Sleep-disordered breathing in overweight and obese children and adolescents: prevalence, characteristics and the role of fat distribution

Aims

To determine the prevalence of sleep‐disordered breathing (SDB) in a clinical sample of overweight and obese children and adolescents, and to examine the contribution of fat distribution.

Methods

Consecutive subjects without chronic lung disease, neuromuscular disease, laryngomalacia, or any genetic or craniofacial syndrome were recruited. All underwent measurements of neck and waist circumference, waist‐to‐hip ratio, % fat mass and polysomnography. Obstructive apnoea index ⩾1 or obstructive apnoea–hypopnoea index (OAHI) ⩾2, further classified as mild (2⩽OAHI<5) or moderate‐to‐severe (OAHI⩾5), were used as diagnostic criteria for obstructive sleep apnoea (OSA). Central sleep apnoea was diagnosed when central apnoeas/hypopnoeas ⩾10 s were present accompanied by >1 age‐specific bradytachycardia and/or >1 desaturation <89%. Subjects with desaturation ⩽85% after central events of any duration were also diagnosed with central sleep apnoea. Primary snoring was diagnosed when: snoring was detected by microphone and normal obstructive indices and saturation.

Results

27 overweight and 64 obese subjects were included (40 boys; mean (standard deviation (SD)) age 11.2 (2.6) years). Among the obese children, 53% were normal, 11% had primary snoring, 11% had mild OSA, 8% had moderate‐to‐severe OSA and 17% had central sleep apnoea. Half of the patients with central sleep apnoea had desaturation <85%. Only enlarged tonsils were predictive of moderate‐to‐severe OSA. On the other hand, higher levels of abdominal obesity and fat mass were associated with central sleep apnoea.

Conclusion

SDB is very common in this clinical sample of overweight children. OSA is not associated with abdominal obesity. On the contrary, higher levels of abdominal obesity and fat mass are associated with central sleep apnoea.Obese children and adolescents are at risk of sleep‐disordered breathing (SDB). Several studies, using polysomnography, have documented the prevalence of obstructive sleep apnoea (OSA) in this group, ranging from 13% to 66%.^1,2,3,4,5 This wide range is probably due to factors such as ethnic predisposition, different inclusion criteria and diagnostic criteria for both obesity and OSA. Marcus et al⁴ also reported on the occurrence of central apnoeas of abnormal duration or followed by desaturation in 4 of 22 children studied. More objective data on the prevalence of these pathological central apnoeas are still lacking.In adults, studies have shown a strong correlation between central adiposity and OSA.^6,7,8,9,10 This association has not yet been studied in childhood obesity. We therefore determined the prevalence and characteristics of OSA and central sleep apnoea in a clinical sample of overweight and obese children and adolescents, and examined the association with fat distribution.     

Medikamentöse Behandlung von Atmungsstörungen bei adenotonsillärer Hyperplasie

Background

Adenotonsillar hyperplasia (ATH) can lead to severe breathing disorders, such as impaired nasal breathing, mouth breathing, snoring and obstructive sleep apnea. In such cases ATH should be treated mostly by performing adenoidectomy and/or adenotonsillectomy. There is increasing evidence that anti-inflammatory medication (AIM) is effective in treating ATH-related breathing disorders.

Objectives

The aim of this study was to provide evidence and recommendations for the use of AIM in the treatment of ATH-related breathing disorders.

Methods

In this study 12 national pediatric sleep experts were included into a Delphi process and formulated indications and recommendations.

Results

The use of AIM in the treatment of ATH-related breathing disorders is sufficiently supported by the results of randomized controlled trials and systematic reviews. Nasal beclometason and nasal mometason have been studied for the treatment of enlarged adenoids and nasal fluticason and oral montelukast for the treatment of obstructive sleep apnea. The use of AIM for first-line treatment should be restricted to selected indications, such as a characteristic patient age and exclusion of an acute upper respiratory tract infection. Evidence-based recommendations are given concerning indications, dosage, treatment duration and correct administration of AIM.

Conclusions

Anti-inflammatory medications are simple and effective alternatives for the treatment of ATH-related breathing disorders. These guidelines are intended to promote the use of AIM by pediatricians in ambulatory care settings.     

