Obstructive Sleep Apnea Syndrome In Children Research Articles

Application of desaturation index in post-surgery follow-up in children with obstructive sleep apnea syndrome.

Adenotonsillectomy is recommended for children who need surgery for obstructive sleep apnea syndrome (OSAS). Overnight, polysomnography (PSG) is suggested for post-surgery follow-up, but this diagnostic technique is time consuming and inconvenient. Desaturation index (DI) has been reported as a good tool for predicting both the presence and severity of OSAS in children. The purpose of this study was to determine the usefulness of the DI for post-surgery follow-up of children with OSAS. This retrospective study enrolled 42 children, aged 3-12years, who were snorers diagnosed with OSAS by overnight PSG and who underwent an adenotonsillectomy. Pre- and postoperative PSG parameters, nocturnal pulse oximetry data, and modified Epworth sleepiness scale scores were assessed. Previously determined cut-off DI values (2.05, 3.50, and 4.15 for mild, moderate, and severe OSAS, respectively) were used to predict residual OSAS. Of the 42 children, obvious improvements were observed in apnea-hypopnea index (AHI, decreased 45.5%), arousal index (decreased 30.5%), DI (decreased 40.4%), and snore index (decreased 100.3%) compared with the preoperative measurements. Among these objective PSG measures, DI had the strongest correlation with AHI both pre- and post-surgeries (r=0.947 and r=0.954, respectively; p all <0.001). The DI change, before and after surgery, also had the strongest positive correlation to the AHI change (r=0.482 and p=0.001). Using the previously determined DI cut-off values to predict postoperative residual OSAS, there was a good positive predictive value (92.6%) for mild residual OSAS and a good negative predictive value for moderate and severe residual OSAS (85.2 and 89.7%, respectively). These findings suggest that DI, as determined using a nocturnal pulse oximeter, may be an alternative tool for postoperative evaluation and follow-up of children with OSAS.

Correlates of Pediatric CPAP Adherence.

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence. A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test. Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex. Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Effect of Sleep State and Position on Obstructive Respiratory Events Distribution in Adolescent Children.

This study aimed to examine the effect of sleep state (rapid eye movement [REM] versus non-rapid eye movement [NREM]) and position (supine versus non-supine position) on obstructive respiratory events distribution in adolescent population (ages 12 to 18 y). This was a retrospective study that included 150 subjects between the ages of 12 to 18 y with an apnea-hypopnea index (AHI) > 1/h. Subjects using REM sleep-suppressant medications and subjects with history of genetic anomalies or craniofacial syndromes were excluded. The median age was 14 y with interquartile range (IQR) of 13 to 16 y, 56% of patients were males and the median body mass index (BMI) z-score was 2.35 (IQR: 1.71-2.59) with 77.3% of patients fulfilling obesity criteria. Respiratory obstructive events were more common in REM sleep. The median REM obstructive AHI (OAHI) was 8.9 events per hour (IQR: 2.74-22.8), whereas the median NREM OAHI was 3.2 events per hour (IQR: 1.44-8.29; p < 0.001). African American adolescents had more REM obstructive events with median REM OAHI of 13.2 events per hour (IQR: 4.88-30.6), which was significantly higher than median REM OAHI of 4.94 (IQR: 2.05-11.36; p = 0.004) in white adolescents. Obstructive events were more common in supine position with higher median supine OAHI of 6.55 (IQR: 4-17.73) when compared to median non-supine OAHI of 2.94 (IQR: 1-6.54; p < 0.001). This study shows that sleep related obstructive respiratory events in the adolescents (12 to 18 y of age) occur predominantly in REM sleep and in supine position.

