Comparison of limited monitoring using a nasal-cannula flow signal to full polysomnography in sleep-disordered breathing

STUDY OBJECTIVES: Evaluate the utility of overnight monitoring limited to nasal cannula airflow and oximetry in the diagnosis of obstructive sleep apnea-hypopnea syndrome (OSAHS). DESIGN: Prospective randomized study, blinded analysis. SETTING: Sleep disorder center, academic institution. PARTICIPANTS: 56 patients with suspected OSAHS, 10 normal volunteers. MEASUREMENTS AND RESULTS: In-laboratory full nocturnal polysomnography (NPSG) and unattended ambulatory study with monitoring of only airflow and oximetry performed in randomized order. Obstructive respiratory events were scored on the full NPSG while visualizing all signals and then rescored on the full NPSG and on the ambulatory study while visualizing only airflow and oximetry signals. Respiratory disturbance indexes (RDI) for the limited studies (RDIFlowNPSG and RDIFlowAmbulatory) were calculated as the sum of the apneas and hypopneas (defined using airflow amplitude and O2 desaturation) divided by the valid flow-signal time. The reference RDIFullNPSG was calculated from the sum of the apneas and hypopneas (defined using flow amplitude, O2 desaturation and electroencephalographic arousal) identified on the full NPSG divided by the total sleep time. RDIFullNPSG was greater than RDIFlowNPSG (bias = 5.6 events per hour) and RDIFlowAmbulatory (bias = 10.9 events per hour), but the differences were mainly in subjects with an RDI > 40 events per hour. The diagnostic sensitivity and specificity for the diagnosis of OSAHS using a cutoff of 18 events per hour were 96% and 93% using the flow signal from the NPSG and 88% and 92% using the flow signal from the ambulatory study performed on a separate night. CONCLUSIONS: In subjects with OSAHS, analysis of the flow signal from a nasal cannula can provide an RDI similar to that obtained in a full NPSG.     

Risk for sleep-disordered breathing and home and classroom behavior in Hispanic preschoolers

Pediatric sleep-disordered breathing (SDB) is known to negatively impact home and classroom behavior. Preschool-age Hispanic children from Spanish-speaking households are at elevated risk for poor school readiness. The authors used a multi-informant approach to assess home and preschool behavior among Hispanic children at risk for SDB (n = 67). Higher parent-reported SDB risk and elevated snoring were associated with parent- and teacher-reported problem behaviors and poorer teacher-reported classroom executive function among boys; elevated snoring was associated with internalizing behaviors among girls. Elevated snoring may be associated with problems related to impaired inhibitory self-control, suggesting the need for early intervention in order to improve school readiness among these a priori defined at-risk Hispanic children.     

Arousals in sleep-disordered breathing: patterns and implications

STUDY OBJECTIVE: To describe the whole spectrum of electroencephalographic (EEG) transients associated with the termination and recovery of obstructed respiratory events and, thus, widen the recognized spectrum of arousal phenomena from sleep. DESIGN: Retrospective review of diagnostic polysomnograms. SETTING: American Academy of Sleep Medicine (AASM)-accredited multidisciplinary sleep disorders center. PATIENTS: 17 patents with obstructive sleep-disordered breathing. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Nasal airflow using a nasal-cannula-pressure-transducer system and oral flow by a thermistor were used to score apneas and hypopneas; the latter included flow-limitation events. The EEG patterns that crested or occurred within 2 to 3 seconds of respiratory recovery were recorded, and posthoc categories were created for the purpose of tabulation ranging from an AASM 3-second arousal to a single K-complex with no electromyographic increase. Chi-square statistic was calculated to assess the difference in EEG patterns at event termination between apneas and hypopneas. Score-rescore agreement was tested. Apneas were significantly more likely to be associated with a 3-second arousal than were hypopneas, but all types of EEG change were seen with both types of events. Spindles were rarely seen with arousal-linked K-complexes. The majority of events in rapid eye movement sleep were terminated with visible electromyography tone increase. CONCLUSIONS: The spectrum of EEG change associated with the termination of respiratory events identified by using a nasal-cannula-pressure-transducer system is wider than that recognized as arousal phenomena by the 1992 AASM criteria. Scoring arousals with the 3-second rule may falsely minimize the apparent impact of abnormal breathing on sleep. The time may be right to update arousal recognition rules.     

