UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Medline ® Abstracts for References 8,29,33-39

of 'Evaluation of suspected obstructive sleep apnea in children'

8
TI
Diagnosis and management of childhood obstructive sleep apnea syndrome.
AU
Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Ward SD, Sheldon SH, Shiffman RN, Lehmann C, Spruyt K, American Academy of Pediatrics
SO
Pediatrics. 2012;130(3):e714.
 
OBJECTIVE: This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).
METHODS: The literature from 1999 through 2011 was evaluated.
RESULTS AND CONCLUSIONS: A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.
AD
PMID
29
TI
Increased behavioral morbidity in school-aged children with sleep-disordered breathing.
AU
Rosen CL, Storfer-Isser A, Taylor HG, Kirchner HL, Emancipator JL, Redline S
SO
Pediatrics. 2004;114(6):1640.
 
OBJECTIVE: To assess whether sleep-disordered breathing (SDB), ranging from primary snoring to obstructive sleep apnea (OSA), is associated with increased behavioral morbidity.
METHODS: A cross-sectional study was conducted of school-aged children in an urban, community-based cohort, stratified for term or preterm (<37 weeks' gestation) birth status. A total of 829 children, 8 to 11 years old (50% female, 46% black, 46% former preterm birth) were recruited from a cohort study. All children had unattended in-home overnight cardiorespiratory recordings of airflow, respiratory effort, oximetry, and heart rate for measurement of the apnea hypopnea index (number of obstructive apneas and hypopneas per hour). SDB was defined by either parent-reported habitual snoring or objectively measured OSA. Functional outcomes were assessed with 2 well-validated parent ratings of behavior problems: the Child Behavioral Checklist and the Conners Parent Rating Scale-Revised:Long.
RESULTS: Forty (5%) children were classified as having OSA (median apnea hypopnea index: 7.1 per hour; interquartile range: 3.1-10.5), 122 (15%) had primary snoring without OSA, and the remaining 667 (80%) had neither snoring nor OSA. Children with SDB had significantly higher odds of elevated problem scores in the following domains: externalizing, hyperactive, emotional lability, oppositional, aggressive, internalizing, somatic complaints, and social problems.
CONCLUSIONS: Children with relatively mild SDB, ranging from primary snoring to OSA, have a higher prevalence of problem behaviors, with the strongest, most consistent associations for externalizing, hyperactive-type behaviors.
AD
Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, 11100 Euclid Ave, RB&C 790 Mail Stop 6003, Cleveland, OH 44106-6003, USA. carol.rosen@case.edu
PMID
33
TI
Inattention, hyperactivity, and symptoms of sleep-disordered breathing.
AU
Chervin RD, Archbold KH, Dillon JE, Panahi P, Pituch KJ, Dahl RE, Guilleminault C
SO
Pediatrics. 2002;109(3):449.
 
OBJECTIVE: Inattention and hyperactivity are frequent among children with sleep-disordered breathing (SDB) and often improve when SDB is treated. However, the frequency of SDB symptoms among inattentive and hyperactive children has received little study.
DESIGN: Cross-sectional survey.
SETTING: Two university-affiliated but community-based general pediatrics clinics.
PATIENTS: Patients consisted of N = 866 children (469 boys), aged 2.0 to 13.9 years (mean: 6.8 plus minus 3.2 years), with clinic appointments.
MEASURES: A validated Pediatric Sleep Questionnaire assessed for habitual snoring (1 item), snoring severity (a 4-item subscale), sleepiness (4 items), and overall risk of SDB (16 items). Parents also completed 2 common behavioral measures, an inattention/hyperactivity scale (IHS) derived from the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, and the hyperactivity index (HI, expressed as a t score) of the Conners' Parent Rating Scale.
RESULTS: Habitual snoring was reported in 16% (95% confidence interval [CI]: 13, 19) of the participants. High HI scores (>60) were found in 13% (95% CI: 11, 16) of all participants, 22% (95% CI: 15, 29) of habitual snorers, and 12% (95% CI: 9, 14) of nonsnorers. Odds ratios between HI>60 and each of the following were: habitual snoring, 2.2 (95% CI: 1.4, 3.6); 1 additional positive symptom-item on the snoring scale, 1.3 (95% CI: 1.1, 1.5); 1 additional positive item on the sleepiness scale, 1.6 (95% CI: 1.4, 2.0); and a 1-standard deviation increase in the overall SDB score, 1.7 (95% CI: 1.4, 2.0; all odds ratios age- and sex-adjusted). Results were similar for high IHS scores (>1.25). Stratification by age and sex showed that most of the association with snoring (but not sleepiness) derived from boys<8 years old.
CONCLUSIONS: Inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and---especially in young boys---snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.
AD
Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, Michigan. chervin@umich.edu
PMID
34
TI
Reduced time in bed and obstructive sleep-disordered breathing in children are associated with cognitive impairment.
AU
Suratt PM, Barth JT, Diamond R, D'Andrea L, Nikova M, Perriello VA Jr, Carskadon MA, Rembold C
SO
Pediatrics. 2007;119(2):320.
 
