SURGICAL AND NON-SURGICAL THERAPY OF OBSTRUCTIVE SLEEP APNEA SYNDROME IN CHILDREN.

Interventions of paediatric obstructive sleep apnea syndrome are complex, varied and multidisciplinary. The goal of the treatment is to restore optimal breathing during the night and to relieve associated symptoms. Evidence suggests that the surgical intervention with removal of the tonsils and adenoids will lead to significant improvements in the most incomplicated cases, as recently reported from a meta-analysis. However, post-operative persistence of this syndrome in paediatric population is more frequent than expected, which supports the idea of the complexity of this syndrome. Adenotomy alone may not be sufficient in children with OSAS, because it does not address oropharyngeal obstruction secondary to tonsillar hyperplasia. Continuous positive airway pressure can effectively treat this syndrome in selected groups of children, improving both nocturnal and daytime symptoms, but poor adherence is a limiting factor. For this reason, CPAP is not recommended as first-line therapy for OSAS when adenotonsillectomy is an option. It is now being investigated the incorporation of nonsurgical approaches for milder forms and for residual OSAS after surgical intervention. Althought adeno­tonsillar hypertrophy is the most common for OSAS in children; obesity is emerging as an equally important etiological factor. Therefore an intensive weight reduction program and adequate sleep hygiene are also important lifestyle changes that may be very effective in mitigating the symptoms of this syndrome. Pharmacological therapy (leukotriene antagonists, topical nasal steroids) is usually use for mild forms of OSAS and in children with associated allergic diseases. Special orthodontic treatment and oropharyngeal exercises are a relatively new and promising alternative therapeutic modality used in selected groups of children with OSAS

Response to the letter "What is the role of ADHD symptoms in obesity affecting cognitive outcome?"

Response to the letter 'What is the role of ADHD symptoms in obesity affecting cognitive outcom

Nephrotic Syndrome Following H1N1 Influenza in a 3-Year-Old Boy

Background: The pandemic influenza A/H1N1, spread through the world in 2009, producing a serious epidemic in Italy. Complications are generally limited to patients at the extremes of age (<6 months or >65 years) and those with comorbid medical illness. The most frequent complications of influenza involve the respiratory system. Case Presentation: A 3-year-old boy with a recent history of upper respiratory tract infection developed a nephrotic syndrome. Together with prednisone, furosemide and albumin bolus, a therapy with oseltamivir was started since the nasopharyngeal swab resulted positive for influenza A/H1N1. Clinical conditions and laboratory findings progressively improved during hospitalization, becoming normal during a 2 month follow up. Conclusion: The possibility of a renal involvement after influenza A/H1N1 infection should be considered

Autonomic imbalance during apneic episodes in pediatric obstructive sleep apnea

OBJECTIVES: To investigate the activity of the autonomic nervous system (ANS) during sleep in children with obstructive sleep apnea (OSA), in order to detect a possible cardiac ANS imbalance analyzing heart rate variability (HRV). METHODS: 43 subjects between 4 and 12years of age (7.26±2.8years), undergoing a diagnostic assessment for OSA were evaluated. A time domain index (R-apnea index) was developed to evaluate HRV strictly related to obstructive events during sleep. Poincaré plot of RR intervals during the whole night was calculated. RESULTS: R-apnea index was negatively correlated with apnea hypopnea index (AHI) (r=-0.360, p=0.028). AHI and the duration of the disease were the only variables that were significantly correlated with R-apnea index. Three groups were subsequently created according to polysomnographic findings considering AHI. R-apnea index resulted significantly lower in patient with severe OSA compared to primary snoring/mild OSA subjects (p<0.05). Looking at Poincaré plot, SD1 showed a diminishing trend with severity of OSA, however not reaching statistical significance. CONCLUSIONS: Our findings suggest an autonomic impairment in OSA children evidenced by the altered HRV both in the very short term (R-apnea index) and in short term (SD1)

Epilepsy and Sleep-Disordered Breathing as False Friends: A Case Report.

