apnoea of prematurity (AOP) are usually based on nursing staff's documentation of pulse oximeter and heart rate alarms.

OBJECTIVE

In an observational study, to compare the accuracy of oxygen saturation (SpO2) and heart rate alarm documentation, and the resulting interventions by nursing staff, with objectively registered events using polysomnographic and video recording.

METHODS

Data on 21 preterm neonates (12 male) with a diagnosis of AOP were analysed. Nursing staff's desaturation (<80% SpO2) and bradycardia (<80/min) alarm documentation was compared with events registered objectively using simultaneous polysomnography. Interventions by nursing staff were evaluated using 24 h video recordings and compared with their chart documentation. Nursing staff had been unaware that the polygraphic and video recordings would be used subsequently for this purpose.

RESULTS

Median (minimum-maximum) postnatal age was 15.5 (3-65) days. 968 SpO2 desaturation events and  415 bradycardias were documented by polysomnography. Nursing staff registered 23% of these desaturation events, and 60% of bradycardias (n=223, and n=133, respectively). Intraclass correlation coefficient (95% CI) between objectively measured desaturation events and those documented by nursing staff was 0.14 (-0.31 to 0.53); and for bradycardias 0.51 (0.11 to 0.78). 225 nursing staff interventions were registered on video, of which 87 (39%) were documented.

CONCLUSIONS

The alarm documentation by neonatal intensive care unit staff does not appear to be sufficiently accurate to permit further understanding and treatment of AOP. It is unclear if the alarms missed here would have led to clinical consequences had they been documented.

Subjective and objective daytime sleepiness in schoolchildren and adolescents: results of a community-based study

OBJECTIVES

We aimed to assess subjective and objective sleepiness in schoolchildren and adolescents by using questionnaires and the Pupillographic Sleepiness Test (PST).

METHODS

An observational, cross-sectional, community-based study was performed. Participants were recruited and balanced by age and gender from schools using stratified random sampling. Sleep problems and subjective sleepiness were assessed using parent- and self-reported questionnaires. Objective sleepiness was assessed in schools under standardized conditions by using the PST and by calculating the natural logarithm of the pupillary unrest index (lnPUI).

RESULTS

In total 163 children (82 boys; age range, 6.6-17.8 years) were enrolled. Age and sleep problems were predictors of subjective sleepiness. Nine PST recordings (5.5%) were excluded due to artifacts (feasibility, 94%). Gender, sleep problems, and sleep duration were predictors of objective sleepiness. Compared to adults (age range, 20-60 years), the lnPUI was higher in children (mean±standard deviation [SD], 1.5±0.4 vs. 2.0±0.4; P<.001) and showed significant gender differences. There was no agreement between measures of subjective sleepiness and the lnPUI (r<0.3). After excluding children with sleep problems, preliminary reference values (mean±SD) for the lnPUI were 2.01±0.43 for boys and 1.93±0.43 for girls, respectively.

CONCLUSIONS

The PST is a feasible method in schoolchildren and adolescents. Sleep problems are predictors of both subjective and objective sleepiness; there is no agreement between the latter. Results of the PST are influenced by sleep duration and specific pediatric gender-stratified reference values are definitively needed.

Treatment of obstructive sleep apnea in infants with trisomy 21 using oral appliances

Objective : To perform a retrospective study to evaluate the effect of oral appliances, aimed at increasing the pharyngeal space, on obstructive sleep apnea (OSA) in infants with trisomy 21 (TS21). Design and Setting : Retrospective study in a tertiary referral center. Intervention : We analyzed data from 51 consecutive infants (mean age, 2.7 months) who underwent polysomnography (PSG) and were offered our treatment concept. Primary study variable was the mixed-obstructive apnea index (MOAI); OSA was defined as a MOAI ≥ 1. Results : Twenty-seven infants (53%) had OSA. Their median MOAI improved from 2.3 (1 to 13) to 0 (0 to 0.2; P < .05). Seven of these infants were treated with an appliance that included some type of velar extension to move the tongue base forward. Of the 24 infants without OSA at admission, follow-up PSG results were available for 13. Three infants from this group had developed OSA by the time of a repeat PSG. Conclusion : In patients with TS21, OSA may already develop in infancy. Early treatment may improve OSA. Oral appliances with some type of velar extension may be considered as an alternative to other treatment procedures.

Prevalence of habitual snoring and associated neurocognitive consequences among Chilean school aged children

OBJECTIVE

To assess the prevalence of habitual snoring and symptoms of sleep disordered breathing (SDB) and their association with neurocognitive consequences in school-aged children.

METHODS

A population based cross-sectional study was carried out in a low income urban setting in Santiago, Chile. A parental SDB-questionnaire was adapted and applied to a community based sample of children aged 7-17 years. Hyperactive/inattentive behavior was assessed using the Conner's rating scale. School grades were obtained and the associations between questionnaire's results and risks for poor academic performance were investigated.