Tratamiento quirúrgico del síndrome de apnea obstructiva del sueño infantil: comparación entre adenoamigdalectomía extracapsular con bisturí frío y reducción mediante radiofrecuencia bipolar

Introduction and objectiveAdenotonsillectomy for treatment of childhood obstructive sleep apnoea is effective. The uncomfortable postoperative period and possible complications have significantly increased the use of partial techniques, seeking to improve these aspects while achieving the same results in resolving sleep apnoea.The aim was to present the experience with 2 consecutive groups of patients, comparing total tonsillectomy to bipolar radiofrequency ablation (RFA). MethodA group of 96 children that underwent total tonsilloadenoidectomy using cold dissection were compared to another group of 101 children that underwent RFA. In all cases, polysomnography was performed before and 1 year after surgery. The percentage of cases with persistent disease (apnea-hypopnea index ≥ 3) and the improvement of clinical symptoms at one year were evaluated. The percentages of surgical and anaesthetic complications in both groups were also compared. ResultThe persistence of the syndrome was comparable in both groups: 25% in the cold dissection and 22.77% in the radiofrequency ablation group. Anaesthetic complications (5% in the group where cold dissection was used and 4.2% in the radiofrequency ablation group) and postoperative bleeding rates were very low and statistically comparable with both techniques. ConclusionIn the treatment of childhood obstructive sleep apnoea syndrome, both extracapsular surgery using cold scalpel and bipolar radiofrequency tunnelling techniques are safe. Likewise, results as to resolution of the syndrome show no statistically significant differences.

Performance characteristics of the French version of the severity hierarchy score for paediatric sleep apnoea screening in clinical settings

BackgroundPaediatric obstructive sleep apnoea syndrome (OSAS) is a highly prevalent condition carrying increased risk for impaired cognitive and cardiovascular function. The standard diagnosis consists of full-night polysomnography (PSG), but limited access to PSG leads to substantial under-diagnosis. The use of a validated and simple diagnostic screening tool to predict OSAS could prioritise night sleep recordings in children at risk of OSAS, and help in clinical decision-making. ObjectiveThis study aimed to prospectively assess the performance of the French version of the severity hierarchy score (SHS) in paediatric OSAS. This score consists of a discriminative subset of six respiratory items, and has already been validated in English for screening OSAS in the general paediatric population. MethodsA total of 96 children (mean age 7.1 ± 2.4 years; BMI z-score: −0.03 ± 1.50) were recruited; they had been were referred to two academic sleep centres in France for the putative diagnosis of sleep-disordered breathing. The parents completed the SHS questionnaire prior to PSG. Sensitivity and specificity of the SHS for detecting moderate OSAS, defined by an apnoea–hypopnoea index (AHI) of ≥5/hours of total sleep time (TST), were assessed, and ROC analysis was performed. ResultsAn SHS score of >2.75 exhibited an 82% sensitivity, 81% specificity, and 92% negative predictive value for detecting an AHI of ≥5/hour TST in the cohort. ConclusionThe French version of the SHS emerged as favourably suited for the screening for OSAS in children.

Critères diagnostiques du syndrome d’apnées obstructives du sommeil

The prevalence of obstructive sleep apnea syndrome (OSAS) is 1–4 % in school-aged children. Adenotonsillar hypertrophy is the most common etiology of OSAS in children. Other causes are obesity; facial or skeletal malformations; and neuromuscular, respiratory, or metabolic diseases. OSAS has been associated with sleep quality disturbance (frequent arousals) and nocturnal gas exchange abnormalities (hypoxemia and sometimes hypercapnia), which can both result in negative health outcomes. The analysis of clinical symptoms and physical examination cannot always distinguish between children with primary snoring and children with OSAS. However, the association of at least one sign of nocturnal upper airway obstruction with other diurnal or nocturnal symptoms can be sufficient to establish OSAS diagnosis in a child more than 3 years of age with clear enlarged tonsils but who is otherwise healthy. In all other cases, polysomnography (the gold standard for the diagnosis of sleep-disordered breathing) must be performed either to declare the diagnosis when clinical assessment is not conclusive or when risk factors are present, or to follow up children with an associated health condition or initial severe OSAS. The equipment used to record sleep and the interpretation criteria are all pediatric-specific. Other methods, such as respiratory polygraphy, are simpler to implement, but further studies are warranted to validate the interpretation criteria of these methods in children. However, in centers with experienced personnel, polygraphy can be used in place of polysomnography. In all cases, the analysis of sleep traces must be manual and performed by personnel under the supervision of medical staff trained to interpret pediatric sleep studies.

Diagnosis and Treatment of Obstructive Sleep Apnea Syndrome in Children.