OBJECTIVE: The purpose of this study was to determine if reduced time in bed as well as the degree of obstructive sleep-disordered breathing predicted the risk of impaired cognitive function in children with adenotonsillar hypertrophy suspected of having obstructive sleep-disordered breathing.
DESIGN: We studied 56 children, aged 6 to 12 years, with adenotonsillar hypertrophy referred for suspected obstructive sleep-disordered breathing. Children were given a sleep diary and underwent wrist actigraphy for 6 consecutive days and nights. On day 7, the children were given general cognitive tests, memory tests, and continuous performance tests followed by attended polysomnography that night. Parents completed snoring and behavior questionnaires.
RESULTS: Shorter mean time in bed for 6 nights and a history of nightly snoring were highly predictive of lower scores for the vocabulary and similarities cognitive function tests. Children who had a mean time in bed of 557 minutes and did not snore nightly were predicted to have vocabulary and similarities scores more than 1 standard deviation higher than children who had a mean time in bed of 521 minutes and snored nightly. Shorter mean time in bed and the log of the apnea hypopnea index also predicted lower vocabulary and similarities scores. Greater night to night variability in time in bed was significantly predictive of lower vocabulary and similarities scores, but variability was not as predictive as mean time in bed. Neither mean time in bed nor the coefficient of variation of time in bed predicted other cognitive or behavioral scores.
CONCLUSIONS: Short or variable time in bed and nightly snoring or higher apnea hypopnea index predicted impaired vocabulary and similarities scores in children with adenotonsillar hypertrophy suspected of having obstructive sleep-disordered breathing. The degree of cognitive impairment attributable to short time in bed and obstructive sleep-disordered breathing is clinically very significant.
AD
Pulmonary Critical Care Division, Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA. ps4p@virginia.edu
PMID
35
TI
Behavior and obstructive sleep apnea in children: is obesity a factor?
AU
Rudnick EF, Mitchell RB
SO
Laryngoscope. 2007;117(8):1463.
 
OBJECTIVES: Children with obstructive sleep apnea (OSA) frequently exhibit behavioral and neurocognitive problems. There is a high prevalence of OSA among obese children. This study aims to evaluate the relationship between OSA and behavioral problems in obese children as compared with normal-weight children (controls).
STUDY DESIGN: Prospective, nonrandomized, controlled study of obese and normal-weight children with OSA presenting to a tertiary medical center for adenotonsillectomy.
METHODS: All study participants underwent preoperative polysomnography to document OSA. Obesity was defined as age- and sex-adjusted body mass index at the 95th percentile or higher. Behavior was evaluated using the Behavior Assessment System for Children (BASC). Preoperatively, the Behavioral Symptoms Index (BSI), a global measure of behavior, and BASC scores for obese and normal-weight children were compared using an unpaired t test.
RESULTS: The study population included 52 children, 18 (35%) of whomwere obese. The mean age of obese children was 8.6 (range, 2.0-14.9) years. The mean age of normal-weight children was 6.4 (range, 2.1-12.9) years. Demographics were otherwise similar. The mean apnea-hypopnea index for obese children was 17.2 (5.0-38.0) and for normal-weight children was 15.7 (5.3-88.0). The BSI score was 55.3 (SD, 15.9) for obese and 55.9 (SD, 15.0) for normal-weight children. Seven (38.9%) obese and 12 (35.3%) normal-weight children had clinically significant or abnormal behavior. Similar results were seen for the BASC scales of atypicality, depression, hyperactivity, and somatization in both groups.
CONCLUSIONS: Behavioral problems are highly prevalent in children with OSA. However, these problems exist independently of whether children are obese or normal weight.
AD
Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298, USA. emilyrudnick@yahoo.com
PMID
36
TI
Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review.
AU
Beebe DW
SO
Sleep. 2006;29(9):1115.
 
