Neurodevelopmental Outcomes at Two Years of Age for Premature Infants Diagnosed With Neonatal Obstructive Sleep Apnea

STUDY OBJECTIVES: Neurocognitive deficits have been shown in school-aged children with sleep apnea. The effect of obstructive sleep apnea (OSA) on the neurodevelopmental outcome of preterm infants is unknown. METHODS: A retrospective chart review was performed for all preterm infants ( 1 event/h. Regression analyses were performed to find a relationship between PSG parameters and cognitive, language, and motor scores. RESULTS: Fifteen patients (males: n = 10) were eligible for the study. Median postmenstrual age at the time of the PSG was 41 weeks (37-46). Median AHI for the cohort was 17.4 events/h (2.2-41.3). Median cognitive, language, and motor scores were 90 (65-125), 89 (65-121), and 91 (61-112), respectively. Mean end-tidal CO2 (median 47 mm Hg [25-60]) negatively correlated with cognitive scores (P = .01) but did not significantly correlate with language or motor scores. AHI was not associated with cognitive, language, or motor scores. CONCLUSIONS: The median score for cognitive, language, and motor scores for preterm infants with neonatal OSA were within one standard deviation of the published norm. Mean end-tidal CO2, independent of AHI, may serve as a biomarker for predicting poor cognitive outcome in preterm infants with neonatal OSA

The Evolving Educational Challenge: Balancing Patient Numbers, Conference Attendance, Sleep, and Resident Wellness

The Accreditation Council on Graduate Medical Education (ACMGE) 2011 guidelines for resident physicians specifically limited interns to 16-hour shifts and forced a paradigm switch from traditional overnight call.1 In “Shift Schedules and Intern Work Hours, Patient Numbers, Conference Attendance, and Sleep at a Single Pediatric Residency Program,”2 we prospectively compared intern work hours, patient numbers, conference attendance, sleep duration, pattern, and quality in 2003 and 2011 ACGME duty hour compliant call schedules at a single pediatric residency program. We concluded that a shift schedule reduced intern work hours and improved sleep duration and pattern. Although intern didactic conference attendance declined significantly during high census months, opportunities for experiential learning in a shift schedule remained robust with unchanged or increased intern patient numbers. Since the publication of our study, the ACGME has removed the 16-hour intern work hour limit, but still requires a maximum 80-hour work week and limits consecutive time on-task to 24 hours, plus 4 hours to transition care.1 Educators aim to provide the best clinical education for residents, while meeting requirements. In this progress report, we consider our study's findings in light of what has been published since October 2016 and discuss innovative scheduling, didactic and experiential resident education, resident sleep, and wellness and areas for future work

The Use of Computer Decision Support for Pediatric Obstructive Sleep Apnea Detection in Primary Care.

Study Objectives To (1) describe outcomes from a computer decision support system (CDSS) for pediatric obstructive sleep apnea (OSA) detection in primary care; and (2) identity the prevalence of children meeting criteria for an OSA referral. Methods A CDSS for OSA was implemented in two urban primary care clinics. Parents of children (age 2 to 11 years) presenting to the clinic were asked if their child snored regularly, with a positive response resulting in six additional OSA screening items. Primary care providers (PCPs) received a prompt for all snoring children, listing applicable OSA signs and symptoms and recommending further evaluation and referral for OSA. Results A total of 2,535 children were screened for snoring, identifying 475 snoring children (18.7%). Among snoring children, PCPs referred 40 (15.4%) for further evaluation. The prevalence of additional OSA signs and symptoms ranged from 3.5% for underweight to 43.7% for overweight. A total of 74.7% of snoring children had at least one additional sign or symptom and thus met American Academy of Pediatrics guidelines criteria for an OSA referral. Conclusions A CDSS can be used to support PCPs in identifying children at risk for OSA. Most snoring children met criteria for further evaluation. It will be important to further evaluate this referral threshold as well as the readiness of the sleep medicine field to meet this need

Unexplained Practice Variation in Primary Care Providers' Concern for Pediatric Obstructive Sleep Apnea

Objective To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography (PSG) completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA. Methods A computer decision support system that automated screening for snoring was implemented in five urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children between 1 and 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site. Results PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (p < .01; OR=0.13), Spanish language (p < .01; OR=0.53), provider training (p=.01; OR=10.19), number of training years (p=.01; OR=4.26) and child age (p<.01), with the youngest children least likely to elicit PCP concern for OSA (OR=0.20). No patient health factors (e.g., obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range 6% to 28%) and between specific providers (range 0% to 63%). Of children referred for PSG (n=100), 61% completed the study. Of these, 67% had OSA. Conclusions Results suggest unexplained small area practice variation in PCP concern for OSA amongst snoring children. It is likely that many children at-risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification

Polysomnography Reference Values in Healthy Newborns

Study objectives: Polysomnography (PSG) is increasingly used in the assessment of infants. Newborn PSG reference values based on recent standardization are not available. This study provides reference values for PSG variables in healthy newborn infants. Methods: Cross-sectional study of normal term newborn infants using standardized PSG collection and American Academy of Sleep Medicine interpretation criteria. Results: Thirty infants born between 37 and 42 weeks gestation underwent PSG testing before 30 days of age (mean 19.6 days). The infants had a mean sleep efficiency of 71% with average proportions of transitional, NREM and REM sleep estimated at 16.1%, 43.3% and 40.6% respectively. Mean arousal index was 14.7 events/h with respiratory arousal index of 1.2 events/h. Mean apnea-hypopnea index (AHI) was 14.9 events/h. Central, obstructive, and mixed apnea indices were 5.4, 2.3, and 1.2 events/h respectively. Mean oxygen saturation in sleep was 97.9% with a nadir of 84.4%. Mean end tidal CO2 was 35.4 mmHg with an average of 6.2% of sleep time spent above end-tidal CO2 45 mmHg and 0.6% above 50 mmHg. Conclusions: The sleep efficiency was significantly lower and the AHI was significantly higher compared to healthy children older than 1 year. The AHI was also higher than reported in healthy infants older than 1 month. These findings suggest current severity classifications of sleep apnea may not apply to newborn infants

Retrospective Analysis of Factors Leading to Pediatric Tracheostomy Decannulation Failure. A Single-Institution Experience

RATIONALE: There is a lack of evidence regarding factors associated with failure of tracheostomy decannulation. OBJECTIVES: We aimed to identify characteristics of pediatric patients who fail a tracheostomy decannulation challenge Methods: A retrospective review was performed on all patients who had a decannulation challenge at a tertiary care center from June 2006 to October 2013. Tracheostomy decannulation failure was defined as reinsertion of the tracheostomy tube within 6 months of the challenge. Data on demographics, indications for tracheostomy, home mechanical ventilation, and comorbidities were collected. Data were also collected on specific airway endoscopic findings during the predecannulation bronchoscopy and airway surgical procedures before decannulation. We attempted to predict the decannulation outcome by analyzing associations. MEASUREMENTS AND MAIN RESULTS: 147 of 189 (77.8%) patients were successfully decannulated on the first attempt. Tracheostomy performed due to chronic respiratory failure decreased odds for decannulation failure (odds ratio = 0.34, 95% confidence interval = 0.15-0.77). Genetic abnormalities (45%) and feeding dysfunction (93%) were increased in the population of patients failing their first attempt. The presence of one comorbidity increased the odds of failure by 68% (odds ratio = 1.68, 95% confidence interval = 1.23-2.29). Decannulation pursuit based on parental expectation of success, rather than medically determined readiness, was associated with a higher chance of failure (P = 0.01). CONCLUSIONS: Our study highlights the role of genetic abnormalities, feeding dysfunction, and multiple comorbidities in patients who fail decannulation. Our findings also demonstrate that the outcome of decannulation may be predicted by the indication for tracheostomy. Patients who had tracheostomy placed for chronic respiratory support had a higher likelihood of success. Absence of a surgically treatable airway obstruction abnormality on the predecannulation bronchoscopy increased the chances of success

Correlation between the clinical severity of laryngomalacia and endoscopic findings

Objective: To correlate the clinical severity of laryngomalacia (LM) with endoscopic findings, swallowing evaluations and polysomnography in a cohort of patients. Method: We conducted a retrospective analysis between 2017-2018 on a cohort of patients diagnosed with upper airway obstruction (UAO), stridor, noisy breathing or laryngomalacia. This study took place at the Pediatric Pulmonology Department, Riley Children's Hospital, Indianapolis, United States of America. Results: There were 157 patients with laryngomalacia included in the study. Patients with severe LM were significantly younger than those with mild LM (p=0.0214) and moderate LM (p=0.0220). Subjects with type I of LM were significantly older than type III (p=0.0051). When associations were tested between polysomnogram (PSG) variables and clinical severity, there were significant associations with age at PSG. The overall apnea-hypopnea index (AHI) in mild (p=0.0103) and moderate (p=0.0242) were significantly lower than the severe group. The rapid eye movement (REM) AHI was significantly lower in moderate cases than severe (p=0.0134). The end-tidal carbon dioxide (EtCO2) peak was significantly lower in mild cases than severe (p=0.0141). The total sleep time (TST) peripheral capillary oxygen saturation (SpO2) 90% occurs in both mild (p=0.0197) and moderate (p=0.0498) were significantly lower than the severe group. Conclusions: The severity of the clinical manifestations of LM did not correlate with the different endoscopic types in our study. The presence of cyanosis was associated with type III LM. Rapid eye movement AHI and EtCO2 in polysomnogram were remained significantly associated with clinical severity

Robin sequence: what the multidisciplinary approach can do

Robin sequence (RS) is a commonly encountered triad of micrognathia, glossoptosis, and airway obstruction, with or without a cleft palate. The management of airway obstruction is of paramount importance, and multiple reviews and retrospective series outline the diagnosis and treatment of RS. This article focuses on the multidisciplinary nature of RS and the specialists’ contributions and thought processes regarding the management of the RS child from birth to skeletal maturity. This review demonstrates that the care of these children extends far beyond the acute airway obstruction and that thorough monitoring and appropriate intervention are required to help them achieve optimal outcomes

Apical Lung Herniation Associated with Continuous Positive Airway Pressure in a 4-Year-Old Girl

We report a case of apical lung herniation through the superior thoracic aperture of an obese child using nocturnal CPAP. Lung herniation has been described in association with congenital thoracic abnormalities and elevated intra-thoracic pressure, such as trauma. This patient was hospitalized with community acquired pneumonia and required nocturnal CPAP for treatment of concurrent obstructive sleep apnea. Her lung hernia was discovered incidentally on routine follow-up chest radiography and resolved with cessation of CPAP treatment. Lung herniation in association with the use of continuous positive airway pressure (CPAP) has not been previously described