First night effect for polysomnographic data in children and adolescents with suspected sleep disordered breathing

Aims

To assess the presence of a first night effect (FNE) in children and adolescents and to examine if a single night polysomnography (PSG) is sufficient for diagnosing obstructive sleep apnoea syndrome (OSAS).

Methods

Prospective case study of 70 patients (group 1: 2–6 years, n = 22; group 2: 7–12 years, n = 32; group 3: 13–17 years, n = 16) referred for OSAS. Diagnostic criteria for OSAS: one or more of the following: (1) obstructive apnoea index (OAI) ⩾1; (2) obstructive apnoea hypopnoea index (oAHI) ⩾2; (3) SaO₂ ⩽89% in association with obstruction.

Results

In all age groups, but mainly in the oldest children, REMS increased during the second night, mainly at the expense of stage 2 sleep. The first night PSG correctly identified OSAS in 86%, 91%, and 100% of the children for groups 1, 2, and 3 respectively. This represents 9% false negatives for OSAS when only the first night PSG was used. All cases missed had mild OSAS, except for one with oAHI >5 on night 2. There were also seven patients with OSAS on night 1 but with a normal PSG on night 2: all had oAHI <5.

Conclusion

There is a FNE in children and adolescents. A single night PSG is sufficient for diagnosing OSAS, but in cases with a suggestive history and examination and with a negative first night, a second night study might be advisable.     

CO2-Laser-Tonsillotomie

Introduction

Partial removal of the tonsils using the CO₂ laser has been experiencing a veritable renaissance since the beginning of the 1990s.

Patients and Method

We present our results of 258 operated children (average age 4.3 years) in a retrospective analysis of patients having surgery between 1993 and 2007.

Results

In all cases, the decision for surgery was based on pharyngeal obstruction without a history of chronic tonsillitis. The procedure was performed in noncontact mode with the CO₂ laser at 10–15 W. One patient had postoperative bleeding (0.38%) but did not require further surgery. There was good postoperative relief of obstructive and snoring symptoms. No tonsillar abscess formation was seen in the follow-up period (median follow-up 4.6 years; range 1 month to 14 years).

Discussion

Taking into account the recent literature as well as our results, CO₂ laser tonsillotomy for simple tonsillar hyperplasia in early childhood has become a scientifically proven and accepted therapy. Moreover, the procedure is associated with low rates of postoperative bleeding and pain as well as a short inpatient period.     

Sleep-disordered breathing in overweight and obese children and adolescents: prevalence, characteristics and the role of fat distribution.

AIMS: To determine the prevalence of sleep-disordered breathing (SDB) in a clinical sample of overweight and obese children and adolescents, and to examine the contribution of fat distribution. METHODS: Consecutive subjects without chronic lung disease, neuromuscular disease, laryngomalacia, or any genetic or craniofacial syndrome were recruited. All underwent measurements of neck and waist circumference, waist-to-hip ratio, % fat mass and polysomnography. Obstructive apnoea index > or =1 or obstructive apnoea-hypopnoea index (OAHI) > or =2, further classified as mild (2< or =OAHI<5) or moderate-to-severe (OAHI> or =5), were used as diagnostic criteria for obstructive sleep apnoea (OSA). Central sleep apnoea was diagnosed when central apnoeas/hypopnoeas > or =10 s were present accompanied by >1 age-specific bradytachycardia and/or >1 desaturation <89%. Subjects with desaturation < or =85% after central events of any duration were also diagnosed with central sleep apnoea. Primary snoring was diagnosed when: snoring was detected by microphone and normal obstructive indices and saturation. RESULTS: 27 overweight and 64 obese subjects were included (40 boys; mean (standard deviation (SD)) age 11.2 (2.6) years). Among the obese children, 53% were normal, 11% had primary snoring, 11% had mild OSA, 8% had moderate-to-severe OSA and 17% had central sleep apnoea. Half of the patients with central sleep apnoea had desaturation <85%. Only enlarged tonsils were predictive of moderate-to-severe OSA. On the other hand, higher levels of abdominal obesity and fat mass were associated with central sleep apnoea. CONCLUSION: SDB is very common in this clinical sample of overweight children. OSA is not associated with abdominal obesity. On the contrary, higher levels of abdominal obesity and fat mass are associated with central sleep apnoea.     