RESULTS

Of 700 questionnaires sent; 523 (75%) returned correctly filled in. Mean age of the subjects was 11.0±2.5 years; 246 (47%) were boys. Prevalence of habitual snoring was 18%. The Conner's rating scale correlated significantly with the SDB-questionnaire's score (r(s)=0.47). Children with habitual snoring showed significantly lower (mean±standard deviation) school grades in Spanish language (5.6±1.2 vs. 5.4±0.9, p-value=0.04) and general average school grades (5.9±0.6 vs. 5.7±0.6, p-value=0.05). After adjustment for possible confounding factors, children with an abnormal SDB questionnaire score had significantly higher risk for poor academic performance in Spanish language, odds ratio (95% confidence interval): 1.82 (1.01-3.27) and physical education 1.85 (1.05-3.26).

DISCUSSION

There was a high prevalence of habitual snoring and symptoms of SDB in this survey of Chilean children, being among the highest reported. The presence of habitual snoring and an abnormal SDB questionnaire were associated with poor academic performance and hyperactive behavior.

Urinary leukotriene excretion profile in children with exercise-induced asthma compared with controls: a preliminary study

BACKGROUND

Leukotrienes are among the most important mediators associated with inflammatory responses in patients with exercise induced asthma (EIA). The aim of this study was to investigate the impact of exercise on the urinary leukotriene profile. Hence, we compared post exercise changes of urinary leukotriene E4 (LTE4) concentration between children with EIA and healthy controls.

METHODS

Ten children with EIA and 15 controls were enrolled. Both groups underwent a standardised exercise challenge test (ECT). LTE4 concentration was measured in urine samples obtained pre and post ECT, using enzyme immunoassay and adjusted by urinary creatinine concentrations.

RESULTS

Median (minimum-maximum) pre ECT concentration of LTE4 was 17.82 (7.58-90.23 pg/ml) in EIA and 17.24 (4.64-64.02 pg/ml) in controls, p=0.86. LTE4 concentration post ECT were 23.37 (4.02-93.00 pg/ml) in EIA and 11.74 (0.13-25.09 pg/ml) in controls, p=0.02. Changes of LTE4 concentration post ECT were 2.54 (-31.98 to 43.31 pg/ml) in cases and -13.53 (-46.00 to 11.02 pg/ml) in controls, p=0.03. There was no significant correlation between basal predicted FEV(1) [%] and changes in LTE4 concentration in cases (i.e., r(s)=0.14) nor controls (i.e., r(s)=0.12). There was a tendency towards more pronounced changes in LTE4 concentration post ECT in children with moderate/mild persistent asthma compared to those with mild but intermittent asthma.

CONCLUSIONS

Children with EIA had significantly higher changes of urinary LTE4 concentrations post ECT compared to healthy controls. Urinary measurement of LTE4 may be an interesting and non-invasive option to assess control of EIA in children.

Myth: gastroesophageal reflux is a pathological entity in the preterm infant

There is concern about possible consequences of gastroesophageal reflux (GER) in preterm infants. GER is perceived to be a frequent condition in these infants, often causing an exhaustive investigation and expensive therapy. We review current evidence for and against an association between GER and apnea, failure to thrive, wheezing and respiratory diseases. Although there are some limitations to the methodologies currently used for detecting GER, there is clearly a lack of unequivocal evidence supporting a causal relationship between GER and its assumed consequences, particularly in preterm infants. Despite physiologic data that stimulation of laryngeal efferents by GER may induce apnea, there is little evidence for a causal relationship between GER and apnea. Studies on preterm infants with failure to thrive have also not demonstrated an association between the latter and GER in most cases, and there is equally little evidence for a casual relationship with respiratory problems. Therefore, we believe that GER in preterm infants is only rarely associated with serious consequences and existing evidence does not support the widespread use of anti-reflux medications for treatment of these signs in this age group. An improvement of methods to identify the few preterm infants at risk for developing serious consequences of GER is urgently needed.

Reference values for pulse oximetry recordings in healthy term neonates during their first 5 days of life

OBJECTIVE

To determine reference values for pulse oximeter saturation (SpO(2)) variables and desaturation event indices in healthy term neonates during their first 5 days of life, and to compare two definitions for the identification of desaturation events.

DESIGN

Observational study (case series). Setting Maternity ward, Department of Neonatology, University Children's Hospital, Tuebingen, Germany.

PATIENTS

209 healthy term neonates (50% boys), median (minimum-maximum) age 2 (0-5) days.

MAIN OUTCOME MEASURES

SpO(2) variables (eg, median SpO(2)) and desaturation events obtained by motion-resistant pulse oximetry (VitaGuard 310; Getemed, incorporating Masimo SET). Desaturation events were identified based either on a good signal quality (SIQ) provided by the device or on the combination of a good SIQ and an undisturbed pulse waveform (SIQ+PW). Desaturation event indices were calculated as desaturation events divided by hour of artefact-free recording time.