Sleep is important for children pertaining to their physical and mental growth. Obstructive sleep apnea syndrome (OSAS) in children has been shown to have different effects as compared to OSAS in adults, including deficits in cognition and neuropsychological functions, hyperactivity, ADHD, behavior problems, aggressive behavior, learning problems and nocturnal enuresis. Hypertrophy of the adenoids and tonsils is a major cause of OSAS in children; therefore, adenotonsillectomy may decrease the effects of OSAS pertaining to physical and mental growth. It is important to accurately diagnose and appropriately treat OSAS in children to prevent OSAS in their adulthood.

Cerebral Blood Flow Response to Hypercapnia in Children with Obstructive Sleep Apnea Syndrome.

Children with obstructive sleep apnea syndrome (OSAS) often experience periods of hypercapnia during sleep, a potent stimulator of cerebral blood flow (CBF). Considering this hypercapnia exposure during sleep, it is possible that children with OSAS have abnormal CBF responses to hypercapnia even during wakefulness. Therefore, we hypothesized that children with OSAS have blunted CBF response to hypercapnia during wakefulness, compared to snorers and controls. CBF changes during hypercapnic ventilatory response (HCVR) were tested in children with OSAS, snorers, and healthy controls using diffuse correlation spectroscopy (DCS). Peak CBF changes with respect to pre-hypercapnic baseline were measured for each group. The study was conducted at an academic pediatric sleep center. Twelve children with OSAS (aged 10.1 ± 2.5 [mean ± standard deviation] y, obstructive apnea hypopnea index [AHI] = 9.4 [5.1-15.4] [median, interquartile range] events/hour), eight snorers (11 ± 3 y, 0.5 [0-1.3] events/hour), and 10 controls (11.4 ± 2.6 y, 0.3 [0.2-0.4] events/hour) were studied. The fractional CBF change during hypercapnia, normalized to the change in end-tidal carbon dioxide, was significantly higher in controls (9 ± 1.8 %/mmHg) compared to OSAS (7.1 ± 1.5, P = 0.023) and snorers (6.7 ± 1.9, P = 0.025). Children with OSAS and snorers have blunted CBF response to hypercapnia during wakefulness compared to controls. Noninvasive DCS blood flow measurements of hypercapnic reactivity offer insights into physiopathology of OSAS in children, which could lead to further understanding about the central nervous system complications of OSAS.

Consequences of Obstructive Sleep Apnea in Children

Obstructive sleep apnea syndrome (OSAS) has various negative health and behavioral consequences in the pediatric population. As shown in adults, there are metabolic derangements such as obesity, insulin sensitivity, dyslipidemia, and metabolic syndrome, as well as cardiovascular derangements like hypertension, chronic inflammation, endothelial dysfunction, ventricular size/function abnormalities, and even elevated pulmonary arterial pressures, that can be seen in children with OSAS. The first two sections will discuss the metabolic and cardiovascular consequences on OSAS in children. The last section summarizes selected studies and reviews on the behavioral, neurocognitive and academic consequences of OSAS in children.

Inflammation and Insufficient or Disordered Sleep

Sleep is not only an essential physiological function, but also serves important roles in promoting growth, maturation, and overall health of humans. There is increasing interest regarding the impact of sleep and its disorders on the regulation of inflammatory processes and end-organ morbidities, particularly in the context of metabolic and cardiovascular diseases (CVD) and their complications. Obstructive sleep apnea syndrome (OSAS) is an increasingly common health problem in children. In the last decade, the emergence of increasing obesity rates has further led to remarkable increases in the prevalence of OSAS, along with more prominent neurocognitive, behavioral, cardiovascular and metabolic morbidities. Although the underlying mechanisms leading to OSAS-induced morbidities are likely multifactorial and remain to be fully elucidated, activation of inflammatory pathways by OSAS has emerged as an important pathophysiological component of the end-organ injury associated with this disorder. To this effect, it would appear that OSAS could be viewed as a chronic, low-grade inflammatory disorder. Furthermore, the concurrent presence of obesity and OSAS poses a theoretically increased risk of OSAS-related complications. In this study, we will critically review the current state of research regarding the impact of insufficient and disrupted sleep and OSAS on the immune processes and inflammatory pathways that underlie childhood OSAS as a distinctive systemic inflammatory condition in children, and will explore potential interactions between OSAS and obesity.

Clinical manifestations of pediatric obstructive sleep apnea syndrome: Clinical utility of the Chinese-version Obstructive Sleep Apnea Questionaire-18.