Mechanisms of sleep-disordered breathing: causes and consequences

Obstructive sleep apnea (OSA) is very common in the general population and is characterized by ineffective inspiratory efforts against a collapsed upper airway during sleep. Collapse occurs mainly at the level of the velopharynx and oropharynx due to a combination of predisposing anatomy and the withdrawal of pharyngeal dilator activity during sleep. Central sleep apnea (CSA) is a manifestation of chemoreflex control instability, leading to periods of inadequate respiratory drive sufficient to trigger breathing, usually alternating with periods of hyperventilation. While both forms of apnea are the result of differing pathophysiology, it has become increasingly clear that OSA and CSA often coexist in the same patient, the existence of one can predispose to the other, and that the two are not as distinct as previously thought. Both OSA and CSA exert a number of acute deleterious effects including intermittent hypoxia, arousals from sleep, and swings in negative intrathoracic pressure, which in turn lead to chronic physiologic consequences such as autonomic dysregulation, endothelial dysfunction, and cardiac remodeling. These underlying pathophysiological mechanisms provide a framework for understanding why OSA and CSA may predispose to cardiovascular diseases like ischemic heart disease and stroke.     

Incidence and microbiology of peritonsillar abscess: the influence of season,age, and gender

To explore the correlations among the incidence, microbiology, season, gender, and age in patients with peritonsillar abscess (PTA) in order to identify risk factors for PTA development. All patients with PTA treated at private ENT practices in Aarhus County and in the Ear-Nose-Throat Departments at Aarhus University Hospital and Randers Hospital from January 2001 to December 2006 were included in the study. Age- and gender-stratified population data for Aarhus County for the same 6 years were obtained. The incidence rate of PTA increased from childhood to peak in teenage life and declined afterward gradually until old age. Girls predominated over boys until the age of 14 years. Subsequently, men were more frequently affected than women. Fusobacterium necrophorum (FN) was significantly more prevalent than group A Streptococcus (GAS) among patients aged 15–24 years (P?<?0.001). In contrast, GAS was significantly more frequently recovered among children aged 0–9 years and adults aged 30–39 years compared with FN (P?<?0.001 and P?=?0.017 respectively). The seasonal variation of PTA was statistically insignificant (P?=?0.437). However, GAS was significantly more frequently recovered in the winter and spring than in the summer (P?=?0.002 and P?=?0.036 respectively). There was a trend toward a higher incidence of FN infection during the summer than the winter (P?=?0.165). Although the collected PTA incidence was stable throughout the year, the microbiology fluctuated with seasons. Patients aged 15–24 years are at an increased risk of PTA due to FN, which may have clinical implications for the diagnostic work-up and treatment of patients with acute tonsillitis.     

Health-related quality of life and sleep-disordered breathing in children

STUDY OBJECTIVES: To assess the extent to which sleep-disordered breathing (SDB) is associated with impairment of health-related quality of life (HRQOL) in children DESIGN: Observational study of pediatric participants in a longitudinal genetic-epidemiologic cohort study of SDB. SETTING: Community-based; studies conducted at participants' homes PARTICIPANTS: 298 children, aged 11.1 years +/- 3.5 SD; 54% females; 61% African-American or Other; 81% with a family member identified with laboratory-confirmed SDB. INTERVENTIONS: Not applicable MEASUREMENTS AND RESULTS: The HRQOL was assessed with the Child Health Questionnaire (CHQ-PF50), a 50-item parent-completed form that measures 14 multidimensional health concepts. Sleep-disordered breathing (SDB) was assessed with ovemight in-home monitoring that recorded nasal-oral airflow, pulse oximetry, chest-wall impedance, and heart rate. Using logistic regression analyses, each CHQ scale outcome was analyzed independently for the effect of SDB, adjusting for other potential confounding variables and for family-correlated data. Significant differences in overall physical health and complaints of bodily pain were observed in children with generally mild levels of SDB. Relationships persisted after adjustment for age, gender, ethnicity, obesity, and asthma. CONCLUSIONS: SDB in children is associated with measurably lower levels of specific dimensions of HRQOL in children. Decrements in HRQOL are measurable even for children with mild SDB, with increasing effects observed with more severe SDB.     

