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Medline ® Abstracts for References 8,40-48

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
40
TI
Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children.
AU
Stradling JR, Thomas G, Warley AR, Williams P, Freeland A
SO
Lancet. 1990;335(8684):249.
 
61 snoring children selected for adenotonsillectomy, mainly for recurrent tonsillitis, were compared with a matched group of 31 healthy children for symptoms of sleep apnoea, extent of sleep hypoxaemia, and amount of sleep disturbance. The studies were repeated six months postoperatively, and after six months in the healthy children. Preoperatively, 61% of the children had degrees of sleep hypoxaemia above normal and 65% had abnormally disturbed sleep. A questionnaire administered to the parents about their children showed abnormal patterns of answers about sleep problems daytime sleepiness, hyperactivity, aggression, learning difficulties, restless sleep, and odd sleeping positions. After adenotonsillectomy, the abnormal hypoxaemia, excessive sleep disturbance, and multiple symptoms almost resolved; a growth spurt also occurred.
AD
Osler Chest Unit, Churchill Hospital, Oxford, UK.
PMID
41
TI
Sleep-disordered breathing and school performance in children.
AU
Gozal D
SO
Pediatrics. 1998;102(3 Pt 1):616.
 
OBJECTIVE: To assess the impact of sleep-associated gas exchange abnormalities (SAGEA) on school academic performance in children.
DESIGN: Prospective study.
SETTING: Urban public elementary schools.
PARTICIPANTS: Two hundred ninety-seven first-grade children whose school performance was in the lowest 10th percentile of their class ranking.
METHODS: Children were screened for obstructive sleep apnea syndrome at home using a detailed parental questionnaire and a single night recording of pulse oximetry and transcutaneous partial pressure of carbon dioxide. If SAGEA was diagnosed, parents were encouraged to seek medical intervention for SAGEA. School grades of all participating children for the school year preceding and after the overnight study were obtained.
RESULTS: SAGEA was identified in 54 children (18.1%). Of these, 24 underwent surgical tonsillectomy and adenoidectomy (TR), whereas in the remaining 30 children, parents elected not to seek any therapeutic intervention (NT). Overall mean grades during the second grade increased from 2.43 +/- 0.17 (SEM) to 2.87 +/- 0.19 in TR, although no significant changes occurred in NT (2.44 +/- 0.13 to 2.46 +/- 0.15). Similarly, no academic improvements occurred in children without SAGEA.
CONCLUSIONS: SAGEA is frequently present in poorly performing first-grade students in whom it adversely affects learning performance. The data suggest that a subset of children with behavioral and learning disabilities could have SAGEA and may benefit from prospective medical evaluation and treatment.
AD
Constance S. Kaufman Pediatric Pulmonary Research Laboratory, Tulane University Comprehensive Sleep Disorders Center, New Orleans, Louisiana, USA.
PMID
42
TI
Natural history of snoring and related behaviour problems between the ages of 4 and 7 years.
AU
Ali NJ, Pitson D, Stradling JR
SO
Arch Dis Child. 1994;71(1):74.
 
In 1989-90 a survey was carried out of the prevalence of snoring and related symptoms in 782 4 to 5 year old children. Two years later, in 1992, the same group of children was studied to gather information on the natural history of snoring and the related behaviour problems. A total of 507/782 (64.8%) completed questionnaires were received. Comparison of the responses with the 1989-90 survey showed that those who did not reply to the questionnaire were no different from the respondents in terms of the prevalence of snoring, daytime sleepiness, hyperactivity, and restless sleep. The overall prevalence of habitual snoring did not change between the two surveys (12.1% in 1989-90 v 11.4% in 1992), though more than half of the children who snored habitually in the original survey no longer did so. There was little change in the prevalence of hyperactivity (24.2% in 1989-90 v 20.7% in 1992) or restless sleep (both 39%) among the 507 who responded to the present survey. The prevalence of daytime sleepiness, however, did decrease substantially (20.7% in 1989-90 v 10.2% in 1992). There was moderate agreement between the individual questionnaire responses for the 1989-90 and 1992 surveys for snoring (weighted kappa 0.52), but poor agreement for the other symptoms (daytime sleepiness 0.37, hyperactivity 0.35, and restless sleep 0.38). Trend analysis showed that the increasing prevalence of sleepiness, hyperactivity, and restless sleep across the snoring categories washighly significant. Daytime sleepiness, hyperactivity, and restless sleep were all significantly more common in the habitual snorers than in those who never snored. Relative risks (95% confidence interval) were as follows: daytime sleepiness 6.13 (2.5 to 14.9), hyperactivity 2.78 (1.6 to 4.7), and restless sleep 2.3 (1.6 to 3.2). Though habitual snoring and the associated behaviour problems resolved spontaneously over two years in about half of the children with these symptoms, there is still the same overall percentage with these problems due to the emergence of new cases.
AD
Osler Chest Unit, Churchill Hospital, Headington, Oxford.
PMID
43
TI
Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study.
AU
Huang YS, Guilleminault C, Li HY, Yang CM, Wu YY, Chen NH
SO
Sleep Med. 2007;8(1):18. Epub 2006 Dec 6.
 