Childhood obstructive sleep apnea syndrome (OSA) affects not only the children's physical health, but also their mental development, behavioral problems and learning difficulties. Therefore, an early diagnosis is important. However, the assessment tools of polysomnography are demanding. The Obstructive Sleep Apnea Questionnaire-18 (OSA-18) is designed to screen OSA and has good reliability and validity. The goal of this study was to validate the Chinese version of the OSA-18, to analyze the frequency of symptoms and find the most common symptoms of OSA in Taiwanese children. We validated the OSA-18 in an ethnic Chinese group and compared the treatment outcomes to show the sensitivity of the questionnaire. The caregivers completed the questionnaire twice at an interval of 4 weeks to test reliability. In the validation study, we included 88 OSA children. The OSA-18 and follow-up polysomnography were performed before and 6 months after adenotonsillectomy. Results showed the excellent test-retest reliability (r = 0.84**) of the OSA-18. There was a statistically significant correlation between the OSA-18 and, respectively, the Apnea-Hypopnea Index (r = 0.29*), and the Hypopnea Index (r = 0.29*). Quality of life showed a significant correlation with the Apnea Index (r = 0.43**), central apnea count (r = 0.50***), and mixed apnea count (r = 0.36*). The cut-off point of the OSA-18 total scores for detecting pediatric OSA in children aged 6-12 years was 66. The common symptoms of pediatric OSA were poor attention span, loud snoring, caregiver worried about child's health, difficulty awakening, and mouth breathing. Our results show that the Chinese version of the OSA-18 is a reliable and valid instrument. The questionnaire also showed improvement in the quality of life of OSA children post-adenotonsillectomy.

Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea.

To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA). At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Presurgery and postsurgery OPSG indices were compared. We defined cure as an apneahypopnea index (AHI) < 1.5/h on the postsurgery OPSG, and we compared the cure rates of different surgeries. A total of 143 children, median age 12.4 y (interquartile range [IQR] 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 y [IQR 9-15]) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT + turbinate trim ± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor. Surgery improved OPSG indices in the majority of obese children with OSA.

Diagnosis of pediatric obstructive sleep apnea: Preliminary findings using automatic analysis of airflow and oximetry recordings obtained at patients’ home

The obstructive sleep apnea syndrome (OSAS) greatly affects both the health and the quality of life of children. Therefore, an early diagnosis is crucial to avoid their severe consequences. However, the standard diagnostic test (polysomnography, PSG) is time-demanding, complex, and costly. We aim at assessing a new methodology for the pediatric OSAS diagnosis to reduce these drawbacks. Airflow (AF) and oxygen saturation (SpO2) at-home recordings from 50 children were automatically processed. Information from the spectrum of AF was evaluated, as well as combined with 3% oxygen desaturation index (ODI3) through a logistic regression model. A bootstrap methodology was conducted to validate the results. OSAS significantly increased the spectral content of AF at two abnormal frequency bands below (BW1) and above (BW2) the normal respiratory range. These novel bands are consistent with the occurrence of apneic events and the posterior respiratory overexertion, respectively. The spectral information from BW1 and BW2 showed complementarity both between them and with ODI3. A logistic regression model built with 3 AF spectral features (2 from BW1 and 1 from BW2) and ODI3 achieved (mean and 95% confidence interval): 85.9% sensitivity [64.5–98.7]; 87.4% specificity [70.2–98.6]; 86.3% accuracy [74.9–95.4]; 0.947 area under the receiver-operating characteristics curve [0.826–1]; 88.4% positive predictive value [72.3–98.5]; and 85.8% negative predictive value [65.8–98.5]. The combination of the spectral information from two novel AF bands with the ODI3 from SpO2 is useful for the diagnosis of OSAS in children.

Continuous positive airway pressure in childhood obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome is probably the most frequent indication for continuous positive airway pressure in children. In some cases, non-invasive two-level ventilation is necessary. Many interfaces are commercially available for children, allowing personalized treatment: nasal or facial masks, or nasal prongs. There are no validated criteria, in terms of age or the disease, for initiating CPAP therapy in children. Close surveillance of facial growth is indispensable.

Tonsillectomy – Orthodontics: Which sequences in children?