Lung function, diagnosis, and treatment of sleep-disordered breathing in children with achondroplasia

Children with achondroplasia are at risk of sleep-disordered breathing. The aim of the study was to evaluate lung function and sleep-disordered breathing in children with achondroplasia. An interview, clinical examination, lung function tests with blood gases, and a polygraphic sleep study were obtained as part of routine annual evaluation in consecutive children with achondroplasia. We included 30 children (median age 3.0 years, range: 0.4-17.1) over a period of 21 months. Habitual snoring and witnessed apneas were observed in 77% and 33% of the patients, respectively. Prior to the sleep study, 10/29 (34%) patients had undergone upper airway surgery and 5/29 (17%) craniocervical decompression operation. Arterial blood gases were abnormal in two (7%) patients. Sleep findings were abnormal in 28/30 (93%) patients. Eleven (37%) patients had an apnea index≥1?event/hr and 26 (87%) had an apnea-hypopnea index≥5?events/hr. The ≥3% desaturation index was >5/hr in 22 (73%) patients. Sixteen (53%) patients had a minimal pulse oximetry<90% but only two (7%) patients had a maximal transcutaneous carbon dioxide pressure>50?mmHg during sleep. As a consequence, the following therapeutic interventions were performed: upper airway surgery in four patients and noninvasive positive pressure ventilation (NPPV) in five other patients, resulting in an improvement in sleep studies in all nine patients. Systematic sleep studies are recommended in children with achondroplasia because of the high prevalence of sleep-disordered breathing. Upper airway surgery and NPPV are effective treatments of sleep-disordered breathing.     

Snoring and sleep-disordered breathing in young children: subjective and objective correlates

STUDY OBJECTIVES: We sought to assess the predictive validity of parental report of snoring and other behaviors by comparing such reports with objective findings from overnight polysomnography for the evaluation of sleep-disordered breathing in 2 nonclinical samples, namely, at-risk preschoolers and an older group reflective of the general community. Predictive validity of snoring alone and a score based on multiple child behaviors were compared to outcome at different levels of severity of sleep-disordered breathing. DESIGN: Retrospective observational study. SETTING: Questionnaires were distributed through school programs; polysomnography was performed at Kosair Children's Hospital in Louisville, Kentucky. PARTICIPANTS: One hundred twenty-two preschoolers and 172 5- to 7-year-olds, and their parents, participated in both subjective-report and objective-recording portions of the study. MEASUREMENTS AND RESULTS: Compared to the presence of snoring on polysomnography, parental report of frequent snoring was highly sensitive and specific for both age groups. At all but the lowest level of severity of sleep-disordered breathing, predictive ability was higher for both groups when a parental-report score based on multiple measures of child behavior was applied, compared to parental report of snoring alone. The profiles of these predictive child behaviors differed between the 2 groups, as did their sensitivity and specificity, at their high ranges of parental report. CONCLUSIONS: Scores derived from parental-report questionnaires of children's snoring and other sleep and wake behaviors can be used as surrogate predictors of snoring or sleep-disordered breathing in children. However, design and interpretation should consider age, risk status, and the purpose of the screening assessment.     

Sleep in overweight adolescents: shorter sleep, poorer sleep quality, sleepiness, and sleep-disordered breathing

OBJECTIVE: To document the sleep of overweight adolescents and to explore the degree to which weight-related sleep pathology might account for diminished psychosocial outcome. METHODS: Sixty children aged 10-16.9 from a weight-management clinic were compared to 22 healthy controls using comprehensive actigraphic, polysomnographic, and parent- and self-report questionnaire assessments. RESULTS: Overweight participants averaged more symptoms of sleep-disordered breathing, later sleep onset, shorter sleep time, and more disrupted sleep than controls. Although the groups did not differ in self-reported sleep habits, multiple concerns were reported by parents of overweight participants, including daytime sleepiness, parasomnias, and inadequate sleep. Group differences in academic grades and depressive symptoms were at least partially accounted for by short sleep and daytime sleepiness. CONCLUSIONS: Excessive weight is associated with an increased risk of sleep problems. There is a need for further research in this area and for clinicians who work with overweight children to evaluate their sleep.     