STUDY OBJECTIVES: To comprehensively review research on the association between childhood sleep-disordered breathing (SDB) and neurobehavioral functioning.
DESIGN: Qualitative and quantitative literature review.
SETTING: N/A.
PATIENTS OR PARTICIPANTS: N/A.
INTERVENTIONS: N/A.
MEASUREMENTS AND RESULTS: The findings of 61 studies of the relationship between childhood SDB and neurobehavioral functioning were critically evaluated and synthesized. There is strong evidence that childhood SDB is associated with deficits in behavior and emotion regulation, scholastic performance, sustained attention, selective attention, and alertness. There is also evidence that SDB has minimal association with a child's typical mood, expressive language skills, visual perception, and working memory. Findings have been insufficient to draw conclusions about intelligence, memory, and some aspects of executive functioning. Mechanisms by which SDB might result in neurobehavioral morbidity are being explored, but clinical symptoms such as chronic snoring remain the best predictors of morbidity. Short-term SDB treatment outcome studies are encouraging, but the long-term outcomes are not known. Failing to treat SDB appears to leave children at risk for long-term neurobehavioral deficits.
CONCLUSIONS: Childhood SDB is associated with neurobehavioral morbidity. Applying commonly used guidelines for causal inference, even in the absence of a much-needed randomized clinical trial, there is strong evidence of association, consistent findings, and specificity of effect. There is suggestive evidence that this association fits the expected temporal pattern and that SDB is a biologically plausible cause of neurobehavioral deficits. Clinicians should be alert to the coexistence of SDB symptoms and concerns about a child's academic progress, attention, arousal, or behavior or emotion regulation.
AD
Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH 45229, USA. dean.beebe@cchmc.org
PMID
37
TI
Persistent snoring in preschool children: predictors and behavioral and developmental correlates.
AU
Beebe DW, Rausch J, Byars KC, Lanphear B, Yolton K
SO
Pediatrics. 2012 Sep;130(3):382-9. Epub 2012 Aug 13.
 
OBJECTIVE: To clarify whether persistent snoring in 2- to 3-year-olds is associated with behavioral and cognitive development, and to identify predictors of transient and persistent snoring.
METHODS: Two hundred forty-nine mother/child pairs participated in a prospective birth cohort study. Based upon parental report of loud snoring≥2 times weekly at 2 and 3 years of age, children were designated as nonsnorers, transient snorers (snored at 2 or 3 years of age, but not both), or persistent snorers (snored at both ages). We compared groups by using validated measures of behavioral and cognitive functioning. Potential predictors of snoring included child race and gender, socioeconomic status (parent education and income), birth weight, prenatal tobacco exposure (maternal serum cotinine), childhood tobacco exposure (serum cotinine), history and duration of breast milk feeding, and body mass relative to norms.
RESULTS: In multivariable analyses, persistent snorers had significantly higher reported overall behavior problems, particularly hyperactivity, depression, and inattention. Nonsnorers had significantly stronger cognitive development than transient and persistent snorers in unadjusted analyses, but not after demographic adjustment. The strongest predictors of the presence and persistence of snoring were lower socioeconomic status and the absence or shorter duration of breast milk feeding. Secondary analyses suggested that race may modify the association of childhood tobacco smoke exposure and snoring.
CONCLUSIONS: Persistent, loud snoring was associated with higher rates of problem behaviors. These results support routine screening and tracking of snoring, especially in children from low socioeconomic backgrounds; referral for follow-up care of persistent snoring in young children; and encouragement and facilitation of infant breastfeeding.
AD
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 3015, 3333 Burnet Ave, Cincinnati, OH 45229-3039, USA. dean.beebe@cchmc.org
PMID
38
TI
Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing.
AU
Perfect MM, Archbold K, Goodwin JL, Levine-Donnerstein D, Quan SF
SO
Sleep. 2013;36(4):517. Epub 2013 Apr 1.
 