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 completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA.

Schmerzmanagement bei Kindern in der Schweiz

Objective

Pain in hospitalized children is often undertreated. The aim of the study was to assess the current pain management for children in Switzerland.

Study design

A postal questionnaire was sent to all pediatric units in Switzerland.

Result

A total of 27 of 45 units replied (60% response). Most units used tools for pain assessment (96%) and had a guideline for pain management (78%). Procedural and postoperative pain are always (100%) treated. Premature infants and children in intensive care units often (>?87%) receive analgesics during invasive procedures. However, only 44% of intensive care units have a guideline for this.

Conclusion

Benefits of an effective pain management in children are well established. Many measures have been applied in Switzerland. However, there is still room for improvement, e.g., less than half of all intensive care units rely on guidelines for analgesics during invasive procedures.     

Melanotic neuroectodermal tumour of infancy: CT and MR findings

Background

Melanotic neuroectodermal tumour of infancy (MNTI) is a rare neoplasm of neural crest origin.

Objective

To describe three further cases of MNTI, with emphasis on CT and MRI findings.

Materials and methods

Data for children with histologically confirmed MNTI following biopsy or surgery were retrieved. Three children with available imaging at the time of diagnosis were included in the study.

Results

All three children had primary tumour in the head and neck region: one in the maxilla, one in the occipital bone (extra-axial but with intracranial extension) and one with an unusual tumour growing exophytically from the subcutaneous tissues adjacent to the occipital bone. All tumours were iso/hypointense both on T1- and T2-weighted MRI, and showed marked contrast enhancement in their non-ossified components. CT allowed identification of bone destruction and remodelling.

Conclusion

Our findings are consistent with previously reported cases of MNTI regarding age at presentation and location in the head and neck region. Our MR findings did not demonstrate the typical pattern of T1-shortening expected from melanin deposition.     

Utility of CT in the diagnosis and management of small-bowel obstruction in children

Background

CT is often used in the diagnosis and management of small-bowel obstruction in children.

Objective

To determine sensitivity of CT in delineating presence, site and cause of small-bowel obstruction in children.

Materials and methods

We retrospectively reviewed the CT scans of 47 children with surgically proven small-bowel obstruction. We noted any findings of obstruction and the site and cause of obstruction. Presence, absence or equivocal findings of bowel obstruction on abdominal radiographs performed prior to CT were also noted. We reviewed patient charts for clinical details and surgical findings, including bowel resection. Statistical analysis was performed using Fisher exact test to determine which CT findings might predict bowel resection.

Results

CT correctly diagnosed small-bowel obstruction in 43/47 (91.5%) cases. CT correctly indicated site of obstruction in 37/47 (78.7%) cases and cause of obstruction in 32/47 (68.1%) cases. Small-bowel feces sign was significantly associated with bowel resection at surgery (P?=?0.0091). No other CT finding was predictive of bowel resection. Out of 41 children who had abdominal radiographs before CT, 29 (70.7%) showed unequivocal obstruction, six (14.6%) showed equivocal findings and six (14.6%) were unremarkable.

Conclusion

CT is highly sensitive in diagnosing small-bowel obstruction in children and is helpful in determining the presence of small-bowel obstruction in many clinically suspected cases with equivocal or normal plain radiographs. CT also helps to determine the site and cause of the obstruction with good sensitivity.     

An experience of facility-based management of severe acute malnutrition in children aged between 6–59 months adopting the World Health Organization recommendations

Objective

To study the output indicators of a nutritional rehabilitation center to assess its performance.

Methods

Data of 182 children aged between 6–59 months with severe acute malnutrition in a nutritional rehabilitation center were analyzed retrospectively. Identification and treatment of severe acute malnutrition was done according to World Health Organization recommendations.

Results

The recovery rate, death rate, defaulter rate, mean (SD) weight gain and mean (SD) duration of stay in the nutritional rehabilitation center were 68%, 2.2%, 4.4%, 13.0 (9.0) g/kg/d, 12.7 (6.8) days, respectively.