Identification of sleep-disordered breathing in children: variation with event definition

STUDY OBJECTIVES: To determine the effect of varying approaches to the measurement of the respiratory disturbance index (RDI) on identification of sleep disordered breathing (SDB) in children. DESIGN: Cross-sectional study of SDB in a well-characterized birth cohort (stratified for term and preterm birth) participating in longitudinal studies of cognition and behavior. SETTING: Community-based; overnight studies conducted in participant's homes. PARTICIPANTS: 433 children, ages 8-11 years, un-referred for clinical assessment of SDB. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Participants underwent unattended overnight in-home recording of respiratory inductance plethysmography, pulse oximetry, body position, and heart rate. The relationships among RDIs derived from various definitions of apnea and hypopneas and thresholds for frequency of events were assessed. Median RDI varied by more than 20-fold for definitions using the more liberal criteria for event definition (all respiratory events; i.e., central or obstructive events and hypopneas with no requirement for associated desaturation) to the most conservative definition (using obstructive apneas only or obstructive apnea and hypopneas requiring a 5% associated desaturation). Prevalence estimates for SDB based on RDIs that included central apneas were 40% to 140% higher than those that excluded central apneas. CONCLUSIONS: Different approaches for quantifying RDI contribute to substantial variability in identification and classification of SDB in children and will lead to discrepant estimates of its presence and severity.     

Prospective study of the association between sleep-disordered breathing and hypertension

BACKGROUND: Sleep-disordered breathing is prevalent in the general population and has been linked to chronically elevated blood pressure in cross-sectional epidemiologic studies. We performed a prospective, population-based study of the association between objectively measured sleep-disordered breathing and hypertension (defined as a laboratory-measured blood pressure of at least 140/90 mm Hg or the use of antihypertensive medications). METHODS: We analyzed data on sleep-disordered breathing, blood pressure, habitus, and health history at base line and after four years of follow-up in 709 participants of the Wisconsin Sleep Cohort Study (and after eight years of follow-up in the case of 184 of these participants). Participants were assessed overnight by 18-channel polysomnography for sleep-disordered breathing, as defined by the apnea-hypopnea index (the number of episodes of apnea and hypopnea per hour of sleep). The odds ratios for the presence of hypertension at the four-year follow-up study according to the apnea-hypopnea index at base line were estimated after adjustment for base-line hypertension status, body-mass index, neck and waist circumference, age, sex, and weekly use of alcohol and cigarettes. RESULTS: Relative to the reference category of an apnea-hypopnea index of 0 events per hour at base line, the odds ratios for the presence of hypertension at follow-up were 1.42 (95 percent confidence interval, 1.13 to 1.78) with an apnea-hypopnea index of 0.1 to 4.9 events per hour at base line as compared with none, 2.03 (95 percent confidence interval, 1.29 to 3.17) with an apnea-hypopnea index of 5.0 to 14.9 events per hour, and 2.89 (95 percent confidence interval, 1.46 to 5.64) with an apnea-hypopnea index of 15.0 or more events per hour. CONCLUSIONS: We found a dose-response association between sleep-disordered breathing at base line and the presence of hypertension four years later that was independent of known confounding factors. The findings suggest that sleep-disordered breathing is likely to be a risk factor for hypertension and consequent cardiovascular morbidity in the general population.     

Haptoglobin phenotype, sleep-disordered breathing, and the prevalence of cardiovascular disease: the Sleep Heart Health Study

BACKGROUND: Diabetes is an independent risk factor for cardiovascular disease, and there is growing evidence that sleep-disordered breathing also may increase the risk of cardiovascular disease. The mechanism responsible for increased susceptibility of people with diabetes to cardiovascular disease is thought to share several features with sleep-disordered breathing, notably increased oxidative stress. We recently demonstrated that a particular haptoglobin phenotype that is associated with differential antioxidant activity is an independent risk factor for cardiovascular disease in individuals with diabetes. We therefore sought to determine whether sleep-disordered breathing and cardiovascular disease are more strongly associated among people with the unfavorable haptoglobin phenotype. METHODS: We tested this hypothesis in 2612 middle-aged and older participants from the Sleep Heart Health Study. Haptoglobin phenotyping was performed by gel electrophoresis. Respiratory disturbance index was assessed by standard methods. Logistic regression analysis was performed to estimate the association between haptoglobin phenotype and cardiovascular disease, adjusting for known cardiovascular risk factors (age, sex, diabetes, smoking, lipid levels, and hypertension). Possible modification by haptoglobin phenotype of the association of sleep-disordered breathing with cardiovascular disease prevalence was explored by examining interaction terms. RESULTS: We found no significant association between haptoglobin phenotype and prevalent cardiovascular disease in this cohort, nor were significant interactions found between haptoglobin phenotype and sleep-disordered breathing on the prevalence of cardiovascular disease. CONCLUSIONS: Sleep-disordered breathing did not appear to interact with haptoglobin phenotype in modifying the association with prevalent cardiovascular disease in the Sleep Heart Health Study. These findings could be due to the absence of association or to survivor bias in these cross-sectional analyses.     