OBJECTIVES: To examine the rates of behavioral and adaptive functioning difficulties among youth who never had sleep disordered breathing (SDB), had remitted SDB, had incident SDB, or had persistent SDB; and to determine if there were increased odds of behavioral difficulties among youth with varying SDB histories relative to those who never had SDB.
METHODS: 263 youth had valid polysomnography and neurobehavioral data at two time points approximately 5 years apart from the prospective Tucson Children's Assessment of Sleep Apnea study. Primary outcomes were the behavior assessment scale for children-2(nd) Edition parent report form (BASC-PRF) and Self-Report of Personality (SRP), and the Adaptive Behavior Assessment System-2(nd) Edition (ABAS-2).
RESULTS: Compared to those who never had SDB, individuals with persistent SDB had significant odds and met more cutoff scores on the BASC-2-PRF externalizing problems composite (odds ratio [OR]3.29; 8.92% vs. 35.3%), behavioral symptoms index (OR 6.82; 7.4% vs. 35.3%) and Hyperactivity subscale (OR 6.82; 11.1% vs. 41.2%). Similarly, greater difficulties was seen for the group with persistent SDB (relative to never) on the ABAS-2 social domain (OR 3.39; 22% vs. 50%), and Communication (OR 4.26; 15% vs. 42.9%) and Self-Care subscales (OR = 2.97; 25.2% vs. 50%). Relative to youth who never had SDB, youth who developed SDB at Time 2 had compromised adaptive skills as evidenced by the BASC-2 PRF adaptive behavior composite (OR 3.34; 15.6% vs. 38.1%) and the ABAS-2 general adaptive composite (OR 2.83; 20.5% vs. 42.1%).
CONCLUSIONS: Youth with current SDB exhibited hyperactivity, attention problems, aggressivity, lower social competency, poorer communication, and/or diminished adaptive skills.
AD
Department of Disability and Psychoeducational Studies, University of Arizona, Tucson, AZ 85721, USA. mperfect@email.arizona.edu
PMID
39
TI
Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention-deficit/hyperactivity disorder.
AU
O'Brien LM, Holbrook CR, Mervis CB, Klaus CJ, Bruner JL, Raffield TJ, Rutherford J, Mehl RC, Wang M, Tuell A, Hume BC, Gozal D
SO
Pediatrics. 2003 Mar;111(3):554-63.
 
OBJECTIVES: This study examined the hypothesis that domains of neurobehavioral function would be selectively affected by sleep-disordered breathing (SDB). Therefore, we assessed potential relationships between objectively measured sleep disturbances and neurobehavioral function in children with reported symptoms of attention-deficit/hyperactivity disorder (ADHD) and also determined the incidence of snoring and other sleep problems in 5- to 7-year-old children in the local community and potential relationships to parental snoring and passive smoking.
METHODS: Parents of 5- to 7-year-old children in public schools were surveyed about their child's sleeping habits using a validated questionnaire. The questionnaire also asked whether they believed their child to be hyperactive or have ADHD. Children with reported symptoms of ADHD and control children were randomly selected and invited to the Sleep Medicine Center for an overnight polysomnographic assessment and a battery of neurocognitive tests.
RESULTS: The questionnaire response rate was 47.6% (n = 5728). Frequent and loud snoring was reported for 673 children (11.7%). Similarly, 418 (7.3%) children were reported to have hyperactivity/ADHD, 313 (76.5%) of which were boys. Eighty-three children with parentally reported symptoms of ADHD were invited for full evaluation at the Sleep Medicine Center together with 34 control children. After assessment with the Conners' Parent Rating Scale, 44 children were designated as having "significant" symptoms of ADHD, 27 as "mild," and 39 designated as "none" (controls). Overnight polysomnography indicated that obstructive sleep apnea was present in 5% of those with significant ADHD symptoms, 26% of those with mild symptoms, and 5% of those with no symptoms. In the cohort, no sleep variable accounted for more than a negligible proportion of the variance in domains of neurobehavioral function.
CONCLUSIONS: An unusually high prevalence of snoring was identified among a group of children designated as showing mild symptoms of ADHD based on the Conners' ADHD index identified from a community sample. However, whereas SDB is not more likely to occur among children with significant ADHD symptoms, it is significantly highly prevalent among children with mild hyperactive behaviors. Sleep studies further revealed that rapid eye movement disturbances are more likely to occur in children with significant symptoms, and they seem to impose significant but mild effects on daytime neurobehavioral functioning. We conclude that in children with significant symptoms of ADHD, the prevalence of SDB is not different from that of the general pediatric population and that rapid eye movement sleep in these children is disturbed and may contribute to the severity of their behavioral manifestations. Furthermore, SDB can lead to mild ADHD-like behaviors that can be readily misperceived and potentially delay the diagnosis and appropriate treatment.
AD
Kosair Children's Hospital Research Institute, and Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, Kentucky 40202, USA.
PMID