Conclusion

Nutritional rehabilitation centers are effective in management of severe malnutrition.     

Nichtinvasive Beatmung bei neuromuskulären Erkrankungen

Introduction. Sleep-disordered breathing (SDB) and respiratory failure (RF) are inevitable consequences of progressive neuromuscular disorders (NMD).The aim of the study was to investigate the immediate impact of noninvasive ventilation (NIV) on SDB, gas exchange, and symptoms in children and adolescents with advanced NMD. Methods. Twenty-six children and adolescents with NMD, aged 12.7±4.7 years,were ventilated noninvasively during sleep because of SDB (n=12) or chronic RF (n=14).Pressure assisted ventilation was applied via masks.The influence of NIV was assessed with arterial blood gas (ABG),polysomnography and capnometry (P_tcCO₂), and a symptom questionnaire before institution of NIV, after 3 days and after 3 months of NIV. Results. NIV normalized ABG in patients with daytime RF and nocturnal respiration and gas exchange. NIV resulted in a significant reduction of sleep arousals and nocturnal heart rate.Patients reported a significant improvement in symptoms (p<0.001 for all). Conclusions. In children with NMD, intermittent nocturnal NIV normalizes sleep-disordered breathing and respiratory failure and thereby improves symptoms as well.     

Heterotaxy syndromes and abnormal bowel rotation

Background

Bowel rotation abnormalities in heterotaxy are common. As more children survive cardiac surgery, the management of gastrointestinal abnormalities has become controversial.

Objective

To evaluate imaging of malrotation in heterotaxy with surgical correlation and provide an algorithm for management.

Materials and methods

Imaging reports of heterotaxic children with upper gastrointestinal (UGI) and/or small bowel follow-through (SBFT) were reviewed. Subsequently, fluoroscopic images were re-reviewed in conjunction with CT/MR studies. The original reports and re-reviewed images were compared and correlated with surgical findings.

Results

Nineteen of 34 children with heterotaxy underwent UGI, 13/19 also had SBFT. In 15/19 reports, bowel rotation was called abnormal: 11 malrotation, 4 non-rotation, no cases of volvulus. Re-review, including CT (10/19) and MR (2/19), designated 17/19 (90%) as abnormal, 10 malrotation (abnormal bowel arrangement, narrow or uncertain length of mesentery) and 7 non-rotation (small bowel and colon on opposite sides plus low cecum with probable broad mesentery). The most useful CT/MR findings were absence of retroperitoneal duodenum in most abnormal cases and location of bowel, especially cecum. Abnormal orientation of mesenteric vessels suggested malrotation but was not universal. Nine children had elective bowel surgery; non-rotation was found in 4/9 and malrotation was found in 5/9, with discrepancies (non-rotation at surgery, malrotation on imaging) with 4 original interpretations and 1 re-review.

Conclusion

We recommend routine, early UGI and SBFT studies once other, urgent clinical concerns have been stabilized, with elective laparoscopic surgery in abnormal or equivocal cases. Cross-sectional imaging, usually obtained for other reasons, can contribute diagnostically. Attempting to assess mesenteric width is important in differentiating non-rotation from malrotation and more accurately identifies appropriate surgical candidates.     

Sleep disordered breathing in children with achondroplasia

Background

Children with achondroplasia often have breathing problems, especially during sleep. The most important treatments are adenotonsillectomy (for treating upper obstruction) and/or neurosurgery (for resolving cervicomedullar junction stenosis).

Data sources

We reviewed the scientific literature on polysomnographic investigations which assessed the severity of respiratory disorders during sleep.

Results

Recent findings have highlighted the importance of clinical investigations in patients with achondroplasia, differentiating between those that look for neurological patterns and those that look for respiratory problems during sleep. In particular, magnetic resonance imaging (MRI) and somatosensory evoked potentials are the main tools to evaluate necessary neurosurgery and over myelopathy, respectively.

Conclusions

The use of polysomnography enables clinicians to identify children with upper airway obstruction and to quantify disease severity; it is not suitable for MRI and/or neurosurgery considerations.