BACKGROUND: Children diagnosed with attention-deficit/hyperactivity disorder (ADHD), based on Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria, may also have obstructive sleep apnea (OSA), but it is unclear whether treating OSA has similar results as methylphenidate (MPH), a commonly used treatment for ADHD.
METHODS: This study enrolled 66 school-age children, referred for and diagnosed with ADHD, and 20 healthy controls. Polysomnography (PSG) performed after ADHD diagnosis showed the presence of mild OSA. After otolaryngological evaluation, parents and referring physicians of the children could select treatment of ADHD with MPH, treatment of OSA with adenotonsillectomy or no treatment. Systematic follow-up was performed six months after initiation of treatment, or diagnosis if no treatment. All children had pre- and post-clinical interviews; pediatric, neurologic, psychiatric and neurocognitive evaluation; PSG; ADHD rating scale, child behavior checklist (CBCL) filled out by parents and teacher; test of variables of attention (TOVA); and the quality of life in children with obstructive sleep disorder questionnaire (OSA-18).
RESULTS: ADHD children had an apnea-hypopnea index (AHI)>1<5 event/hour; 27 were treated with MPH, 25 had adenotonsillectomy, and 14 had no treatment. The surgical and MPH groups improved more than the non-treatment group. When comparing MPH to post-surgery, the PSG and questionnaire sleep variables, some daytime symptoms (including attention span) and TOVA subscales (impulse control, response time and total ADHD score) improved more in the surgical group than the MPH group. The surgical group had an ADHD total score of 21.16+/-7.13 on the ADHD rating scale (ADHD-RS) post-surgery compared to 31.52+/-7.01 pre-surgery (p=0.0001), and the inattention and hyperactivity subscales were also significantly lower (p=0.0001). Finally, the results were significantly different between surgically and MPH-treated groups (ADHD-RS p=0.007). The surgical group also had a TOVA ADHD score lower than -1.8 and close to those obtained in normal controls.
CONCLUSION: A low AHI score of>1 considered abnormal is detrimental to children with ADHD. Recognition and surgical treatment of underlying mild sleep-disordered breathing (SDB) in children with ADHD may prevent unnecessary long-term MPH usage and the potential side effects associated with drug intake.
AD
Department of Child Psychiatry, Chang Gung Memorial University Hospital, Tao-Yuan, Taipei, Taiwan.
PMID
44
TI
Child behavior after adenotonsillectomy for obstructive sleep apnea syndrome.
AU
Mitchell RB, Kelly J
SO
Laryngoscope. 2005;115(11):2051.
 
OBJECTIVE: To study the behavior of children with obstructive sleep apnea syndrome (OSAS) before and after adenotonsillectomy using a standardized behavioral rating scale completed by caregivers.
DESIGN AND SETTING: Prospective study of children with OSAS at the University of New Mexico Children's Hospital, Albuquerque, New Mexico.
METHODS: Children between 2.5 and 18 years of age were included in the study and underwent adenotonsillectomy if the results of polysomnography showed an obstructive apnea/hypopnea index (AHI) of 5 or greater. Caregivers completed the Behavior Assessment System for Children (BASC) before surgery and a second time within 6 months of surgery. Pre- and postoperative BASC t scores were compared using a paired t test. Repeated measures analysis of variance was used to evaluate the contributions of several covariants to these change scores.
RESULTS: The study population included 52 children. The mean age was 7.1 (range 2.5-14.9) years, and the mean AHI was 16.2 (range 5.0-88.0). Preoperative mean BASC t scores for all behavioral scales and composites were greater than 50. The behavioral scales that showed significant improvement after adenotonsillectomy were aggression, atypicality, depression, hyperactivity, and somatization (p<or = .001). Age, ethnicity, parental education, parental income, and AHI were not correlated with changes in BASC scores.
CONCLUSIONS: A high proportion of children with OSAS have externalizing (hyperactivity and aggression) and internalizing (anxiety, depression, and somatization) behavioral problems. These problems improve significantly after adenotonsillectomy. The improvement is dramatic regardless of sex, age, ethnicity, parental education, parental income, or the relative severity of OSAS.
AD
Departments of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA. rbmitchell@vcu.edu
PMID
45
TI
Behavioral changes in children with mild sleep-disordered breathing or obstructive sleep apnea after adenotonsillectomy.
AU
Mitchell RB, Kelly J
SO
Laryngoscope. 2007;117(9):1685.
 