The most common cause of childhood obstructive sleep apnea syndrome (OSAS) is adenotonsillar hypertrophy. Aside from nocturnal symptoms, children with OSAS may present with lower school performance, behavioral disorder, cardiovascular complications and failure to thrive. First-line treatment is adenotonsillectomy; however, residual OSAS on postoperative polygraphy is reported in 20% to 40% of cases. In well-selected cases, orthodontic treatment can play an important role in the management of light to moderate childhood OSAS or residual OSAS after surgery, using growth activators or oral mandibular advancement appliances, rapid maxillary expansion and orofacial rehabilitation. Nevertheless, clinical studies with a high level of evidence of efficacy are lacking. To illustrate therapeutic sequences that may include an orthodontic phase, we present clinical cases encountered in our multidisciplinary outpatients clinic.

The particular case of sleep-disordered breathing in syndromic patients

Classical childhood obstructive sleep apnea syndrome (OSAS) is relatively common, affecting approximately 1% to 2% of children between the ages of 3 to 6 years. Adenotonsillar hypertrophy is the prime cause, and adenotonsillectomy is the first-line treatment, leading to cure in most cases.However, OSAS is also found in some more rare but very numerous disorders, including craniofacial or upper airway deformities such as Pierre Robin sequence, Franceschetti syndrome, craniofacial stenosis, achondroplasia, Down syndrome, Prader-Willi syndrome, and mucopolysaccharidosis. Unlike in classical childhood OSAS, anatomical and functional upper airway abnormalities are the main pathophysiological determinants, clinical symptoms of sleep-disordered breathing are often slight or absent, and the syndrome is usually more severe than classical childhood OSAS and can be observed at any age; systematic sleep study is therefore justified. Isolated adenotonsillectomy is rarely able to cure the OSAS.Management should be multidisciplinary, including, severally or together, a pediatric ENT surgeon, pediatric maxillofacial surgeon, orthodontist, pediatric neurosurgeon, pediatric sleep specialist and an expert in pediatric non-invasive ventilation because of the frequent need for nocturnal respiratory support by non-invasive continuous positive airway pressure.It is important to be aware of these rare pathologies that may underlie OSAS, to enable early screening for sleep-disordered breathing and adapted therapy.

Can a clinical score be used to screen for childhood OSAS?

Pediatric obstructive sleep apnea syndrome (OSAS) is a frequent pathology (1-4% of the general population), often related to adenotonsillar hypertrophy. In France, however, access to polysomnography (PSG) is limited, leading to underdiagnosis. Using a simple, reliable diagnostic tool predictive of OSAS could prioritize prescription of night sleep recordings and help decision making for adenotonsillectomy. The aim of this study was to validate a French version of the sleep apnea Severity Hierarchy Score (SHS), already validated in English in the general population, for screening of childhood OSAS.A prospective study included 86 children (aged 7.0 ± 2.4 years; BMI Z-score, -0.71 ± 1.51; ) referred to 2 academic sleep centers, the Saint-Antoine and Trousseau hospitals (Paris, France) for assessment of sleep disordered breathing. The SHS questionnaire was filled out by the parents prior to overnight PSG. The sensitivity and specificity of the SHS were assessed according to various levels of OSAS severity.A threshold of ≥2.75 on the SHS showed 92% sensitivity, 81% specificity and 96% negative predictive value for moderate to severe OSAS, defined by an apnea hypopnea index3 of 5/hr in the study population.

Obstructive sleep apnea and sickle cell anemia.