Exercise and sleep-disordered breathing: an association independent of body habitus

STUDY OBJECTIVES: The degree to which physical exercise habits are related to sleep-disordered breathing is not known. We sought to investigate the association between a single-item exercise question and laboratory-assessed sleep-disordered breathing. DESIGN: A population-based cross-sectional epidemiologic study of adults measured the association between exercise and sleep-disordered breathing. Hours of weekly planned exercise were assessed by questionnaire. Sleep-disordered breathing was assessed by 18-channel in-laboratory polysomnography and characterized by the apnea-hypopnea index. SETTING: Polysomnography was conducted at the University of Wisconsin General Clinical Research Center sleep laboratory. PATIENTS AND PARTICIPANTS: Participants included 1104 men and women, aged 30 to 60 years, enrolled in the Wisconsin Sleep Cohort Study. MEASUREMENTS AND RESULTS: Associations were modeled using linear and logistic regression, adjusting for body mass index, skinfold measurements, age, sex, and other covariates. Adjusted mean (95% confidence interval) apnea-hypopnea index was 5.3 (4.4, 6.2) events per hour for participants who exercised 0 hours per week; 3.9 (2.8, 5.0) events per hour for those with 1 to 2 hours of exercise; 3.2 (2.2, 4.2) events per hour for those with 3 to 6 hours of exercise; and 2.8 (1.0, 4.6) for those with > 7 hours of exercise (P trend < .001). Similarly, the odds of having moderate or worse sleep-disordered breathing (apnea-hypopnea index > 15 events per hour) significantly decreased with increasing level of exercise. CONCLUSION: Independent of measures of body habitus, lack of exercise was associated with increased severity of sleep-disordered breathing.     

Stroke, obesity and gender: a review of the literature

Cerebrovascular disease constitutes one of the main causes of morbidity, disability and mortality worldwide. Obesity, a major health problem reaching global epidemic proportions, is also associated with morbidity and mortality. The present review provides an update on the current knowledge regarding the association of gender and obesity with stroke prevalence and outcome. We also discuss the areas that future research needs to point towards. In general, gender differences in relation to stroke are increasingly being recognized and evaluated. Age-specific stroke incidence is generally higher in men, except in the elderly. Women are treated less frequently with intravenous thrombolysis compared with men stroke patients and the two genders seem to respond differently to aspirin and statins. Regarding obesity, although it is a well-known predictor of cardiovascular disease, there is a growing body of evidence revealing the presence of an inverse relationship between obesity and outcome in patients with stroke or established cardiovascular disease, the so-called obesity paradox. Further research is warranted on these important topics, as human population is continuously aging and becoming more obese. In this context, the causes of gender differences in stroke prevalence and outcome and the obesity-stroke paradox should be further investigated in future studies.     

Nonlinear heart rate dynamics: circadian profile and influence of age and gender

Heart rate variability (HRV) is used as a marker of autonomic modulation of heart rate. Nonlinear HRV parameters providing information about the scaling behaviour or the complexity of the cardiac system were included. In addition, the chaotic behaviour was quantified by means of the recently developed numerical noise titration technique. 24h Holter recordings of a large healthy population (N=276, 141 males, 18-71 years of age) were available. The goal was to investigate the influence of gender, age and day-night variation on these nonlinear HRV parameters. Numerical titration yielded similar information as other nonlinear HRV parameters do. However, it does not require long and cleaned data and therefore applicable on short (5min) noisy time series. A higher nonlinear behaviour was observed during the night (NLdr; day: 50.8±19.6%, night: 59.1±19.5%; P<0.001) while nonlinear heart rate fluctuations decline with increasing age (NLdr; Pearson correlation coefficient r between -0.260 and -0.319 dependent on gender and day or night, all P<0.01). A clear circadian profile could be found for almost every parameter, showing in particular which changes occur during the transition phases of waking up and going to sleep. Our results support the involvement of the autonomic nervous system in the generation of nonlinear and complex heart rate dynamics.     