OBJECTIVE: To compare changes in behavior after adenotonsillectomy in children with either mild sleep-disordered breathing (SDB) or obstructive sleep apnea (OSA).
STUDY DESIGN: Prospective cohort study.
METHODS: Children at the University of New Mexico Children's Hospital, Albuquerque with mild SDB or OSA were included in the study. All children underwent preoperative polysomnography before adenotonsillectomy. Mild SDB was defined as an apnea-hypopnea index (AHI) less than 5 or an apnea index (AI) less than 1. OSA was defined as an AHI 5 or greater or an AI 1 or greater. Pre- and postoperative scores from the Behavioral Assessment System for Children (BASC) survey were compared using repeated measures analysis of variance.
RESULTS: The mean preoperative AHI for children with mild SDB (n=17) was 3.1 (range, 1.7-4.7), and for children with OSA (n=23) it was 25.3 (range, 10.0-48.0). The mean preoperative BASC scoresfor children with mild SDB were not significantly different from the scores for children with OSA. The demographics in the two groups of children were similar. The behavior symptom index, a global measure of behavior, showed significant improvement after surgery for both groups of children (P<.01). Children also showed significant improvement after adenotonsillectomy in the BASC scales of atypicality, depression, hyperactivity, and somatization. Mean changes in BASC scores after adenotonsillectomy were not significantly different in the two groups of children.
CONCLUSIONS: Behavioral problems are prevalent in children with either mild SDB or OSA, and both groups of children show significant improvements in behavior after adenotonsillectomy.
AD
Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, St. Louis University School of Medicine, St. Louis, Missouri 63104, USA. rmitch11@slu.edu
PMID
46
TI
Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing.
AU
Wei JL, Mayo MS, Smith HJ, Reese M, Weatherly RA
SO
Arch Otolaryngol Head Neck Surg. 2007;133(10):974.
 
OBJECTIVE: To determine changes in behavior and sleep in children before and after adenotonsillectomy for sleep-disordered breathing (SDB) using the validated Pediatric Sleep Questionnaire (PSQ) and Conners' Parent Rating Scale-Revised Short Form (CPRS-RS).
DESIGN: Prospective, nonrandomized study.
SETTING: Ambulatory surgery center affiliated with an academic medical center.
PATIENTS: A total of 117 consecutive children (61 boys and 56 girls) (mean [SD]age, 6.5 [3.1]years) who were clinically diagnosed as having SDB and who had undergone adenotonsillectomy. Complete follow-up data were available in 71 of 117 patients (61%).
INTERVENTIONS: Parents completed the PSQ and CPRS-RS before surgery and 6 months after surgery.
MAIN OUTCOME MEASURES: Changes in age- and sex-adjusted T scores for all 4 CPRS-RS behavior categories (oppositional behavior, cognitive problems or inattention, hyperactivity, and Conners' attention-deficit/hyperactivity disorder [ADHD]index) were determined for each subject before and after surgery. Changes in PSQ scores from a select 22-item sleep-related breathing disorder subscale were also determined.
RESULTS: Preoperatively, the mean (SD) T scores on the CPRS-RS for oppositional behavior, cognitive problems or inattention, hyperactivity, and ADHD index were 59.4 (13.7), 59.5 (13.6), 62.0 (14.4), and 59.9 (13.4), respectively. A T score of 60.0 in any category placed a child in the at-risk group. Postoperatively, T scores for each category were 51.0 (9.6), 51.2 (8.8), 52.4 (10.52), and 50.6 (7.8), respectively. All changes were statistically significant (P<.001) and clinically significant by approximating a change of 1 SD from the baseline score. For the PSQ, the preoperative and postoperative mean (SD) scores were 0.6 (0.1) and 0.1 (0.1), respectively, on a scale of 0 to 1, with scores higher than 0.33 suggesting obstructive sleep apnea. Correlations between sleep and behavior scores were statistically significant before surgery (P=.004 for ADHD index and cognitive problems, P=.008 for oppositional behavior) and after surgery (P=.049 for cognitive problems, P=.03 for oppositional behavior). Higher baseline T scores for the CPRS-RS were associated with larger changes in T scores for the CPRS-RS in all 4 domains (oppositional behavior, cognitive problems or inattention, hyperactivity, and ADHD index).
CONCLUSIONS: Children diagnosed as having SDB experience improvement in both sleep and behavior after adenotonsillectomy. The PSQ and CPRS-RS may be useful adjuncts for screening and following children who undergo adenotonsillectomy for SDB.
AD
Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, and Medical Center, 3901 Rainbow Blvd, Mail Stop 3010, Kansas City, KS 66160, USA. jwei@kumc.edu
PMID
47
TI
Behavior, cognition, and quality of life after adenotonsillectomy for pediatric sleep-disordered breathing: summary of the literature.
AU
Garetz SL
SO
Otolaryngol Head Neck Surg. 2008 Jan;138(1 Suppl):S19-26.
 