     

Contrast enema findings in patients presenting with poor functional outcome after primary repair for Hirschsprung disease

Background

The radiologic evaluation of Hirschsprung disease is well described in the literature. However, there is a paucity of literature describing the appearance of the neo-rectum and colon after repair, specifically describing findings in patients with poor functional outcome, which would suggest the need for reoperation.

Objective

We describe findings on contrast enema and correlate them with surgical findings at reoperation in children with poor functional outcome after primary repair for Hirschsprung disease who suffer from bowel dysfunction that can manifest with either soiling or obstructive symptoms such as enterocolitis.

Materials and methods

Children were identified from our colorectal surgery database. At the time of abstract submission, 35 children had contrast enemas prior to reoperation. Additional children continue to present for evaluation. The majority of children included in the study had their primary repair performed elsewhere. The initial procedures included: Duhamel (n?=?11), Soave (n?=?20) or Swenson (n?=?3). One child had undergone a primary Soave repair and subsequently had a Swenson-type reoperation but continued to have a poor outcome. One child’s initial surgical repair could not be determined. Images were reviewed by a staff pediatric radiologist and a pediatric radiology fellow.

Results

Findings encountered on contrast enema in these children include a distal narrowed segment due to stricture or aganglionic/transitional zone segment (8), dilated/hypomotile distal segment (7), thickened presacral space due to compressing Soave cuff (11), dilated Duhamel pouch (8), active enterocolitis (3) and partially obstructing twist of the pull-through segment (1).

Conclusion

Multiple anatomical and pathological complications exist that can lead to bowel dysfunction in children after repair of Hirschsprung disease. Little recent literature exists regarding the radiographic findings in children. We had the opportunity to review a substantial series of these children, describe the contrast enema findings in these difficult cases and correlate them with operative findings. Radiologic evaluation is key to assessing such patients; it defines the potential anatomical problem with the pull-through and facilitates surgical planning.     

Liver histology in choledochal cyst- pathological changes and response to surgery: the overlooked aspect?

Background

Histological changes in the liver in cases of choledochal cyst are seldom reported. The severity of liver pathology has an impact on the presentation, course and prognosis of hepatobiliary lesions. This study aims to record the histological changes in the liver and response to surgery in patients with choledochal cyst and to correlate these with the clinical symptoms and recovery.

Materials and methods

All children <12 years diagnosed with choledochal cyst were evaluated clinically, radiologically and biochemically at presentation. Excision of the cyst with intra-operative liver biopsy was done. Liver biopsy was repeated after 6 months of surgery. Both the liver biopsies were compared objectively in terms of hepatocellular damage, cholestasis, parenchymal inflammation, bile duct inflammation, bile duct proliferation, portal fibrosis and central venous distension with appropriate statistical tests. Clinical presentation and recovery were correlated with grades of liver pathology.

Results

Forty-six patients were included. Pathological damage was observed in all the livers preoperatively. Post-operatively, significant resolution of histological changes was seen in hepatocellular damage (p < 0.0001), parenchymal inflammation (p = 0.0001), cholestasis (p = 0.0003) and bile duct proliferation (p = 0.0001). Portal fibrosis did not resolve. Central venous distension worsened. Severity of damage correlated significantly with younger age, symptom severity, anomalous pancreatico-biliary junction (APBJ) and obstructive biliary clearance on Tc-99 HIDA scan. Post-operative bile duct proliferation, bile duct inflammation and portal fibrosis were associated with cholangitis, re-do surgery and obstructive Tc-99 HIDA scan clearance in the post-operative period.

Conclusions

All patients with choledochal cyst show pathological changes in liver of varying severity. More severe symptoms, younger age and APBJ are associated with higher degree of liver damage. Except portal fibrosis and central venous distension, all other pathological changes regress after surgery. Regression can be hindered by post-op cholangitis, obstructive biliary clearance and post-op IHBR dilatation.     

Ambulatory clinical parameters and sleep respiratory events in a group of obese children unselected for respiratory problems

Background

Obstructive sleep apnea in children is frequently due to tonsil and adenoid hypertrophy. This study aimed to investigate the relationship between ambulatory clinical parameters and sleep respiratory events in obese children.