The effects of ondansetron on sleep-disordered breathing in the English bulldog

Serotonin and serotoninergic drugs have significant effects on respiration, at many sites throughout the nervous system, and serotonin has been implicated in the pathogenesis of obstructive sleep apnea. Thus, understanding the serotoninergic mechanisms underlying respiratory control may help discover novel pharmacotherapies for sleep-disordered breathing. Ondansetron, a serotonin (5-HT) antagonist selective for the 5-HT3 receptor subtype has recently been shown to suppress sleep-related central apneas in rats, particularly in rapid-eye-movement (REM) sleep. To evaluate the potential of ondansetron in the treatment of obstructive sleep-disordered breathing, we have performed randomized trials of two doses of ondansetron (20 and 40 mg orally) and placebo (4 studies for each of the 3 conditions) in our animal model of obstructive sleep apnea, the English Bulldog. Ondansetron significantly reduced the respiratory disturbance index (RDI) in REM sleep from 24.15+/-4.85 events/hour at placebo to 11.01+/-1.56 events/hour with high dose treatment, n=4, p<0.05. In contrast, the effects of drug on the RDI in non-rapid-eye-movement (NREM) sleep (5.23+/-1.30 events/hour, placebo; 4.31+/-1.36, with 20 mg ondansetron and 2.89+/-1.30 with 40 mg ondansetron, n=4) were not significant. Ondansetron, however, had no effect on either sleep efficiency or sleep architecture, and there were no effects on either oxyhemoglobin saturation nadirs or on the sleep time with saturations <90%. Although a trend towards reduction in the latter measure of oxygenation was seen at the higher dose of ondansetron. These data suggest a therapeutic potential for ondansetron in obstructive sleep-disordered breathing, particularly REM sleep apnea.     

Device-guided breathing in the home setting: Technology, performance and clinical outcomes

Routine practice of slow breathing is a major component of a variety of behavioral treatments of chronic conditions. The present paper addresses the challenge of using device-guided breathing (DGB) as a self-treatment tool in the home setting. The breathing patterns of hypertensive patients treated using DGB over 8 weeks in 15-min daily sessions were analyzed using minute-by-minute stored data. The relationship of breathing pattern with office blood pressure changes over the treatment period was evaluated. The treatment device operated to reduce breathing rate effortlessly while prolonging exhalation: patients were requested to synchronize breathing with the guiding tones, generated in response to the monitored breathing pattern. Breathing modification was highly individualized, repeatable over sessions, and unrelated to clinical or demographic characteristics; it also seemed to reflect behavioral aspects of device-patient interaction. Quality of breathing synchronization with the guiding tones and time spent in slow breathing displayed a relationship with the clinical outcomes. Different DGB methods are believed to share similar features. A possible physiological mechanism underlying the beneficial effect of slow and effortless breathing in chronic conditions is discussed in relation to restoring autonomic balance via lung reflexes.     

Understanding the relationships between breastfeeding,malocclusion, ADHD,sleep-disordered breathing and traumatic dental injuries

Attention-deficit/hyperactivity disorder (ADHD), one of the most common neuropsychiatric disorders that present at young age, may occasionally be associated with physical problems and disorders. Among them exists a group of oral-pharyngeal conditions with considerable clinical morbidity. Previous research that identified absence or short duration of breastfeeding in ADHD children has been reviewed. Essential nutritional factors in breast milk can affect brain development and regulate the manifestation of ADHD symptoms. Low ferritin levels caused by insufficient breastfeeding may contribute to ADHD susceptibility because of the role of iron in dopaminergic activity. Insufficient breast feeding and subsequently excessive bottle-feeding may lead to increased rates of non-nutritive sucking habits, such as pacifier use and thumb-sucking, all of which are associated with the risk of development of malocclusions. Malocclusion refers to an unacceptable deviation from the ideal relationship of the upper and lower teeth and necessitates orthodontic treatment. Sleep-disordered breathing in children may present with neurocognitive symptoms that resemble ADHD and abnormal craniofacial developments, as well as malocclusions, have been cited as part of the syndrome. Obesity, which is an outcome of insufficient breastfeeding, is a shared comorbidity of ADHD and sleep-disordered breathing. The risk of traumatic dental injury is higher in children with ADHD and presence of malocclusions further increases the likelihood of dental injuries.