To ascertain the prevalence of and risk factors for obstructive sleep apnea syndrome (OSAS) in children with sickle cell anemia (SCA). Cross-sectional baseline data were analyzed from the Sleep and Asthma Cohort Study, a multicenter prospective study designed to evaluate the contribution of sleep and breathing abnormalities to SCA-related morbidity in children ages 4 to 18 years, unselected for OSAS symptoms or asthma. Multivariable logistic regression assessed the relationships between OSAS status on the basis of overnight in-laboratory polysomnography and putative risk factors obtained from questionnaires and direct measurements. Participants included 243 children with a median age of 10 years; 50% were boys, 99% were of African heritage, and 95% were homozygous for β(S) hemoglobin. OSAS, defined by obstructive apnea hypopnea indices, was present in 100 (41%) or 25 (10%) children at cutpoints of ≥1 or ≥5, respectively. In univariate analyses, OSAS was associated with higher levels of habitual snoring, lower waking pulse oxygen saturation (Spo2), reduced lung function, less caretaker education, and non-preterm birth. Lower sleep-related Spo2 metrics were also associated with higher obstructive apnea hypopnea indices. In multivariable analyses, habitual snoring and lower waking Spo2 remained risk factors for OSAS in children with SCA. The prevalence of OSAS in children with SCA is higher than in the general pediatric population. Habitual snoring and lower waking Spo2 values, data easily obtained in routine care, were the strongest OSAS risk factors. Because OSAS is a treatable condition with adverse health outcomes, greater efforts are needed to screen, diagnose, and treat OSAS in this high-risk, vulnerable population.

Growth after adenotonsillectomy for obstructive sleep apnea: an RCT.

Adenotonsillectomy for obstructive sleep apnea syndrome (OSAS) may lead to weight gain, which can have deleterious health effects when leading to obesity. However, previous data have been from nonrandomized uncontrolled studies, limiting inferences. This study examined the anthropometric changes over a 7-month interval in a randomized controlled trial of adenotonsillectomy for OSAS, the Childhood Adenotonsillectomy Trial. A total of 464 children who had OSAS (average apnea/hypopnea index [AHI] 5.1/hour), aged 5 to 9.9 years, were randomized to Early Adenotonsillectomy (eAT) or Watchful Waiting and Supportive Care (WWSC). Polysomnography and anthropometry were performed at baseline and 7-month follow-up. Multivariable regression modeling was used to predict the change in weight and growth indices. Interval increases in the BMI z score (0.13 vs. 0.31) was observed in both the WWSC and eAT intervention arms, respectively, but were greater with eAT (P < .0001). Statistical modeling showed that BMI z score increased significantly more in association with eAT after considering the influences of baseline weight and AHI. A greater proportion of overweight children randomized to eAT compared with WWSC developed obesity over the 7-month interval (52% vs. 21%; P < .05). Race, gender, and follow-up AHI were not significantly associated with BMI z score change. eAT for OSAS in children results in clinically significant greater than expected weight gain, even in children overweight at baseline. The increase in adiposity in overweight children places them at further risk for OSAS and the adverse consequences of obesity. Monitoring weight, nutritional counseling, and encouragement of physical activity should be considered after eAT for OSAS.

Pilot study of nasal expiratory positive airway pressure devices for the treatment of childhood obstructive sleep apnea syndrome.

Alternative therapies for childhood obstructive sleep apnea syndrome (OSAS) are needed as OSAS may persist despite adenotonsillectomy, and continuous positive airway pressure (CPAP) adherence is low. Nasal expiratory positive airway pressure (NEPAP) devices have not been studied in children. We hypothesized that NEPAP would result in polysomnographic improvement. Further, we aimed to determine NEPAP adherence, effects on sleepiness, behavior, and quality of life. A randomized, double-blind, placebo-controlled, crossover pilot study was performed. CPAP candidates, 8-16 years old, underwent NEPAP and placebo polysomnograms. Subjects with ≥ 50% reduction in the apnea hypopnea index (AHI) from placebo to NEPAP night or AHI < 5/h on NEPAP night wore NEPAP at home for 30 days. Adherence was assessed by daily phone calls/emails and collecting used devices. Fourteen subjects (age 13.4 ± 1.9 years, BMI z-scores 2.2 ± 1 [mean ± SD]) were studied. There was significant improvement in the obstructive apnea index with NEPAP vs. placebo: 0.6 (0-21.1)/h vs. 4.2 (0-41.9)/h (median [range], p = 0.010) and trends for improvement in other polysomnographic parameters. However, responses were variable, with 3 subjects not improving and 2 worsening. Older children and those with less hypercapnia had a better response. Eight subjects were sent home with devices; one was lost to follow-up, and adherence in the remainder was 83% of nights; these subjects had a significant improvement in sleepiness and quality of life. NEPAP devices are a potential alternative therapy for OSAS in a small subset of children. Due to variability in individual responses, efficacy of NEPAP should be evaluated with polysomnography. www.clinicaltrials.gov, identifier: NCT01768065.