Methods

We carried out a prospective respiratory sleep study between 2013 and 2015. Nails obstruction, tonsils enlargement and palate position were subjectively measured. Italian attention deficit hyperactivity disorder (ADHD) rating scale for parents was also performed. The polygraph study was performed using a portable ambulatory device.

Results

Forty-four obese children were consecutively recruited into this study. Mild sleep respiratory disturbance was showed in 31.8 % of patients; 18.2% previously had an adeno (tonsillectomy). In 50% of these obese children, both apnea-hypopnea index and oxygen desaturation index showed polygraph abnormal results. ADHD rating scale for parents scores were positive in 9.1% of patients.

Conclusions

We found a high rate of mild sleep respiratory disturbance and ADHD-like symptoms referred by parents. The respiratory disturbance was not totally cured by surgery. Finally, otorhinolaryngology variables were not able to explain mild sleep respiratory disturbance.

     

To Compare the Effect of Dextromethorphan, Promethazine and Placebo on Nocturnal Cough in Children Aged 1–12 y with Upper Respiratory Infections: A Randomized Controlled Trial

Objectives

To evaluate whether promethazine and dextromethorphan reduce nocturnal cough and improve sleep quality in children aged 1–12 y with upper respiratory tract infection (URI).

Methods

This randomised double-blinded placebo-controlled trial was conducted in Pediatric outpatient department of Lok Nayak Hospital, Delhi. After randomization into promethazine, dextromethorphan and placebo groups, parental assessment of 120 children with URI for nocturnal cough severity (child), post-tussive vomiting (child) and sleep quality (child and parent) on the night before enrolment and after 3 d of assigned medication was measured using an internally validated indigenously prepared ordinal scale.

Results

Entire cohort improved in all the study parameters after 3 d. However, no superior benefit was noted when individual parameters were compared in the promethazine and dextromethorphan groups with the placebo group. Adverse effects were more frequent in the dextromethorphan and promethazine groups although the difference was not statistically significant.

Conclusions

Nocturnal cough in URI is self-resolving and dextromethorphan and promethazine prescribed for the same are not superior to placebo.     

Small bowel volvulus with a jejunal trichobezoar

Background

Small bowel volvulus caused by a jejunal trichobezoar is an extremely rare and life-threatening emergency in children.

Case characteristics

An 8-year-old girl with abdominal pain and persistent bilious vomiting.

Observation

The abdominal computed tomography scan showed a solitary intraluminal mass and a whirl sign, suggesting the small bowel volvulus. Emergency laparoscopic exploration revealed the rotated segment of small bowel loops by a jejunal trichobezoar.

Outcome

Satisfactory recovery after surgery.

Message

Trichobezoars should be considered in the differential diagnosis of abdominal pain and projectile vomiting in children.     

Pulmonary function and exercise capacity in children following lung resection surgery

Purpose

To study lung function and exercise capacity in children following lung resection surgery.

Methods

Children aged 6?C18?years who had lung resection surgery were studied and compared to normal children (age and sex matched). All had spirometry/body plethysmography and exercise stress test (performed by treadmill and modified Balke protocol).

Results

13 Patients and 13 controls were studied (age 13.2?±?3.3?years; 46.2?% male). The age at the time of lung resection surgery was 6.5?±?4.7?years. The time interval between post-surgery and the tests was 6.8?±?4.4?years. The most common indication for lung resection surgery was congenital lung malformations (61.5?%). 76.9?% of the patients had abnormal lung function. Exercise intolerance due to pulmonary limitations was found in 23.1?% of the patients. At the anaerobic threshold, the $ V_{{{\text{O}}_{2} }} /{\text{kg}} $ was not different between the patients and the controls. However, at the end of the exercise, the patients demonstrated lower peak $ V_{{{\text{O}}_{2} }} /{\text{kg}} $ than the controls (33.6?±?6.0 vs. 39.3?±?8.7?ml/min/kg; p?<?0.01).

Conclusions

Abnormal lung functions and exercise intolerance were found in children following lung resection surgery. Children who had lung resection surgery had lower exercise capacity than normal children if the exercise was beyond the anaerobic threshold.