RESULTS

The mean (SD) of the obtained median SpO(2) was 97.3% (1.4%). There were 36 (17%) subjects with desaturation events to <80% SpO(2) based on SIQ, and 26 (12%) based on SIQ+PW. Median desaturation event rate to <80% SpO(2)/h (75th centile; 95th centile; maximum) was 0 (0; 0.6; 2.3) based on SIQ, and 0 (0; 0.4; 1.7) based on SIQ+PW.

CONCLUSIONS

Desaturation events to <80% SpO(2) were rare in our sample of healthy term neonates during their first 5 days of life. Analysis of SIQ alone could be a quick and simple alternative to traditional analysis of PW. The presented reference values may be used for clinical decision making.

Detection of respiratory events using pulse rate in children with and without obstructive sleep apnea

Oximetry is a simple but insensitive diagnostic test modality for obstructive sleep apnea (OSA) in children. Sensitivity for OSA may be enhanced if pulse rate is analyzed in conjunction with oxygen saturation. We analyzed 25 ambulatory polysomnographic recordings obtained from children with (n = 5) and without (n = 20) OSA. To assess sensitivity and specificity, pulse rate increases were determined during respiratory (i.e., apneas and hypopneas; n = 965) and non-respiratory sleep events (i.e., body movements; n = 1,197), and contrasted to baseline fluctuations (n = 209). The absolute pulse rate increase (APRI) was the parameter that differentiated best between baseline fluctuations and sleep events (area under the receiver operating characteristic curve [AUC]: 0.88). At a cutoff value of 12 beats per minute, APRI showed a sensitivity and specificity for detecting sleep events of 0.81 each. However, AUC was lower for the differentiation between respiratory and non-respiratory sleep events (0.77) and between central and obstructive respiratory events (0.68). In OSA cases, influencing factors for APRI following respiratory events were age, occurrence of a body movement, and severity of concomitant oxygen desaturation. We conclude that pulse rate analysis may be used to detect respiratory events in oximetry recordings in children.

Risk factors and consequences of excessive autonomic activation during sleep in children

PURPOSE

The aim of this study was to assess risk factors for excessive autonomic activation during sleep (EAAS) and its association with sleep problems, impaired behavior, and poor academic performance in primary school children.

METHODS

Data from a community-based study on 997 primary school children were used. Based on nocturnal home pulse oximetry, autonomic activation during sleep was defined as a pulse rate increase by more than 20%. Children with ≥35.9 autonomic activations per hour (i.e., ≥ the 95(th) centile) were classified as suffering from EAAS and compared with controls. Sleep problems, impaired behavior, and academic performance were assessed by parental questionnaires and analysis of school reports.

RESULTS

According to the above-mentioned definition, EAAS was diagnosed in 52 children (67% male). Risk factors for EAAS were male gender (odds ratio [95% confidence interval]: 2.06 [1.14-3.72]) and presence of symptoms of sleep-disordered breathing (3.48 [1.29-9.43]). Children with EAAS had a higher prevalence of hyperactive behavior (39.2% vs. 26.0%; p = 0.05) and enuresis (5.8% vs. 0.8%; p = 0.017) but not of poor academic performance. The association with hyperactive behavior was confirmed in a subsample (n = 119) using the Strengths and Difficulties Questionnaire. Mean (SD) score of the hyperactive-inattentive scale was 4.5 (2.8) for EAAS and 3.4 (2.7) for non-EAAS (p = 0.04).

CONCLUSION

EAAS may be a marker of sleep disruption in children and may predict the occurrence of enuresis and hyperactive behavior.

Population prevalence of obstructive sleep apnoea in a community of German third graders

We aimed to estimate the population prevalence of obstructive sleep apnoea (OSA) in an urban community of German third graders (age range 7.3-12.4 yrs) and the diagnostic test accuracy of two OSA screening methods. Using a cross-sectional study design with a multi-stage sampling strategy, 27 out of 59 primary schools within the city limits of Hanover, Germany, were selected. 1,144 third graders were screened for symptoms and signs of OSA using questionnaires and nocturnal home pulse oximetry. 183 children underwent abbreviated nocturnal home polysomnography (OSA definition: apnoea/hypopnoea index ≥1) and 22 were diagnosed to suffer from OSA. In general, sensitivity for both screening methods was low (<0.6), while specificity was moderately high (mostly >0.7). Independent predictors for OSA were body mass index, history of allergy, a composite questionnaire score, and two oximetry-based criteria. Based on these variables and logistic regression, a prediction model (accuracy; 95% confidence interval: 0.86; 0.71-0.94) was constructed and applied to children who had not successfully undergone polysomnography. This resulted in nine additional OSA cases and an overall design-adjusted population prevalence (95% confidence interval) of 2.8% (1.5-4.1%). Clinical and oximetry findings may be helpful for screening and predicting OSA in primary school children.