Because signs of nocturnal seizures can overlap with sleep respiratory events, clinicians can have difficulty distinguishing abnormal events related to sleep disorders from epileptic seizures. We describe the case of a 3-year-old child presenting with ictal electroencephalographic (EEG) activity associated with a particular form of atypical obstructive sleep apnea, characterized by increased respiratory rate, paradoxical breathing, desaturations, and tonic-dystonic posture associated with movement artifacts. Following cardiorespiratory polysomnography, the patient was initially misdiagnosed as having severe obstructive sleep apnea syndrome

Rapid maxillary expansion outcomes in treatment of obstructive sleep apnea in children

Objectives: Theobjectivesofthisstudyweretoconfirmtheefficacyofrapidmaxillaryexpansioninchildren withmoderateadenotonsillarhypertrophyinalargersampleandtoevaluateretrospectivelyitslong-term benefits in a group of children who underwent orthodontic treatment 10 years ago. Methods: After general clinical examination and overnight polysomnography, all eligible children underwent cephalometric evaluation and started 12 months of therapy with rapid maxillary expansion. Anewpolysomnographywasperformedattheendoftreatment(T1).Fourteenchildrenunderwentclinical evaluation and Brouilette questionnaire, 10 years after the end of treatment (T2). Results: Forty patients were eligible for recruitment. At T1, 34/40 (85%) patients showed a decrease of apnea–hypopneaindex(AHI)greaterthan20%(ΔAHI67.45%±25.73%)andweredefinedresponders.Only 6/40 (15%) showed a decrease &lt;20% of AHI at T1 and were defined as non-responders (ΔAHI −53.47%±61.57%).Moreover,57.5%ofpatientspresentedresidualOSA(AHI&gt;1ev/h)aftertreatment.Disease duration was significantly lower (2.5±1.4 years vs 4.8±1.9 years, p&lt;0.005) and age at disease onset was higher in responder patients compared to non-responders (3.8±1.5 years vs 2.3±1.9 years, p&lt;0.05). Cephalometric variables showed an increase of cranial base angle in non-responder patients (p&lt;0.05). Fourteen children (mean age 17.0±1.9 years) who ended orthodontic treatment 10 years previously showed improvement of Brouilette score. Conclusion: Starting an orthodontic treatment as early as symptoms appear is important in order to increase the efficacy of treatment. An integrated therapy is needed

Oropharyngeal exercises to reduce symptoms of OSA after AT

Abstract Purpose This study evaluated the efficacy of oropharyngeal exercises in children with symptoms of obstructive sleep apnea syndrome (OSA) after adenotonsillectomy. Methods Polysomnographic recordings were performed before adenotonsillectomy and 6 months after surgery. Patients with residual OSA (apnea-Hypopnea Index, AHI&gt;1 and persistence of respiratory symptoms) after adenotonsillectomy were randomized either to a group treated with oropharyngeal exercises (group 1) or to a control group (group 2). A morphofunctional evaluation with Glatzel and Rosenthal tests was performed before and after 2 months of exercises. All the subjects were re-evaluated after exercise through polysomnography and clinical evaluation. The improvement in OSA was defined by ΔAHI: (AHI at T1−AHI at T2)/AHI at T1×100. Results Group 1 was composed of 14 subjects (mean age, 6.01±1.55) while group 2 was composed of 13 subjects (mean age, 5.76 ± 0.82). The AHI was 16.79 ± 9.34 before adenotonsillectomy and 4.72±3.04 after surgery (p&lt;0.001). The ΔAHI was significantly higher in group 1 (58.01 %; range from 40.51 to 75.51 %) than in group 2 (6.96 %; range from −23.04 to 36.96 %). Morphofunctional evaluation demonstrated a reduction in oral breathing (p=0.002), positive Glatzel test (p&lt;0.05), positive Rosenthal test (p&lt;0.05), and increased labial seal (p&lt;0.001), and lip tone (p&lt;0.05). Conclusions Oropharyngeal exercises may be considered as complementary therapy to adenotonsillectomy to effectively treat pediatric OSA