OBJECTIVE: To summarize published studies that evaluate whether adenotonsillectomy performed for sleep-disordered breathing in children is associated with improvements in behavior, cognitive function, and quality of life, whether those improvements show correlation with polysomnographic parameters, and suggest how future studies may provide additional clinically significant information.
METHODS: A computerized search of the medical literature was performed for articles published between 1950 and March 2007 with the use of the OVID Medsearch database.
RESULTS: Analysis revealed 25 articles that satisfied the inclusion and exclusion criteria. All studies showed improvement in one or more of the specified outcome measures including general or disease specific quality of life, behavioral problems including hyperactivity and increased aggression or neurocognitive skills, such as memory, attention, or school performance. Limited correlation was often seen between improvements in outcome measures and polysomnographic variables.
CONCLUSION: Current studies strongly suggest adenotonsillectomy performed for sleep-disordered breathing in children is associated with improvements in quality of life, behavior, and cognitive function, but large, randomized, controlled studies are needed to provide definitive evidence of the benefits of this commonly performed surgical procedure in the general population.
AD
Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109, USA. garetz@med.umich.edu
PMID
48
TI
Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy.
AU
Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE
SO
Pediatrics. 2006 Apr;117(4):e769-78.
 
OBJECTIVES: Most children with sleep-disordered breathing (SDB) have mild-to-moderate forms, for which neurobehavioral complications are believed to be the most important adverse outcomes. To improve understanding of this morbidity, its long-term response to adenotonsillectomy, and its relationship to polysomnographic measures, we studied a series of children before and after clinically indicated adenotonsillectomy or unrelated surgical care.
METHODS: We recorded sleep and assessed behavioral, cognitive, and psychiatric morbidity in 105 children 5.0 to 12.9 years old: 78 were scheduled for clinically indicated adenotonsillectomy, usually for suspected SDB, and 27 for unrelated surgical care. One year later, we repeated all assessments in 100 of these children.
RESULTS: Subjects who had an adenotonsillectomy, in comparison to controls, were more hyperactive on well-validated parent rating scales, inattentive on cognitive testing, sleepy on the Multiple Sleep Latency Test, and likely to have attention-deficit/hyperactivity disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) as judged by a child psychiatrist. In contrast, 1 year later, the 2 groups showed no significant differences in the same measures. Subjects who had an adenotonsillectomy had improved substantially in all measures, and control subjects improved in none. However, polysomnographic assessment of baseline SDB and its subsequent amelioration did not clearly predict either baseline neurobehavioral morbidity or improvement in any area other than sleepiness.
CONCLUSIONS: Children scheduled for adenotonsillectomy often have mild-to-moderate SDB and significant neurobehavioral morbidity, including hyperactivity, inattention, attention-deficit/hyperactivity disorder, and excessive daytime sleepiness, all of which tend to improve by 1 year after surgery. However, the lack of better correspondence between SDB measures and neurobehavioral outcomes suggests the need for better measures or improved understanding of underlying causal mechanisms.
AD
Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA. chervin@umich.edu
PMID