Case reports of sleep phenotypes of ADHD. from hypothesis to clinical practice

Objective: Five sleep ADHD phenotypes have been hypothesized: (a) the hypo-arousal state of the "primary" form of ADHD, (b) the sleep phase advanced disorder, (c) sleep disordered breathing (SDB), (d) restless legs syndrome and/or periodic limb movements disorder (PLMD), and (e) epilepsy. Method: Five case reports are presented; each child but one underwent video-polysomnography. Results: The first case report is an example of ADHD and SDB, with improvement of hypersomnolence after resolution of sleep apnea. The second case shows the impact of delayed sleep onset latency in the pathogenesis of ADHD, and the efficacy of melatonin. The third case report describes the association with PLMD, with amelioration after iron supplementation. The other two cases are examples of ADHD and epilepsy, with clinical improvement after antiepileptic treatment was started. Conclusion: A diagnostic and therapeutic algorithm should be designed to find the best first-line treatment for ADHD and sleep problems/epilepsy. © 2013 SAGE Publications

Cognitive function in preschool children with sleep-disordered breathing

PURPOSE: The purposes of this study were to assess cognitive functions in preschool children with sleep-disordered breathing (SDB) and to compare them with matched control children. METHODS: A clinical sample of 2.5- to 6-year-old children with SDB was recruited. All children underwent sleep clinical record (SCR), which is a polysomnography (PSG)-validated questionnaire for diagnosing SDB, a polysomnography and a neurocognitive assessment. Normal controls were recruited from a kindergarten. They underwent the SCR and the cognitive assessment. RESULTS: We studied 41 children with primary snoring (PS)-mild obstructive sleep apnea syndrome (OSAS; M/F = 15/26, mean age 4.43 ± 0.94), 36 children with moderate-severe OSAS (M/F = 22/14, mean age 4.33 ± 1.02), and 83 controls (M/F = 33/50, mean age 4.5 ± 0.64). In the two groups, no differences were found in duration and age of onset of SDB, while a significant difference emerged in SCR score (p < 0.005). No differences emerged in the three groups in Verbal IQ, Performance IQ, and Global IQ scores, nor in any cognitive subtests. CONCLUSIONS: We demonstrated that SDB of all severities is not associated with cognitive impairment compared to the control group in preschool age

Impact of obesity on cognitive outcome in children with sleep-disordered breathing

OBJECTIVES: The objective of this study was to evaluate the impact of obesity on cognitive impairment, in children with obstructive sleep apnoea (OSA), children with OSA and obesity, and in normal controls. METHODS: Thirty-six children with OSA (group 1), 38 children with OSA and obesity (group 2) and 58 normal controls (group 3) were studied. The Total intelligence quotient (T-IQ), Verbal IQ (V-IQ) and the Performance IQ (P-IQ) scores were obtained using the Wechsler Intelligence Scale for Children - Third Edition Revised. All participants' parents filled out the questionnaire containing the attention deficit and hyperactive disorder rating scale to investigate symptoms of hyperactivity and attention deficit. Obese and non-obese children with sleep-disordered breathing (SDB) underwent polysomnography. RESULTS: T-QI and P-QI scores were significantly lower in group 2 with higher performance impairment at the subtest compared to other groups. In obese children, V-IQ was significantly correlated with age of onset (r = 0.335, p = 0.05) and duration of SDB (r = -0.362, p = 0.02), while P-IQ and T-IQ were correlated with body mass index (BMI) percentile (r = -0.341, p = 0.03) and respiratory disturbance index (RDI) (r = -0.321, p = 0.05), respectively. RDI and BMI negatively influenced T-IQ in obese children with OSA. No correlation was found between sleep parameters and IQ scores or subtest scores in all groups. CONCLUSIONS: Obese children with OSA showed higher cognitive impairment. Obesity has an additive and synergic action with that exerted by OSA, speeding